American Journal of Obstetrics and Gynecology (2006) 195, 11048

www.ajog.org

Postural equilibrium during pregnancy: Decreased stability with an increased reliance on visual cues
n, MD,b Maurice L. Druzin, MD,b Jessica Rose, PhDa,c Erin E. Butler, MS,a,* Iris Colo
Motion & Gait Analysis Laboratory, Lucile Packard Childrens Hospital, Palo Alto, CAa; 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 equilibrium during pregnancy and to examine whether the incidence of falls increases during pregnancy. Study design: Static postural balance measures were collected from 12 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 indicates 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.

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

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

Butler et al
Table I Pregnant and control subject groups Age (y) 32.8 G 5 31.1 G 6 Height (m) 1.62 G 0.1 1.62 G 0.1 Weight (kg) 63.2 G 10.3 56.5 G 7.7

1105

Subject group Pregnant (rst trimester) Control

Body mass index (kg/m2) 24.0 G 3.8 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).

in the center of gravity,4 increased joint laxity,5-9 and alterations in skeletal alignment4,10,11 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 superiorly and anteriorly.4 Accordingly, the developing fetal load places an increased demand on the lumbar spine and abdominal muscles.10 The changing shape and inertia 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 contribute 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 during pregnancy.

Material and methods

Static postural balance measures were collected from 12 pregnant women (11 primigravid women and 1 multigravida 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 conditions: lupus, rheumatoid arthritis, gestational diabetes mellitus, hypertension, musculoskeletal or neurologic abnormalities, and any other medical condition that aects postural stability. The study protocol was approved by the Stanford University Human Subjects

Committee, and informed consent was obtained from all subjects. At the beginning of each session, the pregnant women were asked whether they had lost their balance 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 movement 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 average 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 determine whether weight change was predictive of balance changes, dierence scores were calculated and the Spearman correlation was then used to determine statistical 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 consistent with previously published values for path length and ARD.15-17

1106

Butler et al

Figure 2 Center of pressure measurements: control subject (left); pregnant subject in third trimester (right).

third trimester, compared with control subjects (P ! .05). Furthermore, the dierence between eyes open and eyes closed values of path length signicantly increased 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 association 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 postpartum 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 subjects over time. Although this has not been studied previously 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 neurologic 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.

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 signicantly 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, compared with control subjects (P ! .05). The dierence between eyes open and eyes closed values for path length was signicantly greater in the

Butler et al
Table II Variable Path length (cm/sec) Eyes open Eyes closed ARD (cm) Eyes open Eyes closed Path length and ARD with eyes open and closed for all subjects Control subject group 0.75 G 0.19 0.89 G 0.19 0.41 G 0.18 0.39 G 0.13 First trimester 0.91 G 0.24 1.11 G 0.29 0.56 G 0.19 0.54 G 0.17* Second trimester 0.98 G 0.32* 1.21 G 0.40* 0.63 G 0.17* 0.68 G 0.25* Third trimester 0.96 G 0.21* 1.28 G 0.34* 0.64 G 0.26* 0.68 G 0.24*

1107

After delivery 1.08 G 0.23* 1.24 G 0.20* 0.71 G 0.20* 0.71 G 0.22*

Data are given as mean G SD. * Signicant difference from control values (P ! .05).

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 between change in postural balance values and the change in weight, which suggests that additional factors inuence 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 investigation.4 The lack of correlation between the change in balance and the change in weight and a persistence of reduced 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 because 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 populations.22 Accordingly, diminished static postural equilibrium 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 assistance in the statistical analysis of this work and Rosanne Kermoian, PhD, for her assistance in study design.

References
1. Dunning K, LeMasters G, Levin L, Bhattacharya A, Alterman T, Lordo K. Falls in workers during pregnancy: risk factors, job hazards, and high risk occupations. Am J Ind Med 2003;44:664-72. 2. Abrams B, Parker JD. Maternal weight gain in women with good pregnancy outcome. Obstet Gynecol 1990;76:1-7. 3. Soltani H, Fraser R. A longitudinal study of maternal anthropometric changes in normal weight, overweight and obese women during pregnancy and postpartum. Br J Nutr 2000;84:95-101. 4. Fries EC, Hellebrandt FA. The inuence of pregnancy on the location of the center of gravity, postural stability, and body alignment. Am J Obstet Gynecol 1943;46:374-80. 5. Abramson D, Roberts S, Wilson P. Relaxation of the pelvic joints in pregnancy. Surg Gynecol Obstet 1934;58:595-613. 6. Calguneri M, Bird HA, Wright V. Changes in joint laxity occurring during pregnancy. Ann Rheum Dis 1982;41:126-8. 7. Schauberger C, Rooney B, Goldsmith L, Shenton D, Silva P, Schaper A. Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels. Am J Obstet Gynecol 1996;174:667-71. 8. Dumas GA, Reid JG. Laxity of knee cruciate ligaments during pregnancy. J Orthop Sports Phys Ther 1997;26:2-6. 9. Laros RK Jr. Physiology of normal pregnancy. In: Willson JR, Carrington ER, editors. Obstetrics and Gynecology. St. Louis (MO): Mosby Year Book; 1991. p. 232-46. 10. Ireland ML, Ott SM. The eects of pregnancy on the musculoskeletal system. Clin Orthop 2000;372:169-79. 11. Franklin M, Conner-Kerr T. An analysis of posture and back pain in the rst and third trimesters of pregnancy. J Orthop Sports Phys Ther 1998;28:133-8. 12. Institute of Medicine, Committee on Nutritional Status during Pregnancy and Lactation. Nutrition during pregnancy: part I, weight gain. Washington (DC): National Academy Press; 1990. 13. Center for Disease Control, National Center for Health Statistics. National Health and Nutrition Examination Survey: healthy weight, overweight, and obesity among US adults. Posted: July 2003. Last accessed: March 7, 2006. Available at: http://www. cdc.gov/nchs/data/nhanes/databriefs/adultweight.pdf.

1108
14. Jensen R, Doucet S, Treitz T. Changes in segment mass and mass distribution during pregnancy. J Biomech 1996;29:251-6. 15. Lehman J, Boswell S, Price R, Burleigh A, deLateur B, Jae K, et al. Quantitative evaluation of sway as an indicator of functional balance in post-traumatic brain injury. Arch Physl Med Rehabil 1990;71:955-62. 16. Hufschmidt A, Dichgans J, Mauritz K, Hufschmidt M. Some methods and parameters of body sway quantication and their neurological applications. Arch Psychiatr Nervenkr 1980;228: 135-50. 17. Wol D, Rose J, Jones V, Bloch D, Oehlert J, Gamble J. Postural balance measurements for normal children and adolescents. J Orthop Res 1998;16:271-5. 18. Rose J, Wol D, Jones V, Bloch D, Oehlert J, Gamble J. Postural balance in children with cerebral palsy. Dev Med Child Neurol 2002;44:58-63. 19. Toupet M, Gagey P, Heuschen S. Vestibular patients and aging subjects lose use of visual input and expend more energy in static postural control. In: Vellas BJ, Toupet M, Rubenstein L,

Butler et al
Albarede JL, Christen Y, editors. Falls, balance and gait disorders in the elderly. Paris: Elsevier; 1992. p. 183-98. Choy N, Brauer S, Nitz J. Changes in postural stability in women aged 20 to 80 years. J Gerontol A Biol Sci Med Sci 2003;58:525-30. Carmichael S, Abrams B, Selvin S. The pattern of maternal weight gain in women with good pregnancy outcomes. Am J Public Health 1997;87:1984-8. Kerber KA, Enrietto JA, Jacobson KM, Baloh RW. Disequilibrium in older people: a prospective study. Neurology 1998;51: 574-80. Judge J, Lindsey C, Underwood M, Winsemius D. Balance improvements in older women: eects of exercise training. Phys Ther 1993;73:254-65. Lord S, Ward J, Williams P. Exercise eect on dynamic stability in older women: a randomized controlled trial. Arch Phys Med Rehabil 1996;77:232-6. Tsang WW, Hui-Chan CW. Eect of 4- and 8-wk intensive Tai Chi training on balance control in the elderly. Med Sci Sports Exerc 2004;36:648-57.

20. 21.

22.

23.

24.

25.