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Background As we age, avoiding falls becomes increasingly challenging. While balance training can mitigate such challenges, the specific mechanisms through which balance control improves remains unclear. Methods We investigated the impact of balance training in older adults on feedback control after perturbations, focusing on kinematic balance recovery strategies and muscle synergy activation. Twenty older adults aged over 65 underwent short-term (one session) and long-term (3-weeks, 10 sessions) balance training, and their recovery from unpredictable mediolateral perturbations was assessed. Perturbations consisted of 8° rotations of a robot-controlled platform on which participants were balancing on one leg. We measured full-body 3D kinematics and activation of 15 leg and trunk muscles, from which linear and rotational kinematic balance recovery responses and muscle synergies were obtained. Results Our findings revealed improved balance performance after long-term training, characterized by reduced centre of mass acceleration and (rate of change of) angular momentum. Particularly during the later stage of balance recovery the use of angular momentum to correct centre of mass displacement was reduced after training, decreasing the overshoot in body orientation. Instead, more ankle torque was used to correct centre of mass displacement, but only for perturbations in medial direction. These situation and strategy specific changes indicate adaptations in feedback control. Activation of muscle synergies during balance recovery was also affected by training, specifically the synergies responsible for leg stiffness and ankle torques. Training effects on angular momentum and the leg stiffness synergy were already evident after short-term training. Conclusion We conclude that balance training in older adults refines feedback control through the tuning of control strategies, ultimately enhancing the ability to recover balance.

Abstract Transtibial prosthetic users do often struggle to achieve an optimal prosthetic fit, leading to residual limb pain and stump-socket instability. Prosthetists face challenges in objectively assessing the impact of prosthetic adjustments on residual limb loading. Understanding the mechanical behaviour of the pseudo-joint formed by the residual bone and prosthesis may facilitate prosthetic adjustments and achieving optimal fit. This study aimed to assess the feasibility of using B-mode ultrasound to monitor in vivo residual bone movement within a transtibial prosthetic socket during different stepping tasks. Five transtibial prosthesis users participated, and ultrasound images were captured using a Samsung HM70A system during five dynamic conditions. Bone movement relative to the socket was quantified by tracking the bone contour using Adobe After-Effect. During the study a methodological adjustment was made to improve data quality, and the first two participants were excluded from analysis. The remaining three participants exhibited consistent range of motion, with a signal to noise ratio ranging from 1.12 to 2.59. Medial–lateral and anterior–posterior absolute range of motion varied between 0.03 to 0.88 cm and 0.14 to 0.87 cm, respectively. This study demonstrated that it is feasible to use B-mode ultrasound to monitor in vivo residual bone movement inside an intact prosthetic socket during stepping tasks.

Abstract Background Despite the increasing number of research studies examining the effects of age on the control of posture, the number of annual fall-related injuries and deaths continues to increase. A better understanding of how old age affects the neural mechanisms of postural control and how countermeasures such as balance training could improve the neural control of posture to reduce falls in older individuals is therefore necessary. The aim of this review is to determine the effects of age on the neural correlates of balance skill learning measured during static (standing) and dynamic (walking) balance tasks in healthy individuals. Methods We determined the effects of acute (1–3 sessions) and chronic (> 3 sessions) balance skill training on balance in the trained and in untrained, transfer balance tasks through a systematic review and quantified these effects by robust variance estimation meta-analysis in combination with meta-regression. We systematically searched PubMed, Web of Science, and Cochrane databases. Balance performance and neural plasticity outcomes were extracted and included in the systematic synthesis and meta-analysis. Results Forty-two studies (n = 622 young, n = 699 older individuals) were included in the systematic synthesis. Seventeen studies with 508 in-analysis participants were eligible for a meta-analysis. The overall analysis revealed that acute and chronic balance training had a large effect on the neural correlates of balance skill learning in the two age groups combined (g = 0.79, p

Understanding the mechanisms humans use to stabilize walking is vital for predicting falls in elderly. Modeling studies identified two potential mechanisms to stabilize gait in the anterior-posterior direction: foot placement control and ankle push-off control: foot placement depends on position and velocity of the center-of-mass (CoM) and push-off covaries with deviations between actual and predicted CoM trajectories. While both control mechanisms have been reported in humans, it is unknown whether especially the latter one is employed in unperturbed steady-state walking. Based on the finding of Wang and Srinivasan that foot placement deviates in the same direction as the CoM states in the preceding swing phase, and assuming that this covariance serves the role of stabilizing gait, the covariance between the CoM states and foot placement can be seen as a measure of foot placement accuracy. We subsequently interpreted the residual variance in foot placement from a linear regression model as “errors” that must be compensated, and investigated whether these foot placement errors were correlated to push-off kinetic time series of the subsequent double stance phase. We found ankle push-off torque to be correlated to the foot placement errors in 30 participants when walking at normal and slow speeds, with peak correlations over the double stance phase up to 0.39. Our study suggests that humans use a push-off strategy for correcting foot placement errors in steady-state walking.

Abstract Purpose To determine the efficacy of decreasing spinal curvature – when sleeping laterally – in reducing low-back pain (LBP) and improving sleep quality in people with chronic LBP. Secondly, to investigate whether sleeping positions, nocturnal movements, and skin temperature are related to pain in people with chronic LBP. Methods Sixteen subjects with chronic LBP (50% female, mean age 45.6 ± 13.1 years) slept for one night on their own mattress, followed by three nights on an experimental mattress – designed to reduce spinal curvature in lateral sleeping positions – and then a final night again on their own mattress. Sleep positions, nocturnal movements, skin temperature, and room temperature were measured throughout the five nights. Numerical pain ratings for pain while lying, pain on rising, stiffness on rising, sleep quality, and mattress comfort were recorded for both mattresses. Results The experimental mattress was associated with 18% (p

In human walking, power for propulsion is generated primarily via ankle and hip muscles. The addition of a ‘passive’ hip spring to simple bipedal models appears more efficient than using only push-off impulse, at least, when hip spring associated energetic costs are not considered. Hip flexion and retraction torques, however, are not ‘free’, as they are produced by muscles demanding metabolic energy. Studies evaluating the inclusion of hip actuation costs, especially during the swing phase, and the hip actuation’s energetic benefits are few and far between. It is also unknown whether these possible benefits/effects may depend on speed. We simulated a planar flat-feet model walking stably over a range of speeds. We asked whether the addition of independent hip flexion and retraction remains energetically beneficial when considering work-based metabolic cost of transport (MCOT) with different efficiencies of doing positive and negative work. We found asymmetric hip actuation can reduce the estimated MCOT relative to ankle actuation by up to 6%, but only at medium speeds. The corresponding optimal strategy is zero hip flexion and some hip retraction actuation. The reason for this reduced MCOT is that the decrease in collision loss is larger than the associated increase in hip negative work. This leads to a reduction in total positive mechanical work, which results in an overall lower MCOT. Our study shows how ankle actuation, hip flexion, and retraction actuation can be coordinated to reduce MCOT.

IntroductionChronic low back pain is a common condition that imposes an enormous burden on individuals and society. Physical exercise with education is the most effective treatment, but generally results in small, albeit significant improvements. However, which type of exercise is most effective remains unknown. Core stability training is often used to improve muscle strength and spinal stability in these patients. The majority of the core stability exercises mentioned in intervention studies involve no spinal movements (static motor control exercises). It is questionable if these exercises would improve controlled movements of the spine. Sensor-based exergames controlled with spinal movements could help improve movement control of the spine. The primary aim of this study is to compare the effects of such sensor-based exergames to static motor control exercises on spinal movement control.Methods and analysisIn this quasi-randomized controlled trial, 60 patients with chronic low back pain who are already enrolled in a multidisciplinary rehabilitation programme will be recruited. Patients will be randomly allocated into one of two groups: the Sensor-Based Movement Control group (n = 30) or the Static Motor Control group (n = 30). Both groups will receive 8 weeks of two supervised therapy sessions and four home exercises per week in addition to the rehabilitation programme. At baseline (week 1) and after the intervention (week 10), movement control of the spine will be assessed using a tracking task and clinical movement control test battery. Questionnaires on pain, disability, fear avoidance and quality of life will be taken at baseline, after intervention and at 6- and 12 months follow-up. Repeated measures ANOVAs will be used to evaluate if a significant Group x Time interaction effect exists for the movement control evaluations.DiscussionSensor-based spinal controlled exergames are a novel way to train spinal movement control using meaningful and engaging feedback. The results of this study will inform clinicians and researchers on the efficacy of movement control training for patients with low back pain.Ethics and disseminationEthical approval for this study protocol was obtained from the METC Brabant (protocol number NL76811.028.21).Trial registrationOpen Science Framework Registries (https://osf.io/v3mw9/), registration number: 10.17605/OSF.IO/V3MW9, registered on 1 September 2021.

Abstract Stable walking relies critically on motor responses to signals of head motion provided by the vestibular system, which are phase-dependent and modulated differently within each muscle. It is unclear, however, whether these vestibular contributions also vary according to the stability of the walking task. Here we investigate how vestibular signals influence muscles relevant for gait stability (medial gastrocnemius, gluteus medius and erector spinae)—as well as their net effect on ground reaction forces—while humans walked normally, with mediolateral stabilization, wide and narrow steps. We estimated local dynamic stability of trunk kinematics together with coherence of electrical vestibular stimulation (EVS) with muscle activity and mediolateral ground reaction forces. Walking with external stabilization increased local dynamic stability and decreased coherence between EVS and all muscles/forces compared to normal walking. Wide-base walking also decreased vestibulomotor coherence, though local dynamic stability did not differ. Conversely, narrow-base walking increased local dynamic stability, but produced muscle-specific increases and decreases in coherence that resulted in a net increase in vestibulomotor coherence with ground reaction forces. Overall, our results show that while vestibular contributions may vary with gait stability, they more critically depend on the stabilization demands (i.e. control effort) needed to maintain a stable walking pattern.

Abstract Background The European population is rapidly ageing. There is an urgent need for innovative solutions to reduce fall risk in older adults. Perturbation-based gait training is a promising new method to improve reactive balance responses. Whereas positive effects on task-specific dynamic balance recovery during gait have been shown in clinical or laboratory settings, translation of these effects to daily life gait function and fall risk is limited. We aim to evaluate the effect of a 4-week perturbation-based treadmill training on daily-life dynamic gait stability, assessed with inertial sensor data. Secondary outcomes are balance recovery performance, clinical balance and gait assessment scores, the amount of physical activity in daily life and falls incidence during 6 months follow-up. Methods The study is a monocenter assessor-blinded randomized controlled trial. The target study sample consists of 70 older adults of 65 years and older, living in the community and with an elevated risk of falling. A block-randomization to avoid seasonal effects will be used to allocate the participants into two groups. The experimental group receives a 4-week, two times per week perturbation-based gait training programme on a treadmill, with simulated slips and trips, in combination with cognitive dual tasks. The control group receives a 4-week, two times per week treadmill training programme under cognitive dual-task conditions without perturbations. Participants will be assessed at baseline and after the 4-weeks intervention period on their daily-life gait stability by wearing an inertial sensor on the lower back for seven consecutive days. In addition, clinical balance and gait assessments as well as questionnaires on falls- and gait-efficacy will be taken. Daily life falls will be followed up over 6 months by a fall calendar. Discussion Whereas perturbation-based training has shown positive effects in improving balance recovery strategies and in reducing laboratory falls, this study will contribute to investigate the translation of perturbation-based treadmill training effects in a clinical setting towards improving daily life gait stability and reducing fall risk and falls. Trial registration NTR7703 / NL66322.028.18, Registered: January 8, 2019; Enrolment of the first participant April 8, 2019.

Prolonged trunk flexion is known to affect passive and active stabilization of the trunk. Previous studies have evaluated changes in spinal range of motion, muscle activity and reflex behavior induced by prolonged trunk flexion, whereas the effect on sitting postural control is vastly underexplored. In this study, we compared the effects of supported and unsupported intermittent trunk flexion on center of pressure (CoP) motion during sitting on an unstable seat. Participants (n = 21; 11 males, 23.2 ± 2.0 years; 10 females, age 24.3 ± 4.0) were exposed to 1-h intermittent (60-s sets with 30 s of rest) trunk flexion (80% of the maximal range of motion) and CoP root mean square distance, velocity and frequency before and after the exposure were assessed. Contrary to our hypothesis, there were no main effects of exposure (pre. vs. post flexion protocol; p = 0.128–0.709), no main effects of condition (supported vs. unsupported; p = 0.134–0.931), and no interaction between exposure and condition (p = 0.163–0.912). Our results indicate that prolonged intermittent flexion does not induce any changes in CoP motion during a seated balance task, regardless of the presence of a trunk support during prolonged intermittent flexion. This suggests a successful compensation of decreased passive stiffness by increased reflex activity.

Balance training aims to improve balance and transfer acquired skills to real-life tasks. How older adults adapt gait to different conditions, and whether these adaptations are altered by balance training, remains unclear. We hypothesized that reorganization of modular control of muscle activity is a mechanism underlying adaptation of gait to training and environmental constraints. We investigated the transfer of standing balance training, shown to enhance unipedal balance control, to gait and adaptations in neuromuscular control of gait between normal and narrow-base walking in twenty-two older adults (72.6 ± 4.2 years). At baseline, after one, and after ten training sessions, kinematics and EMG of normal and narrow-base treadmill walking were measured. Gait parameters and temporal activation profiles of five muscle synergies were compared between time-points and gait conditions. Effects of balance training and an interaction between training and gait condition on step width were found, but not on synergies. After ten training sessions step width decreased in narrow-base walking, while step width variability decreased in both conditions. Trunk center of mass displacement and velocity, and the local divergence exponent, were lower in narrow-base compared to normal walking. Activation duration in narrow-base compared to normal walking was shorter for synergies associated with dominant leg weight acceptance and non-dominant leg stance, and longer for the synergy associated with non-dominant heel-strike. Time of peak activation associated with dominant leg stance occurred earlier in narrow-base compared to normal walking, while it was delayed in synergies associated with heel-strikes and non-dominant leg stance. The adaptations of synergies to narrow-base walking may be interpreted as related to more cautious weight transfer to the new stance leg and enhanced control over center of mass movement in the stance phase. The improvement of gait stability due to standing balance training is promising for less mobile older adults.

Postural stability of athletes is commonly tested with single-leg stance (SLS) tests. However, for this population, these tests are insufficiently challenging to achieve high sensitivity. Therefore, a new dynamic SLS test based on standardized translational surface perturbations was developed. This study aimed to assess reliability, sensitivity to learning effects, and internal and concurrent validity of this novel test.Healthy soccer players (21 females, 21 males) performed 2 test sessions. Each session consisted of 2 trials. For one trial, the participant performed a 30-seconds, unperturbed SLS on each leg, followed by 12 platform perturbations per leg.Intraclass Correlation Coefficients (ICC) and correlations between outcomes were calculated for the Center of Pressure speed (CoPs) and Time To Stabilization (TTS). ANOVA was used to assess learning effects. CoPs and TTS showed a fair reliability between sessions (ICC = 0.73–0.76). All variables showed improvement over time within and between sessions (all p < 0.01) and were moderately correlated with CoPs during unperturbed SLS (r = 0.39–0.56).Single-leg dynamic postural stability testing through standardized horizontal platform perturbations yielded sufficiently reliable CoPs and TTS outcome measures in soccer players. The moderate correlations with unperturbed SLS support concurrent validity, but also indicates that the new test captures aspects of postural stability that differ from the conventional, unperturbed SLS test.

Background: The availability of instrumented treadmills that can apply unexpected perturbations during walking has made gait perturbation training more popular in clinical practice. To quantify and monitor balance recovery while training, easy to use measures are needed and may be based on integrated force plate data. Therefore, we aimed to quantify and evaluate different implementations of the recovery performance measure based on center of pressure data.Methods: Recovery performance was calculated based on differences in center of pressure trajectories between unperturbed walking and balance recovery after a perturbation. Five methodological choices leading to 36 different implementations were evaluated. Test-retest reliability, effect sizes, and concurrent validity were evaluated against trunk velocity measures.Results: Differences in measures of (dis-)similarity, time normalization and reference data affected reliability, sensitivity and validity and none of the performance measure implementations based on center of pressure trajectories was superior on all criteria. Measures assessing perturbation effects on trunk velocities provided more reliable and sensitive recovery outcomes.Discussion: Different implementations of the recovery performance measure can be chosen dependent on constraints imposed in the clinical setting.Conclusion: Quantifying recovery performance based on center of pressure data is possible and may be suitable to monitor improvement in recovery performance after gait perturbations in specific clinical setups. Validity of performance measures in general requires further attention.

Identification of individuals at risk of falling is important when designing fall prevention methods. Current measures that estimate gait stability and robustness appear limited in predicting falls in older adults. Inspired by recent findings on changes in phase-dependent local stability within a gait cycle, we devised several phase-dependent stability measures and tested for their usefulness to predict gait robustness in compass walker models. These measures are closely related to the often-employed maximum finite-time Lyapunov exponent and maximum Floquet multiplier that both assess a system's response to infinitesimal perturbations. As such, they entail linearizing the system, but this is realized in a rotating hypersurface orthogonal to the period-one solution followed by estimating the trajectory-normal divergence rate of the swing phases and the foot strikes. We correlated the measures with gait robustness, i.e. the largest perturbation a walker can handle, in two compass walker models with either point or circular feet to estimate their prediction accuracy. To also test for the dependence of the measures under state space transform, we represented the point feet walker in both Euler–Lagrange and Hamiltonian canonical form. Our simulations revealed that for most of the measures their correlation with gait robustness differs between models and between different state space forms. In particular, the latter may jeopardize many stability measures' predictive capacity for gait robustness. The only exception that consistently displayed strong correlations is the divergence of foot strike. Our results admit challenges of using phase-dependent stability measures as objective means to estimate the risk of falling.

The aim of this study was to identify biomechanical characteristics of goalkeeper's diving performance in football. Lower extremity joints powers, moments, and angular velocities, were investigated in seven elite goalkeepers diving to save balls, shot from a ball canon to unanticipated heights (high and low) and sides (right and left). Our result showed that there was a proximal-to-distal sequence for each leg in timing of peak joints powers (p < 0.05). Hip extensors produced the largest (p < 0.05) peak moment, the contralateral (relative to dive side) peak was significantly larger than the ipsilateral one for high (4.56 ± 1.02 N·m·kg−1, and 3.52 ± 0.79 N·m·kg−1) and low dives (3.52 ± 0.79 N·m·kg−1, and 2.52 ± 0.56 N·m·kg−1). The ankle plantar flexors produced the second largest peak moment (p < 0.05), and the peak ipsilateral ankle power and angular velocity were the largest (p < 0.05) of all joints, during high (1,502 ± 338 W, and 14.73 ± 1.36 rad·s−1) and low dives (868 ± 263 W, and 14.14 ± 3.09 rad·s−1). Strength and conditioning coaches need to focus on hip extensors and ankle plantar flexors, and for specificity in power training that should elicit triple extension of the lower limbs' joints in a proximal-to-distal sequence.

Abstract Background Patients with Duchenne muscular dystrophy gradually lose the ability to use different muscles of their body. Consequently, they lose the ability to stabilize their trunk against gravity. This hinders them to effectively perform different daily activities. In this paper, we describe the design, realization and evaluation of a trunk orthosis for these patients that should allow them to move their trunk and maintain stability. Method This study aimed to primarily assess the effectiveness of the trunk support system in terms of unloading of trunk muscles, so only healthy participants were recruited for this phase of the study. Measurements were done on 10 healthy participants (23.4±2.07 [M±SD] years old, average body weight 68.42±24.22 [M±SD] kg). The experiment comprised maintaining a constant trunk posture in three different device conditions (control without orthosis and two conditions with different configurations of the orthosis), at four different flexion angles (10°, 20°, 30°, 40°) for each device condition and for two load conditions (with and without stretching the arms). Electromyography (EMG) signals from the trunk muscles were measured to estimate activation levels of the trunk muscles (iliocostalis, longissimus, external oblique and rectus abdominis) and a motion capture system was used to record the movement of the participants during the experiment. Results Wearing the orthosis caused reductions in longissimus and iliocostalis activity. The average muscle activity level was 5%–10% of maximum voluntary contraction in the unsupported conditions for those particular muscles. This level was reduced to 3%–9% of maximal voluntary contraction for the supported conditions. No effect on external oblique and rectus abdominis activity was observed. Moreover, no pain or discomfort was reported by any of the participants during the experiment. The results from the current experiment also suggests the necessity of lumber stabilizing systems while using trunk orthosis. Conclusion The developed orthosis reduces trunk muscle activation level and provides a solid step for further development of support systems for Duchenne muscular dystrophy patients. Trial registration The current study was approved by the medical ethics committee Arnhem-Nijmegen (study number: NL53143.091.15), The Netherlands.

Inertial measurement units (IMUs) fixed to the lower limbs have been reported to provide accurate estimates of stride lengths (SLs) during walking. Due to technical challenges, validation of such estimates in running is generally limited to speeds (well) below 5 m·s−1. However, athletes sprinting at (sub)maximal effort already surpass 5 m·s−1 after a few strides. The present study aimed to develop and validate IMU-derived SLs during maximal linear overground sprints. Recreational athletes (n = 21) completed two sets of three 35 m sprints executed at 60, 80, and 100% of subjective effort, with an IMU on the instep of each shoe. Reference SLs from start to ~30 m were obtained with a series of video cameras. SLs from IMUs were obtained by double integration of horizontal acceleration with a zero-velocity update, corrected for acceleration artefacts at touch-down of the feet. Peak sprint speeds (mean ± SD) reached at the three levels of effort were 7.02 ± 0.80, 7.65 ± 0.77, and 8.42 ± 0.85 m·s−1, respectively. Biases (±Limits of Agreement) of SLs obtained from all participants during sprints at 60, 80, and 100% effort were 0.01% (±6.33%), −0.75% (±6.39%), and −2.51% (±8.54%), respectively. In conclusion, in recreational athletes wearing IMUs tightly fixed to their shoes, stride length can be estimated with reasonable accuracy during maximal linear sprint acceleration.

Background: Gait is often impaired in people after stroke, restricting personal independence and affecting quality of life. During stroke rehabilitation, walking capacity is conventionally assessed by measuring walking distance and speed. Gait features, such as asymmetry and variability, are not routinely determined, but may provide more specific insights into the patient’s walking capacity. Inertial measurement units offer a feasible and promising tool to determine these gait features. Objective: We examined the test–retest reliability of inertial measurement units-based gait features measured in a two-minute walking assessment in people after stroke and while in clinical rehabilitation. Method: Thirty-one people after stroke performed two assessments with a test–retest interval of 24 h. Each assessment consisted of a two-minute walking test on a 14-m walking path. Participants were equipped with three inertial measurement units, placed at both feet and at the low back. In total, 166 gait features were calculated for each assessment, consisting of spatio-temporal (56), frequency (26), complexity (63), and asymmetry (14) features. The reliability was determined using the intraclass correlation coefficient. Additionally, the minimal detectable change and the relative minimal detectable change were computed. Results: Overall, 107 gait features had good–excellent reliability, consisting of 50 spatio-temporal, 8 frequency, 36 complexity, and 13 symmetry features. The relative minimal detectable change of these features ranged between 0.5 and 1.5 standard deviations. Conclusion: Gait can reliably be assessed in people after stroke in clinical stroke rehabilitation using three inertial measurement units.

The risk of low-back pain in manual material handling could potentially be reduced by back-support exoskeletons. Preferably, the level of exoskeleton support relates to the required muscular effort, and therefore should be proportional to the moment generated by trunk muscle activities. To this end, a regression-based prediction model of this moment could be implemented in exoskeleton control. Such a model must be calibrated to each user according to subject-specific musculoskeletal properties and lifting technique variability through several calibration tasks. Given that an extensive calibration limits the practical feasibility of implementing this approach in the workspace, we aimed to optimize the calibration for obtaining appropriate predictive accuracy during work-related tasks, i.e., symmetric lifting from the ground, box stacking, lifting from a shelf, and pulling/pushing. The root-mean-square error (RMSE) of prediction for the extensive calibration was 21.9 nm (9% of peak moment) and increased up to 35.0 nm for limited calibrations. The results suggest that a set of three optimally selected calibration trials suffice to approach the extensive calibration accuracy. An optimal calibration set should cover each extreme of the relevant lifting characteristics, i.e., mass lifted, lifting technique, and lifting velocity. The RMSEs for the optimal calibration sets were below 24.8 nm (10% of peak moment), and not substantially different than that of the extensive calibration.

Objective: To investigate whether relationships between upper leg muscle strength and activity limitations are non-linear in patients with knee osteoarthritis, and, if so, to determine muscle strength thresholds for limitations in daily activities. Design: Baseline data were used for 562 patients with knee osteoarthritis in the Amsterdam-Osteoarthritis cohort. Upper leg muscle strength (Nm/kg) was measured isokinetically. Activity limitations were measured with the timed Get Up and Go test and timed Stair Climb Test, subdivided into stair-ascent and stair-descent. Linear and non-linear relationships between muscle strength and activity limitations were evaluated, and thresholds were determined. Results: Non-linear models improved model fit compared with linear models. The improvement in percentage variance accounted for was 5.9, 8.2 and 5.2 percentage points for the timed Get Up and Go, stair-ascent and stair-descent times, respectively. Muscle strength thresholds were 0.93 Nm/kg (95% confidence interval (95% CI) 0.82–1.04), 0.89 Nm/kg (95% CI 0.77–1.02) and 0.97 Nm/kg (95% CI 0.85–1.11) for relationships with timed Get Up and Go, stair-ascent and stair-descent times, respectively. Conclusion: In patients with knee osteoarthritis, relationships between muscle strength and activity limitations are non-linear. Patients with muscle strength below the described thresholds might benefit more from muscle strength training to reduce limitations in daily activities than would patients with muscle strength above the thresholds. Further research is needed to assess the clinical value of the thresholds determined.

To reduce the incidence of occupational musculoskeletal disorders, back-support exoskeletons are being introduced to assist manual material handling activities. Using a device of this type, this study investigates the effects of a new control strategy that uses the angular acceleration of the user’s trunk to assist during lifting tasks. To validate this new strategy, its effectiveness was experimentally evaluated relative to the condition without the exoskeleton as well as against existing strategies for comparison. Using the exoskeleton during lifting tasks reduced the peak compression force on the L5S1 disc by up to 16%, with all the control strategies. Substantial differences between the control strategies in the reductions of compression force, lumbar moment and back muscle activation were not observed. However, the new control strategy reduced the movement speed less with respect to the existing strategies. Thanks to improved timing in the assistance in relation to the typical dynamics of the target task, the hindrance to typical movements appeared reduced, thereby promoting intuitiveness and comfort.

It is still unclear how humans control mediolateral (ML) stability in walking and even more so for running. Here, foot placement strategy as a main mechanism to control ML stability was compared between walking and running. Moreover, to verify the role of foot placement as a means to control ML stability in both modes of locomotion, this study investigated the effect of external lateral stabilization on foot placement control. Ten young adults participated in this study. Kinematic data of the trunk (T6) and feet were recorded during walking and running on a treadmill in normal and stabilized conditions. Correlation between ML trunk CoM state and subsequent ML foot placement, step width, and step width variability were assessed. Paired t-tests (either SPM1d or normal) were used to compare aforementioned parameters between normal walking and running. Two-way repeated measures ANOVAs (either SPM1d or normal) were used to test for effects of walking vs. running and of normal vs. stabilized condition. We found a stronger correlation between ML trunk CoM state and ML foot placement and significantly higher step width variability in walking than in running. The correlation between ML trunk CoM state and ML foot placement, step width, and step width variability were significantly decreased by external lateral stabilization in walking and running, and this reduction was stronger in walking than in running. We conclude that ML foot placement is coordinated to ML trunk CoM state to stabilize both walking and running and this coordination is stronger in walking than in running.

Background and Aim: Reliable, valid and sensitive measures of dual-task-associated impairments in patients with Parkinson's disease (PD) may reveal progressive deficits unnoticed under single-task walking. The aim of this study was to quantitatively identify markers of progressive gait deficits in idiopathic PD while walking over a circular trajectory condition in single-task walking and in different dual-task conditions: (1) circular walking while checking boxes on a paper sheet as fast as possible and (2) circular walking while performing subtraction of 7 as fast as possible. In addition, we aimed to study the added value of dual-tasking assessment over single (circular) walking task assessment in the study of PD progression.Methods: The assessments were performed every 6 months over a (up to) 5 years period for 22 patients in early-stage PD, 27 patients in middle-stage PD and 25 healthy controls (HC). Longitudinal changes of 27 gait features extracted from accelerometry were compared between PD groups and HCs using generalized estimating equations analysis, accounting for gait speed, age, and levodopa medication state confounders when required. In addition, dual-task-interference with gait and cognitive performance was assessed, as well as their combination.Results: The results support the validity and robustness of some of the gait features already identified in our previous work as progression markers of the disease in single-task circular walking. However, fewer gait features from dual-task than from single-task assessments were identified as markers of progression in PD. Moreover, we did not clearly identify progressive worsening of dual-task-interference in patients with PD, although some group differences between early and middle stages of PD vs. the control group were observed for dual-task interference with the gait task and with the concurrent tasks.Conclusions: Overall, the results showed that dual-tasking did not have added value in the study of PD progression from circular gait assessments. Our analyses suggest that, while single-task walking might be sensitive enough, dual-tasking may introduce additional (error) variance to the data and may represent complex composite measures of cognitive and motor performance.

Background and Aim: Development of objective, reliable and easy-to-use methods to obtain progression markers of Parkinson’s disease (PD) is required to evaluate interventions and to advance research in PD. This study aimed to provide quantitative markers of progression in idiopathic PD from the assessment of circular gait (walking in circles) with a single body-fixed inertial sensor placed on the lower back.Methods: The assessments were performed every 6 months over a (up to) 5 years period for 22 patients in early-stage PD, 27 patients in middle-stage PD and 25 healthy controls (HC). Longitudinal changes of 24 gait features extracted from accelerometry were compared between PD groups and HCs with generalized estimating equations (GEE) analysis, accounting for gait speed, age and levodopa medication state confounders when required.Results: Five gait features indicated progressive worsening in early stages of PD: number of steps, total duration and harmonic ratios calculated from vertical (VT), medio-lateral (ML), and anterior-posterior (AP) accelerations. For middle stages of PD, three gait features were identified as potential progression markers: stride time variability, and stride regularity from VT and AP acceleration.Conclusion: Faster progressive worsening of gait features in early and middle stages of PD relative to healthy controls over 5 years confirmed the potential of accelerometry-based assessments as quantitative progression markers in early and middle stages of the disease. The difference in significant parameters between both PD groups suggests that distinct domains of gait deteriorate in these PD stages. We conclude that instrumented circular walking assessment is a practical and useful tool in the assessment of PD progression that may have relevant potential to be implemented in clinical trials and even clinical routine, particularly in a developing digital era.

Background: Assessing traditional neuromuscular fall risk factors (i.e., balance, gait, strength) in the elderly has so far mainly been done independently. Functional and integrative testing approaches are scarce. The present study proposes an agility course for an integrative assessment of neuromuscular and also cardiocirculatory capacity in seniors – and tests its criterion validity and reliability.Methods: Thirty-six seniors (age: 69.0 ± 2.8 years; BMI: 25.4 ± 3.5 kg/m2; sex: 19 males/17 females; weekly physical activity: 9.4 ± 5.5 h) participated. They completed four trials of the Agility Challenge for the Elderly (ACE)-course in two sessions separated by 1 week. The course consists of three segments focusing on different agility aspects. Cardiovascular capacity was assessed by 6-min walk test (6MWT), neuromuscular capacity by static, dynamic and perturbed standing balance tasks, habitual gait speed assessment, and rate of torque development testing. Parameters’ predictive strength for the ACE performance was assessed by regression analysis. Reliability was calculated with intraclass correlation coefficients and coefficients of variation.Results: Men completed the course in 43.0 ± 5.7 s and women in 51.9 ± 4.0 s. Overall and split times were explained by 6MWT time (ηp2 = 0.38–0.44), gait speed (ηp2 = 0.29–0.43), and to a lesser extent trunk rotation explosive strength (ηp2 = 0.05–0.12). Static and dynamic balance as well as plantar flexion strength explained the performance in some segments to a very small extent (ηp2 = 0.06–0.08). Good between- and within-day reliability were observed for total course and split times: The ICC for the between-day comparison was 0.93 (0.88–0.96) and ranged between 0.84 and 0.94 for split times. The within-day ICC was 0.94 (0.91–0.97) for overall time and 0.92–0.97 for split times. Coefficients of variation were smaller than 5.7% for within and between day analyses.Conclusion: The ACE course reflects cardiocirculatory and neuromuscular capacity, with the three ACE segments potentially reflecting slightly different domains of neuromuscular (static and dynamic balance, ankle, and trunk strength) performance, whereas cardiocirculatory fitness and gait speed contribute to all segments. Our test can detect changes in overall performance greater than 5.7% and can thus be useful for documenting changes due to interventions in seniors.

The aim of this study was to explore the underlying age-related differences in dynamic motor control during different step ascent conditions using muscle synergy analysis. Eleven older women (67.0 y ± 2.5) and ten young women (22.5 y ± 1.6) performed stepping in forward and lateral directions at step heights of 10, 20 and 30 cm. Surface electromyography was obtained from 10 lower limb and torso muscles. Non-negative matrix factorization was used to identify sets of (n) synergies across age groups and stepping conditions. In addition, variance accounted for (VAF) by the detected number of synergies was compared to assess complexity of motor control. Finally, correlation coefficients of muscle weightings and between-subject variability of the temporal activation patterns were calculated and compared between age groups and stepping conditions. Four synergies accounted for >85% VAF across age groups and stepping conditions. Age and step height showed a significant negative correlation with VAF during forward stepping but not lateral stepping, with lower VAF indicating higher synergy complexity. Muscle weightings showed higher similarity across step heights in older compared to young women. Neuromuscular control of young and community-dwelling older women could not be differentiated based on the number of synergies extracted. Additional analyses of synergy structure and complexity revealed subtle age- and step-height-related differences, indicating that older women rely on more complex neuromuscular control strategies.

Selecting motor strategies in daily life tasks requires a perception of the task requirements as well as of one's own physical abilities. Age-related cognitive and physical changes may affect these perceptions. This might entail that some older adults select inappropriate movement strategies when confronted with daily-life motor tasks, which could lead to balance loss or falls. We investigated whether older adults select motor strategies in accordance with their actual physical ability. Twenty-one older adults were subjected to a stepping down paradigm, in which full-body kinematics of selected and reactive behavior were recorded. Stepping down from a curb can be done with either (1) a relatively low effort but more balance threatening heel landing, or (2) a more controlled but more demanding toe landing. The probability of selecting a toe landing grows with an increase in curb height. We determined the curb height at which participants switched from heel to toe landing during expected stepping down over different heights as an indicator of their perceived ability. During an unexpected step down trial, participants encountered a step down of 0.1 m earlier than expected, because part of the walkway was removed and covered by a black cloth. We evaluated participants' actual physical ability from the reactive behavior, with performance defined as the reduction in kinetic energy between the peak value after landing and the onset of the next step. To unravel whether the selected motor strategies corresponded with actual physical ability, the ability to recover from the unexpected step down was correlated to the height at which the participants switched movement strategy. The switching height was not correlated to the ability to recover from an unexpected step down (ρ = 0.034, p = 0.877). This finding suggests that older adults do not select their movement strategy in stepping down based on their actual abilities, or have an imprecise perception of their actual abilities. Future research should evaluate whether inappropriate motor strategy selection in a stepping down paradigm can explain accidental falls in older adults.

Stable gait requires active control of the mediolateral (ML) kinematics of the body center of mass (CoM) and the base of support (BoS) in relation to each other. Stance leg hip abductor (HA) muscle spindle afference may be used to guide contralateral swing foot placement and adequately position the BoS in relation to the CoM. We studied the role of HA spindle afference in control of ML gait stability in young and older adults by means of muscle vibration. Healthy young (n = 12) and older (age > 65 years, n = 18) adults walked on a treadmill at their preferred speed. In unperturbed trials, individual linear models using each subject’s body CoM position and velocity at mid-swing as inputs accurately predicted foot placement at the end of the swing phase in the young [mean R2 = 0.73 (SD 0.11)], but less so in the older adults [mean R2 = 0.60 (SD 0.14)]. In vibration trials, HA afference was perturbed either left or right by vibration (90 Hz) in a random selection of 40% of the stance phases. After vibrated stance phases, but not after unvibrated stance phases in the same trials, the foot was placed significantly more inward than predicted by individual models for unperturbed gait. The effect of vibration was stronger in young adults, suggesting that older adults rely less on HA spindle afference. These results show that HA spindle afference in the stance phase of gait contributes to the control of subsequent ML foot placement in relation to the kinematics of the CoM, to stabilize gait in the ML direction and that this pocess is impaired in older adults.

Age and age-related diseases have been suggested to decrease entropy of human gait kinematics, which is thought to make older adults more susceptible to falls. In this study we introduce a new entropy measure, called phase-dependent generalized multiscale entropy (PGME), and test whether this measure improves fall-risk prediction in community-dwelling older adults. PGME can assess phase-dependent changes in the stability of gait dynamics that result from kinematic changes in events such as heel strike and toe-off. PGME was assessed for trunk acceleration of 30 s walking epochs in a re-analysis of 1 week of daily-life activity data from the FARAO study, originally described by van Schooten et al. (2016). The re-analyzed data set contained inertial sensor data from 52 single- and 46 multiple-time prospective fallers in a 6 months follow-up period, and an equal number of non-falling controls matched by age, weight, height, gender, and the use of walking aids. The predictive ability of PGME for falls was assessed using a partial least squares regression. PGME had a superior predictive ability of falls among single-time prospective fallers when compared to the other gait features. The single-time fallers had a higher PGME (p < 0.0001) of their trunk acceleration at 60% of their step cycle when compared with non-fallers. No significant differences were found between PGME of multiple-time fallers and non-fallers, but PGME was found to improve the prediction model of multiple-time fallers when combined with other gait features. These findings suggest that taking into account phase-dependent changes in the stability of the gait dynamics has additional value for predicting falls in older people, especially for single-time prospective fallers.

Aging is associated with changes in balance control and elderly take longer to adapt to changing sensory conditions, which may increase falls risk. Low amplitude calf muscle vibration stimulates local sensory afferents/receptors and affects sense of upright when applied in stance. It has been used to assess the extent the nervous system relies on calf muscle somatosensory information and to rapidly change/perturb part of the somatosensory information causing balance unsteadiness by addition and removal of the vibratory stimulus. This study assessed the effect of addition and removal of calf vibration on balance control (in the absence of vision) in elderly individuals (>65 years, n = 99) who did (n = 41) or did not prospectively report falls (n = 58), and in a group of young individuals (18–25 years, n = 23). Participants stood barefoot and blindfolded on a force plate for 135 s. Vibrators (60 Hz, 1 mm) attached bilaterally over the triceps surae muscles were activated twice for 15 s; after 15 and 75 s (45 s for recovery). Balance measures were applied in a windowed (15 s epoch) manner to compare center-of-pressure (CoP) motion before, during and after removal of calf vibration between groups. In each epoch, CoP motion was quantified using linear measures, and non-linear measures to assess temporal structure of CoP motion [using recurrence quantification analysis (RQA) and detrended fluctuation analysis]. Mean CoP displacement during and after vibration did not differ between groups, which suggests that calf proprioception and/or weighting assigned by the nervous system to calf proprioception was similar for the young and both groups of older individuals. Overall, compared to the elderly, CoP motion of young was more predictable and persistent. Balance measures were not different between fallers and non-fallers before and during vibration. However, non-linear aspects of CoP motion of fallers and non-fallers differed after removal of vibration, when dynamic re-weighting is required. During this period fallers exhibited more random CoP motion, which could result from a reduced ability to control balance and/or a reduced ability to dynamically reweight proprioceptive information. These results show that non-linear measures of balance provide evidence for deficits in balance control in people who go on to fall in the following 12 months.

IntroductionInertial measurement units (IMUs) positioned on various body locations allow detailed gait analysis even under unconstrained conditions. From a medical perspective, the assessment of vulnerable populations is of particular relevance, especially in the daily-life environment. Gait analysis algorithms need thorough validation, as many chronic diseases show specific and even unique gait patterns. The aim of this study was therefore to validate an acceleration-based step detection algorithm for patients with Parkinson’s disease (PD) and older adults in both a lab-based and home-like environment.MethodsIn this prospective observational study, data were captured from a single 6-degrees of freedom IMU (APDM) (3DOF accelerometer and 3DOF gyroscope) worn on the lower back. Detection of heel strike (HS) and toe off (TO) on a treadmill was validated against an optoelectronic system (Vicon) (11 PD patients and 12 older adults). A second independent validation study in the home-like environment was performed against video observation (20 PD patients and 12 older adults) and included step counting during turning and non-turning, defined with a previously published algorithm.ResultsA continuous wavelet transform (cwt)-based algorithm was developed for step detection with very high agreement with the optoelectronic system. HS detection in PD patients/older adults, respectively, reached 99/99% accuracy. Similar results were obtained for TO (99/100%). In HS detection, Bland–Altman plots showed a mean difference of 0.002 s [95% confidence interval (CI) −0.09 to 0.10] between the algorithm and the optoelectronic system. The Bland–Altman plot for TO detection showed mean differences of 0.00 s (95% CI −0.12 to 0.12). In the home-like assessment, the algorithm for detection of occurrence of steps during turning reached 90% (PD patients)/90% (older adults) sensitivity, 83/88% specificity, and 88/89% accuracy. The detection of steps during non-turning phases reached 91/91% sensitivity, 90/90% specificity, and 91/91% accuracy.ConclusionThis cwt-based algorithm for step detection measured at the lower back is in high agreement with the optoelectronic system in both PD patients and older adults. This approach and algorithm thus could provide a valuable tool for future research on home-based gait analysis in these vulnerable cohorts.

Over the last decades, various measures have been introduced to assess stability during walking. All of these measures assume that gait stability may be equated with exponential stability, where dynamic stability is quantified by a Floquet multiplier or Lyapunov exponent. These specific constructs of dynamic stability assume that the gait dynamics are time independent and without phase transitions. In this case the temporal change in distance, d(t), between neighboring trajectories in state space is assumed to be an exponential function of time. However, results from walking models and empirical studies show that the assumptions of exponential stability break down in the vicinity of phase transitions that are present in each step cycle. Here we apply a general non-exponential construct of gait stability, called fractional stability, which can define dynamic stability in the presence of phase transitions. Fractional stability employs the fractional indices, α and β, of differential operator which allow modeling of singularities in d(t) that cannot be captured by exponential stability. The fractional stability provided an improved fit of d(t) compared to exponential stability when applied to trunk accelerations during daily-life walking in community-dwelling older adults. Moreover, using multivariate empirical mode decomposition surrogates, we found that the singularities in d(t), which were well modeled by fractional stability, are created by phase-dependent modulation of gait. The new construct of fractional stability may represent a physiologically more valid concept of stability in vicinity of phase transitions and may thus pave the way for a more unified concept of gait stability.

Technological advances in inertial sensors allow for monitoring of daily-life gait characteristics as a proxy for fall risk. The quality of daily-life gait could serve as a valuable outcome for intervention trials, but the uptake of these measures relies on their power to detect relevant changes in fall risk. We collected daily-life gait characteristics in 163 older people (aged 77.5 ± 7.5, 107♀) over two measurement weeks that were two weeks apart. We present variance estimates of daily-life gait characteristics that are sensitive to fall risk and estimate the number of participants required to obtain sufficient statistical power for repeated comparisons. The provided data allows for power analyses for studies using daily-life gait quality as outcome. Our results show that the number of participants required (i.e., 8 to 343 depending on the anticipated effect size and between-measurements correlation) is similar to that generally used in fall prevention trials. We propose that the quality of daily-life gait is a promising outcome for intervention studies that focus on improving balance and mobility and reducing falls.

During sprint acceleration, step length, step rate, ground contact, and airtime are key variables for coaches to guide the training process and technical development of their athletes. In the field, three of these variables are easily obtained with inertial measurement units (IMUs), but, unfortunately, valid estimates of step length with IMUs currently are limited to low speeds (2 ≥ 0.96). The comparison of estimated step lengths to reference measurements showed no significant difference (p > 0.05) and acceptable agreement (root mean square error, RMSE = 8.0 cm, bias ± Limits of Agreement = −0.15 ± 16 cm). Step length estimations further improved (RMSE = 5.7 cm, −0.16 ± 11 cm) after smoothing the original estimated step lengths with a third order polynomial function (R2 = 0.94 ± 0.04). In conclusion, during maximal sprint acceleration, acceptable estimates of stride and step length were obtained from IMU-derived step times and 30-m (split) and 60-m sprint times.

The ability to stand up from a sitting position is essential for older adults to live independently. Body-fixed inertial sensors may provide an approach for quantifying the sit-to-stand (STS) in clinical settings. The aim of this study was to determine whether measurements of STS movements using body-fixed sensors yield parameters that are informative regarding changes in STS performance in older adults with reduced muscle strength. In twenty-seven healthy older adults, handgrip strength was assessed as a proxy for overall muscle strength. Subjects were asked to stand up from a chair placed at three heights. Trunk movements were measured using an inertial sensor fixed to the back. Duration, angular range, and maximum angular velocity of STS phases, as well as the vertical velocity of the extension phase, were calculated. Backwards elimination using Generalized Estimating Equations was used to determine if handgrip strength predicted the STS durations and trunk kinematics. Weaker subjects (i.e., with lower handgrip strength) were slower during the STS and showed a larger flexion angular range and a larger extension angular range. In addition, weaker subjects showed a greater maximum angular velocity, which increased with lower seat heights. Measurements with a single inertial sensor did reveal that older adults with lower handgrip strength employed a different strategy to stand up from a sitting position, involving more dynamic use of the trunk. This effect was greatest when elevating body mass. Trunk kinematic parameters were more sensitive to reduced muscle strength than durations.

Gait analysis can provide valuable information on a person’s condition and rehabilitation progress. Gait is typically captured using external equipment and/or wearable sensors. These tests are largely constrained to specific controlled environments. In addition, gait analysis often requires experts for calibration, operation and/or to place sensors on volunteers. Alternatively, mobility support devices like rollators can be equipped with onboard sensors to monitor gait parameters, while users perform their Activities of Daily Living. Gait analysis in rollators may use odometry and force sensors in the handlebars. However, force based estimation of gait parameters is less accurate than traditional methods, especially when rollators are not properly used. This paper presents an evaluation of force based gait analysis using a smart rollator on different groups of users to determine when this methodology is applicable. In a second stage, the rollator is used in combination with two lab-based gait analysis systems to assess the rollator estimation error. Our results show that: (i) there is an inverse relation between the variance in the force difference between handlebars and support on the handlebars—related to the user condition—and the estimation error; and (ii) this error is lower than 10% when the variation in the force difference is above 7 N. This lower limit was exceeded by the 95.83% of our challenged volunteers. In conclusion, rollators are useful for gait characterization as long as users really need the device for ambulation.