The Physician and Sportsmedicine

ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20

Evaluation of postural stability in youth athletes:

the relationship between two rating systems

David R. Howell, Benjamin J. Shore, Emily Hanson & William P. Meehan III

To cite this article: David R. Howell, Benjamin J. Shore, Emily Hanson & William P. Meehan III
(2016): Evaluation of postural stability in youth athletes: the relationship between two rating
systems, The Physician and Sportsmedicine, DOI: 10.1080/00913847.2016.1197763

To link to this article: http://dx.doi.org/10.1080/00913847.2016.1197763

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 Publisher: Taylor & Francis

Journal: The Physician and Sportsmedicine

DOI: 10.1080/00913847.2016.1197763
Article Type: Original Research

Evaluation of postural stability in youth athletes: the relationship between two rating

systems
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Running title: Evaluation of Postural Stability in Youth Athletes

Authors: David R. Howell, Benjamin J. Shore, Emily Hanson, and William P. Meehan III

Institutional affiliations and title of current position for authors:

David R. Howell:
Post-Doctoral Research Fellow, The Micheli Center for Sports Injury Prevention, Boston
Children’s Hospital, Boston, MA, USA

Benjamin J. Shore: Assistant Professor of Orthopaedic Surgery, Harvard Medical School,

Boston Children’s Hospital

Emily Hanson: Certified Athletic Trainer, The Micheli Center for Sports Injury Prevention,
Boston Children’s Hospital, Boston, MA, USA

William P. Meehan III: Director, The Micheli Center for Sports Injury Prevention, Waltham,
MA, USA; Assistant Professor in Pediatrics and Orthopaedics, Harvard Medical School, Boston
Children’s Hospital

Corresponding Author: David R. Howell, PhD, ATC

The Micheli Center for Sports Injury Prevention; Division of Sports Medicine, Department of
Orthopedics, Boston Children’s Hospital
Address: 9 Hope Avenue, Suite 100, Waltham, MA 02453.
Telephone: (781) 216-2865. Fax: (781) 216-1365.
Email: David.Howell2@childrens.harvard.edu.
 Abstract

Objectives: The Balance Error Scoring System (BESS) has been documented as a useful way to

evaluate postural control following sport-related concussions sustained by youth athletes.

However, limitations have been reported with its use due to the reliance on visual observation as

the primary measurement outcome. The primary purpose of this study was to examine the

correlation between the modified BESS (mBESS) as rated by a clinician and a simultaneous

analysis performed by an integrated video-force plate system. The secondary purpose was to
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assess if a history of prior concussion affected postural control.

Methods: A group of healthy youth athletes (n = 398; mean age 13.7 ± 2.4 years) completed the

mBESS while simultaneously undergoing an integrated video-force plate evaluation to measure

postural stability. Spearman rank-order correlations were used to determine the strength of

correlation between the 2 rating systems. In addition, performance on the mBESS between those

with and without a history of concussion was compared using univariate ANCOVAs.

Results: A moderately high correlation was found during single-leg stance (ρ = -0.64, p < .001),

while a weak correlation was found during tandem stance (ρ = -0.30, p < .001). No postural

control differences were found between groups with and without a concussion history.

Conclusion: The video-force plate rating system correlates well with the clinician rating during

the single-leg stance of the mBESS, but not during double-leg or tandem stances. A history of

concussion did not affect mBESS scores.

Keywords: postural balance; cerebral concussion; kinematics; kinetics; balance error scoring

system,
 Introduction

Balance and postural control are necessary components for everyday functioning [1].

Concussion has been documented to impair the ability to control balance and posture [2–4].

Thus, balance control and postural stability assessments following concussion are often included

during post-injury examinations [5]. Prior studies have used three-dimensional motion capture

and force plate systems to objectively evaluate balance control following concussion, detecting

deficits lasting from several days to many months after injury [2,6,7]. Widespread use of these
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systems in a clinical setting, however, is limited due to cost and space constraints for testing.

Developing portable methods to test postural stability would allow clinicians to identify

impairments resulting from injury in an objective manner, within the confines of a clinical

setting. Prior studies suggest that portable balance testing protocols can be a way to identify

dysfunction following a concussion that augments standard clinical evaluations [3,8].

A common post-concussion postural control assessment, the balance error scoring system

(BESS), consists of measuring the ability of an individual to stand upright in various stances, on

firm or foam surfaces [5,9,10]. By altering the foot position of an individual and the surface

material on which they are standing, the BESS represents a systematic way to alter available

somatosensory and/or visual stimuli. The modified BESS (mBESS), a version of the BESS

which does not include foam surface conditions, has been suggested as a reliable and time-

efficient assessment for clinicians to use in the assessment and management of sport-related

concussion [11,12]. Although it is quick and easy to implement in clinical settings, limitations

have been identified with its use due to practice, learning, and fatigue-related effects [13–15].

Previous studies investigating the duration of practice and learning effects have reported

improvements across one season of athletic participation [14,16]. When repeat administration of
 the BESS occurs, significant improvements have been identified from pre-season to post-season

in healthy athletes as rated by clinicians [14]. The effects resulting from a concussion have been

identified to last up to 5 days post-injury when rated by a clinician [17], but few studies have

studied BESS performance beyond this time period.

Although the mBESS remains a commonly recommended postural control assessment

tool for concussion [5], reliance on examiner judgment may produce inter-rater variability. The

clinical utility of the mBESS as a post-concussion evaluation of postural control may be limited,
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particularly in children and adolescent athletes, who are still developing and improving their

postural control as they age [18]. Thus, numerous recent studies have investigated ways to

increase test objectivity during stance tasks by examining kinematic data using accelerometers

[3,8,19], or kinetic data using pressure platforms [20,21] and force plate systems [22]. While

both forms of assessment provide useful data about postural stability, unique information may be

gathered by integrating both sources of data into a single objective rating of postural control

which combines kinematic and kinetic data [23]. Furthermore, doing so using a portable

examination system may enable clinicians to routinely conduct objective postural control

assessments to monitor recovery from injury. Therefore, the primary objective of this study was

to examine the correlation between clinician rated mBESS scores and simultaneously captured

postural control ratings using a video-force plate system among young, uninjured athletes. The

secondary outcome was to investigate the effect of prior concussion history on these two rating

system measures.

Materials and Methods

Participants
 We conducted a cross-sectional study of athletes who underwent an Injury Prevention

Evaluation (IPE) at a sports injury prevention center between April 2013 and July 2015. During

the IPE, athletes complete a questionnaire about their previous medical history, sports

participation, training regimen, and then undergo a variety of biomechanical, neuromuscular,

anatomical, and physiological measurements, including a postural stability assessment.

Participants were included if they completed the questionnaire documenting their injury history

and underwent an analysis of postural stability that included the mBESS as rated by a trained
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injury prevention specialist (certified athletic trainer or master’s level kinesiologist) and

simultaneously by a video-force plate postural control rating system (Equilibrate, Balance

Engineering LLC, Henrietta, NY). Participants who reported active involvement in at least one

sport at the time of testing were included in the study, while those with an existing ankle injury

at the time of testing [24] or with an intellectual or developmental disability [25,26] were

excluded from the current study. The study protocol was approved by the institutional review

board.

Within the medical history questionnaire, participants were asked if they had ever been

diagnosed with a concussion by a doctor or athletic trainer. Concussion was defined as a brain

injury caused by a direct blow to the head, face, neck, or elsewhere on the body, resulting in the

rapid onset of impairment of neurological function [5]. Thus, a history of concussion was

recorded from the participants’ response. Athletes who reported a prior history of concussion

were able to participate in the study protocol if they had already been medically cleared to

participate in unrestricted physical activity by their physician as a part of the IPE, and were not

experiencing any concussion related symptoms at the time of testing.

Procedures
 Three trials of the mBESS [3] were performed in 3 stances: double-leg, single-leg, and

tandem, each performed on a force plate(s) [11,12]. During double-leg stance, participants were

instructed to stand with their feet positioned side by side. During single-leg stance, participants

stood on the foot that they identified as their non-dominant kicking leg. The tandem stance

consisted of participants standing with their feet positioned where the non-dominant foot was

placed directly behind the dominant foot. During each stance, athletes place their hands on their

iliac crest and close their eyes. Each trial was performed for 20 seconds. Examiners recorded an
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error any time an athlete took their hands off of their iliac crests, opened their eyes, stumbled,

flexed or abducted the hip greater than 30 degrees, lifted their forefoot off of the floor, or

remained out of the proper position for greater than 5 seconds. Per mBESS protocol, the

maximum amount of errors per stance is 10. Four injury prevention specialists administered the

study protocol; previous studies have reported inter-rater reliabilities on the mBESS to range

from 0.85 to 0.95 (ICC) [27,28]. The sum of all errors committed during each stance comprised

respective clinician ratings. The sum of all errors committed across all conditions of the mBESS

comprised the composite clinician score, which ranged from 0 (no errors committed) to 30 (10

errors committed in each of the 3 conditions). Thus, the lower the score on the mBESS, the better

ability the participant demonstrated in remaining in the specified posture.

Simultaneously, postural control was assessed by the video-force plate system during

each trial through a concurrent capture of kinematic and kinetic data [23,29]. While participants

stood on the force plate(s), they wore a motion tracking vest. Markers were attached to the vest

via Velcro, and tracked by two video cameras (Webcam C600, Logitech Inc., Newark, CA,

USA) placed posteriorly and to the left and right of the participant. A set of 7 markers were

placed on anatomical landmarks of participants and tracked using the two cameras, positioned
 posterior and to the left/right of the participant. The marker trajectories were captured at a

sampling rate of 30 Hz and reconstructed from data captured by the 2 video cameras to calculate

the three-dimensional position of each torso marker in space throughout the 20 second trial,

using Balance Engineering software. Markers were placed on the following anatomical

landmarks to define torso movement: superior medial scapular border (left and right), posterior

superior iliac spine (left and right), C7, T7, and sacrum. These anatomical locations provide a

representation of movement of the entire torso during each experimental trial. Seven markers
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were used, rather than a single point, to provide a three-dimensional trajectory of the entire torso

during the 20 second trial for use in further calculations. Center of pressure (COP) data were

collected synchronously as participants stood on the two force platforms, each embedded with 4

force sensors (FC23 Compression Load Cell, Measurement Specialties Inc., Fremont, CA, USA).

Postural stability was automatically quantified using Balance Engineering software [23]

and further analysis was conducted using a custom LabView program (National Instruments

Corp., Austin, TX). Three metrics were obtained during each stance, each representing a

different component of postural control: 1) the overall postural control rating, 2) the frequency of

movement in the sagittal and frontal planes of movement, and 3) the average weight distribution

of the participant on each force plate. The overall postural control rating is a metric representing

the ability of the participant to maintain control of their torso and center of pressure during each

20 second stance, previously used to examine the normative reference values among youth

athletes [23] and the effect of anterior cruciate ligament reconstruction on postural stability [29].

It was calculated using the displacement and variance of the torso marker and COP data: total

displacement was calculated for the weighted sum of the torso marker trajectories and COP path

throughout the 20 second trial, while variance was calculated as the average of the squared
 differences from the mean of torso markers and COP path during the 20 second trial. The marker

and COP displacement and variance calculations were then used to calculate the postural control

rating, according to the following equation:

( & ) ( & )
=

This rating was normalized for the time of the test on a scale from 0-100, where a score

of 100 indicates no torso or center of pressure movement, and has been used in prior studies

evaluating postural control among athletes [23,29]. Additionally, a composite rating was
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calculated as the sum of all 3 stances.

The frequency of movement in the sagittal and frontal planes of movement was also

calculated. This metric is calculated from the rate of torso directional movement changes during

the duration of the trial, calculated separately for frontal (medial-lateral) and sagittal (anterior-

posterior) planes of movement. A low frequency indicates less torso movement change of

direction, while a high frequency indicates a high degree of directional changes of the torso

during the trial. Assuming an inverted pendulum model, double-leg stance control may be

achieved using an ‘ankle-strategy’ and primarily movement is expected in the sagittal plane of

movement [1].

The average weight distribution on each force plate is a variable indicative of basic

weight distribution during each stance, and was calculated from the percentage of total force

applied on each force plate throughout the duration of the test. Right and left percentages are

calculated during double stance, while forward and back foot percentages are calculated during

tandem stance, and the stance foot is calculated during single-leg stance.

Statistical Analyses
 Continuous variables are presented as means ± standard deviations and were compared

using Student’s t-test; categorical variables are presented as percentages and were compared

using Fisher’s exact test. Concurrent validity between mBESS clinician-rated errors and the

video-force plate rating system was determined using Spearman’s rank-order correlations (ρ).

The strength of correlations between clinician-rated mBESS performance and video-force plate

ratings were considered according to the following definitions: no correlation (0-0.19), low

correlation (0.2-0.39), moderate correlation (0.4-0.59), moderately high correlation (0.6-0.79),

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and high correlation (≥0.8) [30]. The reliability of measurements from the video-force plate

overall postural control ratings were evaluated using intraclass correlations (ICCs) across the 3

trials. The mean of the 3 tests in each condition was also compared using one-way analyses of

variance.

Clinician-rated mBESS scores and outcome variables derived from the video-force plate

analysis were also evaluated using a one-way analysis of covariance to determine if differences

existed between groups: those with a history of prior concussion and those without a history of

prior concussion. The following covariates were included in the analysis and were selected due

to prior literature suggesting an effect on postural control: sex [31], age [32], BMI [11], ankle

injury history [33], knee injury history,[34] and migraine history [35]. Statistical significance

was set at p < 0.05 and adjusted using the Bonferroni procedure when multiple comparisons were

made. Statistical analyses were performed with Statistical Package for the Social Sciences (IBM

SPSS Statistics for Windows, Version 23.0.Armoonk, NY: IBM Corp).

Results
 A total of 413 youth athletes underwent injury prevention evaluations during the study

period. Of those, 20 participants were excluded: 10 because they reported an existing ankle

injury at the time of testing, 5 because they reported no active participation in any sport or

activity, and 5 because they had a history of developmental disability. Thus, a total of 393

participants were included in the current study. Participant ages ranged from 8-18 years (mean =

14.3±2.4 years); those with a history of concussion were older, heavier, and had higher BMIs

than those without a history of concussion (Table 1). For participants with a history of prior
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concussion, the most recent injury occurred at a mean of 2.0±1.7 years prior to testing. Sixty-

eight individuals reported sustaining 1 previous concussion, while 24 reported sustaining 2

previous concussions, and 12 reported sustaining 3 or more previous concussions.

No correlation was found between mBESS and video-force plate rated performance

during double-leg stance (ρ = -0.09, p = 0.09; Figure 1A). In contrast, a moderately high

correlation was found between measurements during single-leg stance (ρ = -0.64, p < .001;

Figure 1B) and a low correlation was found during tandem stance (ρ = -0.30, p < .001; Figure

1C). A moderate correlation was found for the sum of all 3 stances (ρ = -0.60, p < .001; Figure

1D). The ICCs in each stance suggested a high degree of internal consistency, as values from the

3 trials were 0.89 (double-leg stance), 0.80 (single-leg stance), and 0.83 (tandem stance). No

significant differences were detected between trials for double-leg stance (p = 0.56), single-leg

stance (p = 0.99), or tandem stance (p = 0.93), suggesting minimal learning effects within the 3

trials as rated by the video-force plate system.

During double-leg stance, only 6 participants committed errors identified by the injury

prevention specialist during the mBESS (4 from the history of prior concussion group, 2 from the

no history of prior concussion group); thus, we were unable to make reliable between group
 comparisons about the effect of prior concussion on performance during the double-leg stance

(Table 2). No significant differences were found during any condition of the mBESS when rated

by a clinician between those with and without a history of concussion (Table 2). Similarly, no

significant overall postural control rating differences were observed between the two groups in

any of the three stances (Table 3). No significant differences between groups were detected for

sagittal plane torso movement frequency or for average weight distribution in each of the 3

stances (Table 4). Participants with a history of concussion demonstrated significantly less
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frontal plane movement frequency during double-leg stance, but not in single-leg or tandem

stances (Table 4).

Discussion

Data obtained from this cross-sectional investigation indicate that clinician ratings on the

mBESS and postural control ratings obtained from video-force plate system are moderately

highly correlated during the single-leg stance of the mBESS; more clinician-observed errors

correlated with more torso and COP movement. The double-leg and tandem stances of the

mBESS, however, did not demonstrate high correlations, suggesting that clinician rated errors

and video-force plate analysis do not possess a strong correlation during these conditions.

Prior studies have examined the association between observer ratings and instrumented

systems of evaluation on static balance tests. Using force plate measurements, Alsalaheen and

colleagues recently observed that BESS error scores and sway velocities are significantly and

highly correlated during single and tandem stances in a group of 36 healthy adolescents [22],

while Caccese and Kaminski observed that pressure platform metrics agreed with human scorers

during all 3 stances of the mBESS in a sample of 111 healthy collegiate athletes [20]. Others
 have quantified postural control and its association with human raters through kinematic analyses

[3,8]. Comparing clinician-rated postural control errors with an accelerometer rating system,

increased diagnostic accuracy after concussion has been reported [3], while an accelerometer

placed on the forehead predicts observer-rated BESS scores [8]. Our data support this previous

work during the single-leg stance of the mBESS. As a moderately high correlation exists

between clinician and video-force plate ratings, the addition of an integrated system including

kinematic and kinetic data may be an appropriate method to increase objectivity of the single-leg
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stance portion of the mBESS.

The lack of moderate or high correlations between clinician-observed errors and the

postural control rating during the tandem and double-leg stances of the mBESS suggests that the

ratings calculated from the video-force plate system were not reflective of the performance

evaluated by the clinician. Previously, clinician raters and an accelerometer placed on the

midline of the pelvis have been identified to rate BESS performance differentially after

concussion, where the instrumented ratings could not distinguish patients with and without a

concussion but clinician raters could, particularly during the tandem stance [19]. The lack of a

strong relationship between rating systems during double-leg and tandem stances observed in our

study may be related to the notion of using a subjective form of rating postural stability to

quantify the maintenance of posture during a 20 second trial, which may not be reflective of true

postural control abilities [36]. Objective rating systems may provide a way to augment clinical

assessments of posture and increase the sensitivity of a testing battery to the effects of

concussion. Future research should seek to identify the added value of an integrated video-force

plate rating system during post-concussion evaluations to objectively detect postural control

impairments.
 The similar postural control performance by this cohort of youth athletes suggests that

both instrumented and observer rating systems were unable to detect differences between those

with and without a history of prior concussion. Our cross-sectional approach to investigate this

question, however, is limited, as the mean time since the previous concussion among those with

a concussion history was 2 years. Previous work has demonstrated balance control deficits using

observer-rated BESS scores for up to one week post-injury [37] and for 5 months post-

concussion using an instrumented system of evaluation [3]. In contrast, dynamic gait deficits
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have been reported to range between 2 months to 5 years after concussion [38–41]. Thus, in

order to detect persistent deficits from concussion, more dynamic and challenging tasks may be

required.

During the double-leg stance condition of the mBESS, only 6 total errors were identified

by clinician raters throughout the entire study cohort (1.2% of all trials). This is likely due to a

basement effect in this condition which has been previously described in healthy individuals and

in those who recently sustained a concussion [12,19]. As a result of this effect, Hunt and

colleagues have suggested that removal of the double stance condition may increase the

reliability of postural control assessments commonly utilized following concussion [12]. Results

from the integrated video-force plate system provided a wider distribution of possible scores

(Figure 1A), potentially limiting such basement effects during the double-leg stance of the

mBESS. As deficits during the double-leg stance with eyes closed may indicate difficulty

controlling precise posture and integrating sensory stimuli [10], the use of objective methods

incorporating both kinematic and kinetic data may allow clinicians to identify subtle postural

stability deficits undetectable during human-rated trials particularly during double-leg quiet

stance tasks.
 Interpretation of the findings from this study must be viewed in light of several

limitations. All study participants reported for testing as a part of a comprehensive evaluation of

injury risk factors and subsequent exercise prescriptions. Therefore, these athletes likely

represent a different cohort than the general population or the general athletic population,

limiting the generalizability of our results. Furthermore, we relied on the retrospective self-

reporting of previous injury history, rather than obtaining medical records for documentation of

concussion occurrences. A prospective approach which tests athletes acutely after concussion
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may provide a more robust method to identify if a combined video-force plate analysis could

augment the diagnosis and management of sport-related concussion by increasing the objectivity

of clinical balance exams. In addition, we did not record how many times and when the athletes

had previously completed an mBESS assessment, which may have affected performance.

Finally, athletes who had a concussion history were older and heavier than those without a

concussion history and these group characteristic differences may have affected our results.

Conclusion

In conclusion, a moderately high correlation was detected between clinician rated

mBESS performance and postural stability measured by a video-force plate system during the

single-leg stance of the mBESS. The use of objective methods to identify deficits following

concussion may assist clinicians by reducing the variability inherent in human judgment and

limiting practice effects, thus representing a useful addition to the multifaceted post-concussion

examination.
 Acknowledgements

The authors gratefully acknowledge Corey Dawkins, MS, ATC, Dennis Borg, MS, ATC, CSCS,

and Jen Morse, MS, CSCS for their assistance in the collection of data.

Declaration of interests

W Meehan receives royalties from ABC-Clio publishing for the sale of his book, Kids, Sports,

and Concussion: A guide for coaches and parents, and royalties from Wolters Kluwer for
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working as an author for UpToDate. He is under contract with ABC-Clio publishing for a future

book entitled, Concussions, and with Springer International publishing for a future book entitled,

Head and Neck Injuries in Young Athletes. His research is funded, in part, by from the Football

Players Health Study at Harvard, which is funded by the National Football League Players

Association and by philanthropic support from the National Hockey League Alumni Association

through the Corey C. Griffin Pro-Am Tournament. The authors have no other relevant

affiliations or financial involvement with any organization or entity with a financial interest in or

financial conflict with the subject matter or materials discussed in the manuscript apart from

those disclosed.
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 Figure 1: Scatterplot and line of best fit describing the relationship between clinician-rated

errors on the mBESS and video-force plate postural control ratings during (A) double-leg stance,

(B) single-leg stance, (C) tandem stance, and (D) the composite of all 3 stances.
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 Table 1: Participant Demographics. Means (SD) are presented for continuous variables, n (%)
are presented for categorical variables.

History of Prior No History of Prior

Characteristic Concussion Concussion
(N=104) (N=289)

Age (years)* 14.8 (2.1) 14.1 (2.4)

Height (cm) 164.8 (10.9) 162.4 (13.4)

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Mass (kg)* 58.2 (13.7) 55.0 (15.9)

BMI (kg/m2) 21.2 (3.5) 20.4 (3.5)

Sex (female) 62 (60%) 179 (62%)

Ankle injury
42 (40%) 100 (35%)
history

Knee injury
11 (11%) 20 (7%)
history

Migraine
10 (10%) 19 (7%)
history

1 sport athletes 14 (13%) 66 (23%)

2 sport athletes 33 (31%) 71 (24%)

3 sport athletes 57 (54%) 152 (52%)

*Youth athletes with a history of concussion were significantly older (p = .006) and heavier (p =
.049) than those without a history of concussion.
 Table 2: Mean (95% CI) scores of athletes during each stance of the mBESS rated by a clinician
(ANCOVA covariates included sex, age, BMI, ankle injury history, knee injury history, and
migraine history).

Concussion History No Concussion Significance

Total Errors Committed
(n=104) History (n=289) (p)

Double-Leg Stance 0.04 (0.01, 0.06) 0.01 (0.00, 0.02) N/A

Single-Leg Stance 3.04 (2.58, 3.50) 3.29 (3.01, 3.57) 0.36

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Tandem Stance 0.29 (0.15, 0.42) 0.22 (0.14, 0.30) 0.41

Total Score 3.37 (2.85, 3.88) 3.51 (3.20, 3.83) 0.63

Table 3: Mean (95% CI) scores of athletes during each stance of the mBESS for the overall
postural control rating of the video-force plate analysis (ANCOVA covariates included sex, age,
BMI, ankle injury history, knee injury history, and migraine history).
Concussion History No Concussion Significance
Variable
(n=104) History (n=289) (p)

Double-Leg Stance 86.6 (84.6, 88.7) 84.6 (83.3, 85.8) 0.10

Single-Leg Stance 50.1 (46.9, 53.4) 48.4 (46.5, 50.3) 0.37

Tandem Stance 70.1 (67.5, 72.7) 69.2 (67.6, 70.8) 0.57

Total Score 204.2 (198.8, 211.6) 201.8 (198.0, 205.6) 0.38

 Table 4: Torso movement frequency in the frontal and sagittal planes of movement, and average
weight distribution, for both groups of study participants (Mean, 95% CI; ANCOVA covariates
included sex, age, BMI, ankle injury history, knee injury history, and migraine history).

Concussion History No Concussion Significance

Stance Condition
(n=104) History (n=289) (p)
Sagittal Plane Torso Movement Frequency

Double-Leg Stance 6.9 (6.4, 7.4) 7.1 (6.8, 7.4) 0.39

Single-Leg Stance 14.3 (13.5, 15.0) 14.6 (14.2, 15.1) 0.41

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Tandem Stance 9.8 (9.4, 10.3) 9.8 (9.5, 10.1) 0.83

Frontal Plane Torso Movement Frequency

Double-Leg Stance 6.7 (6.2, 7.2) 7.4 (7.1, 7.7) 0.01*

Single-Leg Stance 14.7 (13.8, 15.5) 15.2 (14.7, 15.7) 0.26

Tandem Stance 9.3 (8.7, 9.8) 9.6 (9.3, 9.9) 0.28

Average Weight Distribution Percentage

Double-Leg Stance Left
49.9 (49.2, 50.7) 49.9 (49.5, 50.3) 0.88
Foot
Double-Leg Stance Right
50.1 (49.3, 50.8) 50.1 (49.9, 50.5) 0.88
Foot
Single-Leg Stance Foot 98.7 (98.2, 99.2) 98.3 (98.1, 98.6) 0.19
Tandem Stance Forward
36.2 (34.3, 38.2) 36.7 (35.5, 37.8) 0.72
Foot
Tandem Stance Back Foot 63.7 (61.9, 65.6) 63.6 (62.5, 64.7) 0.88

* Participants with a history of concussion demonstrated significantly less frontal plane torso
movement frequency than those without during double-leg stance.