Measurement 98 (2017) 186191

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Measurement
journal homepage: www.elsevier.com/locate/measurement

Evaluation of psychological effects on human postural stability

Nina Grzinic Frelih a,, Anja Podlesek b, Jan Babic c, Gregor Gerak a
a

University of Ljubljana, Faculty of Electrical Engineering, Trzaka 25, 1000 Ljubljana, Slovenia
University of Ljubljana, Faculty of Arts, Department of Psychology, Akerceva 2, 1000 Ljubljana, Slovenia
c
Jozef Stefan Institute, Jamova cesta 39, 1000 Ljubljana, Slovenia
b

a r t i c l e

i n f o

Article history:
Received 3 November 2015
Received in revised form 21 November 2016
Accepted 23 November 2016
Available online 24 November 2016
Keywords:
Postural balance
Awareness of being measured
Biomedical sensors
Force plate

a b s t r a c t
Human postural stability is commonly assessed by a set of posturographic tests during quiet upright
standing. Numerous studies extend these tests with cognitive and mental tasks where various physiological and biomechanical sensors are used in combination with a force plate. The aim of our study was to
determine whether psychological effects of sensor attachment and the awareness of the subject being
measured could influence the posturographic tests performed using the force plate. An experiment
was performed where complete data from 51 participants (13 women and 38 men) were obtained in four
different conditions. Posturographic tests were performed either with eyes open or eyes closed, and
either with biomedical instrumentation sensors attached or not attached. The results indicate that the
presence of biomedical instrumentation sensors had a statistically significant impact on the centre of
pressure path length and ellipse area as well as on the perceived difficulty of the task and its pleasantness. We conclude that the attachment of sensors on the body of the participants during biomechanical
experiments significantly affects the perception of the experimental situation and alters the output of
posturographic tests. It is therefore important to appropriately take into account the possible effects of
psychological strain (such as the awareness of being measured) in the experimental design and in the
interpretation of the results.
2016 Elsevier Ltd. All rights reserved.

1. Introduction
1.1. Posture measurement
Balance is influenced by muscle performance, flexibility, vision
and other sensory inflows, as well as cognitive and emotional factors. Since balance is a complex motor and cognitive function, each
individual has to carefully coordinate information from the proprioceptive, visual and vestibular system with mobility initiatives.
Many studies on standing and holding the balance have been performed by using a force plate. A force plate is a platform designed
to measure the forces applied to its top surface as a subject stands,
steps, or jumps on it. It is regularly used in studying balance, gait,
and sports performance. These studies have mainly been used for
medical purposes and to explore the maintaining of balance in different circumstances, at different mental loads and different tasks,
etc. [1,2]. Studies often included implementation of a variety of
cognitive tasks, e.g. calculation, tracking, video monitoring. It was

Corresponding author.
E-mail address: [email protected] (N. Grzinic Frelih).
http://dx.doi.org/10.1016/j.measurement.2016.11.039
0263-2241/ 2016 Elsevier Ltd. All rights reserved.

determined that the centre of pressure (CoP) of some participants

changed due to an additional cognitive task [3,4].
Besides measuring the CoP, individual studies also included
monitoring of other physiological parameters (e.g. muscle activity,
blood oxygenation, respiration and cardiovascular parameters)
which were measured by means of various biomedical sensors.
Sensors were usually positioned onto the participants body in
such a way as commonly found in a clinical environment [510].
These studies reported that in addition to physical and biochemical
changes, attachment of biomedical instrumentation (BMI) might
result also in changes of participants physiology induced by psychological factors.

1.2. Psychological effects on posture

The impact of participants awareness of being measured during
research experiments is often ignored and not subject to systematic examination. A common example is in the process of noninvasive measurement of blood pressure where the process of
measurement itself can also affect the blood pressure level of the
monitored person. In the clinical field this phenomenon is well
known, described and named the white coat hypertension or white

N. Grzinic Frelih et al. / Measurement 98 (2017) 186191

coat effect [11]. White coat hypertension indicates the increase of

individuals level of psychological arousal due to awareness of
blood pressure measurement, which results in increased blood
pressure level, similarly as other measurements in medicine
depend on the psychological state of the measured participant,
particularly when in a state of anxiety, e.g. variability of heart rate,
electrocardiogram signal, autonomous nervous system parameters,
etc. [1214]. An expressed anxiety does appear in the majority of
medical measurements, especially in those where the physician
is present [11,12]. It is caused by the participants awareness that
she/he is being measured. Often the anxiety can influence the
results of measurement or the measurement itself. In order to
avoid the white coat effect in hypertension studies, a 24-h blood
pressure measurement is used, which statistically limits or
excludes the effect [15]. The effect of anxiety has been demonstrated also in biomechanical studies, e.g. where the measured participants under psychological stress or strain reacted with a change
of physical stability strategy, i.e. with reduced movement amplitude of the CoP [16].
Anxiety is human physiological response that prepares the
organism for struggling with future negative events and is a widely
studied parameter [1719]. Various forms of anxiety are stage
fright, tension, nervousness, fear and concern. In the measurement
situation, anxiety of the participant is caused by the act of measurement. It can be considered as a state of tension due to the performance of measurement and the participation in the monitoring
process, i.e. a tension that emerges because the participant is being
aware that she/he is being measured. As described above, such
measuring anxiety could cause changes in measurement results
and/or in the monitored physiological parameters.
Quiet upright standing is a dynamic biomechanical process
where one maintains the centre of mass by continuously adjusting
the position of body parts. Additionally, different sensors are commonly used in various studies on parameters of the centre of gravity [5,7,9,10]. We were interested whether attaching the sensors
for measuring physiological functions can affect the posturographic parameters. Important psychological effects were reported
in a study where the CoP excursions decreased during performance
of simple cognitive task, assuming that focus of attention was
diverted from the control of posture [2]. Further studies showed
changes in dynamic responses during standing of elderly and neurological patients due to the attenuation of the underlying organs
(vision, impaired basic stability, etc.) [20,21]. These research also
indicated that in some cases periodic movements in muscles were
increased with the increase of anxiety. Therefore, neural mechanisms responsible for the anxiety-associated-behaviour might significantly contribute to the pathophysiology of impairment of
elderly. This was also evident for patients with disorders of central
nervous system such as Parkinsons disease [22].

1.3. Aim of the study

Our main research question was whether we could deduce
changes of CoP due to awareness of being measured. The purpose
of this study was to determine whether we can use a common
force plate to detect any additional changes in CoP when the measured participant is being aware of the measurement. Biomedical
instrumentation (BMI) sensors for measuring physiological parameters were used as a source of strain (stressor). BMI sensors, which
were attached onto the participant during force plate measurement, were thus representing only an additional source of error
in postural balance. Measurements of CoP parameters were performed during two legs quiet upright standing with various combinations of open and closed eyes scenarios, and with and without
the use of BMI sensors.

187

2. Methods
2.1. Participants
The measurements were performed on 54 healthy volunteers.
From 54 participants three measurement sets were eliminated
due to measurement errors and the remaining data of 51 participants was considered for data analysis; 13 women (age:
27.9 years 7.2 years (std), height: 1.67 m 0.04 m (std), weight:
61.2 kg 6.7 kg (std)) and 38 men (age: 28.4 years 6.4 years
(std), height: 1.82 m 0.05 m (std), weight: 85.9 kg 14.2 kg
(std)). Prior to data collection, each participant was provided a
clear description of what was required for participation and was
asked to carefully read and sign the consent form. Participants
were given the right to withdraw from the study at any stage.
The measuring protocol was approved by the National Medical
Ethics Committee.

2.2. Experimental design

A set-up was designed and built for measuring the participants
centre of pressure (CoP), physiological parameters, and psychological parameters, i.e. subjective evaluations of experimental conditions. CoP measurements were performed by means of a force
plate Leonardo Mechanograph GRFP (Leonardo, Novotec Medical,
Pforzheim, Germany) using its software application for stability
and balance parameters estimation (Leonardo Mechanography
RES, Novotec Medical, Pforzheim, Germany). Experiments were
performed using common shoulder width two legs standing. Participants were performing a test in a quiet basic furnished room.
They were required to assume a normal upright standing position
on the elevated floor with the force plate, faced toward a wall 3 m
in front of them and look at a point placed at eye level on the wall.
BMI was used as the psychological stimulus for inducing the
psychological stress. For physiological measurements, i.e. measurements of the activity of the autonomous nervous system of
the participant, the modular psychophysiological data acquisition
(DAQ) device MP150 (Biopac Systems Inc., USA) was used. The Biopac measuring system was composed of the main DAQ module and
amplifier modules for skin temperature, skin conductance, respiration and ECG heart rate measurements. Biopac wired sensors were
selected because of their low weight for negligible disturbing effect
on biomechanics of the participant.
Physiological parameters during the experiment were obtained
from physiological signals of skin conductance (average skin conductance level and short-term temporal changes in skin conductance, i.e. SCR skin conductance response [23]), skin
temperature (average temperature of the skin), respiration (mean
respiratory rate) and heart rate from the electrocardiogram. Skin
temperature was measured at the tip of the ring finger on right
hand. Wet electrodes with conductance gel for skin conductance
measurements were placed on the forefinger and middle finger
of the right hand. Breathing monitoring belt was placed around
the chest of the participant on the lower edge of sternum. ECG
electrodes were attached on wrists of both arms and on the inside
ankle of the right leg (Fig. 1). These psychophysiological parameters were acquired and processed using Acqknowledge 4.2 software package (Biopac Systems Inc., USA).
Participants stood on both legs in four basic experimental conditions, a combination of (i) eyes open (EO) or eyes closed (EC) and
(ii) presence of biomedical sensors (BMI+) or absence of sensors
(BMI ). In two experimental conditions (BMI+ with EO and BMI+
with EC), participants were subjected to psychological stress during the CoP measurements, induced by the notion/awareness that
their physiological functions are being measured with BMI. For the

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N. Grzinic Frelih et al. / Measurement 98 (2017) 186191

Participants estimated how easy it was to keep the balance (DF how difficult this task was on a scale from 1 very difficult to 7
quite easy), how comfortable they felt during the test (EV emotional valence of performing the task on a scale from 1 very
unpleasant to 7 very pleasant), and how much they were focused
on maintaining the balance in each measurement situation (FT
focus on the task on a scale from 1 completely unfocused to 7
totally focused). Scales were chosen specifically for this experiment to obtain the information about what seemed to us the most
relevant dimensions of psychological strain induced by different
experimental conditions.
2.3. Data analysis
Total length of the CoP trajectory (path length PL), which indicates a movement path of the measured participants centre of
pressure in mm, and area of the standard ellipse containing 90%
of all CoP points - Sway Index (standard ellipse area EA), which
indicates a movement surface of the measured participants centre
of pressure in cm2, were calculated during the measurement and
for all experimental conditions [1,10,23]. Calculations of these values that indicate postural stability were performed by force plate
software.
To verify the effect of vision, e.g. eyes open (EO) condition, and
presence of BMI sensors on different dimensions of the CoP and
psychological evaluation, two-way MANOVA was used. Subsequent two-way univariate analyses of variance were carried out
to verify effects of these two parameters on single dependent variables. The relationship between the psychological evaluations, psychophysiological parameters measured in different experimental
conditions with BMI and parameters of the CoP was estimated
using the Pearson correlation coefficient.
3. Results
Fig. 1. Placement of BMI sensors. RSP respiration rate, SC - skin conductance,
SKT - skin temperature, ECG - heart rate.

maximal reliability of the experiment [24], every task was performed for a period of 30 s. Participants were informed when the
trial started and when it stopped. When measuring CoP parameters
with the force plate, conditions with eyes open and closed are frequently used. A standard experimental approach which includes
eyes conditions is the Rombergs test [25].
Participants were instructed to try to maintain their balance in
each experimental condition within the 30 s interval to their best
ability. Parameters of CoP were measured using the force plate in
all experimental conditions. In conditions where the participant
had also biomedical sensors attached, physiological responses of
the autonomous nervous system were measured (skin temperature, skin conductance, heart rate and respiration rate) in addition
to the CoP.
To avoid the potential source of variability in results caused by
the order of measurements within the protocol, we split participants into two groups. Half of the randomly selected participants
were measured first without and afterwards with BMI sensors
attached, and the second half of participants were measured first
with and then without the sensors. The measurement of balance
performance using a force plate could in principle be considered
as a potential source of psychological strain. To minimise the anxiety related to the balance measure itself, participants were invited
to do multiple practice trials with the balance task [26].
At the end of the experiment, participants were asked to grade
their experience of the experiment. Grading was performed for
each of the experimental conditions on a 7-point rating scale.

Fig. 2 shows CoP parameters in four experimental conditions. In

both EO and EC condition, the values of PL and EA were higher in
the condition with no sensors than in the condition with sensor
attached. Overall, the values of the CoP were lower when the participants had their eyes open (EO) during the measurement than
when they had their eyes closed (EC).
Fig. 3 shows assessments of task difficulty, emotional valence
and level of focus. Both in EO condition and in EC condition, partic-

Fig. 2. Completed path of the CoP (PL) and standard ellipse area of the CoP (EA) in
four experimental conditions, i.e. combinations of EO and EC, BMI+ and BMI . Error
bars represent 95% confidence intervals. The numbers written in the bars represent
the average value of the measured parameters in different conditions.

N. Grzinic Frelih et al. / Measurement 98 (2017) 186191

189

tance (in the order of 1 lS; SC in Fig. 4) and heart rate (in the order
of 2 BPM; HR in Fig. 4). Skin temperature (SKT in Fig. 4) was changing slowly and there were no major changes in the respiration rate
(RSP in Fig. 4).
Next, we compared measurements of CoP and physiological
parameters averaged across 30-s intervals only in the two experimental conditions in which the participants had the BMI sensors
attached: (i) in the condition eyes open (EO) and (ii) in the condition eyes closed (EC). A one-way MANOVA showed statistically significant differences in the resulting measures between the
conditions, Pillais Trace = 0.48, F(6, 44) = 6.77, p < 0.001. Subsequent univariate analyses of variance showed statistically significant differences between the conditions for the PL and EA
parameters of CoP (for PL, F(1, 49) = 25.89, p < 0.001,
MSE = 299.63, and for EA, F(1, 49) = 8.14, p = 0.006, MSE = 0.15),
but not for other physiological parameters. In the condition EO,
the path length and ellipse area of CoP were lower than in the condition EC (Fig. 2).
We analysed the correlations between CoP, psychological and
physiological measures (skin conductance, skin temperature, heart
rate and respiration rate) in different conditions. Large Pearson
correlation coefficients were found between the estimated task difficulty and emotional valence, with Pearson correlation coefficients
ranging from 0.55 to 0.63 (p < 0.001) in different conditions, meaning that the easier the task was for the participants, the more
pleasant it felt. Large correlations (ranging from 0.50 to 0.76 in different conditions; p < 0.001) were also found between PL and EA,
which is logical as the two CoP measures are interdependent. With
Bonferroni correction for multiple tests, no other correlation
between the studied measures reached statistical significance.

Fig. 3. Mean assessment and confidence interval of perceived task difficulty DF (1st
column), emotional valence EV (2nd column) and perceived level of focus on the
task FT (3rd column). The average values of assessments are also written in the bars.

ipants found maintaining balance as easier and more comfortable

when no sensors were attached as compared to the situations
when sensors were attached. Maintaining balance with their eyes
open was evaluated as easier and more comfortable than with their
eyes closed.
With MANOVA we have determined that the presence of the
BMI statistically significantly affected the measured parameters;
path length (PL), area of the standard ellipsis (EA), task difficulty
(DF), emotional valence (EV) and focus on the task (FT), Pillais
Trace = 0.54, F(5, 46) = 10.94, p < 0.001. Presence of vision also significantly influenced the measured parameters, Pillais
Trace = 0.71, F(5, 46) = 22.29, p < 0.001. The interaction between
the presence of BMI and vision (EO or EC) was not statistically significant, Pillais Trace = 0.12, F(5, 46) = 1.25, p = 0.301. Post-hoc
univariate analyses of variance showed that the presence of
biomedical instrumentation had a statistically significant impact
on the assessment of path length (PL), the ellipse area (EA), task
difficulty (DF) and emotional valence (EV), but not on the evaluation of the focus on the task (FT), while the presence of vision
had a statistically significant effect on all the measured parameters. Statistical significance of the main effects of sensor attachment and presence of vision on each described parameter is
shown in Table 1.
The attached BMI sensors for measuring skin conductance, skin
temperature, respiratory rate and heart rate represented a source
of disturbance in the CoP measurement process, but we also used
them to monitor the physiological functions during different conditions (Fig. 4). In general, skin conductance and heart rate
increased at the time of holding the balance, indicating the
increase in arousal. Noticeable changes were found in skin conduc-

4. Discussion
This research was an attempt to examine whether the equipment that is usually used in a laboratory setting has an influence
on performance and whether the associated psychological stress
influences participants perceived concentration to the task and
consequently, their stability (balance). Changes in the CoP were
expected to occur due to mental strain as a result of awareness
of the participant of being measured and/or due to the presence
of BMI sensors.
Subjective evaluations of task difficulty and emotional valence
confirmed that in comparison with the conditions where no
biomedical sensors were attached, holding the balance with sensors attached was somewhat more difficult and less pleasant to
participants. At the same time, participants held their stability better when they had BMI sensors attached. A detailed analysis of
measurements showed that the path of the CoP was varying less
when participants had sensors attached. This may be the consequence of the measurement situation experience and the aware-

Table 1
Summary of main effects of the presence of BMI and vision on each dependent variable (vision condition eyes open (EO) vs. eyes closed (EC), sensors condition with BMI
(BMI+) vs. without BMI sensors (BMI ), PL - path length in mm, EA - standard ellipse area, DF - task difficulty, EV emotional valence, FT focus on the task).
Parameter

SS

df

MS

g2p

BMI + vs BMI-

PL
EA
DF
EV
FT

2187.89
0.77
6.00
24.02
0.12

1
1
1
1
1

2187.89
0.77
6.00
24.02
0.12

10.44
11.05
12.64
29.67
0.08

0.002
0.002
0.001
0.000
0.773

0.17
0.18
0.20
0.37
0.00

0.89
0.90
0.94
1.00
0.06

EO vs EC

PL
EA
DF
EV
FT

16612.86
3.96
38.83
5.02
5.34

1
1
1
1
1

16612.86
3.96
38.83
5.02
5.34

41.66
10.99
58.97
11.16
5.35

0.000
0.002
0.000
0.002
0.025

0.45
0.18
0.54
0.18
0.10

1.00
0.90
1.00
0.91
0.62

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N. Grzinic Frelih et al. / Measurement 98 (2017) 186191

Fig. 4. Screenshot example of a measurement of physiological BMI parameters versus time while performing CoP experiment. Each frame in this screenshot represents a 30 s
interval of CoP measurement. Two frames correspond to EO and EC condition of the protocol.

ness of being measured. In many cases, the path length was significantly reduced when sensors were used, which implies that participants awareness of being measured improved their postural
stability. We can speculate that participants redirected their focus
of attention from holding the balance to the awareness of being
measured, which possibly increased their anxiety. Our results correspond to findings of another similar study which concluded that
spontaneous body responses to social threat cues involve freezelike behaviour in humans that consequently induces significant
reductions in body sway [27]. Specific changes in physiological
parameters after attaching the sensors which would reflect
increased arousal could support our hypothesis that attaching
the sensors could increase the anxiety. Unfortunately we do not
know if physiological parameters changed from the conditions
without the sensors attached to the ones with the sensors
attached. To confirm the assumption that arousal due to anxiety
increases when the sensors are attached, future studies should
monitor physiological parameters non-intrusively already prior
to attaching the sensors, so that the participants would be unaware
of physiological measurements.
The results of our measurements also showed that path lengths
of the CoP in conditions eyes closed (EC) were on average approx.
30% higher in comparison with the case eyes open (EO), while the
area of movement of CoP in the same direction increased by an
average of approx. 100% (Fig. 2). Similarly, as in [20,28,29], we
found that the measured CoP parameters were significantly
affected by the presence of vision. Thus participants with their eyes
closed experienced more difficulties in holding their balance. Providing cues about body position in the environment, visual information contributes to the spatial reference frame, complements
vestibular and somatosensory information and helps coordinate
self-motion [30] and postural balance [31]. In EO condition, participants were able to perceive their body posture relatively to horizontal or vertical lines such as ground level and board border.
Major limitations of the study were a small number of participants, no physiological data available in the control condition (as
no sensors could be worn) and no psychological strain measured
directly. Participants were asked how easy the task was and how
comfortable they felt, but this did not always mean they felt
stressed or anxious. Even a difficult task could be interpreted as
a challenge instead of a threat, which is not related to measurement anxiety. Furthermore, participants were asked to rate their
experience of each condition retrospectively at the end of the

experiment. If they had completed the ratings at the end of each

condition, the results might have been different. On the other hand,
real-time rating might possibly impose some psychological strain
on them and would have an effect on their subsequent posture
and experience, which is why we decided to rather obtain these
data at the end of the experiment. Last but not least, in the conditions with no sensors attached we tried to simulate the situation
where the participants would not be aware that they were being
measured. Additionally, performing the experiment in the laboratory might be inherently disturbing to some participants. A nonrepeated-measures design where some subjects would be told that
they should only try the balancing task (e.g. as a warmup), so
that they would not even be aware that they are being measured
while standing on a force plate, would probably be more suitable,
but not informing the participants that they are being measured
would definitely open some ethical issues. Nevertheless, we did
find a difference between the condition with sensors being
attached and the condition without sensors, implying that the
effect of the sensors was large enough to be noticeable. This effect
should be taken into consideration in future studies, as it seems
that the results of studies using biomedical sensors which the participants are aware of might give biased results.
Measurements of human cognitive and emotional factors are
complex since visual and other sensory information from the environment can directly affect the results. Several items in terms of
psychological responses, such as baseline measurements, the normalization for individuals, and different blind tests need to be considered when performing those kind of measurements. A study of
all possible combinations and cases could quickly become unmanageable and hard to compare, therefore in our research we decided
on a simplified experimental design, because we did not want to
exceed the number of observed parameters. Baseline measurements at this point were not relevant as we did not pay attention
to the physiological values. We used biomedical sensors only as a
psychological stimulus for inducing the psychological stress as
described in experimental design.
5. Conclusion
The goal of our research was to determine whether there is an
influence of certain additional stressors on holding the balance.
Awareness of being observed or measured was achieved/increased
by attaching BMI sensors onto participants body.

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The results of our research showed that there was indeed an

influence. They indicated the potential impact of sensor attachment on experience of the participant, resulting in changes in holding the balance. The results of this study are consistent with results
of studies, where other types of anxiety were investigated, like
postural anxiety or freeze-like behaviour as defensive response,
and where changes in participants movement were reported
[22,27].
We conclude that when performing measurements of the balance, one must take into account the measurement situation in
which the participant is placed, even in simple biomechanical tasks
like holding the balance. Attachment of any apparatus/instrumentation on the participant could potentially influence the perception
of experimental situation and, consequently, result in success of
completion of the biomechanical task, e.g. holding the balance.
Therefore, it is necessary to assess the impact of participants
awareness that they are being measured and to take it into account
when interpreting the data.
Findings of our study contribute to the understanding that psychological factors are present in the biomechanical experiments
using BMI sensors, and might affect the measured value. In the
future it would be reasonable to examine what factors specifically
affect the measures (e.g., psychophysiological measures and measures of balance) and how inter-individual differences in psychological variables might be taken into account or controlled for.
For example, perhaps the effects of awareness of being measured
might be reduced by an additional cognitive task that would redirect focus of attention out of the measuring process. The task
should, however, be chosen carefully, not to interfere with the psychological or physiological measures of the studys primary
interest.
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