Postural equilibrium during pregnancy: Decreased stability

with an increased reliance on visual cues

Erin E. Butler, MS,
a,
*
Iris Colon, MD,
b
Maurice L. Druzin, MD,
b
Jessica Rose, PhD
a,c
Motion & Gait Analysis Laboratory, Lucile Packard Childrens Hospital, Palo Alto, CA
a
; Department of Obstetrics
and Gynecology, Division of Maternal Fetal Medicine,
b
and Department of Orthopaedic Surgery,
c
Stanford University
School of Medicine, Stanford, CA
Received for publication March 10, 2006; revised May 16, 2006; accepted June 2, 2006
KEY WORDS
Postural equilibrium
Balance
Fall
Objective: The purpose of this study was to determine whether there are changes in postural equi-
libriumduring pregnancy and to examine whether the incidence of falls increases during pregnancy.
Study design: Static postural balance measures were collected from12 pregnant women at 11 to 14,
19 to 22, and 36 to 39 weeks gestation and at 6 to 8 weeks after delivery and from 12 nulligravid
control subjects who were matched for age, height, weight, and body mass index. Subjects were
asked to stand quietly on a stable force platform for 30 seconds with eyes open and closed. Path
length and average radial displacement were computed on the basis of the average of 3 trials for
each condition. The women were asked at each session if they had sustained a fall in the previous
3 months.
Results: Postural stability remained relatively stable during the first trimester; however, second
and third trimester and postpartum values for path length and average radial displacement with
eyes open and closed were increased significantly compared with the control subjects, which indi-
cates diminished postural balance. The difference between the eyes open and closed values of path
length increased as pregnancy progressed. Although 25% of pregnant women sustained falls, none
of the control subjects had fallen in the past year.
Conclusion: These data suggest that postural stability declines during pregnancy and remains
diminished at 6 to 8 weeks after delivery. The study also indicates that there is an increased reliance
on visual cues to maintain balance during pregnancy.
2006 Mosby, Inc. All rights reserved.
During pregnancy, nearly one-quarter of employed
women sustain a fall, a rate that is comparable with
elderly persons aged R65 years.
1
The leading causes of
falls at work for pregnant women include slippery
oors, moving at a fast pace, and carrying an object
or a child. Throughout pregnancy, numerous physical
and hormonal changes, including weight gain,
2,3
change
Supported in part by grant 5 M01 RR000070 from the National
Center for Research Resources, National Institutes of Health.
Presented at the 26th Annual Meeting of the Society for Maternal
Fetal Medicine, January 30-February 4, 2006, Miami, FL.
* Reprint requests: Erin E. Butler, MS, LPCH Motion & Gait
Analysis Laboratory, 1101 Welch Road, Suite C-10, Palo Alto, CA
94304.
E-mail: erbutler@lpch.org
0002-9378/$ - see front matter 2006 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2006.06.015
American Journal of Obstetrics and Gynecology (2006) 195, 11048
www.ajog.org
in the center of gravity,
4
increased joint laxity,
5-9
and
alterations in skeletal alignment
4,10,11
occur and may
lead to an altered postural balance.
During pregnancy, the total weight that is gained is
approximately 12 to 16 kg,
12
which represents a 16% to
23% increase in body weight, based on the mean weight
reported for women in the United States.
13
The lower
trunk has signicantly greater rates of change in weight
than all other body segments during the second and
third trimesters of pregnancy.
14
As the fetus develops,
the position of the mothers center of gravity moves su-
periorly and anteriorly.
4
Accordingly, the developing fe-
tal load places an increased demand on the lumbar spine
and abdominal muscles.
10
The changing shape and iner-
tia of the lower trunk requires postural adjustments,
such as an elevation of the head, hyperextension of the
cervical spine and extension of the knee and ankle
joints.
4
Similarly, a quantitative analysis of standing
posture has revealed a more posterior head position
and an increase in lumbar lordosis and anterior pelvic
tilt.
11
These anatomic and physiologic changes may con-
tribute to postural instability during pregnancy and may
lead to a higher incidence of falls, as reported in a
sample of employed pregnant women.
1
The purpose of
the present study was to determine whether changes in
static postural equilibrium occur during pregnancy and
to examine whether the incidence of falls increases dur-
ing pregnancy.
Material and methods
Static postural balance measures were collected from 12
pregnant women (11 primigravid women and 1 multi-
gravida women, all singleton gestations) during the rst,
second, and third trimesters at 11 to 14, 19 to 22, and 36
to 39 weeks of gestation, respectively, and at 6 to 8
weeks after delivery and from 12 nulligravid women.
The pregnant and control subjects were comparable in
age, height, weight, and body mass index (Table I).
Exclusion criteria included the following medical con-
ditions: lupus, rheumatoid arthritis, gestational diabetes
mellitus, hypertension, musculoskeletal or neurologic
abnormalities, and any other medical condition that
aects postural stability. The study protocol was ap-
proved by the Stanford University Human Subjects
Committee, and informed consent was obtained from
all subjects. At the beginning of each session, the preg-
nant women were asked whether they had lost their bal-
ance or sustained a fall during the previous 3 months,
and their height and weight were recorded.
Subjects were instructed to stand quietly on a stable
force platform (50 ! 50 cm; model 9284; Kistler
Instrument Corp, Amherst, NY) for three 30-second
trials with eyes open and with eyes closed (Figure 1).
Path length and average radial displacement (ARD) of
the center of pressure, which are 2 standard measures
of postural sway,
15-18
were computed on the basis of
the average of the 3 trials for the eyes open and eyes
closed conditions.
The center of pressure is dened as the center point of
force in the x and y directions that a subject exerts on a
force plate while attempting to stand still; this move-
ment is displayed as a traveling point between the feet
that moves with weight shift. Sample center of pressure
plots are displayed in Figure 2. Path length is the aver-
age distance the center of pressure travels over each
30-second trial. ARD is the mean radial distance of
the center of pressure from the centroid over the entire
trial. The center of pressure reference formulae that
were used in this study were selected because of their
clinical relevance, mathematic integrity, and suitability
for clinical evaluation in any laboratory that is equipped
with a force plate, as previously reported.
17,18
Statistical dierences between pregnant subjects and
control subjects were determined with independent
samples t-tests with a 95% CI (P !.05). The Friedman
test was used to determine whether path length and
ARD values changed within subjects over time. To de-
termine whether weight change was predictive of bal-
ance changes, dierence scores were calculated and the
Spearman correlation was then used to determine statis-
tical signicance between change in weight and change
in balance values.
Results
The mean and SD of path length and ARD with eyes
open and eyes closed for control subjects and pregnant
subjects are listed in Table II. Control values are consis-
tent with previously published values for path length
and ARD.
15-17
Table I Pregnant and control subject groups
Subject group Age (y) Height (m) Weight (kg)
Body mass
index (kg/m
2
)
Pregnant (rst trimester) 32.8 G 5 1.62 G 0.1 63.2 G 10.3 24.0 G 3.8
Control 31.1 G 6 1.62 G 0.1 56.5 G 7.7 21.3 G 1.3
Data are given as mean G SD. There was no signicant difference in these areas between the 2 groups (P ! .05).
Butler et al 1105
There were no signicant dierences between control
and rst trimester values, with the exception of ARD
during eyes closed (P !.05). However, second and third
trimester values for both path length and ARD were sig-
nicantly higher than control subjects with eyes open
and eyes closed (P ! .05; Figure 2). Balance measures
at 6 to 8 weeks after delivery remained elevated, com-
pared with control subjects (P ! .05).
The dierence between eyes open and eyes closed
values for path length was signicantly greater in the
third trimester, compared with control subjects (P !
.05). Furthermore, the dierence between eyes open
and eyes closed values of path length signicantly in-
creased within subjects as the pregnancy progressed
(P ! .05).
The mean and SD of weight gain during pregnancy
was 13 G 3 kg. Mean postpartum weight loss at 6 to 8
weeks was 11 G 3 kg. There was no signicant asso-
ciation between the amount of weight gained during
pregnancy and postural sway measures. There was also
no association between the amount of weight lost during
the 6- to 8-week postpartum period and postural sway
measures.
Two of the 8 women who returned for the postpar-
tum visit reported sustaining a fall as a result of loss
of balance during the course of their pregnancy. The
2 pregnant women who sustained a fall reported doing
so during the second and third trimesters; 1 additional
woman reported feeling clumsy during her second
trimester. No control subjects reported a fall during the
12 months before testing.
Comment
Good static postural control is characterized by a small
sway path (path length) and by a small sway excursion
(ARD) of the center of foot pressure movements.
19
These data suggest that postural stability declines during
pregnancy and remains diminished at 6 to 8 weeks after
delivery. In addition, these data suggest that there is an
increased reliance on vision to maintain balance, as
demonstrated by the increasing dierence between the
eyes open and eyes closed path length values within sub-
jects over time. Although this has not been studied pre-
viously in the pregnant population, an increased reliance
on vision to maintain balance has been reported in the
aging population and in cerebral palsy and other neuro-
logic conditions.
18,20
In general, the rate of weight gain during pregnancy
is small during the rst trimester and becomes higher
and more linear during the second and third trimesters,
with a higher rate of weight gain in the second trimester
Figure 1 Postural balance testing of a pregnant subject on
the force platform.
Figure 2 Center of pressure measurements: control subject
(left); pregnant subject in third trimester (right).
1106 Butler et al
than in the third trimester.
21
The gradual weight gain
that occurs during the rst trimester may explain the
maintenance of postural stability that was found in the
study population during the rst trimester. The higher
rate of weight gain in the second and third trimesters
may explain the decrease in postural stability during
this time period, as evidenced by the increased path
length and ARD values compared with control values.
In this small population, there was no association be-
tween change in postural balance values and the change
in weight, which suggests that additional factors inu-
ence postural stability during pregnancy.
Although it might be suspected that this decreased
postural stability is related to an increase in the height of
the center of gravity and the development of the fetal
load, much of this sway remains present at 6 to 8 weeks
after delivery, which is consistent with previous investi-
gation.
4
The lack of correlation between the change in
balance and the change in weight and a persistence of re-
duced postural stability at 6 to 8 weeks after delivery is
consistent with the hypothesis that decreased postural
stability in pregnant women is related to laxity of the
pelvic ligaments, rather than an increase in the height
of the center of gravity and an increase in weight be-
cause of the developing fetal load.
We found that 25% of the pregnant women sustained
a fall, compared with none of the control subjects. The
25% incidence is consistent with previous reports and
comparable with persons aged R65 years.
1
Balance
measures are correlated highly with falls in certain pop-
ulations.
22
Accordingly, diminished static postural equi-
librium and an increased reliance on visual cues to
maintain balance may explain the high incidence of falls
among pregnant women.
1
These ndings may suggest a
need for postural training during pregnancy and the
postpartum period. Dynamic and static balance training
exercises, which might include Tai Chi and strength
training, have been shown to improve postural stability
in the elderly population.
23-25
Despite the small sample
size in the present study, a decline in postural stability
and an increased reliance on vision for the maintenance
of balance during pregnancy and the postpartum period
is evident. Further studies should be conducted to
corroborate these ndings and to investigate the eects
of exercise on postural sway during pregnancy.
Acknowledgment
We thank Sue Thiemann, MS, for her valuable assis-
tance in the statistical analysis of this work and Rosanne
Kermoian, PhD, for her assistance in study design.
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Path length (cm/sec)
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Eyes closed 0.89 G 0.19 1.11 G 0.29 1.21 G 0.40* 1.28 G 0.34* 1.24 G 0.20*
ARD (cm)
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Eyes closed 0.39 G 0.13 0.54 G 0.17* 0.68 G 0.25* 0.68 G 0.24* 0.71 G 0.22*
Data are given as mean G SD.
* Signicant difference from control values (P ! .05).
Butler et al 1107
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