Briggs Tandem SLS 1989

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surpassed falls as the most frequentcause of accidental death in theUnited States.7 Injury to elderly individuals secondary to a fall m ay resultin a decrease of their quality of life,permanent limitation of their activities, or death.8 Unfortunately, thoseindividuals who have fallen once areprone to fall again.3

Many anatomical and physiologicalchanges have been suggested as reasons for the decrease in equilibriumfound in the elderly po pulation.9-11

Abnormalities have bee n identified inboth the central and the peripheralnervous systems.12-15 Circulatorychanges (eg, atherosclerosis) mayreduce b lood flow to the brain stem,cerebellum, or cerebrum, potentiallyresulting in ischemic signs and symp

toms or lesions of the nervoussystem.13 Musculoskeletal abnormalities in the cervical region may affectthe perception of the head's positionin space.16 Muscle atrophy and weakness, especially of the postural muscles, are prevalent in the aged.17-20

Numerous pathological conditionshave been linked to balance problems. Inner ear or vestibular disorders, neurologic disease processes or

injuries, and hy pertension or circulatory problems are recognized as factors that can contribute to disequilibrium.21 The increased use ofand sensitivity to prescription medications by the elderly population makesthem m ore susceptible to adversedrug reactions and interactions, whichcan resu lt in dizziness, loss of balance, and falls.22

Tests used to evaluate the ability of a

subject to maintain balance weredeveloped as early as 1851 (ie, theRomberg test).23 Since that time, awide variety of balance tests and theirmodifications have been used. In theoriginal Romberg test, the subjectsstood with their feet close together.The examiner observed the amountof body sway exhibited by the subjects, first as the subjects stood withtheir eyes open and then with theireyes closed.

The one-legged stance test (OLST),also referred to as the Solec test, andthe sharpened Romberg test (SR)have been used as substitutes for theRomberg test by some clinicians.

11

The OLST requires the subject tomaintain balance while standing onone leg, whereas the SR requires thesubject to maintain balance while

standing in a tandem heel-to-toeposition.11

The OLST is more difficult for thesubject to perform than either the SRor the Romberg test because of thedecreased area of weight bearing andthe narrowed base of support.11

Developmentally, the test position forthe SR is generally considered a moreprogressive posture requiring ahigher skill level than the Romberg

test position.24

Previous studies haveused a maximum testing period of 30seconds for the OLST and 60 secondsfor the SR and the Romberg test.9,11

Although numerous standing balancetests are currently used to determinebalancing abilities, data regarding theelderly population's performance onthese tests are scarce and incomplete.Some studies have examined thedecline of equilibrium accompanying

aging, but descriptive information isnot available for each specific test.

9'10

The purposes of this study were to1) collect balance data on healthy,elderly w omen using two static balance tests; 2) determine the relationship between the balance times andfalls; and 3 ) determ ine the effect ofwearing shoes on balance. Evaluationof these data could lead to a betterunderstanding of the balance reac

tions of elderly women and m ay assistin the development and analysis oftreatment programs to improve balance and prevent falls.

Four research hypotheses wereposed. First, a difference would befound between the propo rtion of subjects able to reach maximum balancetimes for the SR and the OLST. Second, balance time would decrease asage increases among the elderly.

Third, a negative relationship existsbetween a history of falls and balance

time. Fourth, wearing shoes wouldaffect balance time.

Method

Subjects

Healthy, female subjects between 60and 86 years of age were recruited

from local church groups, sen ior citizen centers, The U niversity of Birmingham at Alabama, retirement apartmentcomplexes, and nutrition centers inthe community. Subjects had to beindep endent in activities of daily livingand able to walk without an assistivedevice. Volunteers with serious musculoskeletal problems (eg, joint replacement, fracture, or surgery) within thepast year, Parkinson's disease, cerebrovascular accident, or multiple scle

rosis we re no t included in the study.Participants read and signed a voluntary consent form approved by theInstitutional Review Board for HumanUse at The University of Alabama atBirmingham. Medical information(including the number of falls withinthe past year and medical history) waselicited verbally from the subjects.

Measurement

A digital stopwatch was used to conduct the timed trials of the balancetests. Subject height and weight weremeasured by the primary investigator(RCB), as were shoe heel height, shoesole thickness at the first metatarsalhead, and shoe heel width and length.The am ount of visible shoe w ear wasestimated as "none," "minimal," or"badly worn." The Harris test was usedto evaluate lower limb dominance.

25

Procedure

During all tests, subjects w ereinstructed to keep their arms by theirsides. If the subjects began to m ovetheir arms to regain balance, theywere instructed to return them totheir sides. The primary investigatordemonstrated each test position forthe subjects prior to testing. Subjectswere given an opportunity to practiceeach test twice before timed trials

began. Subjects who requested helpto assume testing positions were per-

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mitted to use the investigator's arm tosteady themselves prior to starting thetimed trials. No instructions weregiven regarding the subjects' kneeposition or visual fixation. All testingwas performed on level vinyl flooring.

The balance tests performed were theSR and a modified OLST. The SR was

performed in a heel-to-toe standingposition with the dominant footbehind the nondominant foot. Timingwas started after the subjects hadassumed the proper posit ion andindicated that they were ready tobegin. Timing was stopped if the subjects moved their feet from thepro per position, if they opene d theireyes on the eyes-closed trials, or ifthey reached the maximum balancetime of 60 seconds. Three trials were

performed if the maximum balancetime was not reached in either of thefirst two trials. The longe st balancetime of the recorded trials was usedfor the data analysis.

The OLST also was performed in thestanding position with the subjects'arms by their sides. Timing wasstarted when the subjects raised theappropriate foot off the ground. Timing was stopped if the subjects dis

placed the foot they were standingon, touched the suspended foot to theground, used the suspended foot tosupport the weight-bearing l imb, orreached the maximum balance t imeof 45 seconds. Three trials were performed if the maximum balance t imewas not reached in either of the firsttwo trials. The longest balance time ofthe recorded trials was used for thedata analysis.

Most clinicians use a maximum balance time of 30 seconds for the OLSTand we also defined the maximumbalance time for the OLST as 30 seconds for the purposes of this study.We continued recording OLST balance t ime to a maxim um of 45 seconds, however, to provide a moreaccurate statistical calculation of theme an OLST time. By using a 45-second limit for the OLST, weexpected that less of a ceiling effect

would be observed (in mean balancetime calculations) and that a more

normal distribution of balance timeswould be gathered.

The subjects performed each test firstwith their eyes open and then withtheir eyes closed. All tests were performed in both the shoes-on andshoes-off conditions. Halfway throughthe balance testing, a five-minute

break was permitted while subjectschanged shoes-on-shoes-off conditions. Subjects were permitted to restbetween trials or tests as desired. Oneinvestigator stood near the subject atall times to prevent falls attributableto loss of balance.

The order of the balance testsequence was random. Four tes tsequences were possible: 1) SR,right OLST, left OLST; 2) SR, left

OLST, right OLST; 3) right OLST,left OLST, SR; and 4) left OLST,right OLST, SR. Each sequencecould be performed starting eitherwith or without shoes. Test resultswere la ter regrouped and analyzedaccording to foot dominance insteadof right or left OLST conditions.

Two examiners (RCB, SAS) collecteddata for this study. To examine inter-tester reliability, these tw o exam iners

simultaneously timed one subject,who simulated loss of balance, for 25trials (for both tests in various conditions). The Pearson product-momentcorrelation (r) for these 25 pairedtimes was .99.

Data Analysis

Data were analyzed using the statistical analysis system (SAS-PC) computerprogram.26 Subjects were stratified by

age in five-year increments. We examined balance times and the percentage of subjects reaching maximumbalance times within groups by age,number of falls, open-eyes or closed-eyes conditions, and shoes-on orshoes-off conditions. The longest balance time for each condition wasused for the data analysis. A two-wayanalysis of variance (ANOVA) wasused to compare the mean balancetimes of those subjects w ho had fallen

with the mean balance times of allsubjects in their age grou p. A Tukey

multiple range test was used separately on each test to evaluate meanbalance time versus age.26 Shoes-on,shoes-off, eyes-open, and eyes-closedrelationships to mean balance timeswere also evaluated by a Tukey multiple range test.

Results

Two of the 73 participants in thisstudy were unable to comp lete testingbecause of medical problems andwere eliminated from the subjectpool: One subject experienced backpain during the SR, and the othersubject experienced pain duringshoes-off balance testing as a result ofa plantar wart. Thus, a total of 71 subjects completed the testing.

The mean age for all subjects was72.25 years (s = 6.97). Subjects weredivided into five groups according toage. The subjects in Group 1 (n = 14)we re aged 60 to 64 years ( = 62.79,s = 1.31), those in Group 2 (n = 13)we re aged 65 to 69 years ( = 67.08,s = 1.55), those in Group 3 (n = 16)we re aged 70 to 74 years ( = 72.00,s = 1.51), those in Group 4 (n = 16)were aged 75 to 79 years ( = 77.44,s = 1.26), and those in Group 5

(n = 12) were aged 80 to 86 years( = 8 2 . 3 3 , 5 = 1.87).

Eleven subjects were left-foot dominant. The OLST results wer e analyzedaccording to right-leg stance, left-legstance, dominant-leg stance, andnondominant-leg stance (p ≤ .05).

Subjects wore a wide variety of shoestyles. Adjusted heel heights (heelheight minus sole thickness measured

at the first metatarsal head) variedfrom 0.0 to 5.9 cm. Greater than 90%of the subjects had an adjusted heelheight of less than 3.8 cm.

When results of the eyes-open OLST(for all ages) were plotted on a graph,maximal balance times fell into threegeneral clusters. Approximately onehalf of the subjects had maximal balance times of less than 15 seconds.The remainder of the subjects' maxi

mal balance times on this test fell intotwo fairly equal groups. The first

48 / 750 Physical Therapy/Volume 69, Number 9/September 1989







T a b l e 1 . Balance Time Means and Standard Deviations (in Seconds) by Age Group Using Best Trial Time of Three Trials

G r o u p a

1

2

3

4

5

All groups

Test Condit ion

S Rb/S O

c/E O

d

5 6 . 3 7

5 5 . 9 3

48.61g

3 9 . 6 5 g

4 5 . 4 9

4 8 . 9 4

s

13.59

14.67

19.81

2 1 . 8 0

21.08

19.21

SR/SO/EC e

24.58

31.58

24.19

14.13

21.71

2 2 . 9 3

8

20.97

24.82

23.52

14.19

22.12

21.41

SR/SF f/E O

56.41

5 4 . 1 3

49.54

42.96

42.39

4 9 . 0 5

s

13.42

16.26

19.67

24.55

26.09

2 0 . 7 3

SR/SF/EC

3 9 . 9 82 9 . 8 6

3 0 . 2 6g

13.99g

2 1 . 6 6

2 6 . 9 8

s

23.312 4 . 9 3

24.59

18 .56

21.50

23.76

Group

1

2

3

4

5

All groups

Test Condit ion

D-OLST h/SO/EO

3 8 . 4 8

24.31g

18 .46 g, i

10.81 g,i '

10 .65 g, i

2 0 . 4 3

s

11.56

16.79

14.85

11.80

11.33

16.64

D-OLST/SO/EC

5.74

4.27

3.68 g

2.34 g

2.80g

3.75

s

4.21

2.10

2.10

1.05

1.72

2.68

D-OLST/SF/EO

38.11

2 8 . 3 3

2 0 . 1 5g

9.71g,i

12.33g, i

21.52

s

12.99

17.89

16.00

10.39

11.50

17.19

D-OLST/SF/EC

7.73

6.17

4 . 0 8 3

2.82g, i

2.76g, i

4.68

s

5.02

4.84

2.86

1.21

1.93

3.89

G r o u p

1

2

3

4

5

All groups

Test Condit ion

N-OLST J/SO/EO

3 4 . 1 3

2 3 . 8 8

19.603

11.97 g

10.17g, i

19.94

s

14.02

18 .56

16.61

12.95

12.23

16.98

N-OLST/SO/EC

8.33

4.493

2.823

3.213

2.743

4.29

s

5.89

3.55

1.09

1.76

1.83

3.81

N-OLST/SF/EO

3 7 . 7 8

25.713

19.843

10.753 g, i

13.023'''

21 .25

s

13.86

18 .56

18 .03

12.92

13.87

18 .06

N-OLST/SF/EC

9.90

4.763

3.973

2.723

2.933

4 . 8 3

s

8.68

3.83

3.33

2.05

1.33

5.20

group of balance times was distributed evenly between 15 and 44 seconds, and the second group represented those balance times arbitrarilytruncated at the 45-second cutoff time.

Of the 71 participants who completedtesting, 19 reported falling at leastonce within the previous year. Onesubject had fallen four times, 2 hadfallen three times, 5 had fallen twice,and 11 had fallen once. When their

mean balance times were comparedwith the mean balance times of thosesubjects of the same age group whohad not fallen, no statistically significant difference was found betweenthe performance of those who hadfallen and those who had not fallen.

The mean balance times for the entiresample and for each of the five agegroups are provided in Table 1. Forthe SR in the eyes-open-shoes-on and

eyes-closed-shoes-off test conditions,the mean balance times for subjectsin Groups 3 and 4 were significantlyshorter than those for subjects inGroup 1 (p ≤ .05); however, no further differences according to agegroup were observed for the othertwo conditions of the SR A Tukeymultiple range test revealed thatmean balance times for Group 1weresignificantly longer than those for

aGroup 1 (n = 14) = subjects aged 60-64 years; Group 2 (n = 13) = subjects aged 65-69 years; Group 3 (n = 16) = subjects aged 70-74 years;Group 4 (n = 16) = subjects aged 75-79 years; Group 5 (n = 12) = subjects aged 80-86 years.bSR= sharpened Romberg test.

cSO = shoes-on test condition.dEO = eyes-open test condition.eEC = eyes-closed test condition.fSF = shoes-off test condition.

gMean balance times are significantly shorter than Group 1 (p ≤ .05).bD-OLST = one-legged stance test (dominant leg).

'Mean balance times are significantly shorter than Group 2 (p ≤ .05).jN-OLST = one-legged stance test (nondomina nt leg).

Physical Therapy/Volume 69, Number 9/September 1989 7 5 1 / 4 9







Groups 3 , 4, and 5 for all conditionsof the OLST (p≤ .05).

Table 2 lists the percentages of subjects reaching maximum balancetimes according to age group and testcondition. Twice as many subjectsreached m aximum balance times onthe SR than on the OLST (maximum

balance time for the OLST being designated as 30 seco nds). For the SR,only the shoes-on-eyes-open test condition show ed a significant decreasein balance time according to agegroup (p = .013). Only one subjectwas able to reach the 30-second maximum balance time in the eyes-closedOLST; therefore, no basis for analysisaccording to age group existed. Alleyes-open OLST results demonstrateda significant decrease in balance time

as age increased (p ≤ .008).

For each of the th ree tests (SR,dom inant-leg OLST, andnondom inant-leg OLST) shown inTable 3, the subjects' maximal balancetimes fell into one of eight balancetime performance categories. In theshoes-on-eyes-open test condition, 19subjects (26.8%) d id no t reach a maximum balance time on any test (withmaximum balance time for the OLST

being designated as 30 seconds).Three subjects (4.2%) were able toreach a maximum balance time onthe nondom inant-leg OLST, but noton the SR or the dominant-leg OLST.A total of 26 subjects (36.6%) reachedmaximum balance times in the shoes-on-eyes-open test condition. No subjects reached the 30-second maximumbalance time in the shoes-on-eyes-closed test condition of the OLST.

Table 3 also demonstrates that moresubjects reached the m aximum balance time on the SR than on the OLST(with maximum balance time designated as 30 seconds on the OLST).Only 53% of the subjects able to reachthe 60-second maximum balance timeon an eyes-open SR reached the maximum balance time on any eyes-openOLST. Four subjects (5.6%) were ableto reach the 30-second OLST balancetime but did not reach the maximum

balance time on a SR, as comparedwith 32.4% and 35.2% of the subjects

who reached the maximum SR balancetime but did not reach the maximumOLST balance time in the shoes-on-eyes-open and shoes-off-eyes-openconditions, respectively. For eyes-closed test performance, only one subject reached the maximum balancetime on the OLST, whereas 34 subjectsreached the m aximum balance time

on the SR

Using 45 seconds instead of 30 seconds as the cutoff time for the OLSTpermitted a more accurate estimate ofthe population mean balance time. Ifa 30-second OLST cutoff time hadbeen used, mean balance times wouldhave been substantially low er than themean balance times found in thisstudy. Subjects reached a maximalbalance time of 30 seconds during an

OLST in 59 trials. Only 76% of thosewho reached a maximal balance timeof 30 seconds, however, were able toreach the 45-second cutoff time. Eyes-closed OLST mean balance timeswere not affected significantly by the45-second cutoff time because onlyone subject was able to reach a 30-second maximal balance time.

Table 4 shows the results of a two-way ANOVA for each test using the

shoes-on and shoes-off and the eyes-open and eyes-closed test conditionsas factors. The main effects of theeyes-open and eyes-closed test conditions w ere significant (p < .0001 oneach test). Subjects maintained theirbalance longer with their eyes openthan with their eyes closed in boththe SR and the OLST and in both theshoes-on and shoes-off conditions. Nosignificant interaction was foundbetween the shoes-on and shoes-off

and the eyes-open and eyes-closedtest conditions, nor were the maineffects of the shoes-on and shoes-offtest conditions significant.

Discussion

When using a standing test to evaluatebalance, the clinician should recognizethat performance will differ accordingto the age of the subject. Potvin andTourtellotte suggested that the majority

of healthy subjects could m aintain balance for 30 seconds during the OLST,

without reference to age or to eyes-open or eyes-closed conditions.27

Bohannon et al averaged right-leg andleft-leg OLST results of men andwomen to obtain the following meanbalance times according to age (usinga shoes-off condition, a m aximum balance time of 30 seconds, and the bestof five rials): subjects 60 to 69 years of

age, eyes-open condition = 22.5 ± 8.6seconds, eyes-closed condition = 10.2± 8.6 seconds; subjects 70 to 79 yearsof age, eyes-open condition = 14.2 ±9.3 seconds, eyes-closed condition =4.3 ± 3.0 seconds.9

Bohannon et al's9 findings are similar

to those in this study regarding theOLST. Because we discon tinued OLSTbalance timing at 45 seconds, themean time could potentially be

higher than the 30-second standardtime. Only Group 1's mean OLST balance time performance exceeded 30seconds for the eyes-open condition.When statistically analyzed using the30-second maximum balance time,mean balance times for the OLST inthis study are very close to Bohannonet al's9 findings.

By using a higher cutoff time andsmaller age groupings, the clinician

has a more accurate and more realistic value with which to compare hisor her findings. The 45-second OLSTcutoff time decreased the truncatedeffect that a 30-second cutoff timewould have had on the mean balancetime. Although using 45 seconds asthe cutoff time provided a bettermean balance time calculation, using30 seconds as a maximum balancetime for the OLST in clinical settingsstill seems appropriate because it can

provide an indication of those subjects who exhibit poor balanceperformance.

Previous research has indicated thanan inability to maintain balance for 30seconds (standing with feet togetherperforming an eyes-open or eyes-closed Romberg test) is an abnormalfinding for subjects under 79 years ofage.9,27,28 Bohannon et al's subjects,who ranged in age from 60 to 79

years, were able to perform the Romberg test for 30 seconds (eyes-open








T a b l e 2 . Percentages of Subjects Reaching Maximum Balance Times

Groupa

12

3

4

5

All groups

Test Condition

SRb/SO

c/EO

d

%

92.992.3

62.5

43.8

58.3

69.0

x2

= 12.8

df = 4

p = .013

n

1312

10

7

7

49

SR/SO/ECa

%

21.438.5

18.6

6.3

16.7

19.7

NS

NS

NS

n

35

3

1

2

14

SR/SFf/EO

%

92.984.6

68.8

62.5

66.7

74.7

NS

NS

NS

n

1311

11

10

8

53

SR/SF/EC

%

42.930.8

37.5

12.5

16.7

28.2

NS

NS

NS

n

64

6

2

2

20

Group

1

2

3

4

5

All groups

Test Condition

D-OLSTg/SO/EO

%

92.9

46.2

18.8

6.3

8.3

33.8

X2

= 33.2

df = 4

p = .000

n

13

6

3

1

1

24

D-OLST/SO/EC

%

0

0

0

0

0

0

NS

NS

NS

n

0

0

0

0

0

0

D-OLST/SF/EO

%

78.6

53.9

31.3

6.3

8.3

35.2

X2

= 23.3

df = 4

p = .000

n

11

7

5

1

1

25

D-OLST/SF/EC

%

0

0

0

0

0

0

NS

NS

NS

n

0

0

0

0

0

0

Group

1

2

3

4

5

All groups

Test Condition

N-OLSTh/SO/EO

%

64.3

46.2

31.3

12.5

8.3

32.4

x2

= 13.7

df=

4p = .008

n

9

6

5

2

1

23

N-OLST/SO/EC

%

0

0

0

0

0

0

NS

NSNS

n

0

0

0

0

0

0

N-OLST/SF/EO

%

78.6

46.2

31.3

12.5

8.3

35.2

x2

=

df=

P = .

19.7

4001

n

11

6

5

2

1

25

N-OLST/SF/EC

%

7.1

0

0

0

0

1.4

NS

NSNS

n

1

0

0

0

0

1

aGroup 1 (n = 14) = subjects aged 60-64 years; Group 2 (n = 13) = subjects aged 65-69 years; Group 3 (n = 16) = subjects aged 70-74 years;

Group 4 (n = 16) = subjects aged 75-79 years; Group 5 (n = 12) = subjects aged 80-86 years.bSR = sharpen ed Rom berg test (maximum balance time = 60 seconds).

cSO = shoes-on test condition.

dEO = eyes-open test condition.

eEC = eyes-closed test condition.

fSF = shoes-off test condition.

g*D-OLST = one-legged stance test (dominant leg) (maximum balance time = 30 seconds).b

N-OLST = one-legged stance test (nondominant leg) (maximum balance time = 30 seconds).

Physical Therapy/Volume 69, Num ber 9/September 1989 7 5 3 / 5 1







T a b l e 3 . Time Performance of Individuals by Test Condition

Test (sec)

SRa

<60<60

<60

<60

60

60

60

60

TOTAL

D-OLSTb

<30< 30

30

30

< 30

<30

30

30

N-OLSTc

<30

30

<30

30

<30

30

<30

30

Test Condition

SOd/EO

e

n

19

3

0

0

23

2

6

18

71

%

26.8

4.2

0

0

32.4

2.8

8.4

25.4

100

SO/ECf

n

570

0

0

14

0

0

0

71

%

80.3

0

0

0

19.7

0

0

0

100

SFg/EO

n

170

0

1

25

4

4

20

71

%

30.00

0

1.4

35.2

5.6

5.6

28.2

100

SF/EC

n

510

0

0

19

1

0

0

71

%

71.8

0

0

0

26.8

1.4

0

0

100

Test (sec)

SR

<60

<60

<60

<60

60

60

60

60

TOTAL

D-OLST

<45

<45

45

45

<45

<45

45

45

N-OLST

< 45

45

<45

45

< 45

45

<45

45

Test Condition

SO/EO

n

22

0

0

0

29

4

4

12

71

%

31.0

0

0

0

40.9

5.6

5.6

16.9

100

SO/EC

n

57

0

0

0

14

0

0

0

71

%

80.3

0

0

0

19.7

0

0

0

100

SF/EO

n

17

1

0

0

29

6

4

14

71

%

23.9

1.4

0

0

40.9

8.5

5.6

19.7

100

SF/EC

n

51

0

0

0

20

0

0

0

71

%

71.8

0

0

0

28.2

0

0

0

100

and eyes-closed conditions).9 Theresults of our study, however, showthat eyes-closed SR performance forindividuals under 79 years of age wasbelow 30 seconds for approximatelyone half of the population.

There are no current studies thatcompare SR and Romberg test performance. Comparison of the results ofsubjects performing the Romberg testin Bohannon et al's study

9and the

results of subjects performing the SRin this study does indicate a significant difference between these twotests (the SR appears to be more dif-

ficult to perform than the Rombergtest).

In earlier studies, subjects' balancetimes generally decreased as ageincreased.9,11 The balance time-agerelationship appears most evident forthe OLST and to a lesser extent forthe SR. The one exception in the present study is Group 4, who performed

worse on some tests than Group 5.There are several possible explanations for this finding. Group 5 contained two individuals w ho excelledon most tests. Using volunteers, asopposed to random selection, mayhave biased the results. In addition,the health of the individual is generally expected to affect balance tim e.29

Although not statistically significant,lower balance performance on certaintests may be linked to the dispropor

tionate num ber of subjects w ith mus

culoskeletal problems in Group 4. Sixof the seven women who had musculoskeletal problems within the pastfive years were in Group 4.

When comparing eyes-open versuseyes-closed test performance in

elderly subjects, the findings are qu iteclear. Eyes-closed performance wasmarkedly worse than eyes-open performance. If visual acuity had beenchecked and corrected prior to balance testing, there might have beenan even greater difference betweeneyes-open and eyes-closed balanceperformance.30 Rosenthall and Rubin31

and Johnson32 found a decrease in thenumber of otoliths and hair cells inthe vestibular apparatus, potentially

leading to decreased vestibular sensi-

aSR = sharpened Romberg test.

bD-OLST = one-legged stance test (dominant

leg).

cN-OLST = one-legged stance test (nondominant

leg).dSO = shoes-on test condition.

eEO = eyes-open test condition.

fEC = eyes-closed test condition.gSF = shoes-off test condition.

52 / 754 Physical Therapy/Volume 69, Num ber 9/September 1989







T a b l e 4 . Analysis-of-Variance Summary for Eyes-Open-Eyes-Closed Versus Shoes-On-Shoes-Off Test Conditions Using Sharpened

Romberg Test an d One-Legged Stance Tests

Sharpened R om berg T es t

S o u r c e

Aa

Bb

A × B

Error

df

1

1

1

28 0

ss

41004 . 55

307.47

275.50

127522.07

MS

41004 . 55

307.47

275.50

455 . 44

F

90 . 03

0.68

0.60

P

.0001

.4120

.4374

One-Legged Stance Test (Dominant Leg)

Source

A

B

A × B

E r r o r

df

1

1

1

280

SS

19951.10

71.94

0.41

41614 . 13

MS

19951.10

71.94

0.41

148.62

F

134.24

0.48

0.00

P

.0001

.4872

.9583

One-Legged Stance Test (Nondominant Leg)

Source

A

B

A × B

Error

df

1

1

1

280

SS

18261.22

61.13

10.71

45900 . 33

MS

18261.22

61 . 13

10.71

163.93

F

111.40

0.37

0.07

P

.0001

.5419

.7984

tivity for the elderly. Decreased levels

of peripheral sensation and proprioception are other likely contributors

to poor eyes-closed balance

maintenance. 13 '16 '3334 Perhaps vestibu

lar and sensory loss increased the

role that vision plays in balance main

tenance among the elderly.

The testing position of the OLST was

more difficult to maintain than that of

either th e SR or th e Rom berg test.

The OLST may be valuable in making

fine distinctions in balance performance, such as evaluating the results

of treatment used to improve balance.

The R omberg test and the SR appear

to be best suited for detecting major

abnormalities in balance.

A longer max imum balance t ime

could be selected for longitudinal

studies, particularly th ose involving

younger subjects, where pretreatment

balance times on the OLST

approached the 30-second maximum.

For example, a person is able to bal

ance 25 seconds before he or shebegins an exercise program and is

able to balance for 35 seconds after

completing the exercise program .

Using a maximum balance t ime

greater than 30 seconds would be

appropriate for this subject to objec

tively document the amount of

improvement in balance performance.

The SR may not be the test of

choice for certain patient popula

t ions. Obese subjects with largeth igh c i rcumference may not be

able to assume the test posit ion.

The OLST and th e SR place th e hip

in adduction, which may be con-

traindicated for subjects who have

had a recent total hip replacement.

In this study, three trials were permit

ted for each test. Bohannon et al9 and

Graybiel and Fregly11 used u p to five

trials for the OLST. In the current

study, the best trial results wer e dis

tributed evenly among the three trial

sequences except on tests where alarge number of subjects reached

maximum balance t imes. When maxi

mum balance t imes were reached, the

majority were on the first trial. Three

trials appear to provide a good indica

tion of balanc e capabilities.

The information concerning falls

demands careful analysis. For exam

ple, one 63-year-old subject who dem

onstrated excellent balance perfor

mance in this study had fallen fourtimes within the past year; however,

she was highly active and participated

in more dangerous activities such as

mountain hiking and cl imbing ladders

to clear debris off her roof. In con

trast, another subject who had fallen

was 77 years of age, was moderately

obese, had undergone bilateral total

knee replacements , and was

involved in primarily sedentary

activities. The first individual's

increased risk of falling was consis-

aA = eyes-open-eyes-closed test conditions.bB = shoes-on-shoes-off test conditions.

Physical Therapy/Volume 69, Number 9/September 1989 7 5 5 / 5 3







tent with her greater activity level.The second individual may havebeen more prone to falls as a resultof her m edical cond ition. A mo redetailed history concerning falls isneeded for proper analysis. Evaluating whether falls were due to intrinsic or extrinsic causative factors mayhelp us to recognize a relationship

between falls and balancemaintenance.

Clinical Implications

Additional research is needed in thearea of balance maintenance amongthe elderly population. Specifically,the OLST may b e greatly affected if asubject's hip musculature is weak oreasily fatigued. Subjects' balance couldbe tested prior to and after comple

tion of various exercise programs.

In this study, no significant difference was found between the balance times of those subjects whohad fallen within the past year andthose who had not fallen. Subjectswith serious injuries attributable tofalls within the previous year couldnot participate in this study; therefore, our fall-related results areincomplete. Longitudinal studies are

needed to determine whether subjects with poor balance performancehave more falls and injuries attributable to falls. A longitudinal studycould more specifically evaluate theeffect of aging on individual subjects' balance performance.

Foot dominance and sho e wear didnot affect balance test results in thispopulation. Thus, the clinician doesnot need to evaluate foot dominance

and could use either the right or leftleg for the OLST. Barefoot testing maybe preferred because foot abnormalities and ability to stand can be observed mo re easily than when shoesare worn.

The benefits to the clinician of timedstanding balance tests include timeefficiency, low cost, no need for special equipm ent, and the simplicity oftraining testers. Balance tests are one

mo re too l available to the clinicianwhen trying to determine whether

patients are ready to assume moreindepen dence in their ADL. They canbe used to indicate which patientsmay require further diagnostic tests.Standing balance tests provide anindication of the patient's ability tomaintain balance.

Conclusion

The results of this study indicate thatbalance times on the OLST and the SRdecrease as age increases in noninsti-tutionalized elderly women. Eyes-closed test performance was markedlyworse than eyes-open test performance in the elderly women in thisstudy. More subjects were able toreach maximum balance times on theSR than on the OLST. Of the th reetests, the OLST appears to be the

most difficult to administer, followedby the SR and then the Romberg test.Foot dominance and shoe wearingdid not affect balance performance.Expectations regarding balance maintenance should b e adjusted accordingto age.

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