Elsevier

Neuroscience

Volume 267, 16 May 2014, Pages 157-165
Neuroscience

Review
Impaired standing balance: The clinical need for closing the loop

https://doi.org/10.1016/j.neuroscience.2014.02.030Get rights and content

Highlights

  • Impaired balance has a significant impact on health and quality of life in the elderly.

  • There is evidence for therapeutic interventions, which do not focus on underlying systems involved in standing balance.

  • Current clinical balance tests do not allow for identification of the weakest link in impaired standing balance.

  • Closed loop system identification techniques are required to identify underlying causes of impaired balance.

Abstract

Impaired balance may limit mobility and daily activities, and plays a key role in the elderly falling. Maintaining balance requires a concerted action of the sensory, nervous and motor systems, whereby cause and effect mutually affect each other within a closed loop. Aforementioned systems and their connecting pathways are prone to chronological age and disease-related deterioration. System redundancy allows for compensation strategies, e.g. sensory reweighting, to maintain standing balance in spite of the deterioration of underlying systems. Once those strategies fail, impaired balance and possible falls may occur. Targeted interventions to prevent falling require knowledge of the quality of the underlying systems and the compensation strategies used. As current clinical balance tests only measure the ability to maintain standing balance and cannot distinguish between cause and effect in a closed loop, there is a clear clinical need for new techniques to assess standing balance. A way to disentangle cause-and-effect relations to identify primary defects and compensation strategies is based on the application of external disturbances and system identification techniques, applicable in clinical practice. This paper outlines the multiple deteriorations of the underlying systems that may be involved in standing balance, which have to be detected early to prevent impaired standing balance. An overview of clinically used balance tests shows that early detection of impaired standing balance and identification of causal mechanisms is difficult with current tests, thereby hindering the development of well-timed and target-oriented interventions as described next. Finally, a new approach to assess standing balance and to detect the underlying deteriorations is proposed.

Introduction

Impaired standing balance, defined as having difficulties maintaining an upright position in daily life activities, is a common problem among the elderly (Jonsson et al., 2004, Lin and Bhattacharyya, 2012) and has a significant impact on the health and quality of life (Lin and Bhattacharyya, 2012). Impaired standing balance plays a key role in falls (Rubenstein, 2006) and is a strong risk factor for falls (Muir et al., 2010); one third of elderly persons aged 65 or older falls at least once a year (Tinetti and Ginter, 1988, O’Loughlin et al., 1993, Luukinen et al., 1994, Stalenhoef et al., 1999, Chu et al., 2005). Ten percent of falls among community-dwelling elderly persons result in serious injuries, such as hip fractures (1–2%), other fractures (3–5%) or head injuries (5%) (NVKG, 2004). A quarter of the deaths in home situations are the result of falls (CBS, 2013). Furthermore, falls are related to psychosocial factors such as fear of falling and social isolation. (Tinetti et al., 1994, Vellas et al., 1997); the resulting restricted mobility may further deteriorate standing balance (Vellas et al., 1997, Allison et al., 2013). Therefore, falls have a profound socioeconomic impact (Hartholt et al., 2012). To prevent falling, targeted interventions improving standing balance are needed which requires knowledge of the underlying cause of impaired standing balance at an early stage.

The ability to maintain balance requires appropriate interaction of several key systems, i.e. the motor (muscles), nervous and sensory systems, connected via efferent and afferent signal pathways resulting in a closed loop in which cause and effect are interrelated. Aforementioned systems deteriorate with advanced age (Horak et al., 1989, Manchester et al., 1989, Sturnieks et al., 2008) and as a result of specific diseases and medication use (Konrad et al., 1999). System redundancy allows for compensation strategies to maintain balance and so it is only when those strategies fail, e.g. in cases of severe system deterioration, multiple system deterioration and/or environmental disturbances exceeding system resilience, that impaired balance and finally falling may occur. Impaired balance may thus go unnoticed until an advanced stage.

Current clinical balance tests, such as the Berg balance scale (BSS) and the short physical performance battery (SPPB), include an assessment of the ability to maintain standing balance during challenging standing conditions (Whitney et al., 1998, Langley and Mackintosh, 2007) by narrowing the base of support or closing the eyes. However, identification of cause-and-effect relations, primary deterioration and compensation strategies, and ultimately the quality of the underlying systems requires new technical approaches such as closed loop system identification techniques. This allows for early failure detection, so that there are no missed opportunities for targeted interventions and disease management.

The present paper outlines the clinical need for proper balance assessment, describes the available balance tests and proceeds to describe promising control engineering-based solutions and their applicability for clinical practice.

Section snippets

Deterioration of standing balance

Advanced age in combination with (multi) morbidity and the use of medication will result in a variety of deterioration patterns in the underlying systems involved in maintaining standing balance, which subsequently results in a widely heterogeneous pathophysiology of impaired standing balance among the elderly (Horak et al., 1989). Changes in the sensory systems lead to conflicting and inaccurate sensory information about body position. Motor system changes comprise low muscle mass and

Clinical balance tests

Clinical balance tests are developed to assess physical performance, such as the Tinetti balance test (Tinetti, 1986), the functional reach test (Duncan et al., 1990), the BBS (Berg, 1989), the clinical balance test of sensory interaction and balance (CTSIB) (Shumway-Cook and Horak, 1986), the SPPB (Guralnik et al., 1994), the balance error scoring system (BESS) (Finnoff et al., 2009), the star excursion balance test (SEBT) (Gribble et al., 2012) and the Romberg’s test (Rogers, 1980). As daily

Interventions to improve standing balance

Individually targeted multifactorial intervention, including individual risk assessment, is shown to be the most effective with a significant and beneficial effect on the rate of falling (Gillespie et al., 2012). However, due to the lack of clinical tests that can make a distinction between underlying causes of impaired standing balance, nowadays general fall prevention interventions are used, comprising exercising, environmental modification, medication optimization, education, or a

A new method to identify the underlying cause of impaired standing balance

As with current clinical balance tests and posturography it is difficult to identify and to distinguish the primary deterioration of the various underlying systems and the used compensation strategies which are needed to prescribe targeted interventions, there is a clear clinical need for novel techniques to assess standing balance.

Conclusion

There is a clinical need for new techniques to assess standing balance that can detect the underlying cause and primary deterioration in impaired standing balance at an early stage. Externally applied disturbances in combination with closed loop system identification techniques may fill the void, which makes it possible to intervene in impaired standing balance, at an early stage, with targeted interventions.

Acknowledgments

This research is supported by the Dutch Technology Foundation STW, which is part of the Netherlands Organization for Scientific Research (NWO), and which is partly funded by the Ministry of Economic Affairs. Furthermore, this research is supported by the seventh framework program MYOAGE (HEALTH-2007-2.4.5-10).

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