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Assessing ~ynamicBalance
Stephen ). Kinzey, PhD '
Charles W. Armstrong, PhD *
D
ynamic balance is re- Quantification of dynamic balance is often necessary to assess a patient's level of injury or
quired for normal daily ability to function in order to initiate an appropriate plan of care. Some therapists use the star-
activities, such as walk- excursion test in an attempt to quantiQ dynamic balance. This test requires the patient to balance
ing, running, and stair on one leg while reaching with the other leg. For the purpose of this study, the reach was
climbing. Sports activi- performed in four directions. No previous researchers have attempted to evaluate the reliability of
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ties also require proper balance con- this test. Twenty healthy subjects between the ages of 18 and 35 years participated in this study.
trol. The visual, somatosensory, and During two testing sessions, each subject was required to perform five reaching trials in four
vestibular systems all contribute to directions. Reliability estimates, calculated using the intraclass correlation coefficient (2/I), ranged
the maintenance of balance (10) and from 0.67 to 0.87. Six duplicate practice sessions were suggested to increase this range above
may be adversely affected by muscu- 0.86. Task complexity may account for the moderate reliability estimates. Subjects should engage
loskeletal injury, head trauma, dis- in a learning period before being evaluated on the star-excursion test.
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
order to initiate an appropriate plan move in response to muscular activ- new and practical techniques or pro-
of care (15,17). ity. This muscular activity may arise tocols to evaluate dynamic balance
A valid and reliable technique to from any source of external or inter- need to be investigated.
measure balance is stabilometry (17). nal disturbance. During dynamic ac- The starexcursion test is used by
This method uses a force plate or tivity, the center-of-pressure travels some therapists to assess dynamic bal-
other similar device to measure the between the base of support bound- ance. It has been proposed that the
displacement of an individual's cen- aries and sometimes outside the base test meamres dynamic balance, re-
ter-of-pressure while standing in a of support (9). Because stabilometry quiring patients to maintain balance
stationary position (17). Center-of- is performed under static conditions, on a single limb, while manipulating
pressure represents a weighted aver- the results may not be directly appli- the other limb. This test requires the
age of all the pressures over the sur- cable to assessing a patient's capabil- subject to reach along a previously
face area in contact with the ground ity for dynamic activities (21). marked line with one leg while stand-
(20). Quan tification of center-of-pres- Unfortunately, few practical ing on the other leg. This reaching
sure movement may be used to evalu- methods exist for evaluating dynamic task is done along four different diag-
ate numerous parameters (ie., mean balance (7). Methods have been re- onal lines in four different directions.
position of the center-of-pressure, velo- ported to assess dynamic balance in- The distance reached in each direc-
city of center-of-pressure movement, volving perturbation of stationary tion is recorded separately and the
and total distance traveled by the cen- subjects, through translation of a four individual scores are interpreted
ter-of-pressure) influenced by the con- force plate, or by using an external as a representation of dynamic bal-
trol mechanism affecting balance (16). force to perturb the subject and a ance and offer clinicians a practical
Many activities of daily living and nonmoving force plate (5,18).These alternative for assessing dynamic bal-
sports are classified as dynamic activi- methods are costly, impractical, and, ance. The purpose of this study was
position of the feet wa. placed at the in any way possible to achieve a maxi-
center point. This box wa. large mum reach distance without moving
enough to fit the subject's feet while the support foot. These movements
straddling the vertical line. A standard included but were not limited to
tape measure wa. used to quantify the knee flexion of the support limb and
distance (cm) from the center point to dorsiflexion of the support limb; hip
the point that each subject reached flexion in the reaching limb, knee
along each diagonal using the distal extension in the reaching limb, and
part of the foot. Calculators were then plantar flexion in the reaching limb;
used to reduce the trial data into direc- and slight hyperextension of the
tional averages. trunk. Typically, clinicians also use a
FIGURE. Layout of the star-excursion test showing subjective description of what move-
how the tape was applied to the floor. Subjeas stood Protocol ment strategies are used by the pa-
within the square box and reached out in the four tient when performing the star-excur-
diagonal directions. LA = Left-anterior, LP = Left- The subject. completed two test-
sion test. This subjective description
posterior, RA = Right-anterior, RP = Right-posterior. ing sessions (pretest and posttest) 7
days apart. For each session, subjects is then used to identify possible dif-
were instructed to stand with both ferences between limbs.
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to evaluate the reliability of the star- feet positioned inside the boundaries After performing a local survey of
excursion test. of the starting box. A trial was initi- clinicians that used this test, it was
ated when the subject began to reach determined that the star-excursion
in one of the following four diagonal test is usually performed with shoes
METHODS
directions: right-anterior (RA), left- on. Furthermore, no recommenda-
anterior (LA), right-posterior (RP), tions concerning the height of the
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Subjects
and left-posterior (LP). When reach- reaching limb are made when the
Twenty subjects (nine males and ing along the lines to the subject's test is administered. In an attempt to
11 females) volunteered to partici- right, the subject used his/her right keep our protocol similar to a clinical
pate in this study and provided in- leg to reach while using his/her left application, no effort was made to
formed consent as approved by the leg as the support limb and vice control for these items.
Institutional Review Board, University versa. Subject. were not allowed to
of Toledo, Toledo, OH. To qualify touch the ground with the reaching Experimental Design and
for participation, the subjects could leg at any time during the reach. The
not have: 1)incurred any ankle maximal reach distance was the fur- Statistical Analysis
Journal of Orthopaedic & Sports Physical Therapy®
trauma requiring medical attention thest point along the directional line. A pretest-posttest design was used
within the past 2 years, 2) a history of In accordance with the usual test pro- to assess the four dependent mea-
any dizziness, 3) any inner ear disor- tocol, the maximal reach distance was sures corresponding to the average
ders, 4) any nervous system problems, measured visually. The visual mark
of the three best reaches for each
5) any bone or joint abnormalities, was then replaced by a finger, and
diagonal direction: right-anterior
6) a history of loss of consciousness, the distance was then measured using
7) any uncorrected problems with a tape measure. The test administra-
(RA),left-anterior (LA), right-poste-
vision, or 8) any other problem that rior (RP),and left-posterior (LP).
tor was positioned on his knees along
might adversely affect the control of the directional line. The trial was The direction of reach was deter-
balance. All subjects were between complete after the subject returned mined by a balanced Latin square
the ages of 18 and 35 years. to the starting point by placing the to reduce the possibility of an order
reaching leg in the starting box with effect.
the support leg. After completion of Intraclass correlation coefficient
Test Description
a single trial, the subject was given (2,l) (ICC 2,l) (13) and the Spear-
The starexcursion test layout the time necessary to regain the man Brown prophecy (1) were used
consisted of four lines, applied to the proper starting position before start- to estimate the reliability (ie., agree-
floor with athletic tape: two forming ing the next trial. Five consecutive ment between scores) of the starex-
vertical and horizontal lines and two trials in each direction were com- cursion test. The ICC(2.1) was cho-
positioned perpendicular to each pleted before the subject began to sen as the reliability estimate, since it
other and at 45O with respect to the reach in the next direction. provides an estimate that includes
vertical and horizontal lines (Figure). During the starexcursion test, the variability of measurement. taken
A rectangle representing the starting the subject. were instructed to move by any investigator on any subject
the number of sets of scores, and the four components of the test.
DISCUSSION
n = the number of persons observed. Moderate estimates of reliability indi-
Mean square terms were obtained The task of standing in normal cate that a subject mav exhibit a
using the F statistic calculated under adults can be described as a position change in scores due to some unmea-
the reliability procedure in SPSSmfor of quasi-static equilibrium. Standing surable circumstance, a random
WindowsTM, Version 6.1 (SPSS, Inc., is quasi-static because the center-of- movement pattern, or any other pos-
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Chicago, IL). pressure travels within the base of sible influence, including mental
The Spearman Brown prophecy support, indicating overall sway with- state.
estimates the reliability of a test. Us- out a corresponding translation of One possible explanation for
ing only two sets of obsenations, it the base of support (20). these moderate estimates is that the
allows the researcher to estimate how The goal of the starexcursion subjects may have chosen different
many observations might be neces- test is to force subjects to disturb movement trajectories in an attempt
sary to achieve a desired estimate of their equilibrium to a near maximum to obtain a maximal reach distance.
reliability. The Spearman Brown (ie., the reach is maximum but does These random movement trajectories
prophecy is represented by the fol- not cause a fall which would be indic- could contribute to random low or
Journal of Orthopaedic & Sports Physical Therapy®
lowing formula: ative of a maximal disturbance) and high reaches instead of a consistent
then return back to the state of equi- reach distance. Also, the type of
librium (starting point). Normally, movement required during the star-
where k = a factor by which the orig- adults do not challenge their state of excursion test is both multilimb and
inal set of data is lengthened, r,,. = equilibrium to the extent required in multiarticular. For instance, distance
the value of ICC(2,1), and r,,. = the this test. Additionally, the movement reached in an anterior direction
new estimate of reliability. The factor patterns employed in the test are not would be greatly affected by the
k can be altered to decide how many common to normal functional activi- amount of knee flexion and ankle
sets of observations are necessary to dorsiflexion of the support limb and
achieve a suitable estimate of reli- hip flexion, knee extension, and an-
ability. Number of Three kle plantar flexion of the reaching
Direction k Trial Averages limb. These movements inherently
6 have more variability associated with
RESULTS 18 them than .single limb and uniarticu-
6
The reliability estimates obtained 10
lar movements (19). To decrease the
for each of the four reaches are pre- 18 variability involved in a complex ta..k
sented in Table 1. Reaches that were 6 requires practice. Both task complex-
in the left diagonal directions, per- 18 ity and motor ability influence how
6 many practice sessions are necessary
formed while the subjects stood on
18
their right foot, produced the highest to achieve consistent result.. (12).
estimates of reliability: left-anterior, TABLE 2. Summary of the Spearman Brown The human organism uses the
ICC(2,l) = 0.87; left-posterior, prophecy reliability estimates. redundancy within the sensorimotor
system to reduce this variability when metric contraction could contribute ity testing, a slight decrease in move-
realizing the solution to a given task to the lack of consistency in scores. ment time (100 msec) caused a large
(11). Three systems, visual, vestibular, An optimal reach during the star- decrease (20%) in movement accu-
and the somatosensory, are used to excursion test might require precise racy (8).Although no movement
provide the information to the senso- integration of the nervous system time was recorded, subjects might
rimotor system (10). This redun- function and musculoskeletal system. have made adjustments of this m a p i -
dancy is demonstrated when subjects The absolute strength of the support tude, causing a resultant change in
are able to maintain an upright posi- limb musculature may also influence accuracy and reach distance.
tion under the commonly used foam the outcome of the test. Because the
and dome conditions (14), which star-excursion test is novel, the devel-
confuse or eliminate portions of the opment of this integration might be
sensorimotor system used in postural difficult and require practice. The
CONCLUSIONS
control. Although the task of main- practice would allow for the proper The utility of clinical diagnostic
taining upright posture becomes in- neural circuitry to become activated testing is dependent on the reliability
creasingly difficult, subjects are still and the resulting coordination of and validity of the testing procedure.
able to perform under the test condi- movement to be developed. This may Because exact or near exact repeat
tions (eg., maintenance of posture explain the linear relationship be- performances were not exhibited in
when blindfolded) or when confused. tween the amount of practice sessions this investigation, the starexcursion
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Furthermore, in experiments in- and the estimated reliability shown in test might not be an appropriate test
volving the analysis of upper-limb- Table 2. of dynamic balance. While practice
reaching trajectories, visual feedback The speed at which the move- may improve the reliability of the
has been shown to be important in ment is performed may also affect test, clinicians typically do not have
achieving consistency (22). In the the consistency of results. During tar-
an unlimited amount of time to reha-
absence of visual feedback, it has geted reaching tasks involving upper
Copyright © 1998 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
be the basis for evaluation methods Methodology and effects of midazolam lnt J Sports Med 6(3):180- 182, 1985
instead of using novel movements sedation. Acta ~tolaryngol113(3):245- 17. Tropp H, Odenrick P, Sandlund B, Od-
248, 1993 kvist LM: Stabilometry for studying pos-
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sual feedback in rapid movements. 1 tigo of central and beripheral origin.
Exp Psycho1 77(1):155-1 58, 1968 Electromyogr Clin Neurophysiol 27:
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Journal of Orthopaedic & Sports Physical Therapy®