Beam walking can detect differences in walking balance proficiency across a range of sensorimotor abilities
Introduction
There is an urgent need for a quick, simple, and low-cost physical performance measure that can detect differences in balance performance over a broad range of sensorimotor abilities; from individuals with motor impairment to elite athletes recovering from a concussion [1]. Balance ability while walking is a critical factor in determining quality of life [2] yet it is especially difficult to assess. Currently there is no accepted laboratory-based approach to evaluate and study balance ability during walking [3]. Moreover there are no specific tests that reliably assess walking balance impairment or fall risk in a clinical setting [4]. These gaps may be attributable to the scarcity of easily implemented clinically feasible techniques, metrics, and analyses that probe for and quantify failures in human balance performance [5], [6]. This limits the identification of neuromechanical principles that govern better walking balance and the determination of fall risk in patients.
Current laboratory-based biomechanical approaches used to study walking balance typically focus on movements or measures during successful performance. Many laboratory studies characterize the challenge to balance control during walking [7], the strategies used to maintain balance while walking [8], or the strategies used to restore balance after a perturbation to walking [5], [9], [10]. However, the relationship between these strategies or metrics to balance proficiency is unclear.
Clinical balance instruments such as the Berg Balance Scale, the Activities-specific Balance Confidence Scale, the Fullerton Advanced Balance Scale, and the Dynamic Gait Index require little in the way of specialized equipment and are relatively quick and inexpensive to administer. Yet they are not without their limitations. Many of these tools provide a nonspecific evaluation of balance rather than an assessment that specifically targets walking, the behavior when most falls occur [11]. For example they often pool static and dynamic [12], as well as standing and walking [13] balance tasks. However, there is little correlation between such elements [9], [14]. Many of these clinical balance tests show ceiling effects and are usually not sensitive enough to small improvements or decreases in balance ability [15].
The inability of laboratory and clinically based measures to quantify balance proficiency may stem from the use of motor behaviors that are of insufficient difficulty to evoke failures in balance control. If successful balance is defined by the absence of falls [16] then experimental conditions should be of sufficient difficulty to result in a loss of balance. Without conditions that allow for the identification of failures establishing the proficiency with which someone can maintain their balance is speculative. It depends on previously established statistical relationships between a given metric and a self-reported history of falls [17] rather than a direct assessment of walking balance proficiency.
Beam walking has been used to examine the effects of age [14], [18] on walking balance, as well as physical guidance and error augmentation on motor learning [19]. More recently beam walking has been used in attempts to identify cortical events that precede a loss of balance [20]. However its capacity to differentiate levels of walking balance proficiency across a range of sensorimotor abilities and specifically individuals with mild balance impairment remains unknown. Therefore the objective of this study was to test whether a simple and low-cost beam-walking task along with an easily interpreted metric could discriminate across the spectrum of walking balance proficiency (i.e. expert to impaired). Beam walking (Fig. 1) presents a challenge to balance control and provides a simple and stringent assessment of balance failures; individuals are either on or off the beam.
Section snippets
Participant recruitment
Three cohorts of participants were recruited: trained experts (professionally trained ballet dancers), untrained novices, and individuals with unilateral transtibial limb loss (TTLL). Individuals with traumatic TTLL were chosen because of their mild balance impairments that are traditionally difficult to detect with conventional balance assessments. For all participants’ inclusion criteria were age greater than 18 years. Inclusion criteria for individuals with TTLL included: time since limb
Results
Ten experts (professional ballet dancers), 10 untrained novices, and five individuals with unilateral TTLL participated in the study (Table 1). Balance proficiency was visually (Supplementary files A–C) and quantitatively (Fig. 2) different between cohorts. Significant differences were identified between cohorts in the normalized distance walked on the narrow (p < 0.0005) and mid beams (p < 0.0005), but not the wide beam (p > 0.05). Post hoc testing revealed that on the mid and narrow beams experts
Discussion
The assessment of walking balance proficiency remains a challenge. Here we demonstrated that a simple low-cost beam-walking task and a basic measure of distance walked could detect differences in walking balance proficiency across a broad range of sensorimotor abilities. While additional work is necessary to determine whether beam walking is capable of classifying fallers from non-fallers and predicting the likelihood of a fall, the identification of clinical and experimental methods that can
Conflict of interest statement
The authors attest to having no conflict of interest regarding this work.
Acknowledgement
This research was supported by NSF EFRI grant (1137229).
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