Journal ol Sport Rehabilitation. 1999, 8.

171-183
1999 Human Kinetics Publishers, Inc.

Examinaron of a Clinical Method of Assessing

Postural Control During a Functional
Performance Task

Bryan L. Riemann, Nancy A. Caggiano,

and Scott M. Lephart

Postural control and functional performance tests are often uscd separately dur
ing orthopedic postinjury assessments. The purpose o f this investigation was to
examine a clinical method o f assessing postural control during a functional per
formance task. Thirty paiticipants were divided into tw o groups. The first group
was tested three times, the sccond group only once. The same tester evaluated
each participants perform ance during all tcsling sessions, and during the first
tw o tcsling sessions (Group I) two additionnl testers evaluated each performance,
lnlraclass corrclalional cocfficicnts betwccn the three testers ranged from .70 lo
.92. Session 1 (Group 1) scores were pooled with Group 2 scores, and correla-
tional analyses were conductcd betwccn participan! hcight and performance; no
significan! rclationships were revealed. T he scores from G roup 1 were analyzed
using betw ecn-days repeated-measures ANOVAs. Results revealed significan!
iinprovcment betwccn Sessions 1 and 3 for Uic stalic portion o f the test. The
results suggcst tliat the mltiple single-lcg hop-stabilization test offers a method
o f assessing postural control during a functional performance task.

Key Words: cquilibrium, balance, mcasurcmcnt, reliability

Since the work o f Freeman (10), postural control testing has gained widespread
attention in the field of sports and orthopedic medicine (3 ,5 ,8 ,9 ,1 1 , 15-18,22,25,
30,31,33). Tlte results of investigations directly considering postural control follow-
ing knee and ankle articular injury, however, are largely inconclusive. The majority o f
lliese studies were conductcd during static single-leg stance on fttm surfaces under
both eyes-open and eyes-closed conditions (3,11,15,29,33). Through incorporating
strain-gauge forc platfomis into these assessments, changes in centerof pressure and
variability in the horizontal and vertical reaction forces are often calculated to
provide quanlitalive dala on postural steadiness (13,14).

T he authors are with the N euromuscular and Sports Medicine Research Laboralory,
M usculoskcletal Research Ccntcr, Department o f Orthopedic Surgcry, at the Univcrsity of
Pitlsburgh, Piltsburgh, PA 15261.

17
 Riemann, Caggiano, and Lephart

Considering Ihe dynanc n alu reo bolh activicies ofdaily living and athlctic
larticipation, thc relevance o f static (fixed base o f support; firm, unmoving sup-
jort surfacc) testing conditions to functional aclivity remans largely unknown.
Static conditions might potcntially fail to prescnt enough o f a challenge to clicit
xistural control deficiencies in physically active individuis. Furthcrmore, because
iorceplate systems largely depend on center-of-pressure changcs and forces ex-
:rted against the platform from m otor activities surrounding Ihe ankle (20, 32),
hey might fail to reveal allerations and compensations occurring at prxima) limb
:egments. The reports o f increased proxim al segment rcliancc during stance and
icrturbation through advanced kinematic and kinetic mcasurcmcnts in patients
vith ankle injury support tliis notion (24, 31).
The development o f various functional tests, mainly surrounding anterior
:ruciate ligament injuries, is also a popular topic in the orthopedic literature. By
ittempting to recreate the forces encountcred during functional activity in a con-
rolled environment ( 1,2 ,2 1 ), these tests llave been advocated for evaluating func
ional joint stability ( I, 12, 27, 28), monitoring rccovery (28), and determining
iming of retum to participation (4). It has been suggested tliat single-leg hopping
s associated with the requirem ents necessary for sports-related function (27).
Single-leg hop tests performed by patients with unilateral patliology enable bilat
eral comparisons or calculalions o f symmetry scores (1, 23). T he outeome mea-
tures used for the m ajority o f these tasks are distance and/or time (1 ,2 7 , 28).
Although a major advantage of these tests is their ease and the minimal equip-
nent necessary to rale performance (2), tliey have been widely questioned with re-
pect to their sensiti vity in assessing lower extremity perfonnance following injury or
iuring the rehabililation process (1,23). One explanation for their lack of sensitivity
:ould be their hcavy depcndcuce on a maximal cffort(s), without regard to thc control
hat individuis maintain over tlieir bodily cquilibrium before, during, and afler the
novement.
The purpose o f lilis investigation was lo examine a clnica! mclliod o f assessing
postura! control during a functional perfonnance task in nonnal participants. More
specifically, this study aimed to (1) establish the intertester reliability o f using a com
prehensivo error-scoring system for measuring test perfonnance, (2) determine whetlier
:ustomizing the dimensions o f the floor pattern to participant licight would reduce
iny apparent bias associated with a standardizcd floor pattem, and (3) establish the
leaming curves associated with repeated exposure to thc test.

Methods

The Mltiple Single-Leg Hop-Stabilization Test

The mltiple single-leg hop-stabilization test was developed by adopting and adapt-
ing the modifed Bass test described by Johnson and Nelson (19). A numbered
floor pattern (see Figure 1) was marked with 11 pieccs o f wliile athletic tape, each
Assessing Postural Control 173

Tol
m m

E s
E
m E

E E
| start |
Fig u re 1 N u m bered flo o r p a tte r n u sed fo r th e test. In te rta p e distances w ere ad-
ju s te d fo r each p a rtic ip a n t a cco rd in g to his o r h e r heiglit (see text).

2.5 cm square. Rather than using the standardized dimensions provided by Johnson
and Nelson, we modifted intertape distances according to the height o f each par
ticipant. The largest distances that participants are required to hop in the pattern
are for the diagonals betwccn Tape M arks 2 and 3 and Tape Marks 7 and 8. Our
pilot study using 20 participants revealed that m ost participants could maximally
hop approximately 95% o f their height in a purely anterior direction. Using these
data as a reference, w e chose to use 45% o f a participants height for the diagonal
dimensions, the largest intertape distance o f the pattem . For example, for a partici
pant height o f 170 cm the diagonal dimensin would be 76.5 cm, with the dis
tances between adjacent pieces computed using the Pythagorean theorem (54 cm).
Another m ajor modification w e made from the original test involved the
paiticipants using only one limb to complete the entire test, rather than altemating
limbs between tape marks, as Johnson and Nelson described. In an attempt to
reduce o r control upper limb and body movements during the test, we included a
requirement that participants kcep their hands on their iliac crests at all times.
 Riemann, Caggiano, and Lephart

Participants w ere also told that in addition to completely covering each tape mark
on landing, their foot needed to be pointed forward. We incorporated these adjunct
requirem ents into the error-scoring system (see Table 1).

Participants
Thirty recreationally active participants (19 nien, 11 women; age = 21.23 2.9
years, height = 173.37 9.42 cm, w eight = 73.36 13.92 kg) were used in this
investigation. Recreationally active was defined as participating in physical activ-
ity fo r a mnimum o f 20 min, lliree times per week. All o f the participants had no
history o f balance or low er extremity neurological disorders, and no participant
had xnstained a musculoskelclal or hcad injury within the past 12 nionths. The
dom inant leg, being defined as the preferred leg to use to kick a ball, was used for
all data collection. Informed consent was obtained from all participants in accor-
dance with the University o f Pittsburgh Institutional Review Board.

Procedures
Participants were randomly assigned to one o f tw o groups. T he first group o f 15
participants underwent the testing procedures tliree times (48 hr apart). D uring the
first tw o sessions, ntertester reliability data for each participants performance
were collected using three trained teslers. T his sample size was chosen based on
an a priori pow er analysis for p = .8, three testers, and power equal to .8 (7).
Training for each tester w as conducted during a single, 1-hr session and included
collective evaluations and discussions o f several pilot participants completing the
test. O ne o f the co-investigators (NAC) controlled the counting and progression o f
each hop-stabilization sequence. During each test, testers were blinded to the re-
sults o f the other tester evaluations. The same co-investigator (NAC) evaluated
performance during the third testing session.
The second group o f 15 participants underwent only one testing session.
Administration o f the test and cvaluation o f each participants performance was
conducted by the sam e co-investigator (NAC).

Table 1 Error-Scoring System

Landing errors N ot covering tape mark

Stum bling on landing
Foot not facing forward with 10 o f inversin or eversin
H ands o ff hips
Balance errors Touching down w ith nondoininant limb
N ondom inant lim b touching dominant limb
Nondominant lim b moving into excessive flexin, extensin, o r abduction
H ands o ff hips
Assessing Poslural Control 175

Befare beginning the test, participants were given an overview o f the test
and the scoring system and standardized instructions. The instructions emphasized
the error-scoring system and test procedures. Each o f the participants w as given
the opportunity to try several practice hop-stabilization sequences prior to data
collection. The test began with the participant standing at the start location on the
test limb, facing forward with head level and hands on iliac crests (see Figure 2).
When a participant was ready to begin, he or she was allowed to briefly look at the
target location befare hopping to Tape Mark 1 (see Figure 3). On landing, participants
controllcd tlieir balance lo remain in single-leg stance position with hands remaining
on the iliac crests and head level and facing forward. It was important to a successfal
landing to complclely cover the tape mark, with the head and foot pointcd straight
aliead, without the support foot moving from llie original point o f floor contad, the
contralateral limb touching down, or removing the hands from the iliac crests.

Figure 2 T he sta n ce po sitio n used a t th e b e ginning o f th e te st, a s wcll a s d u rin g

each o f the balan c e periods.
 Riemann, Caggiano, and Lephati

Once a participan! established control, the tester began counting 5 s aloud to

mark the beginning o f the balance period. During lilis period, the participant liad
to maintain a stable position, looking forward, witliout touching down or moving
the contralateral limb into excessive (>30) flexin, abduction, o r extensin. At
the end of 5 s, the participant was again allowed to look at the target location and
hop to the next tape mark, landing in the standardized position. T he tester deter-
mined the success of each landing and balancing period using the criteria listed in
Table 1. Committing One o f the errors during a period counted as a failure for that
entire period. At the conclusin o f the test, 10 error points were given for each
period in which there w as a landing error, and 3 error points were given for each
period in which a balance error w as committed. T he sum o f error points was des-
ignated as the total score.

Figure 3 W hile Impping an d landing, p a rticip a u ls were req u ire d to keep tlieir liands
on th e ir iliac cresls w hile looking stra ig h t alicad.
Assessing Postural Control 177

Data Analysis
The landing and balancing scores served as the lw o dcpendent variables for all
statistical analyses. All analyses w ere conducted using SPSS, versin 6.1 (SPSS,
Inc., Chicago), with statistical significance (when applicable) set at .05 a priori.To
determine intertester reiiability, seprate repeated-measures analyses o f variance
(ANOVAs) were conducted on each o f the dependen! variables for each session.
Intraclass correlational coefficients (ICCs) using the (2,1) Shrout and Fleiss meth-
ods outlined by D enegar and Ball (6) were calculated. In addition, standard errors
o f measurement (SEMs) were calculated. T he landing and balance scores from the
second group o f participants w ere pooled with the Session 1 data collected by the
same co-investigator (NAC) for the first group o f participants. To detennine whether
a relationship existed between height and performance, Pearsons bivariate corre
lational analyses w ere conducted between the variables o f height, landing score,
and balance score. The three sessions o f landing and balance scores from the first
group o f participants were analyzed using a between-days repeated-measures
ANOVA for each variable.

Results
M eans, standard deviations, and ranges for the error and balance scores for the
pooled data (N = 30) are given in Table 2. Results o f the reiiability analyses are
summarized in Table 3. T he correlational analyses failed to reveal significant

Table 2 A/s, SDs, and Ranges for the E rror and balance Scores (/V = 30)

Score M ( SD) Rango

Balance 7.3 5.9 0-27

Landing 43.7 23.3 0-90

Table 3 Intertester Rcliabilily Mcasurcs for the Two Tcsling Sessions (N = 15)

Landing Score Balance Score

Session ICC XFM ICC SEM

Session 1 .92 .57 .70 .55

Session 2 .92 .56 .74 .54
178 Riemann, Caggiano. and Lephart

Significantly different than scssion one score.

. Tukeys HSD = 3.59,p < .05.

Figure 4 Balance error score nicans ( S ) foreach of tliree testing sessions (/i = 15).

80
70
60
50
40
30
20
10
0
Session 1 Session 2 Session 3
Figure 5 Landing error score nicaiis ( S ) for eadi of lliree testing sessions (/i = 15).

relationships betwcen heiglit and landing score ( r = -.1401, p = .460) and heiglit
and balance score ( r = .2652,/; = .157). R esults o f the repeated-measures ANOVA
revealed a significant difference between Ihe repeated testing sessions for balance
scores (see Figure 4), F (2 ,28) = 4.32, p = .023, but not Ihe landing scores (see
Figure 5), F (2 ,28) = 1.58, p = .224. Tukeys post hoc analysis revealed ihe differ
ence between Sessions 1 and 3 as being significant (Tukeys HSD = 3.59,p < .05).
Assessing Poslural Control 179

Discussion
The purpose o f this investigaron was to examine a clinical method o f assessing
postural control during a functional performance task the mltiple single-leg hop-
stabilization test. Specifically, this study sought to determine intertester reliability,
relationship between performance and height, and leaming curves associated with
repealed exposures to the test. The m ost important fmding was the demonstration
o f consistent intertester reliability across the tw o sessions; it appears that the ml
tiple single-leg hop-stabilization test offers a reliable clinical method o f assessing
postural control during a functional performance task.
Inherent in the published description o f the modified Bass test (19) were sev-
eral limitations on incorporating the test into clinical assessments. First, the dimen-
sions o f the floor pattem were standardized for all participants. Our experience with
the test demonstrated that although shorter participants had extreme difficulty reach-
ing some o f the tape marks, taller participants did not appear to be challenged. In
addition, the test did not attempt to control upper extremity and body compensation
during periods o f disequilibrium. Finally, the goal o f the test was for participants to
altrnate the limb used to hop through the floor pattem, maintaining a steady position
on the ball o f the support foot for 5 s after each landing. Modeled after the modified
Bass test, the mltiple single-leg hop-stabilization test evolved from alterations to
make the idea bchind the Bass test into a clinically useful method o f measurng func
tional postural control. Specifically, alterations were incorporated to reduce height-
performance test bias, reduce the am ount o f compensatory actions arising from
upper extrem ity and body movement, increase the sensitivity o f isolating deficien-
cies between the lower extremities, and inelude a more functional balancing posi
tion (foot fat).
A m ajor component o f functional testing is providing an activity that re-
creates forces and challenges sim ilar to those an athlete faces during actual partici-
pation in a controlled environment. T he many derivatives o f the single-leg hop test
involve forward propulsin o f the body using one leg. T he test developed in this
investigation involved unique combinations o f controlled forward and/or lateral
movements interspersed with periods o f quiet, single-leg standing. Similar move-
ments often occur during sports such as gymnastics, football, wrestling, and dance.
Future research should investgate characteristic deficiencies associated with spe-
cific pathologies in m oving latcrally, medially, and anteriorly through the floor
pattem . Additionally, the tim e required to complete the mltiple single-leg hop-
stabilization test taxes the m uscular endurance o f the test limb. This aspect o f the
test could give clinicians additional insight into the functional level o f an injured
athlete. W ith respect to task complexity, single-leg hop tests might be better suited
for carlicr postinjury evaluations, whereas the single-leg hop-stabilization test might
be best suited for later stages o f postinjury evaluation. Combining both forms of
single-leg testing w ith other available functional performance tests such as the
carioca test and cocontraction test offers clinicians a battery o f assessments for
determining functional status and assisting in retum -to-play decisions.
180 Riemann, Caggiano, and Lephart

Important to many sports medicine practitioners is the ability to make a func-

tional evaluation o f the severity o f an injury and o f postinjury status without the
nccd for sophisticated or expcnsive equipmcnt. Tlie use o f an error-scoring system
to evalate postura! control during static stancc lias been previously demonstrated
to correlate with mcasurcs provided by forceplate tcchnology (18, 26). As men-
tioned previously, the rcasun for modifying the original error-scoring system was
to attempt to make the test more sensitivo to uppcr extremity and body compensa-
tory actions. Tlie error-scoring system used in our current study was similar to the
Balance Error Scoring System (26), and (herefore the comparable results concem-
ing intertester reliabilily were not surprising. The absolute reliability (SEM) was
less than one error for both the landing and the balance errors across the lwo test-
ing sessions. T hese results, coupled with relative reliability results ranging from
.70 to .92, suggest thal the intertester reliability of the error-scoring system is within
clinically acceptable standards.
In addition to com paring the results o f single-leg hop tests bilaterally (in-
jured vs. uninjured), clinicians and researchers often make interparticipant com-
parisons. Because physical characteristics, cspccially height, and activity levels
influence hopping and postural control abilities, we slrove to modify the original
Bass test to reduce a height-related performance bias. O ur pilot work using physi-
cally active participants rcvcaled that inost parlicipants could maximally hop ap-
proximately 95% o f their height in a purely anterior direction. Using these data as
a guide, we chose to use 45% o f a participant's height for the diagonal dimensions
for several reasons. First, we wanled to havc the participants perform the test bare-
foot to avoid confounding factors arising from differcnt shoes during belween-
subject comparisons. We theorized that repetilive barefoot landings on a hard sup-
port surface by individuis not accustomed to such an activity could potentially
cause increased apprehcnsion toward the end o f the test. In addition, a large focus
of the test resides in landing in a controllcd manner while maintaining postural
control. The desire to challenge participants to ju m p cise to their maxiinal abili
ties, coupled with the goal to ultimately apply the test to injured populations, spurred
us to use a distancc that we felt would be challenging yet attainablc by clinical
populations. Our results demonstrated small nonsignificant correlations b^twpen
test performance and height, supporling the idea that height bias in test perfor
mance can be reduced by adjusting flor pattern dimensions. Furthcr research should
consider the approprialcncss o f Ihc I loor dimensions used in this study for use with
injured populations.
An important aspccl o f clinical evaluation tcchniqucs is knowing whether
improvement on test performance over repeated exposures is the result o f underly-
ing pathology resolution or increased test familiarity. We chose to use threc re
peated sessions with a l-day intertest nlerval to represent the shorter extreme o f
what is typically used in clinical situations. Il is interesting to note that significant
improvement was revealcd only in the more static componenl o f the test. Because
our study is unique in considering static postural control for a period o f time between
Assessing Postural Control 181

dynamic movements, we cannot compare our results with any previously pub-
lished literature. We could only find one other study considering the measurement
of static single-leg stance at identical intertest intervals using a similar enor-scor-
ing system (26). In that study, the authors failed to reveal significant improvement
under an eyes-closcd condition across thrcc testing sessions. With respect to the
current study, w e speculate that the improvement demonstrated during the static
interval might have been a result o f the participants becoming more accustomed to
controlling their posture while preparing to make another dynamic movement.
Further research should consider whcther sim ilar improvements occur with more
clinically applicable intertest intervals, such as weekly o r biweekly.

Conclusin
The results obtained in this investigation suggest that the mltiple single-leg hop-
stabilization test could provide an adjunct clinical procedure for evaluating functional
postural control during a functional performance test. Because the test involves for-
ward and/or lateral movements interspersed with quiet, single-leg standing, the de-
mands for successful completion o f the test cxceed those required for single-leg hop
tests. Thus, tlie single-leg hop-stabilization test might be bcller suited for later stages
of postinjury cvaluations. Further research is required to investgate the use and sensi-
tivity o f the test with pathological populations.

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Acknowledgments
T he authors thank Hcathcr Sites, ATC, for her help with the data collection