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The relation between postural stability and weight distribution in healthy subjects
Linda C. Anker a, Vivian Weerdesteyn a,b,*, Ilse J.W. van Nes a,b, Bart Nienhuis a, Huub Straatman c, Alexander C.H. Geurts b
a Sint Maartenskliniek Research, Development and Education, Nijmegen, The Netherlands Department of Rehabilitation, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands c Department of Epidemiology and Biostatistics, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands b
Received 12 October 2006; received in revised form 14 May 2007; accepted 9 June 2007
Abstract Knowledge of the effects of leg-loading asymmetry on postural control and control asymmetry during quiet upright standing in healthy young and middle-aged subjects is necessary before these relationships in patients with lateralized disorders can be assessed and understood. A posturographic procedure was developed, using a dual-plate force platform, during which 10 younger and 10 middle-aged healthy individuals were required to adopt various degrees of (a) symmetrical weight distributions (0, 5, 10, 20 and 30% of extra body weight loaded onto either leg). Postural control and control asymmetry were quantiﬁed by centre of pressure (CP) ﬂuctuations in the lateral (LAT) and anterior–posterior (AP) directions under both feet together and individually. Subsequently, the relationship between weight distribution on one hand and postural control and control asymmetry on the other hand, was calculated. Results demonstrated that with increasing weightbearing asymmetry (WBA), the overall control of postural sway velocity increased mainly in the LAT direction, where a ﬁrst-order polynomial function ﬁtted best. The asymmetry of control of postural sway velocity increased with increasing weight-bearing asymmetry in favour of the more loaded leg in LAT and AP directions. A ﬁrst-order polynomial was used for both AP and LAT direction. Effects of weightbearing asymmetry on postural control and control asymmetry are due to changes in the biomechanical constraints of upright standing. It was suggested that through increasing weight-bearing asymmetry the postural instability increased by reducing the efﬁciency of hip load/unload mechanisms and increasing the (compensatory) ankle moments. # 2007 Elsevier B.V. All rights reserved.
Keywords: Weight-bearing asymmetry; Postural control; Control asymmetry
1. Introduction Both central and peripheral diseases may cause deterioration of postural control and, especially in the case of lateralized disease, abnormal asymmetry in weight distribution between the legs [1–8]. In most patients with lateralized disease it remains unclear to what extent the persistent leg-loading asymmetry reﬂects fear or inability to cope with the altered sensorimotor constraints (and thus can
* Corresponding author at: Department of Rehabilitation, Radboud University, Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. Tel.: +31 24 36 14 804. E-mail address: firstname.lastname@example.org (V. Weerdesteyn). 0966-6362/$ – see front matter # 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.gaitpost.2007.06.002
be regarded as a maladaptive strategy) or reﬂects an inherent capacity of the central nervous system to adopt a position in which the body sway is optimally controlled (given the sensorimotor impairments). Generally, when postural instability coincides with weight-bearing asymmetry, it is unclear to what extent the decreased stability is related to altered biomechanical constraints or should be considered as a consequence of a neural control problem (e.g. due to pathology). For healthy elderly, a greater weight-bearing asymmetry (WBA) was associated with increased anterior– posterior (AP) postural sway [9,10]. Similar but less strong associations between weight-bearing asymmetry and postural control have been reported for stroke patients [2,10,11]. Between-subjects comparisons, however, can provide only
the participants had to maintain their CP between limits corresponding with 47.C. Participants Twenty healthy individuals participated in this study. They reported that the amplitudes of the ‘centre of pressure’ (CP) under both feet increased with increasing weight-bearing asymmetry in both the lateral (LAT) and AP directions. 51. Anker et al. The coordinates of the CP displacements were passed through a digital. a fully symmetrical standing posture provides maximum stability. during quiet upright standing in healthy adults. Genthon and Rougier  demonstrated the negative effects of an asymmetrical body weight distribution on the control of undisturbed upright stance. However. The width of the bar was always ﬁxed at 5% of the reference width of each participant. All participants gave their written informed consent. it is necessary to know the effects of legloading asymmetry on postural control in healthy subjects. In this way. Procedure During posturography. Four men and six women (mean age Æ S. During the second task. two parallel support bars were placed beside the force platform. participants were asked to stand symmetrically by maintaining their CP (represented as a black circle) as still as possible within the limits of a vertical target bar presented in the middle of the computer screen (Fig. this effect was stronger for the unloaded leg than the loaded one. this study did not look at the CP velocity. The reference width. the participants stood barefoot on the force platform with their arms alongside their trunk and their feet against a ﬁxed foot frame (medial sides of the heels 8. Precise mathematical relationships are essential to correctly interpret postural instability and regulation asymmetry given the concomitant WBA and to adjust these measures for the degree of WBA in a particular test or condition. Signals were processed by six dc ampliﬁers (nonlinearity <0. however. most pronounced in the LAT direction. the precise relationship between WBA (in the frontal plane) and postural stability (in both the frontal and sagittal planes) during normal quiet standing is unknown. Subjects with neurological or orthopaedic diseases or with visual or other sensory deﬁcits were excluded. Five men and ﬁve women (mean age Æ S. the point of application of the resultant of the ground reaction forces (centre of pressure) was determined in a two-dimensional transverse plane for each sample. which recorded the vertical ground reaction forces . and to understand to what extent their postural instability can be attributed to WBA.. with a maximum error of Æ1 mm  in the LAT and AP directions. They assessed various degrees of forced weight-bearing asymmetry in both directions by positioning 2. In order to further unravel this relationship in various types of patients with lateralized disorders. the symmetry in regulation activity between the loaded and unloaded leg). / Gait & Posture 27 (2008) 471–477 limited insight into the relationship between WBA and stability due to possible inter-individual differences in postural strategies. One test series consisted of 10 different balance tasks. 2. low-pass Fourier ﬁlter with a 6 Hz cut-off frequency to eliminate high-frequency components due to noise. 2. During the ﬁrst task. and did not calculate the precise relationship between WBA and changes in postural stability or kinetic regulation symmetry (i.1. in the middle-aged group.3. By means of digital moment-force calculations.D. Each plate was placed on three transducers (hysteresis and non-linearity <1%).5 years) were included in the young group. theoretically. which degree of WBA provokes which degree of stability loss and control asymmetry in healthy subjects? As yet.8 Æ 2. 25.4 cm apart and each foot placed with toes outward at a 98 angle from the sagittal midline).e. For safety purposes.2. at least in healthy subjects [9. which is frequency sensitive and a more reliable parameter in the clinical quantiﬁcation of postural control than CP amplitude [16–18]. The aim of this study was to examine the within-subjects relationship between weight distribution on the one hand and postural control and control asymmetry on the other hand. The following eight tasks were randomized in order. 1c). In other words. only one study has been published that investigated the within-subjects relationship between weight distribution and postural control in healthy adults.5% and 52. was determined (Fig. The lag time between movement of the CP and the cursor was about 16 ms.5% of body-weight loading on either leg (reference feedback task) (Fig. participants faced a grey computer screen (reference task). Approval was obtained from the institutional ethical committee. This would improve the comparability of individual measurements as well as of group data. Data were stored after a 16-bit AD conversion at a sampling rate of 500 Hz.1%) and ﬁrst-order low-pass ﬁlters with a cutoff frequency of 30 Hz.6 Æ 3. Real-size visual CP feedback was provided through a computer screen that was placed 1 m in front of the participants. Methods 2. 1c). 1a). Although. Remarkably. Posturography Postural control was measured by using a force platform consisting of two separate aluminium plates.3 years) were included .D.472 L. For this purpose a posturographic procedure was developed during which participants were ‘forced’ to adopt various standardized asymmetric weight-bearing positions. All balance tasks were done while facing the computer screen. which corresponded to the distance between the anterior borders of the distal tibiae while standing on the platform.12–14]. Subjects were instructed to stand quietly upright with their eyes open for 20 s during all balance tasks.
the reference coordinate system was rotated 98 to the left or to the right of the sagittal midline. the amplitude variability (ACP) of the overall CP ﬂuctuations was determined by calculating the root mean square (RMS) as an estimation of the body sway in the AP . (b) The deﬁnition of the different directions of the right foot. To prevent fatigue. Statistical analysis All balance parameters obtained from corresponding tasks in each of the two test series were averaged. These distances were calculated individually based on the subject’s reference width. After a ﬁrst-order differentiation. After the ﬁrst test series. We assumed that if present.C. 10%. The SI is 0 if there is perfect symmetry. as tested by one-sample t-tests. (c) Scheme of the target bar. but also visual feedback itself has an effect on CP parameters. a random coefﬁcient (RC) regression model (utilizing the SAS procedure PROC MIXED with a random effects maximum likelihood regression procedure) was used to investigate the mathematical relationship between the degree of WBA and the normalised balance parameters. (a) The position of the feet and the reference width. In this way. 2. When signiﬁcant main effects of weight distribution were detected. The balance parameters from the nine tasks with visual feedback were individually normalised. Data analysis First. according to the position of the left and right foot. 2. 1. so that eventually 20 tests were obtained for each subject. Positive values of SI indicate more CP modulation of the loaded leg. As for the analysis of the CP displacements for each foot separately. respectively. the symmetry index (SI) was calculated according to the following equation: SI ¼ 2 Â ðY Loaded À Y Unloaded Þ Â 100% Y Loaded þ Y Unloaded In this equation. The applied degrees of asymmetrical weight loading were 5%. Then. / Gait & Posture 27 (2008) 471–477 473 and LAT directions separately. 5%. the direction of the forced weight-bearing asymmetry was changed after each test. 20%. respectively. All normalised parameters were tested in a three-way ANOVA using Group (young versus middle-aged) as a between-subjects factor and Side (left and right) and WBA (0%.L. YLoaded and YUnloaded are CP parameters derived from the CP ﬂuctuations under the loaded and unloaded foot. The difference in À2 log likelihood between two models (one model has one or two extra parameter(s)) is an indication of the adequacy of the model. the presence of feedback effects could be identiﬁed as any signiﬁcant non-zero normalised value in the 0% WBA condition. This procedure gives a log likelihood for each estimated model. Each test was preceded by a 5 s anticipation period followed by a low-frequency starting tone. the RMS CP velocity (VCP) was calculated. Anker et al. to obtain CP measures congruent with the anatomical orientation of the respective ankle joints (Fig. The difference follows a x2 distribution with one or two degree(s) of freedom. feedback effects would be constant for all WBA conditions. positioned at the sagittal midline. If this difference in À2 log Fig. 20% and 30% of the extra body weight (above 50%) loaded onto either leg. 1b). By normalisation with respect to the nonfeedback condition.5. To express the degree of kinetic regulation asymmetry. The differences between these parameters and their values as obtained from the reference task without feedback were divided by the latter value and multiplied by 100%.4. the complete sequence was repeated. calculation of the above-mentioned ACP and VCP values provided measures of the CP modulation under each foot separately in both the AP and LAT directions. 10%. 30%) as withinsubjects factors. It is possible that not only WBA. all feedback performances were represented as a percentage change with respect to the reference task. the target bar at corresponding distances from the vertical midline of the screen.
4 26.5 8. VCP signiﬁcantly decreased by 12. The corresponding statistical model used to analyze the intra-individual relationship between a normalised balance parameter (Y) and weight-bearing asymmetry for the group as a whole is given in the following polynomial equations .1 7.8 4. 5%.5 S.7 2.9 4. In AP direction. 9.6 7. Results All participants were able to maintain their CP within the borders of the target bar in each task.4 21.0 5.M. / Gait & Posture 27 (2008) 471–477 likelihood is signiﬁcant.M. There were no main effects of group and side.3 7. ( p < 0. Table 1 summarizes the means and S.M.D.E. The solid line is the mean.6 20% 103. Visual feedback had no signiﬁcant effects on SI VCP and SI ACP (Table 1. Values of the various CP parameters increased with increasing degrees of WBA. Fig.M. Data were ﬁtted in ﬁrst-order to third-order polynomials functions.05) (Fig.5 51. 8.E. A summary of the results of the three-way ANOVA with repeated measures is presented in Table 2.1 3.6 38.9 7.8 5.4 8.7 À0.5 4.E.2 6.1 À12. Y it ¼ bi þ b0 þ b1 Â WBAt þ eit ðfirst orderÞ Y it ¼ bi þ b0 þ b1 Â WBAt þ ðb2 Â WBAt Þ2 þ eit ðsecond orderÞ Y it ¼ bi þ b0 þ b1 Â WBAt þ ðb2 Â WBAt Þ2 þ ðb3 Â WBAt Þ3 þ eit ðthird orderÞ In these equations. respectively. The dashed line is the ﬁt of the model used. The index i denotes the subject identiﬁcation (i = 1–20).8% during the reference feedback task compared to the reference task in the LAT direction (Table 1 and Fig.1 6.3 5% 40.1 7.6 8.4% ( p < 0.0 1. expressed as the RMS of the overall CP velocities (VCP) in the frontal plane (a) and the sagittal plane (b) for the different degrees of weight-bearing asymmetry (WBA).474 L.2 6. Postural stability.7 4.C.2 À1. indicating that age and side did not have differential effects on postural stability over the Table 1 Summary of the mean (ÆS.5 6.7 2. whereas WBAt denotes the WBA at t = 0%.4% Fig. then the most complex model is selected.01) and ACP signiﬁcantly increased by 21.M. 10%.4 12. 15. bi the random intercept for individual i.4 À2.E.8 3. In order to ﬁnd the ‘‘best’’ model. Anker et al.9 27.4 À1. 2.2 7. 9. VCP signiﬁcantly increased by 29. 3. The dotted lines are the mean Æ 1.4 3.4 3.E.0 3.3 S.1 6. Yit are the observations for subject i at measurement t.0 28.0 4.6 7.1 8.9 5.3 9. 3a and b).0 39. 2b).3 6.E.s for all parameters in both the frontal and the sagittal planes. Main effects of WBA were present for all parameters. and eit is the ‘error’ for subject i at WBAt.5 À0.6 8.8 À10.7 5.9 À10. nor any interaction effects of WBA by group or by side.5 9.2 S. 20% and 30%.6 35.3 26. except for ACP in AP direction.96 Â overall S.6 17.8 À7.E.4 30% 146.1 À3.9 7.2 .M. b1.5 1.2 50.1 9.1 À0.) for CP velocity (VCP) and CP amplitude (ACP) and the symmetry index (SI) of VCP and ACP for the various degrees of weight-bearing asymmetry (WBA) in the lateral (LAT) and antero-posterior (AP) directions Direction Parameter WBA 0% LAT AP LAT AP VCP ACP VCP ACP SI VCP SI ACP SI VCP SI ACP 29.3 20. b2 and b3 the regression coefﬁcients for the polynomial in WBA.9 3.0 29. all models were compared to determine whether a higher order polynomial function was signiﬁcantly better or not.1 23.5 S.M. Analysis revealed a signiﬁcant effect of visual feedback for VCP LAT ( p < 0.7 10% 62.01).4 6.7 S. 13. 2a).4 25.7 29.
61 0.01 <0.38 F(4. 72) = 0. 72) = 4. / Gait & Posture 27 (2008) 471–477 475 various degrees of WBA.65.54 F(4.92.01 <0. 34. to adopt various asymmetric weight-bearing positions using visual feedback of their CP. 72) = 0. 47. a reduction in postural control efﬁcacy) in the LAT direction.44 1.34) = 1.29. The dotted lines are the mean Æ 1. while standing on a dual-plate force platform.51 F(4.36 F(2.43) = 0.97.89 p-Value <0.64 593.43 0.84 1.01 WBA Â Group F(2.07 F(2.72) = 0.34 p-Value 0. 72) = 1.94 F(4. 53.48. 3. the subjects were required to control their upright standing primarily in the LAT direction.51 <0. Fig.01 <0. which coincided with a relatively small decrease in overall CP velocity in the AP direction during the reference Fig.57) = 22. 47.83 F(2. 41.87 393.27 0. 4. Therefore. Table 2 Summary of the results of the three-way ANOVA of the CP velocity (VCP) and CP amplitude (ACP) values in lateral (LAT) and antero-posterior (AP) directions Direction LAT Parameter VCP ACP AP VCP ACP LAT SI VCP SI ACP AP SI VCP SI ACP WBA F(2.29. 07) = 0.29 F(1.72 À4.13. Remarkably.46 À11.45 F(4.93 0. During all visual feedback tasks.12 F(2.92. Participants were forced.83 F(2.96 F(4.23) = 0.89 0.16 137.31 p-Value 0.23 0.45 var (eit) 924. in the frontal plane (a) and the sagittal plane (b) for the different degrees of weightbearing asymmetry (WBA).97. 34. For SI VCP.49 F(2.43) = 0. PROC MIXED determined that there was no signiﬁcant difference between the three estimated models. 46. 41. 52.57) = 0. 2a).01 <0. 42.38.69 0. 52. expressed as the symmetry index (SI) of the RMS of the CP velocities (VCP) under each foot separately.90.25 0.49) = 0. 38. Discussion The purpose of this study was to examine the intraindividual relationship between weight distribution and postural stability during standing in healthy subjects.28) = 1. For VCP in AP direction.13.87 166.67) = 1.21 F(2. For VCP in LAT direction.38.44 F(2.62 152. Results demonstrated that the postural strategy changed during quiet upright standing with visual feedback compared to the situation without visual feedback.67 0. 47.60 F(2.81 0.90. 38. 72) = 1. the ﬁrstorder (linear) polynomial function was used to describe the relation in LAT direction (Table 3 and Fig.00 F(2.99 À0. 44. 44. The dashed line is the ﬁt of the model used. 07) = 0.23 F(4.L.81) = 1. Anker et al. 72) = 1.78 .188.8.131.52) = 15.64.23) = 0.80 0.87 WBA is weight-bearing asymmetry. the second-order polynomial function was used (Table 3 and Fig.91) = 0.35 F(2.28) = 0. 42.25 0.21 0.36 p-Value 0. 53. 72) = 0. Kinetic regulation asymmetry.45 0.64. Therefore.38 b2 – 0.31 F(1. 3a and b).47 0.49) = 1.48. thus.64 b1 3.55 F(4.046 – – b3 – – – – Variances var (bi) 1575.68 0. Table 3 Summary of the regression coefﬁcients and variances of the CP velocity (VCP) and the VCP symmetry indices (SI) in both the lateral (LAT) and antero-posterior (AP) directions Direction Parameter Coefﬁcients b0 LAT AP LAT AP VCP VCP SI VCP SI VCP 24.01 <0. 2b). 46.38 0.83 F(2.87 0.91) = 47. 72) = 54.66 0.C.28 WBA Â Side F(2.D. The solid line is the mean. 72) = 0. this led to a considerable increase in overall CP velocity (and.84 WBA Â Group Â Side F(2.56.67) = 5. 47.01 0.32.81) = 17.66 0. the subjects were mostly concentrating on their stability in this direction.27 128.54 F(4.41 0. ﬁrst-order polynomials were used in both AP and LAT direction (Table 3. 41.39 F(2. 41.32 F(2.41 F(4.72) = 0. 72) = 0.86 F(2.30 F(2.96 Â overall S.13 À8.
whereas CP velocity is frequency sensitive. this assumption still needs to be validated in a future study. . visual feedback of CP was provided. This indicates that a symmetric weight distribution between the legs during quiet upright standing provides optimal stability in subjects without neural control problems. indicating that the loaded leg became more active in the balance control. we were able to ﬁnd that WBA had a large effect on the VCP in the LAT direction. whereas sagittal-plane balance is primarily under the control of ankle mechanisms . The kinetic regulation activity of the loaded leg was always higher than of the unloaded leg. Apparently. The general destabilising effect of WBA has been reported previously [9. which is the main mechanism of postural control during normal biped standing in the frontal plane . which was mainly related to the 30% WBA condition. However. with a (linear) increment of 4% for each degree of WBA.21].13. particularly in the 30% WBA condition. Results showed that both overall kinetic regulation and regulation asymmetry increased with increasing weightbearing asymmetry. using the exact same experimental setup in which participants would also stand with various degrees of WBA. the VCP under the loaded leg increases which reﬂects the generation of compensatory ankle moments at this side. primarily controlled by the hip abductors and hip adductors.4% for each degree of WBA. by increasing the velocity of the CP displacements especially in the lateral direction. By using visual feedback and requiring speciﬁc degrees of WBA. The kinetic regulation asymmetry increases with increasing WBA. where frontal-plane balance is based on subtle weight shifts.. reﬂects the characteristics of progressive one-legged standing. Because the muscles of the unloaded leg lose their capacity to generate effective stabilizing ankle torques as a result of the unloading. requiring the least correcting actions. The results of the visual feedback tasks clearly show that postural stability is affected by weight distribution. Overall. this pattern of results seems in line with the characteristics of normal biped standing (i. Thus. It is possible that this condition already begins to reﬂect the characteristics of one-legged standing . patients with postural control problems due to lateralized diseases may have a different optimum of weight distribution between the legs. who reported that WBA induced a stronger increase in CP amplitudes for the unloaded support than for the loaded one.15]. despite the fact that from a biomechanical perspective symmetric standing would be optimal. the effects of WBA on postural stability in both planes are related to changes in the biomechanical constraints of upright standing and do not reﬂect changes in the neural control of posture. the hip loading/unloading strategy in the frontal plane is replaced by a primary ankle strategy in this plane which will cause a large increase in the lateral CP velocity under the supporting foot . whereas there was a smaller effect in the AP direction. Both the overall CP velocity and the asymmetry in CP velocity between the legs in both planes show the lowest values when 50% weight is born on each leg. As for the sagittal plane. / Gait & Posture 27 (2008) 471–477 feedback task. both planes of postural control are differently organized and controlled. The major advantage of this procedure was that we were able to apply standardized degrees of asymmetrical weight distribution. symmetrical loading provides the greatest biomechanical stability. Knowledge of the optimal . Indeed. Hence. As for frontal-plane balance. Particularly the higher frequencies within the CP ﬂuctuations reﬂect the stabilizing ankle torques. when standing on one leg. we assumed that the observed change towards a ‘‘tighter’’ postural control strategy as a result of visual feedback would be unaffected by the various degrees of WBA. CP amplitude is insensitive to changes in the mean frequency of regulation. In this approach. However. Although visual feedback modiﬁed the postural control strategy. in order to allow within-subjects comparisons for the effects of WBA on postural control. Several clinical studies have indicated that lateral CP velocities provide more information about the sensorimotor consequences of different lateralized diseases and show the best association with risk of falling [9. In other words. without having changed the values of the other coefﬁcients (b1 and b2).C. increasing WBA may increase the risk of falling. In conclusion. This is different from the work of Genthon and Rougier . the results suggest that the normal ankle strategy is largely maintained. without visual feedback). in our mathematical models.e. it was also found that CP amplitudes were larger on the loaded than on the unloaded side. Based on our results. In addition. during quiet upright standing in healthy adults. Nevertheless. but without visual feedback. A limitation of the present study was that during all weight-bearing asymmetry tasks. A similar change towards a more ‘‘tightened’’ postural control has been reported by Dault et al.15. postural stability decreases with increasing WBA. Anker et al. who found that young subjects were able to decrease the amplitude of their sway in either direction during upright standing with visual feedback involving an increase in frequency of their sway in either direction during upright standing with visual feedback. On the other hand. it must be concluded that the control of subtle weight shifts between the legs is increasingly less effective when one leg is progressively unloaded. with equal contribution of both feet. visual feedback is assumed to be responsible for the intercept (b0) being unequal to zero. this study aimed to determine the withinsubjects relationship between weight distribution on the one hand and postural control and control asymmetry on the other hand.476 L. we conclude that with increasing WBA the strong increase in asymmetry of the lateral VCP under each foot. This change in postural strategy seems to reﬂect a ‘‘tighter’’ (but not better) control of body sway in the LAT direction through more rapid alternations of the direction of the subtle weight shifts during quiet standing. Kinetic regulation asymmetry in AP direction increased by 1. there appeared to be some inﬂuence of WBA on AP postural stability. Apparently.
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