Posture and Locomotion Coupling: A Target for Rehabilitation Interventions in Persons with Parkinson's Disease

Disorders of posture, balance, and gait are debilitating motor manifestations of advancing Parkinson's disease requiring rehabilitation intervention. These problems often reflect difficulties with coupling or sequencing posture and locomotion during complex whole body movements linked with falls. Considerable progress has been made with demonstrating the effectiveness of exercise interventions for individuals with Parkinson's disease. However, gaps remain in the evidence base for specific interventions and the optimal content of exercise interventions. Using a conceptual theoretical framework and experimental findings, this perspective and review advances the viewpoint that rehabilitation interventions focused on separate or isolated components of posture, balance, or gait may limit the effectiveness of current clinical practices. It is argued that treatment effectiveness may be improved by directly targeting posture and locomotion coupling problems as causal factors contributing to balance and gait dysfunction. This approach may help advance current clinical practice and improve outcomes in rehabilitation for persons with Parkinson's disease

Stories and cultural humility: Exploring power and privilege through physical therapist life histories

The purpose of this study was to explore how life experiences, set within their social, cultural, and historical contexts, shape the development of cultural humility in physical therapists (PTs). Cultural humility involves health professionals being actively engaged in an ongoing process with patients, colleagues, communities, and themselves to make sense of the complexities of social and culture differences within relationships in practice. Given demographic trends and health care disparities, it has become critically important to better understand the dynamics of developing trusting relationships to provide quality care. This study was influenced by relationship-centered care, sociocultural, and insurgent multiculturalism theories. A qualitative, life history study was designed to answer four major research questions: (1) What types of life experiences do PTs perceive frame the way they address cultural differences and build relationships? (2) What contextual influences do PTs perceive have facilitated or constrained their development of cultural humility? (3) How do PTs’ life histories elucidate how they attend to or resist facing issues of privilege and power in relationships? (4) What are the implications that attention to one’s own culture, privileges, and biases from a life history perspective hold for health professional curricular and pedagogical choices? Eight PTs participated in this study. The primary research method used was one-onone semi-structured interviews. Data were coded and analyzed for themes through constant comparison and constructing concept maps. Five major themes centered on the development of cultural humility and building trusting relationships could be traced through the life histories: (1) being open-minded and listening attentively as patients tell their stories; (2) responding to a person’s emotions matters; (3) focusing care around a patient’s goals and needs; (4) teaching to engage and empower; and (5) evolving awareness of community needs and assets. Taking into account how participants used their life stories to make experiences and contextual influences meaningful, this study offers a framework for educators who are interested in using narratives to foster professional development. By virtue of ongoing reflection on practice and ones biography, including ones privilege, health professionals can be habitually engaged to action to build trusting relationships across difference

Perturbations of ground support alter posture and locomotion coupling during step initiation in Parkinson's disease

International audienceDuring the initiation of stepping, anticipatory postural adjustments (APAs) for lateral weight transfer and propulsion normally precede the onset of locomotion. In Parkinson's disease (PD), impaired step initiation typically involves altered APA ground force production with delayed step onset and deficits in stepping performance. If, as in stance and gait, sensory information about lower limb load is important for the control of stepping, then perturbations influencing loading conditions could affect the step initiation process. This study investigated the influence of changes in lower limb loading during step initiation in patients with PD and healthy control subjects. Participants performed rapid self-triggered step initiation with the impending single stance limb positioned over a pneumatically actuated platform. In perturbation trials, the stance limb ground support surface was either moved vertically downward (DROP) or upward (ELEVATE) by 1.5 cm shortly after the onset of the APA phase. Overall, PD patients demonstrated a longer APA duration, longer time to first step onset, and slower step speed than controls. In both groups, the DROP perturbation reinforced the intended APA kinetic changes for lateral weight transfer and resulted in a significant reduction in APA duration, increase in peak amplitude, and earlier time to first step onset compared with other conditions. During ELEVATE trials that opposed the intended weight transfer forces both groups rapidly adapted their stepping to preserve standing stability by decreasing step length and duration, and increasing step height and foot placement laterally. The findings suggested that sensory information associated with limb load and/or foot pressure modulates the spatial and temporal parameters of posture and locomotion components of step initiation in interaction with a centrally generated feedforward mode of neural control. Moreover, impaired step initiation in PD may at least acutely be enhanced by augmenting the coupling between posture and locomotion

One Step, Two Steps, Three Steps More Directional Vulnerability to Falls in Community-Dwelling Older People

International audienceFalls leading to disability are common occurrences with advancing age. Stepping is a natural protective option for maintaining balance and preventing falls. There are directionally dependent challenges for protective stepping associated with falls among older individuals. The aim of this study was to determine the stepping response patterns evoked by different directions of externally applied postural disturbances in younger and older adults and in relation to falls. Seventy-five community-dwelling adults were tested: 26 younger adults and 49 older adults. Fall history of older participants was tracked prospectively for 1 year after testing. Steps were randomly evoked in 12 directions by a motorized waist-pull system. The number of recovery steps, type of stepping strategy, and first step kinematic characteristics were determined. Younger participants mainly used single recovery steps regardless of the perturbation direction. For the older groups, multiple steps occurred predominantly and were least for the forwardbackward directions and greatest for the lateral directions. Trials with three or more recovery steps were increased laterally only for the fallers. Overall, fallers initiated stepping earliest, but other stepping characteristics were similar between the groups for forwardbackward perturbations. Aging differences in stepping strategies for diagonal and lateral perturbations included numerous interlimb collisions. Adaptive changes in stepping characteristics between forward and lateral perturbations were also observed in relation to age and risk of falls. These results indicated an age-associated reduction in balance recovery effectiveness through stepping particularly for the lateral direction among older individuals at greater risk for falls