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The Relationship Between Range of Movement, Flexibility, and Balance in the

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 Topics in Geriatric Rehabilitation
SPECIAL FEATURE Vol. 26, No. 2, pp. 147–154
Copyright  c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Relationship Between Range

of Movement, Flexibility, and Balance
in the Elderly
Michael Chiacchiero, PT, DPT; Bethany Dresely, DPT;
Udani Silva, DPT; Ramone DeLosReyes, DPT; Boris Vorik, DPT

This study investigated whether decreased passive lower extremity range of motion (ROM) and
flexibility contribute to falls in the elderly. Eighteen subjects aged 60 years and older partic-
ipated in the study. The subjects were divided into 2 categories, fallers and nonfallers. Both
subject groups underwent ROM and flexibility testing of the lower extremity. A statistically
significant decrease of ROM of hip extension, internal rotation, abduction, ankle dorsiflexion,
and gastrocnemius length was found in the faller group as compared with the nonfaller group.
The findings of this study suggest a link between decreased ROM and falls in the elderly and
that addressing ROM deficits may decrease potential falls. Key words: balance, elderly, falls,
flexibility, passive range of motion

F ALLS are among the leading causes of fa-

tal and nonfatal injuries in the elderly.1
More than 20 billion dollars are spent annu-
ally for the care of the elderly with fall-related
injuries, and this figure has been projected to
cost up to 37 billion dollars by the year 2020.
Information from the Centers for Disease Con-
trol and Prevention showed that the risk of
falls increases with age. In 2001, adults older
than 85 years were 4 to 5 times more likely
This research was completed in partial fulfillment
for the doctorate in physical therapy degree (DPT)
for the last 4 authors (B.D., U.S., R.D., and B.V.) from
the College of Staten Island/Graduate Center of The
City University of New York.
Author Affiliation: College of Staten Island, Staten
Island, New York.
We thank Professors Maria Knikou, Zagloul Ahmed,
and Jeff Rothman from the College of Staten Island
for all their help, guidance, and support throughout
the entire research process. We also thank the
rehabilitation staff of Carmel Richmond Nursing
Home, especially Alex Lakhter, and all subjects who
volunteered in this study.
Corresponding Author: Michael Chiacchiero, PT, DPT,
College of Staten Island, 2800 Victory Blvd, Staten
Island, NY 10314 (michael.chiacchiero@csi.cuny.edu).
to suffer a fall-related injury than adults aged
between 65 and 74 years.1
Balance is the ability to maintain the body’s
center of mass (COM) within the limits of the
base of support.2 Depending on the motor
task, people use 3 different strategies to main-
tain their upright posture. These are known
as ankle, hip, and step strategies. Both hip
and ankle strategies involve activation of hip
and ankle muscles opposite to the direction
of the perturbation.2 When the amplitude of
the perturbation is too large, the step strategy
is utilized. The step strategy is performed by
taking a step in the direction of the perturba-
tion, although the base of support is realigned
under the COM. This allows maintenance of
the COM within the base of support prevent-
ing external forces to disturb balance and thus
maintain upright posture.2
Although these systems and strategies help
to maintain the balance of younger people,
they become less effective in the elderly pop-
ulation because of physiological changes. For
example, a study performed on animals has
shown that the increase in connective tis-
sue in the aging muscle would lead to a de-
crease in flexibility.3 In addition, the muscle

147
 CHIACCHIERO et al

production force is decreased.4 Aging results Table 1. subject characteristics

in a decrement of muscle cross-sectional area
Nonfallers subjects Fallers subjects
and the volume of connective tissue. Fur-
thermore, the decrease in type II fast twitch Subject Age, Subject
muscle fibers would hinder the ability of the No. y Gender No. Age Gender
muscle to create a fast forceful contraction.4 s1 74 M s1 83 M
The aforementioned physiological modifica- s2 77 F s2 79 M
tions result in kinematic changes of the mus- s3 78 F s3 81 M
culoskeletal system. There is a 50% loss of s4 84 M s4 93 M
trunk extensor flexibility after the age of s6 87 M s5 60 F
70 years, which results in COM displacement s7 75 F s6 80 F
posterior to the heels. In addition, ankle joint s8 92 M s7 82 F
flexibility decreases by 50% in women and s9 90 F s8 80 F
35% in men after 55 years of age.2 s10 75 F s9 87 F
Normal functioning of the musculoskeletal Average 81.33 Average 80.55
SD 7.0 SD 8.9
system is imperative for balance maintenance.
The decreased flexibility and strength in the
Abbreviations: F, female; M, male.
elderly also decrease their ability to recover
quickly from a perturbation. Lack of necessary
range of motion (ROM) would decrease the past 12 months. Subject selection was per-
effectiveness of hip and ankle strategies. If a formed by the supervising physical therapist
person is unable to counteract a perturbation at Carmel Richmond Nursing Home, who re-
due to lack of flexibility and lack of appropri- viewed each subject’s medical history to ver-
ate ROM, the perturbation may result in fall. ify his or her eligibility for the study. Selection
Prior research has shown that there is correla- criteria for participation included the follow-
tion between short gastrocnemius muscle and ing: over the age of 60 years, ambulatory, and
increased falls in the elderly.5 full weight bearing with or without an assis-
The objectives of this research study were tive device. Subjects were excluded if they
to establish the relation of ROM and flexi- had a diagnosis of vestibular or central ner-
bility of all major muscle groups of the legs vous system pathology, orthostatic hypoten-
and to establish whether ROM and flexibility sion, the inability to follow one step com-
affect the balance in the elderly population mands, or a fracture within the past year. All
with falls. Findings from the elderly suscepti- subjects participated voluntarily in this study
ble to falls were compared with the findings and signed an informed consent form. The
from the elderly without falls. We hypothe- experimental protocol was approved by the
sized that the ROM of the hip, knee, and ankle institutional review board of the College of
contributes to balance maintenance and thus Staten Island.
their decreased values are strongly associated One subject was unable to complete the
with falls. study secondary to complaints of supine and
side-lying positions. Another subject was ex-
cluded because the results were unable to be
METHODS assessed correctly secondary to spasticity. The
last subject’s ROM could not be assessed cor-
Subjects rectly secondary to hyperaglesia in bilateral
Twenty-one subjects (11 women and 10 lower extremities. In Table 1, subjects’ char-
men; 10 nonfallers and 11 fallers) between acteristics are summarized.
the ages of 60 and 93 years participated in Changes were made to the methodology
this study. Subjects were classified as fallers during the study to accommodate for patient
if they reported 2 or more falls over the discomfort. The Ober test was performed only

148 TOPICS IN GERIATRIC REHABILITATION

RANGE OF MOVEMENT, FLEXIBILITY, AND BALANCE IN THE ELDERLY

in subjects who were able to understand the and ankle plantarflexion, dorsiflexion, inver-
verbal commands for bed mobility that was sion, and eversion. Each ROM was measured
required. Furthermore, the Thomas test was 3 times.
performed only once on each lower extremity
of each subject because of difficulty and dis- Muscle Length Testing
comfort in the testing position. One subject
was excluded from the Thomas test because Muscle length testing of the iliopsoas, ili-
of a medical history of multiple disc hernia- otibial band, hamstrings, and gastrocnemius
tions. Eversion values were omitted in 6 sub- were measured using a goniometer with the
jects because of skewed data attained for ROM muscle isolated and maximally lengthened.
values. The Ober test provides us information about
the length of the tensor fascia lata muscle,
whereas the Thomas test provides informa-
Experimental procedures tion about the length of the rectus femoris
The study consisted of one 40- to 60-minute muscle. The order of testing was Ober test,
session at Carmel Richmond Nursing Home. straight leg raise, gastrocnemius, and Thomas
Each subject participated in 4 separate tests: test.
the Timed Get Up and Go, the Functional
Reach Test, Range of Motion Testing, and Data analysis
Muscle Length Testing.
For each subject, the ROM, flexibility, and
balance tests were normalized to the stan-
Timed Get Up and Go dard values that correspond to values from
For each subject, the time needed to walk measurement of joint motion.6 To normalize
at a normal speed for 6 m was measured. The the data, each subject’s ROM was converted
amount of time it took the subjects to perform into a percentage of normal using the follow-
this test was recorded. ing equation: (subject ROM/normal ROM) ×
100. This percentage was converted to a score
from 0 to 10 according to Table 2. A paired
Functional Reach Test t test was utilized to establish statistically
A tape measure was fixed to the wall so significant differences between fallers and
that it lined up with each subject’s acromion
process. Each subject was given specific di- Table 2. Index conversion chart
rections to “lean forward and without mov-
ROM, flexibility, and FR TUG
ing your feet reach as far as you can and try
to keep your hand along the wall.” No assis- % of normal No. of seconds
tive devices were used for stability. The sub-
0 <0 10 <13
ject was asked to perform this test a total of
1 1–11 9 14–17
3 times. The amount of movement the sub- 2 12–22 8 18–21
ject demonstrated was recorded in inches and 3 23–33 7 22–25
compared to the age-related normal statistics. 4 34–44 6 26–29
5 45–55 5 30–33
Range of Motion Testing 6 56–66 4 34–37
7 67–77 3 38–41
Range of motion of the hip, knee, and an- 8 78–88 2 42–45
kle was measured using a goniometer based 9 89–99 1 46–49
on standardized techniques. Range of mo- 10 >100 0 >49
tion was tested for hip flexion, extension,
abduction, adduction, internal rotation, ex- Abbreviations: FR, functional reach; ROM, range of mo-
ternal rotation; knee flexion and extension; tion; TUG, Timed Up and Go test.

VOL. 26, NO. 2/APRIL–JUNE 2010 149

 CHIACCHIERO et al

Figure 1. Comparison of average flexibility score for nonfallers and fallers. Data are mean ± SD. Sig-
nificantly decreased flexibility in fallers for gastrocnemius and overall flexibility (P > .05). a Significant
difference between fallers and nonfallers. Gastroc indicates gastrocnemius; TFL, tensor fascia lata.

nonfallers for each variable measured (eg, arately between subject groups showed that
ROM, balance, and flexibility). A linear regres- in the nonfaller group the flexibility score
sion was conducted between balance to ROM was significantly higher than that in the faller
and flexibility. group in the gastrocnemius muscle (P < .05)
and overall (see last columns of Fig 1).
RESULTS In Figure 2 and Table 4, the overall ampli-
tude of the ROM score for both subject groups
In Figure 1 and Table 3, the overall am- along with the standard deviation of the mean
plitude of the flexibility score, along with is indicated. The ROM score was statistically
the standard deviation of the average, is in- significant lower in the faller group than in the
dicated for the gastrocnemius, hamstrings, nonfaller group (P < .05). This was the case
rectus femoris, and tensor fascia muscles for for hip extension, hip abduction (Hip Abd),
both subject groups (nonfallers and fallers). A hip internal rotation (Hip IR), and ankle dor-
paired t test conducted for each muscle sep- siflexion (P < .05).
Figure 3 shows the linear regression analy-
sis of combined balance score obtained from
Table 3. Flexibility in fallers and nonfallers
FR and TUG tests versus the average flexibil-
Nonfallers, Fallers, ity and ROM scores. There was no significance
M ± SD M ± SD P found between balance and flexibility/ROM
(nonfaller: R2 = 0.0407, fallers: R2 = 0.0378).
Gastrocnemius 4.67 ± 3.5 1.89 ± 2.5 .036a
Hamstrings 6.89 ± 0.9 6.67 ± 1.2 .335
Rectus femoris 8.33 ± 3.2 8.00 ± 3.1 .411 DISCUSSION
Tensor fascia data 3.5 ± 1.0 3.14 ± 0.7 .249
Average 6.28 ± 1.3 5.10 ± 1.5 .048a It has been shown that the increased
propensity for falling in the elderly is the re-
a Significant difference between nonfallers and fallers. sult of deficiencies in multiple systems. The

150 TOPICS IN GERIATRIC REHABILITATION

RANGE OF MOVEMENT, FLEXIBILITY, AND BALANCE IN THE ELDERLY

Figure 2. Comparison of average ROM score for nonfallers and fallers. Data are mean ± SD. Significantly
decreased ROM in fallers for hip extension, hip internal rotation, hip abduction, ankle dorsiflexion, and
overall ROM (P > .05). a Significant difference between fallers and nonfallers. Abd indicates abduction; Add,
adduction; DF, dorsiflexion; ER, external rotation; EV, eversion; ext, extension; flex, flexion; IN, inversion;
IR, internal rotation; PF, plantar flexion; ROM, range of motion.

impairments of the vestibular, visual, and so-
matosensory systems in the elderly are ma-
jor causes for increased falls and decreased
balance.2 For example, the elderly exhibit an
increase in sensory threshold and decreased
tactile sensitivity for fine touch and pressure/
vibration secondary to receptor loss at the
ankle and foot.7 These changes associated
with the elderly will decrease their ability to
sense external perturbations and therefore ef-
fectively employ the ankle strategy.8 The el-
derly rely upon alternative strategies such as

Table 4. ROM in fallers and nonfallers

Nonfallers, M ± SD Fallers, M ± SD P

Hip extension 5.56 ± 1.1 2 ± 1.7 4.77E-05a

Hip flexion 7.89 ± 0.8 7.56 ± 0.7 .181
Hip external rotation 4.67 ± 0.7 4.44 ± 1.0 .295
Hip internal rotation 7.33 ± 1.0 6.11 ± 1.8 .045a
Hip abduction 5.56 ± 1.0 3.78 ± 0.8 .0004a
Hip adduction 7.22 ± 1.1 6.67 ± 1.3 .172
Knee flexion 8.56 ± 0.9 8.11 ± 1.0 .173
Knee extension 9.56 ± 1.3 9.11 ± 2.7 .330
Ankle dorsiflexion 7.22 ± 1.9 4.89 ± 1.9 .010a
Ankle plantarflexion 9.22 ± 1.4 9.22 ± 0.8 .5
Ankle inversion 8.78 ± 1.3 7.67 ± 2.4 0.120
Ankle eversion 3.89 ± 3.8 5.11 ± 3.5 0.243
Average 7.41 ± 0.4 6.20 ± 0.6 0.0005a

a Significant difference between nonfallers and fallers.

VOL. 26, NO. 2/APRIL–JUNE 2010 151


Figure 3. Comparison of average flexibility/ROM score vs the average balance score for all subjects. No
significant interaction (nonfaller: R2 = 0.0407, fallers: R2 = 0.0378). ROM indicates range of motion.
the hip strategy for even minor perturbations
that a normal healthy adult would be able to
compensate for utilizing the ankle strategy.9
These changes result in the increased need for
the musculoskeletal system to function at an
optimal level. The findings of this study show
that the elderly have decreased flexibility and
ROM, which would impede their ability to re-
gain balance following an external perturba-
tion. Range of motion for hip extension, hip
internal rotation, hip abduction, ankle dor-
siflexion, gastrocnemius length, and general
flexibility were significantly decreased in el-
derly fallers older than 60 years.
The reduction in hip extension combined
with an anterior tilt of the pelvis and resul-
tant restricted hip musculature is a primary
reason for a decrease in stride length and
walking speed in elderly fallers.10 The afore-
mentioned mechanism that may cause a de-
crease in stride length could also contribute
to increased risk of falls. A study by Kerrigan
et al10 has shown that there is a correlation be-
tween decreased stride length and increased
risk of falls. In addition, an increase in the an-
terior pelvic tilt found in fallers would lead
to a displacement of the center of gravity out
of the base of support resulting in a greater
152 TOPICS IN GERIATRIC REHABILITATION
CHIACCHIERO et al
likelihood of falls. The ability of the elderly to
use the hip strategy effectively is even more
paramount, since they use the hip strategy
more often than the ankle strategy because
of biomechanical pathologies and loss of so-
matosensory function at the ankle.8
The aforementioned somatosensory defi-
ciencies at the ankle coupled with our find-
ings showed a significant decrease in ankle
dorsiflexion (DF) and gastrocnemius length
that can lead to deleterious effects on bal-
ance recovery. These results are further sup-
ported by Nolan et al5 and Whipple et al,11
who also concluded that decreased DF and
decreased length of knee and ankle muscles
were causative factors for falls. The adverse
muscle length tension relationship created
by muscle tautness would lead to an elderly
person’s decreased ability to create adequate
torque for balance recovery.
ROM and flexibility overall were also found
to be significantly decreased in fallers as com-
pared with nonfallers (Figs. 1 and 2). A pos-
sible explanation for these findings is the
decreased activation of the muscle spindle
as a result of decreased stretch in the mus-
cle. This may lead to decreased amplitude
of the stretch reflex that would impact the
RANGE OF MOVEMENT, FLEXIBILITY, AND BALANCE IN THE ELDERLY
successful use of the stretch reflex to regain
balance.2 Our results found a significant de-
crease in ROM at the hip, without a decrease
in muscle length. We speculate that the taut
hip capsule would prevent elderly fallers from
stretching the muscle with external perturba-
tion; therefore, the stretch reflex is not acti-
vated properly to prevent falls.
Although it is tempting to speculate that
decrements in the ROM of hip abduction and
hip IR are directly correlated with falling in
the elderly, the cause for this relationship has
not been adequately studied. However, since
decreased pelvic flexibility is correlated to the
reduced speed of walking and decreased step
length, the possibility of falls is increased and
it stands to reason that the decrease in hip
IR observed may result in a higher incidence
of falls.12,13 This can provide a plausible ex-
planation for the lack of hip internal rotation
in fallers. In addition, a study by Maki and
McIlory14 proposed that a decrease in hip ab-
duction would decrease a person’s ability to
contain his or her COM over his or her base of
support (BOS) during the stance phase of gait.
In subjects with decreased hip abduction, the
COM was shifted more toward the swing leg
rather than toward the standing,14 suggesting
that hip abduction is a necessary component
for maintaining a proper COM.
Although a significant correlation was
found when comparing fallers and nonfallers
with regards to ROM and flexibility, there was
no significance between the balance tests and
ROM. These results may be because the bal-
ance tests utilized in this study were not fully
comprehensive to assess balance in this par-
ticular population. Furthermore, it is possible
that some subjects did not fully understand
the verbal commands for the TUG and the
functional reach test, which prevented them
from performing the tests correctly.
The findings of the present study suggest
that there are limitations in specific hip and
ankle motions that may contribute to mus-
culoskeletal deficiencies that result in loss
of balance. A randomized controlled trial
would need to be done in order to investi-
gate whether implementing a stretching pro-
gram that focuses on the significant findings
of this study, such as decreased hip exten-
sion, ankle DF, and decreased gastrocnemius
length would result in improved balance in
the elderly. Assessing and treating flexibility in
the lower extremity may have important im-
plications for improving the quality of reha-
bilitation services for the elderly with balance
impairments.
Another important factor to be considered
is the distribution of forces. It is important
to examine distribution forces during balance
tests to determine which strategy is being
utilized most during ambulation and forward
reaching. The utilization of force plates would
provide objective results to validate which
strategies are being used more in elderly pop-
ulations. These findings can be used in con-
junction with ROM measurements to provide
relevant information about the mobility of
the joints and how it affects different balance
maintenance strategies.
The use of the TUG and FR as balance tests
was a limitation of this study. Using a more
comprehensive test such as the Berg Balance
Test, the Tinetti Assessment Tool, or a more
objective method such as force plates would
have allowed for a more accurate measure of
the subject’s balance. Dynamic balance scales
provide a functional assessment of a person’s
balance capability. By using the Berg Balance
Scale or the Tinetti balance scale, the find-
ings would yield more functional, reliable, and
objective results and further validate the re-
sults of the current study. In addition, increas-
ing the number of subjects and using subjects
from different settings such as community
ambulators rather than residents of a nursing
home would further improve the study.
FUTURE STUDIES
Further research is required to expand the
theories of the current study. A potential study
can investigate the effects of spinal mobility
on balance and falls in the elderly. Instead
of measuring ROM of the lower extremities,
the researchers would assess spinal mobility
VOL. 26, NO. 2/APRIL–JUNE 2010 153

between fallers and nonfallers in the elderly.
The data collected from this study would de-
termine the effects of spinal mobility on bal-
ance and falls in the elderly population. Evalu-
ating and treating spinal mobility may have im-
portant implications for improving the quality
of rehabilitation services for the elderly with
balance impairments.
Physical therapists can benefit from the
study results by utilizing them to improve
the treatment of patients with balance impair-
ments. The findings of this study imply the
importance of addressing ROM and flexibil-
ity deficits in the elderly fallers. Many reha-
bilitation protocols for decreased balance are
focused on improving the somatosensory and
vestibular systems; however, based on our re-
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154 TOPICS IN GERIATRIC REHABILITATION
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CHIACCHIERO et al
search findings, decrements in ROM and flex-
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that this study found to be significant would
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