Gait & Posture 27 (2008) 471477

www.elsevier.com/locate/gaitpost

The relation between postural stability and weight distribution

in healthy subjects
Linda C. Anker a, Vivian Weerdesteyn a,b,*, Ilse J.W. van Nes a,b,
Bart Nienhuis a, Huub Straatman c, Alexander C.H. Geurts b
a
Sint Maartenskliniek Research, Development and Education, Nijmegen, The Netherlands
b
Department of Rehabilitation, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
c
Department of Epidemiology and Biostatistics, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
Received 12 October 2006; received in revised form 14 May 2007; accepted 9 June 2007

Abstract

Knowledge of the effects of leg-loading asymmetry on postural control and control asymmetry during quiet upright standing in healthy
young and middle-aged subjects is necessary before these relationships in patients with lateralized disorders can be assessed and understood.
A posturographic procedure was developed, using a dual-plate force platform, during which 10 younger and 10 middle-aged healthy
individuals were required to adopt various degrees of (a) symmetrical weight distributions (0, 5, 10, 20 and 30% of extra body weight loaded
onto either leg). Postural control and control asymmetry were quantified by centre of pressure (CP) fluctuations in the lateral (LAT) and
anteriorposterior (AP) directions under both feet together and individually. Subsequently, the relationship between weight distribution on
one hand and postural control and control asymmetry on the other hand, was calculated. Results demonstrated that with increasing weight-
bearing asymmetry (WBA), the overall control of postural sway velocity increased mainly in the LAT direction, where a first-order
polynomial function fitted best. The asymmetry of control of postural sway velocity increased with increasing weight-bearing asymmetry in
favour of the more loaded leg in LAT and AP directions. A first-order polynomial was used for both AP and LAT direction. Effects of weight-
bearing asymmetry on postural control and control asymmetry are due to changes in the biomechanical constraints of upright standing. It was
suggested that through increasing weight-bearing asymmetry the postural instability increased by reducing the efficiency of hip load/unload
mechanisms and increasing the (compensatory) ankle moments.
# 2007 Elsevier B.V. All rights reserved.

Keywords: Weight-bearing asymmetry; Postural control; Control asymmetry

1. Introduction be regarded as a maladaptive strategy) or reflects an inherent

Both central and peripheral diseases may cause
deterioration of postural control and, especially in the case
of lateralized disease, abnormal asymmetry in weight
distribution between the legs [18]. In most patients with
lateralized disease it remains unclear to what extent the
persistent leg-loading asymmetry reflects fear or inability to
cope with the altered sensorimotor constraints (and thus can
* Corresponding author at: Department of Rehabilitation, Radboud
University, Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen,
The Netherlands. Tel.: +31 24 36 14 804.
E-mail address: v.weerdesteyn@reval.umcn.nl (V. Weerdesteyn).
capacity of the central nervous system to adopt a position in
which the body sway is optimally controlled (given the
sensorimotor impairments). Generally, when postural
instability coincides with weight-bearing asymmetry, it is
unclear to what extent the decreased stability is related to
altered biomechanical constraints or should be considered as
a consequence of a neural control problem (e.g. due to
pathology). For healthy elderly, a greater weight-bearing
asymmetry (WBA) was associated with increased anterior
posterior (AP) postural sway [9,10]. Similar but less strong
associations between weight-bearing asymmetry and pos-
tural control have been reported for stroke patients [2,10,11].
Between-subjects comparisons, however, can provide only

0966-6362/$ see front matter # 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.gaitpost.2007.06.002
472 L.C. Anker et al. / Gait & Posture 27 (2008) 471477
limited insight into the relationship between WBA and
stability due to possible inter-individual differences in
postural strategies.
In order to further unravel this relationship in various
types of patients with lateralized disorders, and to under-
stand to what extent their postural instability can be
attributed to WBA, it is necessary to know the effects of leg-
loading asymmetry on postural control in healthy subjects.
Although, theoretically, a fully symmetrical standing
posture provides maximum stability, at least in healthy
subjects [9,1214], the precise relationship between WBA
(in the frontal plane) and postural stability (in both the
frontal and sagittal planes) during normal quiet standing is
unknown. In other words, which degree of WBA provokes
which degree of stability loss and control asymmetry in
healthy subjects? As yet, only one study has been published
that investigated the within-subjects relationship between
weight distribution and postural control in healthy adults.
Genthon and Rougier [15] demonstrated the negative effects
of an asymmetrical body weight distribution on the control
of undisturbed upright stance. They reported that the
amplitudes of the centre of pressure (CP) under both feet
increased with increasing weight-bearing asymmetry in both
the lateral (LAT) and AP directions, however, most
pronounced in the LAT direction. Remarkably, this effect
was stronger for the unloaded leg than the loaded one.
However, this study did not look at the CP velocity, which is
frequency sensitive and a more reliable parameter in the
clinical quantification of postural control than CP amplitude
[1618], and did not calculate the precise relationship
between WBA and changes in postural stability or kinetic
regulation symmetry (i.e., the symmetry in regulation
activity between the loaded and unloaded leg). Precise
mathematical relationships are essential to correctly inter-
pret postural instability and regulation asymmetry given the
concomitant WBA and to adjust these measures for the
degree of WBA in a particular test or condition. This would
improve the comparability of individual measurements as
well as of group data.
The aim of this study was to examine the within-subjects
relationship between weight distribution on the one hand
and postural control and control asymmetry on the other
hand, during quiet upright standing in healthy adults. For
this purpose a posturographic procedure was developed
during which participants were forced to adopt various
standardized asymmetric weight-bearing positions.
2. Methods
2.1. Participants
Twenty healthy individuals participated in this study.
Four men and six women (mean age  S.D. 25.8  2.5
years) were included in the young group. Five men and five
women (mean age  S.D. 51.6  3.3 years) were included
in the middle-aged group. Subjects with neurological or
orthopaedic diseases or with visual or other sensory deficits
were excluded. All participants gave their written informed
consent. Approval was obtained from the institutional
ethical committee.
2.2. Posturography
Postural control was measured by using a force platform
consisting of two separate aluminium plates. Each plate was
placed on three transducers (hysteresis and non-linearity
<1%), which recorded the vertical ground reaction forces
[16]. Signals were processed by six dc amplifiers (non-
linearity <0.1%) and first-order low-pass filters with a cut-
off frequency of 30 Hz. Data were stored after a 16-bit AD
conversion at a sampling rate of 500 Hz. By means of digital
moment-force calculations, the point of application of the
resultant of the ground reaction forces (centre of pressure)
was determined in a two-dimensional transverse plane for
each sample, with a maximum error of 1 mm [19] in the
LAT and AP directions. The coordinates of the CP
displacements were passed through a digital, low-pass
Fourier filter with a 6 Hz cut-off frequency to eliminate
high-frequency components due to noise.
For safety purposes, two parallel support bars were
placed beside the force platform. Real-size visual CP
feedback was provided through a computer screen that was
placed 1 m in front of the participants. The lag time between
movement of the CP and the cursor was about 16 ms.
2.3. Procedure
During posturography, the participants stood barefoot on
the force platform with their arms alongside their trunk and
their feet against a fixed foot frame (medial sides of the heels
8.4 cm apart and each foot placed with toes outward at a 98
angle from the sagittal midline). The reference width, which
corresponded to the distance between the anterior borders of
the distal tibiae while standing on the platform, was
determined (Fig. 1a).
All balance tasks were done while facing the computer
screen. Subjects were instructed to stand quietly upright with
their eyes open for 20 s during all balance tasks. One test
series consisted of 10 different balance tasks. During the first
task, participants faced a grey computer screen (reference
task). During the second task, participants were asked to stand
symmetrically by maintaining their CP (represented as a black
circle) as still as possible within the limits of a vertical target
bar presented in the middle of the computer screen (Fig. 1c).
The width of the bar was always fixed at 5% of the reference
width of each participant. In this way, the participants had to
maintain their CP between limits corresponding with 47.5%
and 52.5% of body-weight loading on either leg (reference
feedback task) (Fig. 1c). The following eight tasks were
randomized in order. They assessed various degrees of forced
weight-bearing asymmetry in both directions by positioning
 L.C. Anker et al. / Gait & Posture 27 (2008) 471477
Fig. 1. (a) The position of the feet and the reference width. (b) The
definition of the different directions of the right foot. (c) Scheme of the
target bar, positioned at the sagittal midline.
the target bar at corresponding distances from the vertical
midline of the screen. These distances were calculated
individually based on the subjects reference width. To
prevent fatigue, the direction of the forced weight-bearing
asymmetry was changed after each test.
The applied degrees of asymmetrical weight loading
were 5%, 10%, 20% and 30% of the extra body weight
(above 50%) loaded onto either leg. Each test was preceded
by a 5 s anticipation period followed by a low-frequency
starting tone. After the first test series, the complete
sequence was repeated, so that eventually 20 tests were
obtained for each subject.
2.4. Data analysis
First, the amplitude variability (ACP) of the overall CP
fluctuations was determined by calculating the root mean
square (RMS) as an estimation of the body sway in the AP
473
and LAT directions separately. After a first-order differ-
entiation, the RMS CP velocity (VCP) was calculated.
As for the analysis of the CP displacements for each foot
separately, the reference coordinate system was rotated 98 to
the left or to the right of the sagittal midline, according to the
position of the left and right foot, respectively, to obtain CP
measures congruent with the anatomical orientation of the
respective ankle joints (Fig. 1b). Then, calculation of the
above-mentioned ACP and VCP values provided measures
of the CP modulation under each foot separately in both the
AP and LAT directions. To express the degree of kinetic
regulation asymmetry, the symmetry index (SI) was
calculated according to the following equation:
2  Y Loaded  Y Unloaded
SI  100%
Y Loaded Y Unloaded
In this equation, YLoaded and YUnloaded are CP parameters
derived from the CP fluctuations under the loaded and
unloaded foot, respectively. The SI is 0 if there is perfect
symmetry. Positive values of SI indicate more CP modula-
tion of the loaded leg.
2.5. Statistical analysis
All balance parameters obtained from corresponding
tasks in each of the two test series were averaged. The
balance parameters from the nine tasks with visual feedback
were individually normalised. The differences between
these parameters and their values as obtained from the
reference task without feedback were divided by the latter
value and multiplied by 100%. In this way, all feedback
performances were represented as a percentage change with
respect to the reference task. It is possible that not only
WBA, but also visual feedback itself has an effect on CP
parameters. By normalisation with respect to the non-
feedback condition, the presence of feedback effects could
be identified as any significant non-zero normalised value in
the 0% WBA condition, as tested by one-sample t-tests. We
assumed that if present, feedback effects would be constant
for all WBA conditions. All normalised parameters were
tested in a three-way ANOVA using Group (young versus
middle-aged) as a between-subjects factor and Side (left and
right) and WBA (0%, 5%, 10%, 20%, 30%) as within-
subjects factors. When significant main effects of weight
distribution were detected, a random coefficient (RC)
regression model (utilizing the SAS procedure PROC
MIXED with a random effects maximum likelihood
regression procedure) was used to investigate the mathe-
matical relationship between the degree of WBA and the
normalised balance parameters. This procedure gives a log
likelihood for each estimated model. The difference in
2 log likelihood between two models (one model has one
or two extra parameter(s)) is an indication of the adequacy of
the model. The difference follows a x2 distribution with one
or two degree(s) of freedom. If this difference in 2 log
474 L.C. Anker et al. / Gait & Posture 27 (2008) 471477

likelihood is significant, then the most complex model is

selected. Data were fitted in first-order to third-order
polynomials functions. The corresponding statistical model
used to analyze the intra-individual relationship between a
normalised balance parameter (Y) and weight-bearing
asymmetry for the group as a whole is given in the
following polynomial equations [20].
The index i denotes the subject identification (i = 120),
whereas WBAt denotes the WBA at t = 0%, 5%, 10%, 20%
and 30%, respectively.

Y it bi b0 b1  WBAt eit first order

Y it bi b0 b1  WBAt b2  WBAt 2 eit

second order

Y it bi b0 b1  WBAt b2  WBAt 2
b3  WBAt 3 eit third order

In these equations, Yit are the observations for subject i at

measurement t, bi the random intercept for individual i, b1,
b2 and b3 the regression coefficients for the polynomial in
WBA, and eit is the error for subject i at WBAt.
In order to find the best model, all models were
compared to determine whether a higher order polynomial
Fig. 2. Postural stability, expressed as the RMS of the overall CP velocities
function was significantly better or not. (VCP) in the frontal plane (a) and the sagittal plane (b) for the different
degrees of weight-bearing asymmetry (WBA). The solid line is the mean.
The dotted lines are the mean  1.96  overall S.D. The dashed line is the
3. Results fit of the model used.

All participants were able to maintain their CP within the
borders of the target bar in each task. Table 1 summarizes the
means and S.E.M.s for all parameters in both the frontal and
the sagittal planes.
Analysis revealed a significant effect of visual feedback
for VCP LAT ( p < 0.01). VCP significantly increased by
29.8% during the reference feedback task compared to the
reference task in the LAT direction (Table 1 and Fig. 2a). In
AP direction, VCP significantly decreased by 12.4%
( p < 0.01) and ACP significantly increased by 21.4%
( p < 0.05) (Fig. 2b). Visual feedback had no significant
effects on SI VCP and SI ACP (Table 1, Fig. 3a and b).
A summary of the results of the three-way ANOVA with
repeated measures is presented in Table 2. Main effects of
WBA were present for all parameters, except for ACP in AP
direction. Values of the various CP parameters increased
with increasing degrees of WBA. There were no main
effects of group and side, nor any interaction effects of
WBA by group or by side, indicating that age and side did
not have differential effects on postural stability over the

Table 1
Summary of the mean (S.E.M.) for CP velocity (VCP) and CP amplitude (ACP) and the symmetry index (SI) of VCP and ACP for the various degrees of
weight-bearing asymmetry (WBA) in the lateral (LAT) and antero-posterior (AP) directions
Direction Parameter WBA
0% S.E.M. 5% S.E.M. 10% S.E.M. 20% S.E.M. 30% S.E.M.
LAT VCP 29.8 9.1 40.7 8.2 62.4 9.3 103.0 13.9 146.5 15.1
ACP 7.1 7.0 0.8 6.4 6.9 6.0 28.1 7.4 51.6 7.7
AP VCP 12.4 4.2 10.4 3.1 10.4 3.3 3.3 3.5 17.6 5.3
ACP 21.4 7.5 25.1 9.5 26.0 7.9 26.9 8.1 35.2 9.6
LAT SI VCP 2.4 6.5 0.4 4.0 1.9 4.6 27.0 6.1 50.0 8.4
SI ACP 12.5 9.6 1.2 5.8 7.7 7.1 29.1 8.8 39.6 8.9
AP SI VCP 1.5 7.6 1.7 3.8 4.7 3.9 23.3 5.1 38.7 5.2
SI ACP 0.2 8.3 2.3 4.7 2.7 3.6 20.5 6.4 29.5 6.2
 L.C. Anker et al. / Gait & Posture 27 (2008) 471477 475

various degrees of WBA. For VCP in LAT direction, PROC

MIXED determined that there was no significant difference
between the three estimated models. Therefore, the first-
order (linear) polynomial function was used to describe the
relation in LAT direction (Table 3 and Fig. 2a). For VCP in
AP direction, the second-order polynomial function was
used (Table 3 and Fig. 2b). For SI VCP, first-order
polynomials were used in both AP and LAT direction
(Table 3, Fig. 3a and b).

4. Discussion

The purpose of this study was to examine the intra-

individual relationship between weight distribution and
postural stability during standing in healthy subjects.
Participants were forced, while standing on a dual-plate
force platform, to adopt various asymmetric weight-bearing
positions using visual feedback of their CP.
Results demonstrated that the postural strategy changed
during quiet upright standing with visual feedback
compared to the situation without visual feedback. During
all visual feedback tasks, the subjects were required to
control their upright standing primarily in the LAT direction.
Therefore, the subjects were mostly concentrating on their
stability in this direction. Remarkably, this led to a
Fig. 3. Kinetic regulation asymmetry, expressed as the symmetry index (SI)
of the RMS of the CP velocities (VCP) under each foot separately, in the
considerable increase in overall CP velocity (and, thus, a
frontal plane (a) and the sagittal plane (b) for the different degrees of weight- reduction in postural control efficacy) in the LAT direction,
bearing asymmetry (WBA). The solid line is the mean. The dotted lines are which coincided with a relatively small decrease in overall
the mean  1.96  overall S.D. The dashed line is the fit of the model used. CP velocity in the AP direction during the reference
Table 2
Summary of the results of the three-way ANOVA of the CP velocity (VCP) and CP amplitude (ACP) values in lateral (LAT) and antero-posterior (AP) directions
Direction Parameter WBA p-Value WBA  Group p-Value WBA  Side p-Value WBA  Group  Side p-Value
LAT VCP F(2.38, 42.91) <0.01 F(2.38, 42.91) 0.61 F(2.65, 47.72) = 0.21 0.87 F(2.65, 47.72) = 0.30 0.80
= 47.23 = 0.55
ACP F(4, 72) = 54.31 <0.01 F(4, 72) = 0.29 0.89 F(2.64, 47.43) = 0.12 0.93 F(2.64, 47.43) = 0.83 0.47
AP VCP F(1.92, 34.57) <0.01 F(1.92, 34.57) 0.68 F(2.56, 46, 07) = 0.49 0.66 F(2.56, 46, 07) = 0.86 0.45
= 22.54 = 0.38
ACP F(4, 72) = 0.83 0.51 F(4, 72) = 1.39 0.25 F(2.90, 52.28) = 1.54 0.21 F(2.90, 52.28) = 0.94 0.43
LAT SI VCP F(2.48, 44.81) <0.01 F(2.48, 44.81) 0.23 F(4, 72) = 1.00 0.41 F(4, 72) = 1.07 0.38
= 17.96 = 1.51
SI ACP F(4, 72) = 4.83 <0.01 F(4, 72) = 0.60 0.66 F(2.97, 53.49) = 1.36 0.27 F(2.97, 53.49) = 0.32 0.81
AP SI VCP F(2.13, 38.34) <0.01 F(2.13, 38.34) 0.25 F(2.29, 41.23) = 0.45 0.67 F(2.29, 41.23) = 0.41 0.69
= 15.35 = 1.44
SI ACP F(2.32, 41.67) <0.01 F(2.32, 41.67) 0.28 F(4, 72) = 0.36 0.84 F(4, 72) = 0.31 0.87
= 5.89 = 1.34
WBA is weight-bearing asymmetry.
Table 3
Summary of the regression coefficients and variances of the CP velocity (VCP) and the VCP symmetry indices (SI) in both the lateral (LAT) and antero-posterior
(AP) directions
Direction Parameter Coefficients Variances
b0 b1 b2 b3 var (bi) var (eit)
LAT VCP 24.46 3.99 1575.87 924.27
AP VCP 11.13 0.44 0.046 166.16 128.64
LAT SI VCP 8.72 1.84 137.62 593.87
AP SI VCP 4.64 1.38 152.45 393.78
476 L.C. Anker et al. / Gait & Posture 27 (2008) 471477
feedback task. This change in postural strategy seems to
reflect a tighter (but not better) control of body sway in
the LAT direction through more rapid alternations of the
direction of the subtle weight shifts during quiet standing,
which is the main mechanism of postural control during
normal biped standing in the frontal plane [13]. A similar
change towards a more tightened postural control has
been reported by Dault et al. [21], who found that young
subjects were able to decrease the amplitude of their sway in
either direction during upright standing with visual feedback
involving an increase in frequency of their sway in either
direction during upright standing with visual feedback.
The results of the visual feedback tasks clearly show that
postural stability is affected by weight distribution. Overall,
postural stability decreases with increasing WBA. The
general destabilising effect of WBA has been reported
previously [9,13,15]. By using visual feedback and requiring
specific degrees of WBA, we were able to find that WBA had
a large effect on the VCP in the LAT direction, with a (linear)
increment of 4% for each degree of WBA, whereas there was
a smaller effect in the AP direction. Apparently, both planes
of postural control are differently organized and controlled.
Although visual feedback modified the postural control
strategy, this pattern of results seems in line with the
characteristics of normal biped standing (i.e., without visual
feedback), where frontal-plane balance is based on subtle
weight shifts, primarily controlled by the hip abductors and
hip adductors, whereas sagittal-plane balance is primarily
under the control of ankle mechanisms [13]. Nevertheless,
there appeared to be some influence of WBA on AP postural
stability, which was mainly related to the 30% WBA
condition. It is possible that this condition already begins to
reflect the characteristics of one-legged standing [22].
Because the muscles of the unloaded leg lose their capacity
to generate effective stabilizing ankle torques as a result of
the unloading, the VCP under the loaded leg increases which
reflects the generation of compensatory ankle moments at
this side. As for frontal-plane balance, it must be concluded
that the control of subtle weight shifts between the legs is
increasingly less effective when one leg is progressively
unloaded.
The kinetic regulation asymmetry increases with
increasing WBA. Kinetic regulation asymmetry in AP
direction increased by 1.4% for each degree of WBA. The
kinetic regulation activity of the loaded leg was always
higher than of the unloaded leg, indicating that the loaded
leg became more active in the balance control. In addition, it
was also found that CP amplitudes were larger on the loaded
than on the unloaded side. This is different from the work of
Genthon and Rougier [15], who reported that WBA induced
a stronger increase in CP amplitudes for the unloaded
support than for the loaded one. However, CP amplitude is
insensitive to changes in the mean frequency of regulation,
whereas CP velocity is frequency sensitive. Particularly the
higher frequencies within the CP fluctuations reflect the
stabilizing ankle torques. Based on our results, we conclude
that with increasing WBA the strong increase in asymmetry
of the lateral VCP under each foot, particularly in the 30%
WBA condition, reflects the characteristics of progressive
one-legged standing. Indeed, when standing on one leg, the
hip loading/unloading strategy in the frontal plane is
replaced by a primary ankle strategy in this plane which
will cause a large increase in the lateral CP velocity under
the supporting foot [13]. As for the sagittal plane, the results
suggest that the normal ankle strategy is largely maintained,
with equal contribution of both feet.
A limitation of the present study was that during all
weight-bearing asymmetry tasks, visual feedback of CP was
provided. The major advantage of this procedure was that we
were able to apply standardized degrees of asymmetrical
weight distribution, in order to allow within-subjects
comparisons for the effects of WBA on postural control.
In this approach, we assumed that the observed change
towards a tighter postural control strategy as a result of
visual feedback would be unaffected by the various degrees
of WBA. Hence, in our mathematical models, visual
feedback is assumed to be responsible for the intercept
(b0) being unequal to zero, without having changed the
values of the other coefficients (b1 and b2). However, this
assumption still needs to be validated in a future study, using
the exact same experimental setup in which participants
would also stand with various degrees of WBA, but without
visual feedback.
In conclusion, this study aimed to determine the within-
subjects relationship between weight distribution on the one
hand and postural control and control asymmetry on the
other hand, during quiet upright standing in healthy adults.
Results showed that both overall kinetic regulation and
regulation asymmetry increased with increasing weight-
bearing asymmetry. This indicates that a symmetric weight
distribution between the legs during quiet upright standing
provides optimal stability in subjects without neural control
problems. Both the overall CP velocity and the asymmetry in
CP velocity between the legs in both planes show the lowest
values when 50% weight is born on each leg. Apparently,
symmetrical loading provides the greatest biomechanical
stability, requiring the least correcting actions. In other
words, the effects of WBA on postural stability in both
planes are related to changes in the biomechanical
constraints of upright standing and do not reflect changes
in the neural control of posture.
Several clinical studies have indicated that lateral CP
velocities provide more information about the sensorimotor
consequences of different lateralized diseases and show the
best association with risk of falling [9,15,21]. Thus, by
increasing the velocity of the CP displacements especially in
the lateral direction, increasing WBA may increase the risk
of falling. On the other hand, patients with postural control
problems due to lateralized diseases may have a different
optimum of weight distribution between the legs, despite the
fact that from a biomechanical perspective symmetric
standing would be optimal. Knowledge of the optimal
 L.C. Anker et al. / Gait & Posture 27 (2008) 471477
weight distribution is important to improve rehabilitation
strategies for different groups of patients [15]. Therefore, in
future studies, we will examine the relationship between
postural stability and WBA in patients with lateralized
disease, such as hemiparesis due to stroke, to establish optimal
balance strategies for these patient groups and to identify
individual deviations from optimal weight distribution.
Conflict of interest
The authors have no financial or personal relationships or
affiliations that could influence (or bias) the authors
decisions, work, or manuscript.
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