Mancini et al.

Journal of NeuroEngineering and Rehabilitation 2012, 9:59

http://www.jneuroengrehab.com/content/9/1/59

JNER

RESEARCH

JOURNAL OF NEUROENGINEERING
AND REHABILITATION

Open Access

ISway: a sensitive, valid and reliable measure of

postural control
Martina Mancini1,2*, Arash Salarian1, Patricia Carlson-Kuhta1, Cris Zampieri3, Laurie King1, Lorenzo Chiari2
and Fay B Horak1

Abstract
Background: Clinicians need a practical, objective test of postural control that is sensitive to mild neurological disease,
shows experimental and clinical validity, and has good test-retest reliability. We developed an instrumented test of
postural sway (ISway) using a body-worn accelerometer to offer an objective and practical measure of postural control.
Methods: We conducted two separate studies with two groups of subjects. Study I: sensitivity and experimental
concurrent validity. Thirteen subjects with early, untreated Parkinsons disease (PD) and 12 age-matched control subjects
(CTR) were tested in the laboratory, to compare sway from force-plate COP and inertial sensors. Study II: test-retest
reliability and clinical concurrent validity. A different set of 17 early-to-moderate, treated PD (tested ON medication), and
17 age-matched CTR subjects were tested in the clinic to compare clinical balance tests with sway from inertial sensors.
For reliability, the sensor was removed, subjects rested for 30 min, and the protocol was repeated. Thirteen sway
measures (7 time-domain, 5 frequency-domain measures, and JERK) were computed from the 2D time series
acceleration (ACC) data to determine the best metrics for a clinical balance test.
Results: Both center of pressure (COP) and ACC measures differentiated sway between CTR and untreated PD. JERK and
time-domain measures showed the best test-retest reliability (JERK ICC was 0.86 in PD and 0.87 in CTR; time-domain
measures ICC ranged from 0.55 to 0.84 in PD and from 0.60 to 0.89 in CTR). JERK, all but one time-domain measure, and
one frequency measure were significantly correlated with the clinical postural stability score (r ranged from 0.50 to 0.63,
0.01 < p < 0.05).
Conclusions: Based on these results, we recommend a subset of the most sensitive, reliable, and valid ISway measures to
characterize posture control in PD: 1) JERK, 2) RMS amplitude and mean velocity from the time-domain measures, and 3)
centroidal frequency as the best frequency measure, as valid and reliable measures of balance control from ISway.
Keywords: Postural control, Accelerometers, Inertial sensors, Parkinsons disease

Background
Postural control is the foundation of our ability to stand
and to walk independently. Deterioration in postural control due to normal ageing or neurodegenerative disease
such as Parkinsons disease (PD) is associated with an
increase in risk of falls incurred during activities of daily life
[1,2]. Deterioration in balance control predisposes 68% of
people with PD to fall at least once each year [3]. Although
* Correspondence: [email protected]
1
Department of Neurology, School of Medicine, Oregon Health & Science
University, 505 NW 185th Avenue, Beaverton, OR 97006, USA
2
Biomedical Engineering Unit, Department of Electronics, Computer Science
& Systems, Alma Mater Studiorum-Universita di Bologna, Viale Risorgimento
2, 40136, Bologna, Italy
Full list of author information is available at the end of the article

it is well-known that subjects with PD show postural

instability in advanced stages of the disease [4-7], very few
studies have investigated whether it is possible to identify
abnormal balance in early stages of the disease, prior to
starting antiparkinsonian medication [8-10]. Early identification of abnormal balance in patients with PD is important because new neuroprotective medications are
currently being tested to slow the progression of PD. Neuroprotection needs to begin early in the disease, prior to
significant loss of neurons. Also, early in the disease, it is
often difficult to distinguish idiopathic PD from other,
Parkinson-plus syndromes that have very different Prognoses and it is possible that sway characteristics will differ
among these different basal ganglia diseases.

2012 Mancini et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Mancini et al. Journal of NeuroEngineering and Rehabilitation 2012, 9:59

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Currently, the most common way to evaluate postural

control in the clinic is to use clinical rating scales that are
limited by clinicians bias, insensitivity to mild impairments (ceiling effects), and poor reliability [11-13]. These
limitations are serious concerns for clinicians and
researchers who want to monitor disease progression,
determine intervention efficacy or treat people with mild
balance deficits [14]. Technology currently available for
clinicians and researchers to measure postural control
generally uses force plate analysis of center of pressure
(COP) displacement during quiet stance [6,15]. Experimental studies have demonstrated the sensitivity of COP
measures to postural disorders such as Parkinsons disease
[8,9] and to fall risk in the elderly [16,17]. However, forceplate-based posturography (or stabilometry) is quite large
and expensive and requires a proper installation that may
not be practical for clinical use.
Body-worn accelerometers (ACC) have been proposed
as a portable, low-cost alternative to a force plate for
measurements of postural sway [2,18-21]. Recently, we
showed that ACC-based measures of postural sway are
sensitive to balance disorders in patients with untreated
PD [10]. Moreover, Najafi et al., demonstrated that
ACC-based derived measures of center of mass during
postural sway detect deterioration in patients with diabetic neuropathy [2]. These results suggest that such
measures may provide a sensitive means of measuring
subtle balance deficits in clinical settings.
Despite the potential advantages of accelerometric systems in clinical practice, they still have several drawbacks, such as the need to pre-process data and the
question of how to translate sway measures into clinically understandable outcomes. However, the major
limitation is that there is no consensus as to which
sway-related measures should be considered. Studies have
shown that root mean square (RMS) of the acceleration
signal can be sensitive to test conditions (eye closure,
standing on one foot), to ageing, and to history of falls
[22-24]. We recently presented a relatively new measure
of sway, JERK, as the most discriminative measure to
differentiate sway in patients with untreated PD compared
to age-matched control subjects [10].
In order to make ACC-based measures useful for clinical applications, it is important to assess their validity,
sensitivity, and reliability, compared to gold standard lab
and clinical assessments [25,26]. The relationship
between the same postural sway measures calculated
from the force plate COP and from ACC that would
support the experimental validity of ACC measures have
only been reported in three studies, the first by Adlerton
et al. [20] in one-legged stance trials in healthy adults,
the second by Najafi et al. [2] in diabetic patients, and
the third by Whitney et al., [18] in healthy control subjects during different sensory conditions. No studies

Page 2 of 8

have shown experimental validity of ACC-based measures and force plate-based measures of postural sway
for subjects with very mild balance deficits, such as
those with untreated PD. Our previous study on ACC
measures of postural control only showed which are the
best measures that discriminate between untreated PD
and age-matched control [10]. Moreover, to our knowledge, only one study has presented test-retest reliability
of balance measures calculated from an ACC placed on
the belt of young, healthy adults [27]. There are no studies that have evaluated test-retest reliability of postural
sway in patients with PD and elderly subjects, or studies
that have systematically examined the relative reliability
of amplitude, velocity, and frequency components of
sway. Finally, it is important that a new objective test of
postural control is validated with clinical scales. For
patients with PD, the most common clinical measure of
balance impairment is the postural instability and gait
disability (PIGD) subscore of the Unified Parkinsons
Disease Rating Scale (UPDRS) [28].
The goal of this study was to develop and validate a practical tool that allows clinicians to measure postural sway in
a clinical setting with body-worn accelerometers. We call
our tool the instrumented sway system (ISway). Our vision
is that this tool will provide reliable, automatic analysis of
sway that is sensitive, accurate, robust, and consistent,
without the need for clinical experts to deal with the raw
data. To achieve this objective, we carried out two studies
in order to determine: i) the sensitivity and experimental
concurrent validity of ACC compared to force-plate measures of postural sway; and ii) test-retest reliability and clinical concurrent validity of ACC-based measures compared
to the PIGD. From this information, we recommend a subset of the most sensitive, reliable, and valid ISway measures
to characterize postural control in PD.

Methods
Study design

We carried out two studies. The first study was performed in the motion analysis laboratory, to determine
the sensitivity and experimental concurrent validity of
ACCs compared to force-plate measures (Study I). The
second study took place in the hospital neurology clinic
to determine the test-retest reliability and clinical concurrent validity of the proposed automatic clinical system, ISway (Study II).
Subjects
Study I: sensitivity and experimental concurrent validity

To assess the sensitivity of sway measures to detect

untreated PD and the relationship between ACC and
COP measures, 13 subjects with idiopathic PD and 13
age-matched healthy control subjects participated in the
study (Table 1). One control subject was excluded

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Table 1 Summary of Subject Characteristics for Study I

and II
Study I

UPDRS

Age

Medications

13 PD

28.1(11.2)

60.4 8.5 years

None

12 CTRL
Study II

17 PD
17 CTRL

60.2 8.2 years

28.3 (10.4)

67.1 7.3 years

PD ON medication

67.9 6.1 years

because he was diagnosed with a neurological disorder

after he had been selected to participate, leaving the
control group with 12 subjects. Only subjects with PD
who were early- to mid-stage in the disease course and
had never been treated with dopaminergic or other antiparkinsonian medication were invited to participate. The
PD and control groups showed no significant difference
in age or body mass index (BMI) but the PD group had
more male (7) subjects than control group (5).
Study II: test-retest reliability and clinical concurrent validity

To assess test-retest reliability of the measures and the

relationship with clinical scales, a different group of 17
PD and 17 age-matched control subjects were tested in
the neurology clinic by a research assistant. The patients
with PD were tested in their ON medication condition
(Table 1). The PD and control groups showed no significant difference in age or BMI, but the PD group had
more males (12) than the control group (6).
In both studies, subjects were excluded if they presented
with any neurological disorders other than PD or if they
had any other condition that could affect their balance.
Patients were clinically rated by a trained examiner on the
Motor Section (III) of the UPDRS and the Hoehn and Yahr
Scale immediately before the experimental sessions. The
UPDRS Part III consists of 23 items related to bradykinesia, rigidity, tremor and posture and gait signs of PD, rated
on a 4-point scale [28]. The PIGD consists of the sum of 4
UPDRS sub-items, posture, gait, sit-to-stand and pull test,
with score from 0 (normal) to 16 (severe) [7].
Measurement protocol and data acquisition
Study I: sensitivity and experimental concurrent validity

All participants were instructed to maintain an upright

standing position on a force-plate (AMTI OR6-6, Watertown, MA), with arms crossed and heel-to-heel distance
fixed at 10 cm. Feet were allowed to be externally
rotated at a comfortable amount for each subject [29],
and all the participants wore similar athletic shoes.
Initial stance position was consistent from trial to trial
by tracing foot outlines on the force-plate.
Subjects wore a MTX Xsens sensor (49A33G15, Xsens,
Enschede, NL) with 3-D accelerometers (1.7 g range)
mounted on the posterior trunk at the level of L5, near
the body center of mass. The sensing axes were oriented

Page 3 of 8

along the anatomical antero-posterior (AP), medio-lateral

(ML), and vertical directions. A total of three, 2-minute
trials were performed with eyes open gazing straight ahead
at an art poster.
The COP displacement was calculated from the ground
reaction forces recorded by the force-plate at a 100-Hz
sampling frequency and after applying a 10-Hz cut-off,
zero-phase, low-pass Butterworth filter. Acceleration signals were collected with a 50-Hz sampling frequency,
transformed to a true horizontal-vertical Cartesian coordinate system [30] and filtered with a 3.5 Hz cut-off, zerophase, low-pass Butterworth filter. This filter was applied
also to the COP in order to eliminate possible contributions of tremor at rest, a well-known PD symptom, which
may be present in the range from 4-to-7 Hz [31].
Study II: test-retest reliability and clinical concurrent validity

Subjects wore the same MTX Xsens sensors on the posterior trunk at the level of L5. To ensure a consistent
foot-width position, we constructed a styrofoam wedge
that was placed between the feet before each trial. Three
30 s trials of quiet standing were collected.
The sensor was removed after finishing the 3 ISway
trials. After 30 min resting in a chair the sensor was put
back on and the protocol was repeated. We assumed that
the subjects performances remained the same within this
time period. The same examiner used the same device and
the same protocol to test the subject for the second time.
Automatic instrumented Sway in the clinic: ISway

For the experiments in the clinic, subjects wore a portable data-receiver (X-Bus) wired to the MTX XSens sensors. The sensor recorded 3-D linear accelerations and
angular velocity while the controller continuously, wirelessly streamed data to a laptop via Bluetooth.
A custom MATLAB (MathWorks, Nantick, MA) graphical interface was built to acquire, store and analyze
different components of balance. The software also automatically compared each subjects balance-related measures compared to normative ranges (based on metrics
from healthy subjects) and uploaded the data to a server
for additional analysis.
In addition to the previously described pre-processing of
the acceleration signals, the algorithm includes an automatic inspection of acceleration signals to make sure that
trials in which subjects may have lost their balance were
excluded from the analysis. Specifically, signals were
divided into three 10s windows and the standard deviation
(SD) was computed on each window. If the SD of at least
one of the three windows exceeded 5 times the SD of one
of the other windows, the trial was discarded. After this
automatic check, a total of 13 ACC measures were computed from the 2D acceleration time series, similar to COP
analysis (details in Table 2). In the time-domain, we

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Table 2 Summary of the extracted measures

Measure abbreviation Description
JERK

Time-domain
measures

Sway jerkiness, time derivative of acceleration




Zt 
dACCLAP 2
dACCLML 2

[m2/s5] JERK 12
dt
dt
0

DIST

Mean distance from center of COP (ACC) trajectory

[mm] ([m/s2])

RMS

Root mean square of COP (ACC) time series [mm]

([m/s2])

PATH

Sway path, total length of COP (ACC) trajectory

[mm] ([m/s2])

RANGE

Range of COP displacement (acceleration) [mm]

([m/s2])

MV

Mean velocity COP: PATH/trial duration [m/s];

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relationship between ACC metrics and clinical scores

(UPDRS III and sub-items) in Study II. To evaluate testretest reliability of the ISway, Intra-Class Correlation
(ICC) was used [32]. Since the same subjects and same
device was used for reliability, an ICC(1,1) was used.
The and 95% confidence intervals were reported.

Results
Study I: sensitivity and experimental concurrent validity

ACC-based measures of sway were just as sensitive as

COP measures in differentiating between the untreated
PD and control groups. The COP and ACC traces of a
representative control subject, a mild, untreated PD subject (UPDRS = 17), and a moderate, untreated PD subject (UPDRS = 35) during a quiet stance trial are
illustrated in Figure 1. The size and jerkiness of both the

s
Z
2 Z
2
ACCLML [mm/s]
ACCLAP
ACC:
MF

Mean frequency, the number, per second, of loops

that have to be run by the COP (ACC), to cover a
total trajectory equal to PATH (MF = PATH/
(2**DIST*trial duration) (Hz)

AREA

Sway area, computed as the area spanned from

the COP (ACC) per unit of time [mm2/s] ([m2/s5])

Frequency-domain
measures
PWR

Total power [mm2] ([m2/s4])

F50

Median frequency, frequency below which the

50% of PWR is present (Hz)

F95

95% power frequency, frequency below which the

95% of PWR is present (Hz)

CF

Centroidal frequency (Hz)

FD

Frequency dispersion ()

computed six measures that characterized the ACC trajectory and one measure that estimated the area covered by
the 2D ACC trace. In the frequency-domain, spectral properties were assessed by five measures: one measure that
quantifies the total power of the ACC signal, one measure
that estimates the variability of the frequency content of
the power spectral density of the ACC, and three measures
of characteristic frequencies in the power spectral density
of the ACC signal. We included jerkiness of sway, as
described in a previous paper [10].
Data analysis

Algorithms for signal analysis and statistical evaluation

of the outcomes were written in MATLAB. Differences
between untreated PD and control groups were determined by using a t-test. Differences were assumed significant when P < 0.05. A Pearson Product moment
correlation was used to assess both the relationship
between COP and ACC metrics in Study I and the

Figure 1 Center of pressure (left panel) and acceleration (right

panel) traces in the horizontal plane for three representative
subjects.

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COP and ACC traces are larger in the mild untreated

PD subject and even larger in the moderate, untreated
PD subject compared to control subject.
Consistent with the representative trials in Figure 1,
most time- and frequency-domain measures of both
ACC and COP were sensitive to untreated PD. Table 3
summarizes p-values of the time- and frequency-domain
outcome measures comparing untreated PD and control
subjects, as well as the correlations between ACC and
COP measures.
Most ACC measures of sway were significantly correlated with COP measures of sway, attesting to their concurrent validity (Table 3). Only two measures, MV and
MF were not significantly correlated with COP.
Study II: test-retest reliability and clinical concurrent
validity

Table 4 summarizes the test-retest reliability of ACC

measures for the control and PD groups. Overall, the PD
group showed higher test-retest reliability than the
control group. The JERK and time-domain measures
showed the best reliability (highlighted in Table 4),
whereas the frequency-domain measures had poorer
test-retest reliability.
Table 5 summarizes the clinical concurrent validity. Several ACC measures showed significant correlation with the
PIGD sub-score of the UPDRS III. All except one timedomain measure (MF), one frequency-domain measure

Page 5 of 8

(PWR), and JERK were significantly and positively correlated with the PIGD sub-score related to clinical postural
instability. No significant correlations were found between
ACC measures and the total Motor UPDRS.

Discussion
ISway is an innovative tool that can allow clinicians to
objectively measure posture control during stance easily and
quickly in a clinical setting. The approach of using accelerometers on the belt to quantify postural sway was shown to
be sensitive, valid, and reliable for patients with PD.
The JERK of sway acceleration was found to be the most
sensitive measure to discriminate untreated PD and control subjects [10]. The ISway measures also showed significant differences between the untreated PD and agematched control groups for 5 out of 7 time-domain and 4
out of 5 frequency-domain ACC measures. Similarly, significant differences between groups were observed using
COP measures: 3 out of 7 time-domain and 4 out of 5
frequency-domain COP measures. Subjects with untreated
PD showed larger sway amplitude and area, larger sway
jerkiness but lower frequencies of sway than control subjects. A more detailed discussion of ACC differences in
postural sway between mild PD and control groups is presented in a separate paper [10].
ISway measures of postural sway were validated by
force-plate measures of COP displacement. Many, but not
all, ISway measures were correlated with the gold-standard

Table 3 Sensitivity of COP and ACC-based measures

COP
Control
Mean

SEM

ACC

PD
Mean

p values
SEM

Jerk

NA

Control

Correlation

PD

p values

Mean

SEM

Mean

SEM

0.241

0.023

0.394

0.053

0.0003

Trajectory Measures
DIST

4.370

0.329

6.261

0.423

0.002

0.062

0.005

0.088

0.010

0.02

0.73

0.0001

RMS

5.141

0.371

7.329

0.552

0.003

0.073

0.006

0.106

0.012

0.02

0.74

0.0000

PATH

944.015

89.277

817.707

62.661

0.25

17.183

1.028

22.035

2.128

0.05

0.46

0.200

RANGE

32.247

2.750

40.824

3.385

0.06

0.421

0.031

0.610

0.065

0.01

0.64

0.0007

MV

7.867

0.744

6.814

0.522

0.26

1.328

0.229

1.789

0.241

0.18

0.12

0.56

MF

0.290

0.018

0.181

0.016

0.0001

0.393

0.029

0.378

0.045

0.78

0.33

0.11

0.36

0.002

0.0003

0.005

0.001

0.004

0.68

0.2

2.009

0.269

3.178

0.479

0.04

0.41

0.05

Area Measures
AREA

10.699

1.581

13.138

2.121

1761.7

12966.1

1585.1

0.002

Frequency Measures
PWR

9870.8

F50

0.410

0.015

0.298

0.012

0.00009

0.385

0.014

0.305

0.012

0.0003

0.86

0.000001

F95

1.518

0.069

0.990

0.057

0.0007

1.849

0.121

1.523

0.128

0.07

0.49

0.01

CF

0.666

0.032

0.451

0.023

0.0002

0.722

0.043

0.591

0.038

0.03

0.47

0.02

FD

0.767

0.009

0.827

0.009

0.00005

0.777

0.009

0.839

0.008

0.0003

0.89

0.000001

Those measures in boldface were significantly different between untreated PD and control subjects. Correlations between COP and ACC measures are also reported.

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Table 4 Test-Retest Reliability of ACC-based measures

CTRL
Test I
Jerk

Test II

PD
ICC(1-1)

95%Cl bounds

Test I

Test II

ICC(1-1)

95%Cl bounds

Mean

SEM

Mean

SEM

lower

upper

Mean

SEM

Mean

SEM

lower

upper

0.065

0.007

0.067

0.007

0.87

0.67

0.95

0.235

0.110

0.188

0.066

0.86

0.66

0.95

Trajectory Measures
DIST

0.043

0.003

0.048

0.004

0.70

0.34

0.88

0.089

0.020

0.074

0.014

0.84

0.61

0.94

RMS

0.052

0.003

0.057

0.005

0.71

0.35

0.89

0.108

0.026

0.089

0.017

0.83

0.59

0.93

PATH

4.428

0.220

4.484

0.234

0.89

0.72

0.96

8.232

1.285

7.286

0.909

0.81

0.56

0.93

RANGE

0.275

0.016

0.283

0.020

0.74

0.41

0.90

0.567

0.150

0.494

0.102

0.82

0.58

0.93

MV

0.104

0.012

0.122

0.013

0.68

0.31

0.87

0.211

0.049

0.176

0.029

0.75

0.44

0.90

MF

0.58

0.03

0.55

0.05

0.60

0.17

0.84

0.54

0.04

0.54

0.04

0.55

0.12

0.81

0.0002

0.0021

0.0002

0.76

0.45

0.91

0.0127

0.0059

0.0078

0.0031

0.73

0.40

0.89

0.47

0.08

0.61

0.19

0.84

3.54

2.24

2.04

1.33

0.85

0.64

0.94

Area Measures
AREA

0.0019

Frequency Measures
PWR

0.41

0.04

F50

0.43

0.03

0.41

0.05

0.30

-0.20

0.68

0.36

0.01

0.37

0.02

0.35

-0.13

0.70

F95

1.95

0.10

1.92

0.10

0.59

0.17

0.83

1.78

0.16

2.00

0.14

0.67

0.31

0.87

CF

0.78

0.05

0.76

0.05

0.61

0.19

0.84

0.69

0.05

0.76

0.06

0.69

0.34

0.87

FD

0.76

0.01

0.79

0.02

0.25

-0.25

0.65

0.78

0.01

0.80

0.01

0.61

0.20

0.84

laboratory measures of sway from a force-plate. If the body

was moving like an inverted pendulum, a correlation close
to 1 would be expected between trunk acceleration and
COP displacement [33]. In fact, highly correlated measures
of COP and center of mass amplitudes have also been
reported during quiet stance [34,35]. Moderate to good
correlations were found between COP and ACC parameters, except for MV and MF. One explanation can be
Table 5 Correlation of ACC measures with UPDRS III and
PIGD
UPDRS III

PIGD

0.29 (p = 0.29)

0.55 (p = 0.03)

DIST

0.29 (p = 0.29)

0.57 (p = 0.02)

RMS

0.29 (p = 0.28)

0.57 (p = 0.02)

PATH

0.22 (p = 0.42)

0.50 (p = 0.05)

RANGE

0.29 (p = 0.30)

0.56 (p = 0.03)

MV

0.29 (p = 0.28)

0.63 (p = 0.01)

MF

0.09 (p = 0.72)

JERK
Time-domain measures

AREA

0.37 (p = 0.17)

0.29 (p = 0.29)

0.55 (p = 0.03)

0.30 (p = 0.27)

0.54 (p = 0.04)

Frequency-domain measures
PWR
F50

0.17 (p = 0.54)

0.18 (p = 0.49)

F95

0.24 (p = 0.38)

0.42 (p = 0.12)

CF

0.18 (p = 0.50)

0.34 (p = 0.20)

FD

0.23 (p = 0.41)

0.31 (p = 0.26)

that we used a different formula to calculate MV for COP

and ACC; for ACC, we integrated the acceleration signal
to get the velocity and for COP, we differentiated the COP
displacement. Another explanation for the difference may
be that subjects do not sway strictly as inverted pendulums
[36]. In fact, even quiet stance in young, healthy subjects
includes some hip strategy and the amount of hip strategy
used to control stance posture have been shown to
increase with age.
To our knowledge, this is the first paper reporting
reliability of postural sway measures, in control or PD
subjects, using an accelerometer-based approach. As
expected, ICCs were larger in PD subjects because there
was larger intra-subject variability in sway among PD
subjects than control subjects, without any increase in
variability of performance across sessions. In the PD
group, 6 ACC parameters out of 13 showed excellent
reliability (ICC > .80), 5 good (.60 < ICC < .80), 1 moderate (.40 < ICC < .60), and 1 poor reliability (ICC
< .40). In control subjects, 2 out of 13 ACC parameters
showed excellent reliability, 8 good, 1 moderate, and 2
parameters showed poor reliability. In general, JERK and
time-domain parameters showed better reliability than
frequency-domain parameters, and this has been previously reported in COP based measure of postural sway
[37,38]. Although it is possible that the poor reliability of
sway frequency metrics in people with PD, compared to
other spatial-temporal metrics, could be due to fluctuating tremor, we think this unlikely because we filtered the
acceleration signals below 3.5 Hz. In addition, healthy

Mancini et al. Journal of NeuroEngineering and Rehabilitation 2012, 9:59

http://www.jneuroengrehab.com/content/9/1/59

control subjects showed poorer reliability of the frequency metrics. A possible explanation for the worse
test-retest reliability of frequency-domain parameters
might be the variation in a subjects balance strategy
across the testing sessions, or might be attributed to the
shorter trial duration of trials in study II.
The ISway measures showed good clinical validity as
the measures are related to clinical scores. JERK, 6 out
of 7 time-domain measures, and total power significantly
correlated significantly with PIGD, a UPDRS III subscore
that is used in clinical trials to evaluate postural instability and gait disability based on clinical rating of postural
alignment, the pull test of postural stepping response, sit
to stand and gait [39]. However, ISway measures were
not significantly related with the overall Motor UPDRS
III. Since UPDRS motor scale is composed of scores
mostly related to tremor, bradykinesia and rigidity, its
poor correlation with ISway might suggest that the balance deficiency in early PD is not explained by those
symptoms. In fact, our recent meta-analysis of long-term
effects of deep brain stimulation surgery in patients with
PD show independent decline in PIGD, even when the
rest of the UPDRS cardinal signs slowed their decline
after surgery [40].
The potential application of the ISway is not to be
limited to testing subjects with PD. The ISway provides
a large number of measures that automatically, fully
characterize body sway in amplitude, smoothness, and
frequency; measures that are relevant for testing any
individual with balance deficits. In fact, it is likely that a
different subset of measures in the ISway might be sensitive to different neurological or musculoskeletal constraints. For example, JERK has been shown to be lower
than normal in patients with mild multiple sclerosis
[41]. Further studies are needed to determine the best
subset of postural sway parameters that can predict
future falls or disability during daily activities.

Conclusion
Previous results [23,24,42-44] suggest that postural sway
could be characterized by three relatively independent
characteristics: amplitude, velocity and frequency. Our
results showed the most sensitive and reliable ISway
measures to characterize posture control in PD are: 1)
JERK, for its excellent reliability and sensitivity; 2) RMS
for its best sensitivity and reliability among the timedomain measures and MV, for the best correlation with
clinical score (even if it is not sensitive to untreated PD);
and 3) CF as the best compromise from the frequencydomain measures (sensitive, reliable, and correlated with
COP CF).
In summary, the present accelerometric-based measurement of sway offers an inexpensive and efficient
alternative for quantifying posture control and provides

Page 7 of 8

excellent opportunities for on-line sway analyses. The

method is reliable and can be used together with clinical
balance and mobility tests in various circumstances, particularly in outcome and screening studies.
Competing interests
ISway is used in Mobility Lab by APDM. Drs. Horak and Salarian have
significant financial interests in APDM, a company that has a commercial
interest in the results of this research and technology. This potential conflict
of interest has been reviewed and managed by OHSU and the Integrity
Oversight Council.
Authors contribution
MM participated to study design and data collection, was responsible for
data analysis and interpretation, drafting the manuscript. AS participated to
study design and conception, participated in data analysis and interpretation,
revising manuscript. PCK, CZ, and LK were responsible for data collection
and interpretation, revising critically the manuscript. LC and FBH were
responsible for study design and conception, drafting and revising critically
the manuscript. All authors read and approved the final manuscript.
Acknowledgements
We thank Kelsey Priest and Triana Nagel for scheduling and testing subjects.
This publication was made possible with support from Kinetics Foundation,
NIH grants RC1 NS068678 and R37 AG006457, and in part by the Intramural
Research Program of the NIH, Clinical Center, Rehabilitation Medicine
Department.
Author details
1
Department of Neurology, School of Medicine, Oregon Health & Science
University, 505 NW 185th Avenue, Beaverton, OR 97006, USA. 2Biomedical
Engineering Unit, Department of Electronics, Computer Science & Systems,
Alma Mater Studiorum-Universita di Bologna, Viale Risorgimento 2, 40136,
Bologna, Italy. 3Functional and Applied Biomechanics Laboratory,
Rehabilitation Medicine Department, National Institutes of Health, Clinical
Center, Building 10, MSC 1604, Bethesda, MD 20892, USA.
Received: 26 October 2011 Accepted: 15 August 2012
Published: 22 August 2012
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doi:10.1186/1743-0003-9-59
Cite this article as: Mancini et al.: ISway: a sensitive, valid and reliable
measure of postural control. Journal of NeuroEngineering and
Rehabilitation 2012 9:59.

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