Assessment of the components of stance and dynamic balance in elderly patients after stroke

Evaluarea componentelor echilibrului static i dinamic la pacientul vrstnic post AVC

Ciobanu Doriana1, Niu Cristian2, Deac Anca3

University of Oradea, FGTS, Department of Physical Education, Sports and Physical Therapy 1,2,3
Str. Universitii, nr.1, Oradea, Bihor

Abstract
The purpose of this paper work is to establish the extent in which stroke affects the hemiplaegic patients capacity to
maintain balance and if the location, type of stroke and gender of patient can influence its evolution.
Material and method: 20 subjects were assessed: 17 men, 13 women, average age 56.637.63, 10 subjects with
hemoragic stroke and 10 with ischemic stroke, 14 with right hemiplaegia, 16 with left hemiplaegia. The period of time
passed since the accident was about 2.77 years. The following components were assessed: motor, sensitive and
cognitive of stance balance (quiet stance with eyes closed/open, on the floor and foam) and dynamic balance (10 m
walking, time up and go! TUG) and Activities Specific Confidence Scale (ASCS).
Results. There were significant differences between subjects with hemorrhagic and ischemic AVC regarding ASCS
[t(28) = 3,98; p<0,05]; 10MWT [t(28) = -4,28; p<0,05] i TUG [t(28) = - 5,32; p<0,05]; cognitive component in 10MM
(28) = 3,45; p<0,05], TUG [t (28) = 0,80; p<0,05] and quiet stance on foam/eyes closed [U = -2,74; p<0,05], Quiet
Stance on Foam/cognitive component [U = 50; p>0,05], Quiet stance on foam/ eyes closed/ cognitive component [U =
42; p>0,05]. There are significant differences between 10MWT/10MWT with cognitive component [ t (29)= 0,61; p<
0.05] and also TUG/ TUG with cognitive component [t (29)= 13,75; p< 0.05].
Conclusions: Stance and dynamic balance is affected in all cases, especially in ischemic stroke localized on the righr
side. Localization, type of stroke and gender of patients influence the evolution of balance in hemiplaegic patients.
Key words: cerebrovascular accident,balance assessment, 10 m Walk Test, TUG, Balance Confidence Scale

Rezumat
Lucrarea de fa i propune s stabileasc msura n care AVC-ul afecteaz capacitatea hemiplegicului de a-i
meninere echilibrului i dac localizarea, tipul AVC i genul pacienilor i pot influena evoluia.
Material i metod: S-au evaluat 20 de subieci: 17 brbai, 13 femei, vrsta medie 56,637,63, 10 subiecti cu AVC
hemoragic i 10 cu AVC ischemic, 14 cu hemiplegie dreapta, 16 cu hemiplegie stnga. Timpul trecut de la accident in
medie de 2,77 ani. S-au evaluat componentele motorie, senzitiv, i cognitiv a echilibrului static (stnd cu ochii
nchii/ deschii, pe podea i placa de burete) i dinamic (10 m mers, ridic-te i mergi! TUG) i Activities Specific
Confidence Scale(ASCS).
Rezultate. Exist diferene semnificative ntre subiecii cu AVC hemoragic i ischemic, privind ASCS [t(28) = 3,98;
p<0,05]; 10MM [t(28) = -4,28; p<0,05] i TUG [t(28) = - 5,32; p<0,05]; componenta cognitiv la 10MM (28) = 3,45;
p<0,05], TUG [t (28) = 0,80; p<0,05] i stnd pe burete/ ochii nchii [U = -2,74; p<0,05], stnd pe burete/ componenta
cognitiv [U = 50; p>0,05], stnd pe burete/ ochii nchii/ componenta cognitiv [U = 42; p>0,05]. Exist diferene
semnificative ntre 10MWT/10MWT cu component cognitiv [t (29)= 0,61; p< 0.05] i de asemenea ntre TUG/ TUG
cu component cognitiv [t (29)= 13,75; p< 0.05].
Concluzii: Echilibrul static i dinamic este afectat n toate cazurile, cu preponderen n cazurile de accident vascular
cerebral ischemic localizat pe partea dreapt. Localizarea, tipul AVC i genul pacienilor influeneaz evoluia
echilibrului la pacienii hemiplegici.
Cuvinte cheie: accident vascular cerebral, evaluare, echilibru, test 10 m mers, TUG, Balance Confidence Scale

Introduction
In our society, CVS is a major health problem, being responsible for a series of physical and mental
disabilities of elderly population. [1] European statistics reveal a yearly incidence rate of 300 to 100,000
inhabitants, aged between 35 and 64 years. This rate increases exponentially with age, reaching 3,000 to
100,000 inhabitants for the population over 85 years old. [2]
L.P. Matveev (1980) defined balance as the capacity to maintain a body position. He was also the one
who made the distinction between balance in stance and dynamic balance, i.e., balance in motion. Balance is
a component of coordinating capacities which, according to Blume (1981), quoted by R. Mano (1992) are
organized under the form of a system. An individuals balance capacity, as a copmonent of coordination
capacities, is conditioned by the way in which the peripheral sensitive receptors permanently send
information regarding the environment, position of body segments compared to the entire body. [3]
Maintaining balance for a certain period of time depends on several factors, out of which some are
genetically conditioned, reflexes having an importan role in this respect. [4] Achieving balance requires the
fullfilment of certain conditions, such as: activation of postural muscles should be made according to each
situation; the selection of certain strategic postural responses should be proper and fast; the sensorial
information of detecting position and movements should be intact. Therefore, in achieving body balance of
this extremely important body function, the peripheral inputs arrived from bilateral visual, somato-sensitive
and vestibular receptors peripheral reception, contribute a lot. There are also added the information arrived
from cutaneous receptors (mechano-ceptors). All inputs of the three szstems are integrated in the sensitive
central structures which compare the information arrived through the three systems as well as from the two
body parts and to accomplish the organization in a coherent informational whole. [5] Body balance can be
affected or even lost in situations which overpass the limit values of any of the above mentioned elements.
Balance is frequently disturbed after stroke, with frequent disfunctions in stability, symmetry and
dynamic stability. [6,7,8] Problems might occur at distabilizing external forces reaction (reactive postural
control) or during movement self-initiation (anticipating postural control). Thus, patients are not able to
maintain balance in sitting position or in orthostatic one or change their posture without loosing balance. The
disturbance of central sensori-motor process may lead to the inability of adjusting postural movements to
environmental requirements and it may also lead to motor learning difficulties [7,9].
The CVS patients usually present asymmetry in sitting position or in orthostatics with most of their
wight translated on the unaffected side. They also present an increase in postural balance in orthostatic
position. The delay in motor activity, timing and sequentiality of abnormal muscular activity with an
abnormal contraction, determines disorganization within postural synergies. The specific compensatory
response includes the excessive movements of hip and knee. The corrective responses to disturbances or
unstabilizing forces are usually improper and losses of balance may occur. Patients with hemiplaegia usually
fall towards paralysis. [10] The loss of trunk control is a deficit often noticed after CVS. It may lead to the
following problems: disorders in limb control, increase of collapse/falling risk, loss of ability to interact with
the environment, secondary visual disorders caused by the loss of head/neck/trunk alignment, low
independence in practicing ADLs. [2]
The most frequent compensatory movements and strategies are: wide support base for feet and/or spread
knees, willing movement restriction, the patient standing rigidly and even holding their breath; they loose
their balance even during a deeper breath-in; they do not perform hip flexion when they bend forward, the
flexion is made from trunk and neck; if they are asked to lean sideway to pick up an object from the ground,
they lean forward and laterally because lateral body flexion is poorly controlled, the patients drag their feet
instead of making adjustments with the proper segments. [11]
Hypothesis. The elderly patient after CVS, presents alteration of quiet stance and dynamic balance,
presenting significant differences between men and women, ischemic and hemorrhagic types, as well as
between hemiplaegia localized on the right and left side.
Purpose. The purpose of this paper work is to assess quiet stance and dynamic balance in post CVS patients
and to establish if the balance disorders are related to patients gender (men/women), CVS localization
(left/right hemisphere), as well as CVS type (hemorrhagic or ischemic).
Material and method
Subjects. The assessment was randomized within Medical Rehabilitation Clinical Hospital Felix Spa, on
a number of 30 subjects with hemiplaegia, whoc can walk at least 30 m unassisted, 17 men and 13 women,
aged between 45 and 70 (average age 56.63 7.63). 14 subjects have CVS of hemorrhagic type and 16
subjects have CVS of ischemic type. 16 of the subjects presented hemiplaegia on the left side and 14 on the
right. The period of time passed since the accident was between 4 months and 5 years, the average being of
2.77 1.74 years.
Assessment methods. The followings were tested: quiet stance, proactive balance and patients
confidence in their capacity to maintain balance. When testing the quiet stance, there were assessed the
motor, sensitive, vestibular and visual components.
a. The quiert stance was assessed as follows:
A) The somato-sensitive component was tested in the following positions: standing 2 min,
standing with eyes closed, standing with eyes closed and asking questions cognitive component
(to make maintaining balance more difficult), the subject was asked to stand as straight as
possible.
B) The vestibular component was tested under the following circumstances: on a foam board
(special one to test balance), in orthostatic position, secured in case of falling, with eyes closed
for 10 minutes, just like above with the introduction of the cognitive component, the subject was
asked to stand as straight as possible.
C) The visual component was tested: on the same foam board with eyes open, secured in case of
loosing balance, the cognitive component was also introduced, the subject was asked to try to
stand as straight as possible.
 b. Dynamic balance was assessed with 10 m Walk Test (10MWT), to whitch we added the
assessment of cognitive component (during the test, each subject had to answer some questions). The
10MWT measures the time (in seconds) that it takes a patient to walk 10m; it assesses the short duration
walking speed. The individual walks without assistance 10 meters (32.8 feet) and the time is measured for
the intermediate 6 meters (19.7 feet) to allow for acceleration and deceleration. This test has been used in
gait studies of patients with neurologic movement disorders in general, as well as of patients with stroke and
Parkinson's disease. [12]
c. For proactive balance assesment, Timed "Up & Go" test (TUG) was used. The patiet is
asked to rise from a chair with handles, walk for 10 m as fast as they can and return to the chair. After that,
the patients have to perform one more time the test, but now they must answer some questions. Podsiadlo
D, Richardson S. (1991) demonstrated that the timed "Up & Go" test is a reliable and valid test for
quantifying functional mobility that may also be useful in following clinical change over time. The test is
quick, requires no special equipment or training, and is easily included as part of the routine medical
examination. [13]
d. Activities Specific Balance Confidence Scale (ASCS). For each item, the subject must indicate
his/ her level of confidence in doing the activity without losing balance or becoming unsteady. Subject must
choose one of the percentage points on the scale, form 0% to 100%. If the subject does not currently do the
activity in question, than they must try and imagine how confident they would be in case of doing the
activity. If the subject is normally using a walking aid to do the activity or hold onto someone, they will rate
their confidence as if they were using these supports. Scores mean as follows: 80% = high level of physical
functioning; 50-80% = moderate level of physical functioning; < 50% = low level of physical functioning
[14]. Less than 67% = older adults at risk for falling; predictive of future fall [15]
Nilsagrd YE, Forsberg A., (2012) investigated the practicability and sensitivity to change of the
Activities-specific Balance Confidence Scale (ABC) and the 12-item Walking Scale (WS-12) in persons at
different phases after stroke. The scales are practical to use and sensitive to change for persons with
remaining walking ability at different phases post stroke. [16]

Results
Results were statistically analysed with SPSS 15. For the comparison between men and women,
patients with hemorrhagic and ischemic stroke, regarding ASCS, 10MWT, TUG we used Independent
Sample T test. For comparison between men and women, patients with hemorrhagic and ischemic
stroke, regarding Quiet Stance, we used Two Independent Samples Test. Table 1 and 2 present the
comparison between the average scores of subjects with hemorrhagic and ischemic AVC, regarding
ASCS, 10MWT, TUG (with and without cognitive component). There were significant differences
between subjects with hemorrhagic and ischemic AVC regarding Activities Specific Confidence Scale
[t(28) = 3,98; p<0,05]; 10 m Walk Test [[t(28) = -4,28; p<0,05]; and Timed Up and Go [t(28) = - 5,32;
p<0,05].

Table 1. Comparison between hemorrhagic and ischemic subjects regarding

ASCS, 10MWT, TUG (with and without cognitive component)
Assessment tool Hemorrhagic Ischemic p significance
Activities Specific Confidence Scale (ASCS) 71.3616,67 48.27 15.09 0.000 s Tabl
e 2 10 m Walk Test (10MWT) 18.584,51 26.115.06 0.000 s
TUG 17.592.36 27.667.50 0.001 s
presents the comparison between the average scores of men and women, regarding ASCS, 10MWT, TUG
(with and without cognitive component). There were no significant differences between men and women
regarding Activities Specific Confidence Scale [t(28) = 0,70; p>0,05]; 10 m Walk Test [[t(28) = 1,62;
p>0,05]; and Timed Up and Go [t(28) = 2,21; p>0,05]. Significant differences were found between scores of
10 m Walk Test with cognitive component [t (28) = 3,45; p<0,05], Timed Up and Go with cognitive
component [t (28) = 0,80; p<0,05], and Quiet stance on foam/ eyes closed [U = -2,74; p<0,05].
Table 3 presents the comparison between the average scores of subjects with right and left
hemiplaegia, regarding ASCS, 10MWT, TUG (with and without cognitive component). There were no
significant differences between subjects with hemorrhagic and ischemic AVC regarding Activities Specific
Confidence Scale [t(28) = 0,22; p>0,05]; 10 m Walk Test [t(28) =0,81; p>0,05]; and Timed Up and Go [t(28)
=1;86 p>0,05], 10 m Walk Test with cognitive component [t (28) = -0,89; p>0,05] and Timed Up and Go
with cognitive component [t (28) = 0,46; p>0,05]. Regardind balance in quiet stance assessment, there
are significant differences between subjects with left and right hemiplegia [U = 87; p>0,05]. Also, there were
significant differences for Quiet Stance on Foam [U = 43; p>0,05], Quiet stance on foam/ eyes closed [U =
44; p>0,05], Quiet Stance on Foam/cognitive component [U = 50; p>0,05], Quiet stance on foam/ eyes
closed/ cognitive component [U = 42; p>0,05].

Table 2. Comparison between men and women, regarding

ASCS, 10MWT, TUG (with and without cognitive component) and Quiet stance on foam/eyes closed
Assessment tool Men Women p significance
Activities Specific Confidence Scale 59.9515,07 47.7524.96 0.875 ns
10 m Walk Test 24.285,20 20.606.90 0.113 ns
TUG 24.827.94 22.188.58 0.375 ns
10mWalt Test with cognitive component 25.596.00 25.507.88 0.002 s
TUG with cognitive component 5.1950.68 4.370.63 0.002 s
Quiet stance on foam/ eyes closed 18.50 10.69 0.005 s

Table 3. Comparison between right and left hemiplaegia, regarding ASCS, 10MWT, TUG (with and without
cognitive component) and Quiet stancewith sensitive, vestibular and cognitive component
Assessment tool Right side Left side p significance
Activities Specific Confidence Scale 58.1924.42 60.5614.88 0.753 ns
10 m Walk Test 24.325,72 21.046.39 0.157 ns
TUG 25.3897.34 22.0168.18 0.254 ns
10mWalt Test with cognitive component 22.456.90 21.397.26 0.690 ns
TUG with cognitive component 4.750.81 4.960.88 0.596 ns
Quiet stance 13.14 16.73 0.201 ns
Quiet stance on foam 10.54 19.17 0.002 s
Quiet stance on foam/ eyes closed 10.50 19.20 0.003 s
Quiet stance/ cognitive component 13.93 16 0.438 ns
Quiet stance on foam/cognitive component 11.04 18.40 0.005 s
Quiet stance on foam/eyes closed/ cognitive comp. 10.39 19.30 0.003 s
Regarding the assessment of cognitive component influence on balance, we found that there are significant
differences between 10MWT and 10MWT with cognitive component [ t (29)= 0,61; p< 0.05] and also
between TUG and TUG with cognitive component [t (29)= 13,75; p< 0.05]. (table 4)

Table 4. Mean scores for 10MWT and TUG with and without cognitive component
Assessment tool meanstd.dev. p significance
10 m Walk Test 16.90 6.19
0.040 s
10 m Walk Test with cognitive component 22.636.98
TUG 16.827.84
0,000 s
TUG with cognitive component 26.64 0.77

Discussions
Subjects with hemorrhagic CVS showed an increased confidence in their ability to perform specific
activities (71.3616,67) than those with ischemic CVS (48.27 15.09). Having in mind that the best score is
100% and the worst is 0%, this means that patients with hemorrhagic CVS, with an average score of 71%,
have moderate level of physical functioning, compared to patients with an ischemic CVS. In our study, this
goup of patients had an average score less than 50%, meaning that patients with an ischemic CVS have a low
level of physical functioning, meaning a poor confidence in their abilities to maintain balance durind task
specific activities. Men (58%) seem to have a more moderate level of physical functioning than women
(48%) who have a low level of physical functioning, but with no significant difference beteween those two
groups. Physical functioning has a moderate level both in patients with right and left hemiplaegia, average
scores being 58 60%. In their study, Olayinka Obembe at all. (2011) found that man are more confident
than women, but in thier study it was a significant difference between the two groups. They also found that
ischemic stroke survivors had higher balance confidence. This study found significant difference between
balance performance in hemorrhagic and ischemic hemiparetic stroke survivors. [17] This finding is contrary
to the findings in the study by Salbach et al. who reported that balance self-efficacy was unrelated to stroke
characteristics, such as the type of stroke and the number of strokes sustained. [18] Their average ratings
were 59 and 60 points on the ABC scale in persons with ischemic and hemorrhagic stroke, respectively. But
in agreement with their study, this study found balance confidence to be unrelated to the side of stroke.
This study found no significant difference between stroke survivors with right-sided affectation and
those with left-sided affectation. This finding is in agreement with Andrew and colleagues who found no
association between functional outcome and laterality in patients with stroke. [19]
There were significant differences between subjects with hemorrhagic and ischemic AVC regarding
10 m Walk Test and Timed Up and Go. The first group had an average time of 18 minutes for walking 10 m,
and the second group needed 26 seconds to perform tis task. We found no significant differences between
men and women or between right-sided and left-sided hemiplaegia.
TUG had an average score of 18 seconds for hemorrhagic patients and 28 for ischemic patients,
difference between two groups being significant. There is no significant difference between man and
women and between right-sided and left-sided hemiplegic patients. They had an average score between
18 26 seconds for 10MWT and between 18 and 28 seconds for TUG.
Regardind balance in quiet stance assessment, there are significant differences between subjects with
left and right hemiplaegia. Subjects with left-sided hemiplaegia had a better score (19 seconds) than subjects
with right-sided hemiplegia, who were able to maintain balance on foam only for 11 seconds. Also, subjects
with left-sided hemiplegia were able to stand on foam, with eyes closed about 19 seconds, and subjects with
right-sided hemiplaegia were able to maintain their balance on foam, eyes closed, just 11 seconds. This
means that patients with right sided hemiplaegia had a sensory loss greater thath those with left-sided
hemiplegia.
For the assessment of cogninitive component of balance patient was asked to maintain his balance on
foam and answer some questions, and than he was asked to close his eyes, too. A significand difference had
been observed between patients with left-sided hemiplegia, who were able to maintain balance, on foam and
answer some questions, for 18 seconds, and subjects with right sided hemiplegia, who were able to do the
same thing only for 11 seconds. With eyes closed patient with left-sided hemiplegia were ablr to maintain
balance and answer some questions in the same time, for 14 seconds, and subjects with right-sided
hemiplegia for 10 seconds. This means that, in the case of the subjects with right-sided hemiplegia,
cognitive component interfered with the ability to maintain balance more than in subjects with left-sided
hemiplegia. In our study, age-related changes in balance because of cognitive component showed a greater
interference in women than in men. Women were able to perform the task for an average time of 10 seconds,
and men for an average time of 18 seconds.
Regarding the assessment of cognitive-related balance component, we found that there are
significant differences between 10MWT and 10MWT with cognitive component and also between TUG
and TUG with cognitive component. The average time for walking 10 m was 17 seconds and when they
needed to answer some question, their average time increased to 23 seconds. The same thing happened when
performing TUG. Subjects had an average time of 17 sec, and when was addedd the answering task, the
average time increased to 27 seconds.
The intervention of cognitive component determines the highest degree of unbalance. Out of a total of 30
subjects, presented total unbalance. It is to be mentioned the fact that out of these, there were more
subjects with right sided CVS. In three subjects, total unbalance occurred only when the cognitive
component was added in the assessment. Most subjects from the left sided CVS group presented medium
balance. It can be stated that the most affected group was the one with ischemic type CVS and, respectively,
left sided CVS. Individuals with right sided CVS (some of the cases) presented difficulties in understanding
and cooperating, requiring exemplification of requirements in all assessments.
In the Assessment of vestibular component of balance, both men and women had poor results.
The vestibular component is very affected because the majority of subjects had a severe unbalance
when standing on foam, with eyes closed.
Conclusions
In conclusion, quiet stance and dynamic balance are affected in all cases, especially in cases of
ischemic cerebro-vascular accident localized on the right side. These subjects, besides the the unbalance
imposed by disease, also present difficulties in understanding, cooperation and executing the assessment
steps.
Regarding balance components, the vestibular component is the most affected one, being drastically
emphasized when the cognitive component is introduced, followed by the visual component and then,
closely, by the somato-sensitive one. The CVS type, its localization and gender of subjects are factors which
may influence balance evolution and its changes. That is why it is important that in orienting the kinetic
treatment, these aspects should be taken into consideration. In all cases, the cognitive component interferes
greatly with balance, the latter being much more difficult to maintain when the subject must execute a
cognitive task. In approaching balance reeducation, it is compulsory the assessment of all types of balance
and, at the same time, of all its components, in order to have an image as complete as possible of their
affectation. This way, a correct orientation of kinetic intervention will be provided. Assessment is also
important in predicting the patients capacity to accomplish safly their daily activities, considering that daily
living requires very much the presence of reactive balance, necessary in performing purposful activities.
Balance assessment is also important in allowing the patients to acknowledge their real capacity to maintain
balance, fact which will allow the decrease of falling and injury risks, already existent in old age.
In conclusion, balance assessment is compulsory when the patient is released from rehabilitaiton,
exactly because it establishes the extent in which the patients are capable to safely perform daily activities.
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