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http://pierremarie.gagey.perso.sfr.fr/AN02-a.htm Amplitude of postural sway in the 0.2 Hertz frequency band.

(Study on the normal subject)


Running title: NA2

Pierre-Marie GAGEY* and Michel TOUPET** * Institut de Posturologie, Paris ** Centre d'explorations fonctionnelles vestibulaires, Paris

K.W.: Stabilometry, Frequency analysis, Ventilation, Postural control, Functional anatomy, vestibular function. Summary Until now the clinicians lacked norms to read the frequential analyses of the stabilometric signal of their patients. That work gives a first estimation of the theoretic normal values of the distribution parameters of the normalised amplitude of postural sway in the 0.2 Hz frequency band [NA2], a frequency band corresponding to the ventilation rhythm and on which ten years of clinical experience focus our attention.

Introduction
Since the middle of the XIXth century (Vierordt, 1864), many physiologists have tried and observed how man stands upright. At first these researches did not have any medical impact because the signals of the initial material were hardly readable. Now it is acknowledged that the force platforms in use for nearly 50 years (Ranquet,1953) allow us, thanks to the developments of signal analysis techniques, to explore the control of the orthostatic posture in an easy and totally neutral way (AAN, 1992; Cambier, 1993). It is therefore normal that clinicians should try and use these platforms in order to examine the patients who have difficulties in standing upright because of a clearly defined illness or of disorders still misunderstood. But the clinical use of those force platforms requires the existence of norms to which the performances of the patient can be compared (AFP, 1984). In the absence of any decision of the normalisation committee of the International Society for Postural and Gait Research, the Association Franaise de Posturologie has published, first, building standards for a force platform (Bizzo et al., 1985), then standards of recording conditions and of various spatial parameters (AFP, 1985; 1986). But no norms of frequential analysis of the stabilometric signal have been published so far. The present work will try and fill that gap. This ten years delay may seem strange. Actually, it was hard to direct such

normalisation works prior to a long clinical experience, as shown by the first attempts at using frequential analyses clinically (Taguchi, 1978). During those ten years it has been noticed (Gagey, 1986) and confirmed (Guillemot & Duplan, 1995) that anomalies in the 0.2 Hz frequency band appeared in patients who all showed, for various reasons, functional disorders of the body axis. That distinctive feature of postural sway in the 0.2 Hz frequency band in pathology already gave a first reason for focusing our attention on that frequency. Simultaneously, several fundamental works confirmed that not only did the sway in that frequency band share the same rhythm as ventilation, but that it was also synchronous with ventilatory rhythm (Gurfinkel & Elner, 1968; Le Roux et al., 1976; Hunter & Kearny, 1981; Bouisset & Duchne, 1994). The 0.2 Hz frequency band of postural sway therefore shows distinctive features that justify special attention.

Material and methods


Stabilometric recordings All recordings have been performed on a prototype of stabilometry platform normalised by the Association Franaise de Posturologie (Bizzo et al., 1985), computerized, validated by the works of the same Association (AFP, 1985), and commercially available in southern Europe (CIA.Sistemi, Modena; Dynatronic, Creste; QFP.systems, SophiaAntipolis; Satel, Toulouse; Midicapteurs, Toulouse; Dune, Mulhouse). The sampling is at 5 Hertz. The recording time is of 51.2 s. The analogic signal issued by each of the three strain gauges was filtered by an antiwithdrawal filter, 0/2 Hz running band, structure of the fourth order. The visual environment is strictly normalised: target at 90 cm in front of the subject, with a 2,000 lux light, lateral walls at 50 cm. The position of the feet on the platform is normalised: feet at 30, with a 2 cm space between the heels; barycenter of the polygon of support always situated at the same point, whatever the subject's shoe size. The recordings have been realised in an open eyes situation, eyesight corrected if necessary and according to the subject's habit, then closed eyes in half-light. Only one series of recordings has been realised to study the distribution of the ranges of postural sway. Four series of recordings have been realised, at 8 days interval, same hour and same day of the week, to study the repeatability of the ranges of postural sway. Groups The groups of normal subjects have not been rigorously formed by drawing lots among the French population. For the study of the distribution of the ranges of postural sway, the first volunteers to have come have been questioned and, among them, 36 men and 46 women, between

19 and 60 years of age (mean age 35 years old), have been selected only on interrogation criteria: absence of any acknowledged pathological symptom and especially absence of any pain in the body axis in the three previous months. For the more constraining study of the repeatability of the amplitudes of postural sway, 41 young men, between 18 and 26 years of age (mean age 22 years old), paid, have been selected on more rigorous criteria including a postural clinical examination (Gagey & Weber, 1995) and a series of stabilometric recordings, the spatial parameters of which had to be within the normality limits. Frequential analysis After its normalisation according to its mean value and the application of the Hamming window, the signal has been submitted to Cooley-Turkey's algorithm of the FFT, that has given a value of the amplitude spectrum for each of the 125 elementary frequency bands at 0.02 Hz between 0 and 2.5 Hz. Normalised amplitude of postural sway in the 0.2 Hz frequency band The aim of the work is not the study of the absolute amplitude of postural sway in the given frequency band, but the study of their relative amplitude compared with those of the other frequency bands. We have used the normalised amplitude of postural sway in the 0.2 Hz frequency band (NA2) defined by the following formula: where A represents the amplitude of each elementary frequency band, f, given by the algorithm of the FFT. The limiting values used for the calculation will be discussed later. Statistical analysis The distribution of that NA2 parameter (AN2 in French) has been studied from the recordings, open eyes and closed eyes, of the group of 82 normal subjects, for the left-right sway and the anterior-posterior sway. In order to define, from the observed distribution, the normal mean value and its standard deviation, a first class statistical risk has consisted in eliminating the subjects situated more than two standard deviations away from the mean of that basic distribution. The distribution of the paired difference of that NA2 parameter between two recordings performed in similar conditions has been studied from the four series of recordings, open eyes and closed eyes, of the group of 41 normal subjects, for the left-right sway and the anterior-posterior sway. In order to define, from the observed distribution, the normal mean value of the paired difference and its standard deviation, a first class statistical risk has consisted in eliminating the subjects for which at least one recording showed an NA2 parameter situated more than two standard deviations away from the mean of theoretic normal distribution previously defined. Those statistical risks will be discussed later.

Results
Distribution of the normalised amplitude of postural sway in the 0.2 Hz frequency band, (NA2), in normal subjects Left-right postural sway, open eyes situation Among the 79 subjects remaining after application of the first class risk, the mean of the NA2 parameter for the left-right postural sway in an open eyes situation, is of 11.39 6.95; confidence limit superior to 95%: 25; sum of the X2 = 14010 (fig. 1). FIG. 1 - Distribution of the NA2 parameter in a normal population. Open eyes situation, left-right postural sway. Histogram of the observed distribution, Gaussian curve of the theoretic distribution. Left-right postural sway, closed eyes situation Among the 79 subjects remaining after application of the first class risk, the mean of the NA2 parameter for the left-right postural sway in a closed eyes situation is of 16.57 10.41; confidence limit at 95%: 36.97; sum of the X2 = 32810 (fig. 2). FIG. 2 - Distribution of the NA2 parameter in a normal population. Closed eyes situation, left-right postural sway. Histogram of the observed distribution, Gaussian curve of the theoretic distribution. Anterior-posterior postural sway, open eyes situation Among the 79 subjects remaining after application of the first class risk, the mean of the NA2 parameter for the anterior-posterior postural sway in an open eyes situation is of 8.37 4.86; limit of confidence superior to 95%: 17.9; sum of the X2 = 7377 (fig. 3). FIG. 3 - Distribution of the NA2 parameter in a normal population. Open eyes situation, anterior-posterior postural sway. Histogram of the observed

distribution, Gaussian curve of the theoretic distribution. Anterior-posterior postural sway, closed eyes situation Among the 79 subjects remaining after application of the first class risk, the mean of the NA2 parameter for the anterior-posterior postural sway in a closed eyes situation is of 14.65 7.98; limit of confidence superior to 95%: 30.3; sum of the X2 = 23878 (fig. 4). FIG. 4 - Distribution of the NA2 parameter in a normal population. Closed eyes situation, anterior-posterior postural sway. Histogram of the observed distribution, Gaussian curve of the theoretic distribution.

Distribution of the paired difference of the normalised amplitude of postural sway in the 0.2 Hz frequency band (NA2) between two similar recordings of normal subjects. Left-right postural sway, open eyes situation Among the 170 repetitions remaining after application of the first class risk, the mean of the paired difference of the NA2 parameter for the left-right postural sway in an open eyes situation is of - 0.17 * 9.04; limits of confidence at 95%: -17.89 / + 17.55 (fig. 5). FIG. 5 - Distribution of the paired difference of the NA2 parameter between two similar recordings in a normal population. Open eyes situation, left-right postural sway. Histogram of the observed distribution, Gaussian curve of the theoretic distribution Left-right postural sway, closed eyes situation Among the 222 repetitions remaining after application of the first class risk, the mean of the paired difference of the NA2 parameter for the left-right postural sway in a closed eyes situation is of - 0.23 11.28; limits of confidence at 95%: - 22.34 / + 21.88 (fig. 6).

FIG. 6 - Distribution of the paired difference of the NA2 parameter between two similar recordings in a normal population. Closed eyes situation, left-right postural sway. Histogram of the observed distribution, Gaussian curve of the theoretic distribution. Anterior-posterior postural sway, open eyes situation Among the 168 repetitions remaining after application of the first class risk, the mean of the paired difference of the NA2 parameter for the anterior-posterior postural sway in an open eyes situation is of 0.35 5.56; limits of confidence at 95%: - 10.55 / + 11.25 (fig. 7). FIG. 7 - Distribution of the paired difference of the NA2 parameter between two similar recordings in a normal population. Open eyes situation, anterior-posterior postural sway. Histogram of the observed distribution, Gaussian curve of the theoretic distribution. Anterior-posterior postural sway, closed eyes situation Among the 222 repetitions remaining after application of the first class risk, the mean of the paired difference of the NA2 parameter for the anterior-posterior postural sway in a closed eyes situation is of 1.85 9.85; limits of confidence at 95%: - 17.46 / + 21.16 (fig. 8). FIG. 8 - Distribution of the paired difference of the NA2 parameter between two similar recordings in a normal population. Closed eyes situation, anterior-posterior postural sway. Histogram of the observed distribution, Gaussian curve of the theoretic distribution.

Discussion
The choice of the limits of the frequency band

The limits of the 0.2 Hz frequency band have been set at 0.16 and 0.24 Hz to cover a standard range of ventilatory rhythms (Thayer et al., 1996), but also to take into account the ten years of clinical experience during which fundamentals of the amplitude spectrum have been frequently observed in that scale. The inferior limit of the reference frequency band has been set at 0.04 Hz to eliminate the effects of possible deviation. Indeed, it sometimes happens that the position of the pressure center deviates in a regular and continuous way during the whole time of the recording session. The superior limit of the reference frequency band has been set at 0.6 Hz to take into account the ambiguity of the stabilometric signal. Because it measures forces, the stabilometry platform records the effects of all the accelerations acting on the corporal mass: acceleration of gravity and accelerations of postural sway. But we know that for the lower frequencies we only make a small relative mistake by assimilating the pressure center to the projection of the gravity center on the plane of the polygon of support. However that mistake quickly grows with frequency, and approaches 100% at 0.6 Hz (Gurfinkel, 1973; Gagey & Weber, 1995). When we want to limit the studies to postural sway of the full corporal mass - the only one to be controlled by the postural system (Gagey et al., 1985) - it is useless to take into account the frequency bands of the FFT superior to 0.6 Hz. First class risks A group of normal subjects always comprises subjects who are aberrant compared to the studied variable and those subjects considerably modify the mean and most of all the variance of the observed distribution of that variable. To decide whether or not we will take such subjects into account in the estimation of the parameters of the theoretic normal distribution of the variable, always represents a risk that can be guided only by considerations which are extrinsic to the statistical analysis. In order to estimate the mean and the variance of the theoretic normal distribution of the NA2 parameter, the risk consisted in eliminating all aberrant subjects situated more than two standard deviations away from the mean of the observed distribution. That risk is generous, and needs explaining. The exclusion criteria during the forming of the group of normal subjects were only based on the results of an interrogation, which is hardly restrictive (the complementary explorations of an aberrant subject from that group of normal subjects, for instance, led to the diagnosis and surgical treatment of an acoustical neurinoma that the subject was unaware of). Moreover, clinical experience teaches us to suspect a link between an abnormal amplitude of postural sway around 0.2 Hz and the existence of functional disorders of the body axis - and we know the prevalence of such minor functional disorders to be high in the population. For those various reasons, it seemed wise to take a very restrictive first class risk. In order to estimate the mean and variance of the theoretic normal distribution of the paired difference of the NA2 parameter between two similar recordings, the risk consisted in eliminating the comparisons made on an abnormal parameter, because the study tries and defines the repeatability of the NA2 parameter in a normal

population. Influence of the sway plane on the NA2 parameter In an open eyes situation, there is a statistically very significant difference (p<0.01) between the distributions of the NA2 parameter for the left-right sway and for the anterior-posterior sway. That difference disappears in a closed eyes situation. Influence of vision on the NA2 parameter Whatever the sway plane, there is a statistically very significant difference (p<0.001) between the distributions of the NA2 parameter in open eyes and closed eyes situations. That difference is surprising. To our knowledge it has never been pointed out, and even less explained. We can notice that an occlusion of the eyes leads to a redestribution of the weight of the many afferences participating in the control of the orthostatic posture. The increase, in a closed eyes situation, of the relative importance of the proprioceptive information given by the body axis, could explain that increase of the percentage of the amplitudes of postural sway in the 0.2 Hz band. That hypothesis, not yet checked, is based on the priviledged relations that seem to show between the 0.2 Hz sway and the functionning of the body axis. Conclusion That study, in the normal subject, of the amplitude of postural sway in the 0.2 Hertz frequency band, is limited in many ways. Yet it is enough for a first clinical approach to the 0.2 Hz phenomenon, the results of which will show whether or not it is useful to return to that statistical analysis with more means.

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We thank Rhne-Poulenc society for their financial support.

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