Archives of Gerontology and Geriatrics 52 (2011) 111–114

Correlation between static balance and functional autonomy in elderly women

Fernanda de Noronha Ribeiro Daniel a,*, Rodrigo Gomes de Souza Vale a, Tania Santos Giani a,b,Silvia Bacellar c, Tatiane Escobar a, Mark Stoutenberg d, Estelio Henrique Martin Dantas a

a Laboratory of Human Motricity Biosciences (LABIMH), Castelo Branco University (UCB), Av. Salvador Allende, n. 6700, Recreio do Bandeirantes, Rio de Janeiro, RJ, CEP 22780-160,

Brazilb Estacio de Sa University (UNESA), Av. prefeito Dulcidio Cardoso, n. 2900, Barra da Tijuca, Rio de Janeiro, RJ, CEP 22631-052, Brazilc Instituto Nacional do Cancer (INCA), Rio de Janeiro, Praca da Cruz Vermelha, n. 23, Centro, Rio de Janeiro, RJ, CEP 20230-130, Brazild Department of Epidemiology and Public Health, University of Miami, Miller School of Medicine, 1425 NW 10th Avenue, Suite 214, Miami, 33136 FL, USA

A R T I C L E I N F O

Article history:

Received 25 August 2009

Received in revised form 6 February 2010

Accepted 9 February 2010

Keywords:

Balance

Activities of daily living (ADL)

Postural stability of the elderly

A B S T R A C T

The purpose of the present study was to verify the correlation between static balance and functional

autonomy in elderly women. The sample was a random selection of 32 sedentary elderly women (mean

age = 67.47 � 7.37 years, body mass index = BMI = 27.30 � 5.07 kg/m2), who live in the city of Teresina in

the state of Piauı, Brazil. Static balance was analyzed by stabilometric assessment using an electronic

baropodometer which measured the average of the amplitude of postural oscillations in the right (RLD) and

left (LLD) lateral displacements, anterior (AD) and posterior (PD) displacements, and in the elliptical area (EA)

formed by the body’s center of gravity. Functional autonomy was evaluated by a battery of tests from the

LADEG protocol which is composed of: a 10 m walk (10 mW), getting up from a seated position (GSP), getting

up from the prone position (GPP), getting up from a chair and movement around the house (GCMH), and

putting on and taking off a shirt (PTS). The Spearman’s correlation coefficient (r) indicated a positive and

significant correlation between GPP and LLD (r = 0.382; p = 0.031), GPP and PD (r = 0.398; p = 0.024) and GPP

and EA (r = 0.368; p = 0.038). These results show that sedentary elderly women who spent the greatest

amount of time performing the GPP test achieved the largest mean amplitude of displacement leading to

greater levels of instability.

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1. Introduction

The rapid increase of elderly populations brings greaterattention to the loss of independence in individuals 60 yearsand older. This loss of independence is related to a decrease infunctional capacity in completing activities of daily living (ADL)leading to an increased occurrence of falls which is a leading fear ofthe elderly due to its serious health consequences (Perracine andRamos, 2002; Aslan et al., 2008). According to the BrazilianInstitute of Geography and Statistics (IBGE, 2004), by 2020 theelderly population will increase by approximately 31.8 millionpeople leaving Brazil with the world’s sixth largest elderlypopulation. By 2050, an estimated 18% of the Brazilian populationwill consist of elderly people.

Biological aging is a multifactorial phenomenon which isassociated with profound changes in the activity of cells, tissuesand organs, as well as the reduction of effectiveness through a

* Corresponding author. Tel.: +55 21 2128 2586; fax: +55 21 2128 2594.

E-mail address: fernanda@fernandadaniel.com.br

(F. de Noronha Ribeiro Daniel).

0167-4943/$ – see front matter � 2010 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.archger.2010.02.011

range of physiological processes (Barbosa et al., 2001; Kjaer andJespersen, 2009; Vale et al., 2009). Due to the aging anddeterioration of these different physiological systems, posturalcontrol is altered causing gait abnormalities and posturalinstability (Barauna et al., 2004; Tainaka et al., 2009).

Postural instability and loss of functional autonomy are publichealth issues among elderly people when considering themortality and morbidity rates and the social and economic costscaused by falls (Guimaraes and Farinatti, 2005). Falls, andsubsequent fractures are the most serious consequences ofpostural imbalances and gait abnormalities and are responsiblefor 70% of accidental deaths in people 75 years old and older(Ruwer et al., 2005).

Postural balance is considered the ability to maintain the body’scenter of mass over its base of support, moving the body weightquickly and precisely in different directions from its center, andwalking in a safe, fast and coordinated way while adjusting toexternal disturbances (Ragnarsdottir, 1996; Gazzola et al., 2004;Rugelj, 2009). Thus, in order to control balance, various physicalsystems have to be integrated through the central command, withthis coordinated performance reflecting ones ability to accomplishADLs (Salminen et al., 2009; Wiacek et al., 2009). Maintenance of

Table 1Sample characteristics.

Variables Mean� S.D. Minimum Maximum *p<

Age (years) 67.47�7.37 60.00 86.00 0.206

Height (m) 1.51� 0.07 1.38 1.68 0.349

Body mass (kg) 62.79�13.81 36.80 103.00 0.497

BMI 27.30�5.07 18.04 42.53 0.083

* p refers to the Shapiro–Wilk test of normality.

Table 3Descriptive results of the tests from the LADEG protocol of autonomy of the sample.

Tests Mean� S.D. Minimum Maximum *p<

GSP 9.68�2.51 6.23 16.83 0.006*

GCMH 41.15�6.30 31.08 58.73 0.018*

PTS 11.31�3.36 6.66 19.71 0.010*

10 mW 7.01�1.24 5.45 11.83 0.000*

GPP 3.73�1.33 1.70 7.00 0.010*

LI 26.15�4.26 19.49 36.36 0.257

* p refers to the Shapiro–Wilk test of normality.

Table 2Descriptive results of the amplitude of postural oscillations in the RLD, LLD, AD and

PD displacements, and the EA measured by stabilometric assessment.

Variables Mean� S.D. Minimum Maximum *p<

RLD (cm) 1.15� 0.31 0.60 2.00 0.056

LLD (cm) �1.12� 0.43 �2.10 �0.60 0.006*

AD (cm) 1.46� 0.65 0.80 4.00 0.000*

PD (cm) �1.25� 0.43 �2.20 �0.60 0.145

EA (cm2) 4.53�2.42 1.30 11.34 0.020*

* p refers to the Shapiro–Wilk test of normality.

F. de Noronha Ribeiro Daniel et al. / Archives of Gerontology and Geriatrics 52 (2011) 111–114112

balance can lead to improved performance of ADLs; however, fewstudies have investigated the relation between ADLs and balanceby analyzing the amplitude of displacement in the frontal andsagittal planes and the elliptical area of the center of the body inelderly individuals.

In this context, it appears that decreased levels of balance canaccentuate the possibility of elderly people developing physicaldisabilities and becoming clinically institutionalized. Therefore,the aim of this study was to analyze the correlation levels betweenstatic balance and functional autonomy related to the performanceof ADLs in elderly people.

2. Subjects and methods

2.1. Sample

The study sample was composed of 32 apparently healthy,volunteer, elderly women who had not been enrolled in a physicalexercise program the previous 6 months. All volunteers wereresidents of Picarreira I, from the city of Teresina-PI (Table 1). Thegroup was randomly selected from a larger sample afterperforming a medical evaluation and being considered eligibleto take part in the protocols of assessment.

Women with the following exclusion criteria were ineligible forinclusion in the study: neurologic disorders, disorders of thevestibular system, movement disorders related to cognitivedecline and the use of medications that can harm the balance,posture stability and functional autonomy.

Volunteers were selected, by drawing, as participants for thisstudy from a sample group of 96 eligible elderly women to ensure asample size with a a = 0.05 and a b = 0.20.

All participants were required to sign a consent form (accordingto resolution 196/96 of the National Healthy Council and theDeclaration of Helsinki of 1975). The study was submitted andapproved by the Institutional Ethics Committee and Research inHuman Beings of Piaui State University, UESPI, College of MedicalSciences (protocol no. 89/08).

2.2. Data collection procedure

2.2.1. Anthropometric measurements

To assess body mass, height and BMI, a mechanical scale,accurate to 100 g, was used with a 150 kg-capacity stadiometer(Filizola, Brazil).

2.2.2. Balance assessment

The assessment of the static balance was conducted in themornings in a calm and quiet environment with the averagetemperature ranging between 23 and 25 8C Before starting thetests, the participants remained seated and resting for 5 min.Subjects were then assisted into a standing barefoot position on aforce platform, with the arms besides their body, heels 2 cm apart,feet angled 308 away from each, and looking at a fixed visual targetsituated 90 cm from the platform (AM3 Foot Work Pro, electronicbaropodometer model with 4096 sensors, polycarbonate covered,dimension 645 mm � 520 mm � 25 mm, frequency 200 Hz, Italy).Subjects remained in this position for 20 s. The following

parameters were measured: the average amplitude of posturaloscillations of the center of pressure (COP) in the frontal plane,right (RLD) and left (LLD) lateral displacements, the averageamplitude of postural oscillations of the COP in the sagittal plane,anterior (AD) and posterior (PD) displacements, and the ellipticalarea (EA) formed by the displacement of the body’s center ofgravity on the platform.

2.2.3. Functional autonomy assessment

The following tests from the Latin-American Development forthe Elderly Group (LADEG) protocol of autonomy were used for thefunctional autonomy assessment: a 10 m walk (10 mW) (Spilaet al., 1996), getting up from a seated position (GSP) (Guralniket al., 1994), getting up from the prone position (GPP) (Alexanderet al., 1997), getting up from a chair and movement around thehouse (GCMH) (Andreotti and Okuma, 1999), and putting on andtaking off a shirt (PTS) (Dantas and Vale, 2004; Vale et al., 2006). Alltests were individually conducted and repeated two differenttimes with a minimum of 5 min intervals. The lowest time of thetwo trials was recorded.

After the completion of the tests, the LADEG index of autonomy(LI) was calculated (Vale, 2005), with lower score corresponding toa better result. The LI score was calculated by the followingformula:

LI ¼ ½ð10 mWþ GSPþ GPPþ PTSÞ � 2� þ GCMH

4

where 10 mW, GSP, GPP, PTS e GCMH = time in seconds, LI = LADEGindex in scores.

2.3. Statistical analysis

The data were analyzed using Windows SPSS version 14.0(Chicago, IL) and presented as mean, standard deviation, andminimum and maximum values. The Shapiro–Wilk and Levenetests were used to analyze normality and homogeneity of varianceof the sample data, respectively. The Spearman correlationcoefficient was used to analyze the correlations among thevariables. Statistical significance was set a priori at p < 0.05 level.

3. Results

Table 2 shows the results of descriptive analysis and normalityof stabilometric evaluation of the sample. It can be observed thatthe RLD and the PD exhibited normal distributions.

Table 4Correlation levels between the functional autonomy tests, the amplitude of postural

oscillations in the RLD, LLD, AD and PD displacements and the EA.

Variables RLD LLD AD PD EA

GSP r 0.093 0.114 �0.246 0.153 0.116

p< 0.611 0.536 0.175 0.402 0.527

GCMH r �0.093 0.312 �0.091 0.134 0.213

p< 0.614 0.082 0.621 0.465 0.241

PTS r 0.113 0.070 0.132 0.209 0.251

p< 0.539 0.705 0.472 0.251 0.166

10 mW r �0.019 0.237 �0.174 0.025 0.134

p< 0.917 0.192 0.342 0.891 0.465

GPP r 0.158 0.382* �0.011 0.398* 0.368*

p< 0.389 0.031 0.954 0.024 0.038

LI r �0.008 0.193 �0.117 0.234 0.217

p< 0.964 0.290 0.524 0.198 0.233

* Indicates significant differences.

F. de Noronha Ribeiro Daniel et al. / Archives of Gerontology and Geriatrics 52 (2011) 111–114 113

Table 3 represents the results of the descriptive analysis andnormality of the functional assessment tests. Of the measuredvariables, only the LI shows a normal distribution pattern.

Table 4 depicts the correlation matrix of the analyzed variablesin the study. Significant Spearman correlation coefficients (r) wereobserved between GPP tests and the LLD, PD and EA of the body’scenter of gravity. There was no significant correlation among anyother variables.

4. Discussion

The results of this study present positive and significantcorrelation between GPP tests and the average amplitude of theLLD, PD, and the EA of the body’s center of gravity. These resultsindicate that subjects who required the greatest amount of time toperform the GPP tests also had the greatest distances ofdisplacements and, consequently, the greatest levels of imbalance.

It may be a result of the study sample being comprised ofsedentary individuals and presenting regular functional autonomylevels, as demonstrated by their LI scores (Vale, 2005). Abreu andCaldas (2008) investigated the relationship a general program oftherapeutic exercises and improvements in balance in elderlyindividuals.

Although no significant correlation was seen among theexamined variables, it was observed that the intervention groupdisplayed greater levels of balance than the ambulatory group, asassessed by Berg and POMA tests. Thus, it may be possible toassume that increases in balance in healthy elderly individuals canbe impacted by general exercise intervention programs.

Carvalho et al. (2007) compared balance between elderly whoperformed regular physical activities (n = 28; age = 77.1 � 7.2years) and sedentary elderly individuals (n = 28; age = 79.4 � 8.1years). The result of this study revealed higher and significant scoresin POMA test for the physically active group (r = 0.67; p < 0.001),suggesting that physically active elderly individuals have betterbalance and less fear of falling when compared to sedentary elderlypopulations. A positive correlation (r = 0.76; p < 0.01) was alsodetected between fear of falling and balance (POMA scores), allowingto verify that the increase in FES scores, which indicate levels for fearof falling, was accompanied by greater levels of balance. A positivecorrelation was also identified between fear of falling scores andlevels of physical activity (r = 0.47; p < 0.01) and between levels ofbalance and physical activity (r = 0.67; p < 0.01). Although the testused to assess balance in this study differed from the tests used in thepresent study, these data suggest that a regular physical activityprogram can increase not only the balance in elderly individuals, but

also levels of self-confidence. However, these considerations arelimited due to the fact that the present research did not assess thequantity of falls, fear of falling or self-confidence as in the study ofBastos et al. (2005) in which tests were applied in a Force Platform(AMTI AccuSway Plus, portable) with blindfolded individuals.

The results of the present study may also be influenced bythe BMI of the sample population. Greve et al. (2007) indicatedthat higher BMI levels require greater levels of corporal displace-ment in order to maintain postural balance. Forty young men(BMI = 23.3 � 3.2) underwent a series of functional tests of corporalstability using Biodex Balance System (evaluation protocol level 2). Asignificant correlation was identified between their general stabilityindex and BMI (r = 0.723; dominant side, r = 0.705; non-dominantside), and between their anteroposterior and mediolateral stabilityindexes and BMI (dominant side r = 0.708; and r = 0.728; and non-dominant side r = 0.656; and r = 0.721, anteroposterior and medio-lateral, respectively). These findings support the correlation found inthe present study as the current study sample was consideredoverweight, based on their BMI classification (WHO, 1998).

One other possible explanation for the results in the currentstudy is related to the multiple changes in position required by theGPP tests; starting from the initial prone phase to the standingposition. These adjustments to sudden changes of movement canprovoke a failure in the processing and maintenance of sensorysystem stability. Inaccurate sensorial information, selection of asensorial reference or reaction to rough movements, as well as themusculoskeletal inability to provide a good response, can lead topostural oscillations (Isotalo et al., 2004). Therefore, if thesemovements are performed quickly they can lead to imbalance inelderly individuals who would then be more liable to falls.

The results of the present investigation are in opposition to thestudy of Aikawa et al. (2006) who analyzed postural oscillationsthrough the measurement of degrees rather than amplitudes ofdisplacement. The authors showed that posterior postural oscilla-tions were more pronounced for both the 60–70 (n = 12.15 �12.15) and 71–80 (n = 11.73 � 14.42)-year old groups. The presentstudy found that the antero-displacements were more pronouncedthan the posterior displacements. However, postural oscillations arecommonly found among elderly people and are correlated to changesin the base of support or unexpected displacements such as articularinstability (Perracine and Ramos, 2002) and muscle weakness(Wiacek et al., 2009). A limitation of the present study was thatthese correlations were not investigated preventing the potentialexamination of these correlations.

In conclusion, the results of the present study showed asignificant correlation only between the GPP functional autonomytest and LLD and PD amplitude displacements and EA amongsedentary elderly individuals. Performance of the GPP test requiressudden changes in postural positioning which can lead to greaterpostural imbalances. It is recommended that future studiescompare the variables used in this investigation in activeindividuals and to assess the quantity of falls, fear of falling,self-confidence related to balance, and their correlation toperformance of ADLs at different points along aging curve.

Conflict of interest statement

None.

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