1. 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
, Este´lio 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,
Brazil
b
Esta´cio de Sa´ University (UNESA), Av. prefeito Dulcidio Cardoso, n. 2900, Barra da Tijuca, Rio de Janeiro, RJ, CEP 22631-052, Brazil
c
Instituto Nacional do Caˆncer (INCA), Rio de Janeiro, Prac¸a da Cruz Vermelha, n. 23, Centro, Rio de Janeiro, RJ, CEP 20230-130, Brazil
d
Department of Epidemiology and Public Health, University of Miami, Miller School of Medicine, 1425 NW 10th
Avenue, Suite 214, Miami, 33136 FL, USA
1. Introduction
The rapid increase of elderly populations brings greater
attention to the loss of independence in individuals 60 years
and older. This loss of independence is related to a decrease in
functional capacity in completing activities of daily living (ADL)
leading to an increased occurrence of falls which is a leading fear of
the elderly due to its serious health consequences (Perracine and
Ramos, 2002; Aslan et al., 2008). According to the Brazilian
Institute of Geography and Statistics (IBGE, 2004), by 2020 the
elderly population will increase by approximately 31.8 million
people leaving Brazil with the world’s sixth largest elderly
population. By 2050, an estimated 18% of the Brazilian population
will consist of elderly people.
Biological aging is a multifactorial phenomenon which is
associated with profound changes in the activity of cells, tissues
and organs, as well as the reduction of effectiveness through a
range of physiological processes (Barbosa et al., 2001; Kjaer and
Jespersen, 2009; Vale et al., 2009). Due to the aging and
deterioration of these different physiological systems, postural
control is altered causing gait abnormalities and postural
instability (Barau´ na et al., 2004; Tainaka et al., 2009).
Postural instability and loss of functional autonomy are public
health issues among elderly people when considering the
mortality and morbidity rates and the social and economic costs
caused by falls (Guimara˜es and Farinatti, 2005). Falls, and
subsequent fractures are the most serious consequences of
postural imbalances and gait abnormalities and are responsible
for 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’s
center of mass over its base of support, moving the body weight
quickly and precisely in different directions from its center, and
walking in a safe, fast and coordinated way while adjusting to
external disturbances (Ragnarsdo´ttir, 1996; Gazzola et al., 2004;
Rugelj, 2009). Thus, in order to control balance, various physical
systems have to be integrated through the central command, with
this coordinated performance reflecting ones ability to accomplish
ADLs (Salminen et al., 2009; Wiacek et al., 2009). Maintenance of
Archives of Gerontology and Geriatrics 52 (2011) 111–114
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 Æ 7.37 years, body mass index = BMI = 27.30 Æ 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.
ß 2010 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author. Tel.: +55 21 2128 2586; fax: +55 21 2128 2594.
E-mail address: fernanda@fernandadaniel.com.br
(F. de Noronha Ribeiro Daniel).
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics
journal homepage: www.elsevier.com/locate/archger
0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.archger.2010.02.011

2. balance can lead to improved performance of ADLs; however, few
studies have investigated the relation between ADLs and balance
by analyzing the amplitude of displacement in the frontal and
sagittal planes and the elliptical area of the center of the body in
elderly individuals.
In this context, it appears that decreased levels of balance can
accentuate the possibility of elderly people developing physical
disabilities and becoming clinically institutionalized. Therefore,
the aim of this study was to analyze the correlation levels between
static balance and functional autonomy related to the performance
of 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 physical
exercise program the previous 6 months. All volunteers were
residents of Pic¸arreira I, from the city of Teresina-PI (Table 1). The
group was randomly selected from a larger sample after
performing a medical evaluation and being considered eligible
to take part in the protocols of assessment.
Women with the following exclusion criteria were ineligible for
inclusion in the study: neurologic disorders, disorders of the
vestibular system, movement disorders related to cognitive
decline and the use of medications that can harm the balance,
posture stability and functional autonomy.
Volunteers were selected, by drawing, as participants for this
study from a sample group of 96 eligible elderly women to ensure a
sample size with a a = 0.05 and a b = 0.20.
All participants were required to sign a consent form (according
to resolution 196/96 of the National Healthy Council and the
Declaration of Helsinki of 1975). The study was submitted and
approved by the Institutional Ethics Committee and Research in
Human Beings of Piaui State University, UESPI, College of Medical
Sciences (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 the
mornings in a calm and quiet environment with the average
temperature ranging between 23 and 25 8C Before starting the
tests, the participants remained seated and resting for 5 min.
Subjects were then assisted into a standing barefoot position on a
force platform, with the arms besides their body, heels 2 cm apart,
feet angled 308 away from each, and looking at a fixed visual target
situated 90 cm from the platform (AM3
Foot Work Pro, electronic
baropodometer 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 postural
oscillations of the center of pressure (COP) in the frontal plane,
right (RLD) and left (LLD) lateral displacements, the average
amplitude of postural oscillations of the COP in the sagittal plane,
anterior (AD) and posterior (PD) displacements, and the elliptical
area (EA) formed by the displacement of the body’s center of
gravity on the platform.
2.2.3. Functional autonomy assessment
The following tests from the Latin-American Development for
the Elderly Group (LADEG) protocol of autonomy were used for the
functional autonomy assessment: a 10 m walk (10 mW) (Spila˜
et al., 1996), getting up from a seated position (GSP) (Guralnik
et al., 1994), getting up from the prone position (GPP) (Alexander
et al., 1997), getting up from a chair and movement around the
house (GCMH) (Andreotti and Okuma, 1999), and putting on and
taking off a shirt (PTS) (Dantas and Vale, 2004; Vale et al., 2006). All
tests were individually conducted and repeated two different
times with a minimum of 5 min intervals. The lowest time of the
two trials was recorded.
After the completion of the tests, the LADEG index of autonomy
(LI) was calculated (Vale, 2005), with lower score corresponding to
a better result. The LI score was calculated by the following
formula:
LI ¼
½ð10 mW þ GSP þ GPP þ PTSÞ Â 2Š þ GCMH
4
where 10 mW, GSP, GPP, PTS e GCMH = time in seconds, LI = LADEG
index in scores.
2.3. Statistical analysis
The data were analyzed using Windows SPSS version 14.0
(Chicago, IL) and presented as mean, standard deviation, and
minimum and maximum values. The Shapiro–Wilk and Levene
tests were used to analyze normality and homogeneity of variance
of the sample data, respectively. The Spearman correlation
coefficient was used to analyze the correlations among the
variables. Statistical significance was set a priori at p < 0.05 level.
3. Results
Table 2 shows the results of descriptive analysis and normality
of stabilometric evaluation of the sample. It can be observed that
the RLD and the PD exhibited normal distributions.
Table 1
Sample characteristics.
Variables Mean Æ S.D. Minimum Maximum *
p<
Age (years) 67.47 Æ 7.37 60.00 86.00 0.206
Height (m) 1.51 Æ 0.07 1.38 1.68 0.349
Body mass (kg) 62.79 Æ 13.81 36.80 103.00 0.497
BMI 27.30 Æ 5.07 18.04 42.53 0.083
*
p refers to the Shapiro–Wilk test of normality.
Table 3
Descriptive results of the tests from the LADEG protocol of autonomy of the sample.
Tests Mean Æ S.D. Minimum Maximum *
p<
GSP 9.68 Æ 2.51 6.23 16.83 0.006*
GCMH 41.15 Æ 6.30 31.08 58.73 0.018*
PTS 11.31 Æ 3.36 6.66 19.71 0.010*
10 mW 7.01 Æ 1.24 5.45 11.83 0.000*
GPP 3.73 Æ 1.33 1.70 7.00 0.010*
LI 26.15 Æ 4.26 19.49 36.36 0.257
*
p refers to the Shapiro–Wilk test of normality.
Table 2
Descriptive results of the amplitude of postural oscillations in the RLD, LLD, AD and
PD displacements, and the EA measured by stabilometric assessment.
Variables Mean Æ S.D. Minimum Maximum *
p<
RLD (cm) 1.15 Æ 0.31 0.60 2.00 0.056
LLD (cm) À1.12 Æ 0.43 À2.10 À0.60 0.006*
AD (cm) 1.46 Æ 0.65 0.80 4.00 0.000*
PD (cm) À1.25 Æ 0.43 À2.20 À0.60 0.145
EA (cm2
) 4.53 Æ 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

3. Table 3 represents the results of the descriptive analysis and
normality of the functional assessment tests. Of the measured
variables, only the LI shows a normal distribution pattern.
Table 4 depicts the correlation matrix of the analyzed variables
in the study. Significant Spearman correlation coefficients (r) were
observed between GPP tests and the LLD, PD and EA of the body’s
center of gravity. There was no significant correlation among any
other variables.
4. Discussion
The results of this study present positive and significant
correlation between GPP tests and the average amplitude of the
LLD, PD, and the EA of the body’s center of gravity. These results
indicate that subjects who required the greatest amount of time to
perform the GPP tests also had the greatest distances of
displacements and, consequently, the greatest levels of imbalance.
It may be a result of the study sample being comprised of
sedentary individuals and presenting regular functional autonomy
levels, as demonstrated by their LI scores (Vale, 2005). Abreu and
Caldas (2008) investigated the relationship a general program of
therapeutic exercises and improvements in balance in elderly
individuals.
Although no significant correlation was seen among the
examined variables, it was observed that the intervention group
displayed greater levels of balance than the ambulatory group, as
assessed by Berg and POMA tests. Thus, it may be possible to
assume that increases in balance in healthy elderly individuals can
be impacted by general exercise intervention programs.
Carvalho et al. (2007) compared balance between elderly who
performed regular physical activities (n = 28; age = 77.1 Æ 7.2
years) and sedentary elderly individuals (n = 28; age = 79.4 Æ 8.1
years). The result of this study revealed higher and significant scores
in POMA test for the physically active group (r = 0.67; p < 0.001),
suggesting that physically active elderly individuals have better
balance and less fear of falling when compared to sedentary elderly
populations. A positive correlation (r = 0.76; p < 0.01) was also
detected between fear of falling and balance (POMA scores), allowing
to verify that the increase in FES scores, which indicate levels for fear
of falling, was accompanied by greater levels of balance. A positive
correlation was also identified between fear of falling scores and
levels of physical activity (r = 0.47; p < 0.01) and between levels of
balance and physical activity (r = 0.67; p < 0.01). Although the test
used to assess balance in this study differed from the tests used in the
present study, these data suggest that a regular physical activity
program can increase not only the balance in elderly individuals, but
also levels of self-confidence. However, these considerations are
limited due to the fact that the present research did not assess the
quantity of falls, fear of falling or self-confidence as in the study of
Bastos 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 by
the BMI of the sample population. Greve et al. (2007) indicated
that higher BMI levels require greater levels of corporal displace-
ment in order to maintain postural balance. Forty young men
(BMI = 23.3 Æ 3.2) underwent a series of functional tests of corporal
stability using Biodex Balance System (evaluation protocol level 2). A
significant correlation was identified between their general stability
index and BMI (r = 0.723; dominant side, r = 0.705; non-dominant
side), and between their anteroposterior and mediolateral stability
indexes 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 in
the present study as the current study sample was considered
overweight, based on their BMI classification (WHO, 1998).
One other possible explanation for the results in the current
study is related to the multiple changes in position required by the
GPP tests; starting from the initial prone phase to the standing
position. These adjustments to sudden changes of movement can
provoke a failure in the processing and maintenance of sensory
system stability. Inaccurate sensorial information, selection of a
sensorial reference or reaction to rough movements, as well as the
musculoskeletal inability to provide a good response, can lead to
postural oscillations (Isotalo et al., 2004). Therefore, if these
movements are performed quickly they can lead to imbalance in
elderly individuals who would then be more liable to falls.
The results of the present investigation are in opposition to the
study of Aikawa et al. (2006) who analyzed postural oscillations
through the measurement of degrees rather than amplitudes of
displacement. The authors showed that posterior postural oscilla-
tions were more pronounced for both the 60–70 (n = 12.15 Æ
12.15) and 71–80 (n = 11.73 Æ 14.42)-year old groups. The present
study found that the antero-displacements were more pronounced
than the posterior displacements. However, postural oscillations are
commonly found among elderly people and are correlated to changes
in the base of support or unexpected displacements such as articular
instability (Perracine and Ramos, 2002) and muscle weakness
(Wiacek et al., 2009). A limitation of the present study was that
these correlations were not investigated preventing the potential
examination of these correlations.
In conclusion, the results of the present study showed a
significant correlation only between the GPP functional autonomy
test and LLD and PD amplitude displacements and EA among
sedentary elderly individuals. Performance of the GPP test requires
sudden changes in postural positioning which can lead to greater
postural imbalances. It is recommended that future studies
compare the variables used in this investigation in active
individuals and to assess the quantity of falls, fear of falling,
self-confidence related to balance, and their correlation to
performance of ADLs at different points along aging curve.
Conflict of interest statement
None.
References
Abreu, S.S.E., Caldas, C.P., 2008. Gait speed, balance and age: a correlation study
among elderly women with and without participation in a therapeutic exercise
program. Rev. Bras. Fisioter. 12, 324–330 (in Portuguese).
Aikawa, A.C., Braccialli, L.M.P., Padula, R.S., 2006. Effects of postural alterations and
static balance on falls in institutionalized elderly. Rev. Cienc. Med. 15, 189–196
(in Portuguese).
Table 4
Correlation 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 À0.246 0.153 0.116
p< 0.611 0.536 0.175 0.402 0.527
GCMH r À0.093 0.312 À0.091 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 À0.019 0.237 À0.174 0.025 0.134
p< 0.917 0.192 0.342 0.891 0.465
GPP r 0.158 0.382*
À0.011 0.398*
0.368*
p< 0.389 0.031 0.954 0.024 0.038
LI r À0.008 0.193 À0.117 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

4. Alexander, N.B., Ulbrich, J., Raheja, A., Channer, D., 1997. Rising from the floors in
older adults. J. Am. Geriatr. Soc. 45, 564–569.
Andreotti, R.A., Okuma, S.S., 1999. Validac¸a˜o de uma bateria de testes de atividades
da vida dia´ria para idosos fisicamente independentes. Rev. Paul. Educ. Fis. 13,
46–66 (in Portuguese).
Aslan, U.B., Cavlak, U., Yagci, N., Akdag, B., 2008. Balance performance, aging and
falling: a comparative study based on a Turkish sample. Arch. Gerontol. Geriatr.
46, 283–292.
Barau´ na, M.A., Barbosa, S.R.M., Canto, R.S.T., Silva, R.A.V., Silva, C.D.C., Barau´ na,
K.M.P., 2004. Study of elderly static balance and its correlation with falls. Rev.
Fisioter. Brasil 5, 136–141 (in Portuguese).
Barbosa, S.M., Arakaki, J., Silva, M.F., 2001. Estudo do equilı´brio em idosos atrave´s da
fotogrametria computadorizada. Rev. Fisioter. Brasil 2, 189–196 (in Portu-
guese).
Bastos, A.G.D., Lima, M.A.M.T., Oliveira, L.F., 2005. Evaluation of patients with
dizziness and normal electronystagmography using stabilometry. Rev. Bras.
Otorrinolaringol. 71, 305–310 (in Portuguese).
Carvalho, J., Pinto, J., Mota, J., 2007. Physical activity, balance and fear of falling. A
study with institutionalized older people. Rev. Port. Cien. Desp. 7, 225–231 (in
Portuguese).
Dantas, E.H.M., Vale, R.G.S., 2004. GDLAM’S protocol of functional autonomy
evaluation. Fit. Perf. J. 3, 175–182 doi:10.3900/fpj.3.3.175.e.
Gazzola, J.M., Muchale, S.M., Perracine, M.R., Cordeiro, R.C., Ramos, L.R., 2004.
Functional balance among elderly in a gerontological rehabilitation service.
Rev. Fisioter. Univ. Sa˜o Paulo 11, 1–14 (in Portuguese).
Greve, J., Alonso, A., Bordini, A.C.P.G., Camanho, G.L., 2007. Correlation between
body mass index and postural balance. Clinics 62, 717–720, doi:10.1590/S1807-
59322007000600010 (in Portuguese).
Guimara˜es, J.M.N., Farinatti, P.T.V., 2005. Descriptive analysis of variables theoreti-
cally associated to the risk of falls in elder women. Rev. Bras. Med. Esporte 11,
299–305 (in Portuguese).
Guralnik, J.M., Simonsick, E.M., Ferruci, L., Glynn, R.J., Berkman, L.F., Blazer, D.G.,
Scherr, P.A., Wallace, R.B., 1994. A short physical performance battery assessing
lower extremity function: association with self-reported disability and predic-
tion of mortality and nursing home admission. J. Gerontol. Med. Sci. 49, 85–94.
IBGE (Brazilian Institute of Geography and Statistics), 2004. Projection of Brazil by
sex and age for the period 1980 to 2050, Revision 2004. Coordination of
population and social indicators: Rio de Janeiro. Available at: http://www.
ibge.gov.br/home/estatistica/populac¸a˜o/condic¸a˜odevida/indicadoresminimos/
sinteseindicsociais2004/, approached September 3, 2008 (in Portuguese).
Isotalo, E., Kapoula, Z., Feret, P.H., Gauchonc, K., Zamfirescu, F., Gagey, P.M., 2004.
Monocular versus binocular vision in postural control. Auris Nasus Larynx 31,
11–17.
Kjaer, M., Jespersen, J.G., 2009. The battle to keep or lose skeletal muscle with
ageing. J. Physiol. 587, 1–2.
Perracine, M.R., Ramos, L.R., 2002. Fall-related factors in a cohort of elderly com-
munity residents. Rev. Sau´ de Pu´ blica 36, 709–716 (in Portuguese).
Ragnarsdo´ ttir, M., 1996. The concept of balance. Phys. Ther. 82, 368–375.
Rugelj, D., 2009. The effect of functional balance training in frail nursing home
residents. Arch. Gerontol. Geriatr., doi:10.1016/j.archger.2009.03.009.
Ruwer, S.L., Rossi, A.C., Simon, L.F., 2005. Balance in the elderly. Rev. Bras. Otorri-
nolaringol. 71, 298–303 (in Portuguese).
Salminen, M., Vahlberg, T., Sihvonen, S., Sjosten, N., Piirtola, M., Isoaho, R., Aarnio, P.,
Kivela, S.L., 2009. Effects of risk-based multifactorial fall prevention on postural
balance in the community-dwelling aged: a randomized controlled trial. Arch.
Gerontol. Geriatr. 48, 22–27.
Spila˜, S., Multanen, J., Kallinen, M., Era, P., Suominen, H., 1996. Effects of strength
and endurance training on isometric muscle strength and walking speed in
elderly women. Acta Physiol. Scand. 156, 457–464.
Tainaka, K., Takizawa, T., Katamoto, S., Aoki, J., 2009. Six-year prospective study of
physical fitness and incidence of disability among community-dwelling Japa-
nese elderly women. Geriatr. Gerontol. Int. 9, 21–28.
Vale, R.G.S., 2005. Avaliac¸a˜o da autonomia funcional. Fit. Perf. J. 4, 4 (in Portuguese).
Vale, R.G.S., Pernambuco, C.S., Novaes, J.S., Dantas, E.H.M., 2006. Functional auton-
omy test: to dress and undress a sleeveless shirt (DUSS). R. Bras. Ci. Mov. 14, 71–
78 (in Portuguese).
Vale, R.G.S., Oliveira, R.D., Pernambuco, C.S., Meneses, Y.P.S.F., Novaes, J.S., Andrade,
A.F.D., 2009. Effects of muscle strength and aerobic training on basal serum
levels of IGF-1 and cortisol in elderly women. Arch. Gerontol. Geriatr. 49, 343–
347, doi:10.1016/j.archger.2008.11.011.
Wiacek, M., Hagner, W., Hagner-Derengowska, M., Bluj, B., Drozd, M., Czereba, J.,
Zubrzycki, I.Z., 2009. Correlations between postural stability and strength of
lower body extremities of women population living in long-term care facilities.
Arch. Gerontol. Geriatr. 48, 346–349.
WHO (World Health Organization), 1998. Obesity: preventing and managing the
global epidemic. WHO. Report of a WHO Consultation on Obesity, Geneva.
F. de Noronha Ribeiro Daniel et al. / Archives of Gerontology and Geriatrics 52 (2011) 111–114114