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Purpose: Poor sitting balance is common after stroke and makes leaning and reaching while sitting difficult and dangerous. Virtual reality training (VRT) uses computer hardware and software to track a person's movements and allow him or her to interact with a virtual environment. VRT games are available to train sitting balance after stroke; however, it is unknown how challenging they are. The objectives of this study were to characterize the centre of pressure displacements generated during the performance of VRT in stroke patients (ST) and compare their performance to that of young (YA) and older adults (OA). Materials and Methods: Eight ST participants who could stand for at least four minutes were recruited from an inpatient stroke rehabilitation unit for this cross-sectional, observational pilot study. Eight YA and eight OA were recruited from the community. Participants sat on a pressure mat and played 17 VRT game/difficulty combinations. The area, range and average velocity of centre of pressure displacement were determined for each game/difficulty. Results: Virtually manoeuvring a motorcycle around barriers and leaning to move a ball down a maze produced the greatest displacement of the centre of pressure, particularly in the mediolateral direction. OA moved further and faster in the mediolateral direction than YA. ST's performance was more variable. Conclusions: Some VRT games were more likely to push participants to challenge their limits of stability. Others required less displacement but more trunk stability. These results can guide which VRT games are used for the rehabilitation of sitting balance after stroke.Implications for rehabilitationSome virtual reality training games produce greater displacements of the centre of pressure in sitting than others, suggesting that careful matching between game challenge and desired therapeutic outcome is necessary when selecting games.Virtual reality training performed in sitting with feet on the floor challenges sitting balance in the frontal plane more so than in the sagittal plane.Older adults tend to lean more than younger adults while individuals with stroke move more or less than others, depending on the game.

Background: Virtual reality training (VRT) is engaging and may enhance rehabilitation intensity. Only one previous study has looked at its use to improve sitting balance after stroke., Objective: To determine if supplemental sitting balance exercises, administered via VRT, improve control of sitting balance and upper extremity function in stroke rehabilitation inpatients., Design: Assessor-blinded, placebo-controlled randomized controlled trial., Setting: Stroke inpatient rehabilitation unit., Participants: Seventy-six participants (out of 130 approached) with subacute stroke who could not stand independently were randomized to experimental and control groups. Sixty-nine completed the study., Interventions: The experimental group did VRT that required leaning and reaching, whereas the control group had their trunk restrained and performed VRT that involved only small upper extremity movements to minimize trunk movement. Both groups performed 10-12 sessions of 30-45 minutes. Participants were assessed pre, post, and 1 month after the sessions by a blinded examiner., Outcome Measures: Function in Sitting Test (FIST, primary outcome measure); Ottawa Sitting Scale; Reaching Performance Scale; Wolf Motor Function Test (WMFT)., Results: Thirty-three participants completed the experimental intervention and 36 the control. Pre/post differences for FIST were 3.4 (confidence interval [CI] 0.5;6.3) for the experimental group and 5.3 (2.9;7.7) for the control group. There was a significant improvement over time (adjusted for multiple comparisons, P < .006) on most outcome measures except the WMFT Performance Time Scale (control group; P = .007) and grip strength (P = .008); there were no differences between groups (P > .006)., Conclusions: Siting balance outcomes were similar for both groups; therefore, this study does not support the use of sitting balance exercises provided via VRT for the rehabilitation of sitting balance after stroke. However, because it is only the second study to investigate VRT for sitting balance and upper extremity function, more research, using more challenging exercises and a greater treatment intensity, is required before definitive conclusions are made., (© 2020 American Academy of Physical Medicine and Rehabilitation.)

Background: The individual effects of fatigue and age on postural control have been extensively studied. However, there is a lack of knowledge about the combined effects of fatigue and age on postural control and posture., Research Question: The purpose of this study was to investigate the influence of age and muscle fatigue on bipedal stance postural control and posture., Methods: Twenty-three participants, fourteen young adults and nine older adults performed 30-s bipedal postural trials before and after fatigue. The fatigue protocol consisted in repeating heel raises until exhaustion. Back, hip, knee and ankle joint angles and centre of pressure (COP) displacements were recorded with a 3D motion capture system and a force plate., Results: Fatigue induced similar increases in sway area and COP velocity for both populations. This was associated with a forward displacement of the COP position for both populations but with different postural adaptations. Similar increased flexions (+1.7 to 1.8°) for all joint angles (ankle, knee, hip and back) joints were observed after fatigue for older adults, whereas young adults mainly showed increased flexion for the ankle joint (+3.1°) and decreased flexion at the hip (-1.2°)., Significance: It can be argued that older adults act on all joints because they are too weak to sufficiently modify any joint individually, contrary to young adults. These posture adaptations may be strategies to cope with fatigue by limiting the reliance on fatigued plantarflexors, increasing ankle stiffness, increasing the sensitivity of muscle spindles, increasing the number of degrees of freedom of the task., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The purpose of this investigation was to evaluate the effect of the removal of vision and/or surface compliance on postural stability in strength athletes who habitually use free-weights and compound movements in their training (i.e., powerlifters, Olympic weightlifters), and untrained individuals. Static and dynamic balance testing was performed with eyes open or closed on stable and memory foam surfaces. Both groups had similar increases in postural sway area and velocity during quiet standing testing; whereas group main effects and interactions for dynamic testing revealed that untrained participants experienced greater relative declines in postural performance when voluntary limits of stability are stressed, especially when both vision and surface compliance were deterred. These results demonstrate that in comparison to untrained young adults, postural control variables may be reduced to a lesser extent in strength athletes when sensory constraints are altered; however this appears to be specific to the type of postural task performed.

Postural control is not a fully automatic process, but requires a certain level of attention, particularly as the difficulty of the postural task increases. This study aimed at testing whether experienced contemporary dancers, because of their specialized training involving the control of posture/balance, would present with a dual-task performance suggesting lesser attentional demands associated with dynamic postural control compared with non-dancers. Twenty dancers and 16 non-dancers performed a dynamic postural tracking task in both antero-posterior and side-to-side directions, while standing on a force platform. The postural task was performed, in turn, 1) as a stand-alone task, and concurrently with both 2) a simple reaction time task and 3) a choice reaction time task. Postural control performance was estimated through variables calculated from centre of pressure movements. Although no overall group difference was found in reaction time values, we found a better ability to control the side to side movements of the centre of pressure during the tracking task in dancers compared with non-dancers, which was dependent on the secondary task. This suggests that such increased ability is influenced by available attentional resources.

Previous research has indicated that muscle fatigue due to repeated bouts of physical activity can have negative residual effects on balance; however investigations using multi-joint forms of exercise involved in everyday settings and determination of how control of posture is altered during the physical activity itself are limited. The purpose of this investigation was to evaluate alterations in postural stability before, during, and after prolonged multi-joint STS exercise in healthy young adults. Center of pressure (COP) acquisitions were collected during repetitive STS exercise, while voluntary limits of stability (LOS) testing was performed before, immediately after, and 10min after STS exercise. By 50% total STS exercise time, fatigue resulted in increased anterio-posterior (y) and medio-lateral (x) COP path lengths (p=0.003 and p=0.018 respectively) and an anterior shift of COP at seat-off towards the mid-foot (p=0.010). No significant change in LOS mean amplitude was found after STS exercise; however a significant fatigue effect resulted in increased COPy sway velocity at maximal lean positions (p=0.006), but returned to PRE values after 10min of rest. Declines in postural stability during repetitive STS exercise was associated with reduced control of COP, as well as a reduced ability to stably control COP at extreme postural limits; however, 10min was adequate in young adults for recovery. These results may have important implications for monitoring fall risk due to acute bouts of exercise induced muscle fatigue from repetitive multi-joint activities such as the STS., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Sitting ability and function are commonly impaired after stroke. Balance training has been shown to be helpful, but abundant repetitions are required for optimal recovery and patients must be motivated to perform rehabilitation exercises repeatedly to maximize treatment intensity. Virtual reality training (VRT), which allows patients to interact with a virtual environment using computer software and hardware, is enjoyable and may encourage greater repetition of therapeutic exercises. However, the potential for VRT to promote sitting balance has not yet been explored. The objective of this study is to determine if supplemental VRT-based sitting balance exercises improve sitting balance ability and function in stroke rehabilitation inpatients., Methods/design: This is a single-site, single-blind, parallel-group randomized control trial. Seventy six stroke rehabilitation inpatients who cannot stand independently for greater than one minute but can sit for at least 20 minutes (including at least one minute without support) are being recruited from a tertiary-care dedicated stroke rehabilitation unit. Participants are randomly allocated to experimental or control groups. Both participate in 10-12 sessions of 30-45 minutes of VRT performed in sitting administered by a single physiotherapist, in addition to their traditional therapy. The experimental group plays five games which challenge sitting balance while the control group plays five games which minimize trunk lean. Outcome measures of sitting balance ability (Function in Sitting Test, Ottawa Sitting Scale, quantitative measures of postural sway) and function (Reaching Performance Scale, Wolf Motor Function Test, quantitative measures of the limits of stability) are administered prior to, immediately following, and one month following the intervention by a second physiotherapist blind to the participant's group allocation., Discussion: The treatment of sitting balance post-stroke with VRT has not yet been explored. Results from the current study will provide important evidence for the use of low-cost, accessible VRT as an adjunct intervention to increase sitting balance in lower-functioning patients receiving inpatient rehabilitation. The motivating and enjoyable attributes of VRT may increase exercise dosage, leading to improved function and optimal results from rehabilitation., Trial Registration: https://clinicaltrials.gov/; Identifier: NCT02285933. Registered 06 November 2014. Funded by the Heart & Stroke Foundation of Canada and a generous donation from Tony & Elizabeth Graham.

Background and Purpose: Exercise using virtual reality (VR) has improved balance in adults with traumatic brain injury and community-dwelling older adults. Rigorous randomized studies regarding its efficacy, safety, and applicability with individuals after stroke are lacking. The purpose of this study was to determine whether an adjunct VR therapy improves balance, mobility, and gait in stroke rehabilitation inpatients., Methods: A blinded randomized controlled trial studying 59 stroke survivors on an inpatient stroke rehabilitation unit was performed. The treatment group (n=30) received standard stroke rehabilitation therapy plus a program of VR exercises that challenged balance (eg, soccer goaltending, snowboarding) performed while standing. The control group (n=29) received standard stroke rehabilitation therapy plus exposure to identical VR environments but whose games did not challenge balance (performed in sitting). VR training consisted of 10 to 12 thirty-minute daily sessions for a 3-week period. Objective outcome measures of balance and mobility were assessed before, immediately after, and 1 month after training., Results: Confidence intervals and effect sizes favored the treatment group on the Timed Up and Go and the Two-Minute Walk Test, with both groups meeting minimal clinical important differences after training. More individuals in the treatment group than in the control group showed reduced impairment in the lower extremity as measured by the Chedoke McMaster Leg domain (P=0.04) immediately after training., Conclusions: This VR exercise intervention for inpatient stroke rehabilitation improved mobility-related outcomes. Future studies could include nonambulatory participants as well as the implementation strategies for the clinical use of VR., Clinical Trial Registration Url: http://www.ANZCTR.org.au/. Unique identifier: ACTRN12613000710729., (© 2014 American Heart Association, Inc.)

The reduction in the quality and integration of sensory information with aging could increase the alterations in postural control associated with muscle fatigue observed in younger adults. This study aimed to compare changes in postural control and attentional demands due to ankle muscle fatigue, with intact and reduced proprioceptive information at the ankle, between young and older adults. Eleven young (24 ± 4 years) and 13 older (65 ± 4 years) men stood quietly on a force platform (blindfolded) under four experimental conditions (combinations of firm (FS)/compliant (CS) surfaces and single/dual tasks), before and immediately after a fatiguing exercise. The fatiguing exercise, performed on a dynamometer, consisted of maintaining an isometric contraction of the plantarflexors at 50 % of maximum until exhaustion. Both COP sway area and COP sway velocity were greater on the CS compared to FS and increased with fatigue for both groups in all conditions. COP sway area showed a greater increase with fatigue in older adults when standing on the CS. Reaction time (secondary task) increased significantly after fatigue, but only for older adults when standing on the CS. The effects of fatigue on postural control are more important when proprioceptive information at the ankle is altered. In particular, older adults had more difficulty and may have needed more attention to stand quietly, compared with young adults.

The dual-task paradigm has previously been used to investigate the attentional demands associated with postural control. Previous studies have identified both the focus of attention and the difficulty of a postural task as potential factors influencing dual-task performance. The aim of this study was to examine how the instructed focus of attention influences dual-task performance during quiet standing tasks of various levels of difficulty. Thirteen young adults participated in two testing sessions consisting of standing as still as possible on a force platform in different postural conditions, while simultaneously performing a simple reaction time (RT) task. Postural task difficulty was manipulated by various combinations of three bases of support (feet together, tandem and single leg) and two visual conditions (eyes opened and closed). Participants were instructed to focus on either their balance or their RT performance, depending on the testing session. When comparing postural control with respect to session focus, anterior-posterior sway velocity decreased with the addition of the simple RT task when the focus was on balance, but only during the more difficult dual-task conditions. In contrast, sway area and medial-lateral sway velocity did not change between the two instructed focus sessions. Participants responded faster in all dual-task conditions when focusing on RT performance than on balance. The modified attention allocation index indicated that participants' ability to modulate their allocation of attentional resources to respond positively to instruction was more pronounced in the most challenging postural condition. The present findings could have important implications for the interpretation of dual-task performance in both clinical and research settings.

Muscle fatigue can influence the various mechanisms that regulate balance. Few studies have investigated the effects of trunk extensor muscle fatigue on postural control. The purpose of this study was to evaluate the impact of trunk extensor fatigue during a one-leg balance test in young and elderly adults, as well as to determine the time necessary to recover posture control after fatigue. A total of 36 subjects (18 elderly and 18 young adults) participated in the study. Subjects were tested on a force platform to assess the postural control parameters associated with center of pressure (COP) movements, before and after a fatiguing trunk extension-flexion exercise on a roman chair carried out to exhaustion. Post-fatigue effects and postural control recovery were investigated at different times in minutes (MIN): immediately post-fatigue (postIME), after 5 (rec5MIN), 10 (rec10MIN), and 20 min (rec20MIN). Elderly subjects had greater sway (P < 0.05) than young adults in all COP parameters. In both groups, there was an increase in postIME sway compared with pre-fatigue values for all COP parameters. However, the differences were significant only for the COP velocity parameter, with more pronounced effects in young adults that did not return to pre-fatigue values at the end of rec20MIN. The present study demonstrated a significant effect of trunk extensor muscle fatigue on postural control, which was more evident in young adults than in the elderly.

The aim of the present study was to investigate changes in joint angles and limb positions accompanying postural control impairments induced by fatigue of the ankle plantarflexor muscles and vision removal. Thirteen subjects performed unipedal standing tasks with and without vision before and after isometric fatigue of the plantarflexor muscles. Results indicated that to compensate for the negative effects of fatigue and vision removal on postural control, participants increased flexion at the ankle, knee and back while the free lower limb and the pelvis moved backward and the upper limbs forward. These strategies could be performed to increase the role of non-fatigued muscles and optimize the use of all the joints implicated in unipedal standing., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Poor posture control has been associated with an increased risk of falls and mobility disability among older adults. This study was conducted to assess the test-retest reliability and sensitivity to group differences regarding the time-limit (TLimit) of one-leg standing and selected balance parameters obtained with a force platform in older and young adults. A secondary purpose was to assess the relationship between TLimit and these balance parameters. Twenty-eight healthy older adults (age: 69±5years) and thirty young adults (age: 21±4years) participated in this study. Two one-leg stance tasks were performed: (1) three trials of 30s maximum and (2) one TLimit trial. The following balance parameters were computed: center of pressure area, RMS sway amplitude, and mean velocity and mean frequency in both the anterio-posterior and medio-lateral directions. All balance parameters obtained with the force platform as well as the TLimit variable were sensitive to differences in balance performance between older and young adults. The test-retest reliability of these measures was found to be acceptable (ICC: 0.40-0.85), with better ICC scores observed for mean velocity and mean frequency in the older group. Pearson correlations coefficients (r) between balance parameters and TLimit ranged from -0.16 to -0.54. These results add to the current literature that can be used in the development of measurement tools for evaluating balance in older and young adults., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The purpose of this study was to investigate the changes in postural control and in posture induced by ankle plantarflexor fatigue during a unipedal stance task. We also studied the postural strategies in the antero-posterior and medio-lateral planes used by participants to maintain balance. Thirteen young adults were asked to stand barefoot on their preferred leg as still as possible for 30s with vision or without vision. Participants performed postural trials before and after a fatigue protocol that consisted of standing on toes until exhaustion. Centre of pressure (COP) displacements were measured with a force platform and electrogoniometers were placed at the ankle, knee and hip joints of the support leg to monitor articular angles. Relationships between changes in articular angles and displacements of the COP in the antero-posterior and medio-lateral planes were tested using cross-correlations. Sway area and velocity increased with fatigue, but only without vision. A posterior shift of the mean COP position was also observed after fatigue. Ankle and hip joints were more flexed after fatigue. Moderate to good relationships between COP displacements and ankle angles were observed before and after fatigue in both planes whereas these relationships were low for hip and knee joints. Ankle plantarflexors fatigue induced impairment in postural control and changes in posture. To compensate for the effects of fatigue, participants increased the flexion of the ankle and/or the hip joints but conserved the ankle strategy as the dominant postural strategy in both planes., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Fatiguing exercises used across studies to induce alterations in postural control are diverse and may explain the different findings reported. This study aimed to compare the effects of two types of fatiguing plantarflexion exercises on postural control on a firm and a compliant surface. Ten healthy young men (29 ± 4 years) were asked to stand as steadily as possible for 30 s, blindfolded with feet together, on a firm and a compliant surface before and immediately after an isometric and an isokinetic fatiguing exercise., Results: Maximal force reduction due to fatigue was found significant but similar between exercises. No significant difference was found between the fatiguing exercises on all Center of Pressure (CoP) parameters. Both fatiguing exercises induced increases in CoP excursion area, CoP variability and CoP velocity in both planes (antero-posterior, mediolateral) on the compliant surface. On the firm surface, both fatiguing exercises only induced increases in CoP variability and CoP velocity in the fatigued plane (antero-posterior)., Conclusions: Isometric and isokinetic fatiguing exercises, when producing a similar level of force reduction, induce similar decreases in postural control. The effects of fatigue on postural control in healthy young men are more pronounced when standing on a compliant surface, i.e. when proprioceptive information at the ankle is altered.

The authors aimed to assess the effect of vision on variations in attentional resources allocated to postural control during tasks of various levels of difficulty. Test-retest reliability of postural and cognitive parameters was also evaluated. Twenty adults stood quietly on a force platform during 30-s trials (primary task). Twelve conditions involving combinations of three bases of support, two vision conditions, and the presence or absence of a simple reaction time task (secondary task) were tested. Baseline trials of the reaction time task were also performed with the participants seated. Reaction time and postural parameters demonstrated good to excellent test-retest reliability in most conditions. Postural control was altered by the reduction of the base of support and by the absence of vision. Maintaining an upright stance increased reaction time compared with a seated position, indicating that quiet standing tasks required some attention even in young adults. Changes in postural steadiness were correlated with changes in reaction time, showing a significant relationship between the difficulty of the postural task and the attentional resources allocated to postural control. However, reaction time increased with the reduction of the base of support only without vision. This dual task paradigm showed that vision can compensate for the increase in attentional demands during the most difficult postural tasks.

The aim of the present study was to compare the effects of ankle muscle fatigue on postural control when plantarflexors (PFs) and dorsiflexors (DFs) are fatigued simultaneously compared with separately. This study also investigated the recovery of postural control after fatigue. Sixteen adults (eight women and eight men) performed postural trials before and after an isokinetic fatigue task involving either (i) only PFs (30°s(-1)), (ii) only DFs (120°s(-1)), or (iii) both PFs and DFs simultaneously. The fatigue task involved maximal contractions repeated until the torque produced decreased below 50% of the maximal torque. Postural trials lasted 30s and were performed on one leg with eyes open (EO) or eyes closed (EC). Sway area, medio-lateral (ML) and antero-posterior (AP) positions and velocities were calculated from the center of pressure displacements. With EO, no effect of fatigue was found on postural variables. With EC, sway area and AP velocity increased only when both PFs and DFs were fatigued simultaneously. An effect of fatigue present only when both muscle groups are fatigued simultaneously could be due to impairment in the compensatory activity between agonist and antagonist muscles and/or a greater decrease in proprioception due to a greater number of fatigued muscles. In addition, when PFs and DFs were fatigued simultaneously, sway area and AP velocity returned to pre-fatigue values within 2min, whereas a posterior shift in AP position persisted for 10min. This last result may suggest a longer-lasting change in postural strategy needed for optimal postural control., (Copyright © 2011 Elsevier B.V. All rights reserved.)

The effect of muscle fatigue on quiet standing is equivocal, including its duration/recovery and whether it leads to an increase in attentional demands. The purpose of this study was to assess the effects of ankle and hip muscle fatigue on postural sway and simple reaction time during a unipedal task. Two groups of 14 young adults (mean age=22.50±3.23) had to stand on their dominant leg for 30-s trials before and after fatigue of hip or ankle flexors and extensors. Half of the unipedal trials were performed in a dual-task condition where subjects, in addition to standing, had to respond verbally to an auditory stimulus. Sway area, and sway variability and velocity in the AP and ML planes were calculated using center of pressure data obtained from a force platform. Voice reaction time was recorded seated and during the dual-task condition to assess attentional demands. A main effect of fatigue was found for AP sway variability (p=0.027), AP sway velocity (p=0.017) and ML sway velocity (p=0.004). Both groups showed increased sway velocity in both directions and in reaction time during the dual-task condition (p<0.001), but reaction time did not increase with fatigue. A group by fatigue interaction was found significant for ML sway velocity (p=0.043). Results suggest that hip and ankle fatigue affected postural control in the fatigued plane (AP) but only hip fatigue affected postural control in the non-fatigued plane (ML sway velocity). However, fatigue did not lead to an increase in attentional demands and increased AP and ML sway velocity had recovered within 30min., (Copyright © 2010 Elsevier B.V. All rights reserved.)