Postural stability and fall risk in patients with obstructive sleep apnea: a cross-sectional study



Nocturnal hypoxia and daytime sleepiness resulting from fragmented sleep may impair the ability of postural stability in subjects with OSA. This study investigates the effect of disease severity on postural stability and whether or not it poses a fall risk in individuals with obstructive sleep apnea (OSA).


Forty-nine patients with OSA diagnosed by all-night polysomnography (apnea-hypopnea index (AHI) ≥ 5) and aged 51.4 ± 7.2 years were included in the study. The patients were divided into two groups as severe OSA (AHI ≥ 30, n = 24) and non-severe OSA (5 ≤ AHI ≤ 30, n = 25). All patients were subjected to testing for postural stability (PS), limits of stability (LOST), and the stability index for fall risk (fall risk SI) with the Biodex Balance System®. Daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Biodex measurements and daytime sleepiness were compared between severe and non-severe OSA groups. Univariate analysis was conducted to explore if AHI, ESS score, lowest SaO2 (%), sleep stages (%), or total arousal index predict postural stability scores.


Overall and anterior-posterior PS indices were higher in the severe OSA group (p < 0.05). Dynamic PS and fall risk indices did not differ between groups. AHI and lowest SaO2 (%) were found to be an independent predictor for both overall PS (r = 0.300 and r = 0.286, respectively) and fall risk SI (r = 0.296 and r = 0.374, respectively), whereas stage N1 (%) and stage N3 (%) were an independent predictor for overall LOST score (r = -0.328 and r = 0.298, respectively) (p < 0.05).


Static postural stability of individuals with severe OSA is worse than those with non-severe OSA. Static postural stability worsens, and fall risk increases as AHI increases and the lowest SaO2 decreases in individuals with OSA. On the other hand, dynamic postural stability worsens as stage N1 (%) sleep increases and stage N3 (%) sleep decreases. While nocturnal hypoxia indicators such as AHI and lowest SaO2 are associated with static postural stability, sleep structure-related variables are associated with dynamic stability. Including postural stability assessments in the clinical practice for OSA may help addressing workplace accidents or tendency to fall.

Trial registration registration number: NCT03589417.

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  1. 1.

    Sateia MJ (2014) International classification of sleep disorders. Chest 146(5):1387–1394

    Article  Google Scholar 

  2. 2.

    He K, Kapur VK (2017) Sleep-disordered breathing and excessive daytime sleepiness. Sleep Med Clin 12(3):369–382

    Article  Google Scholar 

  3. 3.

    Punjabi NM (2008) The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc 5(2):136–143

    Article  Google Scholar 

  4. 4.

    Devita M, Montemurro S, Zangrossi A, Ramponi S, Marvisi M, Villani D, Raimondi MC, Merlo P, Rusconi ML, Mondini S (2017) Cognitive and motor reaction times in obstructive sleep apnea syndrome: a study based on computerized measures. Brain and cognition 117:26–32

    Article  Google Scholar 

  5. 5.

    Brauer SG, Woollacott M, Shumway-Cook A (2001) The interacting effects of cognitive demand and recovery of postural stability in balance-impaired elderly persons. J Gerontol A Biol Sci Med Sci 56(8):M489–MM96

    CAS  Article  Google Scholar 

  6. 6.

    Riemann BL, Caggiano NA, Lephart SM (1999) Examination of a clinical method of assessing postural control during a functional performance task. J Sport Rehabil 8(3):171–183

    Article  Google Scholar 

  7. 7.

    Goldie PA, Bach T, Evans O (1989) Force platform measures for evaluating postural control: reliability and validity. Arch Phys Med Rehabil 70(7):510–517

    CAS  PubMed  Google Scholar 

  8. 8.

    Riemann BL, Guskiewicz KM (2000) Effects of mild head injury on postural stability as measured through clinical balance testing. J Athl Train 35(1):19–25

    CAS  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Bougard C, Lepelley M-C, Davenne D (2011) The influences of time-of-day and sleep deprivation on postural control. Exp Brain Res 209(1):109–115

    Article  Google Scholar 

  10. 10.

    Aguiar SA, Barela JA (2014) Sleep deprivation affects sensorimotor coupling in postural control of young adults. Neurosci Lett 574:47–52

    CAS  Article  Google Scholar 

  11. 11.

    Degache F, Goy Y, Vat S, Haba Rubio J, Contal O, Heinzer R (2016) Sleep-disordered breathing and daytime postural stability. Thorax 71(6):543–548

    Article  Google Scholar 

  12. 12.

    Stevens D, Jackson B, Carberry J, McLoughlin J, Barr C, Mukherjee S, Oh A, McEvoy RD, Crotty M, Vakulin A (2020) The impact of obstructive sleep apnea on balance, gait, and falls risk: a narrative review of the literature. J Gerontol A Biol Sci Med Sci 75(12):2450–2460

    Article  Google Scholar 

  13. 13.

    Allali G, Perrig S, Cleusix M, Herrmann FR, Adler D, Gex G, Armand S, Janssens JP, Pepin JL, Assal F (2014) Gait abnormalities in obstructive sleep apnea and impact of continuous positive airway pressure. Respir Physiol Neurobiol 201:31–33

    CAS  Article  Google Scholar 

  14. 14.

    Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM, American Academy of Sleep Medicine (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. J Clin Sleep Med 8(05):597–619

    Article  Google Scholar 

  15. 15.

    Johns MW (1993) Daytime sleepiness, snoring, and obstructive sleep apnea: the Epworth Sleepiness Scale. Chest 103(1):30–36

    CAS  Article  Google Scholar 

  16. 16.

    Izci B, Ardic S, Firat H, Sahin A, Altinors M, Karacan I (2008) Reliability and validity studies of the Turkish version of the Epworth Sleepiness Scale. Sleep Breath 12(2):161–168

    Article  Google Scholar 

  17. 17.

    Cachupe WJ, Shifflett B, Kahanov L, Wughalter EH (2001) Reliability of biodex balance system measures. Meas Phys Educ Exerc Sci 5(2):97–108

    Article  Google Scholar 

  18. 18.

    Fernández-Huerta L, Aravena-Arriagada J, Bernales-Montero M, Córdova-León K (2019) Relationship between sleep quality and postural balance in community-dwelling older persons: a cross-sectional study. Medwave 19(05)

  19. 19.

    Algina J, Olejnik S (2003) Sample size tables for correlation analysis with applications in partial correlation and multiple regression analysis. Multivariate Behav Res 38(3):309–323

    Article  Google Scholar 

  20. 20.

    Wagner LS, Oakley SR, Vang P, Noble BN, Cevette MJ, Stepanek JP (2011) Hypoxia-induced changes in standing balance. Aviat Space Environ Med 82(5):518–522

    Article  Google Scholar 

  21. 21.

    Celle S, Annweiler C, Camicioli R, Barthélémy J-C, Roche F, Beauchet O (2014) Sleep-related breathing disorders and gait variability: a cross-sectional preliminary study. BMC Pulm Med 14(1):140

    Article  Google Scholar 

  22. 22.

    Young T, Palta M, Dempsey J, Peppard PE, Nieto FJ, Hla KM (2009) Burden of sleep apnea: rationale, design, and major findings of the Wisconsin Sleep Cohort study. WMJ 108(5):246–249

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    O'Donoghue FJ, Wellard RM, Rochford PD, Dawson A, Barnes M, Ruehland WR, Jackson ML, Howard ME, Pierce RJ, Jackson GD (2012) Magnetic resonance spectroscopy and neurocognitive dysfunction in obstructive sleep apnea before and after CPAP treatment. Sleep 35(1):41–48

    Article  Google Scholar 

  24. 24.

    Gomez S, Patel M, Berg S, Magnusson M, Johansson R, Fransson P (2008) Effects of proprioceptive vibratory stimulation on body movement at 24 and 36 h of sleep deprivation. Clin Neurophysiol 119(3):617–625

    CAS  Article  Google Scholar 

  25. 25.

    Schlesinger A, Redfern MS, Dahl RE, Jennings JR (1998) Postural control, attention and sleep deprivation. Neuroreport 9(1):49–52

    CAS  Article  Google Scholar 

  26. 26.

    Furtado F, Bruno da Silva BG, Abranches ILL, Abrantes AF, Forner-Cordero A (2016) Chronic low quality sleep impairs postural control in healthy adults. PLoS One 11(10):e0163310

    Article  Google Scholar 

  27. 27.

    Ratnavadivel R, Chau N, Stadler D, Yeo A, McEvoy RD, Catcheside PG (2009) Marked reduction in obstructive sleep apnea severity in slow wave sleep. J Clin Sleep Med 5(6):519–524

    Article  Google Scholar 

  28. 28.

    McCormick D, Westbrook G (2013) Chapter 51. Sleep and Dreaming. 5 ed. In Eric R. Kandel E, James H. Schwartz, Edited, Thomas M. Jessell, Edited, Steven A. Siegelbaum, editor. New York: Principles of neural science, pp. 1140-58

  29. 29.

    Slater G, Steier J (2012) Excessive daytime sleepiness in sleep disorders. J Thorac Dis 4(6):608

    PubMed  PubMed Central  Google Scholar 

  30. 30.

    Uehli K, Mehta AJ, Miedinger D, Hug K, Schindler C, Holsboer-Trachsler E, Leuppi JD, Künzli N (2014) Sleep problems and work injuries: a systematic review and meta-analysis. Sleep Med Rev 18(1):61–73

    Article  Google Scholar 

  31. 31.

    Tyagi S, Perera S, Brach JS (2017) Balance and mobility in community-dwelling older adults: effect of daytime sleepiness. J Am Geriatr Soc 65(5):1019–1025

    Article  Google Scholar 

  32. 32.

    Hayley AC, Williams LJ, Kennedy GA, Holloway KL, Berk M, Brennan-Olsen SL, Pasco JA (2015) Excessive daytime sleepiness and falls among older men and women: cross-sectional examination of a population-based sample. BMC geriatrics 15(1):74

    Article  Google Scholar 

  33. 33.

    Olson L, Cole M, Ambrogetti A (1998) Correlations among Epworth Sleepiness Scale scores, multiple sleep latency tests and psychological symptoms. J Sleep Res 7(4):248–253

    CAS  Article  Google Scholar 

  34. 34.

    Kingshott RN, Engleman H, Deary IJ, Douglas N (1998) Does arousal frequency predict daytime function? Eur Respir J 12(6):1264–1270

    CAS  Article  Google Scholar 

  35. 35.

    Yue HJ, Bardwell W, Ancoli-Israel S, Loredo JS, Dimsdale JE (2009) Arousal frequency is associated with increased fatigue in obstructive sleep apnea. Sleep Breath 13(4):331–339

    Article  Google Scholar 

  36. 36.

    Wali SO, Abaalkhail B, AlQassas I, Alhejaili F, Spence DW, Pandi-Perumal SR (2020) The correlation between oxygen saturation indices and the standard obstructive sleep apnea severity. Ann Thorac Med 15(2):70–75

    CAS  Article  Google Scholar 

  37. 37.

    Sreedharan SE, Agrawal P, Rajith RS, Nair S, Sarma SP, Radhakrishnan A (2016) Clinical and polysomnographic predictors of severe obstructive sleep apnea in the South Indian population. Ann Indian Acad Neurol 19(2):216–220

    Article  Google Scholar 

  38. 38.

    Era P, Sainio P, Koskinen S, Haavisto P, Vaara M, Aromaa A (2006) Postural balance in a random sample of 7,979 subjects aged 30 years and over. Gerontology 52(4):204–213

    CAS  Article  Google Scholar 

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Author information




GYG and HNG designed the study; GYG, HNG, MZ, and MEA performed the study; GYG, SO, and AK collected the data and also reviewed the literature; MZ statistically analyzed the data; and GYG, HNG, MZ, and MEA wrote and critically reviewed the paper. All authors have read and approved the manuscript.

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Correspondence to Gulhan Yilmaz Gokmen.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Ethics Committee of Non-Interventional Clinical Trials, Institute of Medical Sciences, Bezmialem Vakif University, Istanbul, Turkey) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Yilmaz Gokmen, G., Gurses, H.N., Zeren, M. et al. Postural stability and fall risk in patients with obstructive sleep apnea: a cross-sectional study. Sleep Breath (2021).

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  • Daytime sleepiness
  • Fall risk
  • Obstructive sleep apnea
  • Postural stability