Relationship Between

Standing Posture and Stability

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Background and Purpose. This study determined whether persons with
stability impairments have postural aberrations. We investigated whole-
body posture and its relationship to center-of-gravity (COG) stability.
Subjects. Data from 27 subjects with vestibular hypofunction and 26
subjects without vestibular impairment were analyzed. Method. An
optoelectronic full-body system measured kinematics. Force plates
measured ground reaction forces while subjects stood with their feet
30 cm apart and eyes open and with their feet together and eyes closed.
Results. The subjects with vestibular hypofunction demonstrated less
stability than the subjects without impairment, but there were no
postural differences. Subjects with vestibular hypofunction had more
weight on the left lower extremity during standing with feet apart. In
all subjects in both groups, during standing with feet apart, the COG
was anterior to the ankle, knee, back, and shoulder and posterior to
the hip and neck. Subjects had an anterior pelvic tilt, extended trunk
and head, right laterally flexed trunk and pelvis, and flexed knees.
With their feet together, subjects increased their anterior pelvic tilt;
trunk, head, and knee flexion; and anterior COG position. Conclusion
and Discussion. Posture and stability had a low correlation. Subjects
with bilateral vestibular hypofunction did not demonstrate a forward
head or backward trunk lean, as has been reported anecdotally.
Changing from standing with feet apart to feet together increased
whole-body movement patterns to control standing stability.
[Danis CG, Krebs DE, Gill-Body KM, Sahrmann S. Relationship
between standing posture and stability. Phys Ther. 1998;78:502-517.1

Key Words: Center of gravity, Measurement, Posture, Stability, Vestibular hypofunction.

- w h D & I
David E Kmbs
KathleenMGin*
Shi* Sahrmum

Physical Therapy . Volume 78 . Number 5 . M a y 1998


uantification of the relationship between
standing posture and stability has received
limited attention.'-" Posture and stability
require the integration of mechanical, sen-
sory, anci motor processing strategies that permit upright
standing;. Posture can be defined as the rotational and
translatilonal positions of adjoining body segments and
their orientation relative to gra~ity.2.~
We define stability
as the ability to control center-of-gravity (COG) ampli-
tude ancl velocity of displacement while remaining stand-
ing. Generally, smaller amplitudes and velocities of
displacement of the COG yield greater stability. U n p u b
lished research2 has shown that individuals without
vestibular impairment efficiently maintain equilibrium
in quiet standing with minimal muscular activation,
metabol~ccost, and joint loading. Posture and stability
are coupled me~hanically.~,%ody-segment alignment or
postural changes affect COG location, which may alter
stability.!?There appears to be no standard evaluation
and treatment method used for patients with impaired
stability. For example, increasing trunk flexion would
alter whole-body COG position, which may in turn
impair standing stability. Whether treatment for postural
alignment impairments improves standing stability, how-
ever, is unknown.
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Reports of posture analysis using joint kinematics have
been limited. The total body mass can be assumed to be
concentrated at the COG without an alteration of the
body's translational inertia proper tie^.^ In quiet stand-
ing, the whole-body COG is in constant m ~ t i o n . ~ ~ T h e
locations of the joint center and the COG determine the
rotatory moment of the body and its extremities. Gravity
produces rotatory movements via external mechanical
force imposition.%raune and Fischer7 concluded that
the knee, hip, shoulder, and ear normally align perfectly
in the sagittal plane. Other authors"-" have reported
that the knee, hip, and shoulder joints and the ear are
aligned anterior to the ankle joint. Some authors".Y12J3
have suggested that the COG is anterior to the ankle,
knee, and shoulder joints but posterior to the hip joint
and ear in individuals without impairment during stand-
ing with feet apart. Woodhull et a l v e p o r t e d that in
typical standing with the feet 20 to 30 cm apart, a slight
gravitational force extends the hip and knee joints and
posteriorly tilts the pelvis. Levine et all4 reported that
female subjects without impairment had an 11.3-degree
anterior pelvic tilt during quiet standing, as measured

CG Danis, PT, is a recent graduate of the postprofessional physical therapy, orthopedic-sports specialty, master's degree program at MGH Institute
of Health Professions, Boston, Mass.

DE Krebs, PhD, PT, is Professor, MGH Institute of Health Professions, and Director, Massachusetts General Hospital Biomotion Laboratory, 101
Merrimac St, Boston, MA 021144719 (USA) (krebs.david@mgh.harvard.edu).Address all correspondence to Dr Krebs.

KM Gill-Body, PT, is Assistant Professor, MGH Institute of Health Professions.

S Sahrmann, PhD, PT, FAPTA, is Associate Professor of Physical Therapy and Neurology, Physical Therapy Program, Washington University School
of Medicine, St Louis, Mo.

This st~tdywas approved by the MGH Institutional Review Board

This study was supported in part by NIH gran& ROlAGlI255 and NlDRR H133C.60045.

Th,is article was .submittedJanua~y24, 1997, and ~uasaccepted December 17, 1997.

Physical Therapy . Volume 78 . Number 5 . May 1998 Danis et al . 503

using a VICON three-dimensional kinematic system.*'
Five infrared-sensing television cameras detected reflec-
tive targets that were affixed to anatomical landmarks.I4
Persons with acute bilateral vestibular hypofunction
(BVH) or unilateral vestibular hypofunction (UVH)
have been reported to display postural aberrations.'"
Horak and Shupertl+eported that 4 subjects with BVH,
aged 49 to 69 years, had a more forward head position
than did subjects without impairment. They theorized
that individualswith acute BVH align themselves in quiet
standing near the posterior limit of stability (by extend-
ing the trunk) or near the anterior limit of stability.'"
Takemori et allQeported that 12 patients with unilateral
labyrinthectomies, 3 patients with unilateral VIII nerve
section, and 22 patients with unilateral streptomycin
sulfate infusion into the middle ear cavity had a shift in
the COG toward the involved side during quiet standing
in the acute phase. Quantitative measures of variables
that reflect posture in persons with chronic vestibular
hypofunction have not been reported.
Individuals with vestibular hypofunction are reported to
be less stable than individuals without impairment."17 In
one study,Qubjects with BVH standing with feet
together and eyes closed had higher phase-plane stability
than did subjects without impairment. Phase-plane stabil- gated postural changes that occur during standing with
ity can be defined as the combined variances in whole-
body COG displacement and velocity in the antero-
posterior and mediolateral planes. Center-of-gravity
displacement variances alone do not discriminate
between persons with BVH and persons without impair-
ments, thus establishing the importance of measuring
momentum (or velocity) control for analyzing ~tability.~ This hypothesis was based on our second hypothesis
Phase-plane stability has not been analyzed in individuals (subjects with vestibular hypofunction will have an
with UVH. The loss of unilateral vestibular function,
however, has been reported to cause an increase in body
sway when there are coexisting impairments in both the
visual and somatosensory systems.17
There are no published reports that describe, using
quantitative methods, whole-body COG displacement
changes when an individual stands with feet together
and eyes closed as compared with standing with feet
apart and eyes open. Clinicians frequently evaluate and
treat balance impairments in subjects with visual, proprie therefore, would enable individuals to adjust their body
ceptive, and vestibular system impairments. All three
systems are critical sources of afferent information that
influence the control of stability.IHBy eliminating visual
input and narrowing the base of support, it is possible to Method
investigate stability in a more challenging situation.
Information regarding whole-body COG displacement
under various conditions would be useful in clinical
* Oxlurd Mrtrics Ltd, Oxford, England
504 . Donis et al
decision making because control of whole-body COG is
the goal with individuals who have stability impairments.
The primary purpose of our study was to determine
whether persons with stability impairments have postural
aberrations. Individuals with vestibular hypofunction
have been reported to have stability impairment^.^,'^ We
therefore wanted to determine whether these individu-
als also display postural deviations. We hypothesized that
any subject whose neck joint (approximated at the
atlanto-occipital joint) was anterior to the whole-body
COG (forward head) and whose hip joint was posterior
to the COG would display an impairment in stability, as
reflected by a larger variance in COG amplitude and
velocity of displacement in the anteroposterior and
mediolateral planes than in individuals without these
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postural deviations.
A second purpose of our study was to describe sagittal
joint center alignments and their relationship to the
whole-body COG in subjects with vestibular hypofunc-
tion and in subjects without impairments (controls)
during quiet standing. Based on the literature, we
hypothesized that subjects with vestibular hypofunction
will have a more posteriorly tilted pelvis and extended
trunk compared with control subjects. We also investi-
feet together and eyes closed, a more challenging equi-
librium condition than standing with feet apart and eyes
open. Our third hypothesis was that subjects with vestib-
ular hypofunction will demonstrate an anterior COG
shift when standing with feet together and eyes closed as
compared with standing with feet apart and eyes open.
extended trunk). If these individuals are already posi-
tioned near the posterior limit of stability, then it seems
logical that they would have to move anteriorly. When
joints such as the knee and trunk are extended, there is
only one direction in which it is possible to sway (eg,
anteriorly). The body cannot sway posteriorly unless the
feet come off the ground. If the knee and trunk joints
are in more flexion (which shifts the COG anteriorly),
then it is possible to move in more degrees of freedom
(eg, anteriorly and posteriorly). An anterior COG shift,
sway by moving with more degrees of freedom in this
more challenging standing position.
Subiects
The sample consisted of 27 subjects with vestibular
hypofunction and 26 volunteers who served as a control
group. Both groups of subjects were of similar age and
sex. The control subjects reported no orthopedic or
Physical Therapy . Volume 78 . Number 5 . M a y 1998
Table 1.
Descriptive Statistics for Subiects Without Impairment (n=26) and Subiects With Vestibular Hypofunction (n=27)

Subjects Without Impairment Subjects With Vestibular Hypofunction

Sexo Age ( y ) Height ( m ) Weight ( k g ) ~ r o u p ~ Sex Age ( y ) Height (rn) Weight (kg)
M 22.2 1.80 56.82 1 M 46.7 1.78 72.73
M 25.2 1.80 72.73 3 M 48.0 1.79 147.73
M 27.7 1.78 76.36 3 M 48.5 1.72 84.09
M 29.1 1.73 65.91 3 M 50.3 1.72 95.45
M 30.1 1.71 78.18 1 M 54.1 1.55 60.91
M 31.5 1.80 88.64 2 M 56.9 1.78 99.55
M 47.5 1.80 102.27 3 M 66.4 1.66 69.09
M 56.2 1.80 97.73 3 M 66.8 1.72 72.73
M 66.3 1.80 79.55 3 M 67.8 1.75 8 1.82
M 68.8 1.68 71.36 1 M 68.4 1.74 90.91

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M 71.1 1.68 75 .OO 3 M 69.7 1.75 75 .OO
M 71.6 1.79 78.18 3 M 78.2 1.80 79.55
M 72.9 1.80 84.09 3 M 81.7 1.78 77.27
M 77.8 1.75 78.18 3 F 25.5 1.57 68.18
F 20.2 1.68 61.36 2 F 27.7 1.55 47.73
F 26.4 1.62 5 1.36 1 F 33.5 1.65 61.36
F 28.2 1.63 52.27 3 F 43.9 1.65 58.18
F 28.5 1.52 50.91 3 F 44.3 1.63 81.82
F 29.7 1.55 53.64 3 F 47.4 1.68 125.00
F 31.1 1.67 55.9 1 1 F 60.2 1.57 72.73
F 71.2 1.75 87.73 3 F 63.3 1.55 52.73
F 74.6 1.70 73.64 3 F 65.1 1.61 75.91
F 76.2 1.64 60.45 3 F 76.5 1.52 56.82
F 81.2 1.55 58.64 1 F 77.2 1.63 88.18
F 84.4 1.52 50.00 2 F 77.4 1.62 59.09
F 88.0 1.55 43.18 1 F 79.5 1.63 50.91
3 F 80.9 1.57 70.45

14=M 13=M
12=F 14=F
X 49.9 1.69 68.9 X 59.5 1.7 76.9
SD 23.9 0.10 16.3 SD 16.4 0.1 22.0
Minimum 20.2 1.52 43.2 Minimum 25.5 1.5 47.7
Maximum 88.0 1.80 225.0 Maximum 81.7 1.8 147.7
-

M=n~ale,F=:female.
"=bilateral vestibular hypofunction with sinusoidal vertiral axis rotation at 0.05 Hz5O.l (cg,ncarly zero vestibular function), 2=bilateral vestibular hypohlnc tion
with sinnso~dalvertical axis rotation at 0.05 Hz20.1, J=unilateral vestibular hypofunction.

neurologi,calimpairnlents that affect standing stability or
posture and had no impairments based on a brief
physical examination by the tester (eg, gait analysis,
balancing on one foot, analysis of the transfer from a
sitting position to a standing position). Testers were
physicians or physical therapists. All control subjects
were community ambulators without assistive devices.
Subjects with UVH (n= 17) and BVH (n=10) had no
other ne~~romusculoskeletal impairments that could
affect standing stability. The mean time since establish-
ment of the diagnosis was 48 months, with a range of
2 months to 56 years. Of the 17 subjects with UVH,
9 subjects had right UVH and 8 subjects had left Utm.
All subjects with vestibular hypofunction had abnormal
vestibular function tests and clinical examinations, as
evaluated by an otoneurologist. They had reduced ves-
tibular function, not distorted vestibular function as
would be seen in subjects with benign paroxysmal posi-
tional vertigo or Miinikre disease. All subjects with
vestibular hypofiinction were capable of ambulating
without an assistive device during the testing procedure.
Subjects with BVH had vestibulo-ocular reflex gains on
computerized sinusoidal vertical-axis rotation (SVAR) of
at least 2.5 standard deviations below normal and bilat-
erally decreased caloric response^.'^^^^ During the SVAR
test, the subject sits in the dark on a chair connected to
a motorized platform that rotates left to right at frequen-
cies of 0.01 to 1 Hz.lg,Z1The subjects' open-eye-induced
movements are recorded using direct current
ele~tro-oculography.~~~2~ The gain is the ratio of slow-
phase eye movement velocity to stimulus (chair) veloci-
ty.lg Caloric testing involves infusing the ear with warm
and cold water with a closed-loop irrigation, inducing a
burst of nystagmus lasting 1 to 3 minutes. Ice water is
infused into the external auditory canal if the warm and

Physical Thercrp~. Volume 78 . Number 5 . May 1998 Danis et a1 . 505


Figure 1.
During the ankle ioint pointing trial, the pointer array indicates medial
(internal)or lateral (external] rotation of the foot. The examiner aligns the
plane of the pointer array with the ankle ioint mediolateral center and
with the second metatarsal head. The individual without vestibular
hypofunction shown was not a subject in this study.
cold stimulus does not induce a resp~nse.~%ymmetries
in the peak slow-phase velocity of the nystagmus suggest
the possibility of a unilateral lesion.21 Subjects with UVH
had unilateral damage and at least one of the following:
30% unilaterally reduced caloric response, confirmatoly
abnormalities on rotational testing (mildly decreased
low-frequency gains, asymmetrical rotation-induced nys-
tagmus, or increased phase leads), or positional nystag-
mus while lying with the involved ear down."Vhase is
the time-relationship between head and eye velocity.'"
Table 1 presents the subjects' demographic data.
Instrumentation
We collected the postural and stability data at the
Massachusetts General Hospital Biomotion Laboratory
(Boston, Mass). A 4-optoelectric camera Selspot
II/TRACK (Telemetered Kapid Automatic Computer-
ized Kinematic software) full-body kinematic data acqui-
sition systemt was used to collect the kinematic postural
data. Plastic rigid arrays secured to 11 rigid body seg-
t T h e Selspot comporlerlt of the op[orlrctronic systcm is manufactured by
Selective Electronics, Parrille, Sweden. TRACK is the copyrighted rradenlark o f a
computer program developed at thc Massact~l~scttsInstitute of Technology,
506 . Danis et al
ments (head, trunk, pelvis, thighs, shank, feet, and
upper arms) held the infrared light-emitting diodes
(LEDs) (Fig. 1). An infrared detector within each cam-
era tracked the 60 I.EDs. Conversion from camera to
array position and orientation and then to body-segment
position (segment linear data) and orientation (joint
angular data) were implemented using methods previ-
ously described in the literat~re.~~.~"he body-segment
linear data consisted of the sagittal room-referenced
joint center positions of the ankle, knee, hip, shoulder,
back, and neck. The joint angular data consisted of the
room-referenced sagittal and coronal positions of
the trunk and pelvis (eg, pelvic anteroposterior tilt) and
the sagittal positions of the head and knee. Thus, if the
trunk or pelvis were perpendicular to the tloor and
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parallel to the vertical line of gravity, it would be in zero
or neutral flexion or extension. Our system resolution is
<1 mm for linear displacement and <1 degree for
angular d i s p l a c e m e ~ l t . ~ ~ sthis
i n gkinematic data acqui-
sition system to measure upper-body angular kinematics,
Krebs et a125 found high between-trial reliability for these
measures within subjects without vestibular impairments
(trial-to-trial Pearson 7-2.88). Each body segment bas
modeled with 6 degrees of freedom (3 rotations and 3
translations). Ten unconstrained joints, therefore, con-
nected the 11 body segments.
Subject Procedures
Barefoot subjects stood in two positions: (1) eyes open,
feet apart but parallel and with the midheels 30 cm
apart, and (2) eyes closed, feet together (feet parallel
and <1 cm apart). The subjects stood on two Kistler
force plates,: which measured vertical ground reaction
forces (expressed as a percentage of body weight) from
each lower extremity to assess the amount of weight
bearing on each lower extremity in quiet standing. Body
forces were normalized by expressing them as a percent-
age of total body mass calculated from a multisegment
model. The subjects maintained each standing posture
for 17 seconds. They stood about 10 seconds before
7 seconds of data were collected. Subjects stood with
their arms folded across their chest, grasping the elbows,
with their feet pointed forward. The tester instructed
each subject to "Look straight ahead; stand as still as
possible." Two trials of each standing position were
collected, and data from the first (most naive) trial were
analyzed. One chair rise trial was also performed. These
data were used in conjunction with the standing data for
the determination of the knee and hip joint center
10cations.2~During this trial, the subject transferred
from a sitting position to a standing position. The chair
height was equal to the subject's knee height (distance
from floor to medial tibia1 plateau). The subject's Ieet
Cambridge, Mass.
7 Kistler In.;tri~rnt:nts,M'inrerrhur, Switzerland
Physical Therapy . Volume 78 . Number 5 . Moy 1998
 6.15
6.10
1
2.55
2.50
2

"E01 ' 1-m

4.5m
6.05 2.45 0.8
E
0 6.00 E0 2.40 5.0

g"FJ*I;l"W
0.6
5.95 2.35
5.90 2.30 0.4 4.5
0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7
seconds seconds seconds seconds

:fm
4.0

g 3.5
1.8
g -0.2

3.0 -0.4

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1.6
2.5 1.4 -0.6
0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7
seconds seconds seconds seconds

a
u, -3.4 1.6
2.0
1.8 4.4
4.6 - 0.0
0.5

f f 4.2
u,
0 -1.0
h-3.8
4
1.4
8 4.0 g!
8 -1.5
U -4.0 1.2 U
3.8 - 2.0
-4.2
-4.4
0 1 2 3 4 5 6 7
1.O
0.8
0 1 2 3 4 5 6 7
3.6 - 2.50 1 2 3 4 5 6 7
seconds seconds seconds seconds
14
1.o
0.5
8 0.0

u
) -0.5
-1 .o
-1.5
0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7
seconds seconds

Figure 2.
Raw data of representative subject without impairment standing with feet apart, as used in this analysis. Linear data are shown in plots 1 to 7 as the
distance (in centimeters) from the center of the viewing volume (see Tab. 2 for vectorial sign conventions). Plot 1 is the right ankle joint position in the
sagittal plane (eg, the linear displacement of the ankle ioint in global anteroposterior coordinates). Plots 2 to 6 are the sagittal right knee, right hip,
right shoulder, neck, and back ioint positions, respectively. Plot 7 is the sagittal center-ofgravity (COG)position. Angular data, in global coordinates,
are shown in plots 8 to 13. Plot 8 shows the sagittal head angle (eg, the head pitch relative to earth horizontal). Plots 9 to 11 are the sagittal trunk,
pelvic tilt, and knee flexion angles, respectively. Plots 12 and 13 are the coronal trunk and pelvic angles, respectively. Plot 14 shows the vertical
ground reaction forces. The top line is the right ground reaction force and the bottom line i s the left ground reaction force measured under the
respective lower extremity. As the sagittal neck and shoulders (plots 4 and 5) moved farther anterior to the ankle (plot 1) (- 1.5 cm) around the third
second, the trunk (plot 9) became more flexed and the COG moved farther anterior to the ankle.

were 10 c.m apart, and the greater trochanters were 4 cm
behind the edge of the chair during chair rise.
Procedure for Joint Center Locations
Two methods were used to determine joint center
locations. In the first method, two hand-held TRACK
pointers containing an array of LEDs were carefully
aligned by the tester, reflecting the segment orientation
in all 3 planes while the tip of the pointer contacted
specific anatomical landmarks (Fig. 1). The pointer data
were then used to calculate the segment's origin and
transfornlation matrix relative to the segment's fixed
array. Th~esequiet-standing data alone determined the
back, shoulder, ankle, and neck joints. The anatomical
landmarks were the peaks of the iliac crests, acromial
processes, ankle joint mediolateral centers and second
metatarsal heads, and mastoid process, respectively. The
midpoint of the line connecting the two iliac crests was
the back joint that approximated L45. The neck joint
was one neck radius medial to the pointer point loca-
tion, as defined by the pointer array Z-axis. The neck
joint approximated the atlanto-occipital joint.
The second method used average axes of rotation
defined by kinematic and standing data for the knees
and hips. Riley et a12Vound this method to have more
accuracy for locating these lower-limbjoint centers than
the pointing trial alone. The pointer data and the

Physical Therapy . Volume 78 . Number 5 . May 1998 Danis et al . 507


Figure 3.
This 1 1-segment android kinematic model demonstrates mean subiect
posture (anterior pelvic tilt, extended trunk and head, and flexed knees).
Wholebody center-ofgravity location is indicated by +. Solid lines
designate the left side. Vertical ground reaction force (VGRF) i s indi-
cated by the vertical lines arising from the feet; the taller VGRF line is the
left side, indicating that less weight is being borne on the right side
lVGRF lines are discontinuous from the around" in this illustration for
clarity). This android model represents the subiect without impairment
whose data are plotted in Figure 2. The system draws the lower arm to
be aligned with the upper arm, although the subiect stands with his or
her arms folded across his or her chest during the testing.
rotations during the chair rise trial estimated the hip and
knee axes of rotation. For the hip, the pointing plane
intersected the midpoint of a line extending between
the pubic symphysis and the anterior superior iliac
spines. The pointer plane passed through the center of
the knee joint using the tibia1 tubercle to define the
midline plane. Each axis was an average screw axis,
including rotation and translation.Z4 The joint centers
were the intersection of the axes of rotation and thejoint
midsagittal plane.Z4
Procedure for Whole-Body COG location
The mass and center of mass of each body segment were
On a subject-s~ecific basis using
measurements (length and diameter) and regression
508 . Danis et al
equation^.^' The summation of body-segment masses
and their positions and orientations in space defined the
location of the COG. Our system has been shown to be
accurate within 1 cm for the estimation of COG.Z4
Data Collection
Three-dimensional computer graphics assisted in orga-
nizing, viewing, and analyzing the data using Superplot
software, created at the Massachusetts General Hospital
Biomotion Laboratory (Boston, Mass) in PV- WAVE^
(Fig. 2). The Superplot software displays an 11-segment
android kinematic model (Fig. 3 ) . In the 3-
dimensional global coordinate frame, we obtained the
sagittal joint center positions for the ankle, knee, hip,
shoulder, back, and neck; the sagittal and coronal posi-
tions for the trunk and pelvis; and sagittal positions for
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the head and knee. The system calculated a mean for
each 7-second standing position. Kinematic and kinetic
data were rejected for subjects who took a step, as
determined by viewing the android and force-plate data.
These data were excluded for one subject with vestibular
hypofunction who took a step during standing with feet
together. Data for another subject with vestibular hypo-
function were excluded from the analysis of vertical
ground reaction force data because of a problem with
force-plate data collection during standing with feet
together and eyes closed. One subject with vestibular
hypofunction was excluded from postural data analysis
involving the shoulder joint sagittal position secondary
to a problem with data collection with the right arm.
Data Analysis
We used the anklejoint center as the reference point for
construction of the "virtual" computer-generated plumb-
line anteroposterior position and subtracted each sagit-
tal joint center position from the sagittal ankle joint
position (eg, ankle-knee) (Tab. 2). We also subtracted all
sagittal joint center positions from the sagittal COG
position (eg, COGhip) (Tab. 2). A combined phase-
plane stability variable, a,. (root mean square variance of
the COG anteroposterior and mediolateral displace-
ment and COG anteroposterior and mediolateral veloc-
ity), obtained from phase-plane analysis measured stand-
ing stability (Fig. 4 ) . V h e SAS statistical software
generated descriptive and correlational (Pear-
son product-moment correlation coefficient) statistics
for the phase-plane stability variable and all postural
variables listed in Table 2. The correlation between the
phase-plane stability variable and the two postural vari-
ables (COG to hip and COG to neck) was used to
determine whether any subjects whose neck joint was
anterior to the whole-body COG and whose hip joint was
aVisnal Numerics Inc, .5775 Flatiron Pkwy, Suite 220, Boulder, CO 80301.
1 SAS Institute Inc, SAS Canrplis Dr. Gary, NC: 27513.
Physical Therapy . Volume 78 . Number 5 . May 1998
Table 2.
Means (*Standard Deviation) for Phase-Plane Stability and Posture (Sagittal and Coronal Angles and Sagittal Alignments) in Both Groups of
Subjects Standing With Feet Apart and Feet Together

Subiects With Vestibular

Total Sample dofu function Subjects Without Impairment
Feet
Variable Feet Aparl Together Feet Aparl Feet Together Feet Aparl Feet Together

Phase-plane stability
0; 0.8650.41 1.752 1.97" 0.9820.51 2.3622.64" 0.7320.20' 1 .1420.48",g
Sagittal angle
(room referen~ed)~
Pelvis 1.6224.25 4.1955.16" 2.6325.09 5.1926.36' 0.5622.89 3.1953.44'
Trunk - 1.8754.93 0.2024.68' - 1.8525.04 -0.21 54.62" - 1.8924.91 0.61 24.79"

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Head -6.1756.26 0.3658.23" -5.9326.39 0.6928.74" -6.41 26.24 0.0227.86"
Knee 5.0457.09 5.7926.92" 5.8556.00 6.71 26.24 4.2028.11 4.8657.55
Coronal angle
(room referenced)'
Pelvis -1.8022.04 -1.8622.01 -2.3252.22 -2.31 52.30 -1.2621.71 -1.41 21.59
Trunk 0 . 5 8 2 1.71 -0.522 1.73 -0.8521.92 -0.7452.08 -0.302 1.43 -0.302 1.30
Sagittal alignment
(anatomically referencedId
Ankle to COG 4.3423.30 8.3024.17" 4.2923.58 8.3724.71" 4.40t3.05 8.2353.65"
Ankle to back 3,2822.42 2.6522.26" 3.6222.45 2.5522.19" 2.9252.39 2.7422.36
Ankle to neck 4.8454.03 6.3024.37" 5.2324.22 6.1 724.18 4.4323.86 6.4354.63"
Ankle to shoulder 1.8923.01 3.1723.41" 2.3923.23 3.2953.65 1.4022.74 3.0623.22"
Ankle to hip 5.4222.86 4.71 23.01" 5.3323.31 4.3823.21" 5.5 1 22.37 5.0422.82
Ankle to knee 4.2422.14 4.2622.07 4.472 1.88 4.332 1.72 4.01 52.40 4.1852.40
COG to neck 0.4954.35 -2.0O?5.5le 0.9424.86 -2.2026.38" 0.0323.77 - 1.8024.61
COG to shoulder -2.4023.73 -5.2325.19" -1.7924.30 -5.2856.56" -3.0023.03 -5.1723.55"
COG to back - 1.0723.61 -5.6624.86" -0.6723.83 -5.8255.12" -1.4823.41 -5.4924.69"
COG to hip 1.0823.56 -3.5955.09" 1.0423.34 -4.0025.75" 1 . 1 1 %3.84 -3.1924.41"
COG to knee -0.1023.59 -4,0524.41" 0.1 823.82 -4.0425.03" -0.3923.39 -4.0523.79"
"Unitless, Pythagorean average of anteroposterior and n~ediolateralcenter-of-gravity (COG) displacements and velocities.
"n degrees (ohtained from Bdegree-of-freedom coordinate frame); positive values=flexion or anterior tilt, and negative values=extension or posterior tilt for the
prlvis. trunk, and head.
' In degrees (ohtaincd from Megree-of-freedom coordinate frame); positive values=left IateraI flexion, and negative values=right lateral flexion for the pelvis and
trunk.
"Dis~rncein centimeters (obtained from Megrcr-f-freedom coordinate frame); if the number is positive, then the variahle mentioned first is posteriol- to the
variahlc ~nentionedsecond; if thr numher is negative, then the variable mentioned first is anterior to the variahlc mentioned second.
' Significantly diffcrent from standing with feet apart (pair-wise po$t hor simple contrast, B . 0 5 ) .
'Si~nificantlydifirent from suhjecw with vestibular Ilypofunction standing with feet apart (pair-wise posl hor simple contrast, E . 0 . 5 ) .
'Significantl!: diffcrcnt from subjects with vestibular hypofilnction standing with feet together (pairwise po,st hoc simple contrast, B . 0 5 ) .

posterior to the COG would display a stability stability, and (5) left and right vertical ground reaction
impairment. forces. The independent variable was group.

A repeated-measures multivariate analysis of variance
(MANOLTA)was used to determine whether postural
and stability differences existed across subjects with
vestibulal- hypofunction and subjects without impair-
ment in the two standing positions (eyes open and eyes
closed). 'The dependent variables used in this analysis
were the following variables in the two standing posi-
tions: (1) sagittal angles of the pelvis, trunk, head, and
knee, (2) coronal angles of the trunk and pelvis, (3) sag-
ittal distances from two variables (ankle to neck, ankle to
shoulder., ankle to back, ankle to hip, ankle to knee,
ankle to COG, COG to neck, COG to shoulder, COG to
back, COG to hip, and COG to knee), (4) phase-plane
Pair-wise post hoc simple contrasts were used to compare
the sagittal and coronal angles and the sagittal align-
ments shown in Table 2 between the two standing
positions (feet apart and eyes open versus feet together
and eyes closed). Pair-wise post hoc simple contrasts
compared specific postural differences (the sagittal and
coronal angles and the sagittal alignments in Tab. 2)
across the subjects without impairment and the subjects
with vestibular hypofunction to determine whether the
subjects with vestibular hypofunction had a more poste-
riorly tilted pelvis and extended trunk than did the
subjects without impairment. The pair-wise contrast of
the variable "ankle to COG" in the two standing posi-

Physical Therapy . Volume 78 . Number 5 . May 1998 Danis et a1 . 509

 Anteroposterior Plane
2 . 0 - ' " " " " 1 ' " " " " 1 " " ' " " 1 " " " ' " 1 " ' " " " I " ' " " " I " " ' " "
7

-
7

- --
1.5 -
- --
-
- -
*
A
E

S
1.0-
--
-
--
-
I 0.5 ---
4 -
- --
n
- -
g 0-0
7

- - --
--
7

-
-0.5 -
- 1 --
-
7

-. . . . . . . . . - -
-1.0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

-0.6 -0.4 -0.2 0.0 0.2 0.4 0.6 0.8

COG Velocity (crn/a)

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Mediolateral P l a n e
1.5

1.0

Z
S 0.5

-
L
0.0

d
8 -0.5

-1 -0

-1 -5
-0.25 -0.20 -0.15 -0.10 -0.05 0.00 0.05 0.10
COG Velocity (cm/s)

Figure 4.
Whole-body centerafgravity (COG)phase-plane plots with feet together and eyes closed in the anteroposterior and rnediolateral planes (top and
bottom plots, respectively) from the subiectwithout impairment depicted in Figures 2 and 3. COG velocity (in centimeters per second] is the ordinate;
COG displacement (in centimeters) is the abscissa.

tions was used to determine whether subjects with ves- vented the processing of the whole-body COG phase-
tibular hypofunction would demonstrate an anterior plane data.
COG shift when standing with feet together and eyes
closed as compared with standing with feet apart and We also used pair-wise post hoc simple contrasts to
eyes open. determine whether a difference existed in the mean
vertical ground reaction force distribution between the
A pair-wise post hoc simple contrast compared the phase- left and right lower extremities and between the subjects
plane stability variable between the two groups and with vestibular hypofunction and the subjects without
between the two standing positions. Three subjects were impairment. This contrast was performed twice using the
excluded from the contrasts analyzing the stability vari- data from subjects standing with feet apart as well as
able. One subject without impairment was excluded standing with feet together. Furthermore, a pair-wise post
from this analysis because he was a researcher in this hoc simple contrast was used to determine whether the
field and, therefore, may have demonstrated bias in the left vertical ground reaction force distribution was dif-
postural adjustments he made. One subject with vestib- ferent from the right vertical ground reaction force
ular hypofunction took a step during standing with feet distribution. This contrast comparing left and right
together and, therefore, the phase-plane data were not vertical ground reaction force distributions was analyzed
valid throughout this position. With one subject with for the subjects with vestibular hypofunction, for the
vestibular hypofunction, the head array was not visible subjects without impairment, and for all subjects in both
for the entire 7 seconds of data collection, which pre- standing positions.

5 10 . Danis et a1 Physical Therapy . Volume 78 . Number 5 . M a y 1998

Table 3.
Vertical Ground Reaction Force Data (Percentage of Body Weight) During Standing With Feet Apart and Standing With Feet Together in
Subjects Without lmpairment and Subiects With Vestibular Hypofunction
Vertical
Ground Total Sample
Reaction
Forcesa Feet Apart Feet Together
Left 50.05 49.22
Right 49.49 49.17
- -
"Mean percentage of body weight for a 7-second trial.
".eft significantly different from right (pair-wise pas/ hor simple contrast, P <.05). The small discrepancy in total body weighr was due to the fact that body forces
were normalized to total body mass calculated from a multisegment model.
A repeated-measures MANOVA was used to determine
whether differences in posture and stability existed
between the two standing positions (feet together and
eyes closed versus feet apart and eyes open). The depen-
dent variables were the sagittal angles of the pelvis,
trunk, head, and knee; the coronal angles of the pelvis
and trunk; the sagittal alignments stated in Table 2;
phase-plane stability; and the left and right vertical
ground reaction forces. The independent variable was
feet position. We used alpha=.05 as the level of signifi-
cance. We chose r>.60 as the level of correlation that was
clinically meaningful.
Results
Correlaticm of Posture and Stability
There was a low correlation between posture (the sagit-
tal and coronal angles and sagittal alignments shown in
Tab. 2) and standing stability (the phase-plane variable)
in both groups (r<.3). When standing stability was
correlated with all postural variables in the 6 subjects
with the highest phase-plane measurements (the 6 sub-
jects who were least stable) during standing with feet
together, we found one strong correlation: right trunk
lateral flexion increased as the standing stability
increased ( r = .99).
Standing Stability Differences Between the Two Groups
Standing stability was less in the subjects with vestibular
dysfunction (feet apart, ar=0.98; feet together, ar=2.36)
than in the subjects without impairment (feet apart,
ar=0.73; feet together, a,= 1.14) (P<.05) (Tab. 2).
Postural Differences Between the Two Groups
The repeated-measures MANOVA showed no differ-
ences in the postural variables, the phase-plane stability
variable, and the vertical ground reaction forces between
the subjects with vestibular hypofunction and the sub-
jects without impairment (P>.5). No pair-wise contrasts
of postural variables between the subject? with vestibular
hypofunction and the subjects without impairment were
significant (P>.05). Even in the more challenging stand-
ing cond,ition (feet together, eyes closed), posture did
Physical Therapy . Volume 78 . Number 5 . May 1998
Subjects With Vestibular
Hypofunction Subjects Without Impairment
Feet Apart Feet Together Feet Apart Feet Together
52.41 50.76 47.6 1 47.74
47.46b 47.97 51.60 50.33
- ~ -
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not differ between the two groups (Tab. 2). Table 3
presents the mean vertical ground reaction forces for
the left and right lower extremities for the two groups in
the two standing positions. A difference in the vertical
ground reaction force distribution between the left and
right lower extremities existed between the two groups
during standing with feet apart (P<.05) (Tab. 3). The
subjects with vestibular hypofunction had more weight
on the left lower extremity during standing with feet
apart (P<.05) (Tab. 3).
Table 2 summarizes the means for the sagittal and
coronal positions of the pelvis and trunk, the sagittal
positions of the head and knee, and the combined
anteroposterior and mediolateral stability variable (a,)
for the two standing trials (feet together and feet apart)
for the subjects with vestibular hypofunction, the sub-
jects without impairment, and the total sample. During
standing with feet apart, the total sample stood with an
anterior pelvic tilt (1.62"), extended trunk (1.87") and
head (6.17"), and flexed knees (5.04"). The average
subject in both groups also had a slight right laterally
flexed trunk and pelvis of <2 degrees. Table 2 also
presents the mean distances in the sagittal plane from
the ankle joint to the COG, back, neck, shoulder, hip,
and kneejoints and the mean distances from the COG to
the neck, shoulder, knee, back, and hip joints. In all
subjects, the knee, hip, shoulder, neck, and back joints
were anterior to the ankle joint in the sagittal plane
during standing with feet together and with feet apart
(Tab. 2). The COG was anterior to the ankle, knee, back,
and shoulder joints and posterior to the hip and neck
joints in all subjects (Tab. 2).
Differences in Posture and Stability Between the Two
Standing Positions
The repeated-measures MANOVA did not show differ-
ences in the postural variables, the phase-plane stability
variable, and the vertical ground reaction forces between
the two standing positions (feet together and eyes closed
versus feet apart and eyes open) (P>.2) across all
subject?. The total sample of subjects increased their
anterior pelvic tilt, trunk and head flexion, and knee
Danis et al . 51 1
Table 4.
Correlations Among Postural Variables (r]" in Subjects Without lmpairment and Subjects With Vestibular Hypofunction
in the Two Standing Positions

Subjects With
Vestibular Subjects Without
Variable Total Sample Hypofunction Impairment
Standing with feet together/sagittal plane
Ankleshoulder distance/trunk angle .60 .72
Ankleknee distance/knee angle .74 .61 .83
Ankleshoulder distance/ankle-neck distance .69 .74 .65
Trunk angle/neck-COGb distance -.73
Trunk angle/ankleneck distance .65
Neck-COG distance/ankleneck distance - .67 - .67 - .69
Neck-COG distance/ankle-shoulder distance - .66
AnkleCOG distance/neckCOG distance .62 .76
Ankle-COG distance/hip-COG distance -.81 -.83 -.77

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AnkleCOG distance/trunk angle .65
Standing with feet apart/sagittal plane
HipCOG distance/anklehip distance .61
HipCOG distance/ankleCOG distance - .65 - .79
Neck-COG distance/ankleneck distance - .69 -.70 -.68
Ankle-shoulder distance/ankleneck distance .67 .83
Trunk angle/ankleshoulder distance .62
"Clinically significant results only ( r 2 . 6 ) .
COG=center of gravity.

flexion in standing with feet apart compared with stand-
ing with feet together (pair-wise contrast, P<.05)
(Tab. 2). Coronal postures did not change between the
standing positions (Tab. 2). Table 2 specifies pair-wise
contrasts between the standing positions within the total
sample, the subjects with vestibular hypofunction, and
the subjects without impairment. Standing with feet
together and eyes closed was a more challenging equi-
librium condition than standing with feet apart and eyes
open, as demonstrated by increases in the phase-plane
stability in both groups (Tab. 2). In this more challeng-
ing position, the average subject in the total sample had
an anterior shift in the COG from the ankle joint
(3.96 cm) (Tab. 2). In all subjects standing with feet
together, the COG also moved further anterior to the
knee, hip, back, and shoulder (Tab. 2). In the group
with vestibular hypofunction, standing with feet
together, the COG moved farther anterior to the neck
(Tab. 2).
Correlations Between the Postural Variables
Table 4 displays strong correlations among the postural
variables. In all subjects, the majority of strong correla-
tions existed during standing with feet together and eyes
closed as compared with standing with feet apart and
eyes open. One pair of postural variables (hip-COG
distance and ankle-hip distance) was strongly correlated
only during standing with feet apart (Tab. 4). Six pairs of
postural variables were highly correlated only during
standing with feet together (Tab. 4). The subjects with
vestibular hypofunction demonstrated a greater number
of correlations among postural variables than did the
subjects without impairment.
Discussion
Correlation of Posture and Stability
Posture and stability were not strongly correlated in
either group of subjects. Body-segment alignment
changes alter the whole-body COG location." stable
individual is able to control the whole-body COG ampli-
tude and velocity of displacement. Despite using a very
sophisticated kinematic analysis system, however, we
found a very low relationship between posture and
stability in our subjects. The finding of one highly
significant correlation, which was between the phase-
plane stability variable and trunk lateral flexion in the 6
most unsteady subjects, demonstrates that further
research is warranted. Treating minute postural devia-
tions in patients who d o not have musculoskeletal dys-
function is not warranted as a means of improving
stability. Individuals with larger postural deviations may
benefit from "postural correction" to improve stability.
Larger postural differences may have a higher correla-
tion to stability.
Posture in Subjects With Vestibular Hypofunction
The unsteady subjects with vestibular hypofunction did
not have postural aberrations, which differs from obser-
vations by Horak and Shupertl"hat subjects with BVH
may have a more forward head position compared with
subjects without impairment. Our data also do not

51 2 . Danis et al Physical Therapy . Volume 78 . Number 5 . May 1998

Table 5.
Comparison of the Total Sample's Sagittal Joint Center Alignment Relative to the Ankle Joint With That of Individuals Without Impairment
in Prior Studies
Sagittal Coordinatesa
Investigators Knee Hip
Braune and Fischer7 0 0
Akerblom~~,~ 0.8(23) 4.4 (10)
Woodhull et a18cc 3.8(15) 6.2 (15)
Barry-Grtrb10
Harrison et all '3'
Present studyd 4.2422.14(53) 5.4222.86(53)
"Nu~nbersare antcroposterior distanccs (in centimeters) relative to the ankle. Positive nnmben indicate that the joint centers are anterior to the ankle. When
available, standard deviations are given. N is in parentheses.
"nhlejoinl center was "weight-hearing trapezium" found by radiography.
' Ariklr joiri~center was 1 cm anterior to posterior border of lateral malleolus.
"Arikle joiri~.center determined hy pointing trial with feet apart, eyes open.
support Horak and Shupert's theory that subjects with
BVH may align themselves in quiet standing near the
posterior limit of stability.I5 In our study, both the
subjects with vestibular hypofunction and the subjects
without impairment demonstrated a slightly extended
trunk and head during standing with feet apart and eyes
open (Tab. 2 ) . Although the average posture was not
different between the two groups in our study, the
subjects with vestibular hypofunction had higher ranges
for the following joint angles in both standing positions:
pelvic flexion and extension, head flexion and exten-
sion, and pelvic and trunk lateral side bending. One
reason fix the differences in the findings of the two
studies may be related to the diagnoses of the subjects.
We included subjects with BVH and UVH; Horak and
Shupertl%tudied only subjects with BVH. The acuity of
the hypofunction could also account for the differences
in results. In our study, the subjects were not in the acute
phase; their posture may have compensated over time,
although their stability was still impaired. Nonetheless,
our study included the largest number of subjects with
vestibular hypofunction ever reported; thus, this group
may be a more representative group than those in other
studies.
The subjects in our study did not have acute vestibular
hypofunction, yet they stood with more body weight
shifted toward the left lower extremity during standing
with feet apart. We did not find a difference in weight
distribution between subjects with BVH and subjects
with UWI. Each subject with vestibular dysfunction may
compensate differently, and we cannot draw firm con-
clusions from this small sample. During standing with
feet apart, however, the subjects with vestibular hypo-
function had an unequal weight distribution compared
with the subjects without impairment. These findings
suggest that subjects without impairment do not have an
asymmetric weight distribution, in contrast to the report
of Nichols et a1Z8 that young adults without impairment
Physical Therapy . Volume 78 . Number 5 . May 1998
Shoulder Neck Back
0
3.8 (15)
4.2 22.0 (23)
5.5 22.4 (41)
1.8923.01 (52) 4.8424.03(53) 3.2822.42(53)
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shift their weight toward their left lower extremity. Our
findings also differ from the report by Kirby and col-
leaguesZg that subjects without impairment shift their
weight toward their right lower extremity while standing
with their feet together.
Comparison of Postural Findings With Those of
Previous Studies
Our data are similar to the data reported by other
researchers, with the exception of Braune and Fischer,'
who concluded that joint centers aligned perfectly in the
sagittal plane among subjects standing with feet apart
(Tab. 5 ) . Our sample of postural data is the largest ever
reported, using the most advanced data acquisition
system. Many past studies used photographs to measure
posture. It is difficult, however, to identify bony land-
marks on photographs (Fig. 5 ) . According to Kendall
and McCreary's "ideal" alignment, the plumb line refer-
enced from anterior to the ankle joint passes anterior to
the knee, posterior to the hip, through the bodies of the
celvical and lumbar vertebrae, and through the shoulder
joint.30 This statement was made without supporting
data or published research. In our study, the plumb line
drawn from the ankle joint center fell posterior to all
joint centers (Tab. 2 ) . We verified that the location of
the whole-body COG while our subjects stood with feet
apart agreed with the relevant body of literature (Tab.
6). The COG location in relationship to joint centers in
our subjects was similar to that described by Kendall and
M ~ C r e a r yThey
. ~ ~ contended that when the whole-body
COG is slightly anterior to the knee and posterior to the
hip, these joints are stable.30It can be argued, therefore,
that minimal muscular effort is necessary to maintain
neutral alignment, secondary to ligamentous and mus-
cular constraints," but data to support this argument
have not been collected.
Our research contradicts Woodhull and colleagues' con-
clusion that the pelvis typically tilts posteriorly and the
Danis et al . 51 3

Fi ure 5.
%
Su iects were photographed in the sagittal and coronal planes. This
subject without impairment stands in the sagittal view, where the grid
serves as a "virtual" plumb line. Visual identification of bony landmarks
and ioint angles is difficult.
knees e ~ t e n dOur
. ~ results support Levine and Whittle's
finding that female subjects without impairment have an
anterior pelvic tilt in quiet standing.14 In our system,
neutral pelvic tilt is described as zero degrees of pelvic
flexion and extension in relationship to the floor.
Although difficult to detect by looking at Figure 5, the
subject without impairment shown in the figure is stand-
ing with 2 degrees of anterior pelvic tilt. We believe our
instrumented postural data provide greater detail about
joint angles during standing than is possible by visual
obsemation. Thus, positions described as neutral3" actu-
ally consist of a few degrees of flexion or extension,
which are angles that are probably imperceptible by
visual obsemation. Our postural data only slightly deviate
from the "ideal" posture described by Kendall and
McCreary." Clinicians should be cautious not to auto-
matically link postural impairments (or observed devia-
tions from the "ideal" posture) with functional limita-
tions because perfect alignment has never been
reported, even for individuals without im~airment.~-l'
Standing With Feet Together and Eyes Closed: A More
Challenging Equilibrium Condition
The large anterior COG shift that occurred when sub-
jects changed from standing with their feet apart and
5 1 4 . Danis et al
eyes open to standing with their feet together and eyes
closed may have allowed them to obtain more degrees of
freedom of movement in the anterior and posterior
directions. This greater freedom of movement thus
allows individuals to adjust their balance in two direc-
tions while standing in the more challenging equilib
rium condition, as compared with individuals who stand
with their knees extended, allowing only one direction
of movement (eg, flexion). For example, all subjects'
knees were more flexed during standing with feet
together, allowing flexion and extension movements of
the knee to control balance, In subjects with vestibular
hypofunction, the anterior COG shift came primarily
from anterior rotations of the pelvis, trunk, and head
(Tab. 2) and not from anterior translations of the neck,
shoulder, and knee in relationship to the ankle. In these
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subjects, the hip and back actually shifted posteriorly
(Tab. 2), closer to the ankle joint, which is what would
be expected with a flexion moment of the upper torso.
The subjects without impairment, however, had an ante-
rior shift in the shoulder and neck in relationship to the
ankle joint during standing with feet together (Tab. 2)
that could have contributed to the anterior COG shift.
Postural Patterns Controlling Stability When Subiects
Change From Standing With Feet Apart to Standing
With Feet Together
Our results support Krebs and colleagues' contention
that whole-body movement patterns control posture in
persons with vestibular hypofunction and in persons
without impairment during standing with feet together
and eyes closed.31In our study, changes in posture at
multiple body segments were used to control stability
when subjects changed from standing with feet apart
and eyes open to standing with feet together and eyes
closed. These findings differ from Nashner and col-
leagues' report that subjects without impairment used an
ankle strategy when standing with eyes closed.32
One reason that weight shift became more symmetrical
in the subjects with vestibular hypofunction during
standing with feet together may have been their attempt
to deal with a more challenging position (Tab. 3). By
narrowing the base of support, individuals may be more
likely to sway and to take a step. Distributing body weight
more evenly in this position may allow upright stance to
be maintained without stepping. With a larger base of
support (eg, during standing with feet apart), the medial
and lateral limits of stability extend from the outer edge
of one foot to the outer edge of the other foot. When the
base of support is narrowed, the limits of stability
decrease. If body weight is borne primarily on one lower
extremity, the base of support becomes even smaller.
Remaining stable during standing with feet together,
therefore, may be easier with a more symmetrical distri-
bution of body weight.
Physical Therapy . Volume 78 . Number 5 . May 1998
Table 6.
Comparison of the Total Sample's Sagittal Joint Center Alignment in Relationship to the Whole-Body Center of Gravity (COG) Alignment With
That of Individuals Without Impairment in Prior Studies

II Investigators Whole-Body COGa in the Sagiftal Plane ~elativeto

Ankle Knee Hip Shoulder Neck Back

Hellebrondt'2,b 5.0
Akerblo'mP 2.24 20.26 (1 1) 1.6 t 0 . 2 (23) - 1.8 (10)
Fox and 5.36 2 1.46 (66) Slightly anterior In anterior portion
to joint of acromial
center (66) process (66)
WoodhulletaI8 4.9t1.3(15) 1.1+2.4(15) -1.31215 1.2?1.6(15)
Present study 4.34 53.30 (53) 0.10 2 3 . 5 9 (53) - 1.08 t 3 . 5 6 (53) 2.40 53.73 (52) -0.49 24.35 (53) 1.07 23.61 (53)
"Numbers are anteroposterior distances (in centimeters) relative to the whole-body COG. A negative number denotes that the COG is posterior to the joint

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center. When available, standard deviations are given. N is in parentheses.
bDid not specify which part of lateral rnalleolus for ankle reference point.
'Posterior border of lateral malleolus was ankle reference point.

A B -

-Y
6
E -
e!
2
w

E .....
Y -
,
, .
2 _.. ..
B
.-*
- .....
...: -_-.
....: ....
rn
...__. a .
P
2 ... ... ... .,. 3.- .. ,.
.... ....,.
.B
(A
-
>I>
I/i

0 2 4 6 0 2 4 6

Time (s) Time (s)

I-
......
Distance between ankle e l d shoulder
Distance between neck ancl COG ...... Diaance between ankle and shoultler

Figure 6.
The anteroposterior distances between the neck and center of gravity and the ankle and shoulder ioint centers in a typical subject with vestibular
hypofunction during 7 seconds of standing with feet together and eyes closed. There was a negative crosscorrelation between the two distances
(r=-.99). (B] The distances between the ankle and shoulder and the ankle and neck are plotted along a 7-second Xclxis in a "typical" subject with
vestibular hypofunction standing with feet apart. There was a positive crosscorrelation between the two distances (r=.99).

Head/Trunk Movement as Subjects Change From
Standing With Feet Apart to Standing With Feet Together
Changes in postural alignment at the trunk and head to
stabilize the head against gravity did not exist in either
group as subjects changed from standing with feet apart
to standing with feet together. For example, the head
did not extend when the trunk moved into more flexion
(Tab. 2). In both groups, the pelvis, trunk, and head
moved toward a flexed posture during standing with feet
together and eyes closed (Tab. 2). Thus, the head was
stabilized with respect to the trunk (head stabilization on
trunk).3:' Because visual input was impaired during
standing with eyes closed, visual feedback may be more
useful fclr head stabilization to the trunk than has been
reported.33Our findings are similar to those reported by
Shupert et a134but differ from a later report by Shupert
et alS5that individuals whose trunk flexes compensate by
extending the head to stabilize the head in relationship
to gravity (head stabilization in space33). Shupert et a135
contend that patients with vestibular loss do not coordi-
nate the head and trunk movement because such
patients predominantly use an ankle strategy.
Postural Patterns in the Two Groups
Certain postural patterns occurred in both groups. As we
expected, when the sagittal distance between the ankle
and shoulder increased, the neck and COG distance
decreased (Tab. 4). These data support the conclusion

Physical Therapy . Volume 78 . Number 5 . May 1998 Danis et al . 5 15

that whole-body movement patterns occur in quiet
standing to control posture.31 As the sagittal distance
between the ankle and shoulder increased, the distance
between the ankle and neck increased in both groups
during standing with feet together (Tab. 4). Further-
more, as the sagittal distance between the ankle and
COG increased, the sagittal distance between the COG
and hip decreased (Tab. 4). In this example, the COG
moved anteriorly, closer to the hip. Taken collectively,
these postural patterns demonstrated that the subjects
adapted a "forward posture" pattern during standing
with feet together and eyes closed.
Subjects with vestibular hypofunction demonstrated
unique postural patterns as compared with the subjects
without impairment. In both standing positions, they
increased their trunk flexion as the sagittal distance
between the shoulder and ankle and the neck and ankle
increased ('Tab. 4). This finding suggests that whole-
body movement patterns are used to maintain stability in
quiet standing. In addition, as trunk flexion and the
distance between the ankle and shoulder increased, the
distance between the neck and COG decreased (Tab. 4).
This finding is likely due to the COG moving anteriorly
with trunk flexion due to the relatively large trunk mass.
The subjects with vestibular hypofunction, during stand-
ing with feet apart, also had positive cross-correlations
between the distance from ankle to shoulder and the
distance from ankle to neck and between the trunk
angle and the distance from ankle to shoulder (Tab. 4).
Because the subjects with vestibular hypofunction had
greater phase-plane stability, their shoulders, neck, and
trunk could have been swaying more, as compared with
the subjects without impairment. In quiet standing with
feet apart, the subjects with vestibular hypofunction
stood with more weight on the left lower extremity.
Compensation for this asymmetry may have caused
increased body sway.
Our study supplied data to support the concept that
quiet standing is not completely ~ t a t i c As. ~ shown
~~ in
Figures 2 and 6, body segments moved over a course of
7 seconds. The 7-second mean could possibly obscure a
correlation between posture and balance. Within a given
subject, some movements were directly correlated to
COG displacement, whereas other movements were
compensatory arid inversely correlated to COG displace-
ment (Fig. 6). Such stability strategies, therefore, may be
obscured by pooling the data across subjects. A larger
sample size is needed to increase the statistical power
necessary to reveal whether a larger posture-stability
relationship exists.
Conclusions
Posture was minimally correlated with stability, and
posture did not differ between the subjects with vestib-
516 . Danis et al
ular hypofunction and the subjects without impairment.
An anterior COG shift occurred as subjects moved from
standing with feet apart and eyes open to standing with
feet together and eyes closed. The subjects with vestibu-
lar hypofunction had greater phase-plane stability than
did the subjects without impairments in both standing
positions, demonstrating that they had less stability in a
standing position compared with the subjects without
impairment.
We report the postural data from the largest sample of
both subjects with vestibular hypofunction and subjects
without impairment ever reported. The average individ-
ual in the total sample stood in quiet standing with a
slight anterior pelvic tilt (1.6z0), minimally extended
trunk (1.87") and head (6.17"), and flexed knees
Downloaded from https://academic.oup.com/ptj/article/78/5/502/2633290 by guest on 11 July 2021
(5.04"). In the more challenging standing condition
(feet together, eyes closed), all subjects increased their
anterior pelvic tilt, trunk and head flexion, knee flexion,
and anterior COG position. These data support the
concept that segmentally coupled whole-body move-
ment patterns control posture in both groups. Changes
in postural alignment at the trunk and head (head
stabilization in space) to stabilize the head against gravity
were not demonstrated in either group as subjects
changed from standing with feet apart and eyes open to
standing with feet together and eyes closed.
Acknowledgments
We thank Rita Popat, PT, NCS, and the Massachusetts
General Hospital Biomotion Laboratory staff for their
computer assistance.
References
1 Lee WA. A control systerns frarnewor L for under5tanding norrnal and
abnormal poature. Am J Occup Thrr. 1989;43:291-301.
2 Riley PO. Modeling of lhe Biomechanics o f Poslz~rr. Boston. Mass:
Massachusetts Institute of Technology; 1987. Doctoral dissertation.
3 Benda BJ, Riley PO, Krehs DE. Biornechanical rrlationship between
cenler of gravity and center of pr-essur-e dur-ing standing. Ifi1FE; ?'run5
Rehnbil Eng, 1994;2 (1 ) :3-10.
4 Shurnway-Cook A, Woollacort MH. Motor Conf~ol:Theory nnd Prc~cliccil
Applications. Baltimore, Md: Williams & Wilkins; 1995.
5 Riley PO, Berlda BJ, Gill-Body KM, Krebs 1)E. Phasr plane analysis of
stability in quiet standing. JRehabil RPSDm.1!195;32:227-235.
6 Norkin CC, Levangie PK. Joint .S/r~rrturrrind Ftcncfion: A Oomprrhmsiue
Analysis. Philadelphia, Pa: FA Davis Co; 1983.
7 Braune W, Fischer 0;Maqtiet PC;], Furlong R, trans. O n the Centre of
Gravity oj fhr Human Body: A.c Related to the Equipment nf the G m n n
Infant9 Soldier. New York, NY: Springer-Ver-lag;1985.
8 Woodhull AM, Maltrud K, Mello BL. Alignrrtent of the hurnan body
in standing. EurJAppl Physzol. 1985:54:109-115.
9 Akerblom B. Stundzng urrd Szttzng Posture, biilh Sproul R+rprrce to the
Constructton oJChazn. Stockholm, Swcderr: Nordiaka Bokhartdeln; 1948
10 Barry-Greb T. Measurement of Nonnnl and Fonuard Hpud Posturr.
Lexington. Ky: University of Kentucky; 1990. Master's tliesis.
Physical Therapy . Volume 78 . Number 5 . M a y 1998
11 I-Ia~.rison.% I>, T, UTojtowiczC.. Clinical liieasurement of
Barry-(;re),
head and sho~rldcrposture variables. JO~dhopSports Phys 7 % ~1996;23:
. locomotor activities. Phys 7 % 1992;72:505-514.
353-361.
12 Hellehl-andt FA. Standing as a geotropic reflex. Airr JPhysiol (Lond).
1938;121:471-474,
13 Fox MC;, Young DC;. Placement of the gravity line in anteroposterior
standing posturr. Res Q. 1954;25:277-285.
14 I.t%cineD, Whittle MW. The effects of pelv~cmovement on lumbar
lordosis 111 the standing poslclon. J O ~ t h o pSportr Phys Thm. 1996;24:
130-1 35.
15 Horak FB, Shupert C. Role of thr vestibular system in postural
control. In: Herdman S, ed. Vestibular RPhabililalion. Philadelphia, Pa:
FA Davis Co; 199422-46.
16 Takemori S, Ida M, Uniezu H. Vestibular training after sudden loss
of vrstibular fn~~ctions.
O N . J Olurhinolatyngol Relat Spec. 1985;47:
76-83,
17 l3lacL F'O, Shupert CL, Peterka RJ. Nashner LM. Effects of unilateral
loss of vestibular function on the vestibulo-ocular reflex and postural
control. Ann Otol Rhino1 L,a~yngol.1989;98:884-889.
18 Shumway-Cook A, Horak FB. Assessing the infli~enceof sensory
i~ltrractio~l
o n halance: suggestion from the field. P h y ~Thm 1986;66:
1548-3 5510.
19 tirehs DE, Gill-Body KM, Riley PO, Pal-ker SW. Double-blind,
placebo-controlled trial of rehabilitation Cor bilateral vestibular hypo-
function: preliminary report. O t o l a ~ n g o lHead Neck Surg 1993;109:
735-711.
20. Evans MK, Krebs DE. Relationship of vestibulospinal and vestibtl-
locular te!its. Otoln~ngolHpad Nrck Surg. In press.
21 Parker SW. Vestibular evaluation: electronystagmography, rota-
tio~ral testing, and posturography. Clin Electroencephalo. 1993;24:
151-159.
22 Herdlr~an SJ, Sandusky AI., Wain TC, etal. Characteristics of
post~~ral stability in patients with aminoglycoside toxicity. J Vesfib Res.
l!)94;4:71.-80.
23 Antoltr;son EK, Mann RU'. Automatic &DOF kinematic trajectory
acquisition and analysis. Journal of @namic Syst~ms,Measurement, and
Contrnl. 1!)89;111:31-39.
24 Riley PO, Mann RM', Hodgc WA. Modeling of the biomechanics of
5posture .and balance. JBtomr(h. 1990;23:503-506.
Physical Therapy . Volume 78 . Number 5 . May 1998
25 Krebs DE, M'ong D, Jevsevar DS, et al. Trunk kinrmatics dul-ing
~
26 Riley PO, Fijan RS, Hodgc WA, Man11 RM'. Deterrriination of joint
centers for posture studies. In: Stein JL, ed. Thp Biomer.hanics uf h'ormal
and Proslhelic Gail. Fairfield, NJ: American Society of Mechanical
Engineering; 1987;4:131-136.
27 McConville JT, Churchill TD, Kaleps 1, et al. Anthropomefnc Rela~ioit-
ships o/Body Segmenl Mommts oflnmtia. Dayton, Ohio: Wright-Patterson
Air Force Base; 1980. Report No. AFAMRLTR-80.119.
28 Nichols DS, Glenn TM, Hutchinson KJ. Clianges in the mean center
of balance during balance testing in young a d ~ ~ l tPhys
s . Thm. 1995;75:
699-706.
29 Kirby RL, Price NA. MacLeod DA. T h e influence of Coot position on
standing balance. JBzomrch. 1987;20:423-427.
Downloaded from https://academic.oup.com/ptj/article/78/5/502/2633290 by guest on 11 July 2021
30 Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd ed.
Baltin~ore,Md: Williams & U'ilkins; 1983.
31 Krebs DE, Riley PO, Gill-Body KM. Quantitative asses5ment of
posture and stability: Does hip strategy exist? In: Proceedings (yttir 12th
Inlernafioncrl C20ngress of lhr Wnrld Confedmalion fo1 Physical ?7~lrrapj,Junr
25-30, 1995, Wa.shington, IIC. Alexandria, Va: Arnerican Physical Tlier-
apy Association; 1995:640. Abstract.
32 Nashner LM, Black FO, Wall C. Adaptation to altercd srlpport and
visual conditions during stance: patients with vestibular deficits.
JNc~rroscz.1982;2:536-544.
33 Di Fabio RP, Emasithi A. Aging and the mechanisms underlying
head and postural control during voluntary motion. Phys Thm. 1997;
77:458-475.
34 Shupert CL, Black FO, MoraL FB, Nashner I,M. Coordination of the
head and body in response to support surface translatio~~s in normals
ancl patients with bilaterally reduced vestibular fiinction. In: Amblard
B, Berthoz A, Clarac F, eds. Posf~trrand Gail: Dmelopment, Adaptation,
and Modulation-Proceedings of the 9th Inteinofionnl Syrnposirtm on Pos-
lural and Gait Research, MarseillPs. France, 2 9 May-1 Jlrnr, 1998. Amster-
dam, the Netherlands: Elsevier Science Publishers BV; 1988:281-289.
35 Shupert CL, Horak FB, Black FO. The ctl'ect of peripheral disorders
on head-trunk coordination during posti~ralsway in humans. In:
Berthoz A, Graf W, Vidal P, eds. The Head-Neck S e n s q MotorS)~stem.New
York, NY: Oxford University Press Inc; 1992:l.
Danis et a1 . 5 17