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Traumatic brain injury (TBI) often results in balance impairment, increasing the risk of falls, and the chances of further injuries. However, the underlying neural mechanisms of postural control after TBI are not well understood. To this end, we conducted a pilot study to explore the neural mechanisms of unpredictable balance perturbations in 17 chronic TBI participants and 15 matched healthy controls (HC) using the EEG, MRI, and diffusion tensor imaging (DTI) data. As quantitative measures of the functional integration and segregation of the brain networks during the postural task, we computed the global graph‐theoretic network measures (global efficiency and modularity) of brain functional connectivity derived from source‐space EEG in different frequency bands. We observed that the TBI group showed a lower balance performance as measured by the center of pressure displacement during the task, and the Berg Balance Scale (BBS). They also showed reduced brain activation and connectivity during the balance task. Furthermore, the decrease in brain network segregation in alpha‐band from baseline to task was smaller in TBI than HC. The DTI findings revealed widespread structural damage. In terms of the neural correlates, we observed a distinct role played by different frequency bands: theta‐band modularity during the task was negatively correlated with the BBS in the TBI group; lower beta‐band network connectivity was associated with the reduction in white matter structural integrity. Our future studies will focus on how postural training will modulate the functional brain networks in TBI., EEG connectivity graph measures were studied in traumatic brain injury (TBI) during the balance perturbation task. TBI group showed altered brain activation and connectivity during the balance task. Graph‐theoretic measures showed that the task modulation of brain network segregation in alpha‐band was reduced in TBI and the network segregation in theta‐band was associated with postural instability in TBI.

Making rapid and proper compensatory postural adjustments is vital to prevent falls and fall-related injuries. This study aimed to investigate how, especially how rapidly, the multiple lower-limb muscles and joints would respond to the unexpected standing balance perturbations. Unexpected waist-pull perturbations with small, medium and large magnitudes were delivered to twelve healthy young adults from the anterior, posterior, medial and lateral directions. Electromyographical (EMG) and mechanomyographical (MMG) responses of eight dominant-leg muscles (i.e., hip abductor/adductors, hip flexor/extensor, knee flexor/extensor, and ankle dorsiflexor/plantarflexors) together with the lower-limb joint angle, moment, and power data were recorded. The onset latencies, time to peak, peak values, and/or rate of change of these signals were analyzed. Statistical analysis revealed that: (1) agonist muscles resisting the delivered perturbation had faster activation than the antagonist muscles; (2) ankle muscles showed the largest rate of activation among eight muscles following both anteroposterior and mediolateral perturbations; (3) lower-limb joint moments that complied with the perturbation had faster increase; and (4) larger perturbation magnitude tended to evoke a faster response in muscle activities, but not necessarily in joint kinetics/kinematics. These findings provided insights regarding the underlying mechanism and lower-limb muscle activities to maintain reactive standing balance in healthy young adults.

The aim of the present study was to investigate the effect of the application of neuromuscular electrical stimulation to the quadriceps muscle of the paretic limb during externally induced stance perturbations on reactive balance control and on fall outcomes in people with chronic stroke. Ten participants experienced 12 stance treadmill perturbation trails, 6 forward balance perturbation trials and 6 backward balance perturbation trials. For each perturbation condition, three perturbation trials were delivered synchronized with neuromuscular electrical stimulation applied to the quadriceps of the paretic limb and three perturbation trials were delivered without stimulation. Behavioral outcome measures, such as incidence of laboratory falls and number of compensatory steps, kinematic outcome measures, such as margin of stability and minimum hip high values after the perturbation, step initiation time, step execution time and step length of the stepping leg were analyzed. The application of neuromuscular electrical stimulation on the paretic quadriceps between the range of 50 and 500 ms after stance forward and backward perturbations reduced the laboratory falls incidence (p

BackgroundCurrently, there is uncertainty as to whether movement variability is errorful or exploratory.Research questionThis study aimed to determine if gait variability represents exploration to improve stability. We hypothesized that 1) spatiotemporal gait features will be more variable prior to an expected perturbation than during unperturbed walking, and 2) increased spatiotemporal gait variability pre-perturbation will correlate with improved stability post-perturbation.MethodsSixteen healthy young adults completed 15 treadmill walking trials within a motion simulator under two conditions: unperturbed and expecting a perturbation. Participants were instructed not to expect a perturbation for unperturbed trials, and to expect a single transient medio-lateral balance perturbation for perturbed trials. Kinematic data were collected during the trials. Twenty steps were recorded post-perturbation. Unperturbed and pre-perturbation gait variabilities were defined by the short- and long-term variabilities of step length, width, and time, using 100 steps from pre-perturbation and unperturbed trials. Paired t-tests identified between-condition differences in variabilities. Stability was defined as the number of steps to centre of mass restabilization post-perturbation. Multiple regression analyses determined the effect of pre-perturbation variability on stability.ResultsLong-term step width variability was significantly higher pre-perturbation compared to unperturbed walking (mean difference=0.28cm, p=0.0073), with no significant differences between conditions for step length or time variabilities. There was no significant relationship between pre-perturbation variability and post-perturbation restabilization.SignificanceIncreased pre-perturbation step width variability was neither beneficial nor detrimental to stability. However, the increased variability in medio-lateral foot placement suggests that participants adopted an exploratory strategy in anticipation of a perturbation.

The cortical N1 response to balance perturbation is observed in electroencephalography recordings simultaneous to automatic balance-correcting muscle activity. We recently observed larger cortical N1s in individuals who had greater difficulty resisting compensatory steps, suggesting the N1 may be influenced by stepping or changes in response strategy. Here, we test whether the cortical N1 response is influenced by stepping (planned steps versus feet-in-place) or prior planning (planned vs. unplanned steps). We hypothesized that prior planning of a step would reduce the amplitude of the cortical N1 response to balance perturbations. In 19 healthy young adults (ages 19–38; 8 men and 11 women), we measured the cortical N1 amplitude evoked by 48 backward translational support-surface perturbations of unpredictable timing and amplitude in a single experimental session. Participants were asked to plan a stepping reaction on half of perturbations, but to resist stepping otherwise. Perturbations included an easy (8 cm, 16 cm/s) perturbation that was identical across participants and did not naturally elicit compensatory steps, and a height-adjusted difficult (18–22 cm, 38–42 cm/s) perturbation that frequently elicited compensatory steps despite instructions to resist stepping. In contrast to our hypothesis, cortical N1 response amplitudes did not differ between planned and unplanned stepping reactions, but cortical responses were 11% larger with the execution of planned compensatory steps compared with nonstepping responses to difficult perturbations. These results suggest a possible role for the cortical N1 in the execution of compensatory steps for balance recovery, and this role is not influenced by whether the compensatory step was planned before the perturbation. NEW & NOTEWORTHY The cortical N1 response to balance perturbation is larger when executing compensatory steps, suggesting a relationship between the cortical N1 and subsequent motor behavior. Additionally, the cortical N1 response is not impacted by prior planning of the stepping reaction, suggesting that predictability of the motor outcome does not impact the N1 in the same way as predictability of the perturbation stimulus.

Postural reactions (PR) of standing subjects have been mostly investigated in response to platform displacements or body perturbations of fixed magnitude. The objective of this study was to investigate the relationship between PR and the peak force and impulse of the perturbation. In ten healthy young men, standing balance was challenged by anteriorly directed perturbations (peak force: 20–60 N) delivered to the back, at the lumbar (L) or inter-scapular (IS) level, by means of a manual perturbator equipped with a force sensor. Postural reactions as expressed by the displacement of the center of pressure (CoP) were recorded using a force platform. Two sets of 20 randomly ordered perturbations (10 to each site) were delivered in two separate testing sessions. The magnitude of CoP response (∆CoP) was better correlated with the impulse (I) than with the peak force of the perturbation. The normalized response, ∆CoPn = ∆CoP/I, exhibited good reliability (ICCs of 0.93 for IS and 0.82 for L), was higher with IS than with L perturbations (p

Adaptation of automatic postural responses (APR) to balance perturbations might be thought to be impaired by muscle fatigue, given the associated proprioceptive and effector deficits. In this investigation, we aimed to evaluate the effect of muscular fatigue on APR adaptation over repetitive balance perturbations through support base backward translations. APR adaptation was evaluated in three epochs: (a) pre-fatigue; (b) post-fatigue, immediately following fatigue of the plantiflexor muscles through isometric contractions and (c) post-recovery, 30 min after the end of fatiguing activity. Results showed the following: (a) Decreasing amplitudes of joints' maximum excursion over repetitive perturbations in the three fatigue-related epochs. (b) Modulation of joints' excursion was observed in the first trial in the post-fatigue epoch. (c) In the post-fatigue epoch, we found interjoint rescaling, with greater amplitude of hip rotation associated with reduced amplitude of ankles' rotation. (d) Amplitudes of ankles' rotation were similar between the post-fatigue and post-recovery epochs. These findings lead to the conclusions that adaptation of automatic postural responses over repetitive trials was effective under focal muscular fatigue; modulation of the postural response took place in the first perturbation under fatigue, and generalization of response characteristics from post-fatigue to post-recovery suggests that feedforward processes in APRs generation are affected by the recent history of postural responses to stance perturbations.

Reactive responses to balance perturbations have been shown to be improved by training. This investigation aimed to compare the effects of block and random training perturbation schedules on stability gains of compensatory arm and leg movements in response to unpredictable large-magnitude balance perturbations. Perturbations were produced by means of sudden displacements of the support base, associating mode (rotation, translation, combined), direction, and velocity of platform motion. Healthy young participants were assigned to one of three groups: random, block, and control. For the random group, perturbation sequence was unpredictable. For the block group, each balance perturbation was repeated over blocks of four trials. Controls were tested only, serving as reference of first trial responses in the post-test. Evaluation was made through a scale rating stability of compensatory arm and leg movements (CALM). We probed immediate and persistence gains (1-week retention), in addition to generalizability to perturbations of higher velocity and to dual-tasking (mental subtraction). In the post-test both the block and random groups achieved higher leg and global scores in comparison with controls in the most challenging perturbations. In retention and transfer tests, results for the global score indicated higher values for the random than for the block and control groups. These results support the conclusion that high but not low contextual interference in perturbation-based balance training leads to enduring and generalizable increased stability gains of compensatory limb movements in response to unpredictable balance perturbations.

The purpose of this study was to examine the role of foot sole somatosensory information during reactive postural control. Twenty young adults (22.0±1.4y) participated in this study. Baseline skin sensitivity from the foot sole was assessed using Semmes-Weinstein monofilaments. Postural muscle responses, in the form of electromyographic (EMG) onset latencies and amplitudes, were then obtained while participants recovered their balance while standing on a moveable platform that could translate in either the forward or backward direction. Following these baseline measures, the participant's foot soles were immersed in a 0-2°C ice-water bath for 12min followed by a 3min re-immersion period. At the completion of foot cooling, foot sole sensitivity and postural muscle responses to the balance perturbations were re-assessed. Results indicated that the foot cooling protocol reduced foot sole sensitivity and remained reduced throughout the duration of the experiment (p

Balance recovery mechanisms are of paramount importance in situations like public transport where sudden loss of equilibrium can occur. These mechanisms can be altered by aging or pathological disorders. However it is almost impossible to investigate these phenomena in real-life conditions, and the safe environment of a laboratory is needed. This paper investigates how jerk perturbations in the transverse plane similar to those experienced on public transport can be simulated in a controlled manner. A platform capable of producing horizontal perturbations with a person standing on it was developed. Accuracy, repeatability, and load sensitivity of the system were assessed with repeated trials in all four directions of movement. Comparison between the destabilising effect experienced on public transport and the postural response to perturbations from the platform was also made by tracking acceleration of the centre of mass of four subjects in these two situations. Results show that balance perturbations representative of real-life situations, such as standing on public transport, can accurately and repeatedly be produced in a safe and controlled environment with a low-cost and low-maintenance system. Coupled to motion capture technology, the system can be used for pathology assessment and rehabilitation treatments.

Abstarct Objectives Challenging quiet standing tasks for the ankle, knee, hip, and neck joints were used to test the effect of pre-cueing on the reaction time of articular stabilization strategies. Method We assessed balance recovery in 15 subjects who were exposed to backward translations on a movable platform during two conditions: alerted, where participants gazed at a countdown light that pre-cued the onset of the platform translation; and unalerted, without onset time pre-cue. Results We compared the angular variation of the ankle, knee, hip, and neck joints between the two conditions over four window epochs (0–50 ms; 50–100 ms; 100–150 ms; 150–200 ms). When comparing the window epochs of the ankle and hip joints between conditions, a significant effect was observed in the first and second windows. In the second and third windows, a significant effect was only observed in the alerted group, thereby indicating a faster stability for alerted condition. No significant effect was observed for the knee joint, while a significant effect was observed in the neck joint during the third and fourth windows of the alerted condition. Conclusions Pre-cueing can modify the synergies of the automatic reactive postural responses, prioritizing the stabilization of main joints such as the ankle and hip over that of the neck and knee. It was suggested that joint stabilization in the hip occurred due to the involuntary anticipation preprogrammed in the cortex by the visual pre-cue.

30-60% of traumatic brain injury (TBI) patients suffer from long-term balance deficit. Even though motor preparation and execution are altered and slowed in TBI, their relative contribution and importance to posture instability remain poorly understood. This study investigates the impaired cortical dynamics and neuromuscular response in TBI in response to balance perturbation and its relation to balance deficit. 12 TBI and 6 healthy control (HC) participants took the Berg Balance Scale (BBS) test and participated in a balance perturbation task where they were subjected to random anterior/posterior translation, while brain (EEG), muscle (EMG) activities, and center of pressure (COP) were continuously recorded. Using independent component analysis (ICA), the component most responsible for the N1 component of the perturbation evoked potential (PEP) was selected and its amplitude and latency were extracted. Balance task performance was measured by computing the COP displacement during the task. TBI had a significantly lower BBS, larger COP displacement and lower N1 amplitude compared to the HC group. No group differences was found for N1 latency and muscle activity onset delay to the perturbation. BBS was correlated with the COP displacement and N1 amplitude, and COP displacement was correlated with N1 latency. TBI balance deficit may be associated with more impaired than delayed cortical response to balance perturbation.

Stairways, public transport and inclined walkways are often considered as sites with higher likelihood of falls due to a sudden loss of balance. Such sites are usually marked with warning signs, equipped with non-slip surfaces and handles or handrails to avert or decrease this likelihood. Especially, handles are supposed to provide additional support in cases of a sudden loss of balance. However, the mechanisms of using handles for balance at different heights are not yet fully disclosed. We simulated full body perturbations by applying an anterior force to the waist and investigated effectiveness and mechanisms of balance recovery in five different postures: step stance and normal stance with or without holding handles at different heights. Results indicate that both step stance and holding handles at different vertical positions sufficiently assist balance recovery, compared to normal stance. While there was no significant effect of handle in CoM displacement, the shoulder height handle required the lowest handle force, indicating a difference in using the handle.

The role of cortical activity in standing balance is unclear. Here we tested whether perturbation-evoked cortical responses share sensory input with simultaneous balance-correcting muscle responses. We hypothesized that the acceleration-dependent somatosensory signals that drive the initial burst of the muscle automatic postural response also drive the simultaneous perturbation-evoked cortical N1 response. We measured in healthy young adults ( n = 16) the initial burst of the muscle automatic postural response (100–200 ms), startle-related muscle responses (100–200 ms), and the perturbation-evoked cortical N1 potential, i.e., a negative peak in cortical EEG activity (100–200 ms) over the supplementary motor area. Forward and backward translational support-surface balance perturbations were applied at four levels of acceleration and were unpredictable in timing, direction, and acceleration. Our results from averaged and single-trial analyses suggest that although cortical and muscle responses are evoked by the same perturbation stimulus, their amplitudes are independently modulated. Although both muscle and cortical responses increase with acceleration, correlations between single-trial muscle and cortical responses were very weak. Furthermore, across subjects, the scaling of muscle responses to acceleration did not correspond to scaling of cortical responses to acceleration. Moreover, we observed a reduction in cortical response amplitude across trials that was related to a reduction in startle-related—but not balance-correcting—muscle activity. Therefore, cortical response attenuation may be related to a reduction in perceived threat rather than motor adaptation or changes in sensory inflow. We conclude that the cortical N1 reflects integrated sensory inputs simultaneously related to brain stem-mediated balance-correcting muscle responses and startle reflexes. NEW & NOTEWORTHY Reactive balance recovery requires sensory inputs to be transformed into appropriate balance-correcting motor responses via brain stem circuits; these are accompanied by simultaneous and poorly understood cortical responses. We used single-trial analyses to dissociate muscle and cortical response modulation with perturbation acceleration. Although muscle and cortical responses share sensory inputs, they have independent scaling mechanisms. Attenuation of cortical responses with experience reflected attenuation of brain stem-mediated startle responses rather than the amplitude of balance-correcting motor responses.

Hip joint contact loads during activities of daily living are not generally considered high enough to cause acute bone or joint injury. However there is some evidence that hip joint loads may be higher in stumble recovery from loss of balance. A common laboratory method used to evaluate balance recovery performance involves suddenly releasing participants from various static forward lean magnitudes (perturbation intensities). Prior studies have shown that when released from the same perturbation intensity, some older adults are able to recover with a single step, whereas others require multiple steps. The main purpose of this study was to use a musculoskeletal model to determine the effect of three balance perturbation intensities and the use of single versus multiple recovery steps on hip joint contact loads during recovery from forward loss of balance in community dwelling older adults (n=76). We also evaluated the association of peak hip contact loads with perturbation intensity, step length and trunk flexion angle at foot contact at each participant's maximum recoverable lean angle (MRLA). Peak hip joint contact loads were computed using muscle force estimates obtained using Static Optimisation and increased as lean magnitude was increased and were on average 32% higher for Single Steppers compared to Multiple Steppers. At the MRLA, peak hip contact loads ranged from 4.3 to 12.7 body weights and multiple linear stepwise regression further revealed that initial lean angle, step length and trunk angle at foot contact together explained 27% of the total variance in hip joint contact load. Overall findings indicated that older adults experience peak hip joint contact loads during maximal balance recovery by stepping that in some cases exceeded loads reported to cause mechanical failure of cadaver femurs. While step length and trunk flexion angle are strong predictors of step recovery performance they are at best moderate predictors of peak hip joint loading.

Background: Supra-threshold galvanic vestibular stimulation (GVS) can be used to challenge the balance control system by disrupting vestibular inputs. The goal of this study was to propose an objective method to assess variability across subjects in the minimum safe GVS level that causes maximum balance degradation. New method: Thirteen healthy young subjects stood on a compliant foam surface with their eyes closed and tried to maintain a stable upright stance. Variables related to the stability of the trunk and whole body were quantified to characterize the relationship between postural responses and GVS at amplitudes from 0 to 4.5 mA in 0.5 mA increments. The relationship between decrements in postural responses and GVS was linear up to a minimum GVS level (called KNEE). An increase in the stimulation level above that did not lead to any further degradation of balance performance. The KNEE was determined by iteratively performing linear fits to the performance measure at different stimulation levels. Results: There were individual differences in KNEE; it was in the range of 1–2.5 mA across subjects. GVS caused an average performance decrement of 27–99% across six variables at the KNEE level compared to a no-stimulus condition. Comparison to existing methods: We propose a method to consistently attain the maximum level of impairment across subjects using the minimum current intensity, to minimize all types of adverse effects usually observed at high intensities. Conclusions: Individual differences in the disruption of posture control in response to GVS have important implications for testing and training paradigms.

A startling acoustic stimulus (SAS) involuntary releases prepared movements at accelerated latencies, known as the StartReact effect. Previous work has demonstrated intact StartReact in paretic upper extremity movements in people after stroke, suggesting preserved motor preparation. The question remains whether motor preparation of lower extremity movements is also unaffected after stroke. Here, we investigated StartReact effects on ballistic lower extremity movements and on automatic postural responses (APRs) following perturbations to standing balance. These APRs are particularly interesting as they are critical to prevent a fall following balance perturbations, but show substantial delays and poor muscle coordination after stroke. Twelve chronic stroke patients and 12 healthy controls performed voluntary ankle dorsiflexion movements in response to a visual stimulus, and responded to backward balance perturbations evoking APRs. Twenty-five percent of all trials contained a SAS (120 dB) simultaneously with the visual stimulus or balance perturbation. As expected, in the absence of a SAS muscle and movement onset latencies at the paretic side were delayed compared to the non-paretic leg and to controls. The SAS accelerated ankle dorsiflexion onsets in both the legs of the stroke subjects and in controls. Following perturbations, the SAS accelerated bilateral APR onsets not only in controls, but for the first time, we also demonstrated this effect in people after stroke. Moreover, APR inter- and intra-limb muscle coordination was rather weak in our stroke subjects, but substantially improved when the SAS was applied. These findings show preserved movement preparation, suggesting that there is residual (subcortical) capacity for motor recovery.

Contextual cueing advancing the characteristics of an impending balance perturbation has been thought to induce optimized automatic postural responses. In this investigation, we aimed to disambiguate the cognitive and adaptive components of cueing a balance perturbation through the direction sequence of a series of base of support translations. We compared three experimental conditions: (a) block, with one perturbation cueing that the following one would be in the same direction; (b) serial, with one perturbation cueing that the following one would be in the opposite direction; and (c) random, representing a control uncued condition. Participants were instructed about the perturbation sequences. With this arrangement, at the cognitive level there was no directional uncertainty both in the block and serial sequences, while at the non-cognitive level only the block sequence was expected to lead to optimized responses in comparison to the random sequence. Results showed that the block sequence led to the generation of more stable automatic postural responses in comparison to the serial and random sequences, as indicated by lower amplitudes of body sway and lower velocity of center of pressure displacement. Increased balance stability in the block sequence was associated with longer delays of activation onset of leg distal muscles. Comparisons between the serial and random perturbation sequences failed to show any significant differences. These results indicate that optimized postural responses in the block sequence are due to adaptive processes underlying repetitive perturbations over trials rather than to processing of contextual cues at the cognitive level reducing uncertainty about characteristics of an impending perturbation.

The effect of visual condition is more intense in the first trial response in normal subjects and patients and in last trial response only in patients. The first trial effect is more evident in compensated patients in the eyes open condition with any type of perturbation, and in non-compensated patients with the angular displacements in either visual condition.The study of body reaction to FTR can help to understand the complex mechanisms involved in the postural response and to develop new therapies to improve stability and prevent falls in unilateral vestibular deficit (UVD). This work describes the adaptation effect and the visual influence on the postural response to repetitive balance perturbation stimulus in normal subjects, compensated, and uncompensated UVD patients.The magnitude of displacement has been measured when the support surface is linearly or angularly displaced. The differences between results in the first and late trial, and the differences between the eyes open and eyes closed situation have been compared.Compensated patients recover the adaptation ability to unexpected changes on the support surface through visual preference mechanism. Not compensated patients present hypermetric postural response with greater instability in the eyes open and eyes closed situations.

Processing of predictive contextual cues of an impending perturbation is thought to induce adaptive postural responses. Cueing in previous research has been provided through repeated perturbations with a constant foreperiod. This experimental strategy confounds explicit predictive cueing with adaptation and non-specific properties of temporal cueing. Two experiments were performed to assess those factors separately. To perturb upright balance, the base of support was suddenly displaced backwards in three amplitudes: 5, 10 and 15 cm. In Experiment 1, we tested the effect of cueing the amplitude of the impending postural perturbation by means of visual signals, and the effect of adaptation to repeated exposures by comparing block versus random sequences of perturbation. In Experiment 2, we evaluated separately the effects of cueing the characteristics of an impending balance perturbation and cueing the timing of perturbation onset. Results from Experiment 1 showed that the block sequence of perturbations led to increased stability of automatic postural responses, and modulation of magnitude and onset latency of muscular responses. Results from Experiment 2 showed that only the condition cueing timing of platform translation onset led to increased balance stability and modulation of onset latency of muscular responses. Conversely, cueing platform displacement amplitude failed to induce any effects on automatic postural responses in both experiments. Our findings support the interpretation of improved postural responses via optimized sensorimotor processes, at the same time that cast doubt on the notion that cognitive processing of explicit contextual cues advancing the magnitude of an impending perturbation can preset adaptive postural responses.

Background: Impaired hip muscle performance has been implicated as a contributing factor to the increased risk of anterior cruciate ligament (ACL) injury in women. Purpose: To determine the influence of a hip-focused training program on lower extremity biomechanics during a drop-jump task. Study Design: Descriptive laboratory study. Methods: Twenty-one recreationally active women (18-25 years of age) participated in a 4-week training program consisting of hip-focused plyometric and balance perturbation exercises (3 times/wk, 30 min/session). Maximum isometric strength of the hip extensors, hip abductors, and knee extensors was assessed, along with lower extremity biomechanics during a drop-jump task. All assessments were performed within 5 days of initiation and completion of the training program. Results: After training, subjects demonstrated significantly greater maximum isometric strength of the hip extensors (2.87 ± 0.7 vs 3.11 ± 0.7 N·m/kg; P < .01) and hip abductors (2.08 ± 0.7 vs 2.23 ± 0.07 N·m/kg; P = .004). No significant difference in knee extensor strength was observed. After training, subjects landed with significantly greater peak knee flexion (94.0° ± 8.5° vs 98.0° ± 10.1°; P < .001) and hip flexion (83.4° ± 7.6° vs 89.9° ± 8.8°; P = .008) and a lower knee/hip extensor moment ratio (1.33 ± 0.6 vs 0.99 ± 0.3; P = .001). In addition, subjects demonstrated significantly lower peak knee abduction angles (6.8° ± 3.3° vs 5.6° ± 3.1°; P = .04) and average knee adductor moments (0.06 ± 0.1 vs −0.02 ± 0.1 N·m/kg; P < .001). Conclusion: Changes in lower extremity biomechanics consistent with decreased risk for ACL injury were observed after participation in a hip-focused training program. Clinical Relevance: The study results suggest that ACL injury prevention programs targeting hip muscle performance may be important in mitigating biomechanical risk factors associated with ACL injury in women.

Postural responses (PR) to a balance perturbation differ between the first and subsequent perturbations. One explanation for this first trial effect is that perturbations act as startling stimuli that initiate a generalized startle response (GSR) as well as the PR. Startling stimuli, such as startling acoustic stimuli (SAS), are known to elicit GSRs, as well as a StartReact effect, in which prepared movements are initiated earlier by a startling stimulus. In this study, a StartReact effect paradigm was used to determine if balance perturbations can also act as startle stimuli. Subjects completed two blocks of simple reaction time trials involving wrist extension to a visual imperative stimulus (IS). Each block included 15 CONTROL trials that involved a warning cue and subsequent IS, followed by 10 repeated TEST trials, where either a SAS (TESTSAS) or a toes-up support-surface rotation (TESTPERT) was presented coincident with the IS. StartReact effects were observed during the first trial in both TESTSAS and TESTPERT conditions as evidenced by significantly earlier wrist movement and muscle onsets compared with CONTROL. Likewise, StartReact effects were observed in all repeated TESTSAS and TESTPERT trials. In contrast, GSRs in sternocleidomastoid and PRs were large in the first trial, but significantly attenuated over repeated presentation of the TESTPERT trials. Results suggest that balance perturbations can act as startling stimuli. Thus first trial effects are likely PRs which are superimposed with a GSR that is initially large, but habituates over time with repeated exposure to the startling influence of the balance perturbation.

Item does not contain fulltext Perturbation of whole-body stability often evokes rapid arm reactions. It has been suggested that the earliest arm activation is a generic (e.g. startle-like) response to which a later stabilizing (e.g. counterweight or reach-to-grasp) or impact-protection component can be appended. To examine whether the initial part of the reaction is generic, we examined arm reactions evoked by small balance perturbations in 12 healthy young adults while varying perturbation direction (rightward or forward platform translation) and environmental conditions (handrail present or absent). The perturbation magnitude was selected to be sufficiently small to obviate the need to use the arms for stabilization. To avoid adaptation or habituation, analysis focused on each subject's very first exposure to the perturbation. Most subjects exhibited active movement of both arms in reaction to the perturbation, but there was large (non-stereotypical) inter-subject variation in muscle-onset latency and arm kinematics. Furthermore, the velocity and direction of the initial arm movement were affected by perturbation direction, in a manner consistent with functional strategies (counterweight strategy in backward falls, hybrid counterweight/protective strategy in leftward falls). Although subjects never contacted the handrail, responses were slower when it was present. These results are not consistent with a generic stereotyped response, but suggest instead that even the earliest component of first-trial arm reactions was functionally modulated.

Aim of this study was to get insight into the features of the postural adaptation process, occurring during a continuous 3-min and 0.6Hz horizontal sinusoidal oscillation of the body support base. We hypothesized an ongoing temporal organization of the balancing strategy that gradually becomes fine-tuned and more coordinated with the platform movement. The trial was divided into oscillation cycles and for each cycle: leg muscles activity and temporal relationship between Centre of Mass and Centre of Pressure A-P position were analyzed. The results of each cycle were grouped in time-windows of 10 successive cycles (time windows of 16.6s). Muscle activity was initially prominent and diminished progressively. The major burst of Tibialis Anterior (TA) muscle always occurred at the same time instant of the platform oscillation cycle, in advance with respect to the platform posterior turning point. This burst produced a body forward rotation that was delayed throughout the task. During prolonged and repeatable balance perturbation, an ongoing postural adaptation process occurs. When the effects of the perturbation become predictable, the CNS scales the level of muscle activity to counteracting the destabilizing effects of the perturbations. Furthermore, the CNS tunes the kinematics and the kinetic responses optimally by slightly delaying the onset of the body forward rotation, maintaining unchanged the time-pattern of postural muscle activation.

Although commonly prescribed, little research exists on bath grab bars. This study examined the use of bath grab bars following an experimentally induced balance perturbation, the influence of the task on grab bar use, and the influence of balance loss on acceptance of grab bars. A mixed design documented the use of four different grab bar configurations: (a) no bars, (b) vertical/horizontal combination, (c) L-shaped bar, and (d) vertical/angled combination following balance loss. Eighty adults were randomly assigned to three groups. Each group tried the "no bar" configuration and one of the other grab bar configurations. In 25% of the trials for each configuration, balance perturbation was induced. Older adults used grab bars 59.4% of time to regain balance, compared to 13.6% for younger adults. The vertical bar on the side wall was favored by both groups of participants during both bathtub entry and exit. To promote safety in the home, existing building codes must be revised to recommend minimally a vertical grab bar on the side wall. Additional bars may be needed to ensure safety during stand-to-sit and sit-to-stand phases of bath transfers. Initiatives must be taken to decrease the prejudice associated with grab bars.

Positive effects on lateral center of mass (CoM) shifts during balance recovery have been seen with voluntarily unilateral arm raising but not with voluntarily bilateral knee flexion. To determine whether unilateral voluntary knee movements can be effectively incorporated into balance corrections we perturbed the balance of 30 young healthy subjects using multi-directional rotations of the support surface while they simultaneously executed unilateral knee flexion. Combined pitch and roll rotations (7.5 degrees and 60 degrees/s) were presented randomly in six different directions. Subjects were tested in four stance conditions: balance perturbation only (PO); cued flexion of one knee only (KO); combined support surface rotation and cued (at rotation onset) flexion of the uphill knee, contralateral to tilt (CONT), or of the downhill knee, ipsilateral to tilt (IPS). Outcome measures were CoM motion and biomechanical and electromyography (EMG) responses of the legs, arms and trunk. Predicted measures (PO+KO) were compared with combined measures (CONT or IPS). Unilateral knee flexion of the uphill knee (CONT) provided considerable benefit in balance recovery. Subjects rotated their pelvis more to the uphill side than predicted. Downhill knee bending (IPS) also had a positive effect on CoM motion because of a greater than predicted simultaneous lateral shift of the pelvis uphill. KO leg muscle activity showed anticipatory postural activity (APA) with similar profiles to early balance correcting responses. Onsets of muscle responses and knee velocities were earlier for PO, CONT, and IPS compared to KO conditions. EMG response amplitudes for CONT and IPS conditions were generally not different from the PO condition and therefore smaller than predicted. Later stabilizing responses at 400 ms had activation amplitudes generally equal to those predicted from the PO+KO conditions. Our results suggest that because EMG patterns of anticipatory postural activity of voluntary unilateral knee flexion and early balance corrections have similar profiles, the CNS is easily able to incorporate voluntary activation associated with unilateral knee flexion into automatic postural responses. Furthermore, the effect on movement strategies appears to be non-linear. These findings may have important implications for the rehabilitation of balance deficits.

Rapid "change-in-support" (stepping or grasping) balance-recovery reactions play a critical role in preventing falls. Studies investigating age-related impairments in these reactions using differing perturbation methods have shown contradictory results. The discrepancies could be due to the different mechanical and sensory stimuli provided by the different perturbation methods, but could also be due to other confounding factors (e.g. differences in perturbation predictability). This study compared two commonly used perturbation methods: weight-drop cable-pulls (CPs) and motor-driven surface-translations (STs). For each perturbation method, effects of aging on the change-in-support reactions were established by comparing 10 young (22-28 years) and 30 older (64-79 years) adults, using large unpredictable multi-directional perturbations similar to those used in previous studies showing age-related differences. Age-related differences in the pattern and spatio-temporal features of the limb movements were examined for stepping and grasping reactions evoked by antero-posterior perturbation of stance, as well as stepping reactions evoked by lateral perturbations delivered while subjects walked "in-place". Although age-group effects were almost always more pronounced for ST perturbations, the direction of the effect was always the same for both perturbation methods; hence, the perturbation-dependent differences in mechanical and sensory stimuli did not seem to be a critical factor. Perturbation waveform appeared to be a more important factor. For the perturbation methods used here, the ST perturbations were more destabilising than the CP perturbations (leading to a more rapid rise in perturbatory ankle-torque and greater centre-of-mass motion prior to the onset of the postural reaction), and were consequently more effective in revealing age-related deficiencies.

Although considerable arm movements have been observed at loss of balance, research on standing balance focused primarily on the ankle and hip strategies. This study aimed to investigate the effect of arm motion on feet-in-place balance recovery. Participants stood on a single force plate and leaned forward with a straight body posture. They were then released from three forward-lean angles and regained balance without moving their forefeet under arm-swing (AS) and arm-constrained (AC) conditions. Higher success rates and shorter recovery times were found with arm motion under moderate balance perturbations. Recovery time was significantly correlated with peak linear momentum of the arms. Circumduction arm motion caused initial shoulder extension (backward arm movement) to generate reaction forces to pull the body forward, but later forward linear momentum of the arms helped move the whole body backward to avoid forward falling. However, greater lean angles increased difficulty in balance recovery, making the influences of the arms less significant. Since arm motions were observed in all participants with significantly enhanced performance under moderate balance perturbation, it was concluded that moving the arms should also be considered (together with the ankles and hips) as an effective strategy for balance recovery.

Human posture control is a sophisticated process involving the relationship among multiple joints, muscle groups and environment. The aim of this study is to show how the balance perturbation (in posterior-anterior direction) leads to a stretching reflexion on the tibialis anterior (TA) muscle. A case study that involved a male participant with 23 years old. To disturb the participant's balance, it has been employed a specially plataform designed with dimensions 1.5 m by 1.5 m with movement of 5 mm of amplitude on a total time of 3 ms along the axis coinciding with participant's anterior-posterior axis. Soleus (SO) and TA electromyography signal (EMG) has been recorded. Perturbation in the equilibrium was delivered in the posterior-anterior direction. The first event observed was the pre-activation of the TA muscle that leads a reduction in the SO muscle activation, due the stretch reflex at TA.

In order to prevent fall related injuries and their consequences, one needs to be able to predict the outcome of a given balance perturbation: a possible Balance Recovery (BR) or an unavoidable fall? Given that results from the existing experimental studies are difficult to compare and to generalize, we propose to address this question with a numerical tool. Built on existing concepts from the biomechanics and robotics literature, it includes the optimal use of BR reactions and particularly the possibility to perform a recovery step. It allows estimating 1) the possibility to recover a steady balance from a given initial state or perturbation using at most one recovery step; 2) the set of recovery steps leading to a BR. Using standard sets of parameters for young and elderly population, we assessed this modelós predictions against experimental data from the literature in the anterior direction. Two classical representations of the human body (inverted pendulum (IP) vs. linear inverted pendulum (LIP)) were also compared. The results showed that the model correctly predicted the possibility to recover using a single protective step (1-Step BR threshold) and the characteristics (step length and time) of the protective step for both the young and the elderly. This tool has a real potential in the field of fall prevention to detect risky situation. It could also be used to get insights into the neuromuscular mechanisms involved in the BR process.

This study analyzes how multiple sclerosis (MS) does affect one of the most common voluntary activities in life: the gait initiation (GI). The main aim of the work is to characterize the execution of this task by measuring and comparing relevant parameters based on center of pressure (COP) patterns and to study the relationship between these and the level of expanded disability status scale (EDSS). To this aim, 95 MS subjects with an average EDSS score of 2.4 and 35 healthy subjects were tested using a force platform during the transition from standing posture to gait. COP time-series were acquired and processed to extract a number of parameters related to the trajectory followed by the COP. The statistical analysis revealed that only a few measurements were statistically different between the two groups and only these were subsequently correlated with EDSS score. The correlation analysis underlined that a progressive alteration of the task execution can be directly related with the increase of EDSS score. These finding suggest that most of the impairment found in people with MS comes from the first part of the COP pattern, the anticipatory postural adjustments (APAs). The central nervous system performs APAs before every voluntary movement to minimize balance perturbation due to the movement itself. Gait Initiation's APAs consist in some ankle muscles contractions that induce a backward COP shift to the swing limb. The analysis here performed highlighted that MS affected patients have a reduced posterior COP shift that reveals that the anticipatory mechanism is impaired.

An effective stepping response is often critical in avoiding a fall. Our objective was to study the effects of age and balance impairment on anterior and posterior compensatory stepping strategies in response to waist pull perturbations of 1-5% body weight (BW). Based on maximal unipedal stance time (UST), we tested 15 balance-impaired old (BI, UST10s, mean age = 76 years), 12 healthy old (O, UST30s, mean age = 71 years), and 13 healthy young women (Y, UST30s, mean age=23 years). Randomized anterior and posterior pulls of 1-5% body weight (BW) were applied to the waist while kinematic and kinetic recovery responses were recorded. Results show that O and BI required 0.5 more steps than Y to recover balance for posterior pulls of 4-5% BW (P0.01). For anterior pulls of 4-5% BW, only BI had a greater probability of step initiation (Por=0.05 or0.02) and mean number of steps required to recover balance (P0.03). The Y used 93% greater torso extension and 24% greater torso flexion in responding to anterior and posterior pulls, respectively. In the posterior, but not anterior direction, O employed smaller (P0.007), but more laterally-directed (P0.03) steps than the Y. The BI were less able to attenuate their momentum during the step landing in both directions. We conclude that the additional steps required by the BI in both directions occurred because their initial step failed to properly arrest their momentum. Controlling torso inclination before step liftoff and linear momentum after step landing are critical components of successful compensatory stepping.

The present study reports findings from two experiments on the relation between a mental task (silent backward counting) and posture. The first experiment included 30 normal subjects and the second experiment 20 normal subjects. In Experiment 1 postural sway and performance of the mental task were measured in a 2 x 2 dual-task design (with or without mental task and calf stimulation). In Experiment 2 a similar design was used, the only difference being that during trials without the mental task, subjects were instructed to focus on their balance and provide a rating of body sway. Results showed that balance perturbation led to decreased performance on the cognitive task in Experiment 1, but not in Experiment 2. The mental task led to less body sway, while focused attention attenuated the effect. In conclusion, control of body sway and cognitive functioning are to some extent related.

Despite repeated demonstration of how balance can be restored with protective stepping after the initiation of an induced fall, little is known about how accidental falling to the ground with the participant's body resting in a non-standing posture can be avoided during balance recovery. This is due to the difficulties inherent in experimentally eliciting such an event. The purpose of this study was, therefore, to determine failure rate and the characterization for balance recovery after young adults exposed to an experimentally induced novel slipping perturbation. Twenty-four healthy young adults first performed three to nine trials of regular sit-to-stand. In the following trial, slipping suddenly occurred during the termination of the sit-to-stand when the low-friction platform on which the participant stood was released. Participants were given no prior practice or knowledge of the experiment design. Slipping was then repeated in the subsequent trials. The results demonstrated for the first time that a high percentage (62%) of participants failed to recover standing balance, despite the fact that 14 of these 15 participants had initiated stepping at their first encounter of a sudden slip. Such failure was avoided immediately after the first encounter. It was postulated that a delay in the step initiation might have contributed to substantial vertical descent of the center-of-mass, leading to failure of balance recovery in limb collapse. To verify this and other hypotheses, a shift in experimental paradigms is warranted to include the study of spontaneous protective responses elicited when individuals first encounter previously unfamiliar balance perturbation as in real-life situations.

Rapid reach-to-grasp reactions are a prevalent response to sudden loss of balance and play an important role in preventing falls. A previous study indicated that young adults are able to guide functionally effective grasping reactions using visuospatial information (VSI) stored in working memory. The present study addressed whether healthy older adults are also able to use "stored" VSI in this manner or are more dependent on "online" visual control.Liquid-crystal goggles were used to force reliance on either stored or online VSI while reaching to grasp a small handhold in response to unpredictable platform perturbations. A motor-driven device varied the handhold location unpredictably for each trial. Twelve healthy older adults (65-79 years) were compared with 12 young adults (19-29 years) tested in a previous study.Reach-to-grasp reactions were slower and more variable in older adults, regardless of the nature of the available VSI. When forced to rely on stored VSI, both age groups showed a reduction in reach accuracy; however, a tendency to undershoot the handhold was exacerbated in the older adults. Forced reliance on online VSI led to similar delays in both age groups; however, the older adults were more likely to reach with the "wrong" limb (contralateral to the handhold) and/or raise both arms initially (possibly to "buy" more time for final limb selection).Situations that force the central nervous system to rely on either stored or online VSI tend to exacerbate age-related reductions in speed and accuracy of reach-to-grasp balance-recovery reactions. Further work is needed to determine if this increases risk of falling in daily life.

Anticipatory postural adjustments (APAs) prior to step execution are thought to be immutable once released. Here we challenge this assumption by testing whether APAs can be modified online if a body perturbation occurs during execution. Two directions of perturbation (resisting and assisting) relative to the body weight transfer were used during the execution of APAs. We found that APAs are modified online (increase in both ground pressure and muscle activity) to compensate for resisting perturbations. The outcomes of a biomechanical model confirmed that the early changes in the APAs resulted from an active control of the APAs and were not merely mechanical consequences of the perturbation. However, no modification of the initial feedforward command was observed for assisting perturbations. The motor command changes for the resisting perturbation may originate from the mismatch between passively originated forces and those actively specified by the central command when acting in the opposite direction. The absence of a mismatch in the assisting perturbation might explain why the central nervous system was not prompted to modify the APAs in this condition.

Novel compliant floors aim to decrease the risk for fall-related injury by providing substantial force attenuation during the impact phase of falls. Certain models of compliant flooring have been shown to have limited influence on postural sway and successful completion of dynamic balance tasks. However, the effects of these products on balance recovery mechanisms following an externally induced perturbation have yet to be quantified. We used a floor translation paradigm to induce a balance perturbation to thirteen elderly community-dwelling women. Outcome measures included the displacement rates and margins of safety for both the underfoot centre-of-pressure and whole-body centre-of-mass across two novel compliant floors (SmartCell, SofTile), two basic foam surfaces (Firm-Foam, Soft-Foam) and a standard 'Rigid' floor as a control condition. The centre-of-mass and centre-of-pressure margins of safety, and all centre-of-mass displacement rates, were not significantly lower for the two novel compliant flooring systems compared to the control floor. The centre-of-pressure displacement rates were similar to the control floor for the SmartCell floor condition. The majority of the margin of safety and displacement rate variables for the foam floors were significantly lower than the control condition. This study illustrates that the SmartCell and SofTile novel compliant floors have minimal influences on balance and balance control responses following externally induced perturbations in older community-dwelling women, and supports pilot installations of these floors to inform decisions regarding the development of clinical trials.

Ageing commonly disrupts the balance control and compensatory postural responses that contribute to maintaining balance and preventing falls during perturbation of posture. This can lead to increased risk of falling in old adults (65 years old and over). Therefore, improving compensatory postural responses during walking is one of the goals in fall prevention programs. Training is often used to achieve this goal. Most fall prevention programs are usually directed towards improving voluntary postural control. Since compensatory postural responses triggered by a slip or a trip are not under direct volitional control these exercises are less expected to improve compensatory postural responses due to lack of training specificity. Thus, there is a need to investigate the use balance perturbations during walking to train more effectively compensatory postural reactions during walking. This paper describes the Balance Measure & Perturbation System (BaMPer System) a system that provides small, controlled and unpredictable perturbations during treadmill walking providing valuable perturbation, which allows training compensatory postural responses during walking which thus hypothesize to improve compensatory postural responses in older adults.

Older adults often exhibit increased co-contraction in response to a balance perturbation. This response is generally thought to enhance stability by increasing joint stiffness. We investigated the issue of increased stiffness in postural control by exposing seven older (75 +/- 5 y) and ten young (24 +/- 3 y) adults to pseudo-random medial-lateral (ML) floor tilts, and then fitting the measured ML body sway data to a previously-developed postural control model that includes stiffness and damping parameters. Significant increases were found in both parameters in the older adults compared to the young adults. This concurrent increase in stiffness and damping is more stabilizing than an increase in stiffness alone, which can lead to resonances.

Stabilising shifts of the centre of mass (COM) are observed during balance recovery when subjects simultaneously execute voluntary unilateral knee flexion or unilateral arm raising. Here, we examined whether voluntary lateral trunk bending provided more beneficial stabilising effects, and how motor programs of balance corrections are combined with those of the focal voluntary action. The upright balance of 24 healthy young subjects (19-33 years of age) was perturbed using multi-directional rotations of the support-surface. The perturbations consisted of combined pitch and roll rotations (7.5 degrees and 60 degrees/s) presented randomly in six different directions. Three conditions were tested: perturbation of stance only (PO); combined balance perturbation and cued uphill bending of the trunk (CONT); and combined perturbation and cued downhill bending of the trunk (IPS). For comparison, subjects were required to perform trunk bending alone (TO). Outcome measures were biomechanical responses and surface EMG activity of several muscles. Calculated predicted outcomes (PO + TO) were compared with combined measures (CONT or IPS). CONT trunk bending uphill showed two phases of benefit in balance recovery for laterally but, in contrast to voluntary knee bending, not for posterior directed components of the perturbations. IPS trunk bending had negative effects on balance. Early balance correcting muscle responses were marginally greater than PO responses. Prominent secondary balance correcting responses, having a similar timing as voluntary responses observed under TO conditions, were seen under CONT only in trunk muscles. These, and later stabilising, responses had amplitudes as expected from PO + TO conditions being significantly greater than PO responses. The ability with which different muscle synergies for balance corrections and voluntary trunk bending were integrated into one indicates a flexible adjustment of the CNS programs to the demands of both tasks.

The aim of the study was to examine how individuals of different ages react to forward balance perturbations. Thirty-six volunteers, divided into four groups [young (YA), middle-age (MA 40 and MA 50 ), and old (OA) adults], stood on a platform that was either kept stationary, moved backward, or moved forward. EMG onset, EMG time-to-peak, iEMG, and agonist–antagonist co-activation, as well as cumulative angular excursion, maximum center of mass (CM) backward displacement, and CM time-to-reversal were assessed after forward translations. Postural synergies were assessed using principal component analysis (PCA). The results showed that OA activated their muscles later than YA [TA=25ms, RF=17ms] and OA and MA 50 reached the peak of activation later than YA [MA 50 :TA=23ms, RF=32ms, OA:TA=28ms, RF=21ms]. Moreover, OA kept a higher level of activation longer than all younger groups. No differences among groups were observed in co-activation, kinematic, and PCA variables. We conclude that changes in temporal EMG patterns can be seen in the fifth decade. However, such changes have no effect on the CM horizontal displacement and CM time-to-reversal after perturbation, which cannot be justified by the use of different postural synergies, suggesting that temporal aspects of muscle activation could play a minor role in controlling excessive CM displacements after perturbations.

Rapid step reactions evoked by balance perturbation must accommodate constraints on limb motion imposed by obstacles and other environmental features. Recent results suggest that the required visuospatial information (VSI) is acquired and stored “proactively”, prior to perturbation onset (PO); however, the extent to which “online” (post-PO) visual feedback can contribute is not known. To study this, we used large unpredictable platform perturbations to evoke rapid step reactions, while subjects wore liquid crystal goggles that occluded vision: (1) prior to PO (forcing use of online-VSI ), (2) after PO (forcing use of stored-VSI ), or (3) not at all ( normal-VSI ). Subjects stood behind a barrier in which the location of a narrow slot, through which the foot had to be moved during forward step reactions, was varied unpredictably between trials. Within subjects who were able to do the task (6 of 8 young adults tested), responses in stored-VSI and normal-VSI trials were very similar. However, in online-VSI trials, the foot-off time for the step through the slot was delayed (by ∼50 ms, on average). Presumably, this delay allowed more time to acquire and process online-VSI regarding the required foot trajectory, yet subjects were still more likely to select the “wrong” foot (contralateral to the slot location) and to contact the barrier while moving the foot through the slot, in online-VSI trials. These results suggest a critical role for stored-VSI during the earliest phase of the step, in selecting the step limb and planning the initial trajectory. Online acquisition and processing of the required VSI may be too slow to allow effective control of this early phase, particularly in situations where the demands for accurate foot motion are high.