Journal of Physical Therapy and Health Promotion Dec. 2015, Vol. 3 Iss. 4, PP.

47-51

Early Adult Detection is a Good Protector from

Balance Disturbance in Elderly
Omar Farouk Helal*1, Amir Abdel-Raouf El Fiky2
1
Physical Therapy Department, College of Applied Medical Sciences, Umm Al Qura University, KSA, Egypt
2
Department of Physical Therapy for Neurological Disorders and its Surgery, Faculty of Physical Therapy, Cairo University,
KSA, Egypt
* 1 dr.mon5@hotmail.com; 2
dramirksa09@yahoo.com

Abstract- Balance has often been used as a measure of lower extremity function, and any disturbance is considered a critical problem
that has a great risk in elderly subjects. Thus, the early recognition of balance disturbance in adults is highly recommended. To
determine the balance disturbances and risk of falling among University students as well as to establish a database for balance levels
in this university community, cross sectional study was carried out on random samples of 31 young adult male volunteers aged
between 18 to 25 years using the Biodex Balance System (BBS) to measure postural stability and risk of falling. The results showed
that there is a prevalence of balance disturbance as well as a positive correlation between body mass index (BMI) and postural
instability index. There are signs of a high proportion of balance disorder among adult university students, and there is a positive
correlation between BMI and postural instability. When BMI increases, postural control deteriorates.
Keywords- Balance Disturbance; Body Mass Index; Postural Stability

I. INTRODUCTION
Balance is defined as the process of maintaining the center of gravity within the body’s base of support [1], while postural
stability can be defined statically as the ability to maintain a base of support with minimal movement and dynamically as the
ability to perform a task while maintaining a stable position [2].
Normally, in order to keep an upright stance, the central and peripheral components of the nervous system are continually
interacting to maintain body alignment and the center of gravity over the base of support [3,4]. Peripheral components of
balance include the somatosensory, visual, and vestibular systems. The central nervous system assimilates the peripheral inputs
from these systems and selects the most convenient muscular responses to hold body position and posture over the base of
support [5].
Factors that may influence balance ability, and thus any measurement of balance, must be considered in examining balance
as an outcome measurement in rehabilitation or as a risk factor for injury [6,7]. Factors to be considered include: leg
dominance, fatigue or learning effects, age, sex, height, weight, foot size, physical activity level and specificity, and previous
lower-extremity injury [8,9]. Other factors that influence balance include sensory information obtained from the
somatosensory, visual, and vestibular systems and motor responses that affect coordination, joint range of motion (ROM), and
strength [10,11].
The most common technique used to evaluate the static and dynamic aspects of postural stability is the measurement of the
position and displacement of the center of pressure (COP) using a force plate form. Force plate measurements for postural
assessment are widely used in adults, and the reliability is well documented. These devices have typically used force plates
combined with computer software to determine the movement of the center of pressure (COP). The center of pressure is the
central point of pressure that is applied to the foot during contact with the ground, or the point of application of the ground
reaction force on the foot. During stance, the COP can be used to measure the movement of the individual's center of gravity
over the foot. Thus, the COP can be used to index the amount of movement or sway of the center of gravity during stance
[12,13].
Using this method, in contrast to force plate systems, the Biodex Stability System (BSS) uses a circular platform that is free
to move about the anterior-posterior (AP) and medial-lateral (ML) axes simultaneously. In addition to moving about these axes,
it is possible to vary the stability of the platform while varying the stance force applied to the platform. Springs apply this force
to the underside of the platform and can be adjusted to preset resistances established by the manufacturer. Rather than
measuring the deviation of the COP during static conditions, this device measures the degree of tilt about each axis during
dynamic conditions. Thus, the BSS appears to provide more specific information about postural stability and fall risk [14].
Balance disturbance is a critical problem that has a great risk in elderly subjects. Thus, the early recognition of balance
disturbance in adult is highly recommended. Through the early detection of balance disturbance, earlier precautions and
preventive measures can be taken, and a proper solving approach can be sought that can minimize the future risks of balance
disorders that may occur at a late age.

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The purpose of this study is to determine the balance disturbances and risk of falling and to establish a database for balance
levels in the university community. The questions are: do the students have dynamic balance disturbance? Also, is there a
correlation between body mass index and postural stability index?

II. SUBJECTS, MATERIALS AND METHODS

1) Subject
A cross sectional study was carried out on random samples (random selection of the students’ ID numbers from a student
list in the medical colleges) of 31 young adult male volunteers aged between 18 to 25 years that were recruited from University
Students after the approval of the university research ethics committee. Each subject was undertaken with full understanding
and appropriate informed consent. They were medically normal without any associated neurological or lower limb vascular or
musculoskeletal diseases and must be able to ambulate 50 feet without the assistance of another person and to cooperate with
balance testing.
Subjects with evidence of cardiovascular disease (systolic blood pressure > 130 mm Hg and diastolic blood pressure < 60
mm Hg) or with associated Hepatic or Renal diseases were excluded.
Subjects with Type I diabetes (Fasting blood glucose level > 126 mg\dl or < 70 mg\dl), hypercortisolism, malignancy and
users of lower limb orthotics were also excluded along with underweight (Below 20 kg\m2 BMI) or obese subjects (above 30
kg\m2 BMI).
Subjects who use drugs or medicine that might interfere with balance ( alcohol, sedative, tranquilizers) and who have a
disturbance in proprioceptive sensation or vestibular system were also excluded.

2) Data
Data was collected through an interview with the sample by using a Balance Questionnaire Form, which includes the
following parts:
• Socioeconomic level questionnaire (including age, family size, gender parent occupation, education level)
• Medical questionnaires (developed to explore knowledge of the medical status, past history and drug intake by the
volunteers)
• Anthropometric measurements (for anthropometric measurements included weight and height)
• Body Mass Index (calculated by dividing weight (in kilogram) / height (in meters2))

3) Materials and Instrumentation

The Biodex Balance System (BBS; Biodex Inc., Shirley, NY) was used to measure the fall risk balance test (Fig. 1).

Fig. 1 The Biodex Balance System

• Weight measuring device (scale)

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• Vertical height measuring device

• Blood glucose measuring device (Accu-chek active)

4) Procedure
This protocol was used to compare patients with similar age ranges in a normative database. BBS was used to measure
balance and postural stability under dynamic stress. It uses a circular platform that is free to move in the anterior–posterior and
medial-lateral axes simultaneously. The BBS allows up to 20° of foot platform tilt, which permits the ankle joint
mechanoreceptors to be stimulated maximally. The BBS measures, in degrees, the tilt about each axis during dynamic
conditions and calculates an overall stability index (OSI). A high score in the OSI indicates poor balance. The OSI score is
believed to be the best indicator of the overall ability of the patient to balance the platform. The stability of the platform can be
varied by adjusting the level of resistance given by the springs under the platform. The platform stability ranges from 1–12,
with 1 representing the greatest instability. The lower the resistance level, the less stable the platform.

5) Testing Parameters
• Test Duration: 20 seconds
• Level: Eight
• Stance Type: Bilateral
• Eyes open
• Three Trial repetitions.
• 30-second rest period between sets.
A minimum of three test trials should be used to avoid excessive balance deviations. The patient’s performance is noted as
a stability index. Test results are compared to age dependent normative data (Fig. 2).

Fig. 2 Fall Risk Test Result (Normal score according to age group of healthy people)

Scores higher than normative values recommend further assessment for lower extremity strength, proprioception and
vestibular or visual deficiencies. Poor balance is a major contributor to falls.

Statistical analysis
Statistical analysis was conducted using SPSS 17.0 for Windows. A fall risk index greater than 2.3 is considered an
abnormal score (the participant is more prone to fall) according to Biodex balance system measures. Lower values represent
better stability than higher ones.
The Pearson’s correlation coefficient was used to compare the BBS results for postural stability, anteroposterior stability
and lateral stability (mean of three measures) and the BMI index of each volunteer. The level of correlation was considered
positive when R ≥ 0.7 and negative when R< 0.7.

III. RESULTS
For the thirty-one subjects, the mean age was 21.3 ± 1.13 years, and the weight mean was 74.14 ± 8.26 kg, while the height
mean value was 179.96 ± 7.05 cm. The BMI mean value was 25.5 ± 2.7 m2/kg and the mean of the postural stability index
(OSI) was 2.19 ±1.6, while the fall risk index mean was 3.28 ±2.1 as shown in the descriptive data table 1.

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TABLE 1 DESCRIPTIVE ANALYSIS

Std
N Minimum Maximum Mean
Deviation
Postural
31 0.80 8.30 2.1903 1.59966
Stability
Fall Risk Index 31 1.20 9.50 3.2871 2.10503
BMI (Kg/m2) 31 20.20 30.00 25.5484 2.68600
Age
31 20.00 24.00 21.3226 1.13687

The results of the fall risk test revealed that out of the 31 subjects, 15 had a normal fall risk index score, and 16 (which
constitutes more than 50% of the population) had a score of more than 2.3, which mean that they have a high incidence of fall
risk. Ten of the abnormal subjects are regular smokers, while 4 of them are smokers. Eight of the abnormal subjects suffer
from flat-foot, while only one of the normal subjects has a flat-foot.
For the overall stability index (OSI), the correlation between BMI and OSI was R= 0.723, which revealed a positive
correlation between BMI and increased postural instability (greater shifts required in order to keep postural balance). as shown
in the correlation between BMI and OSI chart (Fig. 3).

Fig. 3 The Correlation between BMI and Postural Balance

IV. DISCUSSION
The current study was performed to explore the prevalence of balance disorders among adult students. This is in addition to
evaluating the correlation between body mass index and postural stability among the students whoparticipated.
A cross sectional study was carried out on a random sample of 31 University student volunteers. The test protocol
incorporated in the Biodex Balance System was included to give the clinician normative data to assess their patient's risk for
falling.
At the completion of the test, a Fall Risk Assessment Report can be printed with a score compared to normative data. The
overall stability indexes are then compared with different body mass index values of the students to detect if there is any
correlation between them.
The results of the risk of fall test among the study revealed that sixteen out of thirty one students, which constitutes more
than 50% of the population, showed abnormal fall risk test scores when compared to age dependent normative data. which
means that the majority of the selected sample are suffering from balance disturbance.
The data that was collected from dynamic balance questionnaire forms and the results of risk of the fall test showed that
eight of the students whose results gace abnormal fall risk values have a flat foot, which constitutes 50% of the fall risk
subjects.
The data that was collected from the dynamic balance questionnaire forms and the results of risk of fall test revealed that
ten of the fall risk subjects are regular smokers, which constitutes 62.5% of the subjects with abnormal fall risk values.
The same result was obtained by Iki et al. [14]. They stated that smokers exhibited more unstable posturographic results
than nonsmokers, and smoking habits were suggested to have a long-term effect on the posture control system.
Eight of the fall risk subjects had flat feet, which constitutes 50% of the fall risk subjects. This means that balance is
affected greatly by the shape of the feet in which the increase in flatfoot leads to a decrease in the dynamic balance and an

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increase in fall risk. Paik-Ling and Chris [15] found that as the degree of pes planus deformity increases, the degree of dynamic
postural stability decreases.
This study showed a positive correlation between BMI and increased postural instability (greater shifts required in order to
keep postural balance). This is in agreement with Kejonen et al. [16], who affirmed that excess weight and low level of
physical activity increased postural instability.
A similar study was done by Ledin and Odkvist [17], who demonstrated that the accumulation of fat tissue can reduce body
balance and contribute towards falls among extremely obese teenagers and adult patients.
Our results correspond with McGraw et al. [18], who prescribed that a 20% increase in body mass reduces the ability to
make adjustments in response to external disturbances in the orthostatic position and increases postural instability.. Patients
with BMI greater than 25 kg/m2 maintained shorter times in balance and longer times unbalanced as compared with lower BMI
individuals, such that obesity would influence the limits of postural stability.

V. CONCLUSION
The present study showed, according to fall risk test that captured by the OSI of the Biodex Balance System, that 51.6% of
the selected University students are suffering from balance disturbance. Also, the study’s results indicate that there is a positive
correlation between BMI and postural instability; when BMI increases, the postural control deteriorates.

ACKNOWLEDGEMENT
We wish to acknowledge and appreciate the contribution of the students who volunteered for this study.

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