Postural changes versus balance control and falls in community-living older adults: a systematic review

Alterações posturais versus controle do equilíbrio e quedas em idosos da comunidade: Revisão sistemática

Viviane Lemos Silva Fernandes Darlan Martins Ribeiro Luciana Caetano Fernandes Ruth Losada de Menezes About the authors

Abstract

Introduction:

Since falls are considered to be a public health problem, it is important to identify whether postural changes over time contribute to the risk of falls in older adults.

Objective:

To investigate whether postural changes increase fall risk and/or postural imbalance in healthy, community-dwelling older adults.

Methods:

In April 2016, two reviewers independently searched the PubMed, Web of Science, SPORTDiscus, and CINAHL databases for studies in English published in the previous 10 years, using the following combined keywords: “posture” or (“kyphosis”,“lumbar lordosis”,“flexed posture”,“spinal curvature”,“spinal sagittal contour”) AND “elderly” AND “fall”. Study quality was assessed according to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for observational studies.

Results:

The search retrieved 1,734 articles. Only observational studies that assessed posture, balance, and/or falls in older adults were considered eligible for review. The final sample included 17 articles: reliability and reproducibility of the instruments were not reported in five studies, while two studies offered a questionable description of the instruments used. Fourteen articles analyzed postural changes at the trunk level and three articles assessed them at the ankles and feet. Most studies found a positive association between postural changes and an increased risk for loss of balance and falls.

Conclusion:

Thoracic hyperkyphosis, loss of lumbar lordosis, and decreased plantar arch seem to contribute to greater postural instability, and thus to a higher risk of falls in community-living older adults.

Keywords:
Older Adults; Posture; Postural Balance; Accidental Falls

Resumo

Introdução:

As quedas são consideradas um problema de saúde pública, portanto torna-se relevante identificar se as alterações que a postura sofre no decorrer dos anos contribui para o risco de quedas em idosos.

Objetivo:

Analisar se as alterações posturais favorecem as quedas e/ou desequilíbrio postural, em idosos saudáveis da comunidade.

Métodos:

A busca ocorreu no mês de abril de 2016, de forma independente, por dois revisores, nas bases de dados PubMed, Web of Science, SPORTDiscus, e CINAHL, com delimitação de publicação dos últimos 10 anos, em língua inglesa, com as palavras chaves “posture” ou (“kyphosis”,“lumbar lordose”,“flexed posture”,“spinal curvature”,“spinal sagital contour”) em combinação com “elderly” e “fall”. A qualidade dos estudos foi avaliada pelas diretrizes do STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) para estudos observacionais.

Resultados:

Foram encontrados 1734 artigos, sendo considerados elegíveis, os estudos observacionais com avaliação postural, equilíbrio e/ou quedas em idosos, em um total de 17 artigos analisados. A confiabilidade e reprodutibilidade dos instrumentos não foram informados em cinco estudos, e em dois apresentaram descriçao questionável. Quatorze artigos analisaram alterações posturais a nível de tronco e 03 artigos avaliaram tornozelos e pés. A maioria dos estudos encontraram associaçao entre as alterações posturais com a perda do equilibrio e aumento das quedas em idosos.

Conclusão:

Hipercifose torácica, retificação da lordose lombar, diminuição do arco plantar de idosos que vivem na comunidade, parecem contribuir para maior instabilidade postural, e consequentemente aumentar o risco de quedas na população idosa que vive na comunidade.

Palavras-chave:
Idoso; Postura; Equilíbrio Postural; Acidentes por Quedas

Introduction

Falls are considered to be an important public health problem due to the risks of morbidity and mortality11 Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35(Suppl 2):ii37-ii41.. In Brazil, about 30% of community-living older adults report falling at least once a year22 Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTB, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saude Publica. 2012;46(1):138-46.), (33 Siqueira F, Facchini L, Piccini R, Tomasi E, Thumé E, Silveira D, et al. Prevalência de quedas em idosos e fatores associados. Rev Saude Publica. 2007;41(5):749-56.), (44 Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saude Publica. 2002;36(6):709-16..

In addition to environmental risks55 Moreland J, Richardson J, Chan D, O'Neill J, Bellissimo A, Grum R, et al. Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology. 2003;49(2):93-116., the literature points out several risk factors intrinsic to falls, such as age, female gender, functional disability, balance deficit, gait disorders, sedentary lifestyle, poor health self-perception, use of psychotropic drugs, muscle weakness, reduced visual acuity, cognitive deficits, and polypharmacy11 Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35(Suppl 2):ii37-ii41.), (22 Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTB, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saude Publica. 2012;46(1):138-46.), (33 Siqueira F, Facchini L, Piccini R, Tomasi E, Thumé E, Silveira D, et al. Prevalência de quedas em idosos e fatores associados. Rev Saude Publica. 2007;41(5):749-56.), (44 Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saude Publica. 2002;36(6):709-16.), (55 Moreland J, Richardson J, Chan D, O'Neill J, Bellissimo A, Grum R, et al. Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology. 2003;49(2):93-116.), (66 Ueno M, Kawai S, Mino T, Kamoshita H. Systematic review of fall-related factors among the house-dwelling elderly in Japan. Nihon Ronen Igakkai Zasshi. 2006;43(1):92-101.), (77 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-7..

Although posture is not considered a risk factor for falls, several studies investigated the relationship between posture and body balance and/or falls in older adults88 Abe Y, Aoyagi K, Tsurumoto T, Chen CY, Kanagae M, Mizukami S, et al. Association of spinal inclination with physical performance measures among community-dwelling Japanese women aged 40 years and older. Geriatr Gerontol Int. 2013;13(4):881-6.), (99 Karakasidou P, Skordilis EK, Dontas I, Lyritis GP. Postural profile and falls of osteoporotic women. J Back Musculoskelet Rehabil. 2012;25(1):55-66.), (1010 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal curvature and postural balance in patients with osteoporosis. Osteoporos Int. 2009;20(12):2049-53.), (1111 Sinaki M, Brey RH, Hughes CA, Larson DR, Kaufman KR. Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle strength. Osteoporos Int. 200516(8):1004-10.), (1212 Balzini L, Vannucchi L, Benvenuti F, Benucci M, Monni M, Cappozzo A, et al. Clinical Characteristics of Flexed Posture in Elderly Women. J Am Geriatr Soc. 2003;51(10):1419-26.. The Guide to Physical Therapist Practice of the American Physical Therapy Association (APTA) defines posture as “the alignment and positioning of the body in relation to gravity, center of mass, or base of support”1313 Lindsey C. Comprometimento da Postura. In: Guccione AA, Wong AR, Avers D, editors. Fisioterapia Geriátrica. 3rd ed. Rio de Janeiro: Guanabara Koogan; 2013. p. 263-84.. In ideal posture, there is a state of muscular and skeletal equilibrium and an adequate tension on support structures for a more efficient balance control1313 Lindsey C. Comprometimento da Postura. In: Guccione AA, Wong AR, Avers D, editors. Fisioterapia Geriátrica. 3rd ed. Rio de Janeiro: Guanabara Koogan; 2013. p. 263-84..

Ideal postural alignment is indirectly associated with aging88 Abe Y, Aoyagi K, Tsurumoto T, Chen CY, Kanagae M, Mizukami S, et al. Association of spinal inclination with physical performance measures among community-dwelling Japanese women aged 40 years and older. Geriatr Gerontol Int. 2013;13(4):881-6.), (1212 Balzini L, Vannucchi L, Benvenuti F, Benucci M, Monni M, Cappozzo A, et al. Clinical Characteristics of Flexed Posture in Elderly Women. J Am Geriatr Soc. 2003;51(10):1419-26.), (1414 Drzal-Grabiec J, Snela S, Rykala J, Podgórska J, Banas A. Changes in the body posture of women occurring with age. BMC Geriatr. 2013;13:108.. The body undergoes changes in the bones, muscles, and joints that lead to changes in the physiological spinal curvature1010 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal curvature and postural balance in patients with osteoporosis. Osteoporos Int. 2009;20(12):2049-53.), (1313 Lindsey C. Comprometimento da Postura. In: Guccione AA, Wong AR, Avers D, editors. Fisioterapia Geriátrica. 3rd ed. Rio de Janeiro: Guanabara Koogan; 2013. p. 263-84.. Thoracic hyperkyphosis is the most common, affecting 20 - 40% of older adults worldwide1515 Kado DM. The rehabilitation of hyperkyphotic posture in the elderly. Eur J Phys Rehabil Med. 2009;45(4):583-93., along with osteoporosis as an associated clinical condition1616 Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related hyperkyphosis: its causes, consequences, and management. J Orthop Sports Phys Ther. 2010;40(6):352-60.. Patients with hyperkyphosis may have anterior displacement of the head, protrusion of the scapula, loss of lumbar lordosis1717 Hsu WL, Chen CY, Tsauo JY, Yang RS. Balance control in elderly people with osteoporosis. J Formos Med Assoc. 2014;113(6):334-9., and, consequently, anteriorly project into the line of the center of gravity88 Abe Y, Aoyagi K, Tsurumoto T, Chen CY, Kanagae M, Mizukami S, et al. Association of spinal inclination with physical performance measures among community-dwelling Japanese women aged 40 years and older. Geriatr Gerontol Int. 2013;13(4):881-6.. Changes in the projection of the center of gravity negatively affect body balance control1717 Hsu WL, Chen CY, Tsauo JY, Yang RS. Balance control in elderly people with osteoporosis. J Formos Med Assoc. 2014;113(6):334-9..

The relationship between body balance and postural changes in the vertebral column due to the clinical condition of osteoporosis was also highlighted in the reviews by Hsu et al.1717 Hsu WL, Chen CY, Tsauo JY, Yang RS. Balance control in elderly people with osteoporosis. J Formos Med Assoc. 2014;113(6):334-9. and Groot et al.1818 Groot MH, van der Jagt-Willems HC, van Campen JP, Lems WF, Lamoth CJ. Testing postural control among various osteoporotic patient groups: a literature review. Geriatr Gerontol Int. 2012;12(4):573-85.. These authors found poor balance control in patients with vertebral fractures, thoracic hyperkyphosis, and flexed posture.

A gap exists in the literature for systematic reviews to investigate how changes in postural alignment of different body segments affect postural stability and the risk of falls in healthy older adults. Thus, this study aimed to investigate whether postural changes increase fall risk and/or postural imbalance in healthy, community-dwelling older adults.

Methods

Search Strategy

In April 2016, two reviewers independently searched PubMed, Web of Science, SPORTDiscus, and CINAHL for studies in the last 10 years. After screening titles, abstracts and keywords, full-text versions of potential papers were selected. Discrepancies were resolved by a third reviewer. The following keywords (DESCs and MESH terms) and search strings were used: (posture OR kyphosis OR lumbar lordosis OR flexed posture OR spinal curvature OR spinal sagittal contour AND elderly AND fall).

Selection/Inclusion Criteria

The inclusion criteria were English written observational studies assessing posture, balance, and/or falls in adults 60 years and older. We excluded duplicates, reviews, case studies, theses and dissertations, studies with special populations such as those with a specific pathology (for instance, Parkinson's disease, stroke, osteoporosis, etc.), and articles not available in full text.

Quality assessment

Study quality was assessed according to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for observational studies (Table 1)1919 Malta M, Cardoso LO, Bastos FI, Magnanini MMF, Silva CMFP. Iniciativa STROBE: subsídios para a comunicação de estudos observacionais. Rev Saude Publica. 2010;44(3):559-65..

Table 1
The STROBE checklist for assessment of methodological quality of observational studies

Results

Characteristics of the studies retrieved

Figure 1 shows a flowchart describing the results of each step in the selection procedure. Of 1,734 articles retrieved, 17 were eligible for inclusion.

Figure 1
Flowchart of the selection process using the PRISMA criteria2020 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097..

Fifty per cent of the studies included in this review were conducted in Japan, while the remaining studies were representative of different geographical locations (Australia, USA, Netherlands, Italy, Japan, Malaysia, Poland).

The articles were analyzed with regard to design, sample characteristics, tools used to assess body posture, balance and/or falls risk, and outcomes (Table 2). Three studies have specifically assessed the feet and the ankles and their data are shown separately in Table 3.

Table 2
Characteristics of the studies with regard to methodologies, sample profile, outcomes and tools used for assessing body posture, balance and falls risk

Table 3
Characteristics of the studies with regard to methodologies, sample profile, outcomes and tools used for assessing the feet and the ankle, as well as balance and falls risk

Ten studies (58.8%) were cross-sectional studies, five (29.4%) were cohort studies (two of which were also prospective), one (5.9%) was longitudinal, and one (5.9%) was not defined (Tables 1 and 2). The following methods and tools were used to assess body posture: SpinalMouse88 Abe Y, Aoyagi K, Tsurumoto T, Chen CY, Kanagae M, Mizukami S, et al. Association of spinal inclination with physical performance measures among community-dwelling Japanese women aged 40 years and older. Geriatr Gerontol Int. 2013;13(4):881-6.), (2121 Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa Y, Noguchi H, Kamo K, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28(1):82-7.), (2222 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal sagittal contour affecting falls: cut-off value of the lumbar spine for falls. Gait Posture. 2013;38(2):260-3.), (2323 Miyazaki J, Murata S, Horie J, Uematsu A, Hortobágyi T, Suzuki S. Lumbar lordosis angle (LLA) and leg strength predict walking ability in elderly males. Arch Gerontol Geriatr. 2013;56(1):141-7.), (2424 Imagama S, Ito Z, Wakao N, Seki T, Hirano K, Muramoto A, et al. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013;22(6):1346-53., occiput-to-wall distance (OWD)2525 Antonelli-Incalzi R, Pedone C, Cesari M, Di Iorio A, Bandinelli S, Ferrucci L. Relationship between the occiput-wall distance and physical performance in the elderly: a cross sectional study. Aging Clin Exp Res. 2007;19(3):207-12.), (2626 Groot MH, van der Jagt-Willems HC, van Campen JP, Lems WF, Beijnen JH, Lamoth CJ. A flexed posture in elderly patients is associated with impairments in postural control during walking. Gait Posture. 2014;39(2):767-72.), (2727 Van der Jagt-Willems HC, Groot MH, van Campen JPCM, Lamoth CJC, Lems WF. Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study. BMC Geriatr. 2015;15:34., method using 1.7 cm blocks2828 Kado DM, Huang MH, Nguyen CB, Barrett-Connor E, Greendale GA. Hyperkyphotic posture and risk of injurious falls in older persons: the Rancho Bernardo Study. J Gerontol A Biol Sci Med Sci. 2007;62(6):652-7., flexicurve ruler2929 Regolin F, Carvalho GA. Relationship between thoracic kyphosis, bone mineral density, and postural control in elderly women. Rev Bras Fisioter. 2010;14(6):464-9.), (3030 Eum R, Leveille SG, Kiely DK, Kiel DP, Samelson EJ, Bean JF. Is kyphosis related to mobility, balance, and disability? Am J Phys Med Rehabil. 2013;92(11):980-9., Cobb angle2424 Imagama S, Ito Z, Wakao N, Seki T, Hirano K, Muramoto A, et al. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013;22(6):1346-53.), (2626 Groot MH, van der Jagt-Willems HC, van Campen JP, Lems WF, Beijnen JH, Lamoth CJ. A flexed posture in elderly patients is associated with impairments in postural control during walking. Gait Posture. 2014;39(2):767-72.), (2727 Van der Jagt-Willems HC, Groot MH, van Campen JPCM, Lamoth CJC, Lems WF. Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study. BMC Geriatr. 2015;15:34., photogrammetry/Moiré method3131 Drzal-Grabiec J, Rachwal M, Podgórska-Bednarz J, Rykala J, Snela S, Truszczynska A, et al. The effect of spinal curvature on the photogrammetric assessment on static balance in elderly women. BMC Musculoskelet Disord. 2014;15:186., method with photographic recording3232 Ota S, Goto H, Noda Y, Fujita R, Matsui Y. Relationship between standing postural alignments and physical function among elderly women using day service centers in Japan. J Back Musculoskelet Rehabil. 2015;28(1):111-7. and digital inclinometer3333 Suzuki Y, Kawai H, Kojima M, Shiba Y, Yoshida H, Hirano H, et al. Construct validity of posture as a measure of physical function in elderly individuals: Use of a digitalized inclinometer to assess trunk inclination. Geriatr Gerontol Int. 2016;16(9):1068-73.. Foot posture was assessed using the Foot Posture Index (FPI)3434 Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: A prospective study. J Gerontol A Biol Sci Med Sci. 2006;61(8):866-70.), (3535 Said AM, Manaf H, Bukry SA, Justine M. Mobility and Balance and Their Correlation with Physiological Factors in Elderly with Different Foot Postures. Biomed Res Int. 2015;2015:385269., which tests foot characteristics across six domains: foot posture, foot deformity and lesions, plantar tactile sensation, toe muscle strength and foot pain, and a three-dimensional foot scanner (Footstep PRO, Dream GP Company, Japan)3636 Saghazadeh M, Tsunoda K, Soma Y, Okura T. Static foot posture and mobility associated with postural sway in elderly women using a three-dimensional foot scanner. J Am Podiatr Med Assoc. 2015. [Epub ahead of print].

Falls were ascertained by the administration of a questionnaire, and assessed using the Falls Efficacy Scale (FES)3030 Eum R, Leveille SG, Kiely DK, Kiel DP, Samelson EJ, Bean JF. Is kyphosis related to mobility, balance, and disability? Am J Phys Med Rehabil. 2013;92(11):980-9.. Participants’ falls risk was assessed using Pluijm's assessment2626 Groot MH, van der Jagt-Willems HC, van Campen JP, Lems WF, Beijnen JH, Lamoth CJ. A flexed posture in elderly patients is associated with impairments in postural control during walking. Gait Posture. 2014;39(2):767-72. and the Physiological Profile Assessment (PPA)3434 Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: A prospective study. J Gerontol A Biol Sci Med Sci. 2006;61(8):866-70.. While most studies followed participants for 12 months1010 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal curvature and postural balance in patients with osteoporosis. Osteoporos Int. 2009;20(12):2049-53.), (2121 Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa Y, Noguchi H, Kamo K, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28(1):82-7.), (2424 Imagama S, Ito Z, Wakao N, Seki T, Hirano K, Muramoto A, et al. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013;22(6):1346-53.), (2828 Kado DM, Huang MH, Nguyen CB, Barrett-Connor E, Greendale GA. Hyperkyphotic posture and risk of injurious falls in older persons: the Rancho Bernardo Study. J Gerontol A Biol Sci Med Sci. 2007;62(6):652-7.), (3434 Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: A prospective study. J Gerontol A Biol Sci Med Sci. 2006;61(8):866-70., in one study participants were followed for only six months2727 Van der Jagt-Willems HC, Groot MH, van Campen JPCM, Lamoth CJC, Lems WF. Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study. BMC Geriatr. 2015;15:34..

Body balance was assessed using more accurate methods of measurement, such as stabilometry, force plate1414 Drzal-Grabiec J, Snela S, Rykala J, Podgórska J, Banas A. Changes in the body posture of women occurring with age. BMC Geriatr. 2013;13:108.), (2121 Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa Y, Noguchi H, Kamo K, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28(1):82-7.), (2222 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal sagittal contour affecting falls: cut-off value of the lumbar spine for falls. Gait Posture. 2013;38(2):260-3.), (2424 Imagama S, Ito Z, Wakao N, Seki T, Hirano K, Muramoto A, et al. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013;22(6):1346-53.), (2929 Regolin F, Carvalho GA. Relationship between thoracic kyphosis, bone mineral density, and postural control in elderly women. Rev Bras Fisioter. 2010;14(6):464-9.), (3636 Saghazadeh M, Tsunoda K, Soma Y, Okura T. Static foot posture and mobility associated with postural sway in elderly women using a three-dimensional foot scanner. J Am Podiatr Med Assoc. 2015. [Epub ahead of print], and functional tests such as the Timed Up and Go (TUG) test88 Abe Y, Aoyagi K, Tsurumoto T, Chen CY, Kanagae M, Mizukami S, et al. Association of spinal inclination with physical performance measures among community-dwelling Japanese women aged 40 years and older. Geriatr Gerontol Int. 2013;13(4):881-6.), (2323 Miyazaki J, Murata S, Horie J, Uematsu A, Hortobágyi T, Suzuki S. Lumbar lordosis angle (LLA) and leg strength predict walking ability in elderly males. Arch Gerontol Geriatr. 2013;56(1):141-7.), (3232 Ota S, Goto H, Noda Y, Fujita R, Matsui Y. Relationship between standing postural alignments and physical function among elderly women using day service centers in Japan. J Back Musculoskelet Rehabil. 2015;28(1):111-7.), (3333 Suzuki Y, Kawai H, Kojima M, Shiba Y, Yoshida H, Hirano H, et al. Construct validity of posture as a measure of physical function in elderly individuals: Use of a digitalized inclinometer to assess trunk inclination. Geriatr Gerontol Int. 2016;16(9):1068-73.), (3434 Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: A prospective study. J Gerontol A Biol Sci Med Sci. 2006;61(8):866-70.), (3535 Said AM, Manaf H, Bukry SA, Justine M. Mobility and Balance and Their Correlation with Physiological Factors in Elderly with Different Foot Postures. Biomed Res Int. 2015;2015:385269., functional reach (FR)88 Abe Y, Aoyagi K, Tsurumoto T, Chen CY, Kanagae M, Mizukami S, et al. Association of spinal inclination with physical performance measures among community-dwelling Japanese women aged 40 years and older. Geriatr Gerontol Int. 2013;13(4):881-6., Berg Balance Scale (BBS)3030 Eum R, Leveille SG, Kiely DK, Kiel DP, Samelson EJ, Bean JF. Is kyphosis related to mobility, balance, and disability? Am J Phys Med Rehabil. 2013;92(11):980-9., one-led stance2323 Miyazaki J, Murata S, Horie J, Uematsu A, Hortobágyi T, Suzuki S. Lumbar lordosis angle (LLA) and leg strength predict walking ability in elderly males. Arch Gerontol Geriatr. 2013;56(1):141-7.), (3232 Ota S, Goto H, Noda Y, Fujita R, Matsui Y. Relationship between standing postural alignments and physical function among elderly women using day service centers in Japan. J Back Musculoskelet Rehabil. 2015;28(1):111-7.), (3333 Suzuki Y, Kawai H, Kojima M, Shiba Y, Yoshida H, Hirano H, et al. Construct validity of posture as a measure of physical function in elderly individuals: Use of a digitalized inclinometer to assess trunk inclination. Geriatr Gerontol Int. 2016;16(9):1068-73., Four-Square Step Test (FSST)3434 Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: A prospective study. J Gerontol A Biol Sci Med Sci. 2006;61(8):866-70.), (3535 Said AM, Manaf H, Bukry SA, Justine M. Mobility and Balance and Their Correlation with Physiological Factors in Elderly with Different Foot Postures. Biomed Res Int. 2015;2015:385269. and feet-together stance, semitandem and tandem standing2525 Antonelli-Incalzi R, Pedone C, Cesari M, Di Iorio A, Bandinelli S, Ferrucci L. Relationship between the occiput-wall distance and physical performance in the elderly: a cross sectional study. Aging Clin Exp Res. 2007;19(3):207-12..

The methodological quality of the studies is shown in Table 4. All studies clearly described their objectives, assessment tools, statistics and outcomes. Only one study3131 Drzal-Grabiec J, Rachwal M, Podgórska-Bednarz J, Rykala J, Snela S, Truszczynska A, et al. The effect of spinal curvature on the photogrammetric assessment on static balance in elderly women. BMC Musculoskelet Disord. 2014;15:186. failed to describe the eligibility and inclusion criteria of the participants (sample). Five studies2525 Antonelli-Incalzi R, Pedone C, Cesari M, Di Iorio A, Bandinelli S, Ferrucci L. Relationship between the occiput-wall distance and physical performance in the elderly: a cross sectional study. Aging Clin Exp Res. 2007;19(3):207-12.), (2626 Groot MH, van der Jagt-Willems HC, van Campen JP, Lems WF, Beijnen JH, Lamoth CJ. A flexed posture in elderly patients is associated with impairments in postural control during walking. Gait Posture. 2014;39(2):767-72.), (2929 Regolin F, Carvalho GA. Relationship between thoracic kyphosis, bone mineral density, and postural control in elderly women. Rev Bras Fisioter. 2010;14(6):464-9.), (3333 Suzuki Y, Kawai H, Kojima M, Shiba Y, Yoshida H, Hirano H, et al. Construct validity of posture as a measure of physical function in elderly individuals: Use of a digitalized inclinometer to assess trunk inclination. Geriatr Gerontol Int. 2016;16(9):1068-73. did not describe the reliability of the tools used in the study, while two studies offered a questionable description of the tools' reliability3131 Drzal-Grabiec J, Rachwal M, Podgórska-Bednarz J, Rykala J, Snela S, Truszczynska A, et al. The effect of spinal curvature on the photogrammetric assessment on static balance in elderly women. BMC Musculoskelet Disord. 2014;15:186.), (3636 Saghazadeh M, Tsunoda K, Soma Y, Okura T. Static foot posture and mobility associated with postural sway in elderly women using a three-dimensional foot scanner. J Am Podiatr Med Assoc. 2015. [Epub ahead of print]. All studies but one3232 Ota S, Goto H, Noda Y, Fujita R, Matsui Y. Relationship between standing postural alignments and physical function among elderly women using day service centers in Japan. J Back Musculoskelet Rehabil. 2015;28(1):111-7. described their clinical implications. Finally, three studies did not mention limitations2222 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal sagittal contour affecting falls: cut-off value of the lumbar spine for falls. Gait Posture. 2013;38(2):260-3.), (2626 Groot MH, van der Jagt-Willems HC, van Campen JP, Lems WF, Beijnen JH, Lamoth CJ. A flexed posture in elderly patients is associated with impairments in postural control during walking. Gait Posture. 2014;39(2):767-72.), (3333 Suzuki Y, Kawai H, Kojima M, Shiba Y, Yoshida H, Hirano H, et al. Construct validity of posture as a measure of physical function in elderly individuals: Use of a digitalized inclinometer to assess trunk inclination. Geriatr Gerontol Int. 2016;16(9):1068-73..

Table 4
Methodological assessment results (STROBE)

Discussion

Thus, this systematic review aimed to investigate whether postural changes increase fall risk and/or postural imbalance in healthy, community-dwelling older adults. In total, 17 articles were eligible and included for review. They used different tools to assess body posture, not only at the vertebral level, but also at the level of the ankles and the feet.

Postural deformities, such as thoracic hyperkyphosis, flexed posture, loss of lumbar lordosis, forward trunk inclination, and decreased plantar arch negatively affected postural balance and risk of falls in healthy older adults. Our findings are in line with those reported by Groot, Van der Jagt-Willems1818 Groot MH, van der Jagt-Willems HC, van Campen JP, Lems WF, Lamoth CJ. Testing postural control among various osteoporotic patient groups: a literature review. Geriatr Gerontol Int. 2012;12(4):573-85., in which postural control was affected in osteoporotic older adults with vertebral fractures, thoracic hyperkyphosis and flexed posture.

Most of the studies measured thoracic kyphosis2121 Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa Y, Noguchi H, Kamo K, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28(1):82-7.), (2222 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal sagittal contour affecting falls: cut-off value of the lumbar spine for falls. Gait Posture. 2013;38(2):260-3.), (2323 Miyazaki J, Murata S, Horie J, Uematsu A, Hortobágyi T, Suzuki S. Lumbar lordosis angle (LLA) and leg strength predict walking ability in elderly males. Arch Gerontol Geriatr. 2013;56(1):141-7.), (2424 Imagama S, Ito Z, Wakao N, Seki T, Hirano K, Muramoto A, et al. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013;22(6):1346-53.), (2626 Groot MH, van der Jagt-Willems HC, van Campen JP, Lems WF, Beijnen JH, Lamoth CJ. A flexed posture in elderly patients is associated with impairments in postural control during walking. Gait Posture. 2014;39(2):767-72.), (2727 Van der Jagt-Willems HC, Groot MH, van Campen JPCM, Lamoth CJC, Lems WF. Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study. BMC Geriatr. 2015;15:34.), (2828 Kado DM, Huang MH, Nguyen CB, Barrett-Connor E, Greendale GA. Hyperkyphotic posture and risk of injurious falls in older persons: the Rancho Bernardo Study. J Gerontol A Biol Sci Med Sci. 2007;62(6):652-7.), (2929 Regolin F, Carvalho GA. Relationship between thoracic kyphosis, bone mineral density, and postural control in elderly women. Rev Bras Fisioter. 2010;14(6):464-9.), (3030 Eum R, Leveille SG, Kiely DK, Kiel DP, Samelson EJ, Bean JF. Is kyphosis related to mobility, balance, and disability? Am J Phys Med Rehabil. 2013;92(11):980-9.), (3131 Drzal-Grabiec J, Rachwal M, Podgórska-Bednarz J, Rykala J, Snela S, Truszczynska A, et al. The effect of spinal curvature on the photogrammetric assessment on static balance in elderly women. BMC Musculoskelet Disord. 2014;15:186.. Thirty-six percent of older adults with thoracic hyperkyphosis had experienced falls and were 1.32 times more likely to report a fall in the past year than were those with normal kyphosis2828 Kado DM, Huang MH, Nguyen CB, Barrett-Connor E, Greendale GA. Hyperkyphotic posture and risk of injurious falls in older persons: the Rancho Bernardo Study. J Gerontol A Biol Sci Med Sci. 2007;62(6):652-7.. According to Kado1515 Kado DM. The rehabilitation of hyperkyphotic posture in the elderly. Eur J Phys Rehabil Med. 2009;45(4):583-93., the relationship between thoracic hyperkyphosis and falls in women could be explained by age. In the study by Van der Jagt-Willems et al.2727 Van der Jagt-Willems HC, Groot MH, van Campen JPCM, Lamoth CJC, Lems WF. Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study. BMC Geriatr. 2015;15:34., patients with hyperkyphosis were twice more likely to fall than their counterparts, regardless of sex. In contrast, Kasukawa et al.2121 Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa Y, Noguchi H, Kamo K, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28(1):82-7. and Ishikawa, Miyakoshi et al.2222 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal sagittal contour affecting falls: cut-off value of the lumbar spine for falls. Gait Posture. 2013;38(2):260-3. found no correlation between falls and increased thoracic hyperkyphosis.

Thoracic hyperkyphosis, flexed posture and forward trunk inclination are changes in the sagittal plane of the vertebral column that lead to a forward projection of the gravity line, negatively affecting postural balance3737 Schwab F, Lafage V, Boyce R, Skalli W, Farcy JP. Gravity line analysis in adult volunteers: age-related correlation with spinal parameters, pelvic parameters, and foot position. Spine (Phila Pa 1976). 2006;31(25):E959-67.), (3838 Lafage V, Schwab F, Skalli W, Hawkinson N, Gagey PM, Ondra S, et al. Standing balance and sagittal plane spinal deformity: analysis of spinopelvic and gravity line parameters. Spine (Phila Pa 1976). 2008;33(14):1572-8.. This is confirmed by the findings of this review, in which poorer stabilometry results were associated with postural malalignment and falls2121 Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa Y, Noguchi H, Kamo K, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28(1):82-7.), (2222 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal sagittal contour affecting falls: cut-off value of the lumbar spine for falls. Gait Posture. 2013;38(2):260-3.), (2424 Imagama S, Ito Z, Wakao N, Seki T, Hirano K, Muramoto A, et al. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013;22(6):1346-53.), (2929 Regolin F, Carvalho GA. Relationship between thoracic kyphosis, bone mineral density, and postural control in elderly women. Rev Bras Fisioter. 2010;14(6):464-9.), (3131 Drzal-Grabiec J, Rachwal M, Podgórska-Bednarz J, Rykala J, Snela S, Truszczynska A, et al. The effect of spinal curvature on the photogrammetric assessment on static balance in elderly women. BMC Musculoskelet Disord. 2014;15:186.. Previous studies have also associated thoracic hyperkyphosis with loss of mobility, reduced quality of life and increased falls risk in osteoporotic older adults1111 Sinaki M, Brey RH, Hughes CA, Larson DR, Kaufman KR. Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle strength. Osteoporos Int. 200516(8):1004-10.), (1616 Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related hyperkyphosis: its causes, consequences, and management. J Orthop Sports Phys Ther. 2010;40(6):352-60.), (3939 Katzman WB, Vittinghoff E, Ensrud K, Black DM, Kado DM. Increasing kyphosis predicts worsening mobility in older community-dwelling women: a prospective cohort study. J Am Geriatr Soc. 2011;59(1):96-100.), (4040 MacIntyre NJ, Lorbergs AL, Adachi JD. Inclinometer-based measures of standing posture in older adults with low bone mass are reliable and associated with self-reported, but not performance-based, physical function. Osteoporos Int. 2014;25(2):721-8..

A relevant finding of this systematic review is that balance and risk of falls in older adults is not only affected by thoracic deformities such as thoracic hyperkyphosis. Special attention should be given to the lumbar spine, because several studies found an association between changes in lumbar curvature and poorer balance-test performance (as measured by stabilometry) and increased incidence of falls in healthy older adults2121 Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa Y, Noguchi H, Kamo K, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28(1):82-7.), (2222 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal sagittal contour affecting falls: cut-off value of the lumbar spine for falls. Gait Posture. 2013;38(2):260-3.), (2323 Miyazaki J, Murata S, Horie J, Uematsu A, Hortobágyi T, Suzuki S. Lumbar lordosis angle (LLA) and leg strength predict walking ability in elderly males. Arch Gerontol Geriatr. 2013;56(1):141-7.), (2424 Imagama S, Ito Z, Wakao N, Seki T, Hirano K, Muramoto A, et al. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013;22(6):1346-53.), (3131 Drzal-Grabiec J, Rachwal M, Podgórska-Bednarz J, Rykala J, Snela S, Truszczynska A, et al. The effect of spinal curvature on the photogrammetric assessment on static balance in elderly women. BMC Musculoskelet Disord. 2014;15:186.), (3232 Ota S, Goto H, Noda Y, Fujita R, Matsui Y. Relationship between standing postural alignments and physical function among elderly women using day service centers in Japan. J Back Musculoskelet Rehabil. 2015;28(1):111-7..

Loss of lumbar lordosis leads to pelvic retroversion and posterior shift of the gravity line3838 Lafage V, Schwab F, Skalli W, Hawkinson N, Gagey PM, Ondra S, et al. Standing balance and sagittal plane spinal deformity: analysis of spinopelvic and gravity line parameters. Spine (Phila Pa 1976). 2008;33(14):1572-8.. In the study by Ishikawa et al.1010 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal curvature and postural balance in patients with osteoporosis. Osteoporos Int. 2009;20(12):2049-53., loss of lumbar lordosis increased postural instability and propensity to fall in older adults with osteoporosis. Thus, both thoracic hyperkyphosis and loss of lumbar lordosis induce a displacement of the gravity line (GL) in the sagittal plane, reducing stability limits in all directions, as well as the magnitude of response and displacement speed, especially in the antero-posterior axis, fostering an increased postural balance in older adults3737 Schwab F, Lafage V, Boyce R, Skalli W, Farcy JP. Gravity line analysis in adult volunteers: age-related correlation with spinal parameters, pelvic parameters, and foot position. Spine (Phila Pa 1976). 2006;31(25):E959-67..

Thus, the ankles and feet should also be taken into account when analyzing the influence of posture on balance and the risk of falls in healthy older adults. The feet play an important role in body stabilization, since it contributes to weight load distribution in the bipedal position and influences balance and balance control during gait3434 Menz HB, Morris ME, Lord SR. Foot and ankle risk factors for falls in older people: A prospective study. J Gerontol A Biol Sci Med Sci. 2006;61(8):866-70.), (4141 Menz HB, Morris ME, Lord SR. Foot and ankle characteristics associated with impaired balance and functional ability in older people. J Gerontol A Biol Sci Med Sci. 2005;60(12):1546-52.. Studies have associated foot characteristics with the risk of falls in older adults. Loss of ankle mobility and plantar tactile sensation, deformities and toe weakness were found to negatively affect balance, gait speed and functional mobility test performance77 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-7.), (4141 Menz HB, Morris ME, Lord SR. Foot and ankle characteristics associated with impaired balance and functional ability in older people. J Gerontol A Biol Sci Med Sci. 2005;60(12):1546-52.), (4242 Menz HB, Lord SR. The contribution of foot problems to mobility impairment and falls in community-dwelling older people. J Am Geriatr Soc. 2001;49(12):1651-6..

The maintenance of body balance depends on a complex, coordinate interaction of vestibular, somatosensory and visual systems, which hold the body’s center of mass over the base of support4343 Perracini MR, Gazzola JM. Balance em Idosos. In: Perracini MR, Fló CM, editors. Funcionalidade e Envelhecimento. Rio de Janeiro: Guanabara Koogan; 2009. p. 115-51.. This is why the use of multidimensional measures has been advocated for the assessment of balance and risk of falls in older adults. The Clinical Guidance Statement on Management of Falls4444 Avin KG, Hanke TA, Kirk-Sanchez N, McDonough CM, Shubert TE, Hardage J, et al. Management of falls in community-dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Phys Ther. 2015;95(6):815-34. recommends the screening of different risk factors for falls and interventions, such as foot assessment and footwear correction, with level two evidence. It is important to highlight that other variables associated with postural changes may influence balance impairment and risk of falls in older adults, such as visual and proprioceptive muscle response3131 Drzal-Grabiec J, Rachwal M, Podgórska-Bednarz J, Rykala J, Snela S, Truszczynska A, et al. The effect of spinal curvature on the photogrammetric assessment on static balance in elderly women. BMC Musculoskelet Disord. 2014;15:186., paravertebral muscle weakness2121 Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa Y, Noguchi H, Kamo K, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28(1):82-7.), (2222 Ishikawa Y, Miyakoshi N, Kasukawa Y, Hongo M, Shimada Y. Spinal sagittal contour affecting falls: cut-off value of the lumbar spine for falls. Gait Posture. 2013;38(2):260-3.), (2323 Miyazaki J, Murata S, Horie J, Uematsu A, Hortobágyi T, Suzuki S. Lumbar lordosis angle (LLA) and leg strength predict walking ability in elderly males. Arch Gerontol Geriatr. 2013;56(1):141-7.), (2424 Imagama S, Ito Z, Wakao N, Seki T, Hirano K, Muramoto A, et al. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013;22(6):1346-53., decreased spinal mobility2121 Kasukawa Y, Miyakoshi N, Hongo M, Ishikawa Y, Noguchi H, Kamo K, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28(1):82-7. and low physical function88 Abe Y, Aoyagi K, Tsurumoto T, Chen CY, Kanagae M, Mizukami S, et al. Association of spinal inclination with physical performance measures among community-dwelling Japanese women aged 40 years and older. Geriatr Gerontol Int. 2013;13(4):881-6..

Although postural alignment changes with ageing, stretching and strengthening exercise programs to paravertebral muscles may help to prevent or minimize these changes. In a twelve-month follow-up study, Pawlowsky et al.4545 Pawlowsky SB, Hamel KA, Katzman WB. Stability of kyphosis, strength, and physical performance gains 1 year after a group exercise program in community-dwelling hyperkyphotic older women. Arch Phys Med Rehabil. 2009;90(2):358-61. found that older women receiving in-home physical therapy sessions twice a week for 12 months showed improved paravertebral strength and flexibility, and reduced thoracic kyphosis by 3°. Similar results were found in the study by Katzman et al.4646 Katzman WB, Sellmeyer DE, Stewart AL, Wanek L, Hamel KA. Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women. Arch Phys Med Rehabil. 2007;88(2):192-9. with hyperkyphotic older women.

Despite the complexity of postural control and balance maintenance mechanisms in healthy older adults, this review shows that postural assessment in older adults should be part of the daily clinical routine of physical therapists, as a variable that still needs to be investigated as a risk factor for falls in healthy older adults. Moreover, exercise programs that contribute to increasing paravertebral muscle strength and flexibility should be included in the therapy prescribed by physical therapy professionals.

Some of the limitations of the studies included in this review were, first, the great variability of methods used to assess posture - ranging from more subjective (visual postural assessment) to more accurate technologies (SpinalMouse); second, the great variability of tools used to assess balance - from stabilometry to functional tests; third, some authors did not describe the reliability and reproducibility of the assessment tools; and, finally, the fact that some studies were cross-sectional and therefore did not assess the cause-effect relationship between postural changes, and/or impaired balance in community-living older adults.

Conclusion

This review shows that there is evidence that postural changes such as thoracic hyperkyphosis, loss of lumbar lordosis and decreased plantar arch seem to contribute to the increased postural instability and consequently an increased risk of falls in community-living older adults. However, since there is no consensus on the best method to assess balance in older adults, further studies should be conducted to elucidate this issue. Moreover, longitudinal studies need to be conducted to investigate the cause-effect relationship between age-related postural changes, and balance and falls in community-living older adults.

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    Pawlowsky SB, Hamel KA, Katzman WB. Stability of kyphosis, strength, and physical performance gains 1 year after a group exercise program in community-dwelling hyperkyphotic older women. Arch Phys Med Rehabil. 2009;90(2):358-61.
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    Katzman WB, Sellmeyer DE, Stewart AL, Wanek L, Hamel KA. Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women. Arch Phys Med Rehabil. 2007;88(2):192-9.

Publication Dates

  • Publication in this collection
    2018

History

  • Received
    16 June 2016
  • Accepted
    18 Sept 2017
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