Award
- 2019 - Pilot Grant
Background
Falls are the leading cause of injury in older adults, accounting for about 65% of unintentional injuries treated in emergency departments [1]. Declines in balance and physical function are among the most important risk factors for falls in older adults [2, 3]. While much research has focused on the lower extremity, it is likely that trunk neuromuscular control, defined as the ability to purposefully and accurately move and exert the thoracolumbar spine, plays a key but understudied role in balance and physical function. First, precise and accurate control of trunk movements plays a vital role in postural control during walking and other functional activities, particularly during the turning component of locomotion, in part by helping to maintain head stabilization and equilibrium [4], and indeed muscles in the lumbar and abdominal region are necessary for spine stability [5, 6]. Second, the most common cause of falls in older adults in long-term care facilities is incorrect weight shifting, rather than slipping or tripping [7], suggesting that in many cases improper postural control may be the primary cause of a
fall. Third, older adults with back pain are more likely to fall [8, 9], and trunk neuromuscular control is known to be impaired in back pain patients [10], suggesting a link between impaired motor control and falls. Overall, there is significant motivation to evaluate trunk neuromuscular control in older adults and establish its relationship with
balance and physical function.
Wrist fractures are common injuries among older adults, accounting for about 19% of fractures in adults over age 50 [11], and are the result of a fall in about 90% of cases [12]. Wrist fractures are a sentinel event as they occur at an earlier age than other fragility fractures (e.g. hip, vertebral) and are a strong risk factor for future fractures [13]. Indeed, women who have had a wrist fracture are 1.4-fold more likely to suffer a hip fracture and 5.2-fold more likely to suffer a vertebral fracture than those without a fracture [13]. This effect is even more pronounced in men, as men who have had a fracture are 2.7-fold and 10.7-fold more likely to suffer future hip and vertebral fractures, respectively [13]. Because many wrist fracture patients are relatively young and active,
it is thought they may have subtle impairments in balance or postural control that increase their risk of falling and sustaining an injury. Supporting this concept, one recent study reported worse postural stability in wrist fracture patients 6-24 months post-fracture compared to age-matched controls [14].
Significance
Trunk neuromuscular control may be an important factor underlying balance and physical function. Trunk neuromuscular control has been studied in younger adults, including back pain patients [15, 16]. However, to our knowledge these approaches have not been applied to study trunk neuromuscular control in older adults
through tracking tasks. Trunk tracking tasks are challenging and cognitively demanding tasks that require participants to change their trunk position to match a stationary or moving target. A sudden change in a target position, direction or velocity may be considered as a perturbation to the neuromuscular system. Perturbationbased
exercises are reported to induce adaptation and plasticity in specific areas of the central nervous system that are responsible for control of balance and walking [17]. Performance error measured during tracking tasks, including perturbations, may reflect impairment in trunk neuromuscular control. A poor response to perturbations
in addition to decrements in executive or cognitive control of movements in older adults may represent a possible link between performing attention-demanding physical activities and the risk of loss of balance and falling [18]. Therefore, understanding how target perturbations impact tracking accuracy may provide insight into the
importance of peripheral and central mechanisms for trunk neuromuscular control.
Finally, wrist fracture patients offer a uniquely relevant clinical population for examining whether trunk neuromuscular training can improve balance and physical function. Specifically, these patients have suffered a serious fall-related injury, and are at increased risk for future falls, but typically receive no rehabilitation targeting
balance or physical function. Furthermore, unlike many other fall-related injuries, a wrist fracture does not directly impact nor prohibit testing and training of trunk motor control and mobility. If successful, this project will demonstrate the importance of trunk neuromuscular control for physical function and balance in older adults,
and whether biofeedback-based training targeting trunk control can be effective in improving control, function and balance.
References
References
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