Functional Balance Measures Research Articles

Wii Fit Balance Intervention in Community-Dwelling Older Adults.

The purpose of this exploratory study was to investigate the impact of the Nintendo(®) Wii Fit™ (Nintendo of America, Redmond, WA) on functional and perceived balance measures in an older adult population over a 4- or 8-week program. Twenty-five participants (71.60±7.79 years old) from a local senior center played Wii Fit (balance games, hula hooping, and yoga) for 30 minutes 2 days per week in either a 4-week (n=16) or 8-week (n=9) program. An additional nine participants served as a control group. These participants were independent, community-dwelling healthy overweight older adults (mean body mass index, 27.19±4.99 kg/m(2)). Functional balance measures included the 8-foot time up-and-go, 30-second chair stands, and the Berg Balance Scale and perceived balance were measured using the following scales: Activities-specific Balance Confidence (ABC) Scale, Falls Self-Efficacy Scale, and the Activities of Daily Living (ADL) Scale. A paired t test showed significant changes pre-post program in the mean scores of chair stands, Berg Balance Scale, and ADL Scale for the 4-week participants. For the 8-week participants, significant differences were seen pre-post-program for the Berg Balance Scale, ABC Scale, and ADL Scale. There were no statistical change in the control group in the Berg Balance, ABC, and ADL Scales. The results of this study suggest that Wii Fit playing may be a vehicle for physical activity participation in the older adult population. It is necessary that research on the effects of exergaming on functional and perceived balance in the older adult population must continue.

Development of a Scale to Assess Avoidance Behavior Due to a Fear of Falling: The Fear of Falling Avoidance Behavior Questionnaire

A history of falls or imbalance may lead to a fear of falling, which may lead to self-imposed avoidance of activity; this avoidance may stimulate a vicious cycle of deconditioning and subsequent falls. The purpose of this study was to develop a questionnaire that would quantify avoidance behavior due to a fear of falling. This study consisted of 2 parts: questionnaire development and psychometric testing. Questionnaire development involved an expert panel and 39 residents of an assisted living facility. Sixty-three community-dwelling individuals with various health conditions participated in psychometric testing. Questionnaire development included the evaluation of face and content validity and factor analysis of the initial questionnaire. The final result of questionnaire development was the Fear of Falling Avoidance Behavior Questionnaire (FFABQ). In order to determine its psychometric properties, reliability and construct validity were assessed through administration of the FFABQ to participants twice, 1 week apart, and comparison of the FFABQ with other questionnaires related to fear of falling, functional measures of balance and mobility, and daily activity levels using an activity monitor. The FFABQ had good overall test-retest reliability (intraclass correlation coefficient=.812) and was found to differentiate between participants who were considered "fallers" (ie, at least one fall in the previous year) and those who were considered "nonfallers." The FFABQ predicted time spent sitting or lying and endurance. A relatively small number of people with a fear of falling were willing to participate. Results from this study offer evidence for the reliability and validity of the FFABQ and support the notion that the FFABQ measures avoidance behavior rather than balance confidence, self-efficacy, or fear.

Decreased Muscle Strength Relates to Self-Reported Stooping, Crouching, or Kneeling Difficulty in Older Adults

Bending down and kneeling are fundamental tasks of daily living, yet nearly a quarter of older adults report having difficulty performing or being unable to perform these movements. Older adults with stooping, crouching, or kneeling (SCK) difficulty have demonstrated an increased fall risk. Strength (force-generating capacity) measures may be useful for determining both SCK difficulty and fall risk. The purposes of this study were: (1) to examine muscle strength differences in older adults with and without SCK difficulty and (2) to examine the relative contributions of trunk and leg muscle strength to SCK difficulty. This was a cross-sectional observational study. Community-dwelling older adults (age [X+/-SD]=75.5+/-6.0 years) with SCK difficulty (n=27) or without SCK difficulty (n=21) were tested for leg and trunk strength and functional mobility. Isometric strength at the trunk, hip, knee, and ankle also was normalized by body weight and height. Compared with older adults with no SCK difficulty, those with SCK difficulty had significant decreases in normalized trunk extensor, knee extensor, and ankle dorsiflexor and plantar-flexor strength. In 2 separate multivariate analyses, raw ankle plantar-flexor strength (odds ratio [OR]=0.97, 95% confidence interval [CI]=0.95-0.99) and normalized knee extensor strength (OR=0.61, 95% CI=0.44-0.82) were significantly associated with SCK difficulty. Stooping, crouching, and kneeling difficulty also correlated with measures of functional balance and falls. Although muscle groups that were key to rising from SCK were examined, there are other muscle groups that may contribute to safe SCK performance. Decreased muscle strength, particularly when normalized for body size, predicts SCK difficulty. These data emphasize the importance of strength measurement at multiple levels in predicting self-reported functional impairment.

Psychometric Properties of Functional Balance Assessment in Children With Cerebral Palsy

Background. Children with cerebral palsy often suffer from a lack of balance compared with typically developing children. Because balance capacity is relevant to functional activities, reliable and valid functional balance measures are crucial for the pediatric clinical setting. Objective. This study examined the reliability and validity of 3 functional balance measures. Methods. Thirty children aged 60 to 142 months with Gross Motor Function Classification System (GMFCS) levels of I to IV were recruited. For test-retest reliability, the same physical therapist administered the Functional Reach Test (FRT), Berg Balance Scale (BBS), and Timed Up and Go (TUG) twice. For interrater reliability, the testing processes were video recorded and later scored by another therapist. For convergent validity, children with cerebral palsy received the Gross Motor Function Measures (GMFM), walking speed, and 10-second sit-to-stand test within 1 week and the results evaluated. Results. The 3 functional balance measures had excellent test-retest reliability (intraclass correlation coefficient [ICC] >0.95) and interrater reliability (ICC = 0.98-1.00). With regard to convergent validity, the BBS and the TUG were highly correlated with GMFM total score, walking speed, and the 10-second sit-to-stand test. The discriminate validity indicates that the FRT can distinguish children with cerebral palsy with different GMFCS levels, whereas the BBS total score and TUG failed to distinguish between children with cerebral palsy with GMFCS levels of I and II. Conclusion. The 3 functional balance measures are simple, valid, and reliable for examining children with cerebral palsy and are thus suitable for clinical practice.

Functional Balance and Dual-Task Reaction Times in Older Adults Are Improved by Virtual Reality and Biofeedback Training

Virtual reality (VR) training has been used successfully to rehabilitate functional balance and mobility in both traumatic brain injury (TBI) survivors and elderly subjects. Similarly, computer-based biofeedback (BF) training has resulted in decreased sway during quiet stance and decreased reaction times during a dual-task reaction time paradigm in elderly subjects. The objective of this study was to determine the effect of VR and BF training on balance and reaction time in older adults. Two groups of twelve healthy older adults completed 10-week training programs consisting of two 30-min sessions per week. VR training required that participants lean sideways to juggle a virtual ball. Participants in the BF group viewed a red dot representing their center of gravity on a screen and were required to move the dot to the four corners of the monitor. Measures of functional balance and mobility (Community Balance and Mobility Scale [CB&M]), sway during quiet stance, and reaction time during a dual task paradigm were recorded before training, as well as 1 week and 1 month after the end of the program. Both groups showed significant improvements on the CB&M, as well as decreased reaction times with training. Postural sway during quiet stance did not change significantly.

Tai Chi and Fall Reductions in Older Adults: A Randomized Controlled Trial

The authors' objective was to evaluate the efficacy of a 6-month Tai Chi intervention for decreasing the number of falls and the risk for falling in older persons. This randomized controlled trial involved a sample of 256 physically inactive, community-dwelling adults aged 70 to 92 (mean age, 77.48 years; standard deviation, 4.95 years) who were recruited through a patient database in Portland, Oregon. Participants were randomized to participate in a three-times-per-week Tai Chi group or to a stretching control group for 6 months. The primary outcome measure was the number of falls; the secondary outcome measures included functional balance (Berg Balance Scale, Dynamic Gait Index, Functional Reach, and single-leg standing), physical performance (50-foot speed walk, Up&Go), and fear of falling, assessed at baseline, 3 months, 6 months (intervention termination), and at a 6-month postintervention follow-up. At the end of the 6-month intervention, significantly fewer falls (n=38 vs 73; p=.007), lower proportions of fallers (28% vs 46%; p=.01), and fewer injurious falls (7% vs 18%; p=.03) were observed in the Tai Chi group compared with the stretching control group. After adjusting for baseline covariates, the risk for multiple falls in the Tai Chi group was 55% lower than that of the stretching control group (risk ratio,.45; 95% confidence interval, 0.30 to 0.70). Compared with the stretching control participants, the Tai Chi participants showed significant improvements (p<.001) in all measures of functional balance, physical performance, and reduced fear of falling. Intervention gains in these measures were maintained at a 6-month postintervention follow-up in the Tai Chi group. A three-times-per-week, 6-month Tai Chi program is effective in decreasing the number of falls, the risk for falling, and the fear of falling, and it improves functional balance and physical performance in physically inactive persons aged 70 years or older.

Tai Chi: Improving Functional Balance and Predicting Subsequent Falls in Older Persons

To determine whether improved functional balance through a Tai Chi intervention is related to subsequent reductions in falls among elderly persons. Two hundred fifty-six healthy, physically inactive older adults aged 70-92 (mean age +/- SD = 77.48 +/- 4.95), recruited from a local health system in Portland, OR, participated in a 6-month randomized controlled trial, with allocation to Tai Chi or exercise stretching control, followed by a 6-month postintervention follow-up. Functional balance measures included Berg balance scale, dynamic gait index, and functional reach, assessed during the 6-month intervention period (baseline, 3-month, and 6-month intervention endpoint) and again at the 6-month postintervention follow-up. Fall counts were recorded during the 6-month postintervention follow-up period. Data were analyzed through intention-to-treat analysis of variance and logistic regression procedures. Tai Chi participants who showed improvements in measures of functional balance at the intervention endpoint significantly reduced their risk of falls during the 6-month postintervention period, compared with those in the control condition (odds ratio (OR), 0.27, 95% confidence interval (CI), 0.07-0.96 for Berg balance scale; OR, 0.27, 95% CI, 0.09-0.87 for dynamic gait index; OR, 0.20, 95% CI, 0.05-0.82 for functional reach). Improved functional balance through Tai Chi training is associated with subsequent reductions in fall frequency in older persons.

Evaluation of postural stability in the elderly with stroke

Corriveau H, Hébert R, Raı̂che M, Prince F. Evaluation of postural stability in the elderly with stroke. Arch Phys Med Rehabil 2004;85:1095–101. Objective To compare clinical and biomechanical measures of balance in elderly stroke patients with those of healthy elderly people. Design Two-group comparison design. Setting Laboratory environment. Participants Fifteen poststroke patients and 15 healthy age-matched older adults (N=30). Interventions Not applicable. Main outcome measures The biomechanical variable COP-COM, which represents the distance between the center of pressure (COP) and the center of mass (COM) in terms of root mean square. The mean of 4 trials of the COP-COM variable for each test condition was used for statistical analysis. Furthermore, the different systems (sensory, motor, central processor) related to postural stability were evaluated. Results Statistical significance of the COP-COM variable was larger in the stroke group than in healthy subjects, in both the anteroposterior (AP) and mediolateral (ML) directions. Furthermore, statistically, stroke subjects showed amplitudes of the COP-COM variable that were significantly larger in the eyes-closed condition. The significant negative correlation demonstrated between COP-COM amplitude and the balance scales (Berg, Tinetti) indicated that the patients with larger COP-COM amplitudes had lower clinical balance score. Furthermore, correlation coefficient scores between COP-COM variables in both AP and ML directions and motor performance using Fugl-Meyer Assessment (ρ=−.53, ρ=−.51, respectively) and reaction time (ρ=−.53, ρ=−.44, respectively) were significant. Vibration (ρ=.41) and touch-pressure (ρ=.42) perception thresholds correlated significantly only in the AP direction. Conclusions Evaluating postural stability with COP-COM variable provided an accurate measure of postural stability in poststroke elderly people. Furthermore, postural stability in quiet stance, as measured by COP-COM amplitude, was related to functional measures of balance as well as physiologic factors relating to balance, such as visual conditions, lower-extremity peripheral sensibility, motor recovery, and simple reaction time.

Recovery of standing balance and functional mobility after stroke

Garland SJ, Willems DA, Ivanova TD, Miller KJ. Recovery of standing balance and functional mobility after stroke. Arch Phys Med Rehabil 2003;84:1753–9. Objective To examine the extent to which recovery of functional balance and mobility is accompanied by change in a few specific physiologic measures of postural control. Design Longitudinal prospective study. Setting Laboratory setting in Ontario. Participants Twenty-seven volunteers (age, 64.2±13.7y) undergoing 4 weeks of rehabilitation after stroke participated. At initial testing, patients were 32.7±18.4 days poststroke and exhibited a moderate level of motor recovery (lower-extremity and postural control, stages 3–4 on the Chedoke-McMaster Stroke Assessment Impairment Inventory). Interventions Not applicable. Main outcome measures Three functional measures (Berg Balance Scale, Clinical Outcome Variables Scale, gait speed) were assessed. Three physiologic measures (electromyographic data of hamstrings and soleus muscles bilaterally, postural sway, arm acceleration) were taken while subjects stood quietly on a force platform and while they performed a rapid shoulder flexion movement of the nonparetic upper extremity. Results After 1 month of rehabilitation, there was an overall significant improvement in all outcome measures (functional, physiologic). However, 10 patients failed to show any improvement in the electromyographic activation of hamstrings muscle on the paretic side in response to the rapid arm movement. These patients compensated by increasing the anticipatory activation of the nonparetic hamstrings. Conclusion After stroke, patients showed improvement in both physiologic and functional measures of balance and mobility over a 1-month period. We have identified some patients who may be using compensatory strategies to increase function. The factors that may predict those patients who are likely to use compensatory strategies awaits further study.

Lower-Extremity Muscle Force and Balance Performance in Adults Aged 65 Years and Older

Measures of postural control may be useful for determining fall risk in older people and for determining the outcomes of treatments aimed at improving balance. Commonly used tools measure the output of the postural control system. The purpose of this study was to determine the degree to which one component of postural control (muscle force) contributes to scores on 3 functional balance measures. Fifty community-dwelling volunteers between 65 and 91 years of age (mean = 74.82, SD = 6.11) participated. Based on their histories, 11 subjects were classified as being at risk for falling. Measures were the Berg Balance Scale (BBS), the Functional Reach Test (FRT), and the Timed Get Up & Go Test (GUG). The force generated by 12 lower-extremity muscle groups was measured using a handheld dynamometer. In the group reporting no falls, dorsiflexor and subtalar evertor force accounted for 58% of the score on the BBS, ankle plantar-flexor and subtalar invertor force accounted for 48.4% of the score on the GUG, and ankle plantar-flexor force accounted for 13% of the score on the FRT. Ankle dorsiflexor and hip extensor forces were lower in subjects reporting falls, and force of the ankle dorsiflexors predicted fall status. Distal muscle force measures may be able to contribute to the prediction of functional balance scores; however, the muscles involved in the prediction differ depending on the measure of balance.

Balance in the healthy elderly: posturography and clinical assessment.

To measure balance changes in the healthy elderly using quantitative dynamic posturography. To relate these changes to clinical measures of balance and gait. Elderly subjects screened for health criteria in a longitudinal study were examined using standardized cognitive, neurological, and performance-based tests. Quantitative posturography (Equitest, Neurocom International, Clackamas, Ore) was performed to determine the subject's response to sensory (Sensory Organization Test) and motor perturbations (Motor Coordination Test). Thirty-three healthy, old old subjects (> or =80 years; mean+/-SD age, 88+/-5 years) were compared with 15 subjects younger than 80 years (mean+/-SD age, 72+/-3 years). All were free of centrally active medications. The old old had worse quantitative equilibrium scores compared with subjects younger that 80 years when proprioceptive input was inaccurate and visual input was either preserved or completely absent. Old old subjects showed diminished adaptation to repeated platform rotations and fell more frequently during posturography. Quantitative balance measures correlated with age and functional measures of balance (Tinetti Balance Scale score, timed 1 leg standing). Progressive, functionally evident, age-related quantitative balance changes occur independent of typical geriatric pathological changes. These data should facilitate clinical decisions by allowing the distinction to be made between age-related and pathological changes.

Functional Assessment of Balance and Gait

Individuals must be able to maintain an upright posture under a variety of conditions and to move independently. These constructs of balance and gait are fundamental components of physical functioning and should be incorporated into clinical assessment of older adults. The primary objective, therefore, is to review existing measures of functional balance and gait, concentrating on those which are quantitative, practical for use in clinical settings, and have demonstrated acceptable measurement properties. In addition, we discuss the rationale for the functional assessment of balance and gait, review essential measurement criteria, and discuss the utility of valid standardized measurement in clinical practice.