Trunk symmetry indices can affect the risk of falling in older adults (Correlational study)

doi:10.21203/rs.3.rs-4125969/v1

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Research Article

Trunk symmetry indices can affect the risk of falling in older adults (Correlational study)

https://doi.org/10.21203/rs.3.rs-4125969/v1

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Background

According to the statistics of the World Health Organization (WHO), the number of aging people is increasing. Paying attention to the issues, needs and diseases of this stage is a social necessity to maintain health and functional ability. Falling is one of the most common causes of injury in aging people and affects their health. In this regard, it is necessary to diagnose and evaluate aging patients at risk of falling with noninvasive and low-cost methods. The purpose of this study was to investigate the relationship between trunk symmetry indices and the risk of falling in aging men.

Methods

In the present study, 50 elderly men between 75 and 85 years old were selected. Then, height and weight were measured, and anatomical points were marked on the subjects in three views. To assess the risk of falling, time up and go and functional reach tests were used. Then, with the Photoshop program, the measurements of each line and the markings of each subject were calculated with the formula for each index. The data were analyzed in the SPSS program, and the normality of the data was considered for the relationships between the variables according to the Pearson correlation coefficient at a significance level of 95% (P ≤ 0.05), which was used to evaluate the ability of the indicators to predict the risk of falling. Simple linear regression was used.

Results

Finally, the anterior and posterior trunk symmetry indices and body posture indices were significantly related to the fall risk, except for the anterior trunk symmetry index, which was significantly related to the time up and go test (P ≤ 0.05), and the ability to predict the risk of falling.

Conclusion

The results of the present study show that the presence of asymmetries and structural changes in the posture of the trunk in all three anterior, posterior and lateral views during aging causes disturbances in the balance system of people and increases the risk of falling.

Body position

Posterior trunk symmetry index

Anterior trunk symmetry index

Fall

aging

Aging involves the accumulation of harmful changes in cells and tissues with age, which increases the risk of disease and death. Aging changes can be attributed to developmental and genetic defects, the environment, disease processes and intrinsic factors. This process is called the aging process. [1] Aging is defined as irreversible structural and functional changes in many organs and systems that are more or less severe and differ among people. Many of these factors affect body posture, which changes during life. These changes start between 40 and 50 years of age, and their initial slow progress accelerates after 60 years of age. [2] Aging is a sensitive period of human life that brings challenges and opportunities, so paying attention to the issues, needs and diseases of this stage is a social necessity. The World Health Organization defines aging as people aged 65 and over, and a large percentage of the aging population lives in developing countries. Today, due to improvements in health and treatment and an increase in life expectancy, which is called the "demographic revolution", the world's aging population is increasing. The World Health Organization estimated that the world's aging population will reach 727 million by 2020, and it is expected to reach more than 1.5 billion by 2050. [2]

According to international estimates, it is expected that the aging population in Iran will grow faster than that in other countries since 1419. In 2019, there were one billion people aged 60 and over. This number will increase to 1.4 billion by 2030 and to 1.2 billion by 2050. Data on the population aging rate show that Iran is the second fastest aging country in the world. This important historical change in the global population as well as in Iran requires adaptation to the way societies are structured in all sectors. [2]

With the growth of the aging population, age-related diseases and structural changes in many organs and systems that differ between individuals with different rates or dimensions will burden society. Identifying changes in body condition that occur with aging is a common topic in the field of geriatric medicine that needs much study.(Matlęga, Stępowska, Wiśniewski, & Gajewski, 2020)

One of the problems that affects the health of aging people is falling, which is the most common cause of injury during aging.(Harman, 2001) A fall is an unintentional, sudden descent to a lower level. There is a direct correlation between falls and mortality, morbidity, and reduced functionality. Falls occur frequently in older adults, children, and athletes. Among older adults, associated medical comorbidities correlate with an increased propensity to fall and, in turn, increased susceptibility to injury.(Appeadu & Bordoni, 2023)

In 2012–2014, approximately four million people over 65 years of age required medical care after a fall in the European Union (EU) each year. This percentage increases to approximately 40% in individuals aged 85 years and above. [3] Approximately 10% of falls result in serious injuries, including hip fracture, other fractures, traumatic brain injury, or subdural hematoma.(Appeadu & Bordoni, 2023) The total number of falls (including falls resulting in an injury requiring medical attention) is greater (Harman, 2001; Lacour, Bernard-Demanze, & Dumitrescu, 2008; حسینی, 1397). Approximately one-third of people over the age of 65 years’ experience at least one fall, and 15% fall at least twice in their lifetime.(Rubenstein, 2006)

Among the main consequences following a fall are a significant decrease in quality of life related to health and functional disorders, fear of falling, serious injuries and broken limbs, muscle atrophy and a decrease in muscle strength to perform daily activities, depression, anxiety, and social isolation all of which increase people’s dependence on people around them and family members. (Harman, 2001; Lacour et al., 2008) The costs of treatment, health care and home care assistance, and nursing assistance increase and can affect the general health of the community.(Cuevas-Trisan, 2019)

According to research, falls are often multifactorial, and an aging person may have several risk factors at the same time. More than 400 risk factors for falls have been identified, including several diseases, sarcopenia, obesity, osteoporosis, cognitive impairment, history of falls, drugs that increase the risk of falls, mobility impairment, and psychological and demographic factors(Larsson et al., 2019). Additionally, many intrinsic and extrinsic risk factors for falling have been identified, including weakness of the lower limb muscles, loss of balance, loss of mental ability, loss of sensory information, visual impairment, postural hypotension, and walking impairment. (Lacour et al., 2008), 6] Among the factors mentioned in the literature are posture control systems that affect falls, which involve complex and combined mechanisms.(J. Drzał-Grabiec, Rykała, Podgórska, & Snela, 2012; Lacour et al., 2008)

Body posture is defined as the alignment of body parts, which is considered as an important health indicator. The posture of the human body undergoes many changes that depend on age, gender, body growth, environmental and situational factors.(Schonnop et al., 2013) Body condition indicators are an essential factor for evaluating health and quality of life, especially for the aging; which has been less discussed. Such an index can provide information for targeted health promotion, be used to assess healthy aging and warn of health abnormalities, such as osteoporosis, Sarcopenia, and fall risk estimation .(Harman, 2001; Ludwig, Mazet, Mazet, Hammes, & Schmitt, 2016)

The upper limbs are an important part of the protective reaction against falling, which causes posture disorders in the trunk, postural changes, and asymmetries that occur due to spinal deformities in the anterior, posterior, and lateral views with changes in body tilt, muscle function, and role. Forces and joints can increase the risk of falling. (Stolinski et al., 2017) In most of the studies carried out in the area of indicators of the condition of the trunk during aging, it is mostly on one or more limbs to determine the angles of lumbar lordosis or kyphosis, the angle of the neck and knees, or the postural changes of the lower limbs, which are from a view or sagittal or frontal, that have been investigated and none of them evaluated the effect of trunk symmetry.

Therefore, the aim of our study was to evaluate trunk symmetry indices, including the anterior trunk symmetry index and posterior trunk symmetry index, in the anterior and posterior planes, as well as the body index in the sagittal plane, to determine the relationships between these indices and the risk of falling in aging people.

In the present study, the studied population consisted of men aged between 75 and 85 years in Tehran Province who voluntarily participated in the study and met the conditions for inclusion in the study (Table 1). The samples of the current research were selected in a purposeful and available manner after considering the criteria for entering the research and the satisfaction of the people to participate in the research and were considered as research samples. Based on the inclusion criteria, people who were cared for in the aging center only due to their old age and their physical and mental conditions (able to walk at least 6 meters, have a history of falling at most once and are perceptually aware) according to the information provided by the nurse and their doctor were selected, and they were suitable for the test. Based on the exit criteria, people who did not have the ability to continue to cooperate in the research who experienced illness, weakness, or dizziness during the test or who were not in the case of a doctor's order could be withdrawn from the research. The research measurements were carried out in the aging centers of Tehran Province.

Table 1

**Descriptive statistics of the whole group (total, n = 50)**
Descriptive Statistics
variable	Minimum	Maximum	Mean	Std. Deviation
Age (year)	75	85	78/24	3/30
Weight (kg)	50	110	7/72	12/37
Height (cm)	152	182	167/56	6/86
Data are reported as the mean ± standard deviation.

The fall risk and the variables investigated in this research included the following predictor variables he following criterion variables: anterior trunk symmetry index, posterior trunk symmetry index, and body posture index. In the following, to evaluate the trunk symmetry indices, first. the weight and height of the subjects were taken and then the anatomical points of the indices were marked on the body. A meter was installed on the wall to create a plumb line to calculate the distances of the indicators. Three front, back and side views were taken with a digital camera from a distance of one and a half meters according to the position that was specified for each subject, and then the photos were taken in the Photoshop program according to the lines necessary for calculating the index. was performed, and the relevant formulas were used. Next, to evaluate the risk of falling, two functional tests, time up and go and functional reach tests, were performed. First, the anatomical points of the body indicators were marked as follows: (Fig. 1,2)

2.1. Measurement of trunk indices

Posterior trunk symmetry index: The POTSI parameter is defined as the sum of six indices: three frontal plane asymmetry indices (C7, axilla folds, and waist lines) and three frontal plane height difference indices (acromions, axilla folds, and waist lines). The frontal asymmetry index at the C7 level (FAI-C7) was calculated by dividing the distance between the C7 point and the midline by the height of the trunk. The height of the trunk (e) is the vertical distance between C7 and the beginning of the gluteal cleft. Frontal asymmetry indices at the axilla level (FAI-A) and trunk level (FAI-T) were calculated by dividing the difference in distance between each trunk edge and the midline (c − d, a − b) by the width of the trunk (c + d, a + b). The height indices of trunk asymmetry were calculated by dividing the difference in height at three trunk levels: HDI-S for shoulders, HDI-A for axilla, and HDI-T for the trunk waistline by the trunk height (e). The shoulder point is the point of intersection at shoulder level with a vertical line from each axilla. POTSI was introduced by Suzuki et al. in 1999. (Fig. 1) [2, 10]

The anterior trunk symmetry index (ATSI) is defined as the sum of six indices: three frontal plane asymmetry indices (sternal notch, axilla folds, and waist lines) and three frontal plane height difference indices (acromions, axilla folds, and waist lines). The frontal asymmetry index at the sternal notch level (FAI-SN) was calculated by dividing the distance between the center of the sternal notch and the midline by the height of the trunk. The height of the trunk (e) is the vertical distance between the navel and the center of the sternal notch. Frontal asymmetry indices at the axilla level

(FAI-A) and at the trunk level (FAI-T) were calculated by dividing the difference in the distance between each trunk edge and the midline (c − d, a − b) by the width of the trunk (c + d, a + b). The height indices of trunk asymmetry were calculated by dividing the difference in height at three levels of the trunk: HDI-S for the shoulders, HDI-A for the axilla, and HDI-T for the trunk waist line by the trunk height measured from the navel to the center of the sternal notch (e). The shoulder point is the point of intersection at shoulder level with a vertical line from each axilla. The ATSI was introduced by Stolinski et al. in 2012. (Fig. 1) [3,(Kotwicki & Grivas, 2012)

A B C D

Figure 1. Anatomical landmarks to calculate POTSI (A, B) and ATSI (C, D) values

Distances between the anatomical landmarks on a subject’s trunk surface used for the calculation of the trunk symmetry measures POTSI and ATSI (the authors’ own material) for calculating POTSI (A, B) and ATSI (C, D) anatomical landmarks. Figure A and B legend: “x” indicates the position of the C7 spinous process and the right and left acromions on the posterior trunk surface and of the suprasternal notch and the right and left acromions on the anterior trunk surface. The vertical lines are the plumb lines. Figure B and D legend: a – the distance between the deepest waist indentation on the left side and the midline of the body; b – the distance between the deepest waist indentation on the right side and the midline of the body; c – the distance between the apex of the left axilla and the midline of the body; d – the distance between the apex of the right axilla and the midline of the body; e – the posterior and anterior trunk height measured between the C7 spinous process and the top of the natal cleft and the center of the umbilicus, respectively; f – the difference between the heights of a and b horizontals in relation to each other (the difference in the heights of the deepest waist indentation, right and left); g – the difference between the heights of B and D horizontals in relation to each other (the difference in the heights of the apex of the axilla, right and left); h –the difference between the heights of horizontals marked between the midline of the body and the acromia (the difference in the height of the shoulder points, right and left); I – the distance between the C7 spinous process and the midline of the body (1B) and the suprasternal notch and the midline of the body (1D). (photographs by the authors).

Posture index

The posture index according to Fröhner is a parameter that provides a summarized assessment of trunk alignment by calculating the distances of four body points perpendicular to the ankle joint. The caudal tip of the sternum, the point of maximum lumbar lordosis, the point of maximum thoracic kyphosis and the iliac spine anterior superior (ASIS) act as reference points. The posture index is calculated using (dK + dA) / (dB + dL), where dK = horizontal distance between the thoracic kyphosis and the plumb line, dA = horizontal distance between the ASIS and the plumb line, dB = horizontal distance between the breastbone and the plumb line, and dL = horizontal distance between the lumbar lordosis and the plumb line. A stable posture is indicated by values between 1.0 and 1.3. (Fig. 2) [ 2, 11, 12]

A B

Figure 2. Anatomical landmarks of body posture index

Figure 2. 1) skull, 2) auditory canal, 3) acromion, 4) distal sternum, 5) maximum thoracic kyphosis, 6) ASIS, 7) maximum lumbar lordosis, 8) trochanter major, 9) lateral malleolus, and 10) sole of foot. The following posture parameters in the sagittal plane were used to calculate the posture index: A) ear plumb line distance (dE), shoulder plumb line distance (dS), and hip plumb line distance (dH); b) trunk incline (TI) and upper body tilt (BT); and c) plumb line distances. (photographs by the authors)

2.2. Calculation of the POTSI and ATSI with the formula

After marking the anatomical points, we used their formulas to calculate each index. The methods used to calculate the indices of anterior symmetry of the trunk and posterior symmetry of the trunk are presented in Table 2.

Table 2

Formulas to calculate POTSI and ATSI
POTSI			ATSI
Measure	Index	Formula	Index	Formula
FAI	C7 spinous process FAI-C7	FAI-C7=[i/(c₊d)]×100	Suprasternal notch FAI-SN	FAI-SN=(i/e)×100
	Axillar FAI-A	FAI-A=[\|c-d\|/(c₊d)]×100	Axillar FAI-A	FAI-A=[\|c-d\|/(c₊d)]×100
	Trunk FAI-T	FAI-T=[\|a-b\|/(a₊b)]×100	Trunk FAI-T	FAI-T=[\|a-b\|/(a₊b)]×100
HDI	Shoulder HDI-S	HDI-S =(h/e)×100	Shoulder HDI-S	HDI-S =(h/e)×100
	Axillar HDI-A	HDI-A =(g/e)×100	Axillar HDI-A	HDI-A =(g/e)×100
	Trunk HDI-T	HDI-T =(f/e)×100	Trunk HDI-T	HDI-T =(f/e)×100
POTSI=(FAI-C7 + FAI-A + FAI-T)+(HDI-S + HDI-A + HDI-T) = FAI + HDI			ATSI=(FAI-SN + FAI-A + FAI-T)+(HDI-S + HDI-A + HDI-T) = FAI + HDI

2.3. Time up and go and functional reach tests

After the indicators were calculated, the time up and go test and the functional reach test were used to determine the risk of falling. The time up and go test was performed such that the subjects "get up from a standard armchair, walk a line on the floor at a distance of 3 meters, turn around, turn around, and sit down again. "The entire test process takes time, and the samples in this study performed the test without any equipment or assistance. Before the test, the subjects performed the test once as a trial, and after a few minutes of rest, the main test was taken. The longer the walking time is to more than 10 seconds, the greater the risk of falling. This test includes movements necessary for daily living, such as standing from a chair, walking, changing direction and sitting in a chair, and is a quick and simple way to assess lower limb function, mobility and risk of falls. It is a standardized clinical gait test that is widely used for monitoring patient fall risk and disease progression. In the following, the FRT was carried out in this way. Before the start of the test, the surface of the floor and the wall were free of obstacles and cleaned. The location of the subjects was marked with tape on the floor. FRT is achieved by placing a meter on the wall, parallel to the floor, at the height of the last appendage of the subject's dominant arm. The subject was asked to keep his feet shoulder-width apart, make a fist with his dominant hand, and raise his dominant arm to approximately 90 degrees. The subject was asked to reach forward as far as possible without taking a step or without lifting his or her heels or touching the wall. Then, the distance between the start and end points was measured using the metacarpal head of the third finger as a reference point. The subjects performed the test twice and the best performance was recorded as the test score in centimeters.

Finally, the information recorded from the indicators and tests and the characteristics of the subjects were extracted in the form of an Excel file and analyzed to calculate the data from the research measurements using SPSS software version 26. (Table 3,4)

The data related to the characteristics of the subjects as well as the research variables were analyzed in two sections of descriptive and inferential statistics. After ensuring the normality of the data distribution, using the Kolmogorov‒Smirnov test, the Pearson correlation coefficient test (P ≤ 0/05) was used to investigate the relationship between the trunk symmetry indices and the risk of falling in aging men. Simple linear regression was used to predict trunk symmetry, which is an indicator of the risk of falling during aging. It should be noted that in all the statistical tests of this research, P ≤ 0/05 was considered the minimum significance level of the test variables.

Table 3

**Descriptive statistics of trunk symmetry index scores**
Descriptive Statistics
variable	Minimum	Maximum	Mean	Std. Deviation
ATSI	103.72	375.00	248/13	84/19
POTSI	101.76	446.29	252/08	7/18
PI	.44	1.00	0/75	0/13
Data are reported as the mean ± standard deviation. ATSI = Anterior Trunk Symmetry Index, POTSI = Posterior Trunk Symmetry Index, PI = posture Index

Table 4

Descriptive statistics of the TUG and FRT test scores
Descriptive Statistics
Variable	Minimum	Maximum	Mean	Std. Deviation
TUG	8.98	25.36	16.12	4.29
FRT	61.00	84.00	74/92	5/64
TUG = Time up and go test, FRT = Functional reach test

Table 5

Correlations between trunk symmetry indices and FRT and TUG test scores
	ATSI	POTSI	PI
FRT	R= -0/359 – P = 0/010	R= -0/628 – P = 0/0001	R = 0/560 – P = 0/0001
TUG	R = 0/237 – P = 0/098	R = 0/332 – P = 0/019	R= -0/519 – P = 0/0001
R = Pearson correlation coefficient, p = p value

3.1. Relationships between trunk symmetry indices and FRT and TUG test scores

We found a significant and negative correlation between the anterior trunk symmetry index (P = 0/010, R= -0/359) and the posterior trunk symmetry index (P = 0/0001, R= -0/628) according to the functional reach test. Moreover, the posture index (P = 0/0001, R = 0/560) was significantly positively correlated with the risk of falling in aging men according to the functional reach test. In fact, by increasing the anterior and posterior symmetry of the trunk, the distance of the functional reach test decreases, or vice versa. Moreover, by increasing the posture index score, the distance traveled in the functional reach test increased. There was no significant relationship between the anterior trunk symmetry index and the risk of falling in aging men according to the time up and go test (P = 0/098, R = 0/237). In terms of the index of posterior symmetry of the trunk (P = 0/019, R = 0/332) a significant positive correlation was observed, indicating that increasing the posterior symmetry score of the trunk increased the TUG test time. The posture indices (P = 0/0001, R= -0/519) were significantly negatively correlated, which means that a decrease in the posture index is associated with an increase in the TUG test time. (Table 5)

Table 6

Pearson's correlation coefficient and coefficient of determination for predicting trunk symmetry indices with the risk of falling in older adults
TUG		FRT
R-squared correlation	Pearson's correlation coefficient	R-squared correlation	Pearson's correlation coefficient
0/307	0/554	0/496	0/704

3.2. Predicting trunk symmetry indices for the risk of falling

A simple linear regression test was used to assess the ability of the trunk symmetry indices to predict the risk of falling during aging, and the results are shown in Table 6. In fact, the regression model fitted with the predictor variable of trunk symmetry indicators to determine the risk of falling by the time up and go test was able to explain 30% (R-squared = 0/307) of the changes, and with the functional reach test, 49% (R-squared = 0/496) of the changes were related to the dependent variable.

Table 7

**Results of the ANOVAs (simple linear regression): To be able to predict trunk symmetry indices with the risk of falling in older adults**
Model		Sum of Squares	df	Mean Square	F	Sig.
FRT	regression	776.08	3	258.69	15.10	.0001
	residual	787.59	46	17.12
	Total	1563.68	49
TUG	regression	277.50	3	92.50	6.80	.001
	residual	625.46	46	13.59
	Total	902.97	49

According to the results of the variance analysis (Table 7), the significance level of the F statistic is less than 0.05 (P = 0.0001), which shows that the whole regression process has a good fit and that the results are reliable.

When the beta coefficient is significant and predictable or not, its significance level is less than 0.05. The larger the beta coefficient is, the more predictive the regression model is. Therefore, the anterior trunk symmetry index (P = 0.365) was not significant, and the posterior trunk symmetry index (P = 0.0001) and the posture index (P = 0.006) were significant. The posterior trunk symmetry index (Beta = 0.482) and posture index (Beta = 0.318) were more predictable with the use of the functional reach test. The anterior symmetry index (P = 0.469) and the posterior trunk symmetry index (P = 0.307) were not significant, and the body posture index at the significance level of P = 0.001 (beta = 0.455) was more predictable during the TUG test than did the other indices. (Table 8)

Table 8

Coefficients of the simple linear regression
Coefficients
Model		Unstandardized Coefficients		Standardized Coefficients	t	Sig.
Model		B	Std. Error	Beta	t	Sig.
FRT	(Constant)	74.73	4.78		15.62	.0001
	ATSI	− .008	.008	− .105	− .914	.365
	POTSI	− .032	.008	− .482	-4.02	.0001
	PI	13.48	4.69	.318	2.87	.006
TUG	(Constant)	24.04	4.26		5.64	.0001
	ATSI	.005	.007	.098	.730	.469
	POTSI	.007	.007	.145	1.03	.307
	PI	-14.67	4.18	− .455	-3.50	.001
B= Beta coefficient

The objective of this study was to examine the relationship between trunk symmetry indices and the risk of falling in aging men. To evaluate the risk of falling, the trunk symmetry indices and two functional indices, the TUG and FRT, were measured. Compared to other studies, this was a new approach because, thus far, trunk symmetry and posture indices have not been used to determine the risk of falling, and they have been used mostly in the fields of determining skeletal abnormalities.

Falls are the most serious and common accidents that occur as people age; at the same time, they are a public health issue, and their prevention is important for reducing morbidity, mortality, and medical costs. Screening in the community, even in healthy older people, is useful for early detection. For older adults at risk of falling, a comprehensive approach to assessment is often needed, followed by multidisciplinary and multidomain intervention. (De Rekeneire et al. 2003; Khow and Visvanathan 2017) One of the important components in controlling balance and preventing falls is the alignment of the trunk in aging people. Any change in the alignment of the spine and creating asymmetry causes compensatory movements in the trunk, which affects the walking pattern and the balance system. To improve the assessment methods for determining the risk of falling during aging, many monitoring tools and smart systems have been introduced, including photogrammetric methods, body analyzers, and smart sensors, but each has its own advantages and disadvantages. By using the physical indicators stated in this research, we can determine the physical condition of people and their risk of falling with a standard and quantitative, easy, noninvasive and low-cost screening method and less equipment. (Mubashir, Shao, and Seed 2013)

In all of these studies, the posterior trunk symmetry index (POTSI) has been investigated as a standard evaluation and screening method, especially for the diagnosis of scoliosis and various spinal deformities, as well as its relationship with various variables. Stolinski et al. (2017) used standard digital photogrammetry to analyze the posture and body posture changes of 7- to 10-year-old children and used one of the standard assessment indices for the trunk, which was the posterior symmetry index of the trunk. which has been useful for evaluating trunk symmetry in the frontal plane at all ages. (Matlęga et al., 2020) As mentioned, this index can be used in different age groups; in the mentioned studies, the age group was adults, and the present research was conducted on aged men aged 75 years and above. Recent world population statistics show that the aging population of individuals aged 65 years and older is increasing, which has led to many diseases and changes. One of the changes that occurs in old age is changes in the physiological curvature of the spine due to changes in bones, muscles and joints. Posture is defined as the position of a person's body in space, the alignment of body parts in relation to each other and the environment at a point in time, and it is influenced by each of the body's joints. and creating asymmetries in the back and other dimensions of the body. According to the structural changes of the trunk, there are changes in the range of motion, muscle performance and strength, coordination and torque of joints and forces, all of which are factors that disturb the balance system and increase the risk of falling.(Duangkaew, Bettany-Saltikov, Van Schaik, Kandasamy, & Hogg, 2020; Zahari, Zainudin, & Justine, 2020) (Burkhart & Andrews, 2013) Esthurak et al. (1989) noted the components of postural control disorders during aging, one of which is changes in posture and body position, which can affect fall strategies. (Horak, Shupert, & Mirka, 1989) Ruichi-Sawa et al. (2017) reported that participants with fear of falling syndrome showed significantly more variability, not only in leg movements but also in upper body movements, during walking than did subjects without fear of falling syndrome. They are falling. Their most remarkable finding was that the variety and increase in additional compensatory movements of the trunk accompany walking, and they have stated that more studies should be performed on changes in the upper body so that their connection in the fall during aging is clearer.(Sawa et al., 2014) As mentioned in the research of Storska et al. (2009) and Justna Derzal (2012), aging women and men over 60 years of age have postural changes that naturally include kyphosis, an asymmetric shoulder, a forward head, and scoliosis. This may disturb the symmetry of the trunk and affect many factors including walking. (Justyna Drzał-Grabiec, Snela, Rykała, Podgórska, & Banaś, 2013; Ostrowska, Rożek-Mróz, & Giemza, 2003) Mark Garbiner et al. (2008) reported that the ability to limit trunk movement can prevent the risk of falls in aging people.(Grabiner et al., 2008) Aging is associated with dysfunctions in the vestibular system and vision, a decrease in the speed of information transmission and a change in the way information is processed in the brain, all of which lead to balance and postural disorders. Backward imbalance is a postural disorder characterized by a posterior position of the center of mass relative to the support in standing and sitting positions, predisposing people to fall backward. This postural disorder creates a posterior tilt to the trunk and disturbs the vertical alignment, leading to backward imbalance, which is often observed in the daily clinical practice of aging individuals. An imbalance toward the back and the creation of a slope behind the trunk increase the risk of falling, and serious injuries, such as wrist, hip and vertebral fractures, which are very common, occur as an individual ages.(Tan, Eng, Robinovitch, & Warnick, 2006; Wong et al., 2009) According to this case, qualitative evaluation with functional tests is not enough to determine the risk of falling backward; as a result, the index of posterior symmetry of the trunk was used to use quantitative and qualitative methods to further assess backward imbalance. The posterior slope that is created in the trunk should be measured by the risk of falling.(Manckoundia, Mourey, Pérennou, & Pfitzenmeyer, 2008)

The anterior trunk symmetry index (ATSI) is the same as the posterior trunk symmetry index. In most cases, they are used together and are among the standard assessment methods for determining trunk asymmetries. The difference is that the posterior trunk symmetry index is older and has been known for more than 15 years, while the anterior trunk symmetry index was introduced in 2012, and less research has been done in this field. Stolinski et al. (2013 and 2017) discussed spinal deformities and postural disorders that can be investigated by evaluating the deformation of the trunk surface. In this study, the clinical usefulness of the anterior trunk symmetry index parameter was not yet determined by conducting studies on larger groups of healthy and scoliosis children at different ages, and it needs to be investigated in other groups and variables. In this study, the clinical usefulness of the anterior trunk symmetry index parameter was not yet determined by conducting studies on larger groups of healthy and scoliosis children at different ages, and it needs to be investigated in other groups and variables. (Kotwicki & Grivas, 2012; Stolinski et al., 2017) Anna Matelga et al. (2019) reported that the combined use of anterior and posterior trunk symmetry indices is recommended for diagnosing defective posture in children and adults, and further studies are needed to determine which clinical conditions may lead to certain differences between the corresponding values of the two criteria.(Matlęga et al., 2020) Mahoney et al. (2017) investigated anterior and posterior fluctuations and displacement as well as lateral fluctuations in aging people and reported that one of the factors contributing to falling in aging individuals is slight trunk fluctuations, especially in the anterior and posterior angles, and it has been stated that falling often occurs due to several factors. Factors such as posture changes can also be effective in these fluctuations and deserve to be studied. (Mahoney, Oh-Park, Ayers, & Verghese, 2017) Rosekmore and colleagues (2003) investigated the anterior-posterior curvature of the spine and determined the values of body symmetry deviations in the frontal plane in aging men over 60 years old with standardized parameters, including trunk symmetry indices for upper limb abnormalities. The loss of body posture stability and body stability control disorders that lead to falls and damage to the motor system have been addressed. (Ostrowska et al., 2003) Spinal deformity during aging is a common medical disorder that has a significant and measurable impact on health-related quality of life. Spinal deformity in adults may also be caused by degenerative changes in intervertebral discs and facet joints, which leads to asymmetric collapse of motor segments with segmental and regional deformation. (Mahoney et al., 2017) Spinal deformity can be defined as an abnormality in the alignment, formation or curvature of one or more parts of the spine. Adult spinal deformity describes a wide variety of conditions that result in abnormal alignment of the spine and may result in pain, disability, neurological impairment, or loss of function. Such deformities can involve any combination of the axial, coronal, and sagittal planes. As a result, with the changes that occur in the spine, asymmetries occur in the anterior surface of the trunk. (Ailon et al., 2015)The upper limbs are an important part of the protective reaction against falling, which creates a postural disorder in the upper body, especially the front of the trunk, and changes the body's inclination toward the front, changes the function of muscles and the role of forces and joints, and can increase the risk of falling. Studies on fall protective responses to forward falls have focused on factors that increase the risk of forward falls. (Burkhart & Andrews, 2013)During a forward fall, the distal upper extremity is often used to arrest the body's forward motion, and it has been suggested that 39% of forward fall-initiating impacts result in distal radius fractures, as well as hip fractures and wrist fractures, and 60% of head injuries are related to falls, which are among the most common injuries caused by forward falls. (Schonnop et al., 2013; Tan et al., 2006) (Caplan et al., 2017) According to the importance of this issue, as stated in the present studies and research, the postural changes and asymmetries that occur due to spinal deformities affect the condition of the trunk, especially the front of the trunk. This approach can affect the walking cycle and movement coordination and, ultimately, the severity of aging.

The body posture index (PI) is a standard and easy parameter for detecting spine abnormalities such as kyphosis, lordosis, forward head and flat back, and this method was used in the present study to determine abnormalities and their relationship with the risk of falling during aging. became. Hohan Gang et al. (2019) The aim of this study was to evaluate the parameters of the standing position of the body in the sagittal plane and to determine the dynamics of changes in the standing position of the body with increasing age and the difference between men and women aged 20 to 89 years, which was found to change greatly with increasing age. The angles of the neck, chest, and knees can affect many factors, including balance. (Gong et al., 2019; Ribeiro et al., 2017) Oliver Ludig et al. (2016) used body posture indices to diagnose postural defects in children and adolescents using photogrammetry. In this study, body posture index, a complex parameter that reflects the alignment of several parts of the trunk in the sagittal plane and is suitable for use as a screening parameter (due to its high reliability, correlation, and validity) in daily clinical practice, was mentioned. Is. In this study, it has been stated that other investigations of possible changes of this index on different age groups should be investigated. (Ludwig, Hammes, Kelm, & Schmitt, 2016) Carlo Dindef et al. (2023) identified postural defects in men and women aged 10 to 69 years, and using the stereo photogrammetry method, they examined sagittal posture parameters and stated that this index can help in the early stages to carry out preventive measures. Therefore, it can be an important tool for promoting public health. (Ludwig et al., 2023) According to the studies of Deborah et al. (2007), moderate hyper kyphosis status may represent an easily identifiable independent risk factor for traumatic falls in aging men and is one of the factors that disrupts the balance system; however, in women, this factor has not been fully identified. (Kado, Huang, Nguyen, Barrett-Connor, & Greendale, 2007) Cristina et al. (2017) introduced the use of the body posture index as the fastest way to check body posture, by which deviations and asymmetries of the body can be identified. (Milićev & Vukušić) Carroll et al. (2019) used the body posture index for mentally disabled volleyball players and found that through this evaluation they can identify its relationship with the balance and posture system and the risk of falling. (Bibrowicz et al., 2019) Studies have shown that postural changes such as thoracic hyper kyphosis, loss of lumbar lordosis and reduction of foot arch, head forward, and scoliosis contribute to increasing postural instability and thus increasing the risk of falling in older people. Predictably, people with abnormal posture are at greater risk of falling because their balance is disrupted by the abnormal posture. In general, maintaining the alignment of the spine in the sagittal view depends on muscle strength and proper posture, which stabilize the body's balance and are related to each other. Therefore, improving physical abilities through muscle training and maintaining the sagittal alignment of the spine and reducing asymmetries, in addition to body balance training, may be important for preventing falls and maintaining daily activities during aging. (Imagama et al., 2013) One of the most important abnormalities that can involve all three anterior, posterior and especially lateral views is hyper kyphosis, loss of lumbar lordosis and loss of the forward head. In the present study, according to the statistics, most of the subjects had hyper kyphosis, reduced lumbar lordosis and forward head, which led to sagittal imbalance, displacement of the anterior center of mass, increased postural fluctuations, increased risk of falling, and limitations in daily activities. In fact, the direction of the fall affects the location of the impact so that the fall on the side has the highest risk of hip fracture (Migliarese & White, 2019; Takahashi et al., 2005)When the body position is disrupted in the sagittal view, the mechanical load, bending moments, pressure and shear force increase. It increases on the spine, which can limit the movement and mobility of the chest and affect the rhythm of walking, balance and the ability to control the person to prevent the person from falling. (Duangkaew, 2022; Duangkaew et al., 2020)

As with any study, this investigation has several limitations. First, because some centers and aging people were not willing to take pictures without covering, the number of research samples did not increase. Second, due to limitations in removing the lower body clothing of the subjects, sagittal images of the lower body part were obtained. Third, the research was conducted in a unisex manner.

Further studies should investigate the relationship between trunk symmetry indices and the risk of falling in aging women to determine the difference between these findings and the results of the present study. It is also suggested that a study with more functional tests and a more detailed laboratory test of the risk of falling be conducted so that the relevant results are more accurate. The trunk symmetry indices can also be checked in two groups of elderly people with and without fear of falling.

In general, the results of the present study showed that there is a significant relationship between the risk of falling in aging men and the POTSI and ATSI indices and the PI. However, there was no significant relationship between the anterior trunk symmetry index and the TUG score. As a result, trunk symmetry indices have the ability to predict the risk of falling, and along with FRT tests, they are quantitative assessments for determining the risk of falling. However, the correlation and relationship of trunk symmetry indices were greater in the FRT. Additionally, for physical condition indicators, the PI and POTSI were more strongly correlated and related to functional tests, which shows their greater ability to determine the risk of falling. Additionally, the ATSI had no significant relationship with the TUG test and had a moderate correlation with the FRT test. This finding showed that it has less predictability than the other indicators, so more research needs to be done on it to identify a clearer connection. Based on the results of this study, it is suggested to use standard evaluation and screening parameters for aging to identify the risk of falling during aging by using initial evaluations, and then various exercises and treatment methods to improve postural structure and trunk symmetry for the reduction and prevention of aging falls should be designed.

POTSI

Posterior trunk symmetry index

ATSI

Anterior trunk symmetry index

Posture index

FRT

Functional reach test

TUG

Time up and go

WHO

World Health Organization

European Union

Ethics approval and consent to participate

This research has no risk or harm in terms of measurement methods or tests, and confidentiality has been observed in maintaining the data and photos of the subjects. This research was also conducted by the ethics committee of Tehran University with the code IR.UT.SPORT.REC.1402.016 and was ethically approved.Informed consent was obtained from all participants prior to theassessments.

Consent for publication

To carry out the research, full explanations about the research and its method were first given, and then all the people who volunteered were subjects. A consent form was obtained from the individual or his guardian.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research received no external funding.

Authors' contributions

Conceptualization, Methodology: KH; Data curation, Writing- Original draft preparation: KH; Writing- Reviewing and Editing: KH & MK; Supervision: MK; Validation: MK. All the authors have read and approved the final manuscript.

Acknowledgments

The present research is taken from the master's thesis in the field of adaptive physical education at Tehran University. I hereby thank and appreciate all the professors and all the participants of this research.

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حسینی س. (1397).سقوط سالمندان. Paper presented at the سومینهمایشملیاختلالاتعصبیعضلانیاسکلتی. https://civilica.com/doc/812590.

No competing interests reported.

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Trunk symmetry indices can affect the risk of falling in older adults (Correlational study)

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Abstract

Background

Methods

Results

Conclusion

Figures

1. Introduction

2. Methods

2.1. Measurement of trunk indices

2.2. Calculation of the POTSI and ATSI with the formula

2.3. Time up and go and functional reach tests

3. Results

3.1. Relationships between trunk symmetry indices and FRT and TUG test scores

3.2. Predicting trunk symmetry indices for the risk of falling

4. Discussion

5. Limitations

6. Outlook

7. Conclusion

Abbreviations

Declarations

References

Additional Declarations

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