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Comparison and age-level differences among various step tests for evaluating balance ability in the elderly
Archives of Gerontology and Geriatrics 50 (2010) e51–e54
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Comparison and age-level differences among various step tests for evaluating balance ability in the elderly Sohee Shin *, Shinichi Demura Kanazawa University Graduate School of Natural Science and Technology, Kakuma, Kanazawa, Ishikawa 920-1192, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 January 2009 Received in revised form 17 May 2009 Accepted 20 May 2009 Available online 23 June 2009
This study aimed to examine the difficulty among various step tests (place step, forward single step, forward double step, forward right single step and stairs step) in evaluating the dynamic balance in the elderly and their age level differences. Thirty-two healthy elderly people (age 71.4 6.4 years) and twenty young people performed step tests for 10 s to the pace of a metronome (120 bpm). Evaluation parameters were the time difference between the metronome sound and the time when each foot hit the ground as well as the stride time. The forward single step test had significantly larger values for both of the above parameters than the other tests. A significant age level difference was found in the forward single step test for the time difference and in the forward single step and stairs step tests for the stride time, being longer in the elderly. It was concluded that the forward single step test has larger age-level differences and is more difficult to carry out than the other step tests. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Step test Dynamic balance Balance ability in elderly
1. Introduction The elderly are apt to experience a fall and suffer a minor collision with an object during the fall. Furthermore, a decrease in balance ability is closely associated with the above. Falling in the elderly is frequently associated with large injuries, including fractures, and with a bedridden state requiring long-term nursing care. Maintaining and increasing leg strength and balance ability are very important for the elderly in order to prevent falls. Until now, to evaluate balance ability in the elderly, many tests have been devised from various viewpoints. The following are representative tests: FICST-4 (Rossiter-Fornoff et al., 1995), FSST (Dite and Temple, 2002), Functional Reach (Duncan et al., 1990), Dynamic Gait Index (Shumway-Cook and Woollacott, 1995), Tinetti Performance Oriented Mobility Assessment (Tinetti et al., 1986), Berg Balance Scale (Berg et al., 1995), Timed up & Go Test (Tinetti et al., 1986) and the Activities-Specific Balance Confidence Scale (Powell and Myers, 1995). However, these tests have been developed mainly to evaluate the living ability of the elderly in the nursing home setting. Hence, it has been pointed out that they may not be effective for estimating the balance ability of the healthy elderly (O’Brien et al., 1998; Boulgarides et al., 2003). In addition, all of the tests consist of plural movements and require wide space and sufficient measuring time (Shin and Demura, 2007, in press).
* Corresponding author. Tel.: +81 76 264 2643; fax: +81 76 234 4120. E-mail address: [email protected] (S. Shin). 0167-4943/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2009.05.007
Considering the above problems, Hill et al. (1996) and Nakata et al. (2002) have devised the place step test, which resembles natural gait, to evaluate the dynamic balance ability of the elderly. This test, which measures the step number and the striking time of each foot to the ground within a stipulated time, requires balance ability when the body is supported by one leg because of alternately stepping with both legs (Hill et al., 1996; Nakata et al., 2002). A step test is effective for solving the above problems regarding time and space. However, it has been pointed out that this test is difficult for the elderly with inferior gait ability to perform and incurs the risk of knee injury, because it requires quick stepping with maximal effort. Shin and Demura (2007, in press) proposed a new step test that requires matching stepping to a stipulated tempo. This step test requires submaximal effort and will be more effective to evaluate dynamic balance ability when considering the safety of the elderly. On the other hand, the Four Squares Step (Dite and Temple, 2002), Rapid Stepping Performance (Medell and Alexander, 2000) and Forward Single Step tests have been used to evaluate the balance ability in the elderly, and their validity and reliability have been examined (Miyahara et al., 1999; Medell and Alexander, 2000; Demura et al., 2008). Each of these tests have original characteristics, but there has been no examination of the relationships among the tests or of their difficulty. In addition to the above, it will be important to examine the age level differences between these tests. This study aimed to examine the difficulty and age level differences among various step tests (place step, forward single
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step, forward double step, forward right single step, and stairs step) used to evaluate the dynamic balance ability in the elderly. 2. Methods
2.2.2. Forward double step test The step length to the forward position was set at the length of the lower legs. Subjects stepped as one foot forward, followed by the other foot, and returned each foot to the original position to the tempo of the metronome (Fig. 1-2).
2.1. Subjects Thirty-two healthy elderly women (age 71.4 6.4 years, height 148.7 5.3 cm, weight 53.2 7.1 kg) without leg disorders and who could walk independently and twenty young women participated in the experiment. Prior to testing, the purpose and procedure of this study were explained in detail, and informed consent was obtained from all subjects. Approval for this study was obtained from the Kanazawa University Department of Education Ethical Review Board. 2.2. Apparatuses and methods A gait analysis meter (Walkway MG-1000, Anima and Japan) was used for the step test. This device can measure in real time when the subject’s right or left foot touches the step sheet and takes off from a footprint using foot pressure information. The sampling frequency was 100 Hz. The subjects stood on the stepsheet and stepped to match the tempo of a metronome. A 120 bpm tempo was reported to be the most efficient interval during walking (Toyama and Fujiwara, 1990). Sixty bpm and 40 bpm tempos, which correspond to 1/2 and 1/3 intervals of 120 bpm, were selected as slower tempos (Shin and Demura, 2007, in press). The measurement order of step tests was random. Each step test was carried out for 10 s after one trial practice. 2.2.1. Place step test Subjects stood on a step sheet and stepped at the same place with adjustments of the metronome (Fig. 1-1).
2.2.3. Stairs step test The step height of this test was the same 20 cm as the height of a normal stair step. Subjects stepped up and down, one foot after the other, to the tempo of the metronome (Fig. 1-3). 2.2.4. Forward right single step test The step length to the forward position and to the right side was the same as the length of the lower legs. Subjects stepped to the right side with the right leg and returned to the original position. They then stepped forward and returned to the original position. This series of movements was then repeated (Fig. 1-4). 2.2.5. Forward single step test The step length forward was set to be the same as the length of the lower legs. Subjects stepped forward with the right leg and the returned the original position to the tempo of the metronome. They then repeated this movement (Fig. 1-5). 2.2.6. Parameters The time difference and stride time were selected as evaluation parameters for each step test. The former was defined as the difference between the metronome sound of each tempo and the subject’s step time. The latter was defined as the time between the landing of one leg and the next landing of the same leg. Both evaluation parameters were measured as time per step. In short, the total time was divided by the total step number.
Fig. 1. The various step tests.
S. Shin, S. Demura / Archives of Gerontology and Geriatrics 50 (2010) e51–e54
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Table 1 Results of two-way ANOVA for the time differences times. Step test
PS FDS SS FRSS FSS
The youth
The elderly
ANOVA F-value
Mean(s)
SD
Mean(s)
SD
0.02 0.04 0.02 0.04 0.04
0.01 0.02 0.01 0.01 0.02
0.02 0.10 0.10 0.12 0.35
0.01 0.13 0.09 0.12 0.38
F1 F2 F3
Post hoc Tukey’s HSD
20.5* 12.1* 10.9*
The elderly: FSS > other tests The youth: n.s FSS: the elderly > the youth
Note: 1. F-value: F1: movement, F2: age, F3: interaction. 2. PS: place step, FDS: forward double step, SS: stairs step, FRSS: forward right single step, FSS: forward single step. 3. *p < 0.05.
Table 2 Results of two-way ANOVA for the stride times. Step test
PS FDS SS FRSS FSS
The youth
The elderly
ANOVA F-value
Mean(s)
SD
Mean(s)
SD
0.98 1.01 0.98 0.99 1.02
0.04 0.03 0.05 0.05 0.03
0.99 1.06 1.14 1.13 1.35
0.04 0.15 0.18 0.27 0.39
F1 F2 F3
Post hoc Tukey’s HSD
7.9* 8.9* 6.7*
The elderly: FSS > other tests FRSS and SS > FSS The youth: n.s FSS and SS: the elderly > the youth
Note: 1. F-value: F1: movement, F2: age, F3: interaction. 2. PS: place step, FDS: forward double step, SS: stairs step, FRSS: forward right single step, FSS: forward single step. 3. *p < 0.05.
2.2.7. Statistical analysis Two-way ANOVA was used to test mean differences by age and sex for physical characteristics and age and tempos for evaluation parameters, respectively. Multiple comparisons were examined by Tukey’s HSD method. Pearson’s correlation was used to examine relationships between stepping parameters and age or knee extension strength. The probability level of p < 0.05 indicated statistical significance. 3. Results Tables 1 and 2 show the results of ANOVA for the time difference and the stride time of each step test. Both parameters showed a significant interaction. The time difference was larger in the forward single step test than in the other tests for the elderly, but no significant difference was found among the test for the young participants. A significant age level difference was found in the forward single step test, being larger in the elderly than in the young participants. The stride time was significantly longer in the forward single step test than in the other step tests and in the forward right single step and stairs step tests than in the place step test for the elderly, but no significant difference was found for the younger participants. A significant age difference was found in the forward single step and stairs step tests, with both having larger value in the elderly than in the young participants. 4. Discussion Balance ability is an important physical fitness element for the elderly. Hence, it must be properly measured and evaluated. To evaluate physical fitness in the elderly with inferior physical fitness, tests with high safety should be selected. In addition, it is desirable that the test content relates closely to activities of daily life and is available for rehabilitation and functional recovery (Demura et al., 2008). To propose useful tests for evaluating dynamic balance ability in the elderly, this study examined the difficulty among various step tests (place step, forward single step, forward double step, forward right single step and stairs step) and their age-level differences. The time difference and stride time were larger in the forward single step test than the other tests. Humans have an endemic walk
pattern that allows them to advance semiautomatically with a constant cycle. This gait cycle is divided largely into stance, swing, and double stance phases, and the swing phase consists of acceleration, mid swing and deceleration (Saito et al., 2005). In the forward single step test, subjects repeated stepping one leg forward and returning it to the original position without putting both legs together. In short, because there is not a deceleration phase, created by putting together both legs after stepping forward, the braking force becomes larger when returning the stepping leg (making the direction change). Luchies et al. (2002) reported that stepping in the anterior/posterior directions may be able to identify individuals with subtle balance impairments. In addition, King et al. (2005) and Madigan and Lloyd (2005) examined the step length of the forward single step test and reported that the elderly perform balance recovery by taking short steps. Judge et al. (1996) clarified that the step length in the elderly is largely affected by a decrease in plantarflexion strength. On the other hand, the forward double step resembles the forward single step in that the physical center of gravity moves back and forth. However, because the forward double step includes the mid swing and deceleration phase components, it is judged to have a lower difficulty level than the forward single step. In addition, the forward single step requires movement of the center of gravity back and forth while keeping the body balanced on one leg. Hence, this step movement may be difficult to perform while maintaining a stable posture. In contrast, the forward right single step requires that subjects move one leg in the anteroposterior and horizontal directions alternately. Hence, it is considered that an unstable posture produced by moving the center of gravity back and forth can be recovered by the more stable posture produced when moving it right and left. On the other hand, a significant age difference was found in the stride time of the forward single step and stairs step tests. The stairs step requires exerting large leg strength and is more difficult to perform while maintaining a stable posture than is a flat gait, due to the accompanying up and down shift of the center of gravity. This difficulty is also affected by the height of the stairs. Miyahara et al. (1999) examined how the height of stairs affects the movement of going up and down using three-dimensional movement analysis in ten healthy male adults. They reported that the maximal angle of flexion of the hip, knee and between the
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stepping leg and supporting leg increases significantly with increasing height of the stairs. An increase in range of motion increases the burden on the leg muscles. Hence, the elderly with inferior physical function may experience difficulty performing this task. Takataya et al. (2006) reported that the 60-year-old and 70-year-old individuals showed difficulty walking up stairs with 25 cm and 30 cm heights, respectively, and that the late 70-yearold individuals could not step up stairs with a height over 30 cm, even when using a handrail. This study used stairs with a normal 20 cm height, and subjects proceeded to the next movement after bringing together both legs. Hence, the time difference and stride time may have been shorter in the stairs step test than in the forward single step test. However, it is considered that the stair step makes it more difficult for the elderly with inferior balance ability and leg strength to adjust to the tempo, because significant extension and flexion strength of the knee and ankle joints are required due to the displacement of the physical center of gravity when getting on and off of the stairs. The time difference and stride time are the smallest in the place step test (Shin and Demura, 2007) examined differences among tempos in the place step test and reported that the time difference in the 120 bpm step test was the smallest. The 120 bpm tempo is the most efficient tempo during walking in adults (Toyama and Fujiwara, 1990). From the present results, it was confirmed that even the elderly with inferior physical fitness can easily accomplish place stepping with this tempo. 5. Conclusion In conclusion, the forward single step test has a larger age level difference and a higher difficulty level than the other step tests. References Berg, K., Wood-Dauphinee, S., Williams, J.I., 1995. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand. J. Rehabil. Med. 27, 27–36. Boulgarides, L., McGinty, S., Willett, J., Barnes, C., 2003. Use of clinical and impairment-based tests to predict falls by community-dwelling older adults. Phys. Ther. 83, 328–339. Demura, S., Shin, S., Yamaji, S., 2008. Sex and age differences of relationships among stepping parameters for evaluating dynamic balance in the elderly. J. Physiol. Anthropol. 27, 207–215.
Dite, W., Temple, V.A., 2002. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch. Phys. Med. Rehabil. 83, 1566– 1571. Duncan, P.W., Weiner, D.K., Chandler, J., Studenski, S., 1990. Functional reach: a new clinical measure of balance. J. Gerontol. Biol. Sci. Med. Sci. 45, M192–M197. Hill, K., Bernhardt, J., McGann, D., 1996. A new test of dynamic standing balance for stroke patients: reliability, validity and comparison with healthy elderly. Physiother. Can. 48, 257–262. Judge, J.O., Davis, R.B., Ounpuu, S., 1996. Step length reductions in advanced age: the role of ankle and hip kinetics. J. Gerontol. A: Biol. Sci. Med. Sci. 51, M303– M312. King, G.W., Luchies, C.W., Stylianou, A.P., Schiffman, J.M., Thelen, D.G., 2005. Effects of step length on stepping responses used to arrest a forward fall. Gait Posture 22, 219–224. Luchies, C.W., Schiffman, J., Richards, L.G., Thompson, M.R., Bazuin, D., DeYoung, A.J., 2002. Effects of age, step direction, and reaction condition on the ability to step quickly. J. Gerontol. A: Biol. Sci. Med. Sci. 57, M246–M249. Madigan, M.L., Lloyd, E.M., 2005. Age and stepping limb performance differences during a single-step recovery from a forward fall. J. Gerontol. A: Biol. Sci. Med. Sci. 60, 481–485. Medell, J.L., Alexander, N.B., 2000. A clinical measure of maximal and rapid stepping in older women. J. Gerontol. A: Biol. Sci. Med. Sci. 55, M429–M433. Miyahara, Y., Suzuki, K., Kurogo, Y., Imada, G., Iwatani, C., 1999. Three-dimensional movement analysis of step going up and down in a healthy male adult. Prefectural Rehabilitation 27, 555–564 (in Japanese). Nakata, M., Demura, S., Kitabayashi, T., 2002. Examination of evaluation methods by step movement for estimating the dynamic balance of the elderly. Educ. Health Exerc. 48, 226–232 (in Japanese). O’Brien, K., Pickles, B., Culham, E., 1998. Clinical measures of balance in communitydwelling elderly female fallers and non-fallers. Physiother. Can. Summer 212– 221. Powell, L.E., Myers, A.M., 1995. The Activities-specific Balance Confidence (ABC) Scale. J. Gerontol. A: Biol. Sci. Med. Sci. 50, M28–M34. Rossiter-Fornoff, J.E., Wolf, S.L., Wolfson, L.I., Buchner, D.M., 1995. A cross-sectional validation study of the FICSIT common data base static balance measures. Frailty and Injuries: Cooperative Studies of Intervention Techniques. J. Gerontol. A: Biol. Sci. Med. Sci. 50, M291–M297. Saito, H., Goto, Y., Yanagisawa, K., 2005. Kinematics. Ishiyaku Publishers Inc., Tokyo (in Japanese). Shin, S., Demura, S., 2007. Effective tempo of the step test for dynamic balance ability in the elderly. J. Physiol. Anthropol. 26, 563–567. Shin, S., Demura, S., in press. The relationship of age and leg strength in the step test with stipulated tempo in the elderly. Arch. Gerontol. Geriatr. Shumway-Cook, A., Woollacott, M., 1995. Motor Control: Theory and Practical Applications. Williams and Wilkins, Baltimore. Takataya, K., Kobayashi, Y., Kawamura, R., Nakada, M., Noguchi, C., Yoshikawa, T., Houjou, K., Takizawa, T., Yamagishi, H., 2006. Walking patterns on the floor and the stairs among the elderly according to the level of care. Yamanashi Nurs. J. 5, 31–36 (in Japanese). Tinetti, M.E., Williams, T.F., Myewski, R., 1986. Fall risk index for elderly patients based on number of chronic disabilities. Am. J. Med. 80, 429–434. Toyama, H., Fujiwara, K., 1990. Interference of upper limbs exercise with different automatized levels. Physical Fitness Sports Med. 39, 44–52 (in Japanese).
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Comparison and age-level differences among various step tests for evaluating balance ability in the elderly Sohee Shin *, Shinichi Demura Kanazawa University Graduate School of Natural Science and Technology, Kakuma, Kanazawa, Ishikawa 920-1192, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 January 2009 Received in revised form 17 May 2009 Accepted 20 May 2009 Available online 23 June 2009
This study aimed to examine the difficulty among various step tests (place step, forward single step, forward double step, forward right single step and stairs step) in evaluating the dynamic balance in the elderly and their age level differences. Thirty-two healthy elderly people (age 71.4 6.4 years) and twenty young people performed step tests for 10 s to the pace of a metronome (120 bpm). Evaluation parameters were the time difference between the metronome sound and the time when each foot hit the ground as well as the stride time. The forward single step test had significantly larger values for both of the above parameters than the other tests. A significant age level difference was found in the forward single step test for the time difference and in the forward single step and stairs step tests for the stride time, being longer in the elderly. It was concluded that the forward single step test has larger age-level differences and is more difficult to carry out than the other step tests. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Step test Dynamic balance Balance ability in elderly
1. Introduction The elderly are apt to experience a fall and suffer a minor collision with an object during the fall. Furthermore, a decrease in balance ability is closely associated with the above. Falling in the elderly is frequently associated with large injuries, including fractures, and with a bedridden state requiring long-term nursing care. Maintaining and increasing leg strength and balance ability are very important for the elderly in order to prevent falls. Until now, to evaluate balance ability in the elderly, many tests have been devised from various viewpoints. The following are representative tests: FICST-4 (Rossiter-Fornoff et al., 1995), FSST (Dite and Temple, 2002), Functional Reach (Duncan et al., 1990), Dynamic Gait Index (Shumway-Cook and Woollacott, 1995), Tinetti Performance Oriented Mobility Assessment (Tinetti et al., 1986), Berg Balance Scale (Berg et al., 1995), Timed up & Go Test (Tinetti et al., 1986) and the Activities-Specific Balance Confidence Scale (Powell and Myers, 1995). However, these tests have been developed mainly to evaluate the living ability of the elderly in the nursing home setting. Hence, it has been pointed out that they may not be effective for estimating the balance ability of the healthy elderly (O’Brien et al., 1998; Boulgarides et al., 2003). In addition, all of the tests consist of plural movements and require wide space and sufficient measuring time (Shin and Demura, 2007, in press).
* Corresponding author. Tel.: +81 76 264 2643; fax: +81 76 234 4120. E-mail address: [email protected] (S. Shin). 0167-4943/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2009.05.007
Considering the above problems, Hill et al. (1996) and Nakata et al. (2002) have devised the place step test, which resembles natural gait, to evaluate the dynamic balance ability of the elderly. This test, which measures the step number and the striking time of each foot to the ground within a stipulated time, requires balance ability when the body is supported by one leg because of alternately stepping with both legs (Hill et al., 1996; Nakata et al., 2002). A step test is effective for solving the above problems regarding time and space. However, it has been pointed out that this test is difficult for the elderly with inferior gait ability to perform and incurs the risk of knee injury, because it requires quick stepping with maximal effort. Shin and Demura (2007, in press) proposed a new step test that requires matching stepping to a stipulated tempo. This step test requires submaximal effort and will be more effective to evaluate dynamic balance ability when considering the safety of the elderly. On the other hand, the Four Squares Step (Dite and Temple, 2002), Rapid Stepping Performance (Medell and Alexander, 2000) and Forward Single Step tests have been used to evaluate the balance ability in the elderly, and their validity and reliability have been examined (Miyahara et al., 1999; Medell and Alexander, 2000; Demura et al., 2008). Each of these tests have original characteristics, but there has been no examination of the relationships among the tests or of their difficulty. In addition to the above, it will be important to examine the age level differences between these tests. This study aimed to examine the difficulty and age level differences among various step tests (place step, forward single
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S. Shin, S. Demura / Archives of Gerontology and Geriatrics 50 (2010) e51–e54
step, forward double step, forward right single step, and stairs step) used to evaluate the dynamic balance ability in the elderly. 2. Methods
2.2.2. Forward double step test The step length to the forward position was set at the length of the lower legs. Subjects stepped as one foot forward, followed by the other foot, and returned each foot to the original position to the tempo of the metronome (Fig. 1-2).
2.1. Subjects Thirty-two healthy elderly women (age 71.4 6.4 years, height 148.7 5.3 cm, weight 53.2 7.1 kg) without leg disorders and who could walk independently and twenty young women participated in the experiment. Prior to testing, the purpose and procedure of this study were explained in detail, and informed consent was obtained from all subjects. Approval for this study was obtained from the Kanazawa University Department of Education Ethical Review Board. 2.2. Apparatuses and methods A gait analysis meter (Walkway MG-1000, Anima and Japan) was used for the step test. This device can measure in real time when the subject’s right or left foot touches the step sheet and takes off from a footprint using foot pressure information. The sampling frequency was 100 Hz. The subjects stood on the stepsheet and stepped to match the tempo of a metronome. A 120 bpm tempo was reported to be the most efficient interval during walking (Toyama and Fujiwara, 1990). Sixty bpm and 40 bpm tempos, which correspond to 1/2 and 1/3 intervals of 120 bpm, were selected as slower tempos (Shin and Demura, 2007, in press). The measurement order of step tests was random. Each step test was carried out for 10 s after one trial practice. 2.2.1. Place step test Subjects stood on a step sheet and stepped at the same place with adjustments of the metronome (Fig. 1-1).
2.2.3. Stairs step test The step height of this test was the same 20 cm as the height of a normal stair step. Subjects stepped up and down, one foot after the other, to the tempo of the metronome (Fig. 1-3). 2.2.4. Forward right single step test The step length to the forward position and to the right side was the same as the length of the lower legs. Subjects stepped to the right side with the right leg and returned to the original position. They then stepped forward and returned to the original position. This series of movements was then repeated (Fig. 1-4). 2.2.5. Forward single step test The step length forward was set to be the same as the length of the lower legs. Subjects stepped forward with the right leg and the returned the original position to the tempo of the metronome. They then repeated this movement (Fig. 1-5). 2.2.6. Parameters The time difference and stride time were selected as evaluation parameters for each step test. The former was defined as the difference between the metronome sound of each tempo and the subject’s step time. The latter was defined as the time between the landing of one leg and the next landing of the same leg. Both evaluation parameters were measured as time per step. In short, the total time was divided by the total step number.
Fig. 1. The various step tests.
S. Shin, S. Demura / Archives of Gerontology and Geriatrics 50 (2010) e51–e54
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Table 1 Results of two-way ANOVA for the time differences times. Step test
PS FDS SS FRSS FSS
The youth
The elderly
ANOVA F-value
Mean(s)
SD
Mean(s)
SD
0.02 0.04 0.02 0.04 0.04
0.01 0.02 0.01 0.01 0.02
0.02 0.10 0.10 0.12 0.35
0.01 0.13 0.09 0.12 0.38
F1 F2 F3
Post hoc Tukey’s HSD
20.5* 12.1* 10.9*
The elderly: FSS > other tests The youth: n.s FSS: the elderly > the youth
Note: 1. F-value: F1: movement, F2: age, F3: interaction. 2. PS: place step, FDS: forward double step, SS: stairs step, FRSS: forward right single step, FSS: forward single step. 3. *p < 0.05.
Table 2 Results of two-way ANOVA for the stride times. Step test
PS FDS SS FRSS FSS
The youth
The elderly
ANOVA F-value
Mean(s)
SD
Mean(s)
SD
0.98 1.01 0.98 0.99 1.02
0.04 0.03 0.05 0.05 0.03
0.99 1.06 1.14 1.13 1.35
0.04 0.15 0.18 0.27 0.39
F1 F2 F3
Post hoc Tukey’s HSD
7.9* 8.9* 6.7*
The elderly: FSS > other tests FRSS and SS > FSS The youth: n.s FSS and SS: the elderly > the youth
Note: 1. F-value: F1: movement, F2: age, F3: interaction. 2. PS: place step, FDS: forward double step, SS: stairs step, FRSS: forward right single step, FSS: forward single step. 3. *p < 0.05.
2.2.7. Statistical analysis Two-way ANOVA was used to test mean differences by age and sex for physical characteristics and age and tempos for evaluation parameters, respectively. Multiple comparisons were examined by Tukey’s HSD method. Pearson’s correlation was used to examine relationships between stepping parameters and age or knee extension strength. The probability level of p < 0.05 indicated statistical significance. 3. Results Tables 1 and 2 show the results of ANOVA for the time difference and the stride time of each step test. Both parameters showed a significant interaction. The time difference was larger in the forward single step test than in the other tests for the elderly, but no significant difference was found among the test for the young participants. A significant age level difference was found in the forward single step test, being larger in the elderly than in the young participants. The stride time was significantly longer in the forward single step test than in the other step tests and in the forward right single step and stairs step tests than in the place step test for the elderly, but no significant difference was found for the younger participants. A significant age difference was found in the forward single step and stairs step tests, with both having larger value in the elderly than in the young participants. 4. Discussion Balance ability is an important physical fitness element for the elderly. Hence, it must be properly measured and evaluated. To evaluate physical fitness in the elderly with inferior physical fitness, tests with high safety should be selected. In addition, it is desirable that the test content relates closely to activities of daily life and is available for rehabilitation and functional recovery (Demura et al., 2008). To propose useful tests for evaluating dynamic balance ability in the elderly, this study examined the difficulty among various step tests (place step, forward single step, forward double step, forward right single step and stairs step) and their age-level differences. The time difference and stride time were larger in the forward single step test than the other tests. Humans have an endemic walk
pattern that allows them to advance semiautomatically with a constant cycle. This gait cycle is divided largely into stance, swing, and double stance phases, and the swing phase consists of acceleration, mid swing and deceleration (Saito et al., 2005). In the forward single step test, subjects repeated stepping one leg forward and returning it to the original position without putting both legs together. In short, because there is not a deceleration phase, created by putting together both legs after stepping forward, the braking force becomes larger when returning the stepping leg (making the direction change). Luchies et al. (2002) reported that stepping in the anterior/posterior directions may be able to identify individuals with subtle balance impairments. In addition, King et al. (2005) and Madigan and Lloyd (2005) examined the step length of the forward single step test and reported that the elderly perform balance recovery by taking short steps. Judge et al. (1996) clarified that the step length in the elderly is largely affected by a decrease in plantarflexion strength. On the other hand, the forward double step resembles the forward single step in that the physical center of gravity moves back and forth. However, because the forward double step includes the mid swing and deceleration phase components, it is judged to have a lower difficulty level than the forward single step. In addition, the forward single step requires movement of the center of gravity back and forth while keeping the body balanced on one leg. Hence, this step movement may be difficult to perform while maintaining a stable posture. In contrast, the forward right single step requires that subjects move one leg in the anteroposterior and horizontal directions alternately. Hence, it is considered that an unstable posture produced by moving the center of gravity back and forth can be recovered by the more stable posture produced when moving it right and left. On the other hand, a significant age difference was found in the stride time of the forward single step and stairs step tests. The stairs step requires exerting large leg strength and is more difficult to perform while maintaining a stable posture than is a flat gait, due to the accompanying up and down shift of the center of gravity. This difficulty is also affected by the height of the stairs. Miyahara et al. (1999) examined how the height of stairs affects the movement of going up and down using three-dimensional movement analysis in ten healthy male adults. They reported that the maximal angle of flexion of the hip, knee and between the
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stepping leg and supporting leg increases significantly with increasing height of the stairs. An increase in range of motion increases the burden on the leg muscles. Hence, the elderly with inferior physical function may experience difficulty performing this task. Takataya et al. (2006) reported that the 60-year-old and 70-year-old individuals showed difficulty walking up stairs with 25 cm and 30 cm heights, respectively, and that the late 70-yearold individuals could not step up stairs with a height over 30 cm, even when using a handrail. This study used stairs with a normal 20 cm height, and subjects proceeded to the next movement after bringing together both legs. Hence, the time difference and stride time may have been shorter in the stairs step test than in the forward single step test. However, it is considered that the stair step makes it more difficult for the elderly with inferior balance ability and leg strength to adjust to the tempo, because significant extension and flexion strength of the knee and ankle joints are required due to the displacement of the physical center of gravity when getting on and off of the stairs. The time difference and stride time are the smallest in the place step test (Shin and Demura, 2007) examined differences among tempos in the place step test and reported that the time difference in the 120 bpm step test was the smallest. The 120 bpm tempo is the most efficient tempo during walking in adults (Toyama and Fujiwara, 1990). From the present results, it was confirmed that even the elderly with inferior physical fitness can easily accomplish place stepping with this tempo. 5. Conclusion In conclusion, the forward single step test has a larger age level difference and a higher difficulty level than the other step tests. References Berg, K., Wood-Dauphinee, S., Williams, J.I., 1995. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand. J. Rehabil. Med. 27, 27–36. Boulgarides, L., McGinty, S., Willett, J., Barnes, C., 2003. Use of clinical and impairment-based tests to predict falls by community-dwelling older adults. Phys. Ther. 83, 328–339. Demura, S., Shin, S., Yamaji, S., 2008. Sex and age differences of relationships among stepping parameters for evaluating dynamic balance in the elderly. J. Physiol. Anthropol. 27, 207–215.
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