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CONTRIBUTION TO THE NORMALIZATION OF THE PHYACTION

BALANCE BOARD
De Gunsch E.1, Spielmann F. 1,Van Meerhaege T. 1, di Palma E.2
1: Haute Ecole Libre de BRUXELLES, Ilya PRIGOGINE, Belgium
2: Haute Ecole de la Province de LIEGE, André VESALE, Belgium

INTRODUCTION
As part of classic, so-called “proprioceptive” reeducation, there is currently no simple, objective means
to enable the physiotherapist to assess the stability of an individual in situations of spontaneous loss
of balance.
An electronic balancing board defined as “proprioceptive” has recently been developed by UNIPHY,
the Phyaction Balance.
It is similar to the Freeman type I board [38]
However, until it is tested, the possibilities for using such a platform are reduced to its reeducational
aspect.
In order for a new measuring instrument to have a clinical use, before it becomes available on the
market, it is necessary to have result norms for healthy people, in order to compare them to a
pathological population.
On consulting the literature, we currently find several Italian studies which have already been
conducted on Phyaction Balance [12.45], but none of them have raised this issue.

AIMS OF WORK
The principal objective of this study is to establish the norms of the results of balancing
parameters for the Phyaction Balance board, among healthy subjects.
The establishment of result norms imposes certain constraints, such as the development of a
standardized recording protocol and the knowledge of variables which influence the parameter under
investigation.
Thus the secondary objective is to offer a response to these requirements by providing the elements
required for the present and future development of result norms on the Phyaction Balance board.
But the establishment of such norms raises other questions:
1) Does the order in which the situations are conducted have an impact on the results?
⇒ Which of the 2 eyes-open situations should be conducted first, and what are the consequences on
the results?
2) What are the variables “of interest” which influence balance?
⇒ Could gender, weight, height and the practicing of a sport play a role in dynamic balance?

REVIEW OF THE LITERATURE
“A sick person can only be compared to norms; we never have records of the subject prior to their
illness” Gagey PM (1986) [15].

I. Definition and interests of normalization
“Normalization” in the technical sense of the term, is classically defined by the action of “subjecting
production to norms” developed with the aim of simplifying it, to make it more effective and rational.
In the specific case when the production is a diagnosis tool, normalization has to have a broader
relevance, as the final objective is to establish result “norms” [15].
Based on the example of the validation of the stabilometry platform, we can state that a widespread
marketing of the Phyaction Balance board has to be preceded by a normalization procedure.
This condition is absolutely necessary in order to establish norms of results which will enable the
board to be used as a clinical evaluation tool.
⇒ This procedure has to be conducted in three stages:

A study undertaken on stabilometry by MC Costes et al. The norms for a subject on a stabilometry platform were established for two categories of adults: young. Analysis of the literature shows that 5 types of variables were regularly identified for dynamic balance: ⇒ age. the same can not be said for an adult subject. the 60 year age cut-off point is found in orthostatic balance. height and sport) opinions vary according to the authors of the types of experiences: the influence of gender is contradicted [18. given that the sample will be subdivided into several groups according to the different variables of interest. Indeed. considered 168 healthy subjects aged between 18 and 90 years and divided into 7 groups of 10 years. standardization of the recording protocol. elderly. standardization of the presentation of the results. the number N required can be expressed [11] with a precision of 5% by: ⇒ N = [2 * t *(100/5) * (cv)] ² Where: cv = σ/ μ. but it is not clear that the category of young adults can be extrapolated to individuals in conditions de spontaneous losses of balance. It would therefore appear more prudent to concentrate normalization efforts on a sample whose age range is restricted. The population and variables of interest The norms apply to the entire population which is likely to have recourse to a clinical evaluation on the Phyaction Balance. the anthropometric variables are rarely correlated [10]. if we want to collect results that can be interpreted. 21. if we know that for a child it is necessary to establish several short intervals owing to the rapid development of the maturing system. If the variable has a normal distribution. 24]. 20.96 (Student) for an accuracy of 0. gender. over 60 years. By comparison. which are likely to have an influence on our parameters. II.05. the only one which is not contested is age: the capacity for balancing undeniably depends on it. It therefore appears interesting to conduct research for a specific age range sample. but the age ranges for which balance varies have not been clearly determined. the number of subjects should be even higher than the number of variables to be analyzed. it is important to find out the variables of interest such as gender or age. by forming the corresponding groups for each one. 24]. 20. This highlighted that the balancing performance was lower among people of over 60 years of age. and a high level of sport leads to improved balance [17. Furthermore.- description of the board construction norms. as the importance of these different variables. Among these variables. Number of sample subjects The number of subjects required is going to depend in the expected precision of the result (statistical error) and dispersion characterizing the variable (variation coefficient cv). 2. Norms of results 1. height and sport. t = 1. average. μ and a standard deviation. Nevertheless. weight. On the subject of the impact of other variables: (gender. from 11 to 60 years. weight. but did not clearly establish any difference between young adult groups. σ for the population. 22. . in 1998 [9].

Test Group (TG). The conditions for normalized recordings a) The board Orientation: As we are testing bipodal lateral balance in a standing position.MATERIALS AND METHODS Population 175 healthy subjects between 20 and 30 years of age (88 men. . (Photo 2) 3. 87 women). i. auditive or vestibular disorders. in which the tilting part has a radius of 5 cm (d = 10 cm). 75 men and 75 women. with n = 150. The guide enables a standardized positioning of feet on the board. The Phyaction Balance® board. Photo 2: the mat Photo 3: the guide Method 1. its software and a portable PC.no regular taking of a medicine which would alter the postural system . 13 men and 12 women Inclusion criteria: .no locomotive. sensitive. The mat Cut to the size of the board (42 X 43 cm). . The opening angle is 30°. This choice was determined in order to generate the highest possible level of difficulty to thereby enable the observation of a greater number of variations in the results. the board is placed in a so-called “parallel” position.e. with n = 25. it is then placed on the board. 2. It enables the surface of the board to be made uniform and to help prevent feet from slipping.asymptomatic for a minimum of 6 months. distributed randomly into two groups: .“Control” Group (GC). . Material 1. The blocks: We have chosen to use the board with no additional blocks. visual (non corrected).

Photo 5: positioning of the feet Photo 6: position of the segments Each of the 3 exercises begins with the board tilting to the right. The durations have been set at 30 seconds. 2. which was established to observe the effect of the order of conducting the tests on the results. On the other hand. The same thing with your eyes closed. used the following order: ⇒ GC Order = 1) fixed point 2) feedback 3) eyes closed The subject is standing. . Owing to the guide described above. during the rest phase.The feet are bare and pointing in the same direction as the board. The same thing looking at a fixed point on the screen. The Test Group (TG. it is forbidden to speak during the test in order to maintain proper concentration. The instructions given were: 1. 3. . the heels are 5cm apart and the feet are open at a 30° angle.The Hands are placed on the hips and the knees are bent to better standardize the subject’s position. and keeps the board balanced using feedback from the screen (complete mode) and sound. in order to concentrate better. whilst remaining on the board and keeping his feet in the same position. .b) The recording conditions Three types of situations have been defined: . n = 25). the feet are positioned precisely: the back is 5cm from the rear edge of the board. in a bipedal position. . For the entire duration of the recording. bending your knees slightly and placing your hands on your hips.“Eyes Closed” (EC): the subject has their eyes closed and balances. was subjected to the order in which the following situations are conducted: ⇒ TG Order = 1) feedback 2) fixed point 3) eyes closed.“Fixed Point” (FP): the subject has their eyes open (EO). such that the projection of the centre of gravity towards the ground is situated on the sagittal axis of the platform (Photo 5). and keeps the board balanced by looking at a specific fixed point on the screen. The Control Group (GC. he can speak and change his body position. During the 30s of the exercise you should absolutely remain in this position. An increasingly high-pitched sound is heard if you move off it (feedback situation). the subject must absolutely not speak. Try to remain upright.“Feedback” (FB): the subject has their eyes open (EO). n =150). from which the result norms are established. . either by looking at the graph or the cursor.

c) The environment § § § central vision (foveal vision): the visual target. Conclusions relating to the order of conducting the exercises: - - The averages obtained for the 2 FB and FP situations did not vary according to the type of situation. STATISTICAL RESULTS The difference in the result observed between the 3 situations is highly significant.6). The results in the “fixed point” position are better than in the “feedback” situation. the poorest are for the EC situation (15.3) and finally. The comparison of right and left values for each situation reveals very significantly higher averages for the right side. We were able to highlight that the “FB then FP” order resulted in a greater percentage of real improvements of results for the second exercise. Peripheral vision: The entire computer/tripod unit is in the corner of a room with no indication of the verticality of the walls.01) for the total surface and right and left external surface parameters. The experimenter should ensure that they are not in the subject’s field of vision. then FB (13. There is a low correlation between the BMI and the global parameter. Thus the peripheral vision is limited and can be reproduced. Anthropometric variables (weight and height) represented by the BMI influence the balancing performance when the eyes are closed.7). The EC situation sensitizes the test as this comparison then becomes highly significant (p = -7 10 ). These results are found once again to be highly significant (p<0. at a height of 1m30 (that of the tripod). is placed 1 meter away from the subject.e. which has an increasing relevance: Performances diminish with the increase in the BMI. What are the variables of interest? We have not been able to highlight a significant difference in the balancing performance between men and women. 1. It is therefore possible to advance the hypothesis of a learning effect. 2. the balancing performances are significantly different (p = 10 -8) for each situation: the best are achieved in the FP situation (12. but according to the order in which they were conducted: the situation conducted second led to a better performance than the first. The auditive environment: The room should be as calm as possible with the presence of one experimenter and a waiting subject for the study requirements. . only with visual and auditive feedback. The results of the “eyes closed” situation are far poorer than those for the other two situations. Conclusions regarding the parameters provided by the program: - - - In terms of the overall score. external surface and external time. Only the sports specifically requiring the balancing function had a favorable effect on the overall score. i. for total surface parameters. the computer screen. People who practice sports have a better balancing performance compared with people who do not.

especially if it requires good balancing capacities and if it is conducted to a high standard.ESTABLISHING THE NORM We would propose a performance scale which makes it possible to grade a subject and assess their progress. using the distribution of the score global in the 3 recording situations: Feedback Very good [9 – 11[ Fixed point [9 – 11[ Eyes closed Good [11 – 12. but it should nevertheless take into account the sport practiced. Furthermore. for each situation. Therefore. The results of our study have made it possible to highlight that the order in which the “eyes open” situations were conducted influenced the results: . Five stability levels were established. . weight and height do not play a determining role in the balancing function.7 40 Feedback Fixed point Eyes closed 41. . Even if a low balancing performance correlation was demonstrated with Body Mass Index in an eyesclosed situation. any other attempt at normalizing the parameters of the Phyaction Balance should take into account the above remarks in its evaluation protocol. in terms of the variables of interest.3 30 30. the establishment of norms can be achieved independently of gender.5[ [11 – 12[ [14 – 15[ Average [12.a warm-up test was necessary before any recording.a choice was made: the “feedback” then “fixed point” order however generated a greater percentage improvement the second time around. is represented by the following graph: 60 50 52.7 20 10 0 Very good Good Average Poor Very poor stability levels DISCUSSION These norms correspond to the application of a standardized recording protocol.5 – 14[ [12 – 13[ [15 – 16[ Poor [14 – 15[ [13 – 14[ [16 – 17[ Very poor [15 – 16[ [14 – 16[ [17 – 18[ [13 – 14[ percentage of subjects (%) The percentage of subjects per stability level.

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