PT Classroom - Consideration of Balance Assessments for the Physical Therapist  ׀ by Chai Rasavong, MPT, MBA


Balance is defined as the ability to control the center of gravity over the base of support in a given sensory environment. It is important to us as therapists, because we may sometimes see a population of patients who may have a decrease in balance. In this population balance impairments can affect function which could lead to disability. Besides burns, falls are also one of the top reasons why legal litigation is taken on therapists.



Listed below from the Centers for Disease Control and Prevention are some general statistics of falls in the elderly environment from which therapists should be aware of when treating the elderly population:
• More than one third of adults 65 and older fall each year in the United States (Hornbrook et al. 1994; Hausdorff et al. 2001)
• Among older adults, falls are the leading cause of injury deaths. They are also the most common cause of nonfatal injuries and hospital admissions for trauma (CDC 2006).
• In 2005, 15,800 people 65 and older died from injuries related to unintentional falls; about 1.8 million people 65 and older were treated in emergency departments for nonfatal injuries from falls, and more than 433,000 of these patients were hospitalized (CDC 2008).
• The rates of fall-related deaths among older adults rose significantly over the past decade (Stevens 2006).


Risk Factors For Falls
When treating an elderly patient who may have a higher risk of falls the therapist should be aware of both the extrinsic and intrinsic risk factors for the patient. Extrinsic risk factors are associated with environmental features such as throw rugs, pets, obstacles, etc. While intrinsic risk factors are associated with lower extremity weakness, decrease sensation in the feet, decrease cognitive function, prior history of falls, etc.


Review of Postural Control Horak et al.
When we think of balance we should consider dynamic equilibrium and look at the entire picture and not just examine the individual but the environment and task at hand as well. There are many factors which contribute to balance. The sensory triad of postural control includes vision, somatosensory, and vestibular. A person utilizes vision to scan the environment and develop an anticipatory control or feedback mechanism. A person utilizes somatosensory input from sensory receptors to develop a reactive control mechanism. A person utilizes vestibular input to distinguish where he or she is in relationship to the world. This feature allows the individual to distinguish self motion from environmental motion. Other factors to consider when assessing postural control are ROM, strength, coordination, strategies for maintaining balance (ankle, hip, stepping response), postural response latencies, spatiotemporal coordination, force control and adaptation of postural strategies. Cognitive prowess as well as practice of an activity can affect postural control as well.


Items to Consider When Choosing a Balance Assessment
A. What is the test actually testing for? (specific impairment vs. functional impairment)
B. Can it discriminate between those who have a problem and those who don’t?
C. Is it sensitive to change?
D. Is it a reliable and valid measure?
E. Is it portable or does it have to stay in one location?


Common Balance Assessments Used in the Clinic
A. Berg Balance Scale: a list of 14 tasks that the client is asked to perform. The examiner rates the client on each task using a scoring scale from 0-4, where zero is unable to perform and 4 is able to perform without difficulty.
1) Appears to be the best single predictor of fall status
2) Harada et al. found 84% sensitivity and 78% specificity
3) Has been shown to have excellent interrater reliability (.96) and relatively good concurrent validity with Tinneti’s Performance Oriented Mobility Index (.91) and Mathia’s “Get Up and Go” Test (.76)
4) No gait measures
5) May not have as much functional mobility for higher level mobility

B. Tinetti Assessment Tool (includes balance and gait portion): The balance portion is a list of 9 items scored on scales of either 0-1 or 0-1-2, with the higher numbers reflecting better (more normal) performance. The best possible score is 16. The gait portion is a list of 7 normal aspects of gait that are observed by the examiner as the client walks at a self-selected pace and then a rapid-but-safe pace. Scoring scales are again either 0-1 or 0-1-2, and higher numbers indicate better performance. The best possible score is 12. When combined the Tinetti balance and gait scales offer a best possible score of 28.
1) Harada et al. found 68% sensitivity and 78% specificity for the balance portion and 80% sensitivity and 89% specificity for the gait portion
2) Lacks validation with rehab populations

C. Timed Get-Up-and Go-Test: Measures, in seconds, the time taken by an individual to stand up from a standard arm chair, walk the distance of 3 meters, turn, walk back to the chair, and sit down again. <10 secs is a normal score for young adults. <25secs is normal score for individuals over 65 years. >30 secs is a very abnormal score.
1) Speed of gait has been correlated with falls in older adults and many of our older adults walk slowly
2) Also provides valuable information to the clinician about the ability to rise out of a chair
3) Shumway-Cook et al. found this test to be sensitive (sensitivity = 87%) and specific (specificity = 87%) measure for identifying elderly individuals who are prone to falls
4) Limited use with non-ambulatory rehab patients
5) No impairment level discrimination of cause for balance deficit

D. Functional Reach Test: Test developed for elderly adults used to determine risks for falls. A patient standing with one shoulder close to the wall is asked to extend in front as far as possible without taking a step or losing stability. Scores < 6 or 7 inches indicate limited functional balance. Most healthy individuals with adequate functional balance can reach 10 inches or more.
1) Wernick-Robinson et al. concluded that the functional reach test doesn’t measure dynamic balance
2) Displays high reliability and below average validity
3) Unable to perform for individuals with severe spinal deformity or UE limitations
4) Limited to standing population


No one test is best, but picking the right one for the right population can help us obtain a more clear understanding of the problems underlying imbalance and increase our ability to effectively treat patients with balance disorders.


Miscellaneous - Forms, Handouts and Brochures
What can you do to prevent falls
Check for Safety: A Home Fall Prevention Checklist for Older Adults
Berg Balance Scale
Tinetti Balance Assessment Tool
Timed Get Up and Go Test
Functional Reach Test


1) Harada et al., Screening for balance and Mobility Impairment in Elderly Individuals Living in Residential Care Facilites. Physical Therapy. 1995;75:462-469.
2) Horak et al., Postural Perturbations: New Insights for Treatment of Balance Disorders. Physical Therapy. 1997;77:517-533.
3) Russo et al., Clinical balance Measures: Literature Resources. Neurology Report. 1997;21:29-36.
4) Shumway-Cook et al., Predicting the Probability for Falls in Community-Dwelling Older Adults. Physical Therapy. 1997:77:812-819.
5) Shumway-Cook et al., Predicting the Probability for Falls in Community-Dwelling Older Adults Using the Timed Up & Go Test. Physical Therapy. 2000;80-896-903.
6) Umphred. Neurological Rehabilitation. Mosby-Year Book. 1995 3rd edition. Pg 802-837.
7) Wernick-Robinson et al. Functional Reach: Does it Really Measure Dynamic Balance. Archives of Physical Medicine and Rehabilitation, 1999;80:262-269.


Last revised: February13, 2009
by Chai Rasavong, MPT

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