ASSESSMENT AND TREATMENT OF BALANCE IMPAIRMENTS

Author(s): Mooyeon Oh-Park, MD, Natasha Mehta, MD

Originally published:04/13/2016
Last updated:04/13/2016

1. OVERVIEW AND DESCRIPTION

Definition

Balance, also known as postural control, is the ability to maintain, attain, or correct the center of mass in
relation to the base of support1 and it is necessary for successful daily life tasks. Maintaining normal balance
requires multiple systems (somatosensory, vestibular, visual, musculoskeletal system, and cognition) working
in integrative fashion, and the disorders affecting one or more of these systems may lead to impaired balance.
With aging, even normal individuals show increased truncal sway and reduced postural control due to change
in the individual system as well as central ability to integrate these systems (e.g. attention, reaction time) to
work effectively.

Etiology/Patho-anatomy/physiology

Balance is maintained through a complex process involving sensory detection of body motions, integration of
sensorimotor information within the central nervous system, and execution of appropriate musculoskeletal
responses.

Contributing Factors for Balance Impairment are

 Decreased peripheral sensation (e.g. somatosensory inputs from ankle joints)

 Muscle weakness (e.g. hip abductor, knee extensor/flexor, ankle dorsiflexors)
 Limited range of motion of lower limb joints (e.g. ankle eversion)
 Poor sensory input (visual acuity, reduced vestibular function)
 Pain syndrome
 Fear of falling
 Reduced central integrative processing and cognitive ability (e.g. executive function)
 Specific neurological (central and peripheral) and musculoskeletal disorders
 CNS disorders: Stroke, Parkinson’s disease, cervical myelopathy, hydrocephalus, vitamin B12
deficiency, cerebellar degeneration
 PNS disorders: polyradiculopathy, ganglionopathy, peripheral neuropathy, myopathy
  musculoskeletal conditions (e.g. knee instability from osteoarthritis, painful foot conditions)
 Extrinsic factors
 Poor footwear (too high or too low heeled shoes)
 Environmental factors (uneven terrain, slippery surface, barriers).

Lower limb muscle power (force x velocity of shortening) seems to be more important than muscle strength
correlating with balance deficit. It is hypothesized that when threat to balance (narrowed base of support,
perturbation, loss of vision or proprioception) occurs, rapid responses must be engaged to maintain postural
stability.2 The velocity at which high muscular forces can be generated may be the critical determinants to
maintain balance and prevent a fall.2 Ankle range of motion particularly ankle eversion declines with aging and
is associated with reduced postural control.3 Central integrative processing or the ability for a person to process
the information for appropriate response is a key aspect of postural control mechanism. In older adults,
reaction time in the presence of conflicting sensory inputs is prolonged. There has been increasing evidence
that higher level brain function, particularly executive cognitive function is required for optimal
balance.4 Balance is often impaired during dual task situations particularly in older adults, which might be
explained by the divided attention between maintaining balance and performing secondary tasks.
Psychological distress including fear of falling is also associated with reduced balance in patients with various
neurological disorders.5,6

2. RELEVANCE TO CLINICAL PRACTICE

A study based on the National Health Interview Survey (NHIS) showed that approximately one in five older
individuals in the United States reported balance problems with higher prevalence in women compared to
men.7Notably, more than 20% of patients with balance problems reported that their symptoms are triggered by
medications (18.7% by prescription medications, 1.7% by over the counter medications). Balance impairment
is more than 2.5 times more prevalent among older individuals with pain.8 Falls are well recognized as the
most significant consequences of balance impairment. In addition to falls, nearly 30% of elderly with balance
problems reported that poor balance prevents them from participating in activities (61% in exercise, 46% in
social events, 47% in driving, 38% in work). More importantly, one in four of those with balance impairment
had difficulty in activities of daily living (ADLs).7 Literature showed that various exercise interventions (e.g.
Tai Chi) can improve balance and potentially reduce the risk of the falls in older individuals and individuals
with various disabilities. Balance exercises, thus, improves quality of life, socialization and associated
morbidity/mortality.

3. CLINICAL AND LABORATORY ASSESSMENT

 History

History taking should include self -perceived balance impairment and falls. History taking can be framed for
both patient’s complaints of specific system issues (e.g. foot pain) and description of overall balance
impairment (feeling unsteady). Clinicians should pay attention to associated symptoms (e.g. bradykinesia,
spasticity, back pain) to identify underlying conditions associated with balance impairment:

 Acute and chronic medical problems (recent illness, surgery, hospitalization)

 Medications history including number of medications, new medications, over the counter medications and
any dosing adjustment
 Fall history including circumstances and symptoms (if yes – functional balance test indicated)
 Fear of falling
 Mental Health assessment (e.g. depression, delirium, dementia)
 Functional history (use of assistive device, personal assistance)
 Home environment, including railing on staircase, door width, floor surface (area rugs), grab bars in the
bathroom and shower, equipment (shower chair, etc.)
 Social History of alcohol use, illegal drug use, smoking, other supplements
 Cardiovascular history (arrhythmia, murmurs)

Physical Examination

Clinicians should focus on:

 Vitals, including orthostatic blood pressure and heart rate

 Neurologic examination
 Cognitive function (e.g. Mini Mental Status Examination, Montreal Cognitive Assessment Test)
 Cranial nerves, Sensation (proprioception/vibration), Motor (upper/lower limb and trunk), reflexes,
muscle strength, tone, coordination and Cerebellar function.
 Visual acuity including visual field testing as appropriate
 Hearing & vestibular function (if applicable)
 Musculoskeletal examination
 Standing posture for kyphosis of spine, loss of lumbar lordosis
 Range of motion of hips, knees, ankle, and foot (tightness of hip flexors, knee flexors, and gastrocnemius
muscles)
 Joint swelling and any deformity or instability.
 Footwear
 Looking for excessive worn out pattern on the sole that may threaten stable base of support, Appropriate
heel height,
 Relatively thin sole is better for the balance than excessively thick cushioned sole
 Evaluation of gait mechanics
 Slow gait speed, base of support (wide based), short step/stride length, reduced cadence, increased
double support time
 Reduced ability to tandem walk
 Need for any assistance for gait.

Clinical Balance Assessment

Clinical measurement tools for balance are used to quantify the functional capacity of the sum of multiple
systems that enable postural stability. They are often used as screening tools to identify individuals at elevated
risk for falls requiring further evaluation. However, the value of balance assessment in discriminating fallers
from non-fallers is somewhat limited since fall is multifactorial condition. The norms, cutoff scores for fall
risk, sensitivity and specificity of each tool varies depending on the cutoff scores and population tested.1,9

4. SUMMARY OF CLINICAL BALANCE TESTS

Simple Balance Tests (Readily tested in the clinic)

Cutoff/ Sensitivity,
Mean Value
Balance Test Procedure Specificity
(range) Pros Cons
Risk Value for fall
prediction
Individual is asked
to reach forward
13.2”: older
farther than arm’s
M <7 inches
Functional length without
Reach Test10 changing the base 73%/88.5%, Only
Can be done
of support in 10.5”: Predicting others report assessing
in a small
standing, older F falls in inconsistent static
room
living in older adults results balance
community
1-2 minutes to
complete.

Short Balance, Gait 11-12: Risk of falls 81%/52% for Separate Space to
Physical Speed, Chair healthy in older frailty in component of perform
Performance Stand Tests elderly adults older adults12 mobility can walking
Battery be tested. (4m)
(SPPB)11 Measures lower <7: x3
extremity function
10: 4x risk 7-9: x2
Score range 0-12 for mobility
(higher score is disability
better balance)

Individual stands
up from an arm 7-11: older
Timed Up chair, walks a M
and Go test distance of 3 m,
(TUG)13 >13.5 sec in 87%/87% for Space to
turns, walks back, Dynamic
7-12: older F older adults falls in older perform
and sits down balance
living in for fall risk adults14 TUG
again in the chair
community
(higher score
indicating worse
balance)
Detailed Balance Test
14 items with each High >15-20 min
item scoring from specificity to perform,
0 to 4 (total score 50-55 for <45-49: 53%/96% for
Berg Balance low
range 0-56), living in high risk falls in older
Scale15 Dynamic sensitivity
higher score community for falls adults
balance for fall
indicating better
prediction
balance)
Total score range
0-28 (higher score
Performance is better balance), <19: high
Time
Oriented consisting of risk of No better than consuming
20-68%/
Mobility falling the simple test
25-27: 65-79
Assessment POMA-balance in
of age 63-95% (15 min to
(POMA) subscale 10-11: discriminating
complete)
Scale by POMA-B fallers
Tinetti16 POMA-gait
subscale

Instrumental Balance Assessment

Instrumental balance assessments (e.g. posturography) may have a role in understanding pathophysiology of
balance disorders and evaluating the response to intervention, however, they may have limited role in
predicting risk of falling in patients.17

Instrumental Balance
Description, Advantage, Disadvantages
Test

 Assessment technique to quantify and differentiate among possible

Computerized Dynamic
sensory, motor, and central adaptive impairments to balance control.
Posturography (CDP)
 The cost of the equipment can be substantial.

 Monitor the trajectory of the center of pressure (CoP).

Posturography utilizing
force plates18
 The CoP trajectory reflects the body sway during standing and the ability
of the neuromusculoskeletal systems to integrate information from
multiple sensory systems.
 The correlation between the parameters of posturography and clinical
balance assessment is moderate suggesting that these two measures might
measure different aspects of balance control.

 Portable device mounted on the back of the patient (estimated location of

center of mass) measuring the trunk sway.
 The main advantage is recording trunk sway over long time in real-life
Trunk sway measured by
environment.
Angular Velocity Sensors
 Unlike motion analysis, the AVS can only measure changes relative to
(AVS)19
initial position but not absolute position. The values measured with AVS
showed correlation with the values of posturography.

Laboratory workup and imaging studies

Based on the clinical evaluation, further work-up should be initiated as needed.

For patients with suspected central nervous system (stroke, myelopathy), brain and/or spinal cord
(cervical/thoracic spine) imaging is recommended. If peripheral neuropathy is suspected, the full work-up for
neuropathy including vitamin B12, hemoglobin A1C, thyroid function test (e.g. thyroid stimulating hormone),
serum protein electrophoresis, and electrodiagnosis can be performed. In patients without a clear diagnosis a
complete blood count and a comprehensive metabolic panel should also be considered. Lower limb joint
instability and pain may require imaging studies.

5. TREATMENT STRATEGIES
 Treatment starts with identification of modifiable risk factors for balance problems. Physiatrists will play a
critical role in setting realistic goals of intervention and rehabilitation plan to achieve them. Clinicians should
focus on patient education about the causes and potential implications of balance impairment and rationale for
treatment options including exercise program and home modifications for reduction of anxiety and enhancing
compliance.

Specific strategies are

 Review modifiable risk factors for falls and address them (see the risk factors in the table above, Please see
the Fall Prevention chapter as well)
 Explore the patients’ perceptions of the causes of balance impairments (and falls) and willingness to make
changes to reduce the risk of falls. Approaches facilitating behavior change: providing choices,
personalizing options, and focusing strategies on enhancing quality of life.
 Careful review of medications (including over the counter) considering 20% of unsteadiness in older adults
may have pharmacologic etiology, may reveal medications triggering the unsteadiness
 Pain medications, antispasticity, psychoactive medications-antidepressant, anxiolytic medications
 Being sensitive about emotional distress of older patients with balance impairment related to falls, potential
loss of independence, and further deterioration of conditions.
 Use of ambulatory aids is often associated with the perception of being “old and disabled”. Therefore,
prescription of ambulatory aids should be one after discussing with the patients the need for these devices,
how they can help with their balance, the potential plan to wean off the devices, and their willingness to use
these aids.
 Discuss the importance of strength and balance exercise (Stretching, walking have not been shown to
reduce falls).
 To improve balance, balance exercises should be moderate to high challenge and progress in difficulty,
minimum of 2 hours per week for 25 weeks. Assist patients to find a place where they can engage in this
type of exercise (PT, community programs, home programs)20
 Strengthening exercise, three dimensional exercise (Tai Chi, qi gong, dance, yoga)
 Vitamin D 800 IU per day for those at risk of fall and suspected vitamin D deficiency.
 Offer ongoing monitoring and follow-up

Impact of balance training

Balance training improved balance as measured by the Berg Balance Scale and quantitative postural sway,
resulting in a significant reduction in the rate of falls in older adults. Recent Cochrane review reported that
 exercise programs involving gait, balance, coordination, and functional exercises decrease the rate of falls.
Strengthening exercise, three dimensional exercise (Tai Chi, qi gong, dance, yoga), and combination of these
exercises all appear to improve balance quantifiably.21 However, there is insufficient evidence on the effects of
general physical activity (e.g. walking, cycling), and exercise involving computerized balance program, or
vibration plates on balance.21

6. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES

As balance impairment has been recognized as an important public health issue in US healthcare system, there
is a growing interest from private companies to build supportive tools for patients with balance impairment
(ambulatory monitoring device, high tech glasses enhancing foot placement, virtual reality). For specific
disease population (Parkinson’s disease), trials of neurosurgical tools (e.g. subthalamic or pallidal deep brain
stimulation) are ongoing for balance improvement.22

7. GAPS IN KNOWLEDGE/EVIDENCE

The major pitfalls in the literature and clinical practice in management of balance impairment include lumping
balance disabilities despite the different pathophysiology, failure of enhancing compensatory mechanisms, and
failure to sustain effective exercise interventions. Implementation and Dissemination of currently available
findings about balance assessment and intervention is greatly needed, including the transition of care from the
hospital or clinic to the community.

References

1. Noohu MM, Aparajit BD, H. ME. Relevance of balance measurement tools and balance training for fall
prevention in older adults. Journal of Clinical Gerontology & Geriatrics 2014;5:31-35.
2. Orr R, de Vos NJ, Singh NA, Ross DA, Stavrinos TM, Fiatarone-Singh MA. Power training improves
balance in healthy older adults. J Gerontol A Biol Sci Med Sci 2006;61:78-85.
3. Bok SK, Lee TH, Lee SS. The effects of changes of ankle strength and range of motion according to aging
on balance. Ann Rehabil Med 2013;37:10-16.
4. van Iersel MB, Kessels RP, Bloem BR, Verbeek AL, Olde Rikkert MG. Executive functions are associated
with gait and balance in community-living elderly people. J Gerontol A Biol Sci Med Sci 2008;63:1344-
1349.
5. Bryant MS, Rintala DH, Hou JG, Protas EJ. Influence of fear of falling on gait and balance in Parkinson’s
disease. Disabil Rehabil 2014;36:744-748.
6. Schinkel-Ivy A, Inness EL, Mansfield A. Relationships between fear of falling, balance confidence, and
control of balance, gait, and reactive stepping in individuals with sub-acute stroke. Gait Posture 2015.
7. Lin HW, Bhattacharyya N. Balance disorders in the elderly: epidemiology and functional impact.
Laryngoscope 2012;122:1858-1861.
8. Patel KV, Phelan EA, Leveille SG, Lamb SE, Missikpode C, Wallace RB, Guralnik JM, Turk DC. High
prevalence of falls, fear of falling, and impaired balance in older adults with pain in the United States:
findings from the 2011 National Health and Aging Trends Study. J Am Geriatr Soc 2014;62:1844-1852.
9. Jernigan SD, Pohl PS, Mahnken JD, Kluding PM. Diagnostic accuracy of fall risk assessment tools in
people with diabetic peripheral neuropathy. Phys Ther 2012;92:1461-1470.
10. Gates S, Smith LA, Fisher JD, Lamb SE. Systematic review of accuracy of screening instruments for
predicting fall risk among independently living older adults. J Rehabil Res Dev 2008;45:1105-1116.
11. Vasunilashorn S, Coppin AK, Patel KV, Lauretani F, Ferrucci L, Bandinelli S, Guralnik JM. Use of the
Short Physical Performance Battery Score to predict loss of ability to walk 400 meters: analysis from the
InCHIANTI study. J Gerontol A Biol Sci Med Sci 2009;64:223-229.
12. da Camara SM, Alvarado BE, Guralnik JM, Guerra RO, Maciel AC. Using the Short Physical Performance
Battery to screen for frailty in young-old adults with distinct socioeconomic conditions. Geriatr Gerontol Int
2013;13:421-428.
13. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of
falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr 2014;14:14.
14. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling
older adults using the Timed Up & Go Test. Phys Ther 2000;80:896-903.
15. Muir SW, Berg K, Chesworth B, Speechley M. Use of the Berg Balance Scale for predicting multiple falls
in community-dwelling elderly people: a prospective study. Phys Ther 2008;88:449-459.
16. Faber MJ, Bosscher RJ, van Wieringen PC. Clinimetric properties of the performance-oriented mobility
assessment. Phys Ther 2006;86:944-954.
17. Nardone A, Schieppati M. The role of instrumental assessment of balance in clinical decision making. Eur J
Phys Rehabil Med 2010;46:221-237.
18. Sawacha Z, Carraro E, Contessa P, Guiotto A, Masiero S, Cobelli C. Relationship between clinical and
instrumental balance assessments in chronic post-stroke hemiparesis subjects. J Neuroeng Rehabil
2013;10:95.
19. Whitney SL, Roche JL, Marchetti GF, Lin CC, Steed DP, Furman GR, Musolino MC, Redfern MS. A
comparison of accelerometry and center of pressure measures during computerized dynamic posturography:
a measure of balance. Gait Posture 2011;33:594-599.
20. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the
prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc 2008;56:2234-2243.
21. Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. Exercise for improving balance in older people.
Cochrane Database Syst Rev 2011:CD004963.
22. Maetzler W, Nieuwhof F, Hasmann SE, Bloem BR. Emerging therapies for gait disability and balance
impairment: promises and pitfalls. Mov Disord 2013;28:1576-1586.

Author Disclosure

Mooyeon Oh-Park, MD
Nothing to Disclose

Natasha Mehta, MD
Nothing to Disclose