PTP 512

Neuroscience in Physical Therapy

Postural Control

Reading Assignment
Shumway-Cook: pp. 161-162, 164-193

Min H. Huang, PT, PhD, NCS
Objectives
Define postural control and distinguish between
postural orientation and stability
Describe the concepts of dynamic stability limits
Describe postural control processes, including
the contribution of the motor action component
and the role of sensory functions
Compare and contrast feedback vs. feedforward
postural control
Discuss the attentional demands of postural
control and its impact on stability during multi-
tasks

INTRODUCTION
Postural Control Defined
Postural Control
Controlling body
position in space for
Stability
Orientation
Postural Orientation
Ability to maintain an
appropriate relationship
between body segments
and between the body
and the environment
Base of Support (BOS)
BOS is the area of the body in contact with the
support surface

Gait: Chasing COG
Walking is a state of constant falling
During gait, the COG
falls anterior to the
BOS and the person
must step forward to
re-establish the COG
within the BOS to
avoid falling

Center of Pressure (COP)
COP is the center of the
distribution of total forces
applied to the support surface
COP represents the average
location of these forces but
NOT the forces! It is a point on
a 2-D plane!
CNS activates muscles to
change the location of COP,
which in turns shifts the
location of COG

Biodex Balance System
Systems for Postural Control
Horak et al., 2009
Postural Stability = Balance
Balance is the ability to keep
the vertical projection of the
center of mass (COM), within
the limits of base of support
COM is a point in 3-
dimensional space, usually
around L2 in standing
COG is the vertical projection
of the COM on a 2-dimensional
plane, usually the ground
Horak et al., 1989
McCollum & Leen, 1989
Stability Limits
Stability limits refer to the
boundaries within which the
body can maintain stability
without changing the base of
support.
Previous concepts of stability
limits only consider the area of
the feet utilized to maintain
balance rather static concept

Current Concepts of
Dynamic Stability Limits
Stability limits result from the interaction
between the velocity and position of COM.
Stability limits are the boundaries of the
combined COM velocity and position
possible without the needs to change the
base of support
Other factors, such as muscle strength, range of
motion, fears of falls, perceived stability, and
various aspects of the environment (e.g. lighting,
icy vs. dry) also affect the stability limits.

COM displacement-velocity trajectory. Subjects
stood on a platform that moved unexpectedly.
Left: Stepping response. COP velocity exceed the
velocity threshold.
Right: Non-stepping response. COM did not cross
the stability boundary.
Triangle symbol indicates the initial quiet standing
position.
Pai 2000
Current Concepts of
Dynamic Stability Limits: Try this.
Lean forward as far as possible and then
1. Throw your arms up as fast as possible
2. Throw your arms up as slowly as possible
Which condition do you feel more stable?
Stand in your neural upright position
1. Lean backward as fast and as far as possible
2. Lean backward as slowly and as far as
possible
Which condition do you feel more stable? Which
condition are you able to lean further backward?
Modes of Postural Control:
Feedback vs. Feedforward Processes
Slip on the ice or trip over your cat
vs.
Any voluntary movements

Kandel, 1991
Mode of Postural Control
Feedback control (Compensatory or reactive
postural responses)
Sensory feedback from unexpected
external perturbations triggers postural
responses
Feedforward control (Anticipatory postural
control)
Postural responses are made prior to
voluntary movement that is potentially
destabilizing in order to maintain stability
during the movement

ACTION SYSTEMS IN
POSTURAL CONTROL
Quite Stance Postural Control
Body alignment: ideal
alignment requires the least
amount of energy
Postural Tone: activity in
antigravity postural muscles
increases to counteract the
gravity
Same muscle synergies used
during perturbed stance also
play a role in maintaining
quiet stance.


Postural Control during Perturbed
Stance
Earlier studies of
postural control used a
platform that moves in
the anteroposterior
direction. Subjects
were asked to keep
their feet in place.
These studies
found..
Moving Platform Studies
Movement Strategies to Recover
Anteroposterior Stability
Ankle Hip Stepping
Ankle Strategy
Distal to proximal
muscle activation
pattern
Body sways at
ankles with hips and
knees in relatively
extended positions
Utilized in response
to small
perturbations on
firm surface

Hip Strategy
Proximal muscles
activated first
Produces large,
rapid motion at hip
joints
Utilized when
standing on narrow
BOS (e.g. beam), on
soft surface, or
during larger, faster
perturbations

Stepping or Reaching
Strategy
When subjects were not asked to
keep feet in place, they more
frequently step or reach, instead of
utilizing ankle or hip strategies to
restore balance (McIlroy & Maki, 1993)
Stepping or reaching are natural
responses, not the last resort to
restore balance!
Older adults more frequently step
than young adults (Mille, 2003)

Horak, 2009
Movement Strategies to Recover
Mediolateral Stability
Controlled primarily
through lateral hip and
trunk movement
Proximal to distal
muscle activation
pattern
Loading and unloading
of the two legs
controlled by hip
abductors & adductors








Head motion occurs
in the opposite
direction of hip
and ankle
movement
Head movement
Hip movement
(ABD, ADD)
Ankle movement
Movement Strategies to Recover
Multidirectional Stability
There is a continuum response patterns that
control stability in the 360-degree of possible
perturbation directions
Shumway-Cook, 2007
Movement Strategies to Recover
Multidirectional Stability
Complex postural response patterns in 360-
degree cannot be explained by simple ankle
or hip strategies.
Current concepts:
Synergies are flexible. each muscle
belongs to more than one synergy
Within each synergy, each muscle has a
unique or fixed weighting factor that
represents the level of activation of that
muscle within the synergy
Each synergy activates a specific set of muscles in a
fixed amount. Different combinations of synergies
are activated based on continuous sensory
feedback to adjust postural stability.
Ting, 2005
Clinical Implications of Movement
Strategies for Postural Control
Both quiet stance and recovery of stability in
response to perturbations use common
postural synergies.
Training in one context, e.g. quite stance,
may transfer to improve stability in the other
context, e.g. recovery of perturbed stance
Do not limit training to the activation of a
specific synergy, e.g. ankle or hip strategy
Adaptation is the ability to modify response
according to the task demands
With repeated perturbations, movement
strategies change (within 5-15 trials!)
Several studies in normal adults found
reduced sway with repeated exposure to
platform movements
Adapting Strategies
ANTICIPATORY POSTURAL
CONTROL
Anticipatory Postural Adjustments
(APAs)
Work with a partner. Stand with your arm
outstretched, at about waist height, palm up.
Place a heavy book on your outstretch palm.
1. Have your partner remove the book
2. Lift the book using your opposite arm
Are the responses different between 1 vs. 2
and why?

Anticipatory Postural Adjustments
(APAs)
In A, Gastroc was
activated prior to
biceps.
In B, subject was
support at the
shoulders so the
arm movement did
not disturb posture.
Thus, APAs were
not needed.

Cordo & Nashner, 1982
Anticipatory Postural Adjustments
(APAs)
Postural muscles are activated prior to the
prime movers that produce movement
Same postural synergies utilized during quiet
stance and postural perturbations are also
utilized in APAs.
In Cordo and Nashners study (1982), A & B had
different Central Set, which refers to the state
or readiness of the nervous system that is
determined by the context of a task
Clinical Implications
APAs increase with movement magnitudes
and speed. APAs more frequently present
with faster movements and heavier loads
Practice can affect the timing of APAs, e.g.
dancers activate APAs much earlier in a leg-
lifting task than untrained individuals
APAs are reduced when a support is
given Your patients will never improve
balance if they practice balance tasks while
holding on to // bars!
Neural Systems Controlling
Postural Orientation and Stability
Spinal Cord
Spinal cats can
activate extensor
muscles to support
body but their
postural stability is
poor
Postural stability is
NOT organized at the
spinal cord level
Brainstem
Regulation of
postural tone
Integration of
sensory information
Contribute to
anticipatory
postural control for
voluntary
movements
Basal ganglia-cortical loop controls postural
set, i.e. the ability to modify the postural
muscle activation patterns to changes in the
task or environmental conditions

Neural Systems Controlling Postural
Orientation and Stability
Patient with
Parkinsons
Disease
Neural Systems Controlling Postural
Orientation and Stability
Cerebellar-cortical loop controls the
adaptation of postural muscle activation
amplitudes, i.e. scaling, in response to
changes in task and environmental conditions
Patients with damage to cerebellum were
unable to modify postural muscle activation
amplitudes even after repetitive perturbations
of the support surface (Horak and Diener, 1994).

PERCEPTUAL SYSTEMS IN
POSTURAL CONTROL
Sensory Contributions to Balance
CNS processes information from sensory
receptors throughout the body to determine
the bodys position in space
Vision (especially peripheral vision)
Somatosensation (proprioception,
cutaneous, joint receptors)
Vestibular system
Each sense provides a different frame of
reference, i.e. map
Sensory Weighting Hypothesis
Postural control system is able to reweight
sensory inputs in order to optimize stability in
altered sensory environments.
The gain of a sensory input will depend on
its accuracy as a reference for body motion.
Try this. Stand on one leg with eyes open vs.
closed. Which sense(s) may be weighted
when you close your eyes?
Visual Contributions
Moving Room
Experiment
Lee and Aronson, 1974
sway in young
children and old
adults with room
oscillation (may be
due to reduced
somatosensation)
Vision may not be
reliable
Self motion vs.
object motion?

Somatosensory contributions typically
dominate postural control in response to
transient or fast surface perturbations (in
this type of situation, visual and vestibular
inputs do not help)
Lightly touching a stable surface reduces
sway significantly. The somatosensory
inputs from the touch, rather than the
contact force through touching a surface
(Jeka, 1994; Lackner, 1999)
Somatosensory Contributions
Typically vestibular system contributes less
than somatosensory system
For example, CNS cannot tell whether it is
just head bending forward or the whole body
is leaning forward
Vestibular system provides a frame of
reference relative to the gravity
Vestibular Contributions
Testing Adaptation of Postural to
Changing Sensory Conditions:
Sensory Organization Test (SOT)
Adults and children over age 7 easily
maintain balance on all conditions
Least sway on conditions 1, 2, & 3 where the
support service is providing accurate sensory
information
Greatest sway on conditions 5 & 6 because
only one set of sensory inputs (vestibular) are
accurate and available
Visual cues are more important when the
balance task becomes more challenging

SOT Normal Results
Cognitive Contributions to Balance
Dual-task paradigms
performance in either task because of
limited capacity in information processing
to handle both tasks simultaneously
Different postural and secondary tasks
affect postural control differently
Older or balance-impaired individuals
increase postural sway with difficulty of
secondary cognitive tasks
Cognitive Contributions to Balance
As the difficulty for maintaining stability
, there is in attention resources required
by the postural control system
What type of secondary cognitive task will
affect balance is still unclear
Executive function may be the most
important cognitive function required to
maintain normal balance under dual-task
paradigms
Testing Executive Function during
Walking: Walking Trail Making Test (W-
TMT)
Wright, 2011
MDD: Major
depressive
disorder
ND: Non-
depressed
Balance-impaired older adults with depression
required time to step accurately under
cognitively challenging conditions that require
executive function.
*
Wright, 2011