Biosci. Biotech. Res. Comm. 11(2): 224-230 (2018)
Screening in healthy individuals for risk of falls by
employing various tools: A clinical study
Aksh Chahal
and Nitesh Malhotra
Department of Physical Therapy, Jazan University Jazan, Saudi Arabia
Department of Physiotherapy, Shri Jagdishprasad Jhabarmal Tibrewala University Churela, Rajasthan
333001 India
Body posture involves the relative position and control of the musculature with respect to each other. Muscles play
a pivotal role in maintaining the balance which controls the posture. Present study involves the use of TETRAX®
related tools to determine the risk of falls in different young adults group. In this approach we employ modi ed
Romberg’s Test, Static Postural Alignment Examination and TETRAX® Posturographic method in order to validate
our hypothesis. We have chosen subjects of different age group such as 20-25 years, 26-30 years, 31-35 years and
36-40 years designated as Group A, B,C and D respectively. Present approach segregated all the subjects on the basis
of demographic analysis. Comparison was done in different age groups for risk of fall. In descriptive analysis, it was
concluded that there is high risk of fall is observed in case of group A as compared to other groups. Statistical analy-
sis did not prove the same due to the limitation in number of subjects.
*Corresponding Author:
Received 10
Jan, 2018
Accepted after revision 19
March, 2018
BBRC Print ISSN: 0974-6455
Online ISSN: 2321-4007 CODEN: USA BBRCBA
Thomson Reuters ISI ESC / Clarivate Analytics USA and
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© A Society of Science and Nature Publication, Bhopal India
2018. All rights reserved.
Online Contents Available at: http//
DOI: 10.21786/bbrc/11.1/5
Body Posture involves the relative position and control of
the musculature with respect to each other (Andre et al.,
2015). Muscle recruitment is necessary for maintaining
the postural control; therefore muscle should be active
for maintaining the balance. Balance is a condition in
which all forces acting on the body are being at equilib-
rium such that the centre of gravity lies within the base
of support (Quitschal
et al., 2014). Balance and posture is
being de ned by the System Model of Balance, its com-
ponents are visual, somato-sensory and vestibular. The
impairments in balance can be a consequence of changes
in motor, sensory and integrative aspects of motor control
(Rey et al., 2017). The central nervous system integrates
all the cues coming from the environmental organiza-
Aksh Chahal and Nitesh Malhotra
tion and the sensory system orients it. Incidence of high
risk of fall and increased postural sway is being seen
in older adults and due to these falls there are higher
incidence of fractures other than any injuries (Villiers
and Kalula, 2015), whereas some literatures report that
young adults are also affected with poor posture control
and balance and therefore, more cases of upper extrem-
ity fractures have been reported in young adults due
to falls (Quitschal
et al., 2014, Akdeniz et al., 2016 and
Aydın et al., 2017).
Various tools or measures were employed such as
plumb line or weighted line for normal postural align-
ment, visual inspection for postural alignment and inter-
active posturography system for postural stability (Pail-
lard et al., 2015). Researchers also employed measures
of the initial stance position, centre of alignment, mean
sway path, total excursion and the zone of stability
and considered as reliable measures of postural control
(Anna et al., 2015 and Hung et al., 2016). Amalgamation
of other tools were also being employed such as TET-
RAX® biofeedback video games for balance training is a
feasible adjunctive program that may augment conven-
tional therapy in persons with chronic hemiplegic stroke
(Hung et al., 2016 and Yun & Yoo, 2016). The study
concluded that there is relation risk of fall, balance and
neuromuscular function in 60 years women (Akdeniz
et al., 2016).
Aforementioned studies employed the TETRAX® tool
in combination with other interventions but there is lim-
ited study on the age group 20-40 years. Therefore, there
is need to determine that whether the risk of fall is the
problem in geriatric population only or is it an alarm-
ing problem within young adults of age group (Garcia &
Navarro, 2016 and Rey
et al., 2017).
As there is higher risk of fall and stability index in
individuals with low physical activity. The aim of this
study is screening of balance and postural control in
individuals. The objective of this study is to determine
the risk of fall in the healthy young population by
employing measures such as Modi ed Romberg’s Test,
TETRAX® Posturographic method and Static Postural
Alignment Examination. These tests have intrinsic char-
acteristic features such as accuracy, non-invasive and
weight distribution etc. (Lee et al., 2016) which make
them reliable tools for the determination of risk of fall
among different age group and also on gender bias.
Young healthy adults between age 20-40 individual
were included in the study and were with 10 subjects
each in four respective Groups A (20-25) years, B (26-
30) years, C (31-35) years and D (36-40) years as per
their age. The study was performed at RLJT Hospital &
Research Centre, Jhunjhunu. All subjects were included
after performing Romberg’s test. Exclusion criteria
history of neurological (Guler et al., 2012) or muscu-
loskeletal disorder, laxity in joints pregnancy (Aydın
et al., 2017), ankle sprain, marked cognitive impairment
(Avni et al., 2006), low vision, insuf cient English and
Hindi language skills lack of interest to participate The
experiment was conducted on the basis of Demographic
data and Anthropometric characteristics of the subjects
was recorded including Name, Age, Gender, Height and
Weight, therefore BMI was also recorded prior to the
study. Manual Screening for Postural Control was done
by Modi ed Romberg’s test and Plumb line Posturogra-
phy method.
Tools employed for the screening of healthy indi-
viduals for risk of falls: Modi ed Romberg’s Test was
employed in four different conditions and each con-
dition must be ful lled in order to move to the next
condition. All the conditions were performed standing
with feet together and arms crossed. Condition 1: Each
subject would be supposed to stand on the  oor ( rm
surface) for 15 seconds eyes open. Condition 2: Each
subject would be supposed to stand on the  oor ( rm
surface) for 15 seconds eyes closed.
Condition 3: Each subject would be supposed to stand
to on the memory foam with eyes open for 30 seconds.
Condition 4: Each subject would be supposed to stand
on the memory foam with eyes closed for 30 seconds.
Documentation- It would be done by PASS/FAIL condi-
Failure of the test was de ned under three parameters
i.e 1) The subjects open their eyes in the condition 2 and
4 2) The subjects move their feet or arms to maintain
stability 3) Beginning to fall or requiring intervention of
the examiner to maintain the balance within 30 seconds
threshold time. Static Postural Alignment Examination:
Normal postural alignment in standing can be deter-
mined by using a plumb line. In standing position, the
centre of mass lies at the second sacral vertebrae. Static
posture is examined by using the plumb line method
in standing position with the feet apart, normal stance
width. When viewed from the Sagittal plane the verti-
cal line of gravity (LOG) is expected to fall close to the
external auditory meatus, anterior to the shoulder joint,
anterior to the thorax, posterior to the hip joint, and
slightly anterior to the knee and ankle joint.
TETRAX® Posturographic method: Tool used is TET-
RAX® Computerized Static Posturographic tool. This
system helps in the screening of the Static Postural bal-
ance in healthy individuals. The subjects was asked to
stand in the middle of the four force plates which would
be placed at the right rear, right front, left rear and left
front of the patient’s feet. The sensor plates would then
record the weight bearing based on vertical pressure
Aksh Chahal and Nitesh Malhotra
being applied to the platform via the heels and the toes.
Documentation was done in eight different conditions
1. Normal open position (NO) that is standing straight
with eyes open
2. Normal closed position (NC) that is standing
straight with eyes closed
3. Pillow open (PO) that is standing straight on pil-
lows with eyes open
4. Pillow Closed (PC) that is standing straight on pil-
lows with eyes closed
5. Head right (HR) that is standing straight on sensor
plates with eyes closed, head turned to the right
6. Head left (HL) that is standing straight on sensor
plates with eyes closed, head turned to the left.
7. Head back (HB) that is standing straight on sensor
plates with neck in extension
8. Head Forward (HF) that is standing straight on
sensor plates with neck fully  exed.
The study was performed at same time of the day. Each
position is maintained for 30 seconds. Tetrax® Software
computed the following parameters. Risk of falls with
Numeric value of (0-100)
Low fall risk: 0-35
Moderate fall risk- 36-57
High fall risk- 58-100
Data Analysis: The data analysis was done using Sta-
tistical Package for Social Sciences software Version 17
applying the descriptive data included mean standard
deviation were also calculated Anova test was applied to
calculate the difference in between four groups using F
distribution . The data was analysed using the F- value
and the F crit value. If the F value is greater than the
F crit value then the null hypothesis is rejected but if
F value is less than the F crit value then the research
hypothesis is rejected.
Segregation of healthy individuals according to demo-
graphic analysis:
Subjects (40) were included in the study with mean age
of 30.77 ± 5.78 years. The mean height was 164.25 ±
7.70 cm and mean weight was 64.43 ± 13.83 kg. The
mean BMI was also calculated as 23.98 ± 4.35 and mean
risk of fall was calculated as 34.25 ± 20.32. The ratio of
male and female in the group under investigation was
3:2 (Table 1).
Comparison within groups for risk of fall: Compari-
son was done between the risk of fall 34.25 ± 20.32
years of 4 different age groups30.77 ± 5.78 years and it
was found that there was no signi cant difference seen
in the risk of fall between different age group of healthy
population. (F value> F crit value), (p value > 0.05)
(Table 2.)
For Intra- group comparison, descriptive analysis was
done in which each group subjects were classi ed under
low risk of fall, moderate risk of fall and high risk of fall
It was found that in Group A equal number of people
fall under the category of moderate and high risk of fall.
In Group B 50% of the population was under low risk of
fall and 20% of population is under high risk of fall .As
Table 1. Demographic and anthropometric data of the
Characteristics Mean ± Standard Deviation
Age 30.77 ±5.78
Height ( cm) 164.25 ±7.70
Weight (kg) 64.43 ± 13.83
Body Mass Index (kg/m) 23.98 ± 4.35
Gender (Male/Female) 24/16
Table 2. Comparison of risk of fall and Age
Age (Mean ±SD) Risk of fall (Mean ±SD) F value p value F crit value
30.77±5.78 34.25±20.32 2.575758 0.068935 2.866266
Signi cant at F value Signi cant at ≤0.05 level or> F critical value
Table 3. Result analysis
Source of Variation SS Df MS F P-value F crit
Between Groups 2847.5 3 949.1667 2.575758 0.068935 2.866266
Within Groups 13266 36 368.5
Total 16113.5 39
Signi cant at ≤0.05 level or Signi cant at F value > F critical value
Aksh Chahal and Nitesh Malhotra
FIGURE 1. Illustrate the intragroup risk of fall in percentage
FIGURE 2. Representation of percentage Risk of fall on the basis of gender
Aksh Chahal and Nitesh Malhotra
Table 6. Classi cation of Risk of fall on the Basis of gender
Low risk
of fall
Risk of fall
Risk of fall
Group A
Male 1 2 2
Female 3 1 1
Group B
(26-30 years)
Male 3 3 0
Female 2 0 2
Group C
(31-35 years)
Male 3 3 1
Female 3 0 0
Group D
(36-40 years)
Male 3 3 0
Female 3 1 0
Table 4. Intragroup relation between Demographic details and Risk of fall
Group A
(20-25 years)
Group B
(26-30 years)
Group C
(31-35 years)
Group D
(36-40 years)
Gender (Male: Female) 5:5 6:4 7:3 6:4
Age (Mean ± SD) 23±1 28±1.55 33±1.44 34±1.46
Height (In cm) (Mean ± SD) 167±8.89 163.44±7.59 164±6.93 162±7.41
Weight(In kg) (Mean ± SD) 62±14.50 60.5±8.54 69±9.31 67±19.9
BMI (Mean ± SD) 22±4.58 22.73±3.49 26±2.57 26±5.31
Risk of fall (Mean ± SD) 43±21.70 37.6±19.20 28±18.48 25±17.10
Table 5. Intragroup categorization of risk of fall
Risk of fall
Group A Group B Group C Group D
(20-25 years) (26-30 years) (31-35 years) (36-40 years)
Low Risk of fall. 4 5 6 6
Moderate Risk of fall. 3 3 3 4
High Risk of fall. 3 2 1 0
we move towards the higher Age groups C and D There
was large decrement in the risk of fall, In Group D 0%
Population is under high risk of fall (Figure .1).
It was also found that in higher age group i.e. Group
D neither Males nor Females fall under the category of
high risk of fall and in Group B and C females were not
seen in the category of moderate risk of fall (Table 5
Table 6 & Figure 2).
Statistically, Anova test was used and it was seen that
F value is less than F-crit value therefore the Research
hypothesis was rejected. But through descriptive anal-
ysis there is signi cant difference seen in risk of fall
within the Age groups
In previous studies TETRAX® tool was being used to
assess balance and postural control in individuals with
some disorders, may it be neurological or musculoskeletal
(Dunsky, 2017 and Claeys, 2016). One study
had revealed the reliability of TETRAX® tool in young
adults also with low physical activity According to this
study, TETRAX® measured low fall of risk with lower body
endurance with increment in vigorous activity and total
activity score (Akkaya et al 2015). Researchers employed
these tools for the risk of fall in geriatric population (Gar-
cia, 2016 & Rey
et al., 2017) but none of the studies has
screened only the young individuals. Therefore we were
aimed to introduce TETRAX® TOOL for measuring risk of
fall among various young individual groups.
The most important  nding of this study is that with
increase in age, within the group descriptive analysis
showed that 0 % of the subjects were under high risk of
fall. Previous studies also indicated that there is no cor-
relation between age and risk of fall. Through statistical
analysis, F value is higher than F crit value. Therefore,
Aksh Chahal and Nitesh Malhotra
statistically no signi cant difference is being seen in the
risk of fall between the various age groups. It can be
ascribed due to the fact that strict exclusion criteria and
small population size can be major setback in this  nd-
ing. Furthermore the subjects were also screened only
for one time. However descriptive analysis concluded
that there is signi cant difference seen in risk of fall
within the Age groups. In futuristic approach larger pop-
ulation may allow evaluation of correlation between risk
of fall and age statistically also. In descriptive analysis,
young age group (20 - 25 years) showed high risk of fall
as compared to older age group (36 - 40 years) which
can be due to the equal weight distribution on both the
lower limbs of older age group but low sample size is the
limitation of this discussion.
Present study involves the employment of TETRAX®
tool in combination with the Modi ed Romberg’s Test
and Static Postural Alignment Examination to deter-
mine the risk of fall within young adults of different age
group. Earlier reported literatures employ various tools
in geriatric population for risk of fall. Limited study was
performed in case of young adults. Therefore we were
directed to employ the tools in young adults for risk of
fall. Our results concluded that in descriptive analysis,
there is signi cant difference in the percentage of risk
of fall in different age group. Risk of fall is greater in
younger adults as compared to the subjects having more
age according to descriptive analysis. But statistically
our study did not proof the same due to the limited num-
ber of subjects. The results of this study demonstrates
difference is being observed in risk of fall within the
group of healthy population but after statistical analy-
sis there was no signi cant difference was being seen
between the different age groups of healthy population,
therefore the research hypothesis is being rejected.
Akdeniz S, Hepguler S, Öztürk C and Atamaz F.C. (2016) The
relation between vitamin D and postural balance according to
clinical tests and Tetrax® posturography. The Journal of Physi-
cal Therapy Science Sci. Vol 28: Pages 1272–1277.
Akkaya N, Dog˘anlar N, Çelik E, Engin A.S, Akkaya S, Güngör
H.R., Sahin F. (2015) Test-retest reliability of Tetrax® static Pos-
turography system in young adults with Low physical activity
level .The International Journal of Sports Physical Therapy;
Vol 10(6):Page 893-900.
Anna C D, Schmid M, Bibbo D, Bertollo M, Comani S, Conforto
S (2015) The Effect of Continuous and Discretized Presenta-
tions of Concurrent Augmented Visual Biofeedback on Pos-
tural Control in Quiet Stance. PLOS one. Art No.0132711
Avni N, Avni I, Barenboim E, Azaria B, Zadok D, Kohen-Raz
R, Morad Y (2006) Brief posturographic test as an indicator of
fatigue. Psychiatry and Clinical Neurosciences; Vol 60:Pages
Aydın E, Telliog˘lu A M, Ömürlü I K, Polat G, Turan Y (2017)
Postural balance control in women with generalized joint lax-
ity. Turkish Journal of Physical Medicine and Rehabilitation;
Vol. 63(3):Pages 259-265.
Claeys K, Brumagne S, Deklerck J, Vanderhaeghen J, Dankaerts
W, (2016) Sagittal evaluation of usual standing and sitting
spinal posture. Journal of Bodywork & Movement Therapies;
Vol.20 No.2: Pages 323-333.
Dunsky A, Zeev A and Netz Y. (2017) Balance Performance Is
Task Speci c in Older Adults. BioMed Research International;
Vol 2017, Art. ID 6987017, Pages 1-7.
Esmaili N, Davatchi C, Valikhani M, Daneshpazhooh M, Balighi
K, Hallaji Z, Barzegari M,Akhyani M, Ghodsi Z, Mortazavi H,
Naraghi Z, Toosi S. (2007): Pemphigus vulgaris in iran. The
International society of Dermatology. 46:1166-1170
Garcia J.A, Navarro K.F (2016) Step K innection: A Fall Pre-
vention Game Mindfully Designed for the Elderly. IOS Press;
Vol. 214 :Pages 43-49.
Guler. S, Bir. L. S., Akdag B., and Ardıc F. (2012) The Effect
of Pramipexole Therapy on Balance Disorder and Fall Risk in
Parkinson’s disease at Early Stage: Clinical and Posturographic
Assessment. International Scholarly Research Network; Vol
2012: Article ID 320607:Pages 1-7.
Hung J.W, Yu M.Y, Chang K.C, Lee H.C, Hsieh Y.W and Chen
P.C (2016) Feasibility of Using Tetrax® Biofeedback Video
Games for Balance Training in Patients With Chronic Hemi-
plegic stroke. Physical Medicine & Rehabilitation; Vol 8: Pages
Kendall J.C Hartvigsen J, Azari M.F, French S.D (2016)
Effects of Nonpharmacological Interventions for Dizziness in
Older People: Systematic Review Physical Therapy, Issue 5
Vol(96):Pages 641–649.
Lee H B, Jang E B, Kim J S, Hong J H ,Yu J H, Lee D Y (2016)
A study of Postural Sway according to the Wedge Direction
during one Leg Standing. Indian Journal of Science and Tech-
nology; Vol 9, No. 25: Pages 1-5.
Paillard T., Noé Frédéric (2015) Techniques and Methods for
Testing the Postural Function in healthy and Pathological Sub-
jects Vol2015, Art ID. 891390.
Quatman-Yates CC, Lee A, Hugentobler JA, Kurowski BG, Myer
GD, Riley MA. (2013) Test-retest consistency of a postural sway
assessment protocol for adolescent athletes measured with a
force plate. International Journal of Sports Physical Therapy;
Vol 8(6):741-748.
Quitschal R.M, Fukunagaa J.Y, Gananc M.M, Caovilla H.H.
(2014) Evaluation of postural control in unilateral vestibular
hypofunction, Brazilian Journal of Otorhinolaryngology; Vol.
80(4):Pages 339-345.
Rey M.C.B, Clark T. K., and Merfeld D M. (2017) Balance
screening of Vestibular Function in subjects aged 4Years and
Aksh Chahal and Nitesh Malhotra
Older: a living laboratory experience. Frontier of neurology;
Vol 8: Art. No. 631.
Soto-Varela A, Faraldo-García A, Rossi-Izquierdo M, Lirola-
Delgado A, Vaamonde-Sánchez-Andrade I, del-Río-Valeiras M,
Gayoso-Diz P, Santos-Pérez S (2015) Can we predict the risk of
falls in elderly patients with instability? Auris Nasus Larynx;
Vol 42(1):Pages 8-14.
Villiers, Kalula S.Z (2015) An approach to balance prob-
lems and falls in elderly persons. South African medical jour-
nal; Vol. 105, No. 8: Pages 1-5.
Yun C.K, Yoo J.N (2016) The Effects of Visual Biofeedback Bal-
ance Training on Functional Ability in Children with Cerebral
Palsy: A Pilot Study. Journal of The Korean Society of Physical
Medicine; Vol. 11, No. 3: Pages 133-139.