Sex-specific association between obesity and self-reported falls and injuries among community-dwelling Canadians aged 65 years and older.

This study investigated the relationship between body mass index (BMI) and falls among community-dwelling elderly. Results indicate that obesity is associated with increased falls and there appears to be a sex-specific difference with obese men at higher risk of falling. Obesity is identified as a risk factor for falls in men. INTRODUCTION: The prevalence of falls, fall-related injuries, and obesity has increased over the last decade. The objectives of this study were to investigate sex-specific association and dose-response relationship between BMI and falls (and related injuries) among community-dwelling elderly. METHODS: Our study sample consisted of 15,860 adults aged 65 years or older (6399 men and 9461 women) from the 2008-2009 Canadian Community Health Survey-Healthy Aging (CCHS-HA). Falls, fall-related injuries, and BMI measures were self-reported. For both sex, dose-response curves presenting the relationship between BMI, falls, and fall-related injuries were first examined. Thereafter, multivariate logistic regression analyses were also performed to investigate these relationships after adjustment for potentially confounding variables. RESULTS: Of women, 21.7 % reported a fall and 16.9 % of men. The dose-response relationship between BMI and prevalence of falls showed that underweight and obese individuals reported falling more than normal and overweight individuals; this being more apparent in men than women. Finally, the dose relationship between BMI and prevalence of fall-related injuries showed that only obese men seem more likely to have sustained a fall-related injury. Results from the multivariate analysis showed that obesity in men was significantly associated with higher odds of falling odds ratio (OR) 1.33 (1.04-1.70) and was not significantly associated with higher odds of fall-related injuries OR 1.10 (0.66-1.84) over a 12-month period compared to normal weight men. For women, obesity was not significantly associated with higher fall prevalence OR 0.99 (0.79-1.25) and fall-related injuries OR 0.71 (0.51-1.00). CONCLUSION: Obesity is associated with self-reported falls, and there appears to be a sex-specific difference in elderly persons.

Weight loss and muscular strength affect static balance control.

OBJECTIVE: Overweight individuals sway more than normal weight individuals. Major weight loss improves their balance control despite a related decrease in muscle strength. Presumably, muscular strength is an important factor for balance control. This study investigated the effect that a change in body mass has on relative strength and balance control. METHODOLOGY: Force (isometric knee extension) and balance control (center of pressure speed and range) were studied in three groups; normal weight (BMI <25 kg m(-2)), obese (30 kg m(-2) 40 kg m(-2)) Caucasian male individuals. RESULTS: The excess obese individuals who underwent bariatric surgery as a weight loss strategy were studied before, 3 and 12 months after losing on average, 66.9 kg (+/-95% CI 55.8, 77.9 kg; on average, 45% of their weight). The obese individuals who underwent diet modifications were studied before dieting and when resistance to weight loss occurred after losing on average 11.7 kg (+/-95% CI 9.3, 14.2 kg; on average, 12% of their weight). The control group was studied twice, 50 weeks apart. In obese and excess obese individuals, losing weight reduced absolute knee muscular strength on average, by 8.2 kg (+/-95% CI 3.9, 12.5 kg; on average, 10% of their strength) and 23.9 kg (+/-95% CI 12.1, 35.8 kg; on average, 33% of their strength). However, it also increased balance control measured with speed of the center of foot pressure, on average, by 0.10 cm s(-1) (+/-95% CI 0.05, 0.14 cm s(-1); or increased of 12%) and 0.28 cm s(-1) (+/-95% CI 0.07, 0.47 cm s(-1); increased of 27%), respectively. Relative strength increased approximately by 22% for only the excess obese group 12 months post surgery. CONCLUSION: This suggests, in overweight individuals, weight loss is more efficient at improving balance control than increasing, or even maintaining muscle strength. In these individuals, training programs aimed at improving balance control should primarily target weight loss.

Can prepared anticipatory postural adjustments be updated by proprioception?

Stepping over an obstacle is preceded by a center of pressure (CoP) shift, termed anticipatory postural adjustments (APAs). It provides an acceleration of the center of mass forward and laterally prior to step initiation. The APAs are characterized in the lateral direction by a force exerted by the moving leg onto the ground, followed by an unloading of the stepping leg and completed by an adjustment corresponding to a slow CoP shift toward the supporting foot. While the importance of sensory information in the setting of the APAs is undisputed, it is currently unknown whether sensory information can also be used online to modify the feedforward command of the APAs. The purpose of this study was to investigate how the CNS modulates the APAs when a modification of proprioceptive information (Ia) occurs before or during the initiation of the stepping movement. We used the vibration of ankle muscles acting in the lateral direction to induce modification of the afferent inflow. Subjects learned to step over an obstacle, eyes closed, in synchrony to a tone signal. When vibration was applied during the initiation of the APAs, no change in the early APAs was observed except in the case of a cutaneous stimulation (low frequency vibration); it is thus possible that the CNS relies less on proprioceptive information during this early phase. Only the final adjustment of the CoP seems to take into account the biased proprioceptive information. When vibration was applied well before the APAs onset, a postural reaction toward the side of the vibration was produced. When subjects voluntarily initiated a step after the postural reaction, the thrust amplitude was set according to the direction of the postural reaction. This suggests that the planned motor command of the APAs can be updated online before they are triggered.

Reducing weight increases postural stability in obese and morbid obese men.

OBJECTIVE: To investigate the effect of weight loss on balance control in obese and morbid obese men. METHODS: In a longitudinal and clinical intervention study, postural stability was measured with a force platform before and after weight loss in men. Weight loss was obtained in obese men (mean body mass index (BMI)=33.0 kg/m(2)) by hypocaloric diet until resistance and in morbid obese men (mean BMI=50.5 kg/m(2)) by bariatric surgery. Morbid obese men were tested before surgery, and 3 and 12 months after surgery when they had lost 20 and nearly 50% of initial body weight, respectively. Normal weight individuals (mean BMI=22.7 kg/m(2)) were tested twice within a 6- to 12-month period to serve as control. Body fatness and fat distribution measures, and posturographic parameters of the center of foot pressure (CP) along the antero-posterior and medio-lateral axes for conditions with and without vision were performed in all subjects. RESULTS: Weight loss averaged 12.3 kg after dieting and 71.3 kg after surgery. Body weight remained unchanged in the control group. After weight loss, nearly all measures of postural stability were improved with and without vision (i.e., CP speed and range in antero-posterior and medio-lateral axes). A strong linear relationship was observed between weight loss and improvement in balance control measured from CP speed (adjusted R (2)=0.65, P<0.001). CONCLUSION: Weight loss improves balance control in obese men and the extent of the improvement is directly related to the amount of weight loss. This should decrease the habitual greater risk of falling observed in obese individuals.

Influence of obesity on accurate and rapid arm movement performed from a standing posture.

INTRODUCTION: Obesity yields a decreased postural stability. The potentially negative impact of obesity on the control of upper limb movements, however, has not been documented. This study sought to examine if obesity imposes an additional balance control constraint limiting the speed and accuracy with which an upper limb goal-directed movement performed from an upright standing position can be executed. METHOD: Eight healthy lean subjects (body mass index (BMI) between 20.9 and 25.0 kg/m(2)) and nine healthy obese subjects (BMI between 30.5 and 48.6 kg/m(2)) pointed to a target located in front of them from an upright standing posture. The task was to aim at the target as fast and as precisely as possible after an auditory signal. The difficulty of the task was varied by using different target sizes (0.5, 1.0, 2.5 and 5.0 cm width). Hand movement time (MT) and velocity profiles were measured to quantify the aiming. Centre of pressure and segmental kinematics were analysed to document postural stability. RESULTS: When aiming, the forward centre of pressure (CP) displacement was greater for the obese group than for the normal BMI group (4.6 and 1.9 cm, respectively). For the obese group, a decrease in the target size was associated with an increase in backward CP displacement and CP peak speed whereas for the normal BMI group backward CP displacements and CP peak speed were about the same across all target sizes. Obese participants aimed at the target moving their whole body forward whereas the normal BMI subjects predominantly made an elbow extension and shoulder flexion. For both groups, MT increased with a decreasing target size. Compare to the normal BMI group, this effect was exacerbated for the obese group. For the two smallest targets, movements were on average 115 and 145 ms slower for the obese than for the normal BMI group suggesting that obesity added a balance constraint and limited the speed with which an accurate movement could be done. SUMMARY: Obesity, because of its effects on the control of balance, also imposes constraints on goal-directed movements. From a clinical perspective, obese individuals might be less efficient and more at risk of injuries than normal weight individuals in a large number of work tasks and daily activities requiring upper limb movements performed from an upright standing position.

Effects of lower limbs muscular fatigue on anticipatory postural adjustments during arm motions in humans.

BACKGROUND: The purpose of the present experiment was to examine the effects of lower limbs muscular fatigue on the anticipatory postural adjustments during a voluntary arm raising movement. METHODS: Eight adult males (mean age 29+/-6 years) voluntarily participated to the experiment. Subjects' task consisted in performing an unilateral ante-flexion of the right arm over 90 deg, holding a 500 g weight, once having stabilized their upright posture. A similar movement execution was required. Measurements were made in a no-fatigue situation and under a high level of fatigue of lower limbs. Surface EMG of four postural muscles (the ipsilateral and contralateral Gastrocnemius and the ipsilateral and contralateral Semitendinosus) and of one muscle involved in the arm raising (the Anterior Deltoïdeus of the right arm) was recorded. Body sway was also monitored using a force platform. RESULTS: With fatigue, quantitative EMG analysis showed a decrease of the ipsilateral Semitendinosus activity whereas the temporal EMG analysis showed an increase of its latency with respect to movement onset. CONCLUSIONS: These data suggested a functional adaptation resulting in an invariance of global anticipatory postural adjustments for the two conditions of no-fatigue and fatigue and ensuring an adequate execution of the movement.

Attentional demands for postural control: the effects of aging and sensory reintegration.

The aim of this experiment was to examine if, with aging, the task of reintegrating sensory information perturbs balance and requires additional attentional demand. Young adults and the elderly were asked to maintain a stable upright posture while standing on a force platform. Visual and ankle proprioceptive information were removed or perturbed and suddenly reinserted. Subjects also had to respond vocally as quickly as possible to an unpredictable auditory stimulus presented before or following a sensory reintegration and in control conditions. Reaction times to the auditory stimuli were used as an index of the attentional demands necessary for calibrating the postural system. Reintegration of proprioception in absence of vision and under vision yielded a faster center of pressure velocity for both groups. This effect, however, was more important for the elderly than the young adults. An increased attentional demand was observed for both groups when proprioceptive information had to be reintegrated in absence of vision. Altogether, these results propose that, for the elderly persons, postural contexts requiring a reweighting of sensory inputs could lead to increased risk for loss of balance and falls if insufficient attentional resources are allocated to the postural task.

The effect of expertise in gymnastics on proprioceptive sensory integration in human subjects.

The ability of experts in motor skills requiring a fine postural control to keep a stable upright posture while facing the task of reinserting proprioceptive information was investigated. Seven expert gymnasts and seven experts in other non-gymnastics sports were asked to stand as immobile as possible in two conditions of vision and no-vision. Within a trial, ankle proprioceptive input was modified by means of tendon vibration of both antagonistic ankle muscles. Center of foot pressure (COP) displacements were recorded using a force platform. Contrasting with the non-gymnasts, the gymnasts were able to rapidly take advantage of the reinsertion of proprioceptive information to decrease their COP displacements. These results suggest that the efficiency of the integration process leading to the reweighting of sensory information can be significantly improved through a specific training.

Increased risk for falling associated with obesity: mathematical modeling of postural control.

Recent epidemiological studies report that obesity is positively related to fracture incidence. In the present experiment, a model of postural control was used to examine the impact of an abnormal distribution of body fat in the abdominal area upon postural stability. Obese and lightweight humanoids were destabilized by imposing a small initial angular speed from a neutral standing position. To avoid a loss of stability yielding a stepping reaction or a fall, an ankle torque is necessary to counteract the perturbation. Three torque parameters--ankle torque onset, time to peak torque, and muscular ankle torque--were entered in a program to simulate the intrinsic variability of the human postural control system. A loss of stability was detected when the center of pressure exceeded stability margins. The most striking observation is the nonlinear increase of torque needed to stabilize the humanoid when the motor response was characterized by delayed temporal parameters. The effect was more pronounced when an anterior position of the center of mass was included in the simulations. This suggests that, when submitted to daily postural stresses and perturbations, obese persons (particularly those with an abnormal distribution of body fat in the abdominal area) may be at higher risk of falling than lightweight individuals.

Effects of a reaction time task on postural control in humans.

The purpose of the present experiments was to investigate the effects of a reaction time (RT) task on postural control, during and following the execution. Three different RT tasks consisting in verbal responses to visual and auditory stimuli were supposed to require different demands on cognitive resources. There was also a control condition in which no concurrent task was required. Postural control was assessed using a force platform. Results showed that (1) center of foot pressure (COP) displacements significantly decreased while concurrently performing the RT tasks, (2) this effect lasted for at least 10 s following the secondary task performance and (3) COP displacements decreased similarly, whatever the attentional requirements of the secondary task.

Pointing to a target from an upright position in human: tuning of postural responses when there is target uncertainty.

Human subjects performed, from a standing position, rapid hand pointings to visual targets located within or beyond the prehension space. To examine the interaction between posture and the goal-directed movement we introduced a visual double-step perturbation requiring a reprogramming of the hand movement. Trials directed towards the same spatial goal but differentiated only by the likeliness of a visual double-step were compared. The hand kinematics was not affected by the uncertainty of the visual perturbation; an increased trunk bending, however, was observed. This suggests that uncertainty constraints are integrated in a predictive manner for the optimal coordination of the hand and postural control systems.

Role of the feedforward command and reafferent information in the coordination of a passing prehension task.

The performances of a deafferented patient and five control subjects have been studied during a self-driven passing task in which one hand has to grasp an object transported by the other hand and in a unimanual reach-to-grasp task. The kinematics of the reach and grasp components and the scaling of the grip aperture recorded for the self-driven passing task were very similar in controls and the deafferented subject (GL). In contrast, for the unimanual task when vision was absent, GL's coordination between reaching and grasping was delayed in space and time compared with the control subjects. In addition, frequent reopening of the grip was observed in GL during the final closure phase of the unimanual prehension task. These results support the notion that afferent proprioceptive information resulting from the reaching movement - which seemed to be used to coordinate reaching and grasping commands in the unimanual task - is no longer necessary in the self-induced passing task. Finally, for the externally driven passing task, when the object was passively transported by the experimenter, the coordination was consistently modified in all subjects; grip aperture onset was delayed, thus asserting a specific contribution of the central command or feedforward mechanisms into the anticipation of the grasp onset observed in the self-driven passing task. The origin and nature of the information necessary for building up the feedforward mechanisms remains to be elucidated.

How efficient are central mechanisms for the learning and retention of coincident timing actions?

We compared the adaptive strategy and retention capacity of a deafferented subject and control subjects when intercepting, with a sliding-throw, an apparent movement coming at various speeds. Subjects were submitted to five practice sessions (30 trials per session) and to a retention test. The throwing kinematics was analysed, and spatial and temporal performance errors were measured. With practice, the deafferented subject showed modifications in movement initiation strategies and throwing patterns. With a slow apparent movement, the deafferented subject's initial behavior was characterized by short movement initiation and movement times. With practice, she showed an important increase in movement time in session 5, allowing longer visual control and leading to better temporal and spatial accuracy than that shown in session 1. In the retention session, the deafferented patient showed a late movement initiation strategy, similar to that of the control subjects. This increased movement initiation time was accompanied by an improved temporal accuracy compared to the deafferented subject's early results. However, spatial accuracy improvement was labile and could not be maintained over the retention interval. At the fast speed, all temporal components of the response, namely, movement initiation time (MIT), movement time (MT), and disk travel time (DTT), were similar for the deafferented and control subjects. Overall, the deafferented subject reduced her temporal error through practice, though without attaining the control subjects' accuracy. However, with a fast-moving stimulus, she showed a deteriorated spatial accuracy, even doubling her spatial errors at retention. In brief, the deafferented subject achieved proper temporal (perceptivo-cognitive) lasting control of her interceptive action, whereas spatial (sensorimotor) regulation raised mnemonic problems.

Contribution of ankle, knee, and hip joints to the perception threshold for support surface rotation.

The purpose of the present experiment was to investigate the extent to which subjects can perceive, at very slow velocities, an angular rotation of the support surface about the medio-lateral axis of the ankle, knee, hip, or neck joint when visual cues are not available. Subjects were passively displaced on a slowly rotating platform at .01, .03, and .05 deg/sec. The subjects' task was to detect movements of the platform in four different postural conditions allowing body oscillations about the ankle, knee, hip, or neck joint. In Experiment 1, subjects had to detect backward and forward rotation (pitching). In Experiment 2, they had to detect left and right rotations of the platform (rolling). In Experiment 3, subjects had to detect both backward/forward and left/right rotations of the platform, with the body fixed and the head either fixed or free to move. Overall, when the body was free to oscillate about the ankle, knee, or hip joints, a similar threshold for movement perception was observed. This threshold was lower for rolling than for pitching. Interestingly, in these postural conditions, an unconscious compensation in the direction opposite to the platform rotation was observed on most trials. The threshold for movement perception was much higher when the head was the only segment free to oscillate about the neck joint. These results suggest that, in static conditions, the otoliths are poor detectors of the direction of gravity forces. They also suggest that accurate perception of body orientation is improved when proprioceptive information can be dynamically integrated.

Deafferentation and pointing with visual double-step perturbations.

The capability of reprogramming movement responses following changes in the visual goal has been studied through the double-step paradigm. These studies have shown that: (a) continuous internal feedback-loops correct unconsciously the dynamic errors throughout the movement; (b) proprioceptive information and/or the efference copy have a privileged status among central processes, insuring on-line regulation of the initial motor commands; and (c) generation of the motor program starts after target presentation, and is continuously updated in the direction of the current internal representation of the target, at least until the onset of hand movement. This main corrective process of the initial program appears to be basically independent of visual reafference from the moving hand. However, the agreement with the possibility of a visuomotor loop, based on the comparison of the new updated representation of the target position and on the information from the moving hand, has not determined whether the correcting process is proprioceptive feedback dependent, or whether internal feedback-loops (efferent copies) are responsible for quick corrections of unfolding motor responses. To answer this question, the present experiment investigated the pointing behavior of a deafferented subject, using a double-step paradigm under various conditions of visual feedback and movement initiation. Overall, the present study (a) clearly showed the capacity of the motor system to modify and correct erroneous trajectories on the mere basis of internal feedback-loops and (b) emphasized the crucial role played by the target jump/arm triggering delay and the importance of the eye efferent copy for providing information about the spatial goal of the movement.

Aging and postural control: postural perturbations caused by changing the visual anchor.

OBJECTIVE: To determine the effect of modifying the stable visual anchor on the postural stability of older individuals. The visual anchor was changed by opening doors similar to those found in an elevator cage. Lighting intensities inside and outside the cage were varied to create increasing or decreasing luminosity conditions. The effect of adding a cognitive load (counting backwards) was also tested. DESIGN: A controlled laboratory study. SETTING: Tests performed in a balance laboratory. MEASUREMENTS: Sensory and clinical measurements to insure the integrity of the central and peripheral nervous system. Measures of balance were derived from the recordings of the center of foot pressure. These measures included range and speed of the center of foot pressure. PARTICIPANTS: Eight older, community-dwelling subjects and nine young subjects participated. A sensorimotor evaluation was used to insure that all older individuals were free from any pathologies affecting postural stability. All participants had a low score (indicating high balance confidence) on the Falls Efficacy Scale and no history of falls. RESULTS: Older individuals were affected by modification of the stable visual anchor induced by the opening of doors similar to that of an elevator cage. They showed greater ranges of the center of foot pressure (COP) and speed of the COP after than before the opening of the doors. Furthermore, the increased ranges and speed were two to three times greater than that observed for the young subjects. A lighting intensity considered as comfortable for reading inside the elevator affected the overall postural stability of the older participants negatively. Counting backwards also decreased their overall stability. CONCLUSION: Changing the stable visual anchor, as when exiting an elevator cage, could be a significant risk factor for older persons. Moreover, when combined with a cognitive load or lower lighting intensity inside the elevator cage, the negative effects on the postural stability of older persons are exacerbated.

Modulation of anticipatory postural adjustments in a reactive and a self-triggered mode in humans.

Five subjects raised their preferred arm until horizontal in one of two experimental conditions: (1) in response to a visual signal (reactive condition), and (2) in a self-triggered condition. In both conditions, subjects were instructed to execute the movement at approximately 80% of their maximal velocity, such that all movements were nearly similar. EMG activity was recorded in a focal muscle (Anterior Deltoidus) and in three postural muscles (ipsi-lateral Gastrocnemius, contra-lateral Tensor Fascia Latae and ipsi lateral Semitendinosus) known to be activated prior to the focal muscle. Results showed greater anticipatory postural adjustments in the self-triggered than in the reactive condition for the three postural muscles. It is suggested that similar intentional movements can be triggered by different timing strategies.

High postural constraints affect the organization of reaching and grasping movements.

In the vast majority of prehension experiments, subjects are requested to grasp a static object and to transport it with respect to the body. There are grasping tasks, however, that have different grasping requirements. For example, in rock climbing, the goal is to grasp a hold to transport the body about the grasped object. Unlike simple reaching and grasping movements, the successful hand grip is not the goal of the task per se, and it is the postural stability that primarily determines the success or failure of the task. In the present experiment, we wanted to examine the influence of such postural constraints on the organization of reaching movements. Four expert climbers participated in the study. A climbing simulator, equipped with strain gauges, measured the vertical forces applied by the hands. The subjects performed grasping movements (one-reach and two-reach conditions) towards holds of various depths (easy and difficult holds) in two different postures (standing and climbing conditions). The results showed that the duration of the right-hand transport phase was similar whatever the condition. Unexpectedly, in the climbing condition, the duration of the left-hand transport phase was shorter when the subjects grasped a difficult than when they grasped an easy hold. This result suggests that, in extreme cases such as rock climbing, the postural constraints may prevail over accuracy constraints, since increasing accuracy requirements did not yield an increased duration of the transport phase.

Target speed alone influences the latency and temporal accuracy of interceptive action.

When intercepting a mobile object or an apparent movement, participants show a temporal bias. They are in advance when dealing with a slow-moving stimulus and late with a fast-moving one. We studied participants intercepting an apparent movement by sliding a disk on a table. Using a fast and a slow stimulus speed, we varied three factors: duration of presentation of the stimulus, distance covered by the stimulus, and speed context (constant or varied) of stimulus presentation. In addition to the temporal bias, spatial accuracy and kinematic measures were collected. The temporal bias created by speed was evident across all three factors. Speed, in addition to strongly determining the temporal bias, significantly affected the throwing strategy adopted by the participants, as revealed by latency, movement time, and disk trajectory duration.