International Journal of Audiology

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Clinical assessment of balance: Normative data, and gender and age effects

Luc Vereeck abc; Floris Wuyts bd; Steven Truijen a; Paul Van de Heyning bc a Hoger Instituut voor Kinesitherapie & Ergotherapie, Department of Health Care Sciences, University College of Antwerp, Belgium b Antwerp University Research Centre for Equilibrium and Aerospace (AUREA), Department of Otorhinolaryngology, Antwerp University Hospital, Belgium c Faculty of Medicine, University of Antwerp, Belgium d Faculty of Science, Department of Biomedical Physics, University of Antwerp, Belgium Online Publication Date: 01 February 2008 To cite this Article: Vereeck, Luc, Wuyts, Floris, Truijen, Steven and Van de Heyning, Paul (2008) 'Clinical assessment of balance: Normative data, and gender and age effects', International Journal of Audiology, 47:2, 67 - 75 To link to this article: DOI: 10.1080/14992020701689688 URL: http://dx.doi.org/10.1080/14992020701689688

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Original Article International Journal of Audiology 2008; 47:6775

Luc Vereeck*,$,§ Floris Wuyts $,% Steven Truijen* Paul Van de Heyning$,§


*

Hoger Instituut voor Kinesitherapie & Ergotherapie, Department of Health Care Sciences, University College of Antwerp, Belgium $ Antwerp University Research Centre for Equilibrium and Aerospace (AUREA), Department of Otorhinolaryngology, Antwerp University Hospital, Belgium § Faculty of Medicine, University of Antwerp, Belgium % Faculty of Science, Department of Biomedical Physics, University of Antwerp, Belgium

Key Words

Abstract

Sumario

The purpose of this study was to provide age specific normative data of clinical gait and balance tests and to determine to what extent gender contributes to differences in postural control. Standing balance and walking performance was tested in 318 asymptomatic adults. The logistic regression, using both 10- and 30-second time limits as a dichotomization point, revealed a significant age effect for standing on foam with eyes closed, tandem Romberg with eyes closed (TR-EC), and one leg stance (eyes open and closed). The actual effect of decline was different for each test. Both tandem gait and dynamic gait index showed a ceiling effect up to 60 years of age, with a rapid decline of performance for subjects in their seventies. Linear regression equations indicated that for both men and women, timed up and go test (TUG) times increased with age, but even older subjects should perform the TUG in 10 seconds or less. Women performed significantly poorer on the TUG and TR-EC (30second time limit).

El propo´sito de este estudio fue proveer datos normativos especı´ficos para la edad, de las pruebas clıńicas de marcha y equilibrio y determinar en que´ medida el geńero contribuye a establecer diferencias en el control postural. Se realizaron pruebas de equilibrio de pie´ y de rendimiento en la marcha, en 318 adultos asintoma´ticos. La regression logı´stica usando tiempos lı´mites de 10 y de 30 segundos como punto de dicotomizacioń, revelo´ un efecto significativo de la edad para sujetos de pie´ sobre en hule espuma con los ojos cerrados, durante el tańdem Romberg con ojos cerrados (TR-EC) y en la postura en un pie´ (con ojos abiertos y cerrados). El efecto real del deterioro fue diferente en cada prueba. Tanto la marcha en tańdem como el ´ı ndice dina´mico de la marcha mostraron un efecto de lı´mite hasta los 60 anõs de edad con un deterioro ra´pido del rendimiento en sujetos en los setentas. Las ecuaciones de regresioń linear indicaron que tanto en hombres como en mujeres, los tiempos para iniciar la prueba (TUG) se incrementaron con la edad pero que incluso los sujetos mayores podıán desempenãr el TUG en 10 segundos o menos. Las mujeres se desempenãron significativamente de manera ma´s pobre en el TUG y en el TR-EC (tiempo lı´mite de 30 segundos).

Clinical balance assessment Normative data One leg stance Tandem Romberg Age effect Gender effect

Abbreviations BMI: Body mass index DGI: Dynamic gait index EC: Eyes closed EO: Eyes open IQR: Interquartile range OLS: One leg standing ROMJ: Romberg and Jendrassik manoeuvre SD: Standard deviation SEM: Standard error of mean SOF: Standing on foam SPSS: Statistical package for the social sciences TG: Tandem gait TR: Tandem Romberg TUG: Timed up and go test

Comprehensive management of the patient with vestibular impairment includes control of any underpinning otologic disease process, as well as recovery of normal balance. To identify balance deficits, and measure recovery following inter-

vention, it is useful to measure post morbid balance performance in ways that are simple, robust, and ecologically valid. Balance is a complex motor skill requiring central processing of vestibular, visual, and somatosensory information to activate

ISSN 1499-2027 print/ISSN 1708-8186 online DOI: 10.1080/14992020701689688 # 2008 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society

Luc Vereeck Hoger Instituut voor Kinesitherapie & Ergotherapie, Department of Health Care Sciences, Van Aertselaerstraat 31, Merksem, Antwerpen, B 2170 Belgium. E-mail: [email protected]

Received: November 6, 2006 Accepted: September 17, 2007


the musculoskeletal system to produce postural actions. These actions emerge from an interaction of the individual, the task with its inherent postural demands, and the environmental constraints on postural actions (Shumway-Cook & Woollacott, 2001). Balance performance is therefore usually assessed using a combination of tests, covering different aspects of balance while standing or walking. The present study focuses on clinical tests that are commonly used in the clinic and are relevant for documenting outcome in patients with vestibular system disease (Ekvall Hansson et al, 2004; Gill-Body et al, 2000; Johansson et al, 2001; Kammerlind et al, 2005; Mann et al, 1996; Whitney et al, 2004). The classical Romberg test is often used to assess the ability to maintain an upright posture with reference to a stable base of support. In the literature, numerous alterations have been proposed. Focus has been on trying to differentiate the relative contribution of various sensory systems to maintain standing balance. Patients with a vestibular disorder usually have difficulties standing upright when both visual and support-surface information are altered. In this context the Romberg and Jendrassik manoeuvre (ROMJ), parallel stance on foam (SOF), tandem Romberg (TR), and standing on one leg (OLS) were chosen to assess standing balance. Impaired functional balance performance in patients with vestibular disorders is shown by their ataxic gait pattern and the postural adjustments associated with (un)voluntary movements of the head. The timed up and go test (TUG) was chosen because it incorporates head movements while standing up and turning (Podsiadlo & Richardson, 1991). Furthermore tandem gait (TG) and the dynamic gait index (DGI) were used to see whether subjects could handle a narrow base of support or different movements of the head while walking (ShumwayCook & Woollacott, 1995). Although research indicates that older women fall more frequently than men, the existence of gender-based balance disparities is still controversial. Gender differences were absent during quiet standing activities and forward reaching (Bryant et al, 2005; Duncan et al, 1990; Hageman et al, 1995; Raiva et al, 2005; Rogind et al, 2003). Yet several authors suggest that women perform poorer on timed functional mobility tests and more challenging postural control tasks (Era et al, 2006; Kuh et al, 2005; Samson et al, 2000; Wolfson et al, 1994). On the other hand, when using computerized posturography, older men especially have increased postural sway (Matheson et al, 1999). Increasing age is known to adversely affect postural control, but except for standing on one leg and tandem stance, age related normative data of balance field tests are rarely reported in peerreviewed journals. These factors, however, could be of importance when describing recovery of balance in the rehabilitation process. The goal of this study is to determine the effect of gender and age on postural control and to report normative data for the selected tests.

Methods

normal were included in the study. All subjects gave their written consent before enrolment in the study. If a subject indicated interest in participating, he or she was scheduled for an assessment session. Exclusion criteria used were: (1) actual complaints or a history of vertigo or dizziness; (2) neurologic, otologic, orthopaedic, or other medical conditions impeding balance (e.g. diabetes mellitus, orthostatic hypotension); (3) nursing home residents; (4) dependence on the assistance of another person or the assistance of a support device (e.g. cane, crutch, walker); (5) a fall within the last six months.

Procedures Demographic data were gathered in order to describe the study sample (age, gender, height, weight, body mass index). The balance tests took 20 to 30 minutes depending on the fact of the subject needing all trials to meet the testing criteria. All tests were performed on level vinyl flooring with shoes (except when standing on foam), but shoes were removed if they were unstable (Briggs et al, 1989; Lord & Bashford, 1996; Whitney & Wrisley, 2004). Subjects were permitted to rest between trials or tests as desired. Without interfering with the performance of the participant, the investigator stood close to the subject throughout the entire experimental session to prevent falls or injuries. Time measurements were made with a digital stopwatch.

QUASI-STATIC

BALANCE TESTS

Except for the Romberg and Jendrassik manoeuvre, the participants performed the tests with eyes open (EO) and closed (EC). A subject who requested help to assume a testing position was allowed to use the investigator’s arm to steady himself prior to starting the timed trials. No instructions were given regarding the subject’s knee position or visual fixation. Timing started when the subject assumed the proper position and indicated that he or she was ready to begin the test. Timing stopped when the subject disengaged from the starting position or reached the 30-second time limit. The best of three trials was considered for analysis (Heitmann et al, 1989; Lee, 1998). If a participant reached the 30-second time limit at the first or second trial, we immediately proceeded to the next test. When performing the classical Romberg test, subjects were asked to stand with their eyes closed, feet together, and clasping hands, while abducting arms, thus producing tension (i.e. Jendrassik manoeuvre). While standing on foam, subjects were asked to stand with their hands clasped on a 12-cm thick, medium density foam pad measuring 45 by 45 cm (NeuroCom International Inc., Clackamas, USA). The distance between the feet was approximately 5 cm. The tandem Romberg test involved the participants standing with one foot just in front of the other (heel to toe, no angle allowed). Arms were free to move. Participants could choose which leg they wanted in front and they were allowed to alternate between legs as they wished in between trials. At last, the subjects were asked to stand on one leg, arms free to move. Participants could choose which leg they wanted to stand on and were allowed to alternate between legs in between trials.

Subjects Our subjects were recruited through various means of advertisement from the vicinity of Antwerp, Belgium. All volunteers, adults 20 years of age or older, who perceived their balance to be

WALKING

68

International Journal of Audiology, Volume 47 Number 2

TESTS

Timed up and go test (Podsiadlo & Richardson, 1991): The subject was asked to sit on a standard armchair (46 cm high)


with his back against the chair and feet flat on the floor. He was then instructed*on the word ‘‘start’’, after the warning ‘‘ready’’*to rise and to walk as fast as possible to a mark on the floor 3 metres away, turn around, walk back to the chair and sit down again. Timing commenced on the word ‘‘start’’ and ceased once the subject’s back touched the back of the chair. The participant performed the test three times with his preferred turn (first choice) and then three times with a turn to the other side. The fastest time was considered for analysis. Tandem gait: The subject was asked to walk*eyes open*heel to toe on a straight line for 20 steps at his own pace. The ability to see the seam in the linoleum floor was checked. Counting the steps commenced once the participant started placing one foot before the other, and stopped once a foot touched the floor before proper placement, the heel wasn’t touching the toes, the foot wasn’t placed on the line or the 20 steps limit was reached. The last unsuccessful step was not incorporated in the score. The best performance of a maximum of three trials was considered for analysis. Dynamic gait index (Shumway-Cook & Woollacott, 1995): The DGI consists of performing eight gait tasks, including walking on a level surface, walking at different speeds, performing head turns in the pitch and yaw planes while walking, making a 1808 turn and stop after walking, stepping over and around objects, and stair climbing. The test items are scored on a four-point scale, from 0 to 3. The maximum score of 24 indicates normal performance. We modified the scoring guidelines of the original version, i.e. in test item 5 we asked the subject to do the pivot turn in 2 seconds instead of 3 seconds and the distance between the two cones was 1 metre compared to the 6 feet in the original version (item 7).

Statistics Statistical Package for the Social Sciences (SPSS) 12.0 for Windows, and Sigmastat 2.03 for Windows (SPSS Software, SPSS Inc., Chicago, USA) were used for all data entry and analysis. Descriptive statistics were used to characterize the sample. For each analysis, a significance level of pB0.05 was adopted. Possible differences between men and women for the subject characteristics were analysed using independent samples T-tests. This was performed per decade and for the total sample. Where appropriate, non-parametric statistics were applied. The effect of different subject characteristics on quasi-static balance, TG, and DGI was analysed using logistic regression with the maximal scores taken as dichotomization point. For the quasistatic tests the same procedure was also done with the 10-second time limit as dichotomization point. In order to see whether there was a gender difference in quasi-static balance tests per decade, Fisher’s exact test was used. The TUG scores were analysed using multiple regression analysis. Simple linear

regression was used to calculate the age-effect on TUG scores for men and women separately. One way analysis of variance was used to compare our data on the OLS-EC test with the results of other authors. Multiple comparison procedures (with Bonferroni corrections) were conducted for each decade.

Results Subjects In a period from April 2000 to January 2006, 318 subjects (180 females, 138 males) were recruited and tested. The mean age (standard deviation (SD)) of the subjects was 49.2 (18.7) years (range 20.783.2), men and women being equally old (women 49.4 (18.8) years; men 48.9 (18.6) years; independent samples T-test: p0.79). Men were taller (women 167.2 (6.3) cm; men 178.1 (6.9) cm; independent samples T-test: pB0.001); and heavier (women: 63.0 (8.0) kg; men 77.3 (11.1) kg; independent samples T-test: pB0.001). Body mass index (BMI) was 23.4 (3.0) (range 16.432.7) for all subjects. Men had a higher BMI score than women (women 22.6 (2.7); men 24.4 (3.1); independent samples T-test: p B0.001). Table 1 shows the descriptive data of the same variables (age, height, weight, and BMI) per decade. Men, being taller and heavier than women, remained significant throughout all decades.

Quasi-static balance tests Descriptive data of the quasi-static balance tests are shown in Table 2. The classic Romberg test and Jendrassik manoeuvre, and standing on foam with eyes open could be performed by all subjects. While standing on foam in the eyes closed condition, balance performance started to deteriorate in the seventh decade. More then half of the participants (54%) did not reach the 30-second time limit when they were in their seventies (i.e. eighth decade). The 10-second time limit could not be reached by six subjects in their sixties and 14 participants older than seventy. All participants could perform the tandem Romberg with eyes open for 30 seconds. This test could be easily performed by subjects up to their fifties in the eyes closed condition, but a decline in performance was shown in the sixth decade. Standing on one leg with eyes open could not be performed by a 48 year old women (18.3 sec), 11 out of 56 subjects in their sixties (n 56), and 29 out of 56 subjects in their seventies. Almost everyone could stand for more than 10 seconds, but this limit was still too high for eight septuagenarians (six women, two men). Performance on unipedal stance (eyes closed) already started to deteriorate in the fifth decade. Only two men in their sixties (62 and 63 year old), and no seventy year old subject, could stand for 30 seconds on one leg with eyes

Table 1. Descriptive characteristics of 318 normal volunteers per decade (mean9standard deviation (number of volunteers)). Decade Age (years) Height (cm) Weight (kg) BMI

3

4

5

6

7

24.792.5 (74) 175.798.9 (74) 68.1912.3 (55) 22.092.7 (55)

35.193.1 (45) 172.798.0 (45) 66.3910.6 (41) 22.192.4 (41)

45.293.0 (41) 171.498.0 (41) 71.1913.8 (35) 23.992.9 (35)

53.392.6 (39) 171.498.3 (39) 71.2910.4 (26) 23.992.4 (26)

65.093.0 (60) 169.397.6 (30) 73.1913.2 (28) 25.493.4 (28)


Vereeck/Wuyts/Truijen/Van de Heyning

8 74.693.4 168.498.0 70.999.1 25.192.9

(59) (29) (27) (27)

69


Table 2. Descriptive characteristics of 318 asymptomatic adults for measures of quasi-static balance. Standing on foam (eyes closed) Decade

Mean

SD

Median

Perc 05

3 4 5 6 7 8

30.00 30.00 30.00 30.00 26.02 19.82

.00 .00 .00 .00 8.42 10.52

30.00 30.00 30.00 30.00 30.00 30.00

30.00 30.00 30.00 30.00 6.20 1.70

Interquartile range 30.00 30.00 30.00 30.00 30.00 9.22

30.00 30.00 30.00 30.00 30.00 30.00

Perc 95

Valid N

% 30 s

% 10 s

30.00 30.00 30.00 30.00 30.00 30.00

N74 N43 N32 N30 N56 N56

100 100 100 100 80 46

100 100 100 100 89 75

Perc 95

Valid N

% 30 s

% 10 s

30.00 30.00 30.00 30.00 30.00 30.00

N58 N42 N32 N28 N56 N56

98 100 94 82 36 16

100 100 97 100 64 54

Perc 95

Valid N

% 30 s

% 10 s

30.00 30.00 30.00 30.00 30.00 30.00

N74 N43 N32 N30 N56 N56

100 100 97 100 80 48

100 100 100 100 95 86

Perc 95

Valid N

% 30 s

% 10 s

30.00 30.00 30.00 30.00 28.33 11.78

N74 N43 N31 N29 N56 N56

86 86 45 38 4 0

96 95 90 79 34 5

Tandem Romberg (eyes closed) Decade

Mean

SD

Median

Perc 05

3 4 5 6 7 8

29.94 30.00 28.82 28.03 17.96 13.20

.43 .00 4.66 4.87 10.33 9.50

30.00 30.00 30.00 30.00 16.50 11.26

30.00 30.00 11.46 13.57 4.18 2.27


30.00 30.00 30.00 30.00 30.00 18.74

One leg standing (eyes open) Decade

Mean

SD

Median

Perc 05

3 4 5 6 7 8

30.00 30.00 29.64 30.00 27.74 21.43

.00 .00 2.06 .00 5.25 10.08

30.00 30.00 30.00 30.00 30.00 26.33

30.00 30.00 25.91 30.00 11.59 2.05


30.00 30.00 30.00 30.00 30.00 30.00

One leg standing (eyes closed) Decade

Mean

SD

Median

Perc 05

3 4 5 6 7 8

27.52 27.48 21.77 19.92 8.93 4.87

6.45 6.48 9.09 9.81 7.54 3.46

30.00 30.00 24.75 20.90 5.66 3.93

9.45 8.46 3.94 3.78 1.61 1.18


30.00 30.00 30.00 30.00 12.13 6.03

SD: standard deviation; Perc: percentile; N: number of subjects;%: percentage of subjects reaching 10 or 30 seconds.

10- and 30- second time limits. Only in the sixth decade a gender effect remained when using the TR-EC. Six out of 13 women could not maintain their position for 30 seconds, whereas 14 out of 15 men (93%) could (Fisher’s exact test; p0.029). Performance in women ranged from 13.5 to 30 seconds (mean score TR-EC (SD): 25.7 (6.6) seconds), with only 54% reaching the maximum score.

closed (only three subjects reaching the 10-second time limit). Figure 1 shows the different moments of decline in performance for the four tests in the eyes closed condition. The effect of different subject characteristics (gender (categorical variable), age, body length, body weight, and BMI) was studied using logistic regression. A highly significant age effect (p ranging from 0.002 to B0.001) was seen in all conditions, except for ROMJ, SOF-EO and TR-EO. The detrimental effect of a higher body weight was seen in TR-EC (using both the 10and 30-second time limit as dichotomization point) and OLS-EC (10-second time limit) with p being 0.039, 0.005, and B0.001, respectively). A gender effect was seen in the TR-EC (30-second time limit; p0.002), OLS-EC (10 second time limit; p0.011) and SOF-EC (30-second time limit; p0.016) with men performing better. This gender effect however disappeared when the proportions of men and women failing or succeeding on the different tests, were compared. This was done for both

Walking tests

70


Descriptive data per decade for the timed up and go test are shown in Table 3. All our volunteers needed less than 10 seconds to perform the test. Multiple regression analysis revealed a significant influence of age and gender on TUG-performance (p B0.001 and p0.034 respectively). No other variables were proven to have an effect. Linear regression equations (Table 4) indicate that for both men and women TUG-times increase with age, i.e. with 0.6 seconds and 0.8 seconds per decade respectively


Table 4. Linear regression equations for timed up & go scores (seconds) as function of age (years) for 39 healthy women and 39 healthy men, Pearson correlation coefficients (r) and level of significance (p-value). Linear regression equation

r

p-value

0.077 (age)2.211 0.060 (age)2.523

0.847 0.790

B0.001 B0.001

Women Men

(reaching score 24 or not), logistic regression revealed that age was the only significant factor (p B0.001) for both measures of postural control.

Discussion

Figure 1. Different moments of decline in performance in the four eyes-closed conditions: Romberg with Jendrassik manoeuvre, standing on foam, tandem Romberg, and one leg standing. Dots represent mean time and bars represent standard error of mean. (pB0.001). The correlation between TUG-time and age for the total sample was high (Pearson correlation coefficient 0.82; pB0.001). Obtained data for tandem gait and dynamic gait index are presented in Table 5. Almost every subject could walk on a straight line but the task became difficult for people in their seventies. Thirteen out of 60 sexagenarians (median score TG: 20, interquartile range (IQR): 2020, range: 220) and 28 out of 59 septuagenarians (median score TG: 20, IQR: 720, range: 120) did not reach the 20 steps. Functional balance performance, as expressed by the dynamic gait index total score, again showed to be impaired in the eighth decade (median score DGI: 22, IQR: 2123, range: 1324) and to a lesser extent in the seventh decade (median score DGI: 24, IQR: 2324, range: 2124). Percentile 5 for each decade was: 23.8 (decade three), 24 (decade four), 23 (decade five), 23 (decade six), 21 (decade seven) and 18 (decade eight), indicating 95% of the subjects had higher DGI-scores. When studying the effect of subject characteristics on TG-performance (reaching 20 steps or not) and DGI-score

The first goal of this study was to determine whether age and gender contribute to differences in postural control. An age effect was shown for all assessments, except for ROMJ, SOF-EO, and TR-EO. Furthermore a gender effect was observed when using the TUG, and to a limited extend in the TR-EC, i.e. only middle-aged women (6th decade) performed poorer on the TREC (30-second time limit) when compared with middle-aged men. The second goal of this study was to provide normative data for the selected test. These age-related data show different moments of decline in balance performance for the different tests. Because of the ceiling (in younger adults) and floor effects (in older adults) of some of the quasi-static balance tests, the use of different tests per decade is advocated in order to delimitate poor postural control.

Quasi-static balance tests IMPACT

OF AGE AND GENDER ON QUASI-STATIC BALANCE

PERFORMANCE

N: number of volunteers; SD: standard deviation; SEM: standard error of mean.

Age was found to have a deleterious effect on standing balance performance. This was consistent with other reports studying standing balance in asymptomatic populations incorporating young, middle aged, and older adults (Bohannon et al, 1984; Brinkman et al, 1996; Era et al, 2006; Matheson et al, 1999; Rogind et al, 2003). Logistic regression revealed a gender effect on the SOF-EC, TR-EC, and OLS-EC. Though, when comparing the proportions of women and men failing the tests per decade, only women in their fifties performed significantly worse on the TR-EC using a 30-second time limit. This finding was in agreement with studies showing poorer postural control in women, aged 50 years or more, when standing balance was assessed using either TR or OLS (Era et al, 2006; Kuh et al, 2005; Steffen et al, 2005). However, several studies, using computerized posturography, found either no gender differences or (predominantly older) men having increased postural sway (Bryant et al, 2005; Era et al, 1996, 2006; Hageman et al, 1995; Masui et al, 2005; Raiva et al, 2005; Rogind et al, 2003). These differences may be partly explained by balance strategies being task specific and variable according to age. The presented results suggest applying the same criteria for men and women, except for TR-EC (30-second time limit) in the sixth decade, when assessing postural control by means of quasi-static clinical balance tests.



Table 3. Subject performance (seconds) on the timed up and go (as fast as possible) test. Decade

N

Mean

SD

SEM

Range

3 4 5 6 7 8

27 22 8 7 7 20

4.4 4.6 4.9 5.6 6.7 7.8

0.8 1.0 1.2 1.0 0.7 1.1

0.15 0.21 0.40 0.39 0.25 0.25

2.96.1 3.36.6 3.96.8 4.37.2 6.08.0 4.59.7

71


Table 5. Subject performance on tandem gait and dynamic gait index. Tandem gait (maximum 20 steps: best of three trials) Decade

N

Mean

SD

SEM

Median

IQR

5%95%

range

3 4 5 6 7 8

74 45 40 39 60 59

20 20 20 20 17.2 14.1

5.7 7.0

0.74 0.92

20 20

2020 720

420 220

220 120

IQR

5%95%

range

2324 2324 2124 1824

2324 2324 2224 2224 2124 1324

Dynamic gait index (maximum score: 24) Decade

N

Mean

SD

SEM

3 4 5 6 7 8

74 45 41 39 60 59

24.0 24.0 23.9 23.9 23.2 22.0

0.2 0.2 0.4 0.4 0.9 2.0

0.02 0.02 0.06 0.07 0.12 0.26

Median

24 22

2324 2123

N: number of volunteers; SD: standard deviation; SEM: standard error of mean; IQR: inter quartile range.

COMPARISON

OF QUASI-STATIC BALANCE PERFORMANCE

RESULTS WITH OTHER NORMATIVE STUDIES

The observation that all people up to 80 years can stand in the classical Romberg position with the eyes closed for thirty seconds is consistent with the literature (Bohannon et al, 1984; Brinkman et al, 1996). Table 6 shows that our data also match the test results provided by Cohen and colleagues, when older subjects were asked to stand still on foam with eyes closed (Cohen et al, 1993). It was impossible to compare TR test results with data published by other authors, for they all used 60-second time limits in both eyes open and eyes closed conditions (Franchignoni et al, 1998; Heitmann et al, 1989; Lee, 1998; Potvin & Tourtellotte, 1975; Steffen et al, 2005). The most popular test is one leg standing, but unfortunately many authors use different modalities and provide data only for the entire population studied, making comparison of age-related test results very difficult (Bohannon et al, 1984; Bohannon, 1994; Briggs et al, 1989; Brinkman et al, 1996; Fregly et al, 1973; Gehlsen & Whaley, 1990; Giorgetti et al, 1998; Iverson et al, 1990; Potvin et al, 1980). Four studies allowed comparison of OLS (EO & EC) test results, because data were available per decade and the same cut-off time was used (Bohannon et al, 1984; Briggs et al, 1989; Brinkman et al, 1996; Fregly et al, 1973). The presented data are in agreement with the results reported by the other authors except for the poorer performance of the older subjects (OLS-EO) in the Bohannon study

(Bohannon et al, 1984). This was shown by the percentage of subjects reaching the maximum score (seventh decade: 80% versus 43%; eighth decade: 48% versus 10%). Figure 2 shows the OLS-EC test results on one leg standing presented in four studies.

THE

USE OF A 10-SECOND TIME LIMIT TO INDICATE POOR

PERFORMANCE

In the third and fourth decade a failure in reaching the 5th percentile cut off score of OLS-EC can be considered indicative for a poor performance, being 9.45 and 8.46 seconds respectively. This rationale can be repeated for TR-EC in the fifth (11.46 seconds) and sixth (13.57 seconds) decade, and for SOF-EC in the seventh (6.2 seconds) and eighth decade (1.7 seconds) (Table 2). For practical purposes, we therefore suggest a 10-second time limit while using different tests per decade to delimitate poor performance. It can be remembered more easily and when looking at the raw data, few subjects ( B 5%) could not stand for 10 seconds in the appropriate test condition (third decade (OLS-EC): 4%; fourth decade (OLS-EC): 5%; fifth decade (TREC): 3%; sixth decade (TR-EC): 0% (lowest score: 13.5 seconds); seventh decade (SOF-EC): 11%; eighth decade (SOF-EC): 25%). A medium density foam pad is not always available and 25% of the septuagenarians could not stand for 10 seconds (SOF-EC), suggesting that this test is difficult for subjects in their seventies. Therefore OLS-EO (10 seconds) seems to a better alternative for older people (seventh decade (OLS-EO): 5%; eighth decade

Table 6. Comparison of subject performance (seconds) while standing on foam with eyes closed.

Cohen et al, 1993 Vereeck et al

Number of subjects

Age9SD (range)

1st trial Mean time9SD

15 82

75.195.9 (6584) 72.394.5 (6583)

12.5911.7 14.3911.4

2nd trial Mean time9SD

Best of three trials Mean time9SD

18.3913.1

Age: mean age (years); SD: standard deviation.

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21.9910.2

THE USE OF A 10-SECOND LIMIT AS A MARKER OF POOR TUG


PERFORMANCE

An age effect could be shown for all walking tests. Except for the study of Samson and co-workers, reported ranges of TUG scores have been limited for samples of elderly people and specific patient populations (Samson et al, 2000). Our data support their findings, indicating that, in asymptomatic adults, TUG times tend to be longer with increasing age, but never exceed 10 seconds. This was confirmed, for people up to the age of eighty years, by data describing functional balance performance in community-dwelling older adults (Podsiadlo & Richardson, 1991; Steffen et al, 2002).

TANDEM

Figure 2. Comparison of test results on one leg standing (eyes closed condition) presented in four studies with dots representing mean time and bars representing standard error of mean. All studies used a 30 second cut-off limit.

(OLS-EO): 14%). The use of the OLS-EO with a 10-second limit has the added benefit of identifying risk of frailty in older adults (Rossiter-Fornoff et al, 1995).

Walking tests IMPACT

OF GENDER ON THE TIMED UP AND GO TEST

The timed up and go test is the only walking test where a gender effect could be observed. Although there is little difference in the percentage increase between women and men over the adult age range, the absolute values for TUG-times are higher in women than men at all ages. This was in agreement with the findings of Samson and colleagues. Women walked slower, both when walking as fast as possible or at preferred speed (Samson et al, 2000, 2001). Musselman and Brouwer found no gender differences in gait speed, but they only studied community-dwelling seniors in their seventies (Musselman & Brouwer, 2005). Schultz et al suggested that the source of gender differences in balance maintenance and recovery seems to lie primarily in differences in muscle strengths and speeds of muscle contraction once contraction is initiated, rather than in neural factors underlying the sensory processing or motor planning that leads to the initiation of muscle contraction (Schultz et al, 1997). This hypothesis is confirmed by the observations that women have less functional leg power and are less able to recover balance by taking a single rapid step during a forward fall (Kuh et al, 2005; Musselman & Brouwer, 2005; Samson et al, 2000; Wojcik et al, 1999). The high correlation between lower limb strength and timed walking tasks in women further explains their poorer walking performance (Ringsberg et al, 1999; Samson et al, 2000). Clinical assessment of balance: Normative data, and gender and age effects

GAIT AND DYNAMIC GAIT INDEX

When mentioned in the literature, walking with a narrow base of support is assessed in many different ways, making comparisons very difficult (Brinkman et al, 1996; Fregly et al, 1973; Gehlsen & Whaley, 1990; Giorgetti et al, 1998; Iverson et al, 1990). Potvin and colleagues, using only eight heel-to-toe steps, found no decrease in function with increasing age, whereas Brinkman reported an age effect*showing only descriptive data*using a 3-metre timed tandem walk, adding a 3-second time correction for every mistake (Brinkman et al, 1996; Potvin et al, 1980). The TG test showed a clear ceiling effect up to 60 years of age. Performance started to decline in the seventh decade, and almost half of the number of our volunteers in their seventies did not reach the 20 steps limit. Although all volunteers considered themselves ‘normal’ and an effort was made to exclude those subjects having disorders possibly impeding balance, tandem walking seems to be too difficult for this age group. Normative data of the DGI were never reported. Up to 60 years of age, a score of 23 or 24 should be reached by every individual. Percentile 5 values are presented in Table 5 for every decade.

Conclusions In summary, this study provides age-related values for the performance of adults, aged 20 years and over, on quasi-static and functional balance tests. Whenever needed, results are presented for men and women separately. An age effect is shown for almost all assessments, but the actual effect of decline was different for each test. We therefore suggest the use of different quasi-static balance tests depending on the age of the subject. For each test, based on the 5th percentile, a cut off time of 10 seconds is proposed as a marker of poor balance. In the third and fourth decades the preferred test is OLS-EC. This means that if a subject in his twenties or thirties can’t stand for 10 seconds on one leg with the eyes closed, he or she can be considered as having poor balance. It is important to realize that if elderly subjects fail this test, it is merely an age effect and not a sign of abnormality. The same rationale can be repeated for the fifth and sixth decades using a cut-off time of 10 seconds in tandem stance with eyes closed. In the seventh and eighth decades, the preferred test is standing on one leg with eyes open, again using a cut-off time of 10 seconds. Furthermore TUG times tend to be longer with increasing age, but never exceed 10 seconds. Both TG and DGI show a ceiling effect up to 60 years of age, with a rapid decline in performance for subjects in their seventies. Vereeck/Wuyts/Truijen/Van de Heyning

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A gender effect is noted in the TUG-test and the TR-EC. The finding that, when using field tests, middle-aged women especially have poorer balance, is consistent with the literature. The presented data can be used by clinicians in interpreting test results of clients. These simple, office-based tests can be helpful to document recovery of balance during therapy and to compare the patient’s performance with that of an asymptomatic reference group.

Acknowledgements Sofie De Bruyn, Tom David Van Meel, Elke Flies, Evy Jochems, An Bedeer, Ine`s Van der Wee, Mieke Hoppenbrouwers, and Griet Pauwels for their help with data collection and subject recruitment. This work was supported in part by grant BOF-AUHAproject 465.

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