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Evolution of postural stability after subthalamic nucleus stimulation in Parkinson's disease: a combined clinical and posturometric study.

OBJECTIVES: The occurrence of postural and balance disorders is a frequent feature in advanced forms of Parkinson's disease (PD). However, the pathological substrate of these disturbances is poorly understood. METHODS: In the present work, we investigated the evolution of posturometric parameters [center of pressure (CoP) displacement and CoP area] and axial scores between the pre-operative period and 3 months post-operative in seven PD patients who underwent bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN). RESULTS: After surgery, the patients leaned backwards much more regardless of the STN stimulation, suggesting that surgery could have a deleterious effect on postural adaptation. During the post-operative period, the improvement in axial and postural scores was similar under levodopatherapy and DBS. On the other hand, DBS of the STN significantly reduced the CoP displacement and the CoP area, whereas levodopatherapy tended only to reduce the CoP displacement and to increase the CoP area significantly. CONCLUSIONS: These data suggest that DBS of the STN and levodopa do not act on the same neurological systems involved in posture regulation. DBS of the STN could improve posture via a direct effect on the pedunculopontine nucleus, which is known to be involved in posture regulation.

Adult↗

Low-frequency common modulation of soleus motor unit discharge is enhanced during postural control in humans.

The maintenance of quiet stance requires the activation of muscles bilaterally. The soleus muscles in each leg share a common function in standing; that is, each muscle acts to control antero-posterior (AP) sway on its own side. We sought to determine the extent to which oscillations in motor unit discharge were related in motor unit pairs of the soleus muscles during postural and voluntary isometric tasks, both within and between legs. Subjects stood quietly for 5 min or performed a voluntary isometric plantarflexion contraction in a seated position. During the postural tasks, the excursions of AP sway between legs were highly correlated (rho = 0.86 +/- 0.06). The strength of common modulation of motor unit discharge rates was assessed using time- and frequency-domain analyses. The time-domain common drive analysis revealed that the strongest correlation in motor unit discharge modulation occurred in the postural task with unilateral pairs (rho = 0.71 +/- 0.13) being more strongly correlated than bilateral pairs (rho = 0.50 +/- 0.16). Common modulation of motor unit discharge was lowest for the voluntary tasks, with rho = 0.38 +/- 0.11 and 0.16 +/- 0.08 for unilateral and bilateral pairs, respectively. Similarly, the frequency-domain coherence analysis demonstrated an identical ordering effect, with the largest maximum pooled coherence occurring during standing posture in unilateral (0.070 at 1.6 Hz) and bilateral (0.055 at 1.6 Hz) recordings, whereas minimal coherence was observed in the voluntary task in both unilateral and bilateral recordings within the 0-5 Hz range. These results indicate that in the soleus muscle, common modulation of motor unit discharge is greater during postural tasks than during voluntary isometric tasks and can be observed in both bilateral and unilateral motor unit pairs. Differences in the extent of co-modulation of motor unit discharge between tasks may be attributed to either differences in the descending control or differences in the proprioceptive input between postural and isometric tasks.

Action Potentials↗

The development of postural adjustments during reaching in 6- to 18-month-old infants. Evidence for two transitions.

The present study focused on the developmental changes of postural adjustments accompanying reaching movements in healthy infants. We made a longitudinal study of ten infants between 6 and 18 months of age. During each session multiple surface electromyograms of arm, neck, trunk and leg muscles at the right side of the body were recorded during right-handed reaching movements in two positions ("upright sitting" in an infant chair and "long-leg" sitting without support). Simultaneously the whole session was recorded on video. Comparable data were present from the same infants at 3-5 months. Additionally, 18 infants (8-15 months) were assessed once during similar reaching tasks, but in these infants electromyographic activity of the trunk and neck muscles at both sides of the body were recorded. Our data revealed two transitions in the development of postural adjustments. The first transition was present around 6 months of age. At this age the postural muscles were infrequently activated during reaching movements. At 8 months ample postural activity reappeared and the infants developed the ability to adapt the postural adjustments to task-specific constraints such as arm movement velocity or the sitting position at the onset of the reaching movement. The second transition occurred between 12 and 15 months. Before 15 months the infants did not show consistent anticipatory postural activity, but from 15 months onwards they did, particularly in the neck muscles.

Arm↗

Vestibular perception of self-rotation in different postures: a comparison between sitting and standing subjects.

We investigated whether posture - either seated (S) or upright standing (O, orthostatic) - affects the vestibular perceptions of angular velocity (V) and displacement (D) in the horizontal plane. We also examined whether the two perceptions are equivalent, that is, whether perceived displacement can be viewed as the time integral of perceived velocity. Sinusoidal stimuli were delivered to subjects sitting on a Barany chair or standing on a turning platform. Frequencies ranged from 0.028 Hz to 0.45 Hz, peak-to-peak amplitudes from 11.3 degrees to 180 degrees, and peak velocities from 4 degrees/s to 64 degrees/s. Perceptions were measured by retrospective magnitude estimation in relation to a standard stimulus (STD) of 0.11 Hz, 45 degrees, 16 degrees/s. For D-estimates, two different moduli were assigned to the STD: Either "45 degrees" (allowing subjects to use the familiar degree scale, which can easily be related to the body scheme) or "10" (which bears no relation to an accustomed scale). For V-estimations the modulus was always "10" (there is no "natural" velocity scale). D-estimates exhibited only a marginal, non-significant dependence on posture (S larger than O); they were highly veridical (linear function of stimulus amplitude, gain close to 1) when subjects used the degree scale but had a reduced gain (approximately 0.76) with a modulus of 10. V-estimates, on the other hand, varied with posture (S significantly larger than O), particularly upon presentation of large stimuli; also, they deviated increasingly from veracity as stimulus magnitude increased (saturating function). Finally, posture had no effect upon the vestibular detection threshold. The frequency response of D-estimates, tested with stimuli of constant amplitude and varying frequency, was bimodal at low frequencies: stimuli were either not detected at all or were veridically estimated, on average (with a large scatter, though). The frequency response of V-estimates, tested with stimuli of constant peak velocity, exhibited a continuous increase with stimulation frequency. We conclude that published quantifications of vestibular self-motion perception, collected mostly with sitting subjects, are likely to be applicable also to the more natural situation of standing subjects provided they are based on displacement indications; in contrast, velocity indications appear to be modulated by posture. The different susceptibility of displacement and velocity estimates to posture and their incongruent frequency characteristics suggest that perceived displacement does not, or does not always, equal the time integral of perceived velocity. The persistence of nearly veridical displacement estimates at low frequencies suggests the intervention of cognitive processes.

Acceleration↗

Influence of posture change on intrarenal arterial resistive index measurement.

BACKGROUND: We investigated the influence of posture change on intrarenal arterial resistive index measurement in 80 subjects (38 male, 42 female). METHODS: Three interlobar arteries in the superior, middle, and inferior parts of the right kidney in each subject were examined by color Doppler ultrasound in two different positions (left lateral decubitus and supine). Based on the movement of the kidney caused by posture change, 23 subjects were classified as having a highly mobile kidney (group I) and the other 57 subjects were classified as not having a highly mobile kidney (group II). RESULTS: Fifty-eight kidneys (72.5%), 19 in group I (82.6%) and 39 in group II (68.4%), showed higher resistive index values in the lateral decubitus position than in the supine position. The influence of posture change on resistive index measurement was significant ( p < 0.001 for all subjects, p < 0.01 for group I, p < 0.05 for group II). The ranges of resistive index differences caused by posture change were 0-0.13 for group I and 0-0.11 for group II. The difference in resistive index caused by posture change was not significant between groups. CONCLUSION: Posture change is a potential confounding factor for intrarenal resistive index measurement.

Adult↗

Postural control in horizontal benign paroxysmal positional vertigo.

Sixteen patients affected by benign paroxysmal positional vertigo of the horizontal semicircular canal (BPPV-HSC) were investigated by means of dynamic posturography (DP) and during bithermal caloric stimulation. Data were compared to data from 40 patients with benign paroxysmal positional vertigo of the posterior semicircular canal (BPPV-PSC) and 20 healthy controls. No postural deficit was observed before or after a liberative Lempert's manoeuvre when patients were compared to control subjects. BPPV-PSC postural scores were significantly impaired compared to scores from the BPPV-HSC group. A residual significant postural impairment was also observed after a successful liberative manoeuvre in the BPPV-PSC group. Electronystagmographic recordings before recovery revealed significant hypoexcitability of the affected ear in 8/16 patients of the BPPV-HSC group. After the liberative manoeuvre, a symmetric bilateral response to caloric stimulation was recorded in all patients. Three main conclusions can be drawn from the present data. First, disorders of the horizontal semicircular canal do not change postural control. Second, dynamic posturography can detect the postural imbalance due to posterior semicircular canal dysfunction even after resolution of paroxysmal vertigo attacks. Third, utricular dysfunction can be ruled out as a cause of the residual postural deficit observed in BPPV-PSC patients. Therefore the recovery delay observed even 1 month after the liberative manoeuvre in the BPPV-PSC-group might be due to the persistence of small amounts of residual debris in the canal, to paralysis of ampullar receptors, or to the time needed for central vestibular re-adaptation.

Caloric Tests↗

Multisensory fusion and the stochastic structure of postural sway.

We analyze the stochastic structure of postural sway and demonstrate that this structure imposes important constraints on models of postural control. Linear stochastic models of various orders were fit to the center-of-mass trajectories of subjects during quiet stance in four sensory conditions: (i) light touch and vision, (ii) light touch, (iii) vision, and (iv) neither touch nor vision. For each subject and condition, the model of appropriate order was determined, and this model was characterized by the eigenvalues and coefficients of its autocovariance function. In most cases, postural-sway trajectories were similar to those produced by a third-order model with eigenvalues corresponding to a slow first-order decay plus a faster-decaying damped oscillation. The slow-decay fraction, which we define as the slow-decay autocovariance coefficient divided by the total variance, was usually near 1. We compare the stochastic structure of our data to two linear control-theory models: (i) a proportional-integral-derivative control model in which the postural system's state is assumed to be known, and (ii) an optimal-control model in which the system's state is estimated based on noisy multisensory information using a Kalman filter. Under certain assumptions, both models have eigenvalues consistent with our results. However, the slow-decay fraction predicted by both models is less than we observe. We show that our results are more consistent with a modification of the optimal-control model in which noise is added to the computations performed by the state estimator. This modified model has a slow-decay fraction near 1 in a parameter regime in which sensory information related to the body's velocity is more accurate than sensory information related to position and acceleration. These findings suggest that: (i) computation noise is responsible for much of the variance observed in postural sway, and (ii) the postural control system under the conditions tested resides in the regime of accurate velocity information.

Adult↗

Postural sway at ground and bevel levels in subjects with spina bifida occulta.

To assess whether the postural function is impaired by comparing the performances in upright standing at ground and bevel levels in adult subjects with spina bifida occulta (SBO). Eighty subjects with SBO (38 with minor type and 42 with major type) and 35 healthy control subjects participated in the study. All participants performed ten tests while standing upright on a platform at ground level (0 degrees, baseline) and on a beveled surface (with their feet in dorsiflexion and plantarflexion at 10 degrees and 20 degrees). Tests were done with their eyes open and closed. The postural sway was examined using a force platform (CATSYS, Danish) that records sway intensity and velocity. Sway intensity and sway velocity were universally associated with group, degree of bevel, open- or closed-eyes condition, and dorsiflexion or plantarflexion after adjusting for age and gender. With respect to sway intensity, the differences of minor or major SBO group were significantly decreased at different bevel degrees when compared with control groups, whereas the differences between minor and major SBO were significant differences at 10 degrees and 20 degrees. With respect to sway velocity, the differences of major SBO group were significantly decreased at different bevel degrees when compared with minor SBO and control groups, whereas the difference in minor SBO was only significant at 0 degrees when compared with control. Group differences (minor SBO vs. control, major SBO vs. control) showed a significant decrease in sway velocity when comparing at 10 degrees than at 0 degrees and at 20 degrees than at 0 degrees. In all subjects with SBO, the sway intensity/velocity values obtained with open eyes and with plantarflexion had lower values, when compared with values obtained with closed eyes and with dorsiflexion. This study supports the hypothesis that SBO impairs control of postural sway in both the resting upright and stressful postures. Our results imply that the larger the bone defect at the lumbosacral midline, the more the group differences in different stressful conditions. Both velocity and intensity were able to reflect the function of the postural sway from our results. This is the first report to add the bevel degree and foot position, as well as visual input as being the part of the study in investigating the postural sway.

Adult↗

The effect of captopril on postural hemodynamics and autonomic responses in chronic heart failure.

Both postural abnormalities and autonomic dysfunction have been identified in patients with chronic congestive heart failure (CHF). However, the effect of long-term vasodilator therapy on these phenomena has not been assessed. In this study the hemodynamic and plasma norepinephrine (PNE) responses to upright posture, as well as the cold pressor test and Valsalva's maneuver in 12 patients with severe chronic CHF during both acute and long-term captopril (CPT) therapy, were evaluated. This revealed an absence of the normal hemodynamic adjustments to upright posture and a blunted response of PNE. The heart rate and blood pressure responses to the cold pressor test and Valsalva's maneuver were similarly blunted. The reflex adjustments of systemic resistance during tilt improved with CPT therapy, but the absence of reflex tachycardia in the upright posture persisted. Additionally, there was improvement of the PNE response, and the responses of heart rate and blood pressure to the cold pressor test were virtually normalized during long-term CPT therapy. The abnormal response to the Valsalva maneuver persisted. In conclusion, hemodynamic and reflex-mediated responses to upright posture and the standard assessment of autonomic control mechanisms revealed abnormal patterns in heart failure. While the hemodynamic adjustment to postural changes and sympathetic responsiveness were improved with CPT, complete correction of these abnormalities did not occur. Whether the improvement was a nonspecific vasodilator effect or the result of specific CPT therapy remains to be determined.

Adult↗

Regulation of atrial natriuretic peptide release in pregnancy: responses to posture.

The response of plasma atrial natriuretic peptide to three changes in posture that alter atrial stretch was examined in the late phase of pregnancy: (1) after 20 minutes in lateral recumbency, remaining upright for 2 hours decreased median plasma atrial natriuretic peptide values from 37.8 (25th percentile, 22.9 and 75th percentile; 64.2) to 21.8 (10.1 and 28.4) pg/ml in pregnant women (p less than 0.05) and from 39.2 (27.8 and 51.2) to 24.0 (18.9 and 35.4) pg/ml (p less than 0.001) in age-matched nonpregnant women; (2) prolongation of lateral recumbency from 20 to 80 minutes increased median plasma atrial natriuretic peptide levels from 31.9 (25.6 and 37.3) to 47.8 (33.0 and 74.6) pg/ml in pregnant women (p less than 0.001) and from 36.5 (22 and 58.6) to 54.0 (36.3 and 111.7) pg/ml in nonpregnant women (p less than 0.01); (3) adoption of supine posture during the late phase of normal pregnancy did not alter median plasma atrial natriuretic peptide values significantly [30.4 (26.7 and 42.5) pg/ml during lateral recumbency compared with 34.2 (25.4 and 43.5) pg/ml while supine]. Plasma atrial natriuretic peptide values fell after supine posture in only half the women and supine hypotension occurred in one subject. These studies demonstrate that upright and prolonged lateral recumbent postures significantly influence plasma atrial natriuretic peptide values during pregnancy, as they do in the nonpregnant state, but that supine posture does not alter plasma atrial natriuretic peptide values significantly. Posture must be carefully accounted for in any study of plasma atrial natriuretic peptide in pregnancy.

Adult↗

Fastigial influences on postural tonus as studied by kainate lesions and by local infusion of GABAergic drugs in the rat.

Localized lesions with kainic acid (KA) and local infusion of GABAergic drugs were used to study the role of the nucleus fastigii (NF) in postural tonus. Unilateral axon-sparing KA lesions of NF resulted in ipsilateral limb extensor atonia and contralateral limb extensor hypertonus and abduction. This effect lasted for 3-8 days depending on the dose of KA. Lesions of sites adjacent to the NF failed to produce postural asymmetries. Local infusion of the GABA agonist muscimol (10-50 ng) in the NF produced a reversible postural asymmetry fenomenologically similar to that produced by KA lesions of NF. Infusion of agents blocking GABAergic transmission in the NF (bicuculline, picrotoxin) resulted in a postural asymmetry of inverted laterality in respect to that produced by muscimol. Bilateral KA lesions of NF or bilateral infusion of muscimol resulted in bilateral hyperextension-abduction of the limbs. Infusion of GABAergic drugs in areas adjacent to the NF failed to produce postural changes. The results are interpreted to indicate that the NF exerts a crossed inhibitory and a direct excitatory influence on limb postural tonus.

Animals↗

Postural change and straining induced by distension of the rectum, vagina and urinary bladder of decerebrate dogs.

In decerebrate dogs, stimulation of pelvic afferent fibres and distension of the rectum, vagina and urinary bladder brought about a sustained postural change and rhythmic abdominal compression. The posture, which resulted from flexion of the back and stifle joints, extension of the hip joints and lifting of the tail, was rhythmically intensified with the abdominal compression. The sustained and rhythmic postural changes are similar to those observed in conscious dogs during defaecation. Intratracheal pressure increased with the abdominal compression. Nervous outflow to the muscles of the glottis, diaphragm, abdominal wall, tail and rear legs changed as would be expected from both the postural changes and the increases in intratracheal and intra-abdominal pressure. Nervous outflow to the external sphincter muscles of the anus and urethra increased simultaneously with both kinds of postural change; however, the increased outflow to the anus was suppressed when defaecation was initiated, and the outflow to the urethra was suppressed when micturition was initiated. In about one-third of the dogs, decreases in the outflow of the pelvic rectal branch and slight increases in the outflow of the vesical branch occurred synchronously with the abdominal compression. These results show that postural change and straining for defaecation, micturition and parturition are reflexly organized by the lower brainstem and the spinal cord.

Action Potentials↗

Practice, problems and compliance with postural drainage: a survey of chronic sputum producers.

Fifty outpatients with chronic respiratory disease, who had previously been requested to perform regular postural drainage, were asked to complete a questionnaire designed to assess their usual practice of postural drainage, their impression of its value and their problems and compliance with it. The group performed a median of one session of postural drainage lasting 15 minutes daily, increasing to two sessions lasting nearly 40 minutes daily during exacerbations of chest symptoms. Seventeen patients had difficulty finding time for postural drainage, 15 found it distasteful and in 17 postural drainage caused discomfort or pain. Twenty-seven patients were judged to be performing inadequate postural drainage, despite individual initial instruction and regular follow-up in a respiratory outpatient clinic. Other diverse reasons for poor compliance revealed by the survey are discussed and recommendations made to encourage improved compliance.

Adolescent↗

Postural effects on blood pressure reactivity: implications for studies of laboratory-field generalization.

This study was designed as an in-laboratory evaluation of the significance of postural blood pressure (BP) adjustments in the investigation of laboratory-field generalization. Blood pressure responses were monitored while 20 subjects completed a mental arithmetic task in two postures, seated and standing. Baseline data were also collected in each posture. The standing challenge was regarded as a laboratory representation of real-world standing challenges. Reactivity scores for the seated stressor were calculated as seated task level minus seated baseline level. For the standing stressor, they were calculated in two ways; standing task level minus standing baseline, and standing task level minus seated baseline. It was hypothesized that the standing reactivity scores calculated from standing baselines (i.e. from the same-posture baselines) would be more highly correlated with seated reactivity than would the standing reactivity scores calculated using sitting baselines. This was not found to be the case for either SBP or DBP. Absolute task SBP levels were very similar in both postures, while they were significantly different for DBP, with standing task levels being higher. It was concluded that ignoring posture will not mask SBP reactivity associations between laboratory and field, but that it may do so for DBP, particularly in future studies as our overall understanding of laboratory-field generalization increases.

Adolescent↗

Clinical correlates of motor performance during paced postural tasks in Parkinson's disease.

Bradykinesia and hypokinesia may both play a significant role in postural instability commonly seen in patients with Parkinson's disease. We investigated which factor--movement time or movement amplitude--is the more significant limiting variable in patients with Parkinson's disease during a paced postural task. We also assessed the effect of antiparkinson medication upon these movement factors and the degree of correlation with changes in clinical performance. Subjects performed paced left-right (L-R) and forward-backward (F-B) continuous weight-shifting tasks at slow, medium and fast paces. Ten Parkinson patients were studied both OFF and ON their usual antiparkinson medication. Ten age-matched healthy controls were also tested and subsequently retested on the same schedule as the patients. Movement times and amplitudes were measured and correlated with clinical changes in UPDRS motor subscores. Parkinson patients performed similar to controls with respect to movement time, but significantly displayed underscaled (reduced) movement amplitude. Movement amplitude improved after antiparkinson medication, but remained significantly less than that of controls. Improvements in L-R movement amplitude correlated with clinical improvements in bradykinesia and postural instability, while improved F-B movement amplitude correlated only with reduced postural instability. We conclude that hypometric movement amplitude, and not abnormal movement time, is the primary abnormality observed in Parkinson patients during a paced postural task. Amplitude underscaling seems antiparkinson medication-dependent and improvement correlates with favorable clinical changes in bradykinesia and postural instability scores.

Aged↗

Effect of posture on inter-regional distribution of pulmonary perfusion and VA/Q ratios in man.

Using a gamma camera regional pulmonary perfusion per unit alveolar volume (Q/VA) and ventilation-perfusion ratios (VA/Q) were measured in fourteen normal male volunteers in upright, supine, lateral decubitus, prone and prone suspended postures with inhalation and intravenous infusion of radioactive 81Krm (half-life 13 sec) and inhalation of radioactive 85Krm (half-life 4.4 h). In the vertical axis, Q/VA increased from upper to lower lung regions in upright, lateral decubitus, prone and prone suspended postures but was uniform in supine and within the dependent lung in decubitus postures. Horizontally, Q/VA decreased from cranial to caudal in lateral decubitus, prone suspended, and near the diaphragm in supine. Vertically, VA/Q decreased from upper to lower in all postures except in supine and within the dependent decubitus lung where it increased. VA/Q tended to increase from cranial to caudal in horizontal postures. The effects of gravity on Q/VA and VA/Q vertical distributions are modified when FRC is low (supine, lower decubitus lung) because perfusion is more uniformly distributed. Horizontal gradients of Q/VA and VA/Q are more pronounced under conditions of high local lung volume but also occur in postures where FRC is low.

Adult↗

Triangularis sterni muscle use during eupnea in humans: effect of posture.

The electromyograms of the triangularis sterni (transversus thoracis), of the abdominal external oblique, and of the deeper abdominal muscle layer (internal oblique or transversus abdominis) were recorded with concentric needle electrodes in twenty normal naive subjects breathing quietly in the supine and the standing posture. The triangularis sterni and abdominal muscles were usually silent in the supine posture. In contrast, all subjects in the standing posture showed activity in the abdominal muscles, and sixteen subjects also had activity in the triangularis sterni. The abdominal muscle activity was principally tonic, unrelated to the phases of the breathing cycle, whereas in fifteen subjects the triangularis sterni activity was confined to expiration. Expiratory activation of the triangularis sterni was more frequently observed in the older than in the younger subjects of the study. These observations indicate that unlike in the supine posture, most normal subjects when breathing at rest in the standing posture recruit both the triangularis sterni and the abdominal muscles. This recruitment may compensate for the adverse effects of the standing posture on the diaphragm and rib cage inspiratory muscles.

Adolescent↗

Both motor and sensory abnormalities contribute to changes in foot posture in an experimental rat neuropathic model.

This study was undertaken to find out whether pain contributes to abnormal posture of the foot in rats displaying neuropathic pain behaviors, and if so, whether there is a specific abnormality which reflects the level of pain. We used a rat model of neuropathic pain which is produced by tightly ligating the L5 and L6 spinal nerves just distal to the dorsal root ganglion (DRG). The operation produced neuropathic pain behaviors along with abnormal foot posture as has been shown previously. On the other hand, injury to the same somatic sensory and motor fibers at a more proximal site by sectioning dorsal and ventral roots of the same segments did not produce neuropathic pain behaviors. Rats with dorsal and ventral rhizotomies showed an abnormality of foot posture despite the absence of neuropathic pain behaviors. However, the abnormality in these rats was less severe and lasted for a shorter period of time as compared to rats with spinal nerve ligation. This suggests that peripheral nerve injury in our rat neuropathic pain model produces a foot postural abnormality partially due to motor deficit. However, there is an additional component of the abnormality that is related to sensory function, possibly pain. Close examination of the data indicate that there is no single obvious abnormal foot posture which exclusively represents motor deficit or sensory abnormality. Rather, neuropathic rats are likely to display abnormal foot posture as a result of a complex mixture of motor and sensory abnormalities.

Animals↗