Journal of Bodywork & Movement Therapies 35 (2023) 337–341

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Comparison of sway meter and Kinovea software as a tool of measurement

for the sway parameters during quiet standing: An observational study
Muhammed Rashid a, *, Sherin Siby b, Jerin Mathew c, d, Sayed Asif Basha a, Kavitha Raja a
a
JSS College of Physiotherapy, Mysuru, Karnataka, 570004, India
b
Physical Medicine and Rehabilitation, Zale Lipshy Pavillion – William P. Clements Jr. University Hospital, University of Texas, Southwestern, Medical Centre in Dallas,
Texas, USA
c
Centre for Health, Activity, And Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
d
Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand

A R T I C L E I N F O A B S T R A C T

Handling Editor: Dr Jerrilyn Cambron Background: Several attempts have been made to quantify postural sway, from simple observational techniques to
advanced computer technology. Measuring sway using commercial motion tracking devices and force plates are
Keywords: expensive and not feasible in evaluation on non-standardised surfaces. Video cameras can be used as an
Ambulation affordable alternative to perform human motion capturing, and this data can be analysed using motion tracking
Balance
software like Kinovea; a free, reliable software that provides valid data, and an acceptable level of accuracy in
Falls
angular and linear measurements. This study evaluated the reliability of Kinovea software to measure the sway
Postural sway
Uneven terrain balance amplitude in comparison with sway meter.
Methods: Thirty-six young women were recruited by convenience to this prospective observational study. Sway
amplitude of the participants were measured using a sway meter on three different surfaces, with eyes opened
and closed conditions, using modified Lords sway meter and videography. Videos were later analysed using
Kinovea motion analysing software. The quantitative data of sway parameters were analysed for reliability using
intraclass-correlation co-efficient and Bland Altman plot.
Results: There was an excellent correlation (>0.90) between the sway measurement values obtained from both
methods irrespective of the surfaces. But the reliability was greater for the medio-lateral sway on the pebbled
surfaces (0.981), and least for the anterior posterior sway on the same surface.
Conclusion: This study concludes that, there is an excellent reliability for the video based sway analysis using
Kinovea software. Hence this method can be used as an affordable alternative to measure the sway parameters.

1. Introduction
Posture is the orientation of the body in space that is accomplished
by the control of the body parts by skeletal muscles with respect to each
other and gravity. Postural sway is the small continuous range of
postural shifts that an individual exhibit typically during standing, and it
has a crucial role in postural control, the ability to maintain the centre of
mass (COM) within the base of support with minimal postural sway
(Carini et al., 2017; Stevens and Tomlinson, 1971). Sway parameters
during quiet standing have been used as an indicator of postural control
and the risk of falls, hence measurement and documentation of sway is
important for health care workers (Pavol, 2005).
Postural sway during human quiet standing can be quantified by
tracking the position of the centre of pressure (CoP) using the principles
of a single inverted pendulum model (Yamamoto et al., 2015). Several
attempts have been made to quantify postural sway, from simple
observational techniques to advanced computer technology. These
include postural grid, Lord’s sway meter, inclinometer, and sophisti­
cated technologies like posturography (Ramachandran and Yeg­
naswamy, 2010). However, measuring sway using commercial motion
tracking devices and force plates are expensive and not feasible in
evaluation on non-standardised surfaces. Video cameras can be used as
an affordable alternative to perform human motion capturing, and this
data can be analysed using motion tracking software like Kinovea; a free,
reliable software that provides valid data, and an acceptable level of
accuracy in angular and linear measurements (Allin et al., 2008; Mathew

* Corresponding author.
E-mail addresses: rashidkpvld@gmail.com (M. Rashid), jerin.mathew@otago.ac.nz (J. Mathew).

https://doi.org/10.1016/j.jbmt.2023.04.082
Received 26 May 2021; Received in revised form 19 April 2023; Accepted 19 April 2023
Available online 22 April 2023
1360-8592/© 2023 Elsevier Ltd. All rights reserved.
M. Rashid et al. Journal of Bodywork & Movement Therapies 35 (2023) 337–341

et al., 2017; Puig-Diví et al., 2019; Rashid et al., 2021a,b).

In most low and middle-income countries, surfaces used for ambu­
lation are often of varying textures, including loose-packed surfaces like
sand and pebble. Hence the ability to maintain postural balance is even
more crucial while walking on such uneven terrain as it is a necessary
part of participation. Negotiating such surfaces requires greater postural
control and higher level of coordination (Travers et al., 2018). The
evaluation of sway during outdoor ambulation on uneven surfaces
cannot be performed using force plate. Therefore, this study was
attempted to use videography as an alternate easy method to document
the sway parameters in varying terrains of texture for ambulation. This
study aims to compare the sway amplitudes obtained using Kinovea
software and modified lords sway meter on various surfaces.

2. Methods Fig. 1. The study area preparation for sway measurement on even surface.

The sample size estimation was carried out based on the available
Session 2: Mobile phone (Honor 10 Lite) with a camera resolution of
evidence and recommendations for conducting a reliability study
1080 × 2160 pixels (13 megapixels) was placed orthogonally above the
(Shoukri et al., 2004; Shieh G, 2014). Considering a minimally accept­
pen attached to the sway meter at a distance of 3 m from the ground. The
able Intraclass Correlation Coefficient (ICC) (pH0) of 0.6, an expected
participants were requested to stand with normal footwear and feet
ICC (pH1) of 0.78, with 80% power required a minimum number of 35
three inches apart; hands by their sides; eyes open. The camera placed
participants and the study has completed with 36 healthy young women.
axially recorded the path transcribed by the pen. The initial 6 s are not
The sample size computation was carried out using the G*power 3.0.10
considered to eliminate the initial accelerative motion artifact. Mea­
software (test family: exact; statistical test; correlation-bivariate normal
surements were taken first on even surface, followed by the pre-
model) with the afore described input parameters (Faul et al., 2007).
constructed uneven surfaces. Three trials of videos were recorded with
Individuals with cardio-respiratory, neurological, or any other sys­
a duration of 30 s for each video. One minute of rest was provided be­
temic illness and individuals with any musculoskeletal disorder such as
tween each trial. Participants were excluded from the study if they failed
arthritis and lower limb fracture or those who had recent lower limb
to complete 30 s of standing. Continuous monitoring was provided to
surgery, individuals with any balance and coordination disorder, ankle
ensure safety. A known distance within the area of video coverage was
instability, or under any medication other than over the counter (OTC)
identified and documented for the calibration of the linear measure­
drugs which is known to affect balance and coordination were excluded
ments during analysis.
(Ramachandran and Yegnaswamy, 2010). Written informed consent
Both session 1 and 2 were performed on even surface, sand and
was obtained from recruited participants. The study protocol and con­
pebbled surface.
sent form were reviewed and approved by the institutional research
committee of JSS College of Physiotherapy (IRC-JSSCPT) prior to the
3. Data processing and analysis
commencement of the study (IRC-JSSCPT/23/05/2018). All procedures
performed in accordance with the ethical standards of the institutional
Session 1: The pen in sway meter was used to record participant’s
and/or national research committee and with the 1964 Helsinki decla­
postural sway on a sheet of graph paper which was placed over the
ration and its later amendments or comparable ethical standards (As­
adjustable table. The markings were measured using a scale and
sociation, 2013). The study was reported following the STrengthening
recorded.
the Reporting of OBservational studies in Epidemiology (STROBE)
Session 2: The recorded videos were exported to the Kinovea soft­
guidelines (Vandenbroucke et al., 2014).
ware (version 0.8.25). Frames per second (fps) of the software was
A spacious hall with adequate light was chosen as the study setting to
adjusted with the fps of the camera. Each individual’s video was im­
facilitate video recording. In order to simulate an uneven surface, a
ported separately, and slow-motion feature was used to improve the
platform of 2 × 2 (4 square feet) was constructed with sand and pebbles
visualisation of the motion of the pen (sway amplitude). The tip of the
(Rashid et al., 2020, 2021). A familiarisation process was conducted for
pen was highlighted using the ‘marker tool’ to improve the accuracy of
all the participants before the commencement of data collection. The
tracking. The initial point marked by the tip of the pen was considered as
transfer belt was fastened to the participants’ lumbosacral region to
the centre of the path and starting point. The video frame was calibrated
ensure safety during the test procedures. The test was divided in to two
by providing a reference input of a known distance during video
independent sessions.
recording. The stopwatch function was activated to set the stance
Session 1: The modified Lords sway meter, a device with a rigid 40
duration to 30 s ‘Track path’ function was used to track the tip of the pen
cm long rod with a vertically mounted pen at its end, connected to a 20
for the entire duration of the video, and the resulting image of the path
cm wide metal plate, was fixed at the posterior superior iliac spine (PSIS)
circumscribed by the tip of the pen was used for analysis. Based on the
level of the participant using a firm belt (Ramachandran and Yeg­
starting point as a reference, the outermost points in anterior, posterior,
naswamy, 2010; Rashid et al., 2021). Participants were asked to stand
medial, and lateral directions were identified and marked using the line
with a three-inch distance between feet. A height adjustable table was
tool. The farthest points in each direction pair (AP/ML) were computed
placed behind the individual and a graph paper was kept on it in such a
as the maximum amplitude. To confirm the farthest point when multiple
way so that, the rod of the sway meter was maintained in horizontal
points were close together, repeated analyses were undertaken in all
position when starting the measurement. Graph sheet was secured to
directions. Fig. 2 shows a representative figure of the sway analysis
prevent displacement while taking measurement. The height of the table
using Kinovea software.
was adjusted according to the height of the participant. Participants
Statistical analysis: The data analysis was performed based on the
were allowed to stand still with footwear; hands by their sides; eyes open
guidelines and recommendations for reliability studies (Koo and Li,
on even surface first and followed by the pre-constructed uneven sur­
2016; Steiner et al., 2011). Intra class correlation co-efficient (ICC) and
face. The markings on the graph paper was measured and documented.
Bland Altman plot were considered while comparing the two methods to
The participant and study area preparation for sway measurement on
demonstrate consistency across multiple measures of reliability
even surface is given in Fig. 1.

338
M. Rashid et al.
Fig. 2. The representative figure of the sway analysis using Kinovea software.
(correlation and agreement). Between subject variation was measured
using ICC estimates, and their 95% confident intervals were calculated
using SPSS statistical package version 23 (SPSS Inc, Chicago, IL) based
on a mean-rating (k = 3), absolute-agreement, 2-way mixed-effects
model. The extent of agreement (how closely the measured values
concur between two methods or difference between two measurements)
was measured using Bland Altman plot (Bunce, 2009). The Bland Alt­
man plot of bias (mean difference between two methods) was graphi­
cally constructed using the Bland Altman plot tool on the GraphPad
Prism version 9.1 for Windows (GraphPad Software, San Diego, Cali­
fornia USA). The upper and lower limits of agreement were drawn at
1.96 standard deviations (of observed inter-observer differences) above
and below the line representing the mean difference (solid line); these
dotted lines are expected to enclose 95% of the observed inter-observer
differences (Ranganathan P et al., 2017).
4. Results
Participant’s demographic information are given in Table 1. Two
participants were excluded from the study as their sway amplitude was
much greater compared to others (sway amplitude on a level surface
with eyes open was more than 8 cm). Correlation of sway amplitude
measurements obtained from sway meter and Kinovea software are
given in Table 2.
There was an excellent correlation (>0.90) between the sway mea­
surement values obtained from both methods irrespective of the sur­
faces. The correlation was greater for the medio-lateral sway on the
pebbled surfaces and least for the anterior posterior sway on the same
surface. The Bland Altman plot presented in the Fig. 3 shows the
agreement among the sway measurements obtained from sway meter
and Kinovea software. In Fig. 3, the Y axis shows the difference between
the two paired measurements (sway amplitude obtained from Kinovea
software-sway amplitude obtained from sway meter) and the X axis
represents the average of the sum of these measures ((sway amplitude
obtained from Kinovea software + sway amplitude obtained from
swaymeter)/2). It is clear from the graph that there was good agreement
between the two methods of sway measurements on all surfaces (level,
sand, pebbles) as most of the points are within the 95% CI of the mean
Table 1
Participant demographics (n = 36).
Variables Participants (n = 36)
Age (years) a
21.73 ± 2.04
BMI (kg/m2)a 19.03 ± 1.33
BMI- Body mass index.
a
Mean ± SD.
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Journal of Bodywork & Movement Therapies 35 (2023) 337–341
Table 2
Correlation of sway amplitude obtained using Kinovea software and modified
sway meter.
Variables Intraclass correlation co- 95% Confidence interval
efficient
Upper Lower
bound bound
Even surface AP 0.961 0.939 0.976
sway
Even surface ML 0.976 0.962 0.985
sway
Sand surface AP 0.974 0.958 0.983
sway
Sand surface ML 0.964 0.944 0.978
sway
Pebbled surface AP 0.957 0.93 0.973
sway
Pebbled surface ML 0.981 0.970 0.988
sway
AP- Anterior-posterior, ML- Medio-lateral, CI- Confidence interval.
difference between the two methods. The mean difference and 95%
confidence interval of the mean difference of each method on various
platform is given in Table 3. The medio lateral sway amplitude on
pebbled platform showed less variability between measures as most of
the values are clustered around the mean difference (mean difference
0.02 (0.0,0.04). The mean difference between ML sway amplitude on
pebbled surface was higher, 0.07 (0.05,0.09).
5. Discussion
A good control of the body is the primary goal of the vestibular and
balance system. Sway meter provides an indirect measurement of the
amount of sway exhibited by a person during static or dynamic state.
However, the measurement using traditional sway meters like Lord’s
sway meter can be cumbersome due to the contextual and environ­
mental factors like the outdoor ambulation, various modes of terrains
and inconsistency in the recorded trace from the sway meter. Due to
these issues and practical difficulties of using traditional methods raises
the need for a simple and reliable method for measuring postural sway.
Additionally, overcoming the difficulties of using traditional sway me­
ters, the mode of measurement needs to be feasible, reliable, cost
effective and easy to use and analyse. The use of smartphones and its
features are steadily used in clinical practice for various purposes
including gait analysis, documentation, and clinical examinations
(Finkbiner et al., 2017; Moore and Jayewardene, 2014). Technological
advancement has also improved the capabilities of video recording and
analysis using smartphones in health care sector (Hunt et al., 2021). This
has also increased the release and availability of low cost/freely avail­
able motion analysing software’s that could potentially be used to assess
sway, and Kinovea is one of these easily accessible software.
The purpose of this study was to examine the reliability of video-
based sway analysis using Kinovea software comparing with the tradi­
tional modified Lord’s sway meter. Correlation is not synonymous with
agreement, and therefore we used both agreement (Bland Altman plot)
and correlation (ICC) analysis. The results obtained using Kinovea
software demonstrated an excellent correlation (r > 0.95) between
Kinovea software and sway meter in all terrains. However, the reliability
was greater for the medio-lateral sway on pebbles (r = 0.981), and least
for the anterior posterior sway on the same surface (r = 0.957). Subse­
quent analysis of Bland-Altman statistics demonstrates a meaningful
measurement agreement between two methods consistent with the ICC
values. However, the medio lateral sway amplitude on pebbled platform
showed less variability between measures, as most of the scatters are
close to the mean difference, and the mean difference between ML sway
amplitude on pebbled surface was higher. Though the reason for this
difference is unclear, the authors hypothesise that it is possible that due
to the greater instability experienced on pebbles, participants may have
M. Rashid et al. Journal of Bodywork & Movement Therapies 35 (2023) 337–341

Fig. 3. The bland Altman Plot of the sway measurements on various surfaces.

can be used as an affordable alternative to measure the sway parameters

Table 3
in clinical and research environment.
Comparison of difference between two methods.
Kinovea Sway Mean Confidence interval
CRediT authorship contribution statement
meter difference
Lower Upper
bound bound
Muhammed Rashid: Conceptualization, Methodology, Software,
Even AP 2.65 2.69 0.04 0.02 0.06 Investigation, Writing – original draft, Project administration. Sherin
surface ML 2.27 2.87 0.6 0.5 0.07 Siby: Methodology, Software, Investigation, Writing – original draft,
Sand AP 3.03 3.08 0.05 0.04 0.06
surface ML 2.65 2.72 0.07 0.05 0.09
Project administration. Jerin Mathew: Resources, Software, Supervi­
Pebbled AP 3.22 3.28 0.06 0.05 0.07 sion, Writing - review & editing. Sayed Asif Basha: Supervision, Writing
surface ML 2.84 2.86 0.02 0.0 0.04 – review & editing. Kavitha Raja: Supervision, Writing – review &
AP - Anterior-posterior, ML- Medio-lateral.
editing, Resources, Conceptualization.

been more conscious due to which cognitive systems may have played a
part and this might account for the decreased sway. These results sug­
gest that Kinovea software can be incorporated in the measurement of
sway along with the sway meter. Postural stability is an important
domain to assure safe mobility and activities of daily living. Thus, an
assessment of sway parameters is an important construct in balance
assessment for both diagnostic and therapeutic purposes in clinical
practice (Lajoie and Gallagher, 2004). Our study adds to the growing
literature for comprehensive clinical assessment of balance using a
simple and feasible method.
Our findings should be interpreted with consideration of the study’s
limitations. One of the challenges of using the traditional Lord’s sway
meter is the difficulty in measuring the sway amplitude from the pencil
tracing on the graph paper. This difficulty can be controlled in this study
by using video recording and analysis using Kinovea. Using Kinovea
alone to measure sway is difficult as identification of starting and end­
points becomes a challenge. Hence, we believe that using the sway meter
for tracing and the software for accurate measurement will help to
overcome these challenges. The results of this study are limited to quiet
standing and cannot be extrapolated to the dynamic activity. This needs
to be considered as one of the objectives for future studies.
6. Conclusion
This study concludes that, there is an excellent reliability for the
video-based sway analysis using Kinovea software. Hence this method
Declaration of competing interest
The Authors declare that there is no conflict of interest.
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