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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.
Statistics
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
Conclusion
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
References
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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