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Northern Michigan University NMU Commons Journal Articles FacWorks 1-2018 Changes in balance and joint position sense during a 12-day high altitude trek: The rB itish Services Dhaulagiri medical research expedition Sarah B. Clarke Northern Michigan University, [email protected] Kevin Deighton Leeds Beckett nU iversity Caroline Newman Defence Medical Services Gareth Nicholson Leeds Beckett nU iversity Liam Gallagher Leeds Beckett nU iversity See next page for additional authors Follow this and additional works at: https://commons.nmu.edu/facwork_journalarticles Part of the Musculoskeletal System Commons, Nervous System Commons, Sense Organs Commons, and the Sports Sciences Commons Recommended Citation Clarke SB, Deighton K, Newman C, Nicholson G, Gallagher L, Boos CJ, et al. (2018) Changes in balance and joint position sense during a 12-day high altitude trek: The rB itish Services Dhaulagiri medical research expedition. PLoS ONE 13(1): e0190919. https://doi.org/10.1371/journal. pone.0190919 This Journal Article is brought to you for free and open access by the FacWorks at NMU Commons. It has been accepted for inclusion in Journal Articles by an authorized administrator of NMU Commons. For more information, please contact [email protected],[email protected]. Author(s) Sarah B. Clarke, Kevin Deighton, Caroline Newman, Gareth Nicholson, Liam Gallagher, Christopher J. Boos, Adrian Mellor, David R. Woods, and John P. O'Hara This journal article is available at NMU Commons: https://commons.nmu.edu/facwork_journalarticles/373 RESEARCH ARTICLE Changes in balance and joint position sense during a 12-day high altitude trek: The British Services Dhaulagiri medical research expedition Sarah B. Clarke1,2*, Kevin Deighton1, Caroline Newman3, Gareth Nicholson1, Liam Gallagher1, Christopher J. Boos1,3,4,5, Adrian Mellor1,3,6, David R. Woods1,3,7,8, John P. O'Hara1 a1111111111 a1111111111 1 Institute for Sport, Physical Activity & Leisure, Leeds Beckett University, Leeds, United Kingdom, 2 School a1111111111 of Health and Human Performance, Northern Michigan University, Marquette, Michigan, United States of a1111111111 America, 3 Defence Medical Services, Lichfield, United Kingdom, 4 Department of Cardiology, Poole a1111111111 Hospital NHS Trust, Longfleet Rd, Poole, United Kingdom, 5 Department of Postgraduate Medical Education, Bournemouth University, Bournemouth, United Kingdom, 6 South Tees Hospitals NHS Trust, James Cook University Hospital, Middlesbrough, United Kingdom, 7 Northumbria and Newcastle NHS Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle, United Kingdom, 8 University of Newcastle, Newcastle upon Tyne, United Kingdom OPEN ACCESS * [email protected] Citation: Clarke SB, Deighton K, Newman C, Nicholson G, Gallagher L, Boos CJ, et al. (2018) Changes in balance and joint position sense during Abstract a 12-day high altitude trek: The British Services Dhaulagiri medical research expedition. PLoS ONE Postural control and joint position sense are essential for safely undertaking leisure and profes- 13(1): e0190919. https://doi.org/10.1371/journal. sional activities, particularly at high altitude. We tested whether exposure to a 12-day trek with a pone.0190919 gradual ascent to high altitude impairs postural control and joint position sense. This was a Editor: Yu Ru Kou, National Yang-Ming University, repeated measures observational study of 12 military service personnel (28±4 years). Postural TAIWAN control (sway velocity measured by a portable force platform) during standing balance, a Sharp- Received: March 2, 2017 ened Romberg Test and knee joint position sense were measured, in England (113m elevation) Accepted: December 23, 2017 and at 3 research camps (3619m, 4600m and 5140m) on a 12-day high altitude trek in the Published: January 17, 2018 Dhaulagiri region of Nepal. Pulse oximetry, and Lake Louise scores were also recorded on the morning and evening of each trek day. Data were compared between altitudes and relation- Copyright: © 2018 Clarke et al. This is an open access article distributed under the terms of the ships between pulse oximetry, Lake Louise score, and sway velocity were explored. Total sway Creative Commons Attribution License, which velocity during standing balance with eyes open (p = 0.003, d = 1.9) and during Sharpened permits unrestricted use, distribution, and Romberg test with eyes open (p = 0.007, d = 1.6) was significantly greater at altitudes of 3619m reproduction in any medium, provided the original and 5140m when compared with sea level. Anterior-posterior sway velocity during standing bal- author and source are credited. ance with eyes open was also significantly greater at altitudes of 3619m and 5140m when com- Data Availability Statement: All balance and joint pared with sea level (p = 0.001, d = 1.9). Knee joint position sense was not altered at higher position sense data are available from http:// commons.nmu.edu/facwork_datasets/2/. altitudes. There were no significant correlations between Lake Louise scores, pulse oximetry and postural sway. Despite a gradual ascent profile, exposure to 3619 m was associated with Funding: Research reported in this study was supported by the Surgeon General (Defence impairments in postural control without impairment in knee joint position sense. Importantly, Medical Services) Research Fund, UK and Leeds these impairments did not worsen at higher altitudes of 4600 m or 5140 m. The present findings Beckett University. should be considered during future trekking expeditions when developing training strategies tar- Competing interests: No conflicts of interest, geted to manage impairments in postural control that occur with increasing altitude. financial or otherwise, are declared by the author (s). The content of this manuscript is solely the PLOS ONE | https://doi.org/10.1371/journal.pone.0190919 January 17, 2018 1 / 13 Balance and joint position sense changes during a high altitude trek responsibility of the authors and does not Introduction necessarily represent the official views of the Defence Medical Services. Travel to high altitude among lowlanders has become increasingly common for both profes- sional and leisure purposes. Trekking in Nepal has become one of these popular high altitude adventurous activities; the number of trekking permits obtained by foreigners rose from 14000 in 1985 [1] to 97185 in 2014 [2]. Acute and chronic exposure to high altitude environments may result in clinical syndromes ranging from high altitude headache to acute mountain sick- ness (AMS) and high altitude cerebral edema (HACE). It has been suggested that these syn- dromes manifest along a spectrum transitioning from AMS to HACE with the presentation of serious neurological impairments such as balance and postural control [3]. Maintaining bal- ance and posture is a function of a number of sensory inputs to the central nervous system that include visual, vestibular, and somatosensory components [4]. Postural control is an essential factor required to perform many daily activities and has been utilised as a factor to classify elderly fallers and non-fallers [5]. Travelling over dangerous mountainous terrain has its own inherent risks, and compounding this with these impairments in balance and postural control makes the trekker particularly vulnerable to trips or falls [5]. Decrements in balance that may lead to trips or falls have been well documented during short exposures of 24 hours [6] or less (<60 mins [7±10]) to simulated hypobaric and normo- baric hypoxia. Decrements occur at both high (1500 m to 3500m) and very high altitudes (3500m to 5500m) [6±10], and were also reported during prolonged exposure over two days at terrestrial altitudes of 1630 m and 2590 m [11]. Decrements at terrestrial altitude have been shown to persist for three days at altitudes of 4559 m [12]. Although balance was demonstrated to be impaired at high [12] and very high [6] altitude, few studies have shown any association between balance and AMS. It remains unclear whether such decrements persist or are magni- fied during more prolonged gradual ascents at these altitudes exceeding four days, such as would be experienced during a high altitude trek where acclimatisation occurs in response to the increasing altitude. Therefore, further field research on expedition trekking above 5000 m is warranted, where the occurrence of AMS and HACE is significantly more likely to manifest [3]. Decrements in balance and postural control are especially important, may be magnified, and could provide stronger diagnostic links with AMS and HACE syndromes. The control of static and dynamic posture involves inputs from a number of sensory inputs to the central nervous system. Although the visual and vestibular inputs have been accounted for in previous assessments of balance at high altitude [6,8,10±12], somatosensory inputs have received limited attention. Assessments of balance using a moving platform indicated some impairment in somatosensory input at simulated hypoxia [7,13]. Performance in this task was impaired at 1524 m [7] and 5000 m [13] but the exact sensory mechanisms responsible remain unclear. The adapta- tion of the somatosensory system in extreme cold environments has been investigated using joint position sense [14]. Since a measurement of joint position sense acts as an isolated investigation of the somatosensory system, measurement of joint position sense at high altitudes provides a clearer picture regarding the mechanisms by which decrements in balance occur at these high altitudes.

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