Clinical Neurophysiology 119 (2008) 2424–2436

Contents lists available at ScienceDirect

Clinical Neurophysiology
journal homepage: www.elsevier.com/locate/clinph

Invited review

The clinical utility of posturography

Jasper E. Visser a, Mark G. Carpenter b, Herman van der Kooij c, Bastiaan R. Bloem a,*
a
Department of Neurology, Parkinson Center Nijmegen (ParC), Donders Center for Neuroscience, Radboud University Nijmegen Medical Centre,
P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
b
School of Human Kinetics, University of British Columbia, Vancouver, BC, Canada
c
Department of Biomechanical Engineering, University of Twente, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Postural instability and falls are common and devastating features of ageing and many neurological,
Accepted 30 July 2008 visual, vestibular or orthopedic disorders. Current management of these problems is hampered by the
Available online 12 September 2008 subjective and variable nature of the available clinical balance measures. In this narrative review, we dis-
cuss the clinical utility of posturography as a more objective and quantitative measure of balance and
Keywords: postural instability, focusing on several areas where clinicians presently experience the greatest difficul-
Posturography ties in managing their patients: (a) to make an appropriate differential diagnosis in patients presenting
Clinical utility
with falls or balance impairment; (b) to reliably identify those subjects who are at risk of falling; (c) to
Balance
Postural control
objectively and quantitatively document the outcome of therapeutic interventions; and (d) to gain a bet-
ter pathophysiological understanding of postural instability and falls, as a basis for development of
improved treatment strategies to prevent falling. In each of these fields, posturography offers several the-
oretical advantages and, when applied correctly, provides a useful tool to gain a better understanding of
pathophysiological mechanisms in patients with balance disorders, at the group level. However, based on
the available evidence, none of the existing techniques is currently able to significantly influence the clin-
ical decision making in individual patients. We critically review the shortcomings of posturography as it
is presently used, and conclude with several recommendations for future research.
Ó 2008 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights
reserved.

1. Introduction insecure gait or balance – has relatively limited accuracy when

Balance impairment is common in elderly people and in pa-
tients with a wide range of disorders, including vestibular pathol-
ogy, visual or oculomotor impairment, neurological diseases and
musculoskeletal disorders (Tinetti, 2003; Voermans et al., 2007).
The impact of these balance disorders is enormous, both for af-
fected individuals and for the society at large. One major concern
includes falls, which are associated with a considerable morbidity,
including trauma, immobilization, and fear of renewed falls (King
and Tinetti, 1995; Cumming et al., 2000; Bloem et al., 2001d; Stel
et al., 2004). As a consequence, the quality of life of patients with
balance impairment and falls is markedly diminished.
Against this background, patients with balance impairment re-
quire optimal medical attention, for both diagnostic and therapeu-
tic reasons (Table 1). First, it is necessary to make a reliable
differential diagnosis in patients presenting with falls or balance
impairment. This may be difficult, probably because the ‘‘disease
focused” eye of an experienced clinician – although undoubtedly
sensitive in detecting that something is wrong in patients with an
* Corresponding author. Tel.: +31 24 3615202; fax: +31 24 3541122.
E-mail address: B.Bloem@neuro.umcn.nl (B.R. Bloem).
deciding how balance regulation is affected.
Reliably identifying subjects who are at risk of falling is another
clinical challenge. Several clinical tests, e.g. the ‘‘stops walking
while talking” test, are able to identify subjects at risk for falls rea-
sonably well, but the proportion of false-negative predictions re-
mains high (Woollacott and Shumway-Cook, 2002; Bloem et al.,
2006). Moreover, test execution varies considerably between dif-
ferent clinicians, and interpretation of the outcome is variable
due to the subjective scoring system.
A further example of a clinical need is the development of im-
proved treatment strategies to prevent falls, tailored to individual
needs. This requires insight into the primary pathological pro-
cesses and secondary compensatory strategies that are employed
by patients to reduce falls. What clinicians see in their examination
room is the net result of primary disease processes, plus what the
patient tries to make of this, both in terms of behavioral compen-
sation and adaptive plasticity in the nervous system (Bloem et al.,
2001e; Palop et al., 2006). Unfortunately, clinical balance tests can-
not reliably separate these two aspects, despite potential therapeu-
tic implications. Moreover, it remains difficult for the naked eye to
differentiate between causes (i.e. specific abnormalities in postural
control) and effects (i.e. the consequential imbalance).

1388-2457/$34.00 Ó 2008 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.clinph.2008.07.220
 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436
Table 1
Purposes for assessing balance impairment in clinical practice
 Diagnostic – Differential diagnosis in patients with falls or balance
purposes impairment
– Early detection of subjects at risk of falling
 Therapeutic – Development of optimal treatment strategies tailored to
purposes individual needs
– Objective documentation of therapeutic efficacy
 Long-term – Improved understanding of underlying pathophysiology,
purpose as a basis for renewed treatment strategies
Finally, clinicians require a reliable tool that can be used to
objectively and quantitatively document the outcome of therapeu-
tic interventions. This is desirable not only in clinical practice to
evaluate the success of treatment in individual patients, but also
in a research setting to assess the outcome in clinical trials.
The current management of patients with postural instability is
hampered by the intricate assessment of balance disorders. The
current standard in clinical practice is a combination of history tak-
ing and physical examination, but neither approach is infallible.
Asking about the presence of prior falls is unreliable because pa-
tients often forget their falls (Cummings et al., 1988). Clinically
used balance tests are hampered by their variable execution and
subjective scoring system (Munhoz et al., 2004; Jacobs et al.,
2006). As such, clinical examination of postural control provides
only a relatively crude and subjective estimate of potential abnor-
malities in balance regulation, and may well miss abnormal func-
tioning of selective elements of the balance repertoire.
In this narrative review, we discuss the clinical utility of postur-
ography, as a more objective and quantitative measure of balance
and postural instability. ‘‘Utility” is here interpreted in a broad
sense, i.e. as the answer to the challenges posed in Table 1. This
also includes the more statistical interpretation of utility in terms
of diagnostic yield, for example the sensitivity, specificity or
responsiveness of a particular posturography application.
This narrative review does not intend to provide a comprehensive
listing of all available publications, but rather presents a synopsis of
the different applications of posturography in clinical practice. This
will be illustrated using selected key examples from the literature.
Following a brief summary of the potential advantages of various
posturography techniques, we will outline several main approaches
that are presently available to investigate balance in health and dis-
ease. We then focus on specific areas where clinicians currently
experience difficulties in managing their patients. We specifically
address the ability of the existing techniques to support the individ-
ual decision making by clinicians in these areas. In addition, we will
critically review the shortcomings of posturography as it is presently
used, and provide several recommendations for future research.
2. Advantages of posturography
In this section, we will discuss the available posturography
techniques, and how these applications can overcome the main
drawbacks to the clinically based balance examination: (a) the var-
iability in test performance (within and across different examin-
ers); (b) the subjective nature of the scoring system; and (c) the
inability to unravel details of the underlying pathophysiology in
individual patients. Where appropriate, we will illustrate the
advantages of posturography by showing a salient application in
a specific patient population.
2.1. Static and dynamic posturography
The term posturography refers – literally – to the description of
posture, which we interpret as the rather static relative position of
2425
different body parts with respect to each other. Most frequently,
however, posturography techniques are used to investigate the ac-
tive and passive regulation of balance under a variety of conditions.
Essential elements of most posturography techniques include the
ability to actively manipulate posture or balance, and evaluate
the subject’s response to such interventions. Available posturogra-
phy techniques and possible applications have recently been re-
viewed extensively (Bloem et al., 2003). We will now discuss
several major principles behind posturography techniques.
It is common practice to allocate a particular posturography
technique to one of two major categories: static posturography
or dynamic posturography (Furman et al., 1993). In static postur-
ography, postural control is assessed while subjects maintain
stance in a relatively unperturbed state (usually quiet stance on
a fixed support surface). However, even unperturbed stance is far
from static due the combined influence of gravity and small self-
initiated corrective movements (Kuo et al., 1998; Creath et al.,
2002).
Dynamic posturography involves the use of experimentally in-
duced balance perturbations (Table 2). A common variant is the
use of a movable support surface upon which subjects are stand-
ing. Platforms can usually move in only one direction, but more re-
cent versions allow for perturbations in multiple directions (Henry
et al., 1998; Allum et al., 2002). Balance can then be perturbed
when the support surface makes sudden horizontal translations,
rotations, vertical displacements or a combination thereof (Bloem
et al., 2003). Most investigators use rapid and brief perturbations
in order to study immediate defensive postural reactions, but slow
and oscillatory movements have been used to investigate adapta-
tion, stimulus anticipation and feed-forward postural control
mechanisms (Diener et al., 1982; Dietz et al., 1993). An alternative
approach is to apply external perturbations aimed directly at upper
body segments, for example by pushing and pulling the trunk,
shoulder or pelvis (Wolfson et al., 1986; Rietdyk et al., 1999).
In the remainder of this review, we will discuss static and dy-
namic posturography studies together, because many studies use
both techniques simultaneously to address a certain topic.
2.2. Standardized postural perturbations
Unlike clinical tests, the specific parameters of the balance dis-
turbance used in computerized posturography can be controlled by
the experimenter, e.g. the peak and time-to-peak acceleration,
peak velocity or amplitude of the support surface displacements.
Each of these variables can affect postural control (Diener et al.,
1984b; Szturm and Fallang, 1998; Brown et al., 2001; Carpenter
et al., 2005). A theoretical advantage is that most motor driven
platforms are independent of inter-subject variations in body mass
or mass distribution, as opposed to many clinical balance tests.
Table 2
Types of physical perturbations, as used in dynamic posturography (after Bloem et al.
(2003), with permission from the authors)
External perturbations
 Moving support surface
– Translation, rotation or vertical displacement
– Unidirectional vs. multidirectional
– Abrupt vs. continuous (e.g. sinusoidal)
– Predictable vs. non-predictable stimuli
 Stimuli applied to upper body parts
– Hips
– Trunk
– Head
Self-inflicted perturbations
 Voluntary weight shifts
 Anticipatory postural responses
 Balancing on unstable support surface
2426 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436
2.3. Manipulating specific elements of postural control
Several manipulations can be introduced to render the stance or
balancing task more challenging, for example by reducing the size of
the base of support (e.g. assuming a tandem stance), by decreasing
visual feedback (e.g. eye closure) or by decreasing proprioceptive
feedback (e.g. standing on a compliant surface) (Allum et al.,
2001a; Bloem et al., 2003; Adkin et al., 2005). It is also possible to
use ‘‘sensory perturbations” to selectively manipulate one or more
specific elements of postural control, and this may provide a better
understanding of mechanistic, physiological and pathophysiologi-
cal principles. Examples include movements of the visual scene
(Soechting and Berthoz, 1979), galvanic vestibular stimulation (Fitz-
patrick et al., 1996) or tendon vibration (Polonyova and Hlavacka,
2001). An unusual manipulation was to test subjects while standing
underwater, and this helped to unveil the presence of graviception
as a possible fourth source of afferent information for postural con-
trol (Dietz et al., 1992). We will discuss in some detail the clinical
lessons learned from using two commonly used manipulations:
changes to sensory reweighing, and changes in cognitive load.
2.3.1. Sensory re-weighing
Clinically based studies in patients with ‘‘focal” lesions had al-
ready pointed to the importance of the three main afferent sensory
systems for maintaining postural control – visual, vestibular and
proprioceptive – but it took carefully controlled posturography
studies to reveal how information from these different systems
was centrally weighed and processed (Peterka, 2002; Oie et al.,
2002). The starting point in such studies is that sensory perturba-
tions provide unreliable cues about body sway and velocity. Under
ideal circumstances, the sensory flow of such a perturbed sensory
system should be ignored since it does not serve to stabilize pos-
ture, but rather has a destabilizing effect. As such, sensory pertur-
bations clarify how each sensory afferent system contributes to
balance, and how well subjects can reweigh the available sensory
information in order to maintain balance.
A commercially available application in this field is the Sensory
Organization Test (SOT) or Equitest (NeuroCom International,
Clackamas, Oregon). In the SOT, sensory modalities can be absent
(visual) or conflicting (visual, proprioceptive) by blindfolding and
moving the visual surround and/or platform coupled to body sway.
This creates conditions where either visual feedback, propriocep-
tive feedback, or both are minimized, forcing the non-perturbed
sensory channels to compensate. This compensatory ability is com-
pared to normative data. The SOT is commonly used in clinical re-
search. For example, a reduced capacity to weigh different sensory
inputs depending on changes in the environment has been identi-
fied in populations with different balance deficits, including e.g.
patients with Parkinson’s disease (PD) (Colnat-Coulbois et al.,
2005), peripheral vestibular deficits (Peterka, 2002), peripheral
neuropathy (Di Nardo et al., 1999; Reid et al., 2002) or stroke
(Marigold et al., 2004). A recurrent observation (and apparently
one that is irrespective of the specific disorder that is being stud-
ied) is that patients cannot maintain equilibrium under the more
difficult SOT conditions, especially when they are forced to rely
on vestibular input only. A positive approach is that such findings
identify impairments in re-weighing and integrating afferent infor-
mation as important and common contributors to postural insta-
bility and falls. A more critical interpretation is that this is a very
aspecific finding, simply showing that patients with balance
impairment become extra unstable when their postural defence
mechanisms are stressed to the limits. Indeed, it has been ques-
tioned to what extent the SOT truly addresses vestibulospinal func-
tion (Evans and Krebs, 1999): in patients with bilateral vestibular
loss, SOT scores correlate poorly with clinical measures of balance
control and dynamic gait performance.
2.3.2. Cognitive manipulation
Another form of manipulation involves the application of sec-
ondary or tertiary tasks while subjects maintain their balance.
Such a ‘‘dual task” or multitask paradigm provides insights into
the subject’s ability to simultaneously process tasks of increasing
complexity, and what strategies are employed to deal with such
complex balance tasks. When the secondary task draws upon cog-
nitive resources or demands attention, this paradigm also reveals
to what extent the primary task, i.e. maintaining balance, is under
cognitive control. By adding a secondary cognitive task while bal-
ancing, many researchers have found a deterioration of the pri-
mary balance task in normals, in particular when subjects were
old (see for example Brown et al., 1999; Bloem et al., 2001c)
although this was not a consistent finding (Bootsma-van der
et al., 2003). Such inconsistencies between studies are likely ex-
plained by differences in experimental design, including the diffi-
culty of the primary (postural) task, the nature and complexity of
the secondary tasks, and in particular by the specific instructions
given to the subjects, as this determines where they place their pri-
orities (and where they are willing to accept penalties).
The dual task paradigm also lends itself well for the studies of
patients with balance impairment, and theoretically helps to dis-
entangle the motor and cognitive contributions to postural insta-
bility. Although nuances can be found in the literature, the
overall conclusion is that both secondary motor tasks and second-
ary cognitive tasks negatively affect postural performance in a
wide range of patient populations, over and above the effect seen
in matched controls (Bloem et al., 2006). More complex tasks have
a greater effect than simple secondary tasks (Bond and Morris,
2000; Bloem et al., 2001b). These effects are seen not only in pa-
tients with predominantly cognitive disorders (such as Alzheimer’s
disease) (Alexander et al., 1995; Camicioli et al., 1997) but also in
patients with predominantly motor disorders (such as patients
recovering from limb-saving surgery) (De Visser et al., 2001).
2.4. Objective and quantitative outcome measures
Posturography allows for a detailed and objective analysis of
postural responses, by using a range of quantifiable measures of pos-
tural control (Table 3). This includes kinetic measures (the causes of
movement; related to momentum, inertia, mass, weight and force),
kinematic measures (actual movements of body segments) or
measures of muscle activity such as electromyography (EMG).
Combinations are preferable as the different outcome measures pro-
vide complementary information (‘‘multimodal posturography”).
2.4.1. Kinetics
Kinetic information includes recordings of the center of (foot)
pressure (COP), reactive torques and shear forces applied to the
Table 3
Recording equipment and outcome measures in posturography (after Bloem et al.
(2003), with permission from the authors)
Modality Recording equipment Outcome measure
Kinetics – Forceplates – Center of foot pressure
– Torques
– Shear forces and moments
Kinematics – Motion sensors – Center of gravity
– Segment motion
– Optical motion analysis – 3-D spatial representation
of body (parts) in time
Electromyography – Surface electrodes – Background muscle activity
– Needle electrodes – Individual postural responses
– Inserted wire electrodes – Postural synergies
 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436
support surface, as a function of time. In static posturography
experiments, several descriptive measures can be derived from
COP information to characterize human postural sway, either in
the time-domain or in the frequency-domain (Prieto et al., 1996).
This approach has been used with reasonable success to demon-
strate, at the group level, abnormalities of the postural control sys-
tem in various patient populations. Examples include a higher
mean velocity in the COP movements due to ageing (Prieto et al.,
1996); excessive sway expressed by a larger root mean square of
COP velocities in stroke survivors (Haart et al., 2004); a larger
COP displacement and mean velocity after limb saving surgery in
certain dual task conditions with eyes closed (De Visser et al.,
2001); and a larger COP displacement in vestibular loss patients,
particularly in the more challenging conditions of the SOT (Black
et al., 1988). The effect of treatment has been assessed as well,
e.g. by showing that the excessive sway in stroke survivors im-
proves during the course of rehabilitation (Haart et al., 2004), or
that a 1 Hz body sway oscillation – associated with abnormal large
and fast COP sway – in PD patients vanishes with levodopa treat-
ment and deep brain stimulation of the subthalamic nucleus
(Maurer et al., 2004).
2.4.2. Kinematics
The body’s kinematics can be measured using lightweight mo-
tion sensors attached to the body or using optical motion analysis
systems (Bloem et al., 2003). The latter approach interferes less
with natural body motion, but is more expensive and complex.
The kinematic information can be used to estimate the three-
dimensional coordinates of the center of mass (COM) (Winter
et al., 2003) or to provide insight into postural strategies. This ap-
proach has been used to objectively document the magnitude of
postural instability (i.e. the amount of COM displacement in re-
sponse to a postural perturbation) in specific patient populations
with balance impairment (Bloem et al., 2001c). In addition, de-
tailed studies of individual body segment displacements have
helped to unravel the pathophysiology of postural instability in
specific disorders, sometimes revealing abnormalities that were
not immediately apparent clinically. We will provide two exam-
ples. The first is a dynamic posturography study of patients with
cerebellar ataxia who, unexpectedly, were found to stiffen their
knees in response to sudden platform tilts (Bakker et al., 2006).
This stiffening strategy interfered with the normal rapid compen-
satory knee movements that are needed to minimize body sway.
The second example involves the use of kinematic analyses to
study the regulation of protective arm movements (Bateni et al.,
2004), and their changes with, e.g. ageing or neurological disease
(Allum et al., 2002; Carpenter et al., 2004a).
2.4.3. Electromyography
The muscular response to postural perturbations can also be
quantified, usually with surface EMG techniques. Other techniques
include needle EMG to record from very specific and deeply located
muscles (Cresswell et al., 1994), and ultrasound technology to
track muscle movements (Loram et al., 2004). Changes in postural
responses can be identified by measuring onset latencies, response
amplitudes or postural strategies (the activation pattern among
different muscles working together). Different techniques for mea-
suring EMG in posturography experiments have been comprehen-
sively reviewed elsewhere (Bloem et al., 2003). EMG studies have
helped to clarify the nature of balance deficits in many different
disorders, for example by showing delayed (but appropriately
scaled) muscular responses in patients with lower-leg propriocep-
tive loss (Bloem et al., 2000); or responses that are appropriately
timed, but with excessive or insufficient amplitude, as in patients
with bilateral vestibular loss (Carpenter et al., 2001a); or a poor
co-ordination of responses between different muscle groups,
2427
resulting in co-contraction, as in patients with PD (Carpenter
et al., 2004a).
At a group level, some of these changes in postural responses
are fairly specific for certain pathological conditions, even though
this may not be obvious to the clinical eye. For example, a classical
clinical study suggested that balance deficits caused by PD and ves-
tibular loss could have similar origins (Martin, 1965). This claim
was based on the inspection of simple videographic data which
for both groups revealed a similar fall pattern in response to sup-
port surface tilts. It took a detailed posturography analysis to iden-
tify that PD patients and vestibular loss patients in fact have
distinct neuromuscular patterns, despite similarities in gross pat-
terns of instability. Thus, vestibular loss patients have significantly
decreased amplitudes of long latency postural responses, followed
by excessive compensatory activation of muscles (Carpenter
et al., 2001a). In contrast, PD is associated with significant increases
in the amplitude of medium and long latency responses in both
agonist and antagonist muscle groups, resulting in co-contraction
(Schieppati and Nardone, 1991; Dimitrova et al., 2004; Carpenter
et al., 2004a). The net effect on balance is identical, namely a fall
‘‘like a log” into the direction of the imposed perturbation, but
the pathophysiology is distinct: hypotonic falls in vestibular loss
patients, and stiff falls in PD patients.
2.4.4. Biomechanical modeling
In addition to actual data derived from human subjects, inverse
biomechanical models can be used to calculate joint torques that
can be fed into a forward biomechanical model to quantify how
much of the movements are caused by the net actions of muscles
and ligaments crossing a joint. This technique can also calculate
the effect of gravity, centrifugal and external perturbations on
body movements. This type of analysis showed that in moving
platform studies, the deceleration counteracts the effects of the
acceleration, and that the time between acceleration and decelera-
tion is so short that only the first part of the response can be stud-
ied – and not the complete response to the acceleration (van
Asseldonk et al., 2007). This technique has thus far not been used
in patients.
2.4.5. System identification techniques
It is difficult to distinguish between cause and effect in patients
with balance disorders. System identification techniques can offer
advantages here, as this technique applies an external stimulus
and thereby ‘opens the loop’ of a system in which the controlled
variable (body sway) is fed back to the control variable (muscle
activations) (Fitzpatrick et al., 1996). Opening the loop in human
balance control makes it possible to disentangle different neural
and muscular stabilizing mechanisms from the unstable body
dynamics. Without perturbations, it is impossible to determine if,
for example, changes in EMG activity result in changes in muscle
force that will affect body sway, or that the opposite is true, i.e.
changes in body sway angle are detected by sensors and transmit-
ted to the nervous system that excites the muscle groups reflected
in EMG changes (Van der Kooij et al., 2005). For example, system
identification techniques have been applied to assess asymmetries
in the contribution of the ankle joints of each leg of patients with
hemispheric stroke (van Asseldonk et al., 2006) and PD (Van der
Kooij et al., 2007), which could not be recognized with the naked
clinical eye.
3. Current clinical use of posturography
In the prior section, posturography has been discussed as a tool
to objectively and quantitatively assess balance in a standardized
manner and to understand the physiology and pathophysiology
2428 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436

of postural control, by studying groups of healthy subjects or pa-
tients. The clinical utility of posturography, however, lies in the
support of decision making in individual patients. We will demon-
strate that even the presence of clear differences at the group level
does not automatically imply that a certain posturography test is
also helpful in managing individual patients.
3.1. Diagnostic utility
Several studies have attempted to use posturography as a sup-
plement or even surrogate to clinical tests that could assist clini-
cians in establishing the correct diagnosis. Many techniques have
been studied, in a wide variety of disease entities (Table 4). Most
studies assessed sway using COP recordings or used the commer-
cially available SOT. The results of these studies were inconsistent,
and frequently the diagnostic yield was unsatisfactory. Neverthe-
less, some evidence for clinical utility of posturography has accu-
mulated in selective areas, and several recent developments are
promising, as will be illustrated below.
3.1.1. Diagnostic utility based on group differences
Several studies examined whether posturography could assist
in the differential diagnosis of balance disorders by comparing dif-
ferences between groups. For example, analysis of COP displace-
ment during quiet stance has been used to discriminate between
41 patients with different types of cerebellar pathology and 20
controls (Diener et al., 1984a). Although up to 86% of all patients
showed pathological results, only atrophy of the anterior cerebellar
lobe could be differentiated from other cerebellar pathology, and
some cerebellar lesions could not be differentiated from controls.
In another study, analysis of COP recordings under static and dy-
namic conditions could not discriminate well between patients
with bilateral vestibular loss, patients with cerebellar atrophy
and healthy controls (Baloh et al., 1998). These examples illustrate
that group differences do not automatically imply good discrimina-
tive value.
3.1.2. Diagnostic utility based on disease-specific abnormalities
Another approach focuses on identifying postural abnormalities
that are pathognomonic for specific disorders. For example, a 3 Hz
postural sway is a characteristic posturography finding in anterior
lobe cerebellar atrophy (Diener et al., 1984a). However, its clinical
value is limited as the tremor is clearly visible at the bedside (Baloh
et al., 1998). Another example relates to the patients with primary
orthostatic tremor, who manifest a characteristic increase in sway
activity in higher power spectra frequency bands, with a typical
peak between 12 and 19 Hz (Yarrow et al., 2001; Fung et al.,
2001). This sway frequency nicely correlates to the tremor fre-
quency which is usually not discernable to the naked clinical eye,
but which can be detected using tremor registration with surface
EMG in standing subjects (Piboolnurak et al., 2005). This finding
is perhaps the most specific and best defined abnormality that
can be identified using posturography. However, application in
clinical practice is virtually obviated by the availability of simple
tremor registration with EMG, which is less complex and much
cheaper.
3.1.3. Diagnostic utility characterized by sensitivity and specificity
Only few studies have tested the sensitivity and specificity of
posturography techniques, let alone positive or negative predictive
values. The results varied widely, were often incomplete, or the
operational definitions of sensitivity and specificity were inade-
quate or lacking (Di Fabio, 1995). Moreover, most studies are based
on retrospectively ascertained clinical data, and only few studies

Table 4
Major categories of conditions that have been addressed in studies aiming to evaluate posturography as diagnostic tool: for making the (differential) diagnosis, for estimating fall
risks and for assessing the effect of treatment

Condition (Differential) diagnosis Estimating fall risk Assessing treatment effect

Central nervous system
 Cerebellar diseases Diener et al. (1984a); Baloh et al.
(1998)
 Progressive supranuclear palsy Ondo et al. (2000)
 Parkinson’s disease Bloem et al. (1992) Blaszczyk et al. (2007) Melnick et al. (1999); Rocchi et al. (2002);
Hirsch et al. (2003); Maurer et al. (2003);
Colnat-Coulbois et al. (2005); Shivitz et al.
(2006); Visser et al. (2008)
 Orthostatic tremor Yarrow et al. (2001); Piboolnurak
et al. (2005)
 Stroke Bonan et al. (2004)
 Multipele sclerosis Williams et al. (1997)
 Migraine Dimitri et al. (2001)
 Non-peripheral vertigo and/or Kammerlind et al. (2001)
unsteadiness
Peripheral nervous system
 Peripheral neuropathy Ledin et al. (1990); Uccioli et al.
(1995); Di Nardo et al. (1999); Bloem
et al. (2000); Allum et al. (2001b);
Reid et al. (2002); Nardone and
Schieppati (2007)
 Peripheral vestibular loss Barin et al. (1992); Allum et al. Whitney et al. (2006) O’Neill et al. (1998); Rine et al. (2004)
(2001b)
 Neuritis vestibularis Uimonen et al. (1995)
 Menière’s disease Dimitri et al. (2001)
Other
 Ageing n/a Baloh et al. (1994); n/a
Piirtola and Era (2006)
 Non-organic Goebel et al. (1997)
 Orthopedic disorders Sinaki and Lynn (2002)

Please note that the list of publications is not meant to be exhaustive, but merely to provide an illustration of the wide range of diseases studied.
 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436
provide validation of potential diagnostic value in prospective re-
search (e.g.Buatois et al., 2006). We will discuss a few examples.
One study found that COP recordings during quiet stance had a
sensitivity of 77% and a specificity of 71% for the differentiation be-
tween simulated vertigo and acute vertigo due to vestibular neuri-
tis (Uimonen et al., 1995). Another study used the aforementioned
SOT and investigated various criteria by which (volunteering)
malingerers could be differentiated from both patients with a gen-
uine balance disorder and healthy controls: sensitivity ranged be-
tween 57% and 89%, and specificity between 88% and 100%,
depending on the criteria used. (Goebel et al., 1997). In PD, pres-
ence of abnormal postural responses in the lower legs (i.e. en-
hanced medium latency responses, reduced long latency
responses, or both) correctly identified patients with a sensitivity
of 65% and a specificity of 75% (Bloem et al., 1992). This rather poor
diagnostic yield was explained by the marked overlap between pa-
tients and controls (Fig. 1). Indeed, the clear group differences in
this study were almost exclusively explained by the presence of
abnormal postural responses in severely affected patients – where
a screening tool for PD would be useless. Better results were ob-
tained when the SOT was used to differentiate PD from progressive
supranuclear palsy (PSP) (Ondo et al., 2000). For patients in early
disease stages, this differential diagnosis can be difficult. The SOT
results showed that postural instability occurred earlier in the
course of the disease and was more pronounced in PSP compared
to PD. The best discriminative value was found for the SOT condi-
tion with inaccurate visual and proprioceptive input (sensitivity
95%, specificity 85%), and for a leaning task where subjects actively
controlled their COP (sensitivity 100%, specificity 95%). However,
average disease duration in these patients was about four years –
a time when the diagnosis can usually be made based upon clinical
grounds. A final example is a study that aimed to differentiate be-
tween bilateral peripheral vestibular loss, proprioceptive deficits
due to sensory neuropathy and healthy controls, using different
types of platform perturbations (Allum et al., 2001b). Measures
that provided the greatest diagnostic utility were the amplitude
of trunk angular velocity, the amplitude of balance-correcting
paraspinal responses and the amplitude of trapezius stabilising re-
Fig. 1. Group means (with 95% confidence interval) and individual values for the
normalized amplitude of medium latency balance correcting responses after a toe-
up perturbation of the support platform in 23 PD patients with various degree of
disease severity (Bloem et al., 1992). Although PD patients had a significantly
increased ML amplitude (on the left), there was a marked overlap between patients
and controls (on the right). In addition, clear group differences in this study were
explained by the presence of abnormal postural responses in only a few severely
affected patients (i.e. those above the 95% normality threshold). Modified from
Bloem et al. (1992), with permission of the authors.
2429
sponses, for simple toe-up rotations under eyes-closed conditions.
Although accurate classification was achieved in 71–100% (i.e. sen-
sitivity), the results need to be interpreted with caution due to the
small number of subjects (5 in each patient group, 15 controls) and
lack of specificity measures.
Taken together, the sensitivity and specificity of posturography
techniques reported thus far were at best modest. This is illus-
trated by two meta-analyses (performed over a decade ago), which
showed an overall sensitivity and specificity of only 50% for both
static and dynamic posturography (Di Fabio, 1995; Di Fabio,
1996). Note, however, that these meta-analyses merely addressed
vestibular function, using vestibular function tests such as electro-
nystagmography as criterion standard. Therefore, these figures
may not apply to other fields of interest. Moreover, there is a need
to perform new meta-analyses to incorporate the latest research
findings.
Attempts to improve the sensitivity of dynamic posturography
included modified experimental conditions, e.g. the introduction
of a 45 degree lateral head tilt during testing for diagnosing periph-
eral vestibular loss – a promising technique at a group level (Barin
et al., 1992). However, another study could not extend this group
result to the individual level: the sensitivity of identifying subjects
with abnormal caloric testing, rotatory chair testing, or both, was
only 24% – although the specificity was 90% (Chandra and Shepard,
1996). The additional value of lateral head tilt compared to stan-
dard testing, i.e. a comparison between analyses with and without
lateral head tilt, was not reported.
The use of artificial neural network techniques is a promising
approach which apparently yields a rather good sensitivity and
specificity for distinguishing between different disease entities.
For example, postural sway patterns have been used to discrimi-
nate between normal subjects, postural phobic vertigo, anterior
lobe cerebellar atrophy, primary orthostatic tremor and acute uni-
lateral vestibular neuritis (Krafczyk et al., 2006). Sway measures
were derived from COP recordings during upright stance. Data
from 10 test conditions (e.g. standing on a firm foot support or
on foam) were fed into a standard 3-layer feed-forward back-prop-
agation neural network, which properly classified the controls and
four patient groups with an overall sensitivity and specificity of
0.93 – with controls and orthostatic tremor being differentiated
best from the other conditions. Further research is obviously justi-
fied to further establish the clinical utility of artificial neural net-
work techniques.
3.2. Predicting the risk of falling
Only few studies specifically aimed to predict falls, mainly in
older people. One outcome measure that was felt to be promising
included sway velocity – particularly in the anterior-posterior
direction – because this is higher in groups of older subjects com-
pared to younger people (Baloh et al., 1994). Subsequent work
showed that sway velocity is higher in subjects with subjective
imbalance compared to age-matched controls who considered
their balance to be normal (Baloh et al., 1995). However, sway
velocity during static and dynamic conditions did not correlate
with the frequency of falls in the previous year (Baloh et al.,
1994). Moreover, self-reported fear of falling was inconsistently
correlated with sway velocity in these studies. Note that posturog-
raphy is not the only one to blame for these poor correlations: a
general drawback is that many studies ascertained falls retrospec-
tively based on self-report, but this approach is unreliable (Cum-
mings et al., 1988).
A recent meta-analysis (including the studies mentioned above)
investigated whether posturography measurements can predict
falls among elderly people (Piirtola and Era, 2006). Associations be-
tween falls and certain sway parameters (obtained from COP
2430 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436
recordings) were found in only five of nine prospective studies. The
key findings were as follows. First, particularly indicators of lateral
balance control could predict subsequent falls. Second, measures
derived from dynamic posturography tests were not predictive of
future falls. Unfortunately, this analysis did not report sensitivity
and specificity measures, which renders the results difficult to
interpret in terms of clinical utility.
Studies addressing the risk of falling in specific patient popula-
tions yielded similarly inconsistent results. For example, one study
among PD patients found no correlation between sway measures
and falls in the previous year (Blaszczyk et al., 2007). An example
of a (retrospective) study that aimed to estimate the risk of falling
in individual patients included 100 patients with otherwise
unspecified vestibular disorders, showing that the composite SOT
equilibrium score was associated with recurrent falls (Whitney
et al., 2006). In this study, receiver operating characteristic analysis
indicated a rather unsatisfactory sensitivity of 53% and a specificity
of 87% – indicating that about half of the recurrent fallers would be
missed by dynamic posturography alone. Another prospective
study demonstrated that loss of balance in the most demanding
SOT test with inappropriate somatosensory and visual input (i.e.
with sway referenced support platform and visual surround)
would predict recurrent falls within the next 16 months in healthy
volunteers over 65 years, with an odds-ratio of 3.6 (Buatois et al.,
2006). In this study, however, other types of COP derived measures
were not associated with falling, and sensitivity and specificity
were not given.
3.3. Evaluating the effect of therapeutic interventions
Various posturography studies investigated the effects of spe-
cific treatment strategies on balance and postural control – usually
at the group level. An area that received considerable attention is
the possible effect of bilateral deep brain stimulation on postural
control in PD. The results of static posturography were inconsis-
tent: the effect of STN stimulation has been reported to either de-
crease (Rocchi et al., 2002; Colnat-Coulbois et al., 2005) or increase
sway amplitudes (Maurer et al., 2003). This inconsistency may be
explained by differences in patient selection, in particular the
severity of concurrent dyskinesias. Certain aspects of the SOT have
been reported to improve with bilateral STN stimulation (but not
with antiparkinson medication) in a subset of patients who per-
formed poorly before surgery, suggesting better sensory-motor
integration (Shivitz et al., 2006). Another study found no overall
improvement in stability over and above optimal medication,
although individual subjects seemed to benefit substantially (Vis-
ser et al., 2008). This has also been demonstrated for pallidotomy
in PD (Melnick et al., 1999), and is in line with clinical experience
in most studies (Bakker et al., 2004).
The effect of balance training has also been investigated in dif-
ferent disease populations, usually with the SOT as primary out-
come. In PD, balance and resistance training improved
performance on the SOT, particularly for the more difficult condi-
tions (Hirsch et al., 2003). In addition, the numbers of falls during
testing decreased, and stance duration without falling lengthened.
Similar improvements have been reported in stroke patients (Bo-
nan et al., 2004), elderly subjects with otherwise unspecified cen-
tral nervous system dysfunction (Kammerlind et al., 2001),
children with bilateral vestibular loss (Rine et al., 2004) and oste-
oporotic women (Sinaki and Lynn, 2002).
Such studies illustrate the potential role for posturography in
evaluating the effect of treatment on postural control, but it re-
mains to be determined whether posturography provides a helpful
tool over and above clinical judgment. One study suggested that
this may not be the case: among 37 subjects with peripheral ves-
tibular hypofunction who were tested before and after a vestibular
rehabilitation program, improvements in SOT were not predictive
of changes in a battery of clinical and functional performance tests
(O’Neill et al., 1998).
4. Drawbacks to current posturography
The preceding sections demonstrate the limited clinical utility
of posturography, particularly within individual patients. In the
following section, we discuss several poignant dilemmas that
may explain this conclusion (Table 5), and propose several recom-
mendations for future research.
4.1. Subject selection
4.1.1. Inter- and intra-subject variability
The poor discriminative ability (between health and disease; or
between different diseases) of posturography measures may relate
to the substantial inter-subject and intra-subject variability
(Fig. 2). Even healthy subjects without postural impairment can
show considerable variability in their postural responses (Geurts
et al., 1993; Chandra and Shepard, 1996). This variability will neg-
atively affect the test-retest reliability of posturography, but only
few studies have specifically examined this – and reports are
inconclusive (Geurts et al., 1993; Benvenuti et al., 1999; Helbostad
et al., 2004). It appears that the test-retest reliability of posturo-
graphic measures is highly dependent on the type of measure;
age and disease conditions of the subjects; and the difficulty of
the balance task involved. To reduce inter-subject variability, it is
important to select homogeneous groups. For example, including
subjects who differ widely in age may introduce extra variability
because balance reactions change substantially with ageing (Ledin
et al., 1990; Baloh et al., 1994; Uimonen et al., 1995; Allum et al.,
2002).
4.1.2. Single or multiple disease entities
Additional variability may be caused by lumping different con-
ditions into one ‘‘disease group”, because disease-specific abnor-
malities could create inconsistency in the outcome measures. The
exact nature of the disease is sometimes insufficiently specified,
e.g. ‘‘vestibular disorders” or ‘‘disturbances in the nervous system”.
Another source of heterogeneity is introduced when the systems
affected by the disease differ among subjects, such as in multiple
sclerosis or stroke. Likewise, interventions should be applied uni-
formly across subjects to reduce variability in outcome. And for
obvious reasons, study groups should be carefully matched for age.
Table 5
Summary of potential drawbacks of posturography as it is currently experienced
Study phase Examples
Subject selection  Inter- and intra-subject variability
 Single or multiple disease entities
 Disease severity
 Selection bias
Data collection  Sample duration (static posturography)
 Platform deceleration (dynamic posturography)
 EMG processing
 Habituation and ‘‘first trial effects”
 Influence of cognitive and emotional factors
 Influence of pre-stimulus posture
 Presence of external support
Data analysis and  Choice of descriptive measures for postural
interpretation control
 Meaning of sway
 Statistical concerns
 Ecological validity
 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436
Fig. 2. Illustration of large inter-subject variability in posturography: the mean and
standard deviation for two joint angles are shown, as measured with optical 3D
tracking. Both trunk roll angle after a rightward directed platform perturbation
(relative to a baseline position set at 0 deg, A) and left knee angle for a forward
directed perturbation (absolute values, B) in a group of 18 healthy volunteers and
14 patients with Parkinson disease (PD). Note that while mean values can differ
considerably between groups, differences are obscured by the substantial standard
deviation. The onset of the perturbation is denoted by the vertical dashed line
(Visser, unpublished data).
4.1.3. Disease severity
Compared to controls, standard deviations are usually greater in
patient populations, for several reasons. First, abnormalities may
depend upon disease severity, and patients in various disease
stages are usually included in posturography studies. Furthermore,
including patients with very advanced disease tend to be very
unstable and become easily fatigued, and this can negatively affect
the quality of the data. Patients with late-stage disease are also
prone to develop secondary disease complications, for example
drug-induced dyskinesias in advanced PD or joint deformations
in advanced polyneuropathy, and this further increases variability
in the data. Finally, patients often have co-morbid conditions that
are independent from the disease under study, but that need to be
carefully controlled for in order to reduce variability.
4.1.4. Selection bias
Selection bias may be introduced when studies focusing on the
clinical utility of posturography use baseline posturography results
to define the groups (i.e. baseline posturography is used to define
inclusion criteria). For example, this occurs when subjects are re-
quired to have normal posturography tests in order to be included
in the control group (Chandra and Shepard, 1996; Goebel et al.,
1997).
2431
4.2. Data collection
4.2.1. Sampling duration
One factor which significantly affects posturography measures
is the sampling duration and frequency. Across and within static
posturography studies, sampling duration has varied from several
seconds to 30 min. Several studies have shown that the sampling
duration significantly affects descriptive measures in both the time
and frequency domain (Le Clair and Riach, 1996; Carpenter et al.,
2001c). Extended periods of standing may reveal aspects of pos-
tural sway that are not otherwise observable during shorter sam-
pling periods (Duarte and Zatsiorsky, 2000), because longer
sample durations allow the large amplitude, low frequency compo-
nents of the COP signal to be adequately represented in descriptive
measures (Carpenter et al., 2001c).
4.2.2. Effect of platform deceleration
In dynamic posturography studies using a movable platform,
the acceleration of the support surface represents the true
mechanical perturbation – not the platform displacement or veloc-
ity. What is often forgotten is that the support surface, after the ini-
tial acceleration, by necessity also needs to decelerate when the
maximum excursion has been reached. Importantly, this decelera-
tion of support platform movements may be another potential
source of misinterpretation of posturography data. Because the
stroke of the platform is limited to a few decimeters in most labo-
ratories, the acceleration–deceleration interval is short, so reactive
postural responses elicited by platform acceleration could mix and
interfere with responses triggered by deceleration (McIlroy and
Maki, 1994). This is especially true for the measured COP, joint tor-
que and body sway. In addition, anticipatory mechanisms could be
used to adjust the initial response to, and utilize, non-muscular
torques generated by platform deceleration (Bothner and Jensen,
2001). As shown in Fig. 3, support-surface translations with a long
acceleration–deceleration interval (i.e. 2 s) compared to a short
interval (i.e. 100 ms) induce larger trunk displacements and also
require larger amplitude EMG responses. During perturbations
with a short acceleration–deceleration interval, activity in some
antagonists muscles was associated with the deceleration and
not with the initial acceleration of the support surface (Carpenter
et al., 2005). Finally, the deceleration may also help to stabilize up-
right posture by mechanically countering the effect of the preced-
ing acceleration, thereby possibly obscuring more pronounced
balance difficulties (van Asseldonk et al., 2007). This inherent lim-
itation applies to the vast majority of currently available movable
platform systems, and limits the ecological validity of the obtained
findings.
4.2.3. EMG processing
Many issues regarding EMG processing have not been standard-
ized. The resultant methodological inconsistency across labs ham-
pers an easy comparison among different studies. Examples
include the many variants that are available to correct for the con-
founding influence of variations in background muscle activity
(Bloem et al., 1993), or to normalize EMG data. It would be desir-
able to reach consensus about such issues.
4.2.4. Habituation and ‘‘first trial” effects
To reduce the high variability of human postural responses,
most investigators average their data over multiple trials. How-
ever, postural responses typically habituate, i.e. the response
magnitude decreases when the subjects are serially exposed to
balance perturbations, especially if the stimuli are identical
(e.g. same perturbation direction and size) (Keshner et al.,
1987; Hansen et al., 1988; Bloem et al., 1998). The response to
very first and fully unpracticed trial is typically excluded from
2432 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436
Fig. 3. Single subject average of trunk angular displacement recorded from an older
adult highlights the increased challenge induced by support-surface translations
with a LONG (2000 ms = solid lines) compared to a SHORT (100 ms = dashed lines)
acceleration–deceleration interval (Carpenter, unpublished data).
further analysis, because this response appears to be very differ-
ent from the reactions seen in subsequent trials (Hansen et al.,
1988). This ‘‘first trial reaction” is sometimes referred to as a
startle-like response, although the relation to the startle proper
– as evoked by loud acoustic stimuli – remains unclear. A draw-
back to this averaging procedure is a potential loss of valuable
information which was only present in the first few trials. Spe-
cifically, the first trial reaction may provide useful insights into
the mechanisms associated with truly unexpected falls, and
thereby provide ecologically information about falling in every-
day life where perturbations are also singular (i.e. ‘‘the first”)
and unpredictable events.
4.2.5. Influence of cognitive and emotional factors
Another relevant factor is the contribution of cognitive and
emotional factors. Fear of falling is common in older adults (Yard-
ley and Smith, 2002) and is particularly pronounced in patients
with balance disorders (Bloem et al., 2001a; Watanabe, 2005). Fear
of falling can, its own right, affect postural performance. For exam-
ple, elderly persons who are afraid of falling have significantly lar-
ger spontaneous COP displacements compared to non-fearful
elderly (Maki et al., 1991). Likewise, patients with phobic postural
vertigo have significantly higher frequency components of COP dis-
placements compared to controls (Krafczyk et al., 1999). There is
growing evidence to support a direct link between fear or anxiety
and ‘‘postural performance”. Significant changes in the amplitude
and frequency of COP displacements have been observed when
subjects are required to stand in conditions of increased postural
threat, e.g. standing on the edge of a high surface (Carpenter
et al., 2001b) or when presented with pictures designed to elicit
negative emotional responses (Facchinetti et al., 2006). Also,
amplitudes of long latency muscular responses to unexpected sup-
port-surface rotations increase when subjects stand on high com-
pared to low surface heights (Carpenter et al., 2004b). Based on
these findings, fear and anxiety should be considered as a poten-
tially confounding variable that needs to be controlled, or at least
measured. In particular, comparisons of postural performance in
groups that may have different levels of fear or anxiety may mask
or mimic physiological differences. Furthermore, emotional state
may change over time, or with increasing familiarity with test con-
ditions, and thereby influence results that are based upon time-
dependent measurements.
4.2.6. Influence of pre-stimulus posture
An often neglected factor is the prestimulus posture and base-
line COP position of subjects. Subjects may purposely adjust their
prestimulus posture in order to brace themselves against upcom-
ing perturbations. This anticipatory postural leaning is common
when subjects have prior information about the direction of an
upcoming perturbation. For example, subjects who are exposed
to a predictable series of identical toe-up rotational platform dis-
placements gradually assume a stooped posture (Maki and White-
law, 1993; Tarantola et al., 1997). In addition, prestimulus posture
can be abnormal in patients with neurological disorders, e.g. the
stooped posture in PD or the asymmetric stance in patients with
stroke. Such changes in baseline posture can in turn affect the on-
set latencies and amplitudes of lower leg postural responses
(Bloem et al., 1999). Interestingly, quiet standing is also associated
with continuous ‘‘spontaneous” changes in COM and COP, and even
these subtle changes are sufficient to influence postural reactions
to unpredictable perturbations. For example, both onset latency
and amplitude of postural muscle responses to support-surface
translations are significantly influenced by spontaneous fluctua-
tions in position of the COP at the time of perturbation onset (Tok-
uno et al., 2006). Baseline stance should therefore be controlled
and monitored carefully, for example by providing subjects with
visual feedback about their own initial stance and by stalling the
experiment while baseline posture is outside predefined accept-
able ranges (Bakker et al., 2006; Visser et al., 2008). Any residual
differences in baseline stance could be entered into the statistical
analyses as covariate.
4.2.7. Presence of external support
A relevant environmental factor is the presence and character-
istics of any external support in order to reduce the risk of falls,
for example by equipping subjects with a safety harnesses, by
providing handrails or by positioning research assistants close
to the tested subject. While understandable for ethical reasons,
use of such protective measures may falsely increase the subject’s
balance confidence and reduce their fear of falling, and thereby
unintentionally change postural performance from that experi-
enced by the patient in everyday life. A further – theoretical –
disadvantage of the safety harness is that it provides subjects
with tactile or pressure-sensitive feedback about their amount
of sway and thereby may affect postural performance. Indeed,
even small amounts of proprioceptive feedback (a finger lightly
touching an external frame) can markedly affect postural re-
sponses (Dickstein et al., 2001). Despite this concern, the few
studies that have formally studied the influence of safety har-
nesses, deny that a safety harness significantly alters balance re-
sponses to external perturbations (Freitas et al., 2005) or sway
during quiet standing (Hill et al., 1994). It has been demonstrated,
however, that handrails can influence the ensuing postural re-
sponses, and this apparently depends on their proximity to the
subjects and the prior instructions (Bateni et al., 2004; Maki
and McIlroy, 2006).
 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436
4.3. Data analysis and interpretation
4.3.1. Choice of descriptive measures for postural control
Comparisons between posturography studies are difficult be-
cause of the vast number of descriptive measures used to charac-
terize balance. There is currently no agreement within the field
which parameters should be considered standard, or are superior
in describing balance control.One of the reasons for this lack of
agreement regarding choice of outcome measures in posturogra-
phy experiments is probably the absence of a widely accepted gold
standard for balance, i.e. a definitive test that could serve as refer-
ence for the evaluation of posturography variables and tests. A
popular outcome measure is recording of COP, which is often equa-
ted with ‘‘body sway”. However, this is only correct if the body
moves as a rigid pendulum – which is often not the case – and only
when sway angles and inertial forces are small. It is also unknown
how the COP signal is optimally described. Depending on the spe-
cific cause, postural instability can be identified better using veloc-
ity-related sway measures compared to displacement-related
sway measures. This was demonstrated for PD (Rocchi et al.,
2002; Maurer et al., 2003), peripheral neuropathy (Uccioli et al.,
1995) and ageing (Prieto et al., 1996).
4.3.2. Meaning of sway
Sway is interpreted as the reflection of noise and regulatory
activity within postural control loops. It is, however, unknown
why postural sway occurs during stance and what potential char-
acteristics of a change in sway behavior represent a balance defi-
ciency. There is in fact little scientific agreement on what sway
actually represents. In biomechanical terms, the COP displacement
is the controlling variable, reflecting the net-neuromuscular re-
sponses generated by the CNS to maintain control over the COM,
the controlled variable (Winter et al., 2003). In this view, the
COM displacement is an undesired effect, which needs to be min-
imized by the CNS through adjustments in COP either through
feedforward (Gatev et al., 1999) or feedback (Johansson et al.,
1988) mechanisms. However, the reasons for why the COM is con-
tinuously moving remain unknown, and there is no consensus as to
whether sway is beneficial or unhelpful. Consequently, it remains
unclear how to separate ‘‘good” from ‘‘bad” sway.
4.3.3. Statistical concerns
Given the many uncertainties, many researchers therefore re-
cord a broad range of different parameters. Such ‘‘multimodal”
assessments may be advantageous in being comprehensive, but
interpretation of a significant finding must be made with care be-
cause individual measures may be interrelated (Maurer and Peter-
ka, 2005). Multivariate analyses are required, with appropriate
statistical correction for multiple comparisons. It can be helpful
to increase the strength of the statistics through data reduction,
e.g. by merging variables into a single variable. For example, in a
study determining the effect of STN deep brain stimulation on bal-
ance control in PD, all optically derived kinetic data of 11 body seg-
ments were congregated into one single variable: the vector length
of three-dimensional COM displacement (Visser et al., 2008). And,
in order to prove clinical utility, e.g. for diagnosing individual pa-
tients, tests should be characterized by sensitivity and specificity
– as mentioned before.
4.3.4. Ecological validity
An overriding concern is the lack of ecological validity in pos-
turography experiments. This begins with the simple fact that sub-
jects know that their balance is about to be tested, under highly
artificial conditions where subjects are equipped with multiple
EMG electrodes or LEDs, and perhaps are being viewed by a set
of cameras. The postural perturbations are usually very unnatural;
2433
we already alluded to the confounding effect of decelerations in
moving platform experiments which are absent in daily life. An-
other problem is the need to test subjects repeatedly in order to
better separate signals from noise, but this leads to habituation ef-
fects that do not occur when subjects suddenly fall in daily life. Fi-
nally, most studies limit the number of available response
strategies, i.e. by restricting subjects to respond with feet-in-place
responses, despite the tendency for other ‘change in support reac-
tions’, such as stepping and reaching responses, to be employed
during unrestricted falls (see for review: Maki and McIlroy, 2006).
A final drawback of current posturography techniques is that
these usually address a small subset of the actual balance reper-
toire. Virtually all studies focus on erect standing, while in daily life
more dynamic balance skills are required – involving complex
coordination, e.g. standing up, reaching or picking object, stum-
bling and turning. Importantly, falls in daily life occur mostly dur-
ing such more complex skills. So perhaps we are looking at the
wrong – or too few – aspects of everyday balance.
5. Conclusions and future recommendations
By using carefully controlled experimental conditions, with cal-
ibrated control of the environment, standardized bodily perturba-
tions and use of a comprehensive set of quantitative outcome
measures, posturography has allowed for a detailed analysis of
the complex pathophysiology of balance disorders in groups of pa-
tients. Relatively few studies have addressed the clinical utility in
individual patients, and despite some promising initial findings,
the results have not convincingly shown superiority over clinically
available parameters. The lack of a standardized protocol for quan-
titative posturography makes it difficult to compare the results of
different studies, and this hampers easy implementation in clinical
practice. An important concern is the lack of ecological validity,
and this may explain why currently available posturography mea-
sures correlate poorly with the clinical performance and the pro-
pensity to fall in daily life. The high costs and the dependence on
technical expertise also render posturography less attractive for
clinicians. Taken together, it is still too early for posturography –
as it is currently used – to be applied in current clinical practice
and influence the day-to-day management of individual patients.
Further work is needed to improve the clinical utility of postur-
ography, and we would like to propose a few suggestions. First, fu-
ture studies should include homogeneous patient groups, in terms
of, e.g. diagnosis and stage of disease. Second, there is a clear need
for standardized protocols if meaningful interpretation and com-
parisons are to be derived from posturography experiments in dif-
ferent labs. The test-retest reliability of such protocols should be
determined. Third, when studies aim to test the clinical utility of
a certain posturography approach, the results should be character-
ized in terms of sensitivity and specificity, and preferably also the
positive and negative predictive value.
Insufficient methodological detail found in papers evaluating
the clinical utility of a measure is not unique to the field of postur-
ography research (Reid et al., 1995). As a guideline for future re-
search, researchers could follow the Standards for Reporting of
Diagnostic criteria (STARD) – a consensus statement published
integrally in several leading journals in 2003, about how to con-
duct and report studies of medical tests (Bossuyt et al., 2003).
More work is also needed to improve the ecological validity of
posturography. An interesting development is the use of moving
platforms capable of delivering perturbations with delayed decel-
erations, as this comes closer to real-life conditions such as those
experienced on a bus or subway (De Graaf and Van Weperen,
1997). Others are working to incorporate moving support surfaces
into natural environments such as a living room.
2434 J.E. Visser et al. / Clinical Neurophysiology 119 (2008) 2424–2436
Cost-effectiveness is another aspect that deserves more atten-
tion in future studies, because this is an important factor in the
evaluation of the clinical, day-to-day, usefulness of posturography.
However, this aspect has not been addressed systematically.
Although posturography has been considered among the more
cost-effective tests for diagnosing vertigo in a retrospective study
(Stewart et al., 1999), posturography experiments are usually
rather labor-intensive and typically require expensive equipment.
Data processing and interpretation can also be time-consuming,
although some standardized and automated procedures are avail-
able for commercially available equipment.
Finally, one question – and perhaps the most important one –
remains unanswered: what is the ‘‘ultimate value” of posturogra-
phy, in particular to improve clinical care – for example by afford-
ing more appropriate treatment because of a better diagnosis, or an
improved outcome in a therapeutic setting. Until these results be-
come available, posturography remains a useful scientific tool to
unravel the complex pathophysiology of balance disorders.
Acknowledgements
This project was sponsored by a grant from the Prinses Beatrix
Fonds to Dr. J.E. Visser and Dr. B.R. Bloem. Dr. Bloem was also sup-
ported by an NWO VIDI research Grant (#016.076.352). Dr. M.G.
Carpenter was supported by funding from the Natural Sciences
and Engineering Research Council of Canada. Dr. ir. H. van der Kooij
was supported by the Netherlands Organization of Scientific Re-
search (’Vernieuwings-impuls’ 2001, #016027011).
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