Middle-East Journal of Scientific Research 21 (1): 01-06, 2014

ISSN 1990-9233
© IDOSI Publications, 2014
DOI: 10.5829/idosi.mejsr.2014.21.01.82353

Balance Deficits in Elderly Population

1
Ashraf Darwesh, 1,2Enas Elsayed, 3Hanan Abbas,
4
Amir El-Fiky, 5Ashraf El-Marakby and 1Ahmed Aboelenin

1
Department of Physical Therapy, Faculty of Applied Medical Sciences,
King Abdulaziz University, Jeddah, KSA
2
Department of Neuromuscular disorders and its Surgery,
Faculty of Physical Therapy, Cairo University, Egypt
3
Department of Diagnostic Radiology, Faculty of Applied Medical Sciences,
King Abdulaziz University, Jeddah, KSA
4
Department of Physical Therapy, Faculty of Applied Medical Sciences,
Umm Al-Qura University, Makah, KSA.
5
Department of Physical Therapy for Cardio-pulmonary Disorders and Geriatrics,
Faculty of Physical Therapy, Cairo University, Egypt

Abstract: Impaired balance is common in old population with the resultant high risk of falls. It may increase the
rate of mortality and morbidity, as well as decreased functional abilities. The current study aimed at
investigating the changes of balance in elderly population. Thirty male participants were included and were
assigned into two equal groups; young group aged 20 to 26 years and elderly group aged 60 to 69 years.
Stability index (SI) and dynamic limit of stability from standing position were evaluated by Biodex stability
system. Balance also was assessed clinically by the functional reaching test (FRT). The results showed
significant increase in stability index including overall, antroposerior (A/P) and mediolateral (M/L) stability
indexes, decrease in the directional control, increase in the time elapsed for completing the test and finally
decreased FRT scores in the older group compared to that of the younger one. There was also significant
positive correlation between directional control and FRT scores (p<0.05). It can be concluded that there are age-
related changes of balance resulting in poor performance in standing position and decreased functional
reaching in elderly people.

Key words: Aging % Balance % Biodex Stability System % Functional Reaching Test % Risk of Falls

INTRODUCTION Impaired postural balance in older population is

largely attributed to dysfunction of the cerebellum and
Aging is accompanied with decreased ability to vestibular system, visual impairments, decreased muscle
respond to balance disturbing circumstances resulting power, fitness and agility [3].
in more frequency of falls [1]. The ability to maintain Shumway-Cook and Woollacott [4] reported that
stability, while standing, is an essential characteristic postural control requires harmony between
of person motion. Difficulties in controlling balance musculoskeletal and nervous systems. The
increase the risk of falling and relevant harmful musculoskeletal elements comprise joint range of
complications especially with aging where there is movement, flexibility of the spine, muscular properties
impaired neuromusculoskeletal system contributing to and biomechanical relationships among linked parts of
imbalance and leads to falls [2]. the body. Whereas, the nervous elements, essential to

Corresponding Author: Enas Elsayed, Department of Physical Therapy, Faculty of Applied Medical Sciences,
King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
E-mail: eradwan@kau.edu.sa.

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 Middle-East J. Sci. Res., 21 (1): 01-06, 2014
postural control, encompass motor processes that
include synergies of neuromuscular reaction, sensory
proceedings including the visual, vestibular and
somatosensory systems.
Balance is an essential predictor of falls in old
people. Normal balance is important to perform different
daily functions. Many procedures were designed to
quantitatively examine balance in older subjects [5].
The Biodex stability system is a recent device used
to assess and train balance ability. The system is
developed to excite mechanoreceptors of the joints and to
enhance muscle contraction important for stability [6].
The level of platform tilting during evaluation is
determined by the person’s ability for balance. One of the
parameters, which could be calculated, is the stability
index (SI). The SI quantifies the person’s ability to control
the tilting angle of the platform. It represents the variation
of platform dislocation in degrees from level position in
every movement throughout the assessment. Low SI
indicates many moments and a reduced time spent away
from the level position and interpreted as a better balance
score [7].
MATERIALS AND METHODS
Participants: Thirty male volunteers were selected from
Makah city, KSA. Volunteers were assigned into two
equal groups: Young (control) group; aged 20 to 26 years
and elderly (study) group aged 60 to 69 years. Both
groups were examined in the physical therapy department,
faculty of applied medical sciences, Umm Al-Qura
University, KSA.
Inclusion Criteria: The subject ages ranged from 20 to 30
years and from 60 to70 years for the control and study
groups respectively. All subjects were medically stable
and they had grade good regarding cognition according
to mini mental state examination. Exclusion criteria: Any
disorder that my affect balance or cognition as
neurological; musculoskeletal; and/or vestibular diseases,
drug intake as minor; major tranquilizers or antihistaminic,
or marked visual or auditory impairment.
Procedures: An informed consent was obtained from all
volunteers about agreement of study participation after
explanation from the research team for the study objective
and procedures. Weight and height of the participants
were measured and recorded. Biodex stability system
(Biodex Corporation, shirly, NY) was used for testing both
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stability index and dynamic limit of stability (DLOS). High
scores of overall stability index (OSI), antero/posterior
stability index (APSI) and medio/lateral stability index
(MLSI) indicate poor postural stability. The device
platform stability ranges from 1–8, with one representing
the greatest instability. The system is interfaced with
computer software and connected with printer to print the
test results.
Stability Index: The test was done to examine the person's
ability to control the tilting angle of the platform as it
indicates the amount of platform motion. Increased SI is
indicator of a many motions and therefore less stability
[7]. The subject was instructed to center himself on the
platform before starting the test. In this position, the COG
of the body is centralized over a point of the vertical
ground reaction force. The participant was then informed
to achieve a centered position on the released platform by
shifting position of foot to keep cursor centered on the
screen grid. He kept this position while the investigator
identified the subject's feet positions on the platform grid
through recording the heel coordinates and feet angles.
Heel coordinates were measured from the center of the
back of the heel while the feet angles were determined by
finding a parallel line on the platform coincided to the
central line of the foot. All these values were recorded on
the balance system computer software to be used in each
test to ensure the consistency of the tests that should be
performed in the same centered position. The participant
was then instructed to assume and maintain upright
standing position with opened eyes. All tests were done
at stability level of eight (most stable level). The volunteer
was instructed to maintain a level platform for a period of
20s for each test and rest by sitting for one min. The mean
of three trials for AP, ML indexes and OSI was calculated
and were recorded in both groups.
Dynamic Limits of Stability: It was used to test the
subject’s ability to move from one target to another within
the dimension of limits of stability which is eight degrees
anterior, four degrees posterior and eight degrees on each
side with as little deviation as possible. Prior to starting
the test, the limits of stability (LOS) test screen displayed
eight circles arranged around a central circle. The circles
on the top portion of the screen represented the antero-
medial and antero-lateral LOS. The circles to the left and
right of the center represent medial and lateral limits of
stability, whereas the circles at the bottom of the screen
represent the posterior limits of stability.
 Middle-East J. Sci. Res., 21 (1): 01-06, 2014

The test started, with the footplate centered and the significance was less than 0.05. Pearson test was used for
cursor over the flashing central circle, the subject must correlation between FRT scores and biodex stability
demonstrate adequate neuromuscular control to hold the parameters measured.
cursor inside that central flashing circle until it stopped
flashing. He was then instructed to shift the body weight RESULTS
while the feet were fixed on the footplate to move the
cursor over the second randomly appearing flashing circle General Characteristics of the Participants: There was
and also to hold the cursor inside that flashing circle until no significant difference between the young and elderly
it stopped flashing. The participantwas then asked to groups regarding body weight and height (p>0.05)
move the cursor back to the central flashing circle by (Table 1).
shifting his body weight. Instructions were given to the
subject to repeat the same process for each of the eight Overall, Antero/posterior and Medio/lateral Stability
circles. The circles appeared in a random order until the Indexes: The results revealed significant difference in the
subject hold has completed all eight circles. The elapsed mean values of the OSL, A/PSI and M/LSI between young
time was calculated by the device. Once the subject had and elderly groups (p= 0.002, 0.0001, 0.0001 respectively)
completed all eight circles, the clock stopped and the test (Table 2 and Fig. 1).
trial ended. Then the foot platform automatically returned
to the locked position. Dynamic Limit of Stability: The results also revealed that
At the end of each test trial, a print out report was the mean value of the directional control was significantly
obtained. This report included information about the total different in the elderly group compared to that of the
time elapsed to complete the test and direction control. young one (p=0.0001) (Table 3 and Fig. 2). Moreover,
there was a significant increase the mean values of the
Direction control is represented as a percentage of
time elapsed to complete the test in the elderly
theoretical excursion value; 100% equals perfect control.
group compared to that of the young one (p=0.0001)
A value outside that range represents subject had
(Table 3 and Fig. 3).
difficulty. The mean values of three trials of overall
direction control and total time needed to complete the
Functional Reach Test: The mean values of the FRT
test; on the eighth stability level were calculated for each
37.9±3.2 cm and 25.3±3.8 cm in the young and elderly
participant.
groups respectively. Also, there was a significant
difference in the mean values of the FRT between groups
Functional Reach Test: The functional reach test was
(p=0.0001) (Fig. 4).
developed to evaluate the limits of stability in an anterior
direction. The distance maximally reached anteriorly and
Correlation: Significant positive correlation between
horizontally by a person, while keeping a fixed base of
FRT scores and directional control was revealed in the
support, was measured [8]. The test was done by placing young and the elderly groups (r= 0.89 and 0.66
tape measurement on the wall parallel to the floor, at the respectively) (Table 4 and Fig. 5 and 6).
height of the subject's dominant acromion. Each volunteer
was asked to stand with the feet apart at a comfortable
distance; making a fist and flexing the shoulder forward.
The subject was instructed to reach anteriorly as far as
possible without taking a step or touching the wall. The
distance between the start and end points was measured
using the head of the metacarpal of the third finger as a
reference point. Three trials were performed and an
average was calculated.

Statistical Analysis: Descriptive statistical analysis

had been made for all variables and data are presented
as mean+SD. Independent samples t-test was used Fig . 1: Overall, A/P and M/L stability indexes mean
to compare between young and older groups. Level of values in the young and elderly groups.

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 Middle-East J. Sci. Res., 21 (1): 01-06, 2014

Fig. 2: Directional control mean values in the young and Fig. 6: Correlation between the FRT scores and
elderly groups. directional control in the elderly group.

Table 1: General characteristics of the participants and comparison of

weight and height between the young and elderly groups.
Young Elderly
Parameter Mean ±SD Mean ±SD t p
Age (years) 23.73 ± 2.46 64.07±2.96 40.54 0.0001*
Body weight (Kgm) 74.73±6.12 72.07±7.27 -1.09 0. 29
Height (m2) 1.69±0.71 1.70±0.85 0.07 0.95
*
Significant, Kgm=kilogram, SD= standard deviation

Table 2: Comparison of stability indexes between the young and elderly

Fig. 3: Mean values of the time elapsed to complete the
groups.
test in the young and elderly groups.
Young Elderly
Stability Index Mean ±SD Mean ±SD t p
Overall 0.75±0.35 1.17±0.35 3.258 0.002*
A/P 0.81±0.3 1.48±0.37 5.512 0.0001*
M/L 1.13±0.47 1.77±0.48 3.724 0.0009
*
Significant, SD= standard deviation

Table 3: Comparison of dynamic limit of stability between young and

elderly groups.
Young Elderly
Parameter mean ±SD mean ±SD t p
Fig. 4: Mean values of the FRT scores in the young and Directional control 35.3±6.8 20.87±5.2 6.504 0.0001*
elderly groups. Time elapsed (sec) 44.87±11.9 84.6±22.8 5.975 0.0001*
*Significant.

Table 4: Correlation between the FRT scores and the directional control in
both groups.
Parameter
--------------------------------------------------------------
FRT
-------------------------------------------------------
Group r p
Directional Control Young 0.89 0.0001*

Fig. 5: Correlation between the FRT scores and Elderly 0.66 0.007*

directional control in the young group. *Significant

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 Middle-East J. Sci. Res., 21 (1): 01-06, 2014
DISCUSSION
The current study was conducted to investigate
balance problems in elderly people. Regarding the
stability indexes, the results showed significant difference
between elderly and young groups in all test parameters
that could be explained by increased effort to keep
balance in elderly. This comes in agreement with the
findings drawn by Hojjati and Sheikhpour [9] who found
impaired functional balance, manifested by decreased
scores of Berg balance scale, in females aged 60 years and
older. In the same line, Laughton [10] suggested that
raised postural leaning in short time periods in elderly was
partially due to increased lower extremity muscle
contraction while standing and these contractions were
linked to postural sway.
In addition, Benjuya et al. [11] reported different
variations related to age in the postural control in elderly
who exhibited profound ankle muscular co-activation, in
comparison with younger individuals. Also, this agrees
with Fitzpatrick et al. [12] who reported that ageing is
related to reduced maintenance of postural balance during
standing and when responding to sudden balance
disturbances. Other explanation for increasing stability
indexes in elderly group, which indicates balance
impairment, is the sensory changes in visual,
proprioceptive and vestibular inputs. This comes in
agreement with Lord and Ward [13] who postulated that
with age, the decreased standing balance is associated
with specific sensory and motor deficits such as
weakness of lower limb muscles, peripheral hypoesthesia,
visual impairments and decreased reaction time.
Also, this explanation is supported by Fitzpatrick and
McCloske [14] who suggested that the interaction of
vision, vestibular system and proprioceptive input has
been indicated by altering each of them and recording the
resultant change in postural sway. In normal young
individuals, the changes were minimal, as a result of
compensation by other inputs and it is suggested that
peripheral sensation is the most essential information
source. In elderly and individuals who have sensory
impairments, the increase in sway was greater, denoting
lack of balance control.
In addition, the results of the present study revealed
significant increase in A/P stability index. This is
consistent with Okada et al. [15] who found that when
balance disturbance is externally employed, elderly adults
exhibit what is called ‘‘hip-like’’ strategy, that
5
necessitates contraction of hip muscles. This is due to
reduced ability of muscles around the ankle to produce
enough torque and a delayed onset latency of these
muscles in response to a forward or backward body sway.
The results of the current research revealed
significant increase in M/L stability index. In the same
line, Sturnieks et al. [16] reported that age-related
difference in the lateral direction is clear; proposing that
balance the control in the lateral direction is specifically a
major problem in elderly.
Regarding the dynamic limit of stability test, the
significant decrease in directional control in elderly group
is consistent with the findings of Hatzitaki et al. [1] who
suggested that the increased postural disturbances
employed by the different activities could prevent older
individuals from shifting their center of gravity near to
stability boundaries. Moreover, Hageman et al.[17]
reported that sway during standing at the edge of the
stability limit is observed more in elderly compared to
young one.
The time elapsed to complete the dynamic limit of
stability test was significantly increased in elderly. This
finding is agreed with Lajoie et al. [18] who reported that
normal old individuals exhibit significant slower reaction
times in a narrow base support during standing position
compared to the young individuals.
Finally, the findings of the present work revealed
significant decrease in the scores of functional reach test
in the elderly group. This comes in agreement with King
et al. [19] who examined women's capability, aged 20 to 91
years, to reach as far anteriorly and posteriorly as
possible during upright position, to determine the
functional base of support. They found that the base of
support was significantly reduced over 60 years-old, with
a decrease of 16% per decade thereafter. Subsequent
studies have shown significant age-related decline in
functional reach scores [17, 20].
The association found in the present research
between directional control and FRT scores supports
the clinical validity of the FRT. Its increased
application in the elderly people may serve as valuable
screening test for balance impairments and a sensitive
assessment tool of variations in balance skills. Behrman
et al. [21] demonstrated that a cut off reach score of 10
inches differentiates subjects at high risk for falling
suggesting that the FRT scores may better anticipate the
risk of postural instability that occurs during daily
functions.
 Middle-East J. Sci. Res., 21 (1): 01-06, 2014
CONCLUSION
There are age-related changes of balance resulting in
poor performance in standing position and decreased
functional reaching in elderly people.
ACKNOWLEDGEMENT
The great assistance and participation of
Abdulrazzag Albokhari and Hussam Asseri, graduates
of Physical Therapy Department, Faculty of Applied
Medical Sciences, King Abdulaziz University, are much
appreciated.
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