Biomechanical and age-related differences in balance recovery using the tether-release method.

This paper reviews experimental studies that have used the tether-release method to examine the biomechanical and age-related differences in the stepping response used after a simulated fall. The tether-release method has been used to create a repeatable perturbation that simulates the initial unbalanced configuration of the body during a trip or slip. In this technique, the test subject is held in an initial forward or backward inclined position by means of a horizontal tether or cable. To initiate a fall, the subject is released from this position after a short time delay. This review focuses on studies that have explored various biomechanical parameters in an effort to understand what attributes allow for successful balance recovery by stepping or stumbling. Strong associations between recovery ability and biomechanical parameters such as step length, step timing, and joint torques point to the importance of neuromuscular capacities that relate to lower extremity flexibility, reaction time, and strength. Therefore, the maintenance or enhancement of these necessary attributes should be considered when developing exercise-based fall intervention programs for older adults.     

Voluntary stepping behavior under single- and dual-task conditions in chronic stroke survivors: A comparison between the involved and uninvolved legs

ObjectiveIf balance is lost, quick step execution can prevent falls. Research has shown that speed of voluntary stepping was able to predict future falls in old adults. The aim of the study was to investigate voluntary stepping behavior, as well as to compare timing and leg push-off force–time relation parameters of involved and uninvolved legs in stroke survivors during single- and dual-task conditions. We also aimed to compare timing and leg push-off force–time relation parameters between stroke survivors and healthy individuals in both task conditions.MethodsTen stroke survivors performed a voluntary step execution test with their involved and uninvolved legs under two conditions: while focusing only on the stepping task and while a separate attention-demanding task was performed simultaneously. Temporal parameters related to the step time were measured including the duration of the step initiation phase, the preparatory phase, the swing phase, and the total step time. In addition, force–time parameters representing the push-off power during stepping were calculated from ground reaction data and compared with 10 healthy controls.ResultsThe involved legs of stroke survivors had a significantly slower stepping time than uninvolved legs due to increased swing phase duration during both single- and dual-task conditions. For dual compared to single task, the stepping time increased significantly due to a significant increase in the duration of step initiation. In general, the force time parameters were significantly different in both legs of stroke survivors as compared to healthy controls, with no significant effect of dual compared with single-task conditions in both groups.ConclusionsThe inability of stroke survivors to swing the involved leg quickly may be the most significant factor contributing to the large number of falls to the paretic side. The results suggest that stroke survivors were unable to rapidly produce muscle force in fast actions. This may be the mechanism of delayed execution of a fast step when balance is lost, thus increasing the likelihood of falls in stroke survivors.     

Stepping boundary of external force-controlled perturbations of varying durations: Comparison of experimental data and model simulations

This study investigated the stepping boundary – the force that can be resisted without stepping – for force-controlled perturbations of different durations. Twenty-two healthy young adults (19–37 years old) were instructed to try not to step in response to 86 different force/time combinations of forward waist-pulls. The forces at which 50% of subjects stepped (F₅₀) were identified for each tested perturbation durations. Results showed that F₅₀ decreased hyperbolically when the perturbation’s duration increased and converged toward a constant value (about 10% BW) for longer perturbations (over 1500 ms). The effect of perturbation duration was critical for the shortest perturbations (less than 1 s).In parallel, a simple function was proposed to estimate this stepping boundary. Considering the dynamics of a linear inverted pendulum + foot model and simple balance recovery reactions, we could express the maximum pulling force that can be withstood without stepping as a simple function of the perturbation duration. When used with values of the main model parameters determined experimentally, this function replicated adequately the experimental results.This study demonstrates for the first time that perturbation duration has a major influence on the outcomes of compliant perturbations such as force-controlled pulls. The stepping boundary corresponds to a constant perturbation force-duration product and is largely explained by only two parameters: the reaction time and the displacement of the center of pressure within the functional base of support. Future work should investigate pathological populations and additional parameters characterizing the perturbation time-profile such as the time derivative of the perturbation.     

Stepping threshold with platform-translation and shoulder-pull postural perturbation methods

The type of balance recovery, feet-in-place or stepping, is predicated on the perturbation intensity, often defined by the combination of applied force and displacement. Few studies examined the relationship between characteristics required to produce a stepping response with one of the postural perturbation methods. The purpose of this study was to investigate the relationship between perturbation characteristics (applied force and displacement) required to elicit a forward stepping response with platform-translation and shoulder-pull methods, and to establish whether a common set of perturbation characteristics existed across both perturbation methods. Fourteen young healthy males participated. Temporally unexpected platform translations and shoulder pulls were induced by release of free weights, which fell a controlled height exerting a pull on the platform or on the participant via a shoulder harness. Participants responded with either feet-in-place or stepping responses. The force and displacement were varied to investigate the range of force-displacement combinations required to elicit stepping responses. Force-displacement combinations that elicited stepping responses were recorded and normalized to the participant’s body weight (BW) and the base of support (BOS; participant’s foot length). The lowest force and associated displacement that elicited stepping responses showed an inverse linear relationship during both platform-translation and shoulder-pull trials. The lowest force-displacement combination common to both perturbation methods was found to be 8.75%BW and 105%BOS, which, in the future work, could enable a direct comparison of the neuromuscular and biomechanical responses to different perturbation methods in a manner that attempts to equilibrate the perturbation stimulus across the methods.     

Static versus dynamic predictions of protective stepping following waist–pull perturbations in young and older adults

The purposes of this study were: (1) to determine the frequency of protective stepping for balance recovery in subjects of different ages and fall-status, and (2) to compare predicted stepping based on a dynamic model (Pai and Patton, 1997. Journal of Biomechanics 30, 347–354) involving displacement and velocity combinations of the center of mass (COM) versus a static model based on displacement alone against experimentally induced stepping. Responses to three different magnitudes of forward waist pulls were recorded for 13 young, 18 older-non-fallers and 18 older-fallers. The COM phase plane trajectories derived from motion analysis were compared with the model-predicted threshold values for stepping. We found that the older fallers had the highest percentage of stepping trials (52%), followed by older-non-fallers (17.3%), and young (2.7%) at the lowest perturbation level. Younger subjects stepped less often than the elderly at the middle level. Everyone consistently stepped at the highest level of perturbation. Overall, the dynamic model showed better predictive capacity (65%) than the static model (5%) for estimating the initiation of stepping. Furthermore, the threshold for step initiation derived from the dynamic model could consistently predict when a step must occur. However, it was limited, especially among older fallers at the low perturbation level, in that it considered some steps ‘unnecessary’ that were presumably triggered by fear of falling or other factors.     

Adaptive recovery responses to repeated forward loss of balance in older adults

Experiments designed to assess balance recovery in older adults often involve exposing participants to repeated loss of balance. The purpose of this study was to investigate the adaptive balance recovery response exhibited by older adults following repeated exposure to forward loss of balance induced by releasing participants from a static forward lean angle. Fifty-eight healthy, community-dwelling older adults, aged 65-80 years, participated in the study. Participants were instructed to attempt to recover with a single step and performed four trials at each of three lean angles. Adaptive recovery responses at four events (cable release, toe-off of the stepping foot, foot contact and maximum knee flexion angle following landing in the stepping leg) were quantified for trials performed at the intermediate lean angle using the concept of margin of stability. The antero-posterior and medio-lateral margin of stability were computed as the difference between the velocity-adjusted position of the whole body centre of mass and the corresponding anterior or lateral boundary of the base of support. Across repeated trials adaptations in reactive stepping responses were detected that resulted in improved antero-posterior stability at foot contact and maximum knee flexion angle. Improved antero-posterior stability following repeated trials was explained by more effective control of the whole body centre of mass during the reactive stepping response and not by adjustments in step timing or base of support. The observed adaptations occurred within a single testing session and need to be considered in the design of balance recovery experiments.     

Effects of aging on hip abductor-adductor neuromuscular and mechanical performance during the weight transfer phase of lateral protective stepping

Aging brings about challenges in the ability to recover balance through protective stepping, especially in the lateral direction. Previous work has suggested that lateral protective stepping during weight transfer may be affected by impaired muscle composition and performance of the hip abductors (AB) in older adults. Hence, this study investigated the influence of hip abductor-adductor (AB-AD) neuromuscular performance on the weight transfer phase of lateral protective stepping in younger and older adults. Healthy younger (n = 15) and older adults (n = 15) performed hip AB-AD isometric maximal voluntary contractions (IMVC). Lateral balance perturbations were applied via motorized waist-pulls. Participants were instructed to recover their balance using a single lateral step. Kinetic, kinematic and electromyographic (EMG) data were analyzed during the weight transfer phase. In the hip IMVC task, older adults showed reduced peak AB-AD torque, AB rate of torque development and AB-AD rate of EMG neuromuscular activation (RActv). During the lateral balance perturbations, older individuals had a lower incidence of lateral steps, reduced hip AB-AD RActv and delayed weight transfer. However, several outcomes were larger in the older group, such as, center of mass momentum at step onset, step-side peak rate of vertical force development, hip AB net joint torque, and power. Although older adults had greater hip muscular output during the weight transfer phase, their lateral balance recovery was still impaired. The reduced maximal hip AB-AD capacity, especially RActv, may have been a greater contributor to this impairment, as it affects the ability to generate rapid force, crucial for balance recovery.     

Induced limb collapse in a sudden slip during termination of sit-to-stand

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.     

Factors influencing the quick onset of stepping following postural perturbation.

It has been shown that the stepping to recover balance following a forward fall occurs at a constant time (on average 293 ms) (Do et al. Journal of Biomechanics 15, 1982, 933-939). In this study, we tested the hypothesis according to which programming to make fast movement could trigger the movement earlier than when programming self-pace movement. The same experimental paradigm of forward fall was used (see Do et al., 1982) to induce stepping. Different extents of stepping were manipulated by instructions: Subjects were instructed to step to recover their balance naturally (control condition); to make shorter steps than in the control condition; longer steps; faster steps. Lastly, a fast step was also induced by the biomechanical constraint on the initial posture, i.e. by inclining the subject forward at his maximum capacity. Data were collected from 12 subjects. The variables analyzed were the onset latency of step execution and other classical parameters (time of heel-contact, duration of the swing phase, step length, center of mass progression velocity, and step velocity). The results showed that the onset of stepping was unchanged in the longer- and faster-step conditions, relative to the control condition (mean control value = 280 ms). In contrast, the onset of stepping was significantly earlier in the short-step condition, and when the initial inclination was greater (250 and 252 ms, respectively). The swing phase duration in these two conditions averaged 140 and 185 ms, was significantly shorter than in the other conditions, whereas step length was obviously expected to be shorter in the shorter-step condition and longer in the longer-step condition than in the other conditions. Step length was similar between the other conditions. We conclude that neither step length or step velocity programming could induce an earlier onset latency of stepping. Step programming in relation to these specific instructions seemed to concern the extent of step execution and not the time of triggering of the stepping. We suggest that the control of short swing phase duration resulted in an earlier onset latency of stepping to recover the balance. This control depends on the combination of biomechanical constraints and cognitive processes, including subject's interpretation of the instructions and evaluation of the risk of fall.     

Minimal step length necessary for recovery of forward balance loss with a single step

Although the boundary conditions necessary to trigger a step in reaction to a forward balance loss have been predicted in previous research, the relationship between minimal step length needed for balance recovery with this single step and the center of mass (COM) motion state (i.e., its position and velocity) remains unknown. The purpose of this paper was to present a theoretical framework within which the minimal step length needed for balance recovery can be estimated. We therefore developed a simplified four-segment sagittal model of human body stepping for balance recovery. The work-energy principle of the Newtonian mechanics was employed in the simulation to determine the amount of excess mechanical energy that can be absorbed as a function of step length and the corresponding eccentric joint work that can be generated in a single step. We found that an increase in initial forward velocity and a greater forward shift of the COM require a corresponding increase in the minimal step length needed for balance recovery. Furthermore, the minimal step length is also a function of the muscle strength at the ankle: the lower the muscle strength, the greater the minimal step length required. Our theoretical framework reduces the complexity associated with previous studies relying on forward dynamics and iterative optimization processes. This method may also be applied to study aspects of balance control such as the prevention of balance loss in the posterior or mediolateral direction.     

Thresholds for step initiation induced by support-surface translation: a dynamic center-of-mass model provides much better prediction than a static model

The need to initiate a step in order to recover balance could, in theory, be predicted by a static model based solely on displacement of the center of mass (COM) with respect to the base of support (BOS), or by a dynamic model based on the interaction between COM displacement and velocity. The purpose of this study was to determine whether the dynamic model provides better prediction than the static model regarding the need to step in response to moving-platform perturbation. The COM phase plane trajectories were determined for 10 healthy young adults for trials where the supporting platform was translated at three different acceleration levels in anterior and posterior directions. These trajectories were compared with the thresholds for step initiation predicted by the static and dynamic COM models. A single-link-plus-foot biomechanical model was employed to mathematically simulate termination of the COM movement, without stepping, using the measured platform acceleration as the input. An optimization routine was used to determine the stability boundaries in COM state space so as to establish the dynamic thresholds where a compensatory step must be initiated in order to recover balance. In the static model, the threshold for step initiation was reached if the COM was displaced beyond the BOS limits. The dynamic model showed substantially better accuracy than the static model in predicting the need to step in order to recover balance: 71% of all stepping responses predicted correctly by the dynamic model versus only 11% by the static model. These results support the proposition that the central nervous system must react to and control dynamic effects, i.e. COM velocity, as well as COM displacement in order to maintain stability with respect to the existing BOS without stepping.     

Balance control in stepping down expected and unexpected level changes

Stepping down an elevation in ongoing gait is a common task that can cause falls when the level change is unexpected. The aim of this study was to compare expected and unexpected stepping down. We hypothesized that unexpected stepping would lead to loss of control over the movement and potentially falls due to buckling of the leading leg at landing. Ten male subjects repeatedly walked over a platform on which they stepped down an expected 10-cm height difference. In 5 out of 50 trials, the height difference was encountered unexpectedly early. Kinematics and ground reaction forces under both feet were measured during the stride in which the height difference was negotiated. Stepping down involved a substantial increase in forward horizontal and angular momenta (approximately 40 N s and 20 N ms). In expected stepping down, step length was significantly increased (17%), which allowed control of these forward horizontal and angular momenta immediately following landing. In unexpected stepping down, the time between expected ground contact and actual ground contact (110 ms) appeared too short to substantially adjust leg movement and increase step length. Although buckling of the leg did not occur, presumably due to its more vertical orientation at landing, momentum could not be sufficiently attenuated at landing, but a fall was prevented by a rapid step of the trailing limb. The lack of control of momentum might cause a fall, when the capacity to make such a rapid step falls short, as in the elderly, or when the height difference is larger.     

Force-Controlled Balance Perturbations Associated with Falls in Older People: A Prospective Cohort Study

Balance recovery from an unpredictable postural perturbation can be a challenging task for many older people and poor recovery could contribute to their risk of falls. This study examined associations between responses to unpredictable perturbations and fall risk in older people. 242 older adults (80.0±4.4 years) underwent assessments of stepping responses to multi-directional force-controlled waist-pull perturbations. Participants returned monthly falls calendars for the subsequent 12 months. Future falls were associated with lower force thresholds for stepping in the posterior and lateral but not anterior directions. Those with lower posterior force thresholds for stepping were 68% more likely to fall at home than those with higher force thresholds for stepping. These results suggest that amount of force that can be withstood following an unpredictable balance perturbation predicts future falls in community-dwelling older adults. Perturbations in the posterior direction best discriminated between future fallers and non-fallers.     

Balance Recovery Prediction with Multiple Strategies for Standing Humans

Human balance recovery from external disturbances is a complex process, and simulating it remains an open challenge. In particular, there still is a need for a comprehensive numerical tool capable of predicting the outcome of a balance perturbation, including in particular the three elementary recovery strategies: ankle, hip and stepping with variable step duration. In order to fill this gap we further developed a previously proposed multiple step balance recovery prediction tool to include the use of the hip strategy and variable step duration. Simulated recovery reactions are compared against observations from different experimental situations from the literature. Reasonable accuracy in terms of step positions and durations were obtained for these different situations using a single set of controller parameters. Moreover, variations in the use of the hip strategy and the step duration between situations were consistent with biomechanical observations. Such a model could be useful to better understand the balance recovery mechanisms, and could also be used to identify potentially hazardous situations.     

Muscle contributions to recovery from forward loss of balance by stepping

The purpose of this study was to determine the muscular contributions to the stepping phase of recovery from forward loss of balance in 5 young and 5 older adults that were able to recover balance in a single step, and 5 older adults that required multiple steps. Forward loss of balance was achieved by releasing participants from a static forward lean angle. All participants were instructed to attempt to recover balance by taking a rapid single step. A scalable anatomical model consisting of 36 degrees-of-freedom was used to compute kinematics and joint moments from motion capture and force plate data. Forces for 94 muscle actuators were computed using static optimisation and induced acceleration analysis was used to compute individual muscle contributions to net lumbar spine joint, and stepping side hip joint and knee joint accelerations during recovery. Older adults that required multiple recovery steps used a significantly shorter and faster initial recovery step and adopted significantly more trunk flexion throughout recovery compared to the older single steppers. Older multiple steppers also produced significantly more force in the stance side hamstrings, which resulted in significantly higher hamstring induced flexion accelerations at the lumbar spine and extension accelerations at the hip. However since the net joint lumbar spine and hip accelerations remained similar between older multiple steppers and older single steppers, we suggest that the recovery strategy adopted by older multiple steppers was less efficient as well as less effective than for older single steppers.     

Consequences of forward translation of the point of force application for the mechanics of running

In running humans, the point of force application between the foot and the ground moves forwards during the stance phase. Our aim was to determine the mechanical consequences of this 'point of force translation' (POFT). We modified the planar spring-mass model of locomotion to incorporate POFT, and then compared spring-mass simulations with and without POFT. We found that, if leg stiffness is adjusted appropriately, it is possible to maintain very similar values of peak vertical ground reaction force (GRF), stance time, contact length and vertical centre of mass displacement, whether or not POFT occurs. The leg stiffness required to achieve this increased as the distance of POFT increased. Peak horizontal GRF and mechanical work per step were lower when POFT occurred. The results indicate that the lack of POFT in the traditional spring-mass model should not prevent it from providing good predictions of peak vertical GRF, stance time, contact length and vertical centre of mass displacement in running humans, if an appropriate spring stiffness is used. However, the model can be expected to overestimate peak horizontal GRF and mechanical work per step. When POFT occurs, the spring stiffness in the traditional spring-mass model is not equivalent to leg stiffness. Therefore, caution should be exercised when using spring stiffness to understand how the musculoskeletal system adapts to different running conditions. This can explain the contradictory results in the literature regarding the effect of running speed on leg stiffness.     

Muscle activities used by young and old adults when stepping to regain balance during a forward fall

The current study was undertaken to determine if age-related differences in muscle activities might relate to older adults being significantly less able than young adults to recover balance during a forward fall. Fourteen young and twelve older healthy males were released from forward leans of various magnitudes and asked to regain standing balance by taking a single forward step. Myoelectric signals were recorded from 12 lower extremity muscles and processed to compare the muscle activation patterns of young and older adults. Young adults successfully recovered from significantly larger leans than older adults using a single step (32.2° vs. 23.5°). Muscular latency times, the time between release and activity onset, ranged from 73 to 114 ms with no significant age-related differences in the shortest muscular latency times. The overall response muscular activation patterns were similar for young and older adults. However older adults were slower to deactivate three stance leg muscles and also demonstrated delays in activating the step leg hip flexors and knee extensors prior to and during the swing phase. In the forward fall paradigm studied, age-differences in balance recovery performance do not seem due to slowness in response onset but may relate to differences in muscle activation timing during the stepping movement.     

The influence of track compliance on running

A model of running is proposed in which the leg is represented as a rack-and-pinion element in series with a damped spring. The rack-and-pinion element emphasizes the role of descending commands, while the damped spring represents the dynamic properties of muscles and the position and the rate sensitivity of reflexes. This model is used to predict separately the effect of track compliance on step length and ground contact time. The predictions are compared with experiments in which athletes ran over tracks of controlled spring stiffness. A sharp spike in foot force up to 5 times body weight was found on hard surfaces, but this spike disappeared as the athletes ran on soft experimental tracks. Both ground contact time and step length increased on very compliant surfaces, leading to moderately reduced running speeds, but a range of track stiffness was discovered which actually enhances speed.     

Normal gait characteristics under temporal and distance constraints

Walking patterns of 53 males and 39 females, all in good health, were studied at slow, free, and fast speeds using a walkway system developed by the author. Three males and three females, also in good health, were then studied under constrained walking conditions such as rhythm constraint, speed coupled with constraint, walking up or down a slope, line stepping contraint, stepping onto a marked square, and starting/stopping of walking. In the first set of experiments, the following results were obtained. When increasing speed, the male had a tendency to increase step length and the female had a tendency to increase cadence. The relationships between the speed and the statistics of gait parameters, i.e. the coefficient of variation and the symmetry were examined. The data in this experiment were also applied to Grieve's gait equations which formulated the relationships between step frequency and speed, or between swing time and cycle time.In the second set of experiments the following results were obtained. Although rhythm constraint (induced by a metronome) resulted in no difference of gait between males and females, a difference did appear in the case of speed coupled with constraint. When walking up and down a slope, the ascent case showed a longer step length and a lower cadence compared with the descent. The idea of functional asymmetry, a supporting function of the left leg and a moving function of the right leg, is well accepted. However, in this study of the effect of line stepping constraints predominant right-left functional differences were found. The perturbation of gait when the subjects stepped onto a marked square resembling a force-plate was recorded quantitatively. With regard to the starting and stopping characteristics of walking, it was concluded that the two steps from starting and the three steps before stopping should be excluded from ordinary data due to their acceleration and deceleration properties.     

Adaptation of reflexive feedback during arm posture to different environments

 In this study we have examined the ability of the central nervous system (CNS) to use spinal reflexes to minimize displacements during postural control while continuous force perturbations were applied at the hand. The subjects were instructed to minimize the displacements of the hand from a reference position that resulted from the force perturbations. The perturbations were imposed in one direction by means of a hydraulic manipulator of which the virtual mass and damping were varied. Resistance to the perturbations came from intrinsic and reflexive stiffness, and from the virtual environment. It is hypothesized that reflexive feedback during posture maintenance is optimally adjusted such that position deviations are minimal for a given virtual environment. Frequency response functions were estimated, capturing all mechanical properties of the arm at the end point (hand) level. Intrinsic and reflexive parameters were quantified by fitting a linear neuromuscular model to the frequency responses. The reflexive length feedback gain increased strongly with damping and little with the eigenfrequency of the total combined system (i.e. arm plus environment). The reflexive velocity feedback gain decreased slightly with relative damping at the largest eigenfrequency and more markedly at smaller eigenfrequencies. In the case of highest reflex gains, the total system remained stable and sufficiently damped while the responses of only the arm were severely underdamped and sometimes even unstable. To further analyse these results, a model optimization was performed. Intrinsic and reflexive parameters were optimized such that two criterion functions were minimized. The first concerns performance and penalized hand displacements from a reference point. The second one weights afferent control effort to avoid inefficient feedback. The simulations showed good similarities with the estimated values. Length feedback was adequately predicted by the model for all conditions. The predicted velocity feedback gains were larger in all cases, probably indicating a mutual gain limiting relation between length and velocity afferent signals. The results suggest that both reflex gains seem to be adjusted by the CNS, where in particular the length feedback gain was optimal so as to maximize performance at minimum control effort. Received: 23 July 2001 / Accepted in revised form: 15 January 2002