Examination of the Relationship Among Balance,Physical Activity,and Anthropometry in Athletes With Visual Impairments

Abstract

Introduction

Although it is well documented in the literature that individuals with visual impairments have low physical activity levels and impaired body compositions and postural controls compared with peers without vision loss, the relation between these parameters in athletes with visual impairments is unknown.

Research Question

Here, we (i) evaluated the physical activity levels, balance measures, and anthropometry parameters in athletes with visual impairments and peers without vision loss controls and (ii) compared these variables between the two groups.

Methods

We designed a retrospective observational study with parallel groups conducted on 33 athletes with visual impairments and 33 sighted controls matched for age and sex. We also utilized a questionnaire about physical activity levels and assessed static balance for 4 conditions (eyes-open firm surface, eyes-closed firm surface, eyes-open foam surface, and eyes-closed foam surface) and anthropometry.

Results

In athletes with visual impairments, body composition, body mass index (BMI), physical activity level, and static balance parameters revealed no significant relationship (p > .05), whereas eyes-open and -closed firm and foam surface conditions were positively related with physical activity at a moderate level (r = 0.39, r = 0.38, p < .05, respectively). Moderate-intensity and high-intensity physical activity was positively associated with fat-free mass (r = 0.82, r = 0.68, p < .01, respectively) and negatively related with body mass, fat %, and fat mass (r = −0.67, r = −0.52, r = −0.72, r = −0.66, r = −0.50, r = −0.50, p < .01, respectively). Athletes with visual impairments presented lower static balance than the sighted controls for three conditions, while eyes-closed foam surface scores were similar in both groups. The physical activity levels were higher for athletes with visual impairments (p < .05). However, we found no difference in the body composition and BMI between two groups (p > .05).

Discussion

Sports participation from individuals with visual impairments is related to higher physical activity levels, resulting in better anthropometric profile. The balance control was not related to physical activity levels in athletes with visual impairments.

Keywords

static balance goalball B1 football physical activity body mass index body composition

The postural equilibrium system controls balance orientation and stability. The harmonious interactions of somatosensory, vestibular, and visual systems result in a good maintenance of the balance (Jazi, Purrajabi, Movahedi, & Jalali, 2012; Parreira, Grecco, & Oliveira, 2017). Individuals with visual impairments (i.e., blindness or low vision) rely on vestibular and somatosensory systems for postural stability maintenance (Ray, Horvat, Croce, Mason, & Wolf, 2008), consequently impairing static and dynamic activities (Hallemans, Ortibus, Meire, & Aerts, 2010).

There is a wealth of research emphasizing that individuals with visual impairments have reduced dynamic and static balance abilities when compared to peers without vision loss (Müürsepp, Arjokesse, Ereline, Pääsuke, & Gapeyeva, 2018; Parreira et al., 2017), yet studies carried out with athletes who are visually impaired are limited (Aydog, Aydog, Cakci, & Doral, 2006; da Silva et al., 2018). It can be argued that athletes develop sport-specific balance adaptations, and this adaptation may, in turn, contribute to activities of daily living. It has been well acknowledged that physical activity participation promotes health-related quality of life (Gill et al., 2013). Unfortunately, the physical activity levels of individuals with visual impairments are low; their body mass indexes (BMIs) are high; and balance abilities are lower when compared to peers without vision loss (Colgan, Bopp, Starkoff, & Lieberman, 2016; Furtado, Morato, Potenza, & Gutierrez, 2016; Kobberling, Jankowski, & Leger, 1991). Therefore, the goal of this study was to investigate the association among balance, physical activity, BMI, and body composition in athletes with visual impairments and compare those with sighted, matched controls. We hypothesized that physical activity levels, anthropometric variables (body composition and BMI), and balance parameters of athletes with visual impairments would be similar with those of their sighted peers.

Methods

Participants

Thirty-three B1 football and goalball athletes with visual impairments (14 females and 19 males) and 33 physically active sighted athletes (15 females and 18 males), who were free of injury and chronic illnesses, took part in this study voluntarily. International Blind Sports Association (IBSA) sport classes (International Blind Sports Federation, 2018) were adopted for athletes with visual impairments (21=B1 sport class, 8=B2 sport class, and 4=B3 sport class). Athletes in sport class B1 had blindness, with a visual acuity in the better eye of greater than 3/60; athletes in sport class B2 had profound visual impairment, with a visual acuity in the better eye of less than 6/18, but 3/60 or better; and athletes in sport class B3 had mild visual impairment, with a visual acuity in the better eye of less than 6/12, but 6/18 or better (Bourne et al., 2017). Consent forms were read twice and signed by the athletes. Ethical approval was attained by the Non-Interventional Clinical Research Ethics Board (Decision no: 2019/08-35). Before the study, familiarization with the tests and procedures were undertaken for the athletes. Muscle fatigue and vigorous physical activity may affect balance control; therefore, the balance test did not take place after training and athletes who were engaged in vigorous physical activity were excluded from the study (Barbieri, dos Santos, Vitorio, van Dieen, & Gobbi, 2013).

Procedures

Height was measured by a stadiometer with an accuracy of ± .1 cm (Holtain, England). Measurements of body composition components were performed with foot-to-foot bioelectrical impedance analysis using a digital scale (Tanita TBF401A, Tanita Corporation, Tokyo, Japan). Self-reported physical activity levels of participants were evaluated through the short version of the International Physical Activity Questionnaire (da Silva et al., 2018; Marmeleira, Laranjo, Marques, & Batalha, 2013), and physical activity scoring was performed as described elsewhere (Craig et al., 2003).

Balance and sensory integration scores of athletes were measured by the Biodex-BioSway device (Biodex Medical Systems, Shirley, NY) (Aydog et al., 2006). The Modified Clinical Test for Sensory Integration and Balance (m-CTSIB) is a test protocol to assess the integration of somatosensory, visual, and vestibular senses with regard to balance and compensates when one or more of those senses are compromised on a static surface. The m-CTSIB consists of 4 different testing protocols: eyes-open and -closed firm surface (EO-FIS; EC-FIS); eyes-open and -closed foam surface (EO-FOS; EC-FOS). Athletes were tested barefoot for EO-FIS, EC-FIS, EO-FOS, and EC-FOS conditions and they were assessed for 30 seconds. One familiarization trial was completed prior to each four conditions.

Statistical Analysis

Descriptive analyses, including mean values, were analyzed for each measure recorded, and normal distribution of dataset was checked with the Shapiro-Wilk test. Normality distribution was met (p < .05); therefore, Pearson r correlations including 95% confidence intervals (95% CI) were used to check whether there was an association among balance, physical activity level, BMI, and body composition in athletes with visual impairments. Differences between groups were determined with independent samples t-test. SPSS statistical software version 22.0 (Chicago, IL) was used to perform the analyses. Statistical significance was set at p < .05.

Results

As shown in Table 1, there were no significant differences in athletes with and without visual impairments for age, physical characteristics, BMI, body composition, sport age, weekly and daily training duration, and the eyes-open foam surface balance parameter. The physical activity levels of athletes with visual impairments were found to be higher than those of their sighted peers. On the contrary, eyes-open and -closed firm surface and eyes-open foam surface balance condition scores were better in sighted athletes.

Table 1.

Sport Age, Training Frequency, Physical Characteristics, BMI, Physical Activity Level, and Static Balance Scores of Athletes.

Variable	Sighted		VI		t	p	Cohen’s d
Variable	M	SD	M	SD	t	p	Cohen’s d
Sport age (year)	10.93	3.78	9.87	3.29	1.207	.232	.298
Training (week/day)	3.84	1.25	3.75	1.24	.318	.752	.079
Training (day/hr)	2.20	1.05	2.48	1.18	−1.020	.311	−.253
Age (year)	22.60	3.07	24.31	5.31	−1.590	.117	−.389
Height (cm)	175.0	.09	170.3	.09	1.940	.057	.471
BM (kg)	73.54	11.82	69.29	13.05	1.377	.173	.339
BMI (kg.m⁻²)	23.85	2.04	23.69	2.53	.285	.776	.071
Fat %	16.04	7.46	16.23	7.57	−.100	.921	−.024
FM (kg)	11.55	5.22	11.08	4.78	.824	.413	.094
FFM (kg)	60.80	15.19	57.79	14.25	.379	.706	.204
Physical activity level
Total (MET-minutes/wk)	3775.3	2786.4	6112.4	2182.3	−3.757	.000*	−.849
Walking (MET-minutes/wk)	1575.5	1488.5	684.2	673.1	3.097	.003*	.721
MIPA (MET-minutes/wk)	330.9	502	2390.6	1855.9	−6.149	.000*	−1.215
HIPA (MET-minutes/wk)	1867.8	2183.2	3037.5	2269.7	−2.118	.038*	−.511
Static balance
EO-FIS	.29	.08	.70	.29	−7.664	.000*	−1.378
EC-FIS	.57	.16	.74	.27	−3.017	.004*	−.705
EO-FOS	.65	.14	1.80	.58	−10.941	.000*	−1.606
EC-FOS	1.72	.39	1.69	.41	.339	.736	.084

Note. Mean parameter values for each of the analyses are shown for the visually impaired (VI) athletes (n = 33) and sighted athletes (n = 33), as well as the results of t-tests comparing the parameter estimates between the two groups. Causes of vision impairments are congenital (n = 14), glaucoma (n = 5), retinitis pigmentosa (n = 4), fever (n = 3), traumatic (n = 2), retinitis detachment (n = 1), amblyopia (n = 1), cataract (n = 19), optic atrophy (n = 1), and doctor fault (n = 1). BM = body mass; BMI = body mass index; FM = fat mass; FFM = fat-free mass; MIPA = moderate-intensity physical activity; HIPA = high-intensity physical activity; EO-FIS = eyes-open firm surface; EC-FIS = eyes-closed firm surface; EO-FOS = eyes-open foam surface; EC-FOS = eyes-closed foam surface.

^*p < .05.

No correlation was found among balance scores in four visual conditions, BMI, body composition, and weekly physical activity level (p > .05). Moderate physical activity was positively associated with eyes-open firm and foam surfaces (r = 0.39, r = 0.38, p < .05, respectively), whereas eyes-closed firm and foam surfaces conditions were not related to any physical activity parameters (p > .05). The complete dataset is included Table 2.

Table 2.

Descriptive Statistics and Correlations for Static Balance, Physical Activity Level, Body Composition, and BMI in Atheletes With Visual Impairments.

Variable	n	M	SD	1	2	3	4	5	6	7	8	9	10	11	12	13
1. BM (kg)	33	69.29	13.05	—
2. BMI	33	23.69	2.53	.83	—
3. Fat %	33	16.23	7.57	−.38	.00	—
4. FM (kg)	33	11.08	4.78	.19	.37	.87	—
5. FFM (kg)	33	57.79	14.25	.92	.65	−.65	−.32	—
6. Total (MET-minutes/wk)	33	6112.4	2182.3	.04	−.09	−.18	−.19	.12	—
7. Walking(MET-minutes/wk)	33	684.2	673.1	.24	−.04	−.37*	−.33	.35*	.73	—
8. MIPA (MET-minutes/wk)	33	2390.6	1855.9	−.67**	−.41*	−.72**	−.50**	.82**	.13	−.09	—
9. HIPA (MET-minutes/wk)	33	3037.5	2269.7	−.52**	.25	−.66**	−.50**	.68**	.63	.48	−.65	—
10. EO-FIS	33	.70	.29	−.20	−.14	.30	.20	−.27	−.05	−.93	.39*	−.34	—
11. EC-FIS	33	.74	.27	.16	.08	−.02	−.03	.19	.15	.00	−.07	.20	.41	—
12. EO-FOS	33	1.80	.58	−.33	−.30	.11	.01	−.32	−.07	−.14	.38*	−.33	.32	.07	—
13. EC-FOS	33	1.69	.41	−.01	−.07	.09	−.00	−.04	−.15	−.16	−.17	−.24	.50	.37	.40	—

Note. BM = body mass; BMI = body mass index; FM = fat mass; FFM = fat-free mass; MIPA = moderate-intensity physical activity; HIPA = high-intensity physical activity; EO-FIS = eyes-open firm surface; EC-FIS = eyes-closed firm surface; EO-FOS = eyes-open foam surface; EC-FOS = eyes-closed foam surface.

^*p < .05.

^**p < .01.

Discussion

In this study, we found that BMI and body composition characteristics of athletes with and without visual impairments were similar, indicating that these two groups were evenly matched and supported our hypothesis, whereas physical activity levels of athletes with visual impairments were greater than those of their sighted peers. One of the possible explanations for this finding is that the participants with visual impairments in the current study were international-level athletes, and they participated in this study during their national training camps, where the intensity of the trainings were higher than their daily physical activity programs. Conversely, standing balance scores were worse in athletes with visual impairments compared to the sighted group, refuting our hypothesis. Similarly, absence of visual information results in poor static and dynamic balance in individuals with visual impairments (Aydog et al., 2006), thus reinforcing the role of vision on locomotion control (Hallemans et al., 2010). Nevertheless, athletes without vision loss scored similar in dynamic sway during eyes-closed foam surface condition when compared to athletes with visual impairments which partly supported our hypothesis. These findings are in line with the literature about athletes with visual impairments (da Silva et al., 2018) and non-athletes (Hakkinen, Holopainen, Kautiainen, Sillanpaa, & Hakkinen, 2006), showing that somatosensory and vestibular systems served as compensatory mechanisms for balance control in individuals with visual impairments. In our study, one possible argument for these findings is that goalball and B1 football athletes practice their modalities wearing eyeshades, which eliminates the differences in vision level. Therefore, they obtain the information about the environment and the localization of the body segments through hearing and touch in dynamic tasks.

In athletes with visual impairments, there were no associations among physical activity, static balance, BMI, and body composition. Similarly, it was found that motor skills such as balance and gait were not dependent on physical characteristics of children with visual impairments (Uysal, Erden, Akbayrak, & Demirturk, 2010). On the other hand, we found low positive correlation between moderate physical activity and eyes-open bilateral stance on firm and foam surface. This finding is in line with another study that reported relation between postural control and leisure time physical activity in children and adolescents with visual impairments (Müürsepp et al., 2018). Our findings on balance should be interpreted with caution due to limited specificity inherent of static or quasi static balance tests (Tsigilis, Zachopoulou, & Mavridis, 2001). We suggest future studies that include specific tests should consider sport-specific balance skills for athletes with visual impairments.

Interestingly, integratively, our results confirmed the sport participation as an important inductor of improvements in physical activity level, body composition, and functionality in individuals with visual impairments. It has been reported that sedentary individuals with visual impairments have higher body mass, BMI, and fat mass, and their physical fitness levels are lower than male and female goalball players (Karakaya, Aki, & Ergun, 2009). The characteristics of reduced mobility policies that promote higher participation in Paralympic sports will positively affect the physical activity levels, coordinative, and physical capacities in people with visual impairments (Furtado et al., 2016).

The observational nature precludes causal inferences from this study. Further, we suggest the quantitative techniques of physical activity determination such as accelerometer and pedometers rather than self-report measures in future studies. We conclude that high-level athletes with visual impairments show higher physical activity levels, similar body compositions, and lower balance abilities compared to sighted individuals. Furthermore, there is no direct link between physical activity level and balance ability, and the quantity of physical activity at moderate and high intensities were related to body composition in athletes with visual impairments.

Footnotes

Acknowledgments

We thank the Turkish Blind Sports Federation for their full support. This research would not be complete without B1 football and goalball athletes. We fully appreciate their willingness to be part of this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ferhat Esatbeyoglu

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