Gait & Posture 27 (2008) 471477 www.elsevier.

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The relation between postural stability and weight distribution in healthy subjects
Linda C. Anker a, Vivian Weerdesteyn a,b,*, Ilse J.W. van Nes a,b, Bart Nienhuis a, Huub Straatman c, Alexander C.H. Geurts b
a Sint Maartenskliniek Research, Development and Education, Nijmegen, The Netherlands Department of Rehabilitation, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands c Department of Epidemiology and Biostatistics, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands b

Received 12 October 2006; received in revised form 14 May 2007; accepted 9 June 2007

Abstract Knowledge of the effects of leg-loading asymmetry on postural control and control asymmetry during quiet upright standing in healthy young and middle-aged subjects is necessary before these relationships in patients with lateralized disorders can be assessed and understood. A posturographic procedure was developed, using a dual-plate force platform, during which 10 younger and 10 middle-aged healthy individuals were required to adopt various degrees of (a) symmetrical weight distributions (0, 5, 10, 20 and 30% of extra body weight loaded onto either leg). Postural control and control asymmetry were quantied by centre of pressure (CP) uctuations in the lateral (LAT) and anteriorposterior (AP) directions under both feet together and individually. Subsequently, the relationship between weight distribution on one hand and postural control and control asymmetry on the other hand, was calculated. Results demonstrated that with increasing weightbearing asymmetry (WBA), the overall control of postural sway velocity increased mainly in the LAT direction, where a rst-order polynomial function tted best. The asymmetry of control of postural sway velocity increased with increasing weight-bearing asymmetry in favour of the more loaded leg in LAT and AP directions. A rst-order polynomial was used for both AP and LAT direction. Effects of weightbearing asymmetry on postural control and control asymmetry are due to changes in the biomechanical constraints of upright standing. It was suggested that through increasing weight-bearing asymmetry the postural instability increased by reducing the efciency of hip load/unload mechanisms and increasing the (compensatory) ankle moments. # 2007 Elsevier B.V. All rights reserved.
Keywords: Weight-bearing asymmetry; Postural control; Control asymmetry

1. Introduction Both central and peripheral diseases may cause deterioration of postural control and, especially in the case of lateralized disease, abnormal asymmetry in weight distribution between the legs [18]. In most patients with lateralized disease it remains unclear to what extent the persistent leg-loading asymmetry reects fear or inability to cope with the altered sensorimotor constraints (and thus can
* Corresponding author at: Department of Rehabilitation, Radboud University, Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. Tel.: +31 24 36 14 804. E-mail address: v.weerdesteyn@reval.umcn.nl (V. Weerdesteyn). 0966-6362/$ see front matter # 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.gaitpost.2007.06.002

be regarded as a maladaptive strategy) or reects an inherent capacity of the central nervous system to adopt a position in which the body sway is optimally controlled (given the sensorimotor impairments). Generally, when postural instability coincides with weight-bearing asymmetry, it is unclear to what extent the decreased stability is related to altered biomechanical constraints or should be considered as a consequence of a neural control problem (e.g. due to pathology). For healthy elderly, a greater weight-bearing asymmetry (WBA) was associated with increased anterior posterior (AP) postural sway [9,10]. Similar but less strong associations between weight-bearing asymmetry and postural control have been reported for stroke patients [2,10,11]. Between-subjects comparisons, however, can provide only

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limited insight into the relationship between WBA and stability due to possible inter-individual differences in postural strategies. In order to further unravel this relationship in various types of patients with lateralized disorders, and to understand to what extent their postural instability can be attributed to WBA, it is necessary to know the effects of legloading asymmetry on postural control in healthy subjects. Although, theoretically, a fully symmetrical standing posture provides maximum stability, at least in healthy subjects [9,1214], the precise relationship between WBA (in the frontal plane) and postural stability (in both the frontal and sagittal planes) during normal quiet standing is unknown. In other words, which degree of WBA provokes which degree of stability loss and control asymmetry in healthy subjects? As yet, only one study has been published that investigated the within-subjects relationship between weight distribution and postural control in healthy adults. Genthon and Rougier [15] demonstrated the negative effects of an asymmetrical body weight distribution on the control of undisturbed upright stance. They reported that the amplitudes of the centre of pressure (CP) under both feet increased with increasing weight-bearing asymmetry in both the lateral (LAT) and AP directions, however, most pronounced in the LAT direction. Remarkably, this effect was stronger for the unloaded leg than the loaded one. However, this study did not look at the CP velocity, which is frequency sensitive and a more reliable parameter in the clinical quantication of postural control than CP amplitude [1618], and did not calculate the precise relationship between WBA and changes in postural stability or kinetic regulation symmetry (i.e., the symmetry in regulation activity between the loaded and unloaded leg). Precise mathematical relationships are essential to correctly interpret postural instability and regulation asymmetry given the concomitant WBA and to adjust these measures for the degree of WBA in a particular test or condition. This would improve the comparability of individual measurements as well as of group data. The aim of this study was to examine the within-subjects relationship between weight distribution on the one hand and postural control and control asymmetry on the other hand, during quiet upright standing in healthy adults. For this purpose a posturographic procedure was developed during which participants were forced to adopt various standardized asymmetric weight-bearing positions.

in the middle-aged group. Subjects with neurological or orthopaedic diseases or with visual or other sensory decits were excluded. All participants gave their written informed consent. Approval was obtained from the institutional ethical committee. 2.2. Posturography Postural control was measured by using a force platform consisting of two separate aluminium plates. Each plate was placed on three transducers (hysteresis and non-linearity <1%), which recorded the vertical ground reaction forces [16]. Signals were processed by six dc ampliers (nonlinearity <0.1%) and rst-order low-pass lters with a cutoff frequency of 30 Hz. Data were stored after a 16-bit AD conversion at a sampling rate of 500 Hz. By means of digital moment-force calculations, the point of application of the resultant of the ground reaction forces (centre of pressure) was determined in a two-dimensional transverse plane for each sample, with a maximum error of 1 mm [19] in the LAT and AP directions. The coordinates of the CP displacements were passed through a digital, low-pass Fourier lter with a 6 Hz cut-off frequency to eliminate high-frequency components due to noise. For safety purposes, two parallel support bars were placed beside the force platform. Real-size visual CP feedback was provided through a computer screen that was placed 1 m in front of the participants. The lag time between movement of the CP and the cursor was about 16 ms. 2.3. Procedure During posturography, the participants stood barefoot on the force platform with their arms alongside their trunk and their feet against a xed foot frame (medial sides of the heels 8.4 cm apart and each foot placed with toes outward at a 98 angle from the sagittal midline). The reference width, which corresponded to the distance between the anterior borders of the distal tibiae while standing on the platform, was determined (Fig. 1a). All balance tasks were done while facing the computer screen. Subjects were instructed to stand quietly upright with their eyes open for 20 s during all balance tasks. One test series consisted of 10 different balance tasks. During the rst task, participants faced a grey computer screen (reference task). During the second task, participants were asked to stand symmetrically by maintaining their CP (represented as a black circle) as still as possible within the limits of a vertical target bar presented in the middle of the computer screen (Fig. 1c). The width of the bar was always xed at 5% of the reference width of each participant. In this way, the participants had to maintain their CP between limits corresponding with 47.5% and 52.5% of body-weight loading on either leg (reference feedback task) (Fig. 1c). The following eight tasks were randomized in order. They assessed various degrees of forced weight-bearing asymmetry in both directions by positioning

2. Methods 2.1. Participants Twenty healthy individuals participated in this study. Four men and six women (mean age S.D. 25.8 2.5 years) were included in the young group. Five men and ve women (mean age S.D. 51.6 3.3 years) were included

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and LAT directions separately. After a rst-order differentiation, the RMS CP velocity (VCP) was calculated. As for the analysis of the CP displacements for each foot separately, the reference coordinate system was rotated 98 to the left or to the right of the sagittal midline, according to the position of the left and right foot, respectively, to obtain CP measures congruent with the anatomical orientation of the respective ankle joints (Fig. 1b). Then, calculation of the above-mentioned ACP and VCP values provided measures of the CP modulation under each foot separately in both the AP and LAT directions. To express the degree of kinetic regulation asymmetry, the symmetry index (SI) was calculated according to the following equation: SI 2 Y Loaded Y Unloaded 100% Y Loaded Y Unloaded

In this equation, YLoaded and YUnloaded are CP parameters derived from the CP uctuations under the loaded and unloaded foot, respectively. The SI is 0 if there is perfect symmetry. Positive values of SI indicate more CP modulation of the loaded leg. 2.5. Statistical analysis All balance parameters obtained from corresponding tasks in each of the two test series were averaged. The balance parameters from the nine tasks with visual feedback were individually normalised. The differences between these parameters and their values as obtained from the reference task without feedback were divided by the latter value and multiplied by 100%. In this way, all feedback performances were represented as a percentage change with respect to the reference task. It is possible that not only WBA, but also visual feedback itself has an effect on CP parameters. By normalisation with respect to the nonfeedback condition, the presence of feedback effects could be identied as any signicant non-zero normalised value in the 0% WBA condition, as tested by one-sample t-tests. We assumed that if present, feedback effects would be constant for all WBA conditions. All normalised parameters were tested in a three-way ANOVA using Group (young versus middle-aged) as a between-subjects factor and Side (left and right) and WBA (0%, 5%, 10%, 20%, 30%) as withinsubjects factors. When signicant main effects of weight distribution were detected, a random coefcient (RC) regression model (utilizing the SAS procedure PROC MIXED with a random effects maximum likelihood regression procedure) was used to investigate the mathematical relationship between the degree of WBA and the normalised balance parameters. This procedure gives a log likelihood for each estimated model. The difference in 2 log likelihood between two models (one model has one or two extra parameter(s)) is an indication of the adequacy of the model. The difference follows a x2 distribution with one or two degree(s) of freedom. If this difference in 2 log

Fig. 1. (a) The position of the feet and the reference width. (b) The denition of the different directions of the right foot. (c) Scheme of the target bar, positioned at the sagittal midline.

the target bar at corresponding distances from the vertical midline of the screen. These distances were calculated individually based on the subjects reference width. To prevent fatigue, the direction of the forced weight-bearing asymmetry was changed after each test. The applied degrees of asymmetrical weight loading were 5%, 10%, 20% and 30% of the extra body weight (above 50%) loaded onto either leg. Each test was preceded by a 5 s anticipation period followed by a low-frequency starting tone. After the rst test series, the complete sequence was repeated, so that eventually 20 tests were obtained for each subject. 2.4. Data analysis First, the amplitude variability (ACP) of the overall CP uctuations was determined by calculating the root mean square (RMS) as an estimation of the body sway in the AP

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likelihood is signicant, then the most complex model is selected. Data were tted in rst-order to third-order polynomials functions. The corresponding statistical model used to analyze the intra-individual relationship between a normalised balance parameter (Y) and weight-bearing asymmetry for the group as a whole is given in the following polynomial equations [20]. The index i denotes the subject identication (i = 120), whereas WBAt denotes the WBA at t = 0%, 5%, 10%, 20% and 30%, respectively. Y it bi b0 b1 WBAt eit first order

Y it bi b0 b1 WBAt b2 WBAt 2 eit second order Y it bi b0 b1 WBAt b2 WBAt 2 b3 WBAt 3 eit third order

In these equations, Yit are the observations for subject i at measurement t, bi the random intercept for individual i, b1, b2 and b3 the regression coefcients for the polynomial in WBA, and eit is the error for subject i at WBAt. In order to nd the best model, all models were compared to determine whether a higher order polynomial function was signicantly better or not.

3. Results All participants were able to maintain their CP within the borders of the target bar in each task. Table 1 summarizes the means and S.E.M.s for all parameters in both the frontal and the sagittal planes. Analysis revealed a signicant effect of visual feedback for VCP LAT ( p < 0.01). VCP signicantly increased by 29.8% during the reference feedback task compared to the reference task in the LAT direction (Table 1 and Fig. 2a). In AP direction, VCP signicantly decreased by 12.4% ( p < 0.01) and ACP signicantly increased by 21.4%

Fig. 2. Postural stability, expressed as the RMS of the overall CP velocities (VCP) in the frontal plane (a) and the sagittal plane (b) for the different degrees of weight-bearing asymmetry (WBA). The solid line is the mean. The dotted lines are the mean 1.96 overall S.D. The dashed line is the t of the model used.

( p < 0.05) (Fig. 2b). Visual feedback had no signicant effects on SI VCP and SI ACP (Table 1, Fig. 3a and b). A summary of the results of the three-way ANOVA with repeated measures is presented in Table 2. Main effects of WBA were present for all parameters, except for ACP in AP direction. Values of the various CP parameters increased with increasing degrees of WBA. There were no main effects of group and side, nor any interaction effects of WBA by group or by side, indicating that age and side did not have differential effects on postural stability over the

Table 1 Summary of the mean (S.E.M.) for CP velocity (VCP) and CP amplitude (ACP) and the symmetry index (SI) of VCP and ACP for the various degrees of weight-bearing asymmetry (WBA) in the lateral (LAT) and antero-posterior (AP) directions Direction Parameter WBA 0% LAT AP LAT AP VCP ACP VCP ACP SI VCP SI ACP SI VCP SI ACP 29.8 7.1 12.4 21.4 2.4 12.5 1.5 0.2 S.E.M. 9.1 7.0 4.2 7.5 6.5 9.6 7.6 8.3 5% 40.7 0.8 10.4 25.1 0.4 1.2 1.7 2.3 S.E.M. 8.2 6.4 3.1 9.5 4.0 5.8 3.8 4.7 10% 62.4 6.9 10.4 26.0 1.9 7.7 4.7 2.7 S.E.M. 9.3 6.0 3.3 7.9 4.6 7.1 3.9 3.6 20% 103.0 28.1 3.3 26.9 27.0 29.1 23.3 20.5 S.E.M. 13.9 7.4 3.5 8.1 6.1 8.8 5.1 6.4 30% 146.5 51.6 17.6 35.2 50.0 39.6 38.7 29.5 S.E.M. 15.1 7.7 5.3 9.6 8.4 8.9 5.2 6.2

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various degrees of WBA. For VCP in LAT direction, PROC MIXED determined that there was no signicant difference between the three estimated models. Therefore, the rstorder (linear) polynomial function was used to describe the relation in LAT direction (Table 3 and Fig. 2a). For VCP in AP direction, the second-order polynomial function was used (Table 3 and Fig. 2b). For SI VCP, rst-order polynomials were used in both AP and LAT direction (Table 3, Fig. 3a and b). 4. Discussion The purpose of this study was to examine the intraindividual relationship between weight distribution and postural stability during standing in healthy subjects. Participants were forced, while standing on a dual-plate force platform, to adopt various asymmetric weight-bearing positions using visual feedback of their CP. Results demonstrated that the postural strategy changed during quiet upright standing with visual feedback compared to the situation without visual feedback. During all visual feedback tasks, the subjects were required to control their upright standing primarily in the LAT direction. Therefore, the subjects were mostly concentrating on their stability in this direction. Remarkably, this led to a considerable increase in overall CP velocity (and, thus, a reduction in postural control efcacy) in the LAT direction, which coincided with a relatively small decrease in overall CP velocity in the AP direction during the reference

Fig. 3. Kinetic regulation asymmetry, expressed as the symmetry index (SI) of the RMS of the CP velocities (VCP) under each foot separately, in the frontal plane (a) and the sagittal plane (b) for the different degrees of weightbearing asymmetry (WBA). The solid line is the mean. The dotted lines are the mean 1.96 overall S.D. The dashed line is the t of the model used.

Table 2 Summary of the results of the three-way ANOVA of the CP velocity (VCP) and CP amplitude (ACP) values in lateral (LAT) and antero-posterior (AP) directions Direction LAT Parameter VCP ACP AP VCP ACP LAT SI VCP SI ACP AP SI VCP SI ACP WBA F(2.38, 42.91) = 47.23 F(4, 72) = 54.31 F(1.92, 34.57) = 22.54 F(4, 72) = 0.83 F(2.48, 44.81) = 17.96 F(4, 72) = 4.83 F(2.13, 38.34) = 15.35 F(2.32, 41.67) = 5.89 p-Value <0.01 <0.01 <0.01 0.51 <0.01 <0.01 <0.01 <0.01 WBA Group F(2.38, 42.91) = 0.55 F(4, 72) = 0.29 F(1.92, 34.57) = 0.38 F(4, 72) = 1.39 F(2.48, 44.81) = 1.51 F(4, 72) = 0.60 F(2.13, 38.34) = 1.44 F(2.32, 41.67) = 1.34 p-Value 0.61 0.89 0.68 0.25 0.23 0.66 0.25 0.28 WBA Side F(2.65, 47.72) = 0.21 F(2.64, 47.43) = 0.12 F(2.56, 46, 07) = 0.49 F(2.90, 52.28) = 1.54 F(4, 72) = 1.00 F(2.97, 53.49) = 1.36 F(2.29, 41.23) = 0.45 F(4, 72) = 0.36 p-Value 0.87 0.93 0.66 0.21 0.41 0.27 0.67 0.84 WBA Group Side F(2.65, 47.72) = 0.30 F(2.64, 47.43) = 0.83 F(2.56, 46, 07) = 0.86 F(2.90, 52.28) = 0.94 F(4, 72) = 1.07 F(2.97, 53.49) = 0.32 F(2.29, 41.23) = 0.41 F(4, 72) = 0.31 p-Value 0.80 0.47 0.45 0.43 0.38 0.81 0.69 0.87

WBA is weight-bearing asymmetry. Table 3 Summary of the regression coefcients and variances of the CP velocity (VCP) and the VCP symmetry indices (SI) in both the lateral (LAT) and antero-posterior (AP) directions Direction Parameter Coefcients b0 LAT AP LAT AP VCP VCP SI VCP SI VCP 24.46 11.13 8.72 4.64 b1 3.99 0.44 1.84 1.38 b2 0.046 b3 Variances var (bi) 1575.87 166.16 137.62 152.45 var (eit) 924.27 128.64 593.87 393.78

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feedback task. This change in postural strategy seems to reect a tighter (but not better) control of body sway in the LAT direction through more rapid alternations of the direction of the subtle weight shifts during quiet standing, which is the main mechanism of postural control during normal biped standing in the frontal plane [13]. A similar change towards a more tightened postural control has been reported by Dault et al. [21], who found that young subjects were able to decrease the amplitude of their sway in either direction during upright standing with visual feedback involving an increase in frequency of their sway in either direction during upright standing with visual feedback. The results of the visual feedback tasks clearly show that postural stability is affected by weight distribution. Overall, postural stability decreases with increasing WBA. The general destabilising effect of WBA has been reported previously [9,13,15]. By using visual feedback and requiring specic degrees of WBA, we were able to nd that WBA had a large effect on the VCP in the LAT direction, with a (linear) increment of 4% for each degree of WBA, whereas there was a smaller effect in the AP direction. Apparently, both planes of postural control are differently organized and controlled. Although visual feedback modied the postural control strategy, this pattern of results seems in line with the characteristics of normal biped standing (i.e., without visual feedback), where frontal-plane balance is based on subtle weight shifts, primarily controlled by the hip abductors and hip adductors, whereas sagittal-plane balance is primarily under the control of ankle mechanisms [13]. Nevertheless, there appeared to be some inuence of WBA on AP postural stability, which was mainly related to the 30% WBA condition. It is possible that this condition already begins to reect the characteristics of one-legged standing [22]. Because the muscles of the unloaded leg lose their capacity to generate effective stabilizing ankle torques as a result of the unloading, the VCP under the loaded leg increases which reects the generation of compensatory ankle moments at this side. As for frontal-plane balance, it must be concluded that the control of subtle weight shifts between the legs is increasingly less effective when one leg is progressively unloaded. The kinetic regulation asymmetry increases with increasing WBA. Kinetic regulation asymmetry in AP direction increased by 1.4% for each degree of WBA. The kinetic regulation activity of the loaded leg was always higher than of the unloaded leg, indicating that the loaded leg became more active in the balance control. In addition, it was also found that CP amplitudes were larger on the loaded than on the unloaded side. This is different from the work of Genthon and Rougier [15], who reported that WBA induced a stronger increase in CP amplitudes for the unloaded support than for the loaded one. However, CP amplitude is insensitive to changes in the mean frequency of regulation, whereas CP velocity is frequency sensitive. Particularly the higher frequencies within the CP uctuations reect the stabilizing ankle torques. Based on our results, we conclude

that with increasing WBA the strong increase in asymmetry of the lateral VCP under each foot, particularly in the 30% WBA condition, reects the characteristics of progressive one-legged standing. Indeed, when standing on one leg, the hip loading/unloading strategy in the frontal plane is replaced by a primary ankle strategy in this plane which will cause a large increase in the lateral CP velocity under the supporting foot [13]. As for the sagittal plane, the results suggest that the normal ankle strategy is largely maintained, with equal contribution of both feet. A limitation of the present study was that during all weight-bearing asymmetry tasks, visual feedback of CP was provided. The major advantage of this procedure was that we were able to apply standardized degrees of asymmetrical weight distribution, in order to allow within-subjects comparisons for the effects of WBA on postural control. In this approach, we assumed that the observed change towards a tighter postural control strategy as a result of visual feedback would be unaffected by the various degrees of WBA. Hence, in our mathematical models, visual feedback is assumed to be responsible for the intercept (b0) being unequal to zero, without having changed the values of the other coefcients (b1 and b2). However, this assumption still needs to be validated in a future study, using the exact same experimental setup in which participants would also stand with various degrees of WBA, but without visual feedback. In conclusion, this study aimed to determine the withinsubjects relationship between weight distribution on the one hand and postural control and control asymmetry on the other hand, during quiet upright standing in healthy adults. Results showed that both overall kinetic regulation and regulation asymmetry increased with increasing weightbearing asymmetry. This indicates that a symmetric weight distribution between the legs during quiet upright standing provides optimal stability in subjects without neural control problems. Both the overall CP velocity and the asymmetry in CP velocity between the legs in both planes show the lowest values when 50% weight is born on each leg. Apparently, symmetrical loading provides the greatest biomechanical stability, requiring the least correcting actions. In other words, the effects of WBA on postural stability in both planes are related to changes in the biomechanical constraints of upright standing and do not reect changes in the neural control of posture. Several clinical studies have indicated that lateral CP velocities provide more information about the sensorimotor consequences of different lateralized diseases and show the best association with risk of falling [9,15,21]. Thus, by increasing the velocity of the CP displacements especially in the lateral direction, increasing WBA may increase the risk of falling. On the other hand, patients with postural control problems due to lateralized diseases may have a different optimum of weight distribution between the legs, despite the fact that from a biomechanical perspective symmetric standing would be optimal. Knowledge of the optimal

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weight distribution is important to improve rehabilitation strategies for different groups of patients [15]. Therefore, in future studies, we will examine the relationship between postural stability and WBA in patients with lateralized disease, such as hemiparesis due to stroke, to establish optimal balance strategies for these patient groups and to identify individual deviations from optimal weight distribution.

Conict of interest The authors have no nancial or personal relationships or afliations that could inuence (or bias) the authors decisions, work, or manuscript.

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