The visual, somatosensory, and vestibular systems all contribute to the maintenance of balance. Many activities of daily living and sports are classified as dynamic activities. Some therapists use the Star-Excursion Test in an attempt to quantiQ dynamic balance.
The visual, somatosensory, and vestibular systems all contribute to the maintenance of balance. Many activities of daily living and sports are classified as dynamic activities. Some therapists use the Star-Excursion Test in an attempt to quantiQ dynamic balance.
The visual, somatosensory, and vestibular systems all contribute to the maintenance of balance. Many activities of daily living and sports are classified as dynamic activities. Some therapists use the Star-Excursion Test in an attempt to quantiQ dynamic balance.
Stephen ). Kinzey, PhD ' Charles W. Armstrong, PhD * D ynamic balance is re- quired for normal daily activities, such as walk- ing, running, and stair climbing. Sports activi- ties also require proper balance con- trol. The visual, somatosensory, and vestibular systems all contribute to the maintenance of balance (10) and may be adversely affected by muscu- loskeletal injury, head trauma, dis- ease, or aging. These influences on the visual, somatosensory, and vestib- ular systems might decrease a per- son's ability to perform dynamic ac- tivities and, thus, impede normal daily functioning (2,6,17,23). Quanti- fication of balance, or postural con- trol, is often necessary to assess the level of injury or ability to function in order to initiate an appropriate plan of care (15,17). A valid and reliable technique to measure balance is stabilometry (1 7). This method uses a force plate or other similar device to measure the displacement of an individual's cen- ter-of-pressure while standing in a stationary position (1 7). Center-of- pressure represents a weighted aver- age of all the pressures over the sur- face area in contact with the ground (20). Quan tification of center-of-pres- sure movement may be used to evalu- ate numerous parameters (ie., mean position of the center-of-pressure, velo- city of center-of-pressure movement, and total distance traveled by the cen- ter-of-pressure) influenced by the con- trol mechanism affecting balance (16). Many activities of daily living and sports are classified as dynamic activi- Quantification of dynamic balance is often necessary to assess a patient's level of injury or ability to function in order to initiate an appropriate plan of care. Some therapists use the star- excursion test in an attempt to quantiQ dynamic balance. This test requires the patient to balance on one leg while reaching with the other leg. For the purpose of this study, the reach was performed in four directions. No previous researchers have attempted to evaluate the reliability of this test. Twenty healthy subjects between the ages of 18 and 35 years participated in this study. During two testing sessions, each subject was required to perform five reaching trials in four directions. Reliability estimates, calculated using the intraclass correlation coefficient (2/ I ) , ranged from 0.67 to 0.87. Six duplicate practice sessions were suggested to increase this range above 0.86. Task complexity may account for the moderate reliability estimates. Subjects should engage in a learning period before being evaluated on the star-excursion test. Key Words: dynamic balance, lower extremity, reaching, reliability ' Assistant Professor, Department of Exercise Science and Leisure Management, Applied Biomechanics and Motor Performance Laboratory, The University of Mississippi, University, MS 38677 Professor, Department of Health Promotion and Human Performance, Applied Biomechanics Laboratory, The University of Toledo, Toledo, OH ties (9). Dynamic activities are those that cause the center of gravity to move in response to muscular activ- ity. This muscular activity may arise from any source of external or inter- nal disturbance. During dynamic ac- tivity, the center-of-pressure travels between the base of support bound- aries and sometimes outside the base of support (9). Because stabilometry is performed under static conditions, the results may not be directly appli- cable to assessing a patient's capabil- ity for dynamic activities (21). Unfortunately, few practical methods exist for evaluating dynamic balance (7). Methods have been re- ported to assess dynamic balance in- volving perturbation of stationary subjects, through translation of a force plate, or by using an external force to perturb the subject and a nonmoving force plate (5,18). These methods are costly, impractical, and, under some conditions, may pose a risk to subjects. For these reasons, new and practical techniques or pro- tocols to evaluate dynamic balance need to be investigated. The starexcursion test is used by some therapists to assess dynamic bal- ance. It has been proposed that the test meamres dynamic balance, re- quiring patients to maintain balance on a single limb, while manipulating the other limb. This test requires the subject to reach along a previously marked line with one leg while stand- ing on the other leg. This reaching task is done along four different diag- onal lines in four different directions. The distance reached in each direc- tion is recorded separately and the four individual scores are interpreted as a representation of dynamic bal- ance and offer clinicians a practical alternative for assessing dynamic bal- ance. The purpose of this study was Volume 27 Number 5 May 1W8 JOSPT R E S E A R C H S T U D Y FIGURE. Layout of the star-excursion test showing how the tape was applied to the floor. Subjeas stood within the square box and reached out in the four diagonal directions. LA = Left-anterior, LP = Left- posterior, RA = Right-anterior, RP = Right-posterior. to evaluate the reliability of the star- excursion test. METHODS Subjects Twenty subjects (nine males and 11 females) volunteered to partici- pate in this study and provided in- formed consent as approved by the Institutional Review Board, University of Toledo, Toledo, OH. To qualify for participation, the subjects could not have: 1) incurred any ankle trauma requiring medical attention within the past 2 years, 2) a history of any dizziness, 3) any inner ear disor- ders, 4) any nervous system problems, 5) any bone or joint abnormalities, 6) a history of loss of consciousness, 7) any uncorrected problems with vision, or 8) any other problem that might adversely affect the control of balance. All subjects were between the ages of 18 and 35 years. Test Description The starexcursion test layout consisted of four lines, applied to the floor with athletic tape: two forming vertical and horizontal lines and two positioned perpendicular to each other and at 45O with respect to the vertical and horizontal lines (Figure). A rectangle representing the starting position of the feet wa. placed at the center point. This box wa. large enough to fit the subject's feet while straddling the vertical line. A standard tape measure wa. used to quantify the distance (cm) from the center point to the point that each subject reached along each diagonal using the distal part of the foot. Calculators were then used to reduce the trial data into direc- tional averages. Protocol The subject. completed two test- ing sessions (pretest and posttest) 7 days apart. For each session, subjects were instructed to stand with both feet positioned inside the boundaries of the starting box. A trial was initi- ated when the subject began to reach in one of the following four diagonal directions: right-anterior (RA), left- anterior (LA), right-posterior (RP) , and left-posterior (LP). When reach- ing along the lines to the subject's right, the subject used his/her right leg to reach while using his/her left leg as the support limb and vice versa. Subject. were not allowed to touch the ground with the reaching leg at any time during the reach. The maximal reach distance was the fur- thest point along the directional line. In accordance with the usual test pro- tocol, the maximal reach distance was measured visually. The visual mark was then replaced by a finger, and the distance was then measured using a tape measure. The test administra- tor was positioned on his knees along the directional line. The trial was complete after the subject returned to the starting point by placing the reaching leg in the starting box with the support leg. After completion of a single trial, the subject was given the time necessary to regain the proper starting position before start- ing the next trial. Five consecutive trials in each direction were com- pleted before the subject began to reach in the next direction. During the starexcursion test, the subject. were instructed to move in any way possible to achieve a maxi- mum reach distance without moving the support foot. These movements included but were not limited to knee flexion of the support limb and dorsiflexion of the support limb; hip flexion in the reaching limb, knee extension in the reaching limb, and plantar flexion in the reaching limb; and slight hyperextension of the trunk. Typically, clinicians also use a subjective description of what move- ment strategies are used by the pa- tient when performing the star-excur- sion test. This subjective description is then used to identify possible dif- ferences between limbs. After performing a local survey of clinicians that used this test, it was determined that the star-excursion test is usually performed with shoes on. Furthermore, no recommenda- tions concerning the height of the reaching limb are made when the test is administered. In an attempt to keep our protocol similar to a clinical application, no effort was made to control for these items. Experimental Design and Statistical Analysis A pretest-posttest design was used to assess the four dependent mea- sures corresponding to the average of the three best reaches for each diagonal direction: right-anterior (RA), left-anterior (LA), right-poste- rior (RP), and left-posterior (LP) . The direction of reach was deter- mined by a balanced Latin square to reduce the possibility of an order effect. Intraclass correlation coefficient (2,l) (ICC 2, l) (13) and the Spear- man Brown prophecy (1) were used to estimate the reliability (ie., agree- ment between scores) of the starex- cursion test. The ICC(2.1) was cho- sen as the reliability estimate, since it provides an estimate that includes the variability of measurement. taken by any investigator on any subject JOSFT Volume 27 Number 5 May 1998 3.57 RE S E ARCH S T U D Y Left- Righ Left- Righ iredion ICC(2,l) SEM anterior 0.87 3.43 t-anterior 0.67 4.78 posterior 0.87 3.48 1-posterior 0.82 3.99 TABLE 1. Summary oi the ICC(2,l) estimates o i reliability and standard error of measurement (SEM). (13). The ICC(2.1) is represented by the following equation (13): where BMS = between mean square, EMS = residual mean square, JMS = between judges' mean square, k = the number of sets of scores, and n = the number of persons observed. Mean square terms were obtained using the F statistic calculated under the reliability procedure in SPSSm for WindowsTM, Version 6.1 (SPSS, Inc., Chicago, IL). The Spearman Brown prophecy estimates the reliability of a test. Us- ing only two sets of obsenations, it allows the researcher to estimate how many observations might be neces- sary to achieve a desired estimate of reliability. The Spearman Brown prophecy is represented by the fol- lowing formula: where k = a factor by which the orig- inal set of data is lengthened, r,,. = the value of ICC(2,1), and r,,. = the new estimate of reliability. The factor k can be altered to decide how many sets of observations are necessary to achieve a suitable estimate of reli- ability. RESULTS The reliability estimates obtained for each of the four reaches are pre- sented in Table 1. Reaches that were in the left diagonal directions, per- formed while the subjects stood on their right foot, produced the highest estimates of reliability: left-anterior, ICC(2,l) = 0.87; left-posterior, ICC(2,l) = 0.87. The ICC(2,l) esti- mates for reaches along the right an- terior and posterior diagonal direc- tions were 0.67 and 0.82, respectively. Table 2 contains the results from the Spearman Brown prophecy. The Spearman Brown prophecy provides an indication that at least six practice sessions of five trials per direction per session, taking the average of the best three reaches, may be necessary to achieve a reliability measure rang- ing from 0.86 to 0.95. A minimum reliability estimate of 0.95 would be achieved if the subject engaged in 18 separate practice sessions, consisting of five trials per direction per session. DISCUSSION The task of standing in normal adults can be described as a position of quasi-static equilibrium. Standing is quasi-static because the center-of- pressure travels within the base of support, indicating overall sway with- out a corresponding translation of the base of support (20). The goal of the starexcursion test is to force subjects to disturb their equilibrium to a near maximum (ie., the reach is maximum but does not cause a fall which would be indic- ative of a maximal disturbance) and then return back to the state of equi- librium (starting point). Normally, adults do not challenge their state of equilibrium to the extent required in this test. Additionally, the movement patterns employed in the test are not common to normal functional activi- Direction k Number of Three Trial Averages 6 18 6 10 18 6 18 6 18 TABLE 2. Summary of the Spearman Brown prophecy reliability estimates. The goal of the star- excursion test is to force subjects to disturb their equilibrium to a near maximum. ties or those involved in sports. Thus, the task involved in the starexcursion test would appear to be a novel one. Table 1 lists the moderate reli- ability estimates that were found for the four components of the test. Moderate estimates of reliability indi- cate that a subject mav exhibit a change in scores due to some unmea- surable circumstance, a random movement pattern, or any other pos- sible influence, including mental state. One possible explanation for these moderate estimates is that the subjects may have chosen different movement trajectories in an attempt to obtain a maximal reach distance. These random movement trajectories could contribute to random low or high reaches instead of a consistent reach distance. Also, the type of movement required during the star- excursion test is both multilimb and multiarticular. For instance, distance reached in an anterior direction would be greatly affected by the amount of knee flexion and ankle dorsiflexion of the support limb and hip flexion, knee extension, and an- kle plantar flexion of the reaching limb. These movements inherently have more variability associated with them than .single limb and uniarticu- lar movements (19). To decrease the variability involved in a complex ta..k requires practice. Both task complex- ity and motor ability influence how many practice sessions are necessary to achieve consistent result.. (12). The human organism uses the redundancy within the sensorimotor 358 Volume 27 Number 5 Mav 1998 JOSPT R E S E A R C H S T U D Y system to reduce this variability when realizing the solution to a given task (1 1 ). Three systems, visual, vestibular, and the somatosensory, are used to provide the information to the senso- rimotor system (10). This redun- dancy is demonstrated when subjects are able to maintain an upright posi- tion under the commonly used foam and dome conditions (14), which confuse or eliminate portions of the sensorimotor system used in postural control. Although the task of main- taining upright posture becomes in- creasingly difficult, subjects are still able to perform under the test condi- tions (eg., maintenance of posture when blindfolded) or when confused. Furthermore, in experiments in- volving the analysis of upper-limb- reaching trajectories, visual feedback has been shown to be important in achieving consistency (22). In the absence of visual feedback, it has been proposed that an individual may use internal models of the limb to aid in the positioning during reaching tasks (3). Additional infor- mation regarding the position of the lower limb may be arrived at using proprioceptive mechanisms. Proprio- ceptive feedback during reaching provides information regarding the limb position and has been shown to be important in the development of an internal coordinate system (4). It is important to note that because hu- mans rarely engage in reaching tasks using their lower limbs, these neural pathways which are readily available during upper extremity reaches may not be as readily available when de- scribing lower limb movement. Finally, the strategy chosen by the subjects in performing the test involved a controlled lowering of the body to maximize the reach. This was accomplished through eccentric and isometric contractions of the knee extensors of the supporting limb. The extent to which this can be done is clearly dependent on the strength of these muscles. It is possible then that the ability to control the support limb in a partial squat using an iso- metric contraction could contribute to the lack of consistency in scores. An optimal reach during the star- excursion test might require precise integration of the nervous system function and musculoskeletal system. The absolute strength of the support limb musculature may also influence the outcome of the test. Because the star-excursion test is novel, the devel- opment of this integration might be difficult and require practice. The practice would allow for the proper neural circuitry to become activated and the resulting coordination of movement to be developed. This may explain the linear relationship be- tween the amount of practice sessions and the estimated reliability shown in Table 2. The speed at which the move- ment is performed may also affect the consistency of results. During tar- geted reaching tasks involving upper limb movement, speed has a direct Both task complexity and motor ability influence how many practice sessions are necessary to achieve consistent results. relationship with accuracy and pro- vides an experimental example of Fitt's Law (8). As the limb speed in- creases, the accuracy of the limb movement decreases. It is probable that the same relationship in the lower limb exists during the starex- cursion test. The starexcursion test requires a manual measurement when the subject achieves maximum reach distance. Therefore, the s ub jects did not use a strategy that in- volved a rapid reach with the lower limb when performing the starexcur- sion test. However, in upper extrem- ity testing, a slight decrease in move- ment time (100 msec) caused a large decrease (20%) in movement accu- racy (8). Although no movement time was recorded, subjects might have made adjustments of this mapi - tude, causing a resultant change in accuracy and reach distance. CONCLUSIONS The utility of clinical diagnostic testing is dependent on the reliability and validity of the testing procedure. Because exact or near exact repeat performances were not exhibited in this investigation, the starexcursion test might not be an appropriate test of dynamic balance. While practice may improve the reliability of the test, clinicians typically do not have an unlimited amount of time to reha- bilitate an individual's injury. There- fore, the time necessary to practice the starexcursion test is not always available. Without reliability, there can be no validity; therefore, we must ques- tion what exactly is measured during the starexcursion test. Although the starexcursion test may not provide an appropriate method for evaluating a patient's dynamic balance, it may play an important part in rehabilita- tion. Because of the strength, move- ment complexity, and neural control associated with the starexcursion test, it may be a useful activity for progres- sively stimulating the involved systems in selected patients. In light of the present findings, it seems that a test of dynamic balance should involve activities that are more common and in accordance with activities of daily living. For in- stance, we might have typical move- ment patterns that occur when we descend stairs. Therefore, it might be possible that dynamic activities of this type could be structured in such a way that reliable measurements could be made. Typical movements that are normally performed should probably JOSPT Volume 27 Number 5 May 1998 R E S E A R C H S TUDY be the basis for evaluation methods Methodology and effects of midazolam lnt J Sports Med 6(3): 180- 182, 1 985 instead of using novel movements sedation. Acta ~tol aryngol 113(3):245- 17. 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