Journal of Athletic Training

2007;42(1):3541
 by the National Athletic Trainers Association, Inc
www.journalofathletictraining.org

Time-of-Day Influences on Static and Dynamic

Postural Control
Phillip A. Gribble, PhD, ATC; W. Steven Tucker, MS, ATC; Paul A. White, ATC
University of Toledo, Toledo, OH
Context: Assessment of postural control is used extensively
in clinical and research applications. Time of day affects aspects of physical performance, but whether it also affects postural control is unknown.
Objective: To determine the influence of time of day on static
and dynamic postural control.
Design: For each static postural control variable, a separate
3-way (day, time, eye) repeated-measures analysis of variance
(ANOVA) was performed. For the dynamic postural control variable, a 2-way (day, time) repeated-measures ANOVA was performed.
Setting: University research laboratory.
Patients or Other Participants: Thirty healthy college-aged
subjects.
Intervention(s): Static and dynamic postural control of each
subject was assessed in a laboratory at 10:00, 15:00, and 20:00
on 2 consecutive days.
Main Outcome Measure(s): Unilateral static postural control
was assessed with eyes open and closed on a forceplate using

center-of-pressure velocity in the anterior-posterior and mediallateral planes as the dependent variables. Dynamic postural
control was assessed with the anterior reaching direction of the
Star Excursion Balance Test using reach distances normalized
to leg length as the dependent variable.
Results: For static postural control, velocity scores in both
directions were lower at 10:00 than at 15:00 and 20:00 on day
1 (P .05). For dynamic postural control, normalized reach
distance was greater at 10:00 than at 15:00 and 20:00 (P
.05).
Conclusions: Time of day had a consistent influence on dynamic postural control that suggests performance of this task
may be better in the morning than in the afternoon or evening.
The influence of time of day on static postural control was not
as consistent and we feel requires further investigation. These
findings have implications for researchers and clinicians when
implementing and interpreting postural control testing.
Key Words: balance, diurnal patterns, circadian rhythms,
Star Excursion Balance Test

Key Points
Performance on a dynamic postural control task was better in the morning than in the afternoon or evening.
The influence of the time of day on static postural control was less consistent than was observed for dynamic postural
control.
When comparing postural control across days or groups, it may be important to keep the time of day consistent for
dynamic tasks.

easures of postural control have been used in laboratory and clinical settings as a means of assessing
stability and neuromuscular control in healthy and
injured subjects. Postural control measures may be compared
across groups of subjects, conditions, or a period of several
days. Various instrumented and clinical tests quantify postural
control statically, with the goal of remaining in a stable position, or dynamically, as one attempts to maintain a stable
base of support while performing another task.1
The goal of establishing and maintaining a stable base of
support during a postural control task depends on the integration of visual, vestibular, and somatosensory inputs and the
ability to create the correct combination of motor responses to
control the position of the center of mass.2 Optimization of
cognitive and motor functions is required to complete the task
and may be assessed through measures of static and dynamic
postural control. These measures may be highly specific in
terms of the portions of the postural control system that become challenged, suggesting that perhaps different factors or
combinations of factors influence each test.
Physiologic and neurologic functions in humans are influ-

enced by diurnal patterns that follow a proposed circadian

rhythm.3,4 Throughout a 24-hour period, cognitive and metabolic processes that affect mental and physical activities fluctuate. Although individuals may deviate from the reported
rhythms, optimal periods of time exist throughout the cycles
for various aspects of human function.5,6
As summarized in literature reviews by Winget et al5 and
Cappaert,6 many variables related to physical activity and exercise performance, such as cognitive abilities, reaction time,
strength, body temperature, and heart rate, are at optimal levels
in the early afternoon hours. Some of these factors may contribute to postural control and could create daily fluctuations
in this aspect of neuromuscular control.
However, few authors have investigated the influence of
time of day on postural control, with most attention focusing
on the combined effects of time of day and sleep deprivation
on postural control. Schlesinger et al7 and Uimonen et al8 reported that among sleep-deprived subjects, postural control
was affected in the morning hours. More specifically, Schlesinger et al7 stated that these morning disruptions in postural
control only occurred when the postural control task was com-

Journal of Athletic Training

35

plex, requiring more concentration and attention. However,

these 2 groups only assessed posture during morning hours.
Additional measures throughout a 24-hour period would be
necessary to determine an influence of time of day on these
factors.
Gribble and Hertel9 assessed center of pressure velocity
(COPV) on a forceplate with a bilateral stance every 6 hours
during 48 hours of sleep deprivation. Even under the influence
of extreme sleep deprivation for 2 consecutive days, COPV
was consistently smaller in the early mornings than in the evenings, suggesting a pattern in which postural control was
worse around 18:00. Similarly, Nakano et al10 reported that
during 19 hours of sleep deprivation that began at 15:00 and
ended at 9:00 the following morning, postural control excursions were lowest around midnight and highest between 5:00
and 8:00.
Although variables influencing physical activity seem to
peak in the afternoon hours, the optimal time of day for postural control is not as definite and has only been closely examined under the influence of sleep deprivation. Our purpose
was to examine the influence of the time of day on measures
of static and dynamic postural control among healthy individuals who were not sleep deprived. If postural control is better
or more consistent at certain times of day, researchers and
clinicians may need to consider this factor when assessing postural control among groups or during serial testing of an individuals postural control.
METHODS
Thirty subjects (13 men, 17 women: age 21.8 3.74
years, height 173.57 7.90 cm, mass 70.12 13.67
kg) from a university community volunteered for this study.
All subjects read and signed an informed consent form approved by the institutional review board, which also approved
the study. Subjects were free from all lower extremity injury,
head injury, and vestibular disorders for 12 months. Subjects
were asked to refrain from exercise and consumption of food
or beverages, other than water, for 2 hours before each testing
session. Additionally, subjects were asked to report the average number of hours they sleep in a typical night and to attempt to obtain that amount of sleep on the nights before both
testing days.
Subjects reported to the laboratory for 6 separate testing
sessions over a 48-hour period. On consecutive days, we assessed static and dynamic postural control at 10:00, 15:00, and
20:00. The order of static and dynamic assessments was randomized. During the initial session, leg length of a designated
testing leg was measured with a standard tape measure from
the anterior superior iliac spine to the distal portion of the
medial malleolus.

Figure 1. Anterior reach direction of the Star Excursion Balance

Test.

their vision on a large X on the wall 3.66 m in front of

them and 1.52 m from the floor. Subjects were instructed to
keep the non-test limb off the ground in a comfortable position
without touching the test limb. The test limb was determined
as the limb the subject would choose to stand on while kicking
a ball. A trial was discarded and repeated if the subject touched
the forceplate or the floor of the surrounding testing area with
the non-test leg during the trial.
Raw data were collected using the MotionMonitor software
package (Innovative Sports Technologies Inc, Chicago, IL).
Using MATLAB (version 5.3; The MathWorks, Inc, Natick,
MA), COPV was calculated in the anterior-posterior (COPVX)
and medial-lateral (COPVY) directions using the following
formula:

VEL

i1500

COP .02COP
i

i1

1500

Static Postural Control

Static postural control was assessed on a forceplate (model
NC-4060; Bertec Corp, Columbus, OH) with the subject in a
single-limb stance with eyes-open and eyes-closed conditions
with the hands on the iliac crests. Center of pressure was sampled at 50 Hz during 30-second trials with 30 seconds of rest
between trials. Three trials each of the eyes-open and eyesclosed conditions were performed for a total of 6 trials per
testing session. The order of condition was randomized. During the eyes-open condition, subjects were instructed to focus

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Dynamic Postural Control

Dynamic postural control was assessed with the anterior
reach of the Star Excursion Balance Test (SEBT), which is
performed on a grid of 8 lines 45 from one another and secured to the ground (Figure 1).11 The same test limb for the
single-limb static postural control measures was used for the
SEBT. The foot of the test limb was positioned in the middle
of the grid, so that the foot was bisected equally in the anteriorposterior and medial-lateral planes. This position was recorded

for each individual, so the foot of the testing leg could be

repositioned identically for all test sessions.
The SEBT consists of 8 reaching directions: anterior, anteromedial, medial, posteromedial, posterior, posterolateral,
lateral, and anterolateral (Figure 1). We chose the anterior direction because it requires movement in a forward direction,
which mimics most daily activities. Subjects were asked to
reach as far as possible along the designated line, lightly touch
the line on the ground with the most distal part of the reaching
foot, and return the reaching leg back to double-leg stance,
while maintaining a single-leg stance with the other leg in the
center of the grid. Subjects were instructed to keep their hands
on their iliac crests and to keep the heel of the stance leg on
the ground at all times.
Before the test trials during each test session, subjects performed 6 practice trials to provide a warm-up and overcome
any learning effect.12 After the 6 practice trials, subjects were
given a 5-minute rest period before performing the test trials.
Subjects completed 3 test trials in the same manner. They were
provided as much time as needed between trials so that fatigue
could be avoided. During the test trials, the reach distances
were recorded with a mark on the tape line at the point of
maximal reach and measured from the center of the grid. The
average of the 3 reaches was normalized by dividing by the
previously measured leg length to standardize the maximum
reach distance (%MAXD).13 A trial was discarded and repeated if the investigator noted the subject used the reaching
leg for a substantial amount of support at any time, removed
the foot from the center of the grid, or was unable to maintain
balance on the support leg throughout the trial.

Figure 2. Anterior-posterior center of pressure (COPVX) day-bytime interaction. Significant differences (P .05) demonstrated as
follows. *Between day 1 (10:00) and day 1 (15:00). Between day 2
(20:00) and day 2 (10:00 and 15:00) and day 1 (10:00, 15:00, and
20:00). Between day 2 (15:00) and day 2 (10:00) and day 1 (15:00
and 20:00).

Statistical Analysis
We calculated the means and standard errors for the 3 trials
of each static postural condition and the SEBT. For the static
postural control measures, the dependent variables were
COPVX and COPVY. For both COPVX and COPVY, separate
day (1, 2) by time (10:00, 15:00, 20:00) by eye (open, closed)
by sex (male, female) repeated-measures analyses of variance
were conducted.
For the dynamic postural control measures, the dependent
variable was %MAXD for the anterior reaching direction. A
day (1, 2) by time (10:00, 15:00, 20:00) by sex (male, female)
repeated-measures analysis of variance was obtained.
All statistical analyses were performed with SPSS (version
12.0; SPSS Inc, Chicago, IL) Significance was set a priori at
P .05. In the case of significant interactions, we applied
Scheffe post hoc testing.
RESULTS
Static Postural Control
Anterior-Posterior Center of Pressure. For COPVX, the
day-by-time interaction was significant (F2,58 3.849, P
.027; Figure 2). Scheffe post hoc testing revealed that, on day
1, postural control in the anterior-posterior direction was significantly better at 10:00 (0.120 0.008 m/s) than at 15:00
(0.125 0.008 m/s). Postural control during the 15:00 session
on day 2 (0.116 0.008 m/s) was significantly better than at
the 10:00 session on day 2 (0.122 0.008 m/s), the 15:00
session on day 1 (0.125 0.008 m/s), and the 20:00 session
on day 1 (0.123 0.008 m/s). Ultimately, COPVX during the

Figure 3. Anterior-posterior center of pressure (COPVX) main effect for eye condition (mean SE). *Indicates P .05; EO, eyes
open; and EC, eyes closed.

20:00 session on day 2 (0.110 .007 m/s) was significantly

better than all other testing sessions.
Additionally, we found a significant main effect for eye condition (F1,29 155.265, P .001; Figure 3). The eyes-open
condition produced significantly better postural control (0.071
0.004 m/s) compared with the eyes-closed condition (0.167
0.011 m/s).
Medial-Lateral Center of Pressure. For COPVY, the dayby-time interaction was statistically significant (F2,58 5.804,
P .005; Figure 4). Scheffe post hoc testing revealed that on
day 1, postural control in the medial-lateral direction was significantly better at 10:00 (0.130 0.007 m/s) and 20:00
(0.135 0.006 m/s) than at 15:00 (0.141 0.008 m/s). On
day 2, COPVY was significantly lower at 20:00 (0.131
0.007 m/s) and 15:00 (0.133 0.008 m/s) than at 10:00
(0.1390.008 m/s).
Additionally, the main effect for eye condition was significant (F1,29 224.881, P .001; Figure 5). The eyes-open
condition produced significantly better postural control (0.091
0.005 m/s) than the eyes-closed condition (0.179 0.009
m/s).
Dynamic Postural Control
The time-by-sex interaction was significant for the anterior
reaching direction (F2,56 3.42, P .04; Figure 6). Scheffe

Journal of Athletic Training

37

Figure 4. Medial-lateral center of pressure (COPVY) day-by-time

interaction. Significant differences (P .05) demonstrated as follows. *Between day 1 (10:00) and day 1 (15:00) and day 2 (10:00).
Between day 1 (20:00) and day 1 (15:00). Between day 2 (15:00)
and day 1 (15:00) and day 2 (10:00). Between day 2 (20:00) and
day 1 (15:00) and day 2 (10:00).

Figure 5. Medial-lateral center of pressure (COPVY) main effect for

eye condition (mean SE). *Indicates P .05; EO, eyes open; and
EC, eyes closed.

Figure 6. Time-by-sex interaction for the anterior reach of the Star

Excursion Balance Test (standardized maximum reach distance
[%MAXD] SE). *Indicates P .05.

post hoc testing revealed that, among the women, %MAXD

was significantly greater at 10:00 (0.824 0.015) than at 20:
00 (0.811 0.016).
The main effect for time was also significant (F2,56 3.205,
P .048; Figure 7). The 10:00 session produced the greatest
%MAXD (0.821 0.011) compared with the 15:00 (0.814
0.012) and 20:00 (0.814 0.012) testing sessions.

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Figure 7. Time main effect in anterior reach (standardized maximum reach distance [%MAXD] SE). *Indicates P .05.

DISCUSSION
Based on our results, time of day seems to influence measures of postural control. To our knowledge, no previous investigators have studied the influence of time of day on postural control except among subjects who were sleep deprived.
In our study, testing took place during waking hours only, and
subjects were instructed to acquire a normal nights sleep the
night before both testing days. The results of this study have
implications for how researchers and clinicians schedule and
interpret postural control testing when making comparisons
across days and groups of subjects.
Maintaining a stable base of support during a postural control task requires the integration of sensory input to create the
appropriate motor responses needed to make limb and trunk
corrections. Although the goals in static versus dynamic postural control tasks are somewhat different, the mechanisms of
controlling the center of mass in both these tasks may be influenced by the time of day. Previous authors have suggested
that numerous physiologic and neurologic variables are influenced by diurnal patterns and that most of these factors seem
to peak in the afternoon to early evening.5,6
Even though the potential for physical performance increases in the afternoon, this does not seem to equate with improved
postural control. The goal in a static postural control task is
to minimize the movement of the center of mass, requiring
small but frequent motor responses.2 These intricate contractions may not require optimal physical capability but perhaps
optimal organization of the sensory information. For the dynamic postural control task in our study, movement of the
center of mass is required to complete the goal, and larger
muscle contractions are needed than in the static measure, suggesting a necessary component of strength to complete the
task. However, the movement patterns of the dynamic task
must be appropriate without compromising the base of support
of the stance leg. For instance, a large-amplitude muscle contraction would be detrimental to controlling ones base of support. Variables needed for optimal physical performance, such
as sufficient blood flow and maximum strength levels, which
are affected by the time of day, may not be necessary for either
measure of postural control.
Static Postural Control
For the instrumented static postural control measures on day
1, the morning session produced smaller COPVX and COPVY
than the afternoon session, whereas the night session was not

statistically different from the morning or afternoon times, indicating that static postural control was best in the morning
and worse in the afternoon during the first 24 hours of testing.
Cognitive function has been suggested to peak early in human
circadian rhythms.14,15 Although these previous investigations
of cognitive function pertain to measures of short-term memory recall, they do suggest that daily tasks requiring a sustained level of cognition may peak in the morning hours. The
task of minimizing ones base of support during a 30-second
trial of single-leg balance is more challenging than the normal
double-limb stance one assumes during activities of daily living and would require a heightened level of attention. Perhaps
elevated cognitive ability in the morning hours allows for more
efficient maintenance of the center of mass during this task.
Interestingly, for the static postural control measures, the
time period of optimal performance shifted from the morning
to the evening session between the first and second 24-hour
periods. This could suggest a learning effect resulting from 2
consecutive days of performing this task. During the initial
24-hour period, the task most likely was novel to the subjects.
As one is exposed to a new task, perhaps the novelty is overcome through repetition of the task, and performance may be
improved through establishment of motor patterns.16 On day
2, the subjects may have learned how to minimize the movement of the center of mass, and postural control continued to
improve. If static postural control was observed to improve
steadily from the initial session to the final session, one could
assume a learning effect existed for this test throughout the
duration of the study. However, the same pattern was not observed during the first 24-hour period, which could be attributed to the task still presenting as novel. This may have allowed influences on postural control from additional factors,
one of which may have been diurnal patterns.
For the static postural control measures, practice trials were
not provided as they were for the dynamic postural control
task. The rationale for practice trials for the SEBT is well
established12 and how this relates to any possible learning effect throughout the study will be discussed later. An argument
could be made that the lack of practice trials for the static
postural control measurement led to the development of a
learning effect across the 2 days of the current study. However,
in a recent investigation among young healthy individuals, no
practice effect for single-limb static postural control testing
was seen across 2 consecutive days of testing.17 The authors
concluded that because measures of COPV did not significantly improve over multiple trials of eyes-open and eyesclosed testing on the same day or between consecutive days,
multiple practice trials were not needed when using a singlelimb static postural control test.
Stephenson et al17 demonstrated no learning effect within
testing sessions and between consecutive testing days, suggesting the differences in the static postural control results in
our study within and between days 1 and 2 were not associated
with a lack of practice trials but related to the potential novelty
of the task. However, in our study, subjects performed a total
of 36 single-limb static postural control trials spread across 6
separate testing sessions, whereas the subjects in the Stephenson et al17 study performed 11 trials during each testing session on consecutive days, for a total of 22 trials. In contrast
to our dynamic postural control measure, static postural control displayed 2 different patterns on days 1 and 2. The lack
of improvement on day 1 from the morning to the evening
could suggest an influence other than practice, potentially a

diurnal pattern similar to what was observed in the dynamic

postural control measurement. On the second day of testing, a
practice effect may have shaped the results, as the static measurement improved from the morning to the evening session.
Because we included more total testing trials that were dispersed across more testing sessions throughout the day compared with Stephenson et al,17 we are cautious to conclude
that our results can be attributed completely to a learning effect
or an influence of time of day. We feel it is necessary to include additional consecutive testing days and comparisons between nonconsecutive testing days to determine if a learning
effect or an effect from the time of day is more influential on
serial static postural control testing.
For both COPVX and COPVY, significant main effects existed for the eye condition, not surprisingly demonstrating that
postural control was worse with the eyes closed. Removing
vision places more emphasis on the vestibular and somatosensory input systems to the central nervous system,18 challenging the maintenance of the base of support, as evidenced by
a larger COPV. Although this finding is not novel, our result
confirms the greater challenge of postural control when vision
is removed. However, this effect was the same at all 3 testing
sessions on both days, with no significant interaction of eye
condition with day or time. Future researchers should determine if the time of day may be influencing the somatosensory
and vestibular inputs that help the central nervous system
maintain postural control or if this time-of-day influence is
specific to the central nervous system.
Dynamic Postural Control
During the dynamic postural control task, the anterior reach
of the SEBT was influenced by the time of day, as the mornings produced the best performance. The goal of the SEBT is
to produce maximum effort to complete a gross motor task
while maintaining a stable base of support. Achieving this goal
requires concentration and muscle recruitment and strength, as
well as task integration with environmental information to produce an optimal level of neuromuscular control to complete
the task without compromising the base of support.19 The
main effect for time showed that the largest reach distances
and, therefore, superior demonstration of dynamic postural
control occurred during the morning sessions on both testing
days. In contrast to the static postural control measure, no shift
in the optimal time of day for performance was noted from
day 1 to day 2. Thus, dynamic postural control as measured
with the SEBT was influenced by the time of day. Additionally, this relationship appeared to be strongest among women.
Similar to the discussion of static postural control measures,
circadian rhythm seems to have an influence on dynamic postural control that does not coincide with other previously investigated variables of physical activity. Performance on the
dynamic postural control task peaked in the morning session,
contradicting most physical performance variables, which peak
in the afternoon.5,6
As expected in any postural control task, the SEBT requires
integration of sensory inputs from the visual, vestibular, and
somatosensory systems, as well as appropriate motor responses to maintain the body over the base of support. However,
the movements and associated muscle contractions for the
SEBT are obviously of larger magnitude than required for a
static position. Earl and Hertel20 identified the quadriceps as
the primary muscle group contributing to performance on the

Journal of Athletic Training

39

anterior reach of the SEBT. Wyse et al21 examined isometric

strength of the knee flexors and extensors at time periods
(8:00 to 9:00, 13:00 to 14:00, and 18:00 to 19:00) similar to
ours. They reported that knee flexor and extensor strength
peaked between 18:00 and 19:00, a finding that was consistent
on 3 separate testing days. Although knee strength measured
isometrically culminates in the evenings, the dynamic postural
control task from the current study relies on knee extensor
muscle activation and peaked in the morning. Therefore,
strength and dynamic postural control may not be directly related, or perhaps they are not influenced by the same diurnal
pattern. Future authors should use electromyography to determine the extent of this relationship.
The interaction of sex and time on the dynamic postural
control measure, suggesting that the performance of the women was improved in the morning compared with the afternoon
and evenings, unlike that of the men, may also relate to the
contributions of the quadriceps muscles. In general, women
use a quadriceps-dominant pattern of knee control, whereas
men tend to recruit more hamstrings.22,23 Because the anterior
reaching direction of the SEBT requires more quadriceps activation,20 perhaps the women were able to demonstrate the
pattern of improved dynamic postural control in the morning
compared with the afternoon and evening due to differences
in quadriceps activation capability at different times of day.
However, what may be more interesting is the main effect of
time on dynamic postural control, demonstrating that, across
both days, regardless of sex, the task was performed optimally
in the morning. Therefore, the time of day seemed to be a
consistent influence on dynamic postural control.
Because the goal is to achieve a maximum reach distance
without compromising the base of support, interaction with
ones environment affects the perceived constraints of the task.
We might expect that, as subjects performed this task 6 times
during 2 consecutive 24-hour periods, a learning effect would
be evident as subjects discovered how to complete the task,
and reach distances would steadily improve from the beginning to the end of the study. However, no difference across
the testing days indicates that multiple exposures to this task
did not supersede the influence of time of day on performance.
Clinical Significance
Clinicians and researchers use postural control testing as an
indicator of neuromuscular control and proper communication
between the central and peripheral nervous systems. Such testing provides information on the magnitude of influence an
injury (eg, closed head injury, lower extremity injury) or an
intervention (eg, modalities, bracing, physical activity) has on
the individuals ability to synthesize environmental information and make proper corrective movements, so that upright
posture and a base of support is maintained.
The SEBT is a commonly incorporated rehabilitation tool
that also has been used as an effective diagnostic tool for identifying functional deficits in dynamic postural control associated with lower extremity conditions.2427 Our results indicate
mornings may produce better performance than afternoons or
evenings, and this influence seems to be stronger among women than men. When choosing to use this test for comparisons
across days or groups, one may need to maintain consistency
of the time of day. If the mornings produce significantly larger
reaching distances, then any comparisons across days or between groups to determine rehabilitation progressions or dif-

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ferences in research applications also need to be implemented

in the mornings. Additionally, because SEBT performance in
the afternoon and evening testing sessions was not significantly different, repeated testing could be compared adequately during either of these testing times.
Static postural control measures are commonly performed
in a clinical setting (ie, modified Romberg test) and in research
laboratory settings using instrumented postural measures similar to what we used in this study. We observed that the influence of the time of day on static postural control was less
consistent than what was observed for the dynamic measure.
The initial day of static postural testing demonstrated that performance in the morning was better than in the evening and,
ultimately, performance was worst in the afternoon. This may
be important when introducing a static postural control measure to a subject for the first time. If possible, it may be prudent to avoid the afternoon when conducting an initial assessment of static postural control to eliminate any detrimental
time-of-day influence on the measure. However, when comparing several assessments of static postural control, controlling for the time of day of each testing session may not be
needed, as our results did not support a consistent time-of-day
influence on the static postural control measure across the testing days.
An initial goal of our investigation was to determine if there
is a need to standardize testing times for postural control. If
an ideal time of day was discovered when postural control was
optimal, clinicians and researchers would be encouraged to
schedule their assessments accordingly. Additionally, if a consistent pattern of diurnal pattern influence was discovered
across 2 consecutive days of testing, we theorized that this
would affect the planning and interpretation of serial postural
control testing. The time of day appeared to have a more
prominent influence on dynamic postural control, mornings
being associated with the best performance. However, mornings may also be an ideal testing time for static postural control based on the first day of testing. If we consider ways to
control for the potential influences of circadian rhythms on
measures of postural control, it may be beneficial to use a
measure of dynamic postural control, such as the SEBT. Clearly, further research is needed to determine the influence of time
of day on postural control and the clinical implications of that
influence.
Limitations
Subjects in this study were expected to acquire a normal
nights sleep before both testing days; however, although subjects slept as they usually would, the number of hours of sleep
was not constant for all subjects. We attempted to examine an
influence of circadian rhythms, which are subject to changes
in body temperature and may be influenced by eating and
physical activity. The amount and content of food intake were
not controlled in this study, but subjects were asked to not eat
anything for 2 hours before each testing session. Many of the
subjects in this study were physically active. The level of
physical activity was not controlled, but subjects were asked
to refrain from exercise for 2 hours before each testing session.
This study was conducted across a 48-hour period and
seems to suggest potential effects of the time of day on postural control. However, whether these results would be consistent across multiple days of testing is unknown. This approach will help determine variability or consistency in the

influence of the time of day on postural control. Therefore,

future authors should continue the assessments for more than
48 hours, perhaps as long as an entire week, to determine the
extent of these influences.
CONCLUSIONS
A significant influence of diurnal patterns on dynamic postural control was noted across 2 consecutive days of testing;
the influence on static postural control seemed to be less consistent. These findings have implications for researchers and
clinicians implementing and interpreting postural control testing. When using serial dynamic postural control testing and
making comparisons across time or groups, one may need to
control for the time of day. However, the time of day may not
be as important when conducting static postural control measures. For the dynamic postural control test, consistent patterns
were displayed across the 2 consecutive testing days; with the
static postural control testing, the patterns across the 2 days
were not as uniform. This result would suggest that the SEBT
may be a consistent postural control measurement tool to use
across multiple days if applied at the same time of day for
each testing session.
Our findings could influence clinicians interpretation of
postural control measures when a return-to-play decision is
necessary. For instance, if the morning is the best time of day
for optimal dynamic postural control, physicians, athletic trainers, and physical therapists using these tests to determine the
level of postural control after concussion or injury to the lower
extremity may want to consider the time of day when assessing a patients improvements in dynamic postural control.
However, when examining the results of static serial postural
control testing, this issue seems to be less important. We feel
that for both measures, additional consecutive days of testing
are needed to determine if a consistent influence of the time
of day is present.
Although we report significant differences in static and dynamic postural control related to the time of day, it is difficult
to determine if these measured differences represent substantial differences in function, as only healthy subjects were tested. Future investigators should determine if the neuromuscular
differences across the time of day as measured through postural control exist between healthy and injured populations.
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Phillip A. Gribble, PhD, ATC, contributed to conception and design; acquisition and analysis and interpretation of the data; and drafting,
critical revision, and final approval of the article. W. Steven Tucker, MS, ATC, and Paul A. White, ATC, contributed to acquisition and
analysis and interpretation of the data and critical revision and final approval of the article.
Address correspondence to Phillip A. Gribble, PhD, ATC, 2801 West Bancroft Street, Mailstop #119, University of Toledo, Toledo, OH
43606. Address e-mail to phillip.gribble@utoledo.edu.

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