This research work was supported by NIH grant R01 DC009031. Thanks to Sharon L Congdon, Melody A Fregia, and Nathan Silver for technical support.

The test methodologies described in this study were developed with healthy control subjects and patients with vestibular disorders. Healthy control subjects had no known history of neurologic, otologic, or musculoskeletal disorders. Patients with vestibular disorders had abnormal responses on a battery of objective tests of the vestibular system, including tests of the vestibulo-ocular reflex in darkness, positional tests, and cervical vestibular-evoked myogenic potentials. These studies were approved by the Institutional Review Board for Human Subjects Research at Baylor College of Medicine, Houston, Texas, USA.
NOTE: In a study of 1869, healthy subjects aged 4 to 85 years who were tested at Space Center Houston, a community science education center, subjects were tested with the methodology described in this paper. Participants first removed their shoes but wore socks. Science educators then tested participants on Tandem Walking with eyes closed and on CTSIB on compliant foam with three conditions, each with eyes closed, standing still with the head still, standing still with slow head nodding in pitch (up/down), and standing still with slow head shaking in yaw (right/ left).
1. Patients/research subjects
<ol>
	<li>Ensure that individuals can stand erect, unsupported, for at least 30 s. They must be able to follow the instructions.</li>
</ol>
2. Environment and equipment
<ol>
	<li>Perform the tests in a well-lighted room with a firm surface, e.g., vinyl tile or industrial carpeting. Do not perform these tests on plush carpeting.</li>
	<li>Use a stopwatch, clock with a second hand, or digital timer for CTSIB. No timing device is needed for TW.</li>
	<li>To perform CTSIB, use medium-density, compliant foam which meets the following compliance criterion: PSI = 0.85-0.95. This type of foam is commonly known as temper foam or memory foam. The norms were developed with foam of the following size: 40.64 cm X 45.72 cm X 10 cm. A larger slab of foam may be used if desired, but it is not necessary. 
	&#8203;NOTE: More than one manufacturer makes this foam. Using the foam with the correct compliance characteristics is essential. If another type of foam is used, the published norms will not apply.</li>
</ol>
3. Methodology for CTSIB
<ol>
	<li>Place the foam near a corner of the room or a wall for safety. Have the individual first practice the test on the floor with eyes open to learn the basic movements involved.
	<ol>
		<li>Instruct the individual being tested to stand erect, not touching anything against the legs or back, with feet together, side by side. Ensure that the individual&#39;s arms are crossed at the waist, with each hand holding the contralateral elbow or comfortably crossed at the waist.</li>
		<li>Instruct the individual to look straight ahead. Perform 1-3 test trials for 5-10 s, on the foam, with arms crossed at the waist, feet adjacent, standing erect and looking straight ahead, with nothing touching the legs or back.</li>
		<li>To steady the individual, place a hand on the person&#39;s shoulder while the person looks straight ahead.</li>
		<li>To start the test trial say, &#34;Close your eyes&#34;. Remove the hand from the person&#39;s shoulder, say &#34;Go&#34;, and begin timing the trial for up to 30 s. Perform this trial only once. If the individual appeared frightened, distracted by a noise, or did not understand the instructions, perform a second trial and consider the first trial a training trial. 
		NOTE: The individual will have increased postural sway with eyes closed, which may be a source of concern to the person being tested. Gently advise the individual not to worry about it.</li>
		<li>Dependent measure: Measure the time the individual can maintain the erect posture before making an error, up to 30 s, for each CTSIB condition. 
		&#8203;NOTE: Errors are opening the eyes, moving the arms, taking a step, or leaning against the wall.</li>
	</ol>
	</li>
	<li>Perform Trial 1 with the head stationary. If the person has difficulty on Trial 1 the first time, consider that trial a training trial, and give it a second time. Use the score from the second trial.</li>
	<li>Perform Trial 2 with head nodding (up/down) slowly at 0.3 Hz in time to a real metronome or digital metronome application.
	<ol>
		<li>Prior to starting Trial 2, have the individual stand on the floor with eyes open and practice nodding the head in time to the sound until the maximum upper and lower head movements occur in time to the maximum and minimum sounds on the application so that the individual can move at 0.3 Hz.</li>
		<li>To perform Trial 2, instruct the individual to stand on the foam, with feet adjacent and arms crossed, as in Trial 1.</li>
		<li>Start the sound on the metronome or metronome app before the individual closes his/ her eyes. Then instruct the individual to close his/ her eyes while the hand of the investigator is on the person&#39;s shoulder to steady him/her.</li>
		<li>To begin Trial 2, instruct the individual to nod his/her head (head moves up/ down) in time to the sound when &#34;Go&#34; is heard.</li>
		<li>Remove the hand from the individual&#39;s shoulder, say &#34;Go&#34; and simultaneously start the timer.</li>
		<li>After this trial, allow the individual to rest for a few seconds by stepping off the foam and sitting down if desired.</li>
	</ol>
	</li>
	<li>Perform Trial 3 with the head shaking (left/right) at 0.3 Hz, in time to the sound. Otherwise, use the same procedure for Trial 2.</li>
</ol>
4. Methodology for Tandem Walking
<ol>
	<li>Make sure the room has no obstructions where the individual will walk over a distance of approximately 4.5 m forward and approximately 1 m on either side of the individual. More space can be used but is not required.</li>
	<li>Demonstrate the test for the individual for 3 to 5 steps: Put one foot heel-to-toe in front of the other foot. Repeat for 4 more steps so the individual will know the task.</li>
	<li>Practice trial:
	<ol>
		<li>Instruct the individual to perform a practice trial with eyes open, arms crossed at the waist as for the CTSIB, without wearing shoes but wearing socks for good hygiene.</li>
		<li>Have the individual place one foot directly in front of the other, with no more than 2.4 cm (1 inch) between the front and rear feet. Ensure that the individual performs the practice trial for up to 5 steps. If needed, use more than one practice trial for the individual to understand the motor task.</li>
	</ol>
	</li>
	<li>Test trial: Have the individual stand with arms crossed, feet at a comfortable distance apart, without wearing shoes but wearing socks for good hygiene. Instruct the individual to close his/her eyes and perform 10 heel-to-toe steps, as described in step 4.3, when the investigator says, &#34;Go.&#34;</li>
	<li>Do not time the test.</li>
	<li>Dependent measure: Measure the total number of correct tandem steps performed out of 10 steps, even if the steps are not consecutive. To count incorrect steps, count with the fingers of one hand, the way children use fingers to count. Count the total number of steps aloud, but do not say the number of incorrect steps aloud during the test. 
	&#8203;NOTE: Errors are: opening the eyes, moving the arms, stepping out of line, or stepping too far ahead of the rear foot.</li>
</ol>
5. Scoring for CTSIB and TW
<ol>
	<li>To score the trials, two sources provide data. Use the norms for children and young adults on CTSIB and TW from the paper with those published data9. Also, CTSIB and TW norms for adults aged 21 to 90 are available in the paper with those published data8.</li>
	<li>Compare the individual&#39;s scores to the published data to determine if the scores are normal or abnormal for the individual&#39;s age group and, for CTSIB, for each condition.</li>
</ol>

Implementing Vestibular Disorder Screening Tests

<ol>
	<li>Wilson, V. J., Melvill Jones, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Mammalian Vestibular Physiology. , (1979).</li><li>Bergen, G., Stevens, M. R., Burns, E. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Falls+and+fall+injuries+among+adults+aged+&#8805;65+years-United+States,+2014.">Falls and fall injuries among adults aged &#8805;65 years-United States, 2014.</a> MMWR Morbidity and Mortality Weekly Report. 65 (37), 993-998 (2016).</li><li>Burns, E., Kakara, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Deaths+from+falls+among+persons+aged+&gt;+65+years+-+United+States,+2017+-+2016.">Deaths from falls among persons aged &gt; 65 years - United States, 2017 - 2016.</a> MMWR Morbidity and Mortality Weekly Report. 67 (18), 509-514 (2018).</li><li>Strupp, M., Brandt, T., Dieterich, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Vertigo and Dizziness. , (2023).</li><li>Lanska, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Romberg+sign+and+early+instruments+for+measuring+postural+sway.">The Romberg sign and early instruments for measuring postural sway.</a> Seminars in Neurology. 22 (4), 409-418 (2002).</li><li>Horak, F. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+measurement+of+postural+control+in+adults.">Clinical measurement of postural control in adults.</a> Physical Therapy. 67 (12), 1881-1885 (1987).</li><li>Gosselin, G., Fagan, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Foam+pads+properties+and+their+effects+on+posturography+in+participants+of+different+weight.">Foam pads properties and their effects on posturography in participants of different weight.</a> Chiropractic &amp; Manual Therapies. 23 (1), 2 (2015).</li><li>Lin, C. -. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Test-retest+reliability+of+postural+stability+on+two+different+foam+pads.">Test-retest reliability of postural stability on two different foam pads.</a> Journal of Nature and Science. 1 (2), e43 (2015).</li><li>Cohen, H. S., Sangi-Haghpehkar, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Differences+in+responses+on+the+modified+clinical+test+of+sensory+interaction+and+balance+on+medium+firm+and+medium+density+foam+in+healthy+controls+and+patients+with+vestibular+disorders.">Differences in responses on the modified clinical test of sensory interaction and balance on medium firm and medium density foam in healthy controls and patients with vestibular disorders.</a> Biomedicine Hub. 5 (1), 1548-1555 (2020).</li><li>Patel, M., Fransson, P. A., Lush, D., Gomez, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+foam+surface+properties+on+postural+stability+assessment+while+standing.">The effect of foam surface properties on postural stability assessment while standing.</a> Gait &amp; Posture. 28 (4), 649-656 (2008).</li><li>Cohen, H. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tandem+walking+as+a+quick+screening+test+for+vestibular+disorders.">Tandem walking as a quick screening test for vestibular disorders.</a> The Laryngoscope. 128 (7), 1687-1691 (2018).</li><li>Cohen, H. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Screening+for+vestibular+disorders+using+the+modified+clinical+test+of+sensory+interaction+and+balance+and+tandem+walking+with+eyes+closed.">Screening for vestibular disorders using the modified clinical test of sensory interaction and balance and tandem walking with eyes closed.</a> Otology &amp; Neurotology. 40 (5), 658-665 (2019).</li><li>Friello, P., Silver, N., Sangi-Haghpeykar, H., Cohen, H. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Screening+for+balance+in+children+and+adults+in+a+community+science+education+setting:+normative+data,+influence+of+age,+sex,+and+body+mass+index,+and+feasibility.">Screening for balance in children and adults in a community science education setting: normative data, influence of age, sex, and body mass index, and feasibility.</a> PLoS One. 17 (5), e0268030 (2022).</li><li>Bermudez Rey, M. C., Clark, T. K., Merfeld, D. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Balance+screening+of+vestibular+function+in+subjects+aged+4+years+and+older:+a+living+laboratory.">Balance screening of vestibular function in subjects aged 4 years and older: a living laboratory.</a> Frontiers in Neurology. 8, 631 (2017).</li><li>Shumway-Cook, A., Horak, F. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessing+the+influence+of+sensory+interaction+on+balance.">Assessing the influence of sensory interaction on balance.</a> Physical Therapy. 66 (10), 1548-1550 (1986).</li></ol>

The author has nothing to disclose.

These screening tests require minimal or no technology and minimal space. Administration and scoring are quick and easy. Therefore, these screening tests are widely used in healthcare settings by medical providers, occupational therapists, and physical therapists in rehabilitation clinics and epidemiologic screening studies. These tests can be used to screen patients for vestibular disorders and also to screen people with non-vestibular disorders such as presbyastasis. Other balance impairments may also be screened with these tests, but the list of possible disorders is too long to describe here. Clinicians who are trained in the assessment and treatment of various types of vestibular and non-vestibular balance disorders can use these screening tests as part of the clinical toolbox.
The tests have some limitations. These tests can only be used with people who are able to follow the instructions and are able to stand unassisted. Musculoskeletal problems, such as arthritis and joint deformities, amputation of a toe, significant weakness, and incoordination affecting the feet and lower extremities will all affect the test results. Similarly, movement disorders of the nervous system, such as Parkinson&#39;s disease, will affect test results. Musculoskeletal and movement disorders may interfere with the ability to stand long enough to perform the test, to have good enough weight-shifting ability, or even the motor control to perform the tests at all. To be consistent with the normative data, shoes should not be worn, but socks should be worn for good hygiene. Obesity affects the outcome5. The type of compliant foam used for CTSIB affects the outcome. If the test administrator prefers to use a different type of foam, then the test administrator should follow the advice of Shumway-Cook and Horak, the originators of CTSIB, and develop norms on healthy individuals before testing with patients15.
These normed balance tests are useful for screening balance in a wide range of ages. They require minimal equipment and minimal time but provide valid and reliable data for use in a variety of settings. The test administrator should use foam with the correct density characteristics, and individuals should perform the tests without shoes but while wearing socks, with eyes closed. Test sensitivity (to patients) and specificity (to healthy controls) will be improved if both tests are used. Test scores will be influenced by the presence of movement disorders, musculoskeletal disorders, or difficulty following instructions. Therefore, interpret the data with care in the presence of such problems.

Screening the vestibular system, the sensory system with receptors in the inner ear that detect head movement, is notoriously difficult. Due to the presence of the vestibulo-spinal tracts, which project from the vestibular nuclei in the rostral medulla down through cervical, thoracic, and lumbosacral levels of the spinal cord, the head velocity signals generated by the vestibular system influence balance during standing and walking1. For that reason, many people with disorders of the vestibular system have impaired balance and are at risk of falling. For example, 25% of American seniors over the age of 65 years fall every year2, and the death rate from falls in the United States in 2016 ranged from 24.2 to 142.7 per 100,000 people, depending on the state3. Therefore, balance testing is often a component of a clinical assessment or screening for a vestibular impairment and is often used in clinical research4. These tests may also be useful for on-site screening of athletes, post-flight astronauts, military personnel, and other individuals who may show some balance problems. Such individuals might need to be screened near an athletic field, at a landing site, in an emergency field hospital, or some other emergency situation, respectively, before being transported a long distance to comprehensive healthcare facilities for detailed testing.
To screen people for balance disorders, two different kinds of balance testing are often used. Standing still and shifting weight, such as when washing dishes at the kitchen sink, involves somewhat different skills than translating the body through space when walking. Both kinds of balance should be examined. Balance testing is often performed with a narrow base of support to make a test challenging for the individual. For example, testing standing balance with feet close together and eyes closed is based on the Romberg sign, i.e., that patients have a good balance with eyes open but lose their balance with eyes closed1. This test has been sharpened over the years several times until the current modified version of the Romberg, or Clinical Test of Sensory Integration and Balance (CTSIB)4, was more useful for clinical screening than previous tests by being simpler, shorter, and having proven good sensitivity. The current version uses unstable, medium-density, compliant foam on the support surface and has been sharpened even further with head movements. These modifications have been used in recent studies showing age-related normative data on children and adults and also in studies showing that the norms are specific to the foam used7,8,9,10.
Tandem walking (TW), also known as heel-toe walking, is performed on the floor, with the subject wearing socks but not wearing shoes and with eyes closed. Recent studies provide age-related normative data on children and adults11,12,13. Reduced performance on TW and CTSIB may be consistent with a disorder of the vestibular system, although balance tests are not direct tests of the vestibular system. When TW and CTSIB are given together to patients who do not have musculoskeletal deformities or significant neurologic problems, the sensitivity of the tests to vestibular disorders is higher than when only TW or CTSIB is given12.
Using the methodology described in this paper, several studies have been performed with healthy participants. For example, a study of 292 healthy controls and 90 patients with vestibular disorders - as indicated on standard, clinical objective tests of the vestibular system using bi-thermal caloric testing, vestibular evoked myogenic potentials, and Dix-Hallpike testing - showed age-related declines among controls on the CTSIB conditions and TW11,12,13.The sensitivity of the individual tests was moderate for TW7 and CTSIB8, but the sensitivity of the combined battery was &#62; 0.9. In a study of CTSIB at the Museum of Science Boston, healthy participants were able to test themselves on CTSIB on compliant foam with the head still condition14. Age-related changes among children and adults were found by that group, too.
These performance-based screening tests cannot be learned from reading about them in the research papers. This paper aims to inform the reader exactly how to perform these tests.

<table><tbody><tr><td>10 cm thick, medium density, Sunmate foam</td><td>Dynamic Systems, Leicester, NC, USA;</td><td>sunmatecushions.com</td><td>Either this foam or foam by another manufacturer that has the same compliance characteristics as medium density Sunmate foam will be sufficient. Use a slab of foam large enough for an adult man&#039;s feet, e.g. 40.65 cm X 45.72 cm or larger</td></tr><tr><td>Metronome app</td><td>Any source</td><td>N/A</td><td>Either a real, physical metronome or a metronome app that can provide an auditory cue at 0.3 Hz. 0.3 Hz is the equivalent of 18 beats per minute, but using 20 beats per minute is acceptable if your app only goes that low.</td></tr><tr><td>Stopwatch</td><td>Any source</td><td>N/A</td><td>Any timing device in tenths of seconds will be sufficient</td></tr></tbody></table>

screening people on standing balance with romberg testing and walking balance with tandem walking

The goal of this protocol is to inform readers about the exact procedures to use to perform two screening tests for vestibular disorders: tandem walking (TW) with eyes closed, also known as heel-toe walking, and the Clinical Test of Sensory Integration and Balance (CTSIB), which is also known as the modified Romberg. The study describes the steps for performing each test and each of the three CTSIB subtests so that the reader will be able to replicate the test conditions for use in the clinic, in the clinical laboratory, or in any other situation needing valid and reliable screening for balance skill which might be affected by changes in vestibular system function. The procedures detailed here can be easily administered and take less than 1 min per trial. References to published papers with normative data are provided. The representative results section includes examples of data collected with these screening tests.

As with other studies, age-related changes were found on tandem walking and for CTSIB, especially for young children and older adults, although the data for the oldest old may not be reliable due to the small sample size. Figure 1 shows the data for the three conditions of CTSIB. Figure 2 shows the data for eye-closed tandem walking. Young children had reduced scores for both tests compared to children aged 10 and older. Scores declined in the middle- and especially older age. In this particular study, the data for the oldest subjects are unreliable due to small sample sizes.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65663/65663fig01.jpg" /> 
Figure 1: Mean CTSIB data by age groups. The data are the time in seconds. (A) CTSIB head still. (B) CTSIB head yaw. (C) CTSIB head pitch. This figure has been modified from the original paper and used with permission from Friello et al.13. <a href="https://www.jove.com/files/ftp_upload/65663/65663fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/65663/65663fig02.jpg" /> 
Figure 2: Median TW data by age groups. The data are the number of correct tandem steps. Ranges were from 1 to 10 but varied by age; refer to Friello et al.13 for details. This figure has been modified from the original paper and used with permission from Friello et al.13. <a href="https://www.jove.com/files/ftp_upload/65663/65663fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Developing Low-Tech Balance Assessment Methods for Broad-Spectrum Healthcare Applications at JoVE.com

Author Spotlight: Developing Low-Tech Balance Assessment Methods for Broad-Spectrum Healthcare Applications 

This article describes procedures for screening people for standing and walking balance impairments using two normed, rapid, low-tech balance tests.

Screening People on Standing Balance with Romberg Testing and Walking Balance with Tandem Walking

The goal of this protocol is to inform readers about the exact procedures to use to perform two screening tests for vestibular disorders: tandem walking ...

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4.4K Views.  Baylor College of Medicine. This article describes procedures for screening people for standing and walking balance impairments using two normed, rapid, low-tech balance tests. 

Video: Author Spotlight: Developing Low-Tech Balance Assessment Methods for Broad-Spectrum Healthcare Applications 

Community-based Adapted Tango Dancing for Individuals with Parkinson's Disease and Older Adults

Adapted tango dancing improves mobility and balance in older adults and additional populations with balance impairments. It is composed of very simple step elements. Adapted tango involves movement initiation and cessation, multi-directional perturbations, varied speeds and rhythms. Focus on foot placement, whole body coordination, and attention to partner, path of movement, and aesthetics likely underlie adapted tango&#8217;s demonstrated efficacy for improving mobility and balance. In this paper, we describe the methodology to disseminate the adapted tango teaching methods to dance instructor trainees and to implement the adapted tango by the trainees in the community for older adults and individuals with Parkinson&#8217;s Disease (PD). Efficacy in improving mobility (measured with the Timed Up and Go, Tandem stance, Berg Balance Scale, Gait Speed and 30 sec chair stand), safety and fidelity of the program is maximized through targeted instructor and volunteer training and a structured detailed syllabus outlining class practices and progression.

Adapted tango has demonstrated efficacy for improving mobility and balance. We describe the dissemination of adapted tango teaching methods to dance instructor trainees and the implementation of adapted tango by the trainees in the community for improving mobility and balance in older adults and individuals with Parkinson&#8217;s disease.

Adapted tango dancing improves mobility and balance in older adults and additional populations with balance impairments. It is composed of very simple ...

Substantiating Appropriate Motion Capture Techniques for the Assessment of Nordic Walking Gait and Posture in Older Adults

Nordic walking (NW) has become a safe and simple form of exercise in recent years, and in studying this gait pattern, various data collection techniques have been employed, each with positives and negatives. The aim was to determine the effect of NW on older adult gait and posture and to determine optimal use of different data collection systems in both short and long duration analysis. Gait and posture during NW and normal walking were assessed in 17 healthy older adults (age: 69 &#177; 7.3). Participants performed two trials of 6 Minute Walk Tests (6MWT) (1 with poles (WP) and 1 without poles (NP)) and 6 trials of a 5m walk (3 WP and 3 NP). Motion was recorded using two systems, a 6-sensor accelerometry system and an 8-camera 3-dimensional motion capture system, in order to quantify spatial-temporal, kinematic, and kinetic parameters.
With both systems, participants demonstrated increased stride length and double support and decreased gait speed and cadence WP compared to NP (p &#60;0.05). Also, with motion capture, larger single support time was found WP (p &#60;0.05). With 3-D capture, smaller hip power generation and moments of force were found at heel contact and pre-swing as well as smaller knee power absorption at heel contact, pre-swing, and terminal swing WP compared to NP, when assessed over one cycle (p &#60;0.05). Also, WP yielded smaller moments of force at heel contact and terminal swing along with larger moments at mid-stance of a gait cycle (p &#60;0.05). No changes were found for posture.
NW seems appropriate for promoting a normal gait pattern in older adults. Three-dimensional motion capture should primarily be used during short duration gait analysis (i.e. single gait cycle), while accelerometry systems should be primarily employed in instances requiring longer duration analysis such as during the 6MWT.

The aim was to substantiate optimal use of data collection techniques for Nordic walking gait and posture analysis. Three-dimensional motion capture should be used during short duration analysis (i.e. single gait cycle), while accelerometry should be employed for longer duration analysis (i.e. repeated cycles) like a 6 Minute Walk Test.

Nordic walking (NW) has become a safe and simple form of exercise in recent years, and in studying this gait pattern, various data collection techniques ...

Sit-to-stand-and-walk from 120% Knee Height: A Novel Approach to Assess Dynamic Postural Control Independent of Lead-limb

Individuals with sensorimotor pathology e.g., stroke have difficulty executing the common task of rising from sitting and initiating gait (sit-to-walk: STW). Thus, in clinical rehabilitation separation of sit-to-stand and gait initiation - termed sit-to-stand-and-walk (STSW) - is usual. However, a standardized STSW protocol with a clearly defined analytical approach suitable for pathological assessment has yet to be defined.
Hence, a goal-orientated protocol is defined that is suitable for healthy and compromised individuals by requiring the rising phase to be initiated from 120% knee height with a wide base of support independent of lead limb. Optical capture of three-dimensional (3D) segmental movement trajectories, and force platforms to yield two-dimensional (2D) center-of-pressure (COP) trajectories permit tracking of the horizontal distance between COP and whole-body-center-of-mass (BCOM), the decrease of which increases positional stability but is proposed to represent poor dynamic postural control.
BCOM-COP distance is expressed with and without normalization to subjects&#39; leg length. Whilst COP-BCOM distances vary through STSW, normalized data at the key movement events of seat-off and initial toe-off (TO1) during steps 1 and 2 have low intra and inter subject variability in 5 repeated trials performed by 10 young healthy individuals. Thus, comparing COP-BCOM distance at key events during performance of an STSW paradigm between patients with upper motor neuron injury, or other compromised patient groups, and normative data in young healthy individuals is a novel methodology for evaluation of dynamic postural stability.

Here, we present a novel protocol to measure positional stability at key events during the sit-to-stand-to-walk using the center-of-pressure to the whole-body-center-of-mass distance. This was derived from the force platform and three-dimensional motion-capture technology. The paradigm is reliable and can be utilized for the assessment of neurologically compromised individuals.

Individuals with sensorimotor pathology e.g., stroke have difficulty executing the common task of rising from sitting and initiating gait (sit-to-walk: ...

Computerized Dynamic Posturography for Postural Control Assessment in Patients with Intermittent Claudication

Computerized dynamic posturography with the EquiTest is an objective technique for measuring postural strategies under challenging static and dynamic conditions. As part of a diagnostic assessment, the early detection of postural deficits is important so that appropriate and targeted interventions can be prescribed. The Sensory Organization Test (SOT) on the EquiTest determines an individual&#39;s use of the sensory systems (somatosensory, visual, and vestibular) that are responsible for postural control. Somatosensory and visual input are altered by the calibrated sway-referenced support surface and visual surround, which move in the anterior-posterior direction in response to the individual&#39;s postural sway. This creates a conflicting sensory experience. The Motor Control Test (MCT) challenges postural control by creating unexpected postural disturbances in the form of backwards and forwards translations. The translations are graded in magnitude and the time to recover from the perturbation is computed.
Intermittent claudication, the most common symptom of peripheral arterial disease, is characterized by a cramping pain in the lower limbs and caused by muscle ischemia secondary to reduced blood flow to working muscles during physical exertion. Claudicants often display poor balance, making them susceptible to falls and activity avoidance. The Ankle Brachial Pressure Index (ABPI) is a noninvasive method for indicating the presence of peripheral arterial disease and intermittent claudication, a common symptom in the lower extremities. ABPI is measured as the highest systolic pressure from either the dorsalis pedis or posterior tibial artery divided by the highest brachial artery systolic pressure from either arm. This paper will focus on the use of computerized dynamic posturography in the assessment of balance in claudicants.

Individuals with intermittent claudication exhibit poor balance compared to healthy controls. Computerized dynamic posturography is an objective method for measuring an individual's postural responses to balance disturbances. This provides an objective reflection of the person&#x2019;s ability to respond to situations under which sensory stimuli are altered and unexpected perturbations occur.

Computerized dynamic posturography with the EquiTest is an objective technique for measuring postural strategies under challenging static and dynamic ...

Medicine

Quantitative Static and Dynamic Assessment of Balance Control in Stroke Patients

In patients with stroke, damage to the central nervous system (CNS) can affect the postural stability and increase the risk of falling. Therefore, accurately assessing the balance is important to understand the type, extent, and causes of balance deficit, and to identify individualized interventions. Clinical assessment methods for balance function can be broadly divided into observation, scale assessment, and balance instrument testing. Here, a clinical protocol is presented for static and dynamic balance assessment in stroke patients, which includes three semiquantitative balance function scale assessments (i.e., Berg Balance Scale, Timed Up and Go Test, and Fugl-Meyer Assessment) and three quantitative instrumental balance evaluation (i.e., Stability Assessment Module, Proprioceptive Assessment Module, and Limit of Stability Module). It is recommended that clinicians consider the use of both classic clinical balance scales and instrumental balance measurements when assessing stroke patients to improve the accuracy of assessments, leading to a better individualized treatment plan.

Presented here is a quantitative, clinical balance assessment method suitable for stroke patients with balance disorders.

In patients with stroke, damage to the central nervous system (CNS) can affect the postural stability and increase the risk of falling. Therefore, ...

Exergaming in Older People Living with HIV Improves Balance, Mobility and Ameliorates Some Aspects of Frailty

Approximately 1.2 million people in the United States live with HIV infection. Medical advancements have increased the life expectancy and this cohort is aging. HIV-positive individuals have a high incidence of frailty (~20%) characterized by depression and sedentary behavior. Exercise would be healthy, but due to the frail status of many HIV-positive individuals, conventional exercise is too taxing. The aim of this study was to evaluate the effectiveness and acceptability of a novel game-based training program (exergame) in ameliorating some aspects of frailty in HIV-infected individuals. Ten older people living with HIV were enrolled in an exergame intervention. Patients performed balance exercises such as weight shifting, ankle reaching, and obstacle crossing. Real-time visual/audio lower-extremity joint motion feedback was provided using wearable sensors to assist feedback and encourage subjects to accurately execute each exercise task. Patients trained twice a week for 45 min for 6 weeks. Changes in balance, gait, psychosocial parameters and quality of life parameters were assessed at the beginning, midterm and at conclusion of the training program. Ten patients completed the study and their results analyzed. The mean age was 57.2 &#177; 9.2 years. The participants showed a significant reduction in center of mass sway (78.2%, p = .045) during the semi-tandem balance stance with eyes closed and showed a significant increase in gait speed during a dual task motor-cognitive assessment (9.3%, p = .048) with an increase in stride velocity of over 0.1 m/sec. A significant reduction in reported pain occurred (43.5%, p = .041). Preliminary results of this exergame intervention show promise in improving balance and mobility while requiring older people living with HIV to be more active. The exergame can be continued at home and may have long term as well as short-term benefits for ameliorating frailty associated with HIV infection.

Persons infected with HIV are often frail, depressed and live a sedentary lifestyle for which conventional exercise is too taxing. Here, we present an exercise protocol that ameliorates aspects of frailty in HIV-infected persons. An exergame integrating cognitive control was developed using biosensors that measured balance, weight-shifting and obstacle crossing.

Approximately 1.2 million people in the United States live with HIV infection. Medical advancements have increased the life expectancy and this cohort is ...

Motor Dual-Tasks for Gait Analysis and Evaluation in Post-Stroke Patients

Eighteen stroke patients were recruited for this study involving the evaluation of cognition and walking ability and multitask gait analysis. Multitask gait analysis consisted of a single walking task (Task 0), a simple motor dual-task (water-holding, Task 1), and a complex motor dual-task (crossing obstacles, Task 2). The task of crossing obstacles was considered to be equivalent to the combination of a simple walking task and a complex motor task as it involved more nervous system, skeletal movement, and cognitive resources. To eliminate heterogeneity in the results of the gait analysis of the stroke patients, the dual-task gait cost values were calculated for various kinematic parameters. The major differences were observed in the proximal joint angles, especially in the angles of the trunk, pelvis, and hip joints, which were significantly larger in the dual motor tasks than in the single walking task. This research protocol aims to provide a basis for the clinical diagnosis of gait function and an in-depth study of motor control in stroke patients with motor control deficits through the analyses of dual-motor walking tasks.

This paper presents a protocol specifically for dual motor task gait analysis in stroke patients with motor control deficits.

Eighteen stroke patients were recruited for this study involving the evaluation of cognition and walking ability and multitask gait analysis. Multitask ...

Neuroscience

Lower Limb Biomechanical Analysis of Healthy Participants

Biomechanical analysis techniques are useful in the study of human movement. The aim of this study was to introduce a technique for the lower limb biomechanical assessment in healthy participants using commercially available systems. Separate protocols were introduced for the gait analysis and muscle strength testing systems. To ensure maximum accuracy for gait assessment, attention should be given to the marker placements and self-paced treadmill acclimatization time. Similarly, participant positioning, a practice trial, and verbal encouragement are three critical stages in muscle strength testing. The current evidence suggests that the methodology outlined in this article may be effective for the assessment of lower limb biomechanics.

This article introduces a comprehensive experimental methodology on two of the latest technologies available to measure the lower limb biomechanics of individuals.

Biomechanical analysis techniques are useful in the study of human movement. The aim of this study was to introduce a technique for the lower limb ...

Dual-Task Stroop Paradigm for Detecting Cognitive Deficits in High-Functioning Stroke Patients

General clinical cognitive assessment scales are not sensitive enough to cognitive impairment in high-functioning stroke patients. The dual-task assessment has advantages for identifying cognitive deficits in high-functioning stroke patients and has been gradually applied in clinical assessment and cognitive training. Moreover, the Stroop paradigm has higher sensitivity and specificity for attentional assessment than conventional clinical cognitive assessment scales. Therefore, this study presents the dual-task assessment based on the Stroop paradigm to identify cognitive deficits in high-functioning stroke patients. This study demonstrates a single- and dual-task evaluation based on the Stroop paradigm and confirms its feasibility through case experiments and synchronized functional near-infrared spectroscopy evaluation. The Stroop reaction time and correct rate are used as the main indicators to evaluate the cognitive level of the subjects. This study protocol aims to provide new ideas to figure out the ceiling effect in general clinical assessment failure for high-functioning stroke patients.

Clinical assessment scales are notsensitive enough to cognitive dysfunction in high-functioning stroke patients. The dual-task paradigm presents advantages and potential in the assessment and cognitive training of cognitive dysfunction. The study here proposes a dual-task Stroop paradigm to identify cognitive dysfunction in high-functioning stroke patients.

General clinical cognitive assessment scales are not sensitive enough to cognitive impairment in high-functioning stroke patients. The dual-task ...

Motor Exam II

Source:Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women&#39;s/Massachusetts General Hospital, Boston, Massachusetts, USA
There are two main types of reflexes that are tested on a neurological examination: stretch (or deep tendon reflexes) and superficial reflexes. A deep tendon reflex (DTR) results from the stimulation of a stretch-sensitive afferent from a neuromuscular spindle, which, via a single synapse, stimulates a motor nerve leading to a muscle contraction. DTRs are increased in chronic upper motor neuron lesions (lesions of the pyramidal tract) and decreased in lower motor neuron lesions and nerve and muscle disorders. There is a wide variation of responses and reflexes graded from 0 to 4+ (Table 1).
DTRs are commonly tested to help localize neurologic disorders. A common method of recording findings during the DTR examination is using a stick figure diagram. The DTR test can help distinguish upper and lower motor neuron problems, and can assist in localizing nerve root compression as well. Although the DTR of nearly any skeletal muscle could be tested, the reflexes that are routinely tested are: brachioradialis, biceps, triceps, patellar, and Achilles (Table 2).
Superficial reflexes are segmental reflex responses that result from stimulation of a specific sensory input (cutaneous or conjunctival) and the corresponding motor response. These reflexes include the corneal, conjunctival, abdominal, cremasteric, anal wink and plantar (Babinski) reflexes. The plantar reflex is a polysynaptic reflex elicited by stroking the lateral aspect of the sole with the normal response being plantar flexion of the great toe. This reflex changes with the normal development of the nervous system. In infants the toe will dorsiflex, but by 2 years of age the toe responds by plantar flexing. With damage to the pyramidal system, there is an unmasking of the more primitive reflex and the toe becomes &#34;upgoing&#34; or a positive Babinski sign.
The evaluations of coordination and gait are performed as a part of the neurological motor examination and can help a clinician localize lesions or recognize movement disorders. The coordination of movements and gait has complex multi-level regulation and requires an integrated function of different components of the nervous system. This part of the neurological examination allows the examiner to assess the function of the cerebellum, the cerebellar connections, and other tracts including brainstem structures. Coordination is assessed by looking for smooth and accurate movement, and requires the integration of sensory feedback with motor output, most of which occurs in the cerebellum. An impaired ability to coordinate the rate, range, timing, direction, or force of voluntary movement is called ataxia. Testing coordination includes evaluation of rapid alternating movements and point-to-point coordination, both of which can be altered as a result of cerebellar dysfunction. As in other parts of the examination, observation is the first step in the evaluation of the patient. A careful observation of a patient&#39;s gait can help the clinician screen for problems including weakness, movement disorders, spasticity, and cerebellar disease. No neurologic examination is complete without the assessment of gait. Occasionally, the only sign of a serious neurologic disorder is an impaired gait.

Motor Exam II: Reflex, Coordination, Gait and Station Testing

Source:Tracey A. Milligan, MD; Tamara B. Kaplan, MD; Neurology, Brigham and Women&#39;s/Massachusetts General Hospital, Boston, Massachusetts, USA
There ...