Responsiveness of Static and Dynamic Postural Balance Measures in Patients with Anterior Cruciate Ligament Reconstruction Following Physiotherapy Intervention

Document Type : RESEARCH PAPER


1 Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

2 Department of Physical therapy, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran


Background:The main goal of physiotherapy for patients with anterior cruciate ligament reconstruction (ACL-R) is to improve postural control and retain knee function. Therefore, clinicians need to use evaluative tools that assess postural changes during physiotherapy. To maximize the clinical utility of the results of these tools, the extracted measures should have appropriate psychometric properties of reliability, validity and responsiveness. No study has yet addressed responsiveness of postural measures in these patients. This study was designed to investigate the responsiveness and determine the minimal clinically important changes (MCIC) of static and dynamic postural measures in patients with (ACL-R) following physiotherapy.
: Static and dynamic postural measures were evaluated at first occasion and again after four weeks physiotherapy. The static measures consisted of center of pressure (COP) parameters while dynamic measures included the stability indices. Correlation analysis and ROC curve were applied for assessing the responsiveness.
The meanand SD velocity of COP had acceptable responsiveness in both conditions of standing on injured leg with open-eyes and on uninjured leg with closed-eyes, both with nocognitive task. For dynamic measures, stability indices in double-leg standing with closed-eyes with cognitive task condition attained acceptable responsiveness. MCICs for mean and SD velocity in anteroposterior and mediolateral directions were 0.28cm/s, 0.008cm/s, 0.02cm/s, respectively in standing on injured leg with open-eyes; and 0.14cm/s, 0.07cm/s, 0.06cm/s, respectively in uninjured leg with closed-eyes condition. Also, MCICs for anteroposterior, mediolateral and total stability indices were 0.51◦, 0.37◦, 0.34◦, respectively in DCT condition.
Our findings provide evidence for selection of appropriate static and dynamic postural measures for assessment of changes in these patients. MCICs for these measures were determined, which provide practical information for clinicians to make decision on clinical significance of changes in patients’ status.


Main Subjects

1. Bonfim TR, Jansen Paccola CA, Barela JA. Proprioceptive
and behavior impairments in individuals with
anterior cruciate ligament reconstructed knees. Arch
Phys Med Rehabil. 2003; 84(8):1217-23.
2. Howells BE, Ardern CL, Webster KE. Is postural
control restored following anterior cruciate ligament
reconstruction? A systematic review. Knee Surg
Sports Traumatol Arthrosc. 2011; 19(7):1168-77.
3. Logerstedt D, Lynch A, Axe MJ, Snyder-Mackler L.
Symmetry restoration and functional recovery before
and after anterior cruciate ligament reconstruction.
Knee Surg Sports Traumatol Arthrosc. 2013;
4. Zouita Ben Moussa A, Zouita S, Dziri C, Ben Salah FZ.
Single-leg assessment of postural stability and knee
functional outcome two years after anterior cruciate
ligament reconstruction. Ann Phys Rehabil Med.
2009; 52(6):475-84.
5. Hinman MR. Factors affecting reliability of the Biodex
Balance System: a summary of four studies. J Sport
Rrehabil. 2000; 9(3):240-52.
6. Mohammadirad S, Salavati M, Takamjani IE, Akhbari
B, Sherafat S, Mazaheri M, et al. Intra and intersession
reliability of a postural control protocol in athletes with
and without anterior cruciate ligament reconstruction:
a dual-task paradigm. Int J Sports Phys Ther. 2012;
7. Salavati M, Hadian MR, Mazaheri M, Negahban H,
Ebrahimi I, Talebian S, et al. Test–retest reliabty of
center of pressure measures of postural stability
during quiet standing in a group with musculoskeletal
disorders consisting of low back pain, anterior cruciate
ligament injury and functional ankle instability. Gait
Posture. 2009; 29(3):460-4.
8. Niknam H, Sarmadi A, Salavati M, Madadi F. Reliability
of the center of pressure parameters after ACL
reconstruction surgery. Zahedan J Res Med Sci. 2013;
9. Stratford PW, Binkley JM, Riddle DL. Health status
measures: strategies and analytic methods for assessing
change scores. Phys Ther. 1996; 76(10):1109-23.
10. Husted JA, Cook RJ, Farewell VT, Gladman DD. Methods
for assessing responsiveness: a critical review and
recommendations. J Clin Epidemiol. 2000; 53(5):459-68.
11. Negahban H, Mostafaee N, Sohani SM, Hessam
M, Tabesh H, Montazeri A. Responsiveness and
minimally important differences for selected Persianversion
of outcome measures used in patients with
patellofemoral pain syndrome. Disabil Rehabil. 2015;
12. Strand LI, Anderson B, Lygren H, Skouen JS, Ostelo
R, Magnussen LH. Responsiveness to change of 10
physical tests used for patients with back pain. Phys
Ther. 2011; 91(3):404-15.
13. de Yébenes Prous MJ, Salvanés FR, Ortells LC.
Responsiveness of outcome measures. Reumatol Clin.
2008; 4(6):240-7.
14. Revicki D, Hays RD, Cella D, Sloan J. Recommended
methods for determining responsiveness and
minimally important differences for patient-reported
outcomes. J Clin Epidemiol. 2008; 61(2):102-9.
15. Lehman LA, Velozo CA. Ability to detect change in
patient function: responsiveness designs and methods
of calculation. J Hand Ther. 2010; 23(4):361-70.
16. Houweling TA. Reporting improvement from patientreported
outcome measures: a review. Clin Chiropr.
2010; 13(1):15-22.
17. Negahban H, Ahmadi P, Salehi R, Mehravar M,
Goharpey S. Attentional demands of postural control
during single leg stance in patients with anterior 
cruciate ligament reconstruction. Neurosci Lett.
2013; 556(1):118-23.
18. Lafond D, Corriveau H, Hébert R, Prince F. Intrasession
reliability of center of pressure measures of postural
steadiness in healthy elderly people. Arch Phys Med
Rehabil. 2004; 85(6):896-901.
19. Rafał S, Janusz M, Wiesław O, Robert S. Test-retest
reliability of measurements of the center of pressure
displacement in quiet standing and during maximal
voluntary body leaning among healthy elderly men. J
Hum Kinet. 2011; 28(1):15-23.
20. Negahban H, Hadian MR, Salavati M, Mazaheri
M, Talebian S, Jafari AH, et al. The effects of dualtasking
on postural control in people with unilateral
anterior cruciate ligament injury. Gait Posture. 2009;
21. Atilgan OE. Relationships between perceptual-motor
skills and postural balance in nine years old boys.
Educ Res Rev. 2012; 7(24):517-25.
22. Stratford PW, Riddle DL. Assessing sensitivity to
change: choosing the appropriate change coefficient.
Health Qual Life Outcomes. 2005; 3(1):23.
23. Deyo RA, Centor RM. Assessing the responsiveness
of functional scales to clinical change: an analogy
to diagnostic test performance. J Chronic Dis. 1986;
24. Ross SE, Guskiewicz KM, Gross MT, Yu B. Balance
measures for discriminating between functionally
unstable and stable ankles. Med Sci Sports Exerc.
2009; 41(2):399-407.
25. Wikstrom EA, Fournier KA, McKeon PO. Postural
control differs between those with and without chronic
ankle instability. Gait Posture. 2010; 32(1):82-6.
26. Lin WC, Moseley AM, Refshauge KM, Bundy AC. The
lower extremity functional scale has good clinimetric
properties in people with ankle fracture. Phys Ther.
2009; 89(6):580-8.
27. Moghadam M, Ashayeri H, Salavati M, Sarafzadeh
J, Taghipoor KD, Saeedi A, et al. Reliability of center
of pressure measures of postural stability in healthy
older adults: effects of postural task difficulty and
cognitive load. Gait Posture. 2011; 33(4):651-5.
28. Luoto S, Aalto H, Taimela S, Hurri H, Pyykkö I, Alaranta
H. One‐footed and externally disturbed two‐footed
postural control in patients with chronic low back
pain and healthy control subjects: a controlled study
with follow‐up. Spine. 1998; 23(19):2081-9.
29. Maki BE, Holliday PJ, Fernie GR. Aging and postural
control. A comparison of spontaneous- and inducedsway
balance tests. J Am Geriatr Soc. 1990; 38(1):1-9.
30. Norman GR, Stratford P, Regehr G. Methodological
problems in the retrospective computation of
responsiveness to change: the lesson of Cronbach. J
Clin Epidemiol. 1997; 50(8):869-79.
Volume 5, Issue 3
May 2017
Pages 153-167
  • Receive Date: 30 August 2016
  • Revise Date: 01 October 2016
  • Accept Date: 19 January 2017
  • First Publish Date: 01 May 2017