Journal of Aging and Physical Activity, 2020, 28, 269-275

https://doi.org/10.1123/japa.2019-0127
© 2020 Human Kinetics, Inc. ORIGINAL RESEARCH

The Relationship Between Trunk Muscle Thickness

and Static Postural Balance in Older Adults
Ece Acar, Tamer Çankaya, and Serkan Öner

Trunk muscles are required for safety of movement in aging. The authors aimed to investigate the relationship between trunk
muscle thickness and the static postural balance in older adults. A total of 31 females and 23 males with a mean age of
73.39 ± 6.09 completed the study. The thickness of the trunk muscles was determined with ultrasound imaging. Postural balance
was assessed with force plate. There was a positive weak correlation between right and left upper rectus abdominis muscle
thickness and anterior stability area (p < .05, r > .3). The negative and moderate correlation was determined between the left lower
rectus abdominis and the perturbated stability sway value (p < .01, r > .5). The increase in trunk muscle thickness in older adults
increases the postural stability area and decreases the postural sway especially in the mediolateral direction.

Keywords: rectus abdominis, stability area, sway area

The loss of balance is one of the common problems that older
adults and 20–33% of the individuals aged 65 years and older
experience (Lin & Bhattacharyya, 2012). Postural balance is
defined as the muscle balance performed by the whole body to
keep the center of mass within the support surface (Barker, Bird, &
Talevski, 2015). Muscle balance decreases and loss of balance may
occur with advanced age due to the decrease in nerve conduction
rate and sensory input, and loss of muscle tissue (Viswanathan &
Sudarsky, 2012). These losses occur in the form of a decrease in the
stability area, which is the farthest distance that could be achieved
without changing the support surface during static posture, and an
increase in the area of postural sway, which represents the dis-
placement that occurs in the pressure center during static posture
(Hageman, Leibowitz, & Blanke, 1995). A higher stability area and
a lower sway area are the indicators of a stable balance.
Trunk muscles have important functions in balance and mobil-
ity and give a stable ground for the extremities by providing postural
support and stability to the spine (Hodges et al., 2003; Hodges &
Richardson, 1997; Suri, Kiely, Leveille, Frontera, & Bean, 2009).
Also trunk muscles participate in pelvic stabilization with hip
muscles (Tateuchi et al., 2013). Trunk flexion angle at foot contact
and step length has been shown to account for 51% of the variance in
whole-body dynamic stability at the time of foot contact of the
stepping leg (Carty, Mills, & Barrett, 2011). The remaining terms
further suggest that successful recovery is a whole-body control task,
which requires adequate trunk control and generation of adequate
lower limb moments and powers to produce a long and rapid step
(Graham, Carty, Lloyd, & Barrett et al., 2015). Thus, it is possible to
balance the changes in force and direction during movements with
the trunk muscles. Therefore, it could be suggested that trunk
muscles are required for both the quality and safety of movement.
It was reported that there is an increase in trunk muscle activity in
positions that require more stability, and the increase in abdominal
Acar is with the Department of Physical Therapy, Vocational School of Health
Services, Karabuk University, Karabuk, Turkey. Çankaya is with the Department of
Physical Therapy and Rehabilitation, Faculty of Health Sciences, Bolu Abant Izzet
Baysal University, Bolu, Turkey. Öner is with the Department of Radiology, Faculty
of Medicine, Karabuk University, Karabuk, Turkey. Acar (eceacar@karabuk.edu.tr)
is corresponding author.
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and lumbar muscle thickness significantly increases the static and
dynamic balance skills of individuals (Anderson & Behm, 2005;
Hicks et al., 2005). Loss of strength in trunk muscles in older adults
may lead to changes in the body posture, deterioration in proprio-
ceptive senses, and loss of balance (Sturnieks, St George, & Lord,
2008). Based on the synthesis of the previously mentioned infor-
mation, it could be suggested that the decrease in the trunk muscle
thickness in the older adults may have a role in the loss of the balance
skills by decreasing the force released by these muscles. In other
words, the decrease in muscle mass may lead to the loss of muscle
strength, which, in turn, may lead to a decrease in muscle functions.
However, the correlations between these factors are not yet fully
discovered. Although there are several studies on the correlations
between the thickness, strength, and function of upper and lower
extremity muscles in older adults, these correlations between the
trunk muscles play an important role in stability and need to be
further examined (Abe, Loenneke, Thiebaud, & Loftin, 2014).
Considering the undesired consequences of balance losses
such as falling among older adults, it is important to determine
the factors that affect these losses. Thus, the aim of the present
study was to investigate the correlation between trunk muscle
thickness and static postural balance skills.
Methods
The study was conducted with the individuals who were able to
stand at least 2 min without support, able to transfer activity
independently, and with a mini-mental test score of 24 points or
higher were included in the study. Individuals with any problem
that affects their balance and walking (otorhinolaryngological
or neurological disorders); lumbar or abdominal surgery; severe
visual loss or eye-related problems (retinopathy, etc.); lower
extremity amputation; or severe deformity were not included
in the study. Ethics committee approval was obtained from
Bolu Abant Izzet Baysal University Clinical Trials Ethics Com-
mittee (2017/110). Written consent forms were signed by all
participants.
Sociodemographic and physical characteristics of the indivi-
duals such as gender, age, height (measured in meters), weight
(measured in kilograms), and dominant extremity were recorded.
269
270 Acar et al.

Tinetti Fall Efficiency Scale, physical function, and physical role

difficulty scores were applied as subscale of short form-36.
Thickness of trunk muscles was determined with anteropos-
terior (AP) diameter measurement using ultrasound imaging in
upper rectus abdominis (URA), central rectus abdominis (CRA),
lower rectus abdominis (LRA), obliquus externus (OE), obliquus
internus (OI), and transversus abdominis (TrA) muscles, and with
AP and mediolateral (ML) diameter measurements in lumbar
erector spinae muscle (LES) and lumbar multifidus muscles.
The validity and reliability of the ultrasound examination of the
lumbar and abdominal muscles in older subjects was performed
(Wilson et al., 2016). Postural balance functions were determined
with the force platform in stability and postural sway areas.

Determination of Muscle Thickness

Muscle thickness was determined with Toshiba Aplio 300 ultraso-
nography device (Canon Medical Systems Corporation, Tokyo,
Japan). A 7.5 MHz linear probe was used for analysis. The wide
view feature was enabled to examine a wide area. The validity and
reliability of the ultrasound examination of the lumbar and abdom-
inal muscles in aging was performed (Wilson et al., 2016). Ultra-
sound measuring may be problematic due to including increasing
in the subcutaneous fat layer, or fatty infiltrates between the muscle
fibers, which may lead to an increase in echogenicity. Therefore, it
was stated that the use of thickness rather than thickness change
rate may be more effective in studies.
Measurements were conducted on the right and left sides of the
subjects and by an experienced radiologist and a physiotherapist.
The thickness values for all muscles were measured in millimeters
(mm) during rest and maximum voluntary contraction (MVC). The
thickness change ratio (TCR) was calculated using this formula
(MVC thickness − resting thickness)/(resting thickness) (Wilson
et al., 2016). A rest period of 3 min was allowed between measure-
ments. All movements were instructed before the measurements.
When the movements were learned clearly, the measurements for
each muscle were performed one time.
Upper rectus abdominis and CRA were measured at the second
and third layers between the proximal fibrous band and the inter-
mediate fibrous band, and the LRA was measured at the lowest
layers between the umbilical fibrous band and the pubic area and at
the region where the muscle was the thickest. For resting thickness
measurements, individuals were allowed to lie in supine position
with hip knee flexion by supporting the knee of the individuals with
a cushion. MVC thickness measurements were conducted when the
trunk was in flexion in supine position with hip knee flexion
application of force on the shoulders without altering the position
of the individual for URA and CRA and by providing force to the
maximum hip flexion for LRA (Tahan et al., 2016; Wachi et al.,
2017). Measurement positions and CRA ultrasound images are
presented in Figure 1.
For the measurement of the thickness of OE, OI, and TrA
muscles, the individual was allowed to lie in a supine position with
hip knee flexion by supported with a cushion under the knee. The
probe was placed 15 mm further from the muscle tendon junction
at the superior part of the umbilicus and the right side of the
abdominal line. The location of the probe was not changed for OE
muscle MVC thickness measurement, and the individual was asked
to move his elbow on the measurement side closer to the opposite
side knee while the arms were crossed under the chin. To measure
the OI muscle MVC thickness, the individual was asked to do the
same movement in the opposite direction. TrA muscle MVC
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Figure 1 — Central rectus abdominis measurement position and
ultrasound image. (a) Resting measurement position. (b) Maximum
voluntary contraction measurement position. (c) Ultrasound image on
resting. (d) Ultrasound image on maximum voluntary contraction.
thickness measurement was conducted in the drawing-in position
(John & Beith, 2007; Park, 2013; Skeie, Borge, Leboeuf-Yde,
Bolton, & Wedderkopp, 2015; Sugaya, Abe, & Sakamoto, 2014).
Lumbar erector spinae measurements were conducted in a
nonsupported relaxed sitting position on the fifth lumbar vertebra
and 4 cm lateral of the middle waist line. The subjects were asked to
extend their body as much as possible for MVC thickness mea-
surements. The lumbar multifidus thickness measurements were
conducted on the line of the fifth lumbar vertebra transverse
process, whereas the subject was in the prone position and arms
were in a coronoid position (90° of elbow flexion and 120° of
shoulder abduction). The abdomen was supported with cushions.
To measure MVC thickness, the individual was asked to raise the
opposite arm as much as possible. Force was applied on the scapula
without changing the position of the individual (Kiesel et al., 2007;
Watanabe et al., 2004). To record the thicknesses in the directions
of the AP and ML obtained with the LES and lumbar multifidus
muscles, the cross-sectional area (CSA = AP thickness × ML thick-
ness) was conducted for these muscles as well (Wallwork, Stanton,
Freke, & Hides, 2009).
Assessment of Postural Balance
Postural balance was assessed statically using the force platform
with the Bertec Balance Legacy System device (OH, USA). During
the measurements, the individual was asked to stand on the
platform and to keep his arms loosely near the body. The medial
malleolus of the individuals was placed of the medial malleolus line
on the platform, and the feet were slightly open and parallel to each
other. When the positions and movements were learned clearly, the
measurements were performed one time.
Factors of postural balance were considered in two main func-
tions of the postural stability area and postural sway area. The postural
stability was determined as the anterior stability area (ASA), posterior
stability area, right stability area, and left stability area.
 Trunk Muscles on Postural Balance in Older Adults 271

Postural sway area measurements were repeated on a hard Table 1 Abdominal Muscle Thickness and Lumbar
floor and on a foam floor. It was repeated in four positions for each Muscle CSAs and the Changes in These Figures Based
individual as follows: normal stability eyes open, normal stability on the Right and Left Sides
eyes closed (NSEC), perturbated stability eyes open, and pertur-
bated stability eyes closed (PSEC). The hard floor consists of a n = 54 Minimum Maximum X ± SD z p
square platform, each side 20 inches long and 2.25 inches high. The URA (mm)
foam floor consists of a square piece of medium density foam Right 3.53 11.63 6.85 ± 1.54 −0.806 .420
inside a vinyl cover each side 20 inches long and 3 inches high.
Left 3.91 11.44 6.98 ± 1.67
During these measurements, the individual was asked to hold the
cursor on the computer screen static for 30 s. CRA (mm)
Right 3.73 12.63 8.12 ± 1.69 −1.017 .314
Statistical Analysis Left 3.80 13.32 8.25 ± 1.84
Statistical analyses were conducted with SPSS (Statistical Package LRA (mm)
for the Social Sciences, version 20.0; IBM Corp., NY) software. The Right 3.70 14.30 9.17 ± 2.18 −0.554 .580
normal distribution of the variables was determined using visual Left 3.42 14.70 9.10 ± 2.44
(histogram and probability graphs) and analytical methods (Kolmo- OE (mm)
gorov–Smirnov test). Descriptive analyzes were presented in mean
Right 1.93 9.42 5.13 ± 1.59 −4.007 .000*
and SD figures. Differences between sociodemographic and physical
characteristics according to gender were determined by Mann– Left 2.81 10.70 5.79 ± 1.61
Whitney U test. In the comparison of the dependent measurements, OI (mm)
statistical significance was determined by paired t test for normally Right 3.81 15.10 7.66 ± 2.72 −0.917 .359
distributed variables and with Wilcoxon test for variables at least one Left 3.50 14.52 7.43 ± 2.70
of which was not normally distributed. Correlation coefficients and TrA (mm)
statistical significance of normally distributed variables were deter-
Right 1.82 7.80 4.29 ± 1.40 −0.723 .473
mined by Pearson test, and Spearman test was used in the presence of
at least one nonnormally distributed variable. Correlation was Left 1.91 7.51 4.38 ± 1.25
considered as present when the correlation coefficient was at least LES-CSA
.3 and statistically significant. Type 1 error level was considered as (mm2)
5% in statistical significance. Right 6.84 29.24 15.72 ± 5.88 −0.435 .664
Left 6.08 27.36 15.41 ± 5.12
Results LMF-CSA
(mm2)
Fifty-four individuals (31 females and 23 males) with a mean age of Right 4.98 26.91 11.36 ± 4.47 −0.822 .411
73.39 ± 6.09 participated in the study. The mean height of the
Left 5.32 20.24 11.39 ± 3.54
subjects was 1.63 ± 0.08 m, body weight was 69.65 ± 9.46 kg, and
body mass index was 26.06 ± 1.87 kg/m2. It was determined that 50 Note. n = number of individuals; X = arithmetic mean; z = Wilcoxon test;
p = statistical error; URA = upper rectus abdominis; CRA = central rectus abdo-
individuals were right-side dominant and four individuals were minis; LRA = lower rectus abdominis; OE = obliquus externus; OI = obliquus
left-side dominant. Tinetti Fall Efficiency Scale score 19.28 ± 7.55 internus; TrA = transversus abdominis; LES = lumbar erector spina; LMF = lum-
points, physical function score 74.72 ± 21.27 points, and physical bar multifidus; CSA = cross-sectional area.
role difficulty score 73.89 ± 40.23 points. *Significant based on the Wilcoxon test, p < .005.
Age (female 71.06 ± 5.37; male 76.52 ± 5.68), height (female
1.59 ± 0.07 m; male 1.69 ± 0.05 m), and body weight (female
65.40 ± 9.12 kg; male 75.37 ± 6.54 kg) were found to be statistically the lowest stability area was on the back (3.60 ± 2.15 cm). ASA
significant according to gender (p < .05), whereas body mass index was measured as 3.60 ± 2.15 cm, and left stability area was
(female 25.78 ± 2.02 kg/m2; male 26.43 ± 1.62 kg/m2), Tinetti Fall measured as 6.20 ± 2.20.
Efficiency Scale (female 19.42 ± 7.61; male 19.13 ± 7.51), physical The results of the postural sway area measurements on the hard
function (female 73.26 ± 21.19; male 74.97 ± 21.37), and physical and foam floors demonstrated that the highest sway was observed
role difficulty (female 72.16 ± 39.23; male 73.91 ± 40.23) were not in the AP direction (1.28 ± 0.44 cm) in PSEC position, and the
significant (p > .05). lowest sway was observed in normal stability eyes open and NSEC
Review of the muscular thicknesses of abdominal muscles positions in the ML direction (0.28 ± 0.26 cm; 0.28 ± 0.18 cm). The
measured in resting position demonstrated that the muscle with the analysis of the variations in AP and ML sway areas based on open
highest thickness was LRA (right: 9.17 ± 2.18 mm; left: 9.10 ± or closed eyes demonstrated that only the difference in AP sway
2.44 mm) and the muscle with the lowest thickness was TrA (right: area was significant in hard floor measurements (normal stability;
4.29 ± 1.40 mm; left: 4.38 ± 1.25 mm). Analysis of the difference p = .007). The variations in AP and ML sway areas were statisti-
between the right and left muscle thickness of the subjects demon- cally significant based on the eye status (pAP = 0.000; pML = 0.000).
strated that OE muscle thickness were significantly different (right: Sway area values are presented in Table 2.
5.13 ± 1.59 mm; left: 5.79 ± 1.61 mm; p = .000). The correlation
between abdominal region muscle thickness and lumbar region Muscle Thickness and Postural Stability Area
cross-sectional area of the subjects and right and left side values
are presented in Table 1. The correlation between the thickness of the abdominal and lumbar
The postural stability area measurements demonstrated that muscles in the resting position and the individual stability areas was
the highest stability area was on the right side (6.28 ± 2.37 cm), and examined. It was determined that there was a positive weak
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272 Acar et al.

correlation between ASA and right URA (p = .012, r = .339); left and left CRA TCR (p = .018 r = .320). A positive and weak
URA (p = .012, r = .341); and left TrA muscle thickness (p = .016, correlation was determined between ASA and right URA (p = .06,
r = .326). A weak positive correlation was determined between r = .370); right CRA (p = .024, r = .307); and left CRA TCR
ASA and left TrA muscle thickness (p = .019, r = .319). A positive (p = .013, r = .333). There was a positive and moderate correlation
and moderate correlation was determined between left stability area between RSA and right OE (p = .003, r = .403) and right LES TCR
and left URA thickness (p = .000, r = .461), and a positive weak (p = .001, r = .455).
correlation was determined between right URA (p = .009, r = .352);
right OE (p = .016, r = .326); and right TrA muscle thickness Muscle Thickness and Postural Sway Area
(p = .018, r = .320). The correlation between muscle thickness
and stability areas is presented in Table 3. The thickness of the abdominal and lumbar muscles in resting
Comparison of the rate of thickness change in the muscles and position and the sway area values obtained in four measurement
individual stability areas exhibited a positive weak correlation positions were compared. There was a positive weak correlation
between ASA and the changes in right CRA (p = .018, r = .332) between AP sway and the right OE resting thickness in the NSEC
position (p = .024, r = .306), and there was a positive and moderate
correlation between the NSEC-AP sway and right ES cross-
Table 2 Sway Area Values and Changes Due to Eyes sectional area (p = .000, r = .517) and the left ES cross-sectional
Positions (95% Confidence Interval) area (p = .000, r = .480). There was a weak positive correlation
between PSEC-AP sway and left URA thickness (p = .022,
n = 54 X ± SD t/z p r = .312); NSEC-ML sway; and left URA thickness (p = .024,
Anteroposterior (cm) r = .307). There was a negative and weak correlation between
NSEO 0.52 ± 0.26 −2.682 .007* PSEC-ML sway and left OI muscle thickness (p = .010, r = −.346)
and a negative and moderate correlation between the left LRA
NSEC 0.66 ± 0.28
(p = .000, r = −.551). The correlation between muscle thickness and
Mediolateral (cm) stability areas is presented in Table 4.
NSEO 0.28 ± 0.26 −1.670 .095 Review of the correlation between the muscle TCR and the
NSEC 0.28 ± 0.18 individual sway areas demonstrated that there was a negative and
Anteroposterior (cm) weak correlation between the perturbated stability eyes open-ML
PSEO 0.60 ± 0.28 −5.963 .000* sway area and URA TCR (p = .025, r = −.304).
PSEC 1.28 ± 0.44
Mediolateral (cm) Discussion
PSEO 0.50 ± 0.22 −7.448 .000**
PSEC 0.82 ± 0.33 The present study aimed to investigate the correlation between
trunk muscle thickness and the static postural balance skills of
Note. n = number of individuals; X = arithmetic mean; t = paired t test; z =
Wilcoxon test; p = statistical error; NSEO = normal stability eyes open; the individuals. It was determined that there was a correlation
NSEC = normal stability eyes closed; PSEO = perturbated stability eyes open; between trunk muscle thickness and individual balance skills. The
PSEC = perturbated stability eyes closed. increased muscle thickness in rectus abdominis was associated
*Significant based on the Wilcoxon test, p < .005. **Significant based on paired with increased AP stability and decreased ML sway. Similarly, the
t test. increase in OE muscle thickness was associated with an increased

Table 3 The Correlation Muscle Thickness and Stability Areas (95% Confidence Interval)
Upper Central Lower Lumbar Lumbar
rectus rectus rectus Obliquus Obliquus Transversus erector multifidus
n = 54 abdominis abdominis abdominis externus internus abdominis spina (CSA) (CSA)
The correlation between right
muscle thickness and stability
area (r)
Anterior sway area .339* .158 .022 .221 .022 .196 .209 .284
Posterior sway area .176 .080 .218 .150 .024 .232 −.012 −.024
Right sway area .261 −.019 −.074 .164 .016 .299 .231 .063
Left sway area .352* .251 .044 .327* .114 .320* .202 .157
The correlation between left
muscle thickness and stability
area (r)
Anterior sway area .341* .039 −.010 .085 .124 .326* .235 .177
Posterior sway area .223 .161 .146 .332 .207 .319* −.065 −.234
Right sway area .461** .221 .085 .286 .308 .309* .267 .337*
Left sway area .218 .000 −.152 .113 .037 .243 .147 .150
Note. n = number of individuals; r = correlation coefficient; CSA = cross-sectional area.
*Significance based on Spearman test (statistical error < 0.05). **Significance based on Spearman test (statistical error < 0.01).

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 Trunk Muscles on Postural Balance in Older Adults 273

Table 4 The Correlation Between Muscle Thickness and Postural Sway Areas (95% Confidence Interval)
Upper Central Lower Lumbar Lumbar
rectus rectus rectus Obliquus Obliquus Transversus erector multifidus
n = 54 abdominis abdominis abdominis externus internus abdominis spina (CSA) (CSA)
The correlation between
right muscle thickness
and sway area (r)
NSEO-AP .143 .221 .157 −.330 −.110 .048 −.111 −.770
NSEC-AP .227 .157 .134 .306* −.011 .073 .517 .272
PSEO-AP .070 .192 .149 .034 .293 .252 −.001 .008
PSEC-AP .053 .068 −.201 .124 −.080 −.151 −.178 −.103
NSEO-ML .076 −.060 −.198 .196 .164 .172 −.013 −.097
NSEC-ML .079 .031 −.123 .245 .007 .103 .039 −.009
PSEO-ML .005 .126 .177 −.132 −.053 .031 −.313 −.276
PSEC-ML −.202 −.248 −.414* −.262 −.173 −.169 −.398 −.137
The correlation between
left muscle thickness
and sway area (r)
NSEO-AP .219 .186 .036 .136 .010 .165 −.083 −.265
NSEC-AP .251 .195 .259 .161 .111 −.046 .480** .219
PSEO-AP .067 .159 −.008 .192 .084 .211 −.056 −.194
PSEC-AP .312* .089 .030 .002 −.044 −.260 .001 .108
NSEO-ML .239 −.068 −.194 .076 −.014 −.002 .051 −.130
NSEC-ML .307* −.017 −.032 .045 .079 −.019 .137 .002
PSEO-ML .108 .248 .101 .148 −.010 .068 −.346 −.375
PSEC-ML −.005 −.291 −.551** −.235 −.346 −.197 −.276 −.129
Note. n = number of individuals; p = statistical error; r = correlation coefficient; NSEO = normal stability eyes open; NSEC = normal stability eyes closed; PSEO =
perturbated stability eyes open; PSEC = perturbated stability eyes closed; AP = anteroposterior; ML = mediolateral; CSA = cross-sectional area.
*Significance based on Spearman test (statistical error < 0.05). **Significance based on Spearman test (statistical error < 0.01).

stability area, and a thick OI muscle was associated with decreased
sway. It was observed that correlations with the sway area were
more significant in the measurements conducted on the foam floor.
Postural changes are observed in the thoracic and lumbar
region with aging, and individuals acquire a forward curved
posture. This posture may lead to the shortening of the abdominal
muscles. In the present study, the fact that the ASAs of the
individuals with higher URA and TrA muscle thickness were
larger could be due to anterior-oriented posture of the individuals
during activities. In a study performed by Hicks et al. (2005), it was
reported that the increase in total trunk muscle thickness decreased
the time of sitting and standing for the individuals and had a
positive impact on balance skills. In the present study, although the
stability areas of the individuals were not examined based on the
direction, it is known that standing up from a chair creates an
anterior push and acceleration, and furthermore, older adults tend
to bend forward when standing up to keep their pressure center
within the support surface (Papa & Cappozzo, 2000). In the present
study, the fact that there was a correlation between URA and TrA
along with CRA muscle thickness and increased ASA might be due
to stabilization function of the abdominal muscles. Another finding
obtained in the present study, the increase in right OE muscle
thickness and the presence of a high lateral stability area were
consistent with the previously mentioned statement. Thus, it is
possible to suggest that the muscle thickness has a positive effect
on the muscle function when stabilization function is concerned.
In terms of sway areas, it was determined that the increase in
OI and LRA muscle thickness decreased the ML sway area on the
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foam floor. This may be considered as an indication that the
abdominal muscles hold the entire body stable including the trunk.
Furthermore, this correlation was only relevant in the measure-
ments conducted on foam (perturbated) floor, and it supported the
fact that the abdominal muscles are more associated with the
activities conducted on unstable floors (Anderson & Behm,
2005). In a similar study, it was reported that there was a negative
correlation between TrA thickness and sway area (Gong, 2013). In
the present study, there was no correlation between the TrA
thickness and the sway area; however, the thickness of this muscle
was associated with a greater stability area (Masaki et al., 2016).
Thus, TrA may be involved in both balance skills. Future studies
could investigate the presence of the correlation between the
stability area and TrA thickness on foam floor.
In the present study, it was determined that OE bilateral LES
section areas and muscle thickness of the individuals with higher
right postural sway in the AP direction when NSEC were higher.
This may be due to the stabilization function of the OE muscle
or could be due to the confusion created by the fact that the majority
of the participants in our study were right-side dominant. In terms of
LES, it was observed that echogenicity in lumbar region muscles
changed during ultrasound measurements. This was an indication of
excess fat in muscles. However, as we did not assess echogenicity,
we cannot comment on the amount of adipose tissue. We considered
that the increase in LES muscle thickness was misleading.
Although there was a significant increase in AP sway area in
the measurements conducted when older adults’ eyes were open
and closed, there was no significant difference in ML sway areas.
274 Acar et al.
In other words, when the balance became difficult on stable floor, the
sway in the AP direction increased. Another reason for the increase
in AP sway in individuals may be the ankle strategy mechanism
responsible for the situation. In fact, Borreani et al. (2014) reported
that the activation of ankle muscles was higher in the balance tests.
Similarly, Engelhart et al. (2015) reported that the most older patients
and young individuals had higher ankle strategy levels. In the present
study, we did not attempt to prevent this mechanism during mea-
surements. This could be a confounding factor in terms of the
conditions that we find associated with OE and LES. In addition,
changes in spine position with advancing age result anterior dis-
placement of the center of gravity. The positive correlation between
the increase in rectus abdominis muscle thickness in the superficial
group and balance functions could be related to the increase in AP
sway. Individuals increase the AP sway in an insecure condition,
especially on stable floor, and therefore, the muscles in the AP
direction are used more, and thus, these muscles become subject to
more axial loads. These loads may cause the muscle to maintain its
thickness by reducing or preventing atrophy (Hides et al., 2007).
Furthermore, we considered that the determination of TCR
instead of thickness measurement may give an idea about muscle
function. Similarly, Kim et al. (2014) stated that TCR measurement
may be a more useful measurement in their study. In the present
study, although we determined significant correlations with TCR,
several correlations were statistically weak. We suggested that this
could be induced by the fact that we only investigated static balance
skills instead of active functions.
Limitations
In the present study, although we aimed to investigate the correla-
tion between trunk muscle thicknesses and postural balance skills
of individuals, certain conditions that occurred before or during the
study led to limitations in the present study. We did not approach to
prevent ankle and hip strategies during the tests on static balance
skills. This may be misleading, perhaps due to the compensation of
the trunk-related losses by the lower extremities. As the present
study focused on muscle thickness and thickness change rate, the
intramuscular fat rate was not determined. Even though we paid
attention to the rest time required for individuals, all procedures
were only completed by individuals who has not fall risk and were
in good physical condition. Even participants had same physical
activity levels, dynamically moving, sitting, or laying down times
was not measured with objective methods. For this reason, we may
not notice minor changes. In addition, hip and lower extremity
muscles may be more effective in achieving balance as individuals
with no orthopedic problems are included in this study. This may
have led to a limitation by lowering the correlation rates.
Conclusion
Thick trunk muscles in older adults are associated with their wide
stability areas and narrow sway areas. Thus, individuals with higher
trunk muscle thickness exhibit higher stable postural balance. It is
necessary to focus on rectus abdominis, as its muscle thickness is
positively correlated with several balance parameters. As the thick-
ness of the muscles relatively exposed to axial loading is high,
activities that maintain the upright position of the spine can be
emphasized in the prevention of muscle atrophy in older individuals.
The activation of the muscles of the OE, OI, and transversus
abdominis is particularly effective in reducing postural release.
Therefore, exercises to increase the activation of these muscles can
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be performed in individuals who often fall sideways and who need
to reduce ML sway (Granacher et al., 2013).
It is important to assess the muscle thickness or to determine
the cross-sectional area in structural evaluation of muscles in older
adults, as well as the thickness change rate and the amount of
intramuscular fat.
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