Balance Performance on the Postural Stress Test: Comparison of Young Adults, Healthy Elderly, and Fallers Julie M Chandler,

Pamela W Duncan and Stephanie A Studenski PHYS THER. 1990; 70:410-415.

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Research Reporf

Balance Performance on the Postural Stress Test: Comparison of Young Adults, Healthy Elderly, and Fallers

The putpose of thI3 study was to compare the postural responses of thee groups of indiuid~ak--healthyyoung adults (n = 42; age, 20-40 yean); healtby, community-dwelling elderly indiuiduak (n = 66;age, 60-102 years), and elderly indiz/idLak with a history offrequent falls ( n = 10; age, 6 6 9 5 yean)--using the postural stress test (PST). i%e PST is a simple, clinically appliulble, quuntitative measure of a n individual's ability to withstand a series of graded destabilizing fwces applied at the level of the subject5 waist. Elderly fallers tend to score lower on the P , T than elderly nonfallen, but age-related d@wnces in pastural responses during the PST bate not been established. Each subject uundenvent the PST using a method and scoring procedure desm'bedpreuiously. Results of this study con$m previous findings that elderlyfallers score sign@cantly lolver on the PST than either young adult or nonfalling elderly individuals. i%I3 study also showed that there was no dtfeyence in balance strategy scores between the young adults and the healthy elderly subjects. W e f o r e , it appears that poor p e r j i i n c e on the PST cannot be anributed to age alone, but may be predictive of pathological processes that predkpase an individual to j i q w t falls. [Chandler JM, Duncan P K S t i SA. Balance p e r f o m m e on the postural stress test: comparison of young adul&,haltby elderly, and fallen Pbys 7ber.1990; 70:410-415.]

Julie M Chandler Pamela W Duncan Stephanie A Studenski

Key Words: Equilibrium; Geriatl^ltl^la; Tests and measurements,functional.

The postural adjustments underlying good standing balance are the result of integration of afferent input-proprioceptive, vestibular, and visualinto effective motor responses that minimize body sway and maintain the body's center of mass within its base

of support. Assessment of these components of standing balance is a basic pan of the evaluation of instability and falling in a variety of patients. Many quantitative methods for testing standing balance have been developed. The major quantitative methods

--

J Chandler, MS, PT, is Clinical Associate, Graduate Program in Physical Therapy, Duke University, PO Box 3965, Durham, KC 27710 (USA). Address all correspondence to Ms Chandler.
P Duncan, MA, F'T, is Associate Professor, Graduate Program in Physical Therapy, Duke Ilniversity. S Studenski, MD, is Assistant Professor, Department of Medicine, Duke University, and Chief, Reha. bilitation Medicine Service, Veteran's Administration Hospital, Durham, UC 27705. This research was conducted in the Department o f Physical Therapy at Duke University and in the Postural Control Laboratory at the Durham Veteran's Administration Hospital and was supported with Funding from the Charles A Dana Foundation Inc. This study was approved by the Duke University Institutional Review Board.
7bb article ulas submitted Janzuuy 18, 1983,and ulas accepted March 12, 1990.

that have evolved include 1) timed balance tests,',2 2) measures of static and dynamic postural sway that use force platforms or other instruments to measure body sway?.4 and 3) balance tests that challenge the subject's postural control system by perturbing the base of support and that analyze the subject's motor responses by integrated electromyography.5,6The cost and complexity of some of these tests make them impractical for clinical application. One safe, semi-quantitative, and inexpensive measure of balance performance introduced by Wolfson and colleagues7 is the postural stress test (PST). In this test, motor responses to postural perturbations of varying 410111

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Fig. 1. Scoring of the postural shes test. Ratings are based on the adaptit~eness o f balance strategies used @ subjectsfollowing (I%%, 3%,and 4% of body weighlj. Reponses are ranked in qualitatiz~ely decreasing order of adaptiveeach po.~teriorperturbation n e s . Balance strate@,scores of 2 through 0 indicate ineffective balance responses tbat u~ould remit in a fall. (Reprinted with permission @om the Ammencan Geriabia SocieQ and Wolfson LI, Whipple R, Amaman P, et al. Shesing the postural response: a quantitative method for testing balance.J Am Geriatr Soc. 1786;34:845-850.7)
degrees are measured during normal standing by using a simple pulleyweight system that displaces the center of gravity behnd the base of suppon.7 Specifically, the PST measures an individual's ability to withstand a series of destabilizing forces applied at the level of the subject's waist. Scoring of the postural responses is based on a ninepoint ordinal scale (Fig. I), where a score of 9 represents the most e5cient postural response and a score of 0 represents a complete failure to remain upright. Wolfson et al7 have used the PST primarily with elderly individuals and have determined 1) that elderly nursing-home residents who fall score signif cantly lower than elderly, nonfalling nursing-home residents or young controls and 2) that elderly, nonfalling nursing-home residents score significantly lower than young controls. They conclude that the PST can be used to effectively predict those at high risk for falling. Furthermore, because older subjects tended to have lower balance scores, Wolfson et a1 suggest that the PST can be used longitudinally to follow balance responses in an individual and that the PST can be used as a tool for further clarifying the nature of balance responses. Once individuals are identified to be at risk for falling, they may be aided by conditioning of balance responses or other interventions to counteract balance deficits. The authors' sample of nonfalling elderly individuals, however, consisted primarily of nursing-home residents, a group not representative of the healthy, community-dwelling, elderly population. It remains unclear, therefore, whether truly age-related differences in balance performance are measured by the PST. Age-related changes in postural control are well documented in the literature. Woollacott and colleagues6 cite evidence for changes at all levels of the postural control hierarchy in the aging motor system. Such changes appear to be greatest at the higher level of vestibular control, moderate at the level of automatic postural responses, and minimal at the monosynaptic level. Specifically, the authors report results of their own work showing that automatic postural responses were delayed and that synergistic organization of postural responses was altered in a group of elderly individuals (aged 61-75 years) who underwent sudden movement of the support surface. Furthermore, Overstall et a18 have reported that sway while standing on a nonmoving surface (static sway) increases with age, especially in women. In a group of individuals aged 75 to 84 years,

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Rrocklehurst et a19 found that static sway was also significantly increased in individuals who experienced chronic falls. Although such measures of static and dynamic postural control are sensitive to the effects of age, they require expensive equipment and are therefore not widely available for clinical use. The PST differs from these measures in that it is an inexpensive test that can he easily administered in a clinical setting. Wolfson et a17 demonstrated that the PST is sensitive to changes in postural control in both elderly nursing-home nonfallers and in elderly nursing-home fallers. It remains unclear, however, whether the PST is sensitive to alterations in postural control in healthy, community-dwelling, elderly individuals. The purpose of this study was to compare performance on the PST among three groups: 1) healthy young adults; 2) healthy, community-dwelling,nonfalling, elderly individuals; and 3) elderly individuals with a history of frequent falls. The research question of interest was whether age-related changes in balance performance are measureti by the PST. We hypothesized that there would be no difference in balance performance between the young adults and the healthy elderly subjects, but that there would be a significant ddference in balance performance between the elderly fallers and both young and elderly nonfallers.

Group
Elderly fallers

Table 1 . Subject Groups IdentiJied @ Age and Gender

Age ( ~ r ) X

Range

Gender M

Young adult controls Healthy elderly nonfallers

30.6 70.7 78.2

6.3 7.4 8.0

(2wo) (66102) (6695)

14 29 7

28 37 3

who has had two or more unexplained falls within the 6-month period prior to the study in the absence of syncope, acute illness, or an unusual environmental event or activity. A fall was defined as any disturbance of balance that results in a failure to maintain upright posture during routine activities. All healthy, community-dwelling, elderly volunteers were screened for a history of lower-quarter orthopedic problems, neurologic disease, dizziness, and visual deficits. Any volunteers who had a history of major orthopedic (eg, hip replacement, fused joint, or amputation), visual, neurologic, vestibular, or other balance disorder were excluded from the study. Informed consent was obtained from each individual prior to participation in the study. Subjects were recruited from the following sources: Duke University Medical Center (Durham, NC), the Durham Veteran's Administration Medical Center, Duke University medical and graduate schools, and the Duke University Aging Center's registry of healthy, communitydwelling, elderly individuals.
Fig. 2. Subject positioning,for the postural stress test. Subject stands with normal posture as weights are dropped along pullq track, providing a destabilizing ,force posteriorly.

Method
Subjects One hundred eighteen male and female volunteers participated in this study. The subjects were divided into three groups: 1) healthy young adult controls; 2) healthy, communitydwelling, nonfalling, elderly individuals; and 3) elderly fallers (Table 1). A faller was defined as an individual

Procedure
Each subject underwent the postural stress test as described by Wolfson et al.7 We designed a pulley-weight system and followed their testing procedure to deliver a destabilizing force at

the waist level of each subject. The subjects faced away from the pulley system and stood with their arms at their sides, their eyes open, and their feet in a normal, comfortable stance (Fig. 2). A weight belt was fastened around each subject's waist, and the pulley system was then attached to the belt at the subject's back. Each of three specified weights (llh%, 3%, and 4V"% of body weight, with a maximum weight of 10 Ib*) was used to produce a destabilizing force. For each trial, one investigator stood behind the subject, supported the weight, and then dropped it approxi-

'1 Ib = 0.4536 kg.

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mately 2 ftt along the pulley track, creating a posterior force at the subject's waist. A second investigator guarded the subject to ensure that he or she would not fall. A third investigator stood about 12 ft from the subject and videotaped the subject's performance on the PST. No visible cues were given to the subject by any of the investigators to indicate when the weights were about to be dropped. Prior to the start of the test, the subjects were informed that their balance would be disturbed and that their goal was to maintain their balance in whatever way was necessary during the test. No practice trials were performed. All subjects were guarded with similar care, regardless of whether they were fallers or nonfallers. Weights were dropped consistently in order of increasing magnitude; the subjects, however, were not informed about either the relative magnitude of the perturbing force or the exact moment that the perturbation would occur. Each subject performed a total of three trials.

A BSS of 6 or 5 is assigned if the sub-

ject takes one or two steps (balance strategy 6) or more than two steps (balance strategy 5) backward in addition to flexing the trunk and shoulder to recover balance. A BSS of 4 or 3 is assigned when a subject shows no evidence of trunk and shoulder synergies and compensates for posterior displacement solely by taking one or two steps (balance strategy 4) or more than two steps (balance strategy 3) backward. A BSS of 2 is assigned when the subject shows inadequate shoulder and trunk synergies and stepping reactions to recover balance. A BSS of 1 is assigned when the subject shows no synergies or stepping reactions but demonstrates a protective landing response in anticipation of a fall. A BSS of 0 is assigned when no corrective or protective landing responses are demonstrated. Each of three trials was scored for each subject. The total score for the three trials was calculated and referred to as the total BSS.7 A maximum total BSS of 27 (9 X 3 trials) was possible. All subjects tested (N = 118) were videotaped during each of the three PST trials. A sample (n = 88) of those tested was used to determine the interobserver agreement rate. Two observers independently viewed the videotapes and scored each trial. The number of trials in which there was total agreement between the observers was divided by the total number of trials (3 X 88) and multiplied by 100. The interobserver agreement rate was 89.2%. Being satisfied that our interobserver agreement for PST scoring was suficiently high, we proceeded to analyze the PST data for the three groups of subjects. In cases of disagreement, the BSS assigned by the third examiner was used. The investigators who scored balance responses from the videotapes may have been aware of the falling status

of the subject. Because scoring was based on the presence or absence of specific balance responses, however, they believed that their scoring was not influenced by knowledge about the subject.

Number of trials with effective balance. In addition to the total BSS, the number of trials with effective balance was recorded for each subject. E$ectiw balance was defined as the subject's ability to maintain upright posture without intervention of another person or object. A trial with effective balance, therefore, was associated with a BSS of 3 or above on the rating scale (Fig. 1). A maximum of three trials with effective balance was obtainable. Data Analysis
The total BSS for each subject was calculated by summing the BSSs across the three individual trials. Because of the ordinal nature of these data, the Kruskal-Wallis rank-order nonparametric statistical test was used to assess differences in the total BSSs among the three groups of subjects. Further pair-wise comparisons between groups were then made using Ryan's test for ordered data. The percentage of subjects in each group maintaining effective balance on each trial was calculated. A comparison of the number of effective balance trials among the three groups is presented graphically in Figure 3. To control for a potential age effect on total BSS between the healthy elderly subjects (mean age = 70.7 years) and the elderly fallers (mean age = 78.2 years), we reanalyzed the data, eliminating the data on all healthy elderly subjects aged 60 to 69 years from the analysis. The median total BSS of the remaining healthy elderly subjects (n = 37, mean age = 75.5 years) was 21, the same as that of the entire group of healthy elderly subjects, thereby yielding the same statistically significant result on the Kruskal-Wallis test. Subsequent discussion will therefore refer to results obtained on the entire group of

Scoring Balance strategy scores. The motor responses that the subject used to recover balance after each perturbation were videotaped. An RCA highquality camera-recorder* was located approximately 12 ft from the subject and about 45 degrees to the right of the frontal plane. Two of the three investigators independently viewed the videotape in order to score the subject's balance responses.
Scoring was based on the nine-point scale described by Wolfson et a17 (Fig. 1). A balance strategy score (HSS) of 9 represents the most eficient level of response in which only minor postural adjustments are used to recover balance. Balance strategy scores of 8 and 7 indicate that additional ankle, shoulder, or trunk motion is needed to maintain balance.

* ~ o d eCPR l 250, RCA Corp, Consumer Electronics Div, 600 N Sherman Dr, PO Box 1976, Indianapolis. IN 46206.

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healthy, community-dwelling, elderly subiects.

Fallers (n=10) Healthy Elderly (n=66) Young Adults (n=42)

There was a significant difference in the ranks of the BSSs across the three groups (H = 21.94, d f = 2, p < .01). Post hoc analysis (Ryan's test for ordered data) demonstrated a significant difference in the ranks of the BSSs between the young adult controls and the fallers and between the healthy elderly subjects and the fallers, but not between the healthy elderly subjects and the young adult controls (Table 2). All 118 subjects demonstrated effective balance on trial 1, the mildest perturbation (I%% of body weight). On trial 2 (3% of body weight), all young adult controls and healthy elderly subjects maintained effective balance, whereas only 60% of the fallers were able to d o so. On the third and most forceful perturbation (4%% of body weight), all of the young adult controls and all but one of the healthy elderly subjects were able to maintain effective balance. By contrast, only 50% of the fallers were able to maintain effective balance (Fig. 3).

100-

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Number of Trials with Effective Balance

Fig. 3 . Companion of the number of effective balance trials among the three groups. Fipre shows the percentage ofsu&ects in each group scoring 3 or higher (effective balance) on each of the three postural stress test trials. At least 98% of all su&ects in the young adult and healtby elderly groups scored 3 or higher on all three trials, whereas only 50% of the fallers were able to do so. Forty percent of the fallers had only one trial with effective balance.
three-step strategies, along with the shoulder and trunk synergies, to realign their center of gravity over their base of support. Balance strategy scores of 6 o r 5 were common for both groups. This latter finding is in contrast to that of Wolfson et a1,7 who found that elderly nonfalling nursing-home residents used less shoulder and trunk flexion during the more forceful perturbations and therefore received lower BSSs than the younger controls. They further suggest that the loss of

Our findings suggest that healthy, community-dwelling, elderly individuals demonstrate balance strategies similar to those of young adults as measured by the PST. Elderly fallers, however, showed significantly less effective balance strategies and were therefore more likely to fail portions of the test, especially as the backwardperturbation force increased. The balance strategies demonstrated by the healthy elderly subjects and the young adult controls follow the same pattern described by Wolfson et al.' In both studies, for example, elderly subjects and young adults primarily used an ankle dorsiflexion strategy at the lowest perturbation in order to effectively recover balance. A BSS of 9 was common in both groups. With increasing perturbations, both groups tended to use wellcontrolled one- to

Table 2. Comparison of Balance Strategy Scores (BSSs) Among the Three Su&ect
Groups
Total BSS Young Adults (n = 42)
Median BSS Median rank

Healthy Elderly (n = 66) 21

65

Fallers (n = 10) 12 4.5

2 1
65

Medlan BSS on each Trlal

Trial 1 ( 1l / 2 % BWB) Trial 2 (3% BW) Trial 3 ( 4 1 / 2 % BW)
"BW = body weight.

9
6 6

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shoulder and trunk flexion synergies in older nonfalling individuals represents a mild deterioration in postural response that may be associated with age alone. Because our study did not show a significant difference between BSSs on the PST in the young adults and the healthy elderly subjects, we hypothesize that the postural responses to backward perturbations, as meawred by the PST, d o not necessarily deteriorate with age. Wolfson and colleague^'^ observation is more likely related to the fact their their sample of nonfalling nursing-home residents is not representative of the healthy, community-dwelling, elderly population. Our finding that elderly fallers showed significantly less effective balance strategies on the PST than either nonfalling elderly subject5 or young adult controls is similar to that reported by Wolfson et al.' At the lowest perturbation, RSSs ranged from 7 to 3, indicating that subtle, covert postural adjustments (as described by a BSS of 9) were not sufficient to recover balance. At the more forceful perturbations, fallers typically took multiple small steps backward, with or without associated trunk and shoulder synergies, but often failed to recover their balance without intervention from one of the examiners. Although there were gender differences between our group of healthy,

community-dwelling, elderly subjects (56% women) and our group of elderly fallers (30% women), we d o not believe that gender account? for the differences in RSSs on the PST between the two groups. Insubstantial evidence exists in the literature to suggest that gender significantly influences age-related changes in postural control. Overstall et aln found that static sway increased with age, especially in women. In a more recent study, Rrocklehurst et a19 found that sway wa5 influenced by age only, not by gender. To date, no other investigator has shown that there are significant differences between men and women in postural control mea5ures. Overstall and a5sociates'n finding that women may show increased sway should not be overlooked. However, the fact that our sample of fallers consisted primarily of men and our sample of healthy, nonfalling, elderly subjects consisted primarily of women strengthens our argument that gender did not contribute significantly to our findings.

our conclusions. Yet, the relatively high incidence of ineffective balance responses (BSSs of 2 or less), coupled with relatively low RSSs on the PST in the elderly fallers as compared with the healthy elderly subjects and the young adult controls, suggest5 that the PST may be a sensitive, easily administered clinical tool for identifying and monitoring individuals who have serious balance deficits. Further testing of the PST in a larger sample of elderly fallers is warranted.
References
1 Potvin AR, Syndulko K, Tourtellotte WW, et al. Human neurological function and the aging process. J A m Gerian Soc. 1980;28:1-9. 2 Bohannon RW, Larkin PA, Cook AC, et al. Decrease in timed balance test scores with aging. P@s 7bm. 1984;64:1067-1070. 3 Fernie GR, Gryfe CI, Halliday PJ, et a]. The relationship of postural sway in standing to the incidence of falls in geriatric subjects. Age Ageing 1982;l:ll-16. 4 Shimba T. An estimation of center of gravity from force platform data. J Biomech. 1984;17:5>60. 5 Nashner LM. Fixed patterns of rapid posture during stance responses among leg ~nuscles Exp Brairz Kes 1977;30:1>24. 6 Woollacott MH, Shumway-Cook A, Nashner I.M. Postural reflexes and aging. In: Mortimer J, Pirozzolo F, Malletta G, eds. 7be Aging Ner11ou< System. New York, NY: Praeger Publishers; 1982:98. 7 Wolfson LI, Whipple R, k n e r m a n P, et al. Stressing the postural response: a quantitative method for testing balance. J Am Gerian Soc. 1986;34:84>850. 8 Overstall PW, Exton-Smith AN, Imms FJ, et al. Falls in the elderly related to postural imbalance. Br Med J. 1977;1:261-264. 9 Brocklehurst JC, Robenson D, James-Groom P: Clinical correlates of sway in old age: sensory modalities. Age Ageing. 1982;ll :I-10.

Summary
Based on data from our large sample of healthy, community-dwelling, nonfalling, elderly individuals, it appears that the PST may not be sensitive enough to detect subtle age-related deteriorations in postural control. In addition, the fact that our sample of elderly fallers was limited to only 10 subjects may restrict the strength of

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Balance Performance on the Postural Stress Test: Comparison of Young Adults, Healthy Elderly, and Fallers Julie M Chandler, Pamela W Duncan and Stephanie A Studenski PHYS THER. 1990; 70:410-415.

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