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Archives of Gerontology and Geriatrics 51 (2010) e19–e23

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Analysis of postural control in elderly subjects suffering from Psychomotor Disadaptation Syndrome (PDS)
´ ronique Dubost b, France Mourey a,b,c, Pierre Pfitzenmeyer a,b,c, Eric Matheron a, Ve Patrick Manckoundia a,b,c,*

´ – Plasticite ´: Performance, Dysfonctionnement, Vieillissement et Technologies d’optimisation, Universite ´ de Bourgogne, INSERM/U887 Motricite ´ des Sciences du Sport, F-21078 Dijon Cedex, France Faculte ´decine Interne Geriatrie, Ho ˆpital de Champmaillot, CHU de Dijon, 2, rue Jules Violle, F-21079 Dijon Cedex, France Service de Me c ´rontopo ˆle, Ho ˆpital de Champmaillot, CHU de Dijon, 2, rue Jules Violle, F-21079 Dijon Cedex, France Ge



Article history: Received 3 March 2009 Received in revised form 5 July 2009 Accepted 8 July 2009 Available online 8 August 2009 Keywords: Falls in elderly Backward disequilibrium Fear of falling Upright stance Postural control

PDS is a geriatric affliction, described in 1999, characterized by postural impairments, including backward disequilibrium, freezing, a deterioration in the ability to anticipate postural adjustments, anxiety and fear of falling, inducing loss of autonomy. This study compared 10 subjects suffering from PDS, aged 87.3 Æ 4.9 years, with 10 control subjects, aged 85.4 Æ 7.9 years concerning postural control (body sway amplitude). In all participants, postural control was assessed using the SwayStarTM system in natural (spontaneous) and standardized stances, eyes open and eyes closed over a period of 40 s. It was found that: (1) with eyes open, subjects with PDS showed greater body sway amplitude than did controls whatever the position (natural or standardized) and the plane (sagittal or frontal) considered (F1,16 = 6.05; p = 0.026), (2) with eyes closed, subjects with PDS showed greater body sway amplitude than did controls in the natural stance whatever the plane (F1,18 = 7.65; p = 0.013). In conclusion, PDS has a negative effect on postural control. This data must be taken into account during the rehabilitation of patients with this syndrome. ß 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction The prevalence and the severity of posture and gait disorders increase with aging (Manckoundia et al., 2008a). Indeed, balance control is a complex sensori-motor function which requires the integration of vestibular, visual and somesthetic information into the central nervous system (pyramidal, extrapyramidal and cerebellar systems) in order to maintain antigravitar postures and to produce a suitable response to any balance perturbation (Horak and McPherson, 1996). Moreover, the quality of muscle and joints is important in the balance function. Increased age is associated with impaired performance in vestibular, visual and somesthesic systems, a decline in the speed of information transmission and changes in the mode of information processing in the brain, all of which lead to balance and postural disorders (Manckoundia et al., 2008b). Concerning the vestibule, it has been reported that the number of vestibular hair cells falls by 20–40% in healthy subjects aged 70 years and

´ decine Interne Geriatrie, Ho ˆ pital de * Corresponding author at: Service de Me Champmaillot, CHU de Dijon, 2, rue Jules Violle, F-21079 Dijon Cedex, France. Tel.: +333 80 29 39 70; fax: +333 80 29 36 21. E-mail address: (P. Manckoundia). 0167-4943/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2009.07.003

older, when compared to young subjects, and the number of vestibular nerve fibers has also been found to decrease with age (Alpini et al., 2004). Regarding vision, decreased visual acuity, restriction of visual field, poor depth perception, losses in contrast sensitivity at intermediate and high spatial frequencies have been found in elderly subjects (Alpini et al., 2004). At the somesthesic level, various alterations in the morphology and functions of the peripheral nervous system are related to aging. Elderly subjects also suffer from a loss of myelinated and unmyelinated nerve fibers associated with axonal atrophy. Aging also induces a decline in nerve conduction velocity and sensory discrimination (Verdu et al., 2000). Moreover, the age-related decline in muscle and joint quality contributes to the proprioceptive abnormalities and also explains effector disorders found in elderly subjects. Indeed, with advancing age, the frequency of sarcopenia increases and the decrease in muscle mass is associated with the replacement of muscle fibers by fat and connective tissue (Lexell, 1995; Alpini et al., 2004; Crepaldi and Maggi, 2005). Additionally, there is an increase in degenerative osteo-articular lesions and osteoporosis (Crepaldi and Maggi, 2005). One consequence of these age-related impairments is the increase in anterior–posterior body sways as reported by Lord et al. (1991). The negative effects of certain syndromes or chronic pathologies on posture and gait will compound those of physiological

Matheron et al. slow gait steps with a shuffle-like gait (‘‘marche a speed and a tendency to have BD.. 1. psychological intervention and medical management) with regard to motor abilities and fear of falling (Manckoundia et al. aboulia. Switzerland. a direct correlation was found between BD and the postural vertical (self-perception of the body’s orientation in space) in the sagittal plane (Manckoundia et al. we assessed cognitive function using the mini-mental state examination (MMSE) (Folstein et al. Fall is the main precipitating factor of PDS in subjects with predisposing factors. Mourey et al. indifference. / Archives of Gerontology and Geriatrics 51 (2010) e19–e23 aging. body weight and height were measured in order to calculate the body mass index (BMI). and the protocol of the study was approved by the local ethics committee. Procedure For each participant. no author has focused on postural control in subjects with PDS. and trunk sway was recorded with a sampling frequency of 100 Hz (Gill et al. post-fall syndrome (Pfitzenmeyer et al. the objective of the present study was to analyze postural control in the upright stance in subjects suffering from PDS compared with elderly control (EC) subjects. 2004). for all of the subjects enrolled in this study. We recorded their detailed medical history.3 Æ 4.. which reflect postural stability in the upright stance. which are non-specific of PDS. Thus. small ` petits pas’’). 4 conditions were recorded in random order. Among these syndromes and chronic pathologies there is the PDS and its acute form. axial and limb rigidity and the loss of reactive postural responses and protective reactions. apathy. For the eyes-closed conditions. Some studies in the literature have taken an interest in subjects with PDS. 1). excluding subjects with moderate to severe cognitive disorders) and to stand up without aid for at least 60 s. and defined by a posterior body tilt (Mourey et al. During the physical examination. 1963) and the instrumental activities of daily living (IADL) (Lawton and Brody. 1999. Participants The first group was composed of 10 elderly subjects (5 women and 5 men). the diagnosis of PDS was made by a geriatrician according to the clinical features of this syndrome. The mobility of hips. . predisposing subjects to backward falls. fear of falling and ptophobia (Pfitzenmeyer et al. knees and ankles was assessed. PDS is characterized by postural impairments. were calculated online using trapezoid integration of angular velocities. Subjects were excluded in cases of non-treated orthopedic disease.4 Æ 7.01 degrees/s) placed on a belt behind the subject (Fig. 2. 2004). 85. number of and types of drugs consumed per day and the number of falls during the last six months. 1982).. Thus. accuracy of 0. 1969) scales. The second group was composed of 10 matched EC subjects (5 women and 5 men). As previously described.. The transducers were connected to a computer by a Bluetooth system. They were all able to hear. with PDS. The main postural disorder associated with PDS is backward disequilibrium (BD)... 2007a). Gait disorders. Participants and methods 2. For each subject.9 years). SwayStarTM system placed on lumbar belt to measure trunk sway in the frontal and sagittal planes. 1988). characterized by a posterior position of the center of mass with respect to the base of support in the standing and sitting position. include freezing. Finally. 1975) and the cognitive deterioration rate (CDR) (Hughes et al. Methods The trunk sway was measured with two angular velocity transducers using the SwayStarTM system (Balance International Innovations GmbH. the psychological state using the 15-item geriatric depression scale (GDS) (Yesavage.3. 2001). to our knowledge.e.. the equipment contained an Analog-Digital converter of 16 bits. 74–95 years of age (mean age. psychological features are characterized by bradyphrenia. to see adequately. 2001). and if they showed significant joint limitations. neurological signs. including the number of chronic diseases. Moreover. severe malignant or non-malignant disease and neurological affections. Angular deviations (in degrees). for 40 s. Indeed.. However.9 years). 87..e20 E. This study was performed in accordance with the Helsinki declaration and written consent was obtained from all subjects or their guardians. subjects with PDS have been shown to benefit from a multidisciplinary intervention program (physical rehabilitation. 2007b). Neurological signs of PDS include reactional muscular hypertonia... 2.2. and the level of dependence using the activities of daily living (ADL) (Katz et al. postural stability was assessed in the upright stance both in a natural (spontaneous) position and in a standardized stance (4 cm between each heel and 30 degrees feet angle) eyes open and closed. All participants of the two groups were recruited in the same geriatrics center. 1999).1.. subjects Fig. gait disturbances and psychological disorders (Pfitzenmeyer et al. from 76 to 93 years of age (mean age. 2. to follow instructions (i. Moreover. One transducer measured angular velocity deviations in the frontal plane and the second in the sagittal plane.

Fig.328 0. Main effects First. Moreover.353 0.1 21.4 2. and 2. Results Clinical characteristics and scores for cognitive. p = 0.0 23. IADL) were determined for each subject. 2A) Two subjects with PDS who were unable to maintain the standardized stance were excluded from these analyses.571 0. the comparisons between the two groups were performed using a mixed ANOVA design with two main factors (the position: natural and standardized stance.9 Æ 1.23 Æ 1.9 Æ 1.17 PDS group 4.2 Æ 2.1 Æ 1.2 Æ 0.8 Æ 3.037 0.7 Æ 4. they could then maintain an upright stance without assistance. In contrast.1 Æ 1.22 Æ 0. For postural control with the eyes open. 2. (B) Mean trunk sway in the normal upright stance for PDS and control groups in the frontal and sagittal planes with eyes closed. With eyes open Natural stance Sagittal Frontal Standardized stance Sagittal Frontal Eyes closed Natural stance Sagittal Frontal Control group 1.D. 3.71 Æ 0.4 and 2. Postural control with eyes open (Fig..9 Æ 1.05).9 Æ 1.55 Æ 0.017). 3. subjects with PDS were found to be more dependent than controls.037 for ADL scores. given the fragility of these hospitalized patients.005 Note: p-Values regard the Mann–Whitney test.9 Æ 0. It was thus always possible to record postural sways with eyes closed and without assistance for 40 s.85 Æ 2.7 2.7 and Table 2 Angular deviation values (mean + S. 2.13 1. For all statistical analyses.8 Æ 2. when these subjects with PDS were first held by a trained evaluator in the upright stance for 30 s.15 Æ 0. Clinical characteristics Subjects with PDS showed a significantly higher number chronic diseases than did controls (respectively 4.4 Æ 1.3 Æ 4. This constituted a 5th condition (normal stance after help and eyes closed) only applied to subjects with PDS. each condition was recorded only once for all of the subjects.5 8. (A) Mean trunk sway in the normal and standardized stance for PDS and control groups in the frontal and sagittal planes with eyes open.7 Æ 1.6 p 0.64 4. PDS had one main significant effect on postural control in the upright stance: there was greater instability in the PDS group than in the control group whatever the position and the plane Table 1 Comparison of control and PDS groups regarding the mean scores (ÆS. number of falls during the last six months and BMI score).77 Æ 0.73 Æ 0.8 Æ 2. Concerning the experiment. the angular deviations in each condition and in the sagittal and frontal planes were analyzed for each subject. p = 0.23 0..65 Æ 1.57 1.05. psychological and independence tests are reported in Table 1.) of the measured parameters. were performed using the Mann–Whitney U-test.005).14 1. Matheron et al.7.017 0. Cognitive psychological and independence parameters No difference was found between the two groups either for the cognitive function (MMSE and CDR) or for the psychology state (GDS).54 Æ 0. statistical significance was accepted for p < 0.1 0.0 Æ 3. the ADL and IADL scores were notably lower in the PDS group than in the control group (respectively 3.73 0. / Archives of Gerontology and Geriatrics 51 (2010) e19–e23 e21 with PDS were unable to maintain balance.9 Æ 1.696 0. Comparisons between PDS and control groups concerning the clinical.98 0.1 Æ 5. number of types of drugs consumed/day.5 0. p = 0. and means were calculated for each group. Asterisk indicates significant difference (p < 0. However. in the natural and standardized stances with eyes open and in the natural stance with eyes closed.7 8.46 2.e.6 5. cognitive.E.9 3.4 5.021 0.2 Æ 0.26 3. psychological and independence parameters.7 2. 3. CDR) and psychological (GDS) characteristics and autonomy (ADL.M.021 for IADL scores).6.4.1 4. .9 4.3.4 Æ 1.E.7 and 5.31 1. cognitive (MMSE.92 Æ 0. 3. trunk sway amplitude (angular deviations) in the natural position after 30 s of assistance in subjects with PDS (i.2. there was no difference between the two groups concerning the BMI and the number of drugs consumed/day.1 Æ 1. Data and statistical analyses Clinical (number of chronic diseases. Furthermore.4. the number of falls per subject during the last six months was significantly higher in the PDS group than in the control group (respectively 0.2 Æ 4. 5.1.6 3. Table 2 reports means of angular deviations for control and PDS groups in the sagittal and frontal planes. However. For postural control with the eyes closed. p = 0.4 PDS group 27.894 0. Indeed.8 Æ 2.5.1 Æ 1. the trunk sway plane: frontal and sagittal) and one inter-subject factor (PDS or not).) (sway in degrees) for control and PDS groups. The post hoc comparisons were done by Fischer’s PLSD test. For each parameter.72 Æ 0. Moreover each exercise was separated by a 3-min rest period. 5th condition) were compared with the trunk sway amplitude (angular deviations) in the natural position in control subjects using oneway ANOVA.3.8 Æ 2.7 0. a mean was calculated for each group (PDS or control). Characteristics BMI (kg/m2) Number of chronic diseases Number of drugs/day MMSE (/30) CDR (/3) GDS (/15) ADL (/6) IADL (/8) Number of falls during the last six months Control group 28.1. 3.4.27 2.

Interaction between PDS. 4. p = 0. is associated with an increased risk of falling (Chu et al. 1994.2. Making the patients feel confident could also decrease oppositional hypertonicity. 4. indeed.043).2. the number of diseases was higher in subjects with PDS than in control subjects..16 = 4. The two groups showed similar anthropometrical data. elderly subjects with PDS were more dependent than control individuals.18 = 34. Moreover. subjects with PDS showed greater amplitude of trunk sway for both the sagittal and frontal plane. F1. Moreover falls were more frequent among subjects with PDS compared with controls. Confirmation of the high risk of fall and the frailty associated with PDS This study showed that subjects with PDS fell more often than control subjects. Pfitzenmeyer et al. Indeed. sagittal and frontal trunk sway were both higher in PDS patient than in control patients (respectively p < 0. Moreover. but it remains lower than the sagittal body sway which is linked to the BD. Williams et al. depression. this has never proven previously. and (ii) significantly greater sagittal trunk sway compared with the control group (p < 0.. controlled assessment of static balance. In the PDS group. there was thus a period of adaptation before they were able to maintain the upright stance correctly. they were more dependent. According to Pfitzenmeyer et al. p = 0. normal pressure hydrocephalus. 1999.4.18 = 7. 1999.2. Fisher’s PLSD post hoc test showed that there was (i) a significantly higher trunk sway in the sagittal plane than in the frontal plane (p < 0. 3. multiple system atrophy. sagittal trunk sway in the PDS group was higher than that in the control group (p < 0. 2004) which are both certainly accentuated by closing the eyes. the statistical analysis found a plane effect: there was a greater trunk sway in the sagittal plane than in the frontal plane (F1.02). Mourey et al. Indeed. When PDS patients were deprived of visual input.16 = 0. Patients with PDS fell when they closed their eyes In the upright stance with eyes closed. The cognitive process intervenes during postural control (Melzer et al..3.85. 2B) 3.05. p = 0.. lymphomas of the nervous system. Putting a hand on the patients’ shoulders could be considered confidence building. However.. 2004).0004).16. or stress reduction in a situation which they find distressing (eyes closed).3. evaluated through the measurement of angular deviation using SwayStarTM in subjects suffering from PDS compared with EC subjects. Fisher’s PLSD post hoc test showed that in the natural stance. Lewy body disease. Interaction between PDS and the trunk sway plane There was a significant interaction between PDS and the trunk sway plane (F1.4. even with their eyes closed. HIV infection.e22 E.58. 4. p = 0. Secondly.001). Moreover. and a resulting a loss of autonomy (Mourey et al. p < 0.. meningoencephalitis.65. progressive supranuclear palsy. the fear of falling could result from a lack of confidence. p = 0. This is explained by the fact that PDS could be a consequence of several afflictions or chronic diseases such as Parkinsonian syndromes. 1999). Binswanger’s disease.1. sagittal trunk oscillations were greater than frontal oscillations (F1. and secondly PDS induces a loss of autonomy during its progression (Pfitzenmeyer et al. patients were able to keep their eyes closed for at least 40 s.. Interaction between PDS and the trunk sway plane There was a significant interaction between PDS and the trunk sway plane (F1.0001). one of the main characteristics of PDS. there was a significant trunk sway plane effect.. In contrast. Fisher’s PLSD post hoc test showed that sagittal trunk sway was higher in PDS patients than in controls (p < 0. PDS is associated with a high risk of falling because of BD (Pfitzenmeyer et al. position and the trunk sway plane (F1. 1999.. (2004). 3. in particularly those suffering from PDS.001). in behavior due to hemisphere stroke (Pe which frontal body sway predominates. Postural control in the natural stance with eyes closed (Fig..18 = 6. (1999) and Mourey et al. Indeed. Indeed. confinement to bed and falls (Pfitzenmeyer et al.547). Mourey et al. Moreover.027). 4.. 2001). Mourey et al. Mourey et al. position and the trunk sway plane There was a significant interaction between PDS.001). we showed that the amplitude of trunk sway is greater in subjects with PDS than in controls. Manckoundia et al.. postural disability. This is consistent with previous studies reporting that the upright stance generates anxiety and psychomotor inhibition in these patients (Tinetti et al. and this could be true in PDS patients when visual input is disrupted. 3. cognitive function.001 and p < 0. 1999. First PDS appears in elderly subjects with predisposing afflictions which are associated with dependence. and psychological state.16 = 5.53.013). p = 0. PDS patients tended to be unable to stabilize their standing position and fall backwards..1. This is contrary to what is found in patients with pushing ´ rennou et al. 2008b) and gait and neurological disorders. subcortical vascular lesions. whatever the position (natural and standardized stances. Furthermore. This study confirms an increase in body sway in subjects with PDS which is greater in the sagittal plane than in the frontal plane. Earlier studies reported that postural instability induced .4. in the standardized stance. 2008). 2004). Patients with PDS showed greater instability Sagittal body sway in the upright stance generally increases with age (Lord et al. thus allowing us to record postural stability. when an investigator put his/her hand on their shoulder for 30 s prior to the test. Additionally. / Archives of Gerontology and Geriatrics 51 (2010) e19–e23 considered (F1. 1999.. This is in accordance with the literature. subjects with PDS showed greater instability than controls in normal stance and in both the frontal and sagittal planes (F1. These results could be consistent with previous studies suggesting a link between falling and the control of lateral sway (Melzer et al. thus to the pathophysiology of PDS.. 2004). This explains also the fact that the difference between PDS and control subjects with regard to body sway is greater in the sagittal plane than in the frontal plane in both normal and standardized stances.000001). the experiment was easy to carry out. Discussion This study is the first systematic.026). SwayStarTM appeared to be suitable for frail persons. all of the subjects were able to keep their body stable. Matheron et al. p = 0. 3. This increase in body sway in the sagittal plane was also emphasised in PDS.3. (1997) suggested that lateral sway was a stronger predictor of falling than was aging.16 = 20. Indeed. 2004).. In this position.38.01). 2004). Immediately afterwards. the frontal body sway found in patients with PDS is related to the overall instability. This increase in sagittal body sway in patients with PDS could be explained by BD and by phobia of the standing position of gait characterizing this syndrome (Pfitzenmeyer et al.. 1991).97.16 = 6. Main effects There was a main effect of PDS on postural control. The standardized stance reduces the area of sustentation and thus increases the difficulty of keeping the posture stable.3. These findings are in accordance with previous clinical research.

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