Examination of balance

PTP 565

Quote of the day

The greatest crime is not developing your own potential. When you do what you do best, you are helping others.

Roger Williams

Objectives

• Define balance terminology• Recognize the use of the ICF Model in balance

examination• Correctly select and complete a balance

examination using objective measures (SLS, Romberg/Tandem Romberg, Functional Reach, Berg, Tinetti, CTSIB, and ABC)

• Recognize normal versus abnormal results of balance testing (including fall risk)

• Document results of balance testing

Assessing a patient with balance dysfunction can be

• Complicated• Confusing• Discouraging• Challenging• Rewarding

What types of patients have the potential for balance impairment?

Definitions

• Postural control• Balance• Center of gravity• Base of support• Postural orientation• Limits of stability• Anticipatory postural responses• Reactionary postural responses• Sensory interaction/orientation

Fundamental Exam

• Examination– Taking a history– Systems review– Tests and Measures• Body structure and function• Activity• Participation

Taking a History

• Chief complaint• Medical history• Recent history of falls/close falls• Medications• Confidence level (participation level)

Systems Review

• Cardiovascular• Integumentary• Neuromuscular• Musculoskeletal

ICF Model

Body Functions and Structure

• ROM• Ms. Strength• Ms. Tone• Coordination• Cognition• Posture• Pain

Body Functions and Structure

• Sensory Systems (cont)– Somatosensory• Light touch• Proprioception/Vibration• Pain

– Vision– Vestibular

• Perception

Body Functions and Structure

• Sensory Strategies– Why is sensory interaction important? – How do we test sensory interaction in the lab?– How is sensory interaction testing different then

sensory testing?• Sensory Systems used to hold balance– Vision– Vestibular– Somatosensory

Body Functions and Structure

• Motor Strategies– Ankle– Hip– Stepping

Motor Strategies: Ankle

• Control of postural sway from ankles and feet• Head and hips travel in the same direction at

the same time with the body moving as a unit over the feet

• When it is appropriate to use an ankle strategy?– Firm surface– Foot well supported– Slow moving with minimal displacement

Motor Strategies: Hip

• Control of postural sway from pelvis and trunk• Head and hips travel in opposite directions• When is it appropriate to use a hip strategy?– Foot not completely supported– Quick and large displacements

Motor Strategies: Stepping

• Steps with the feet to establish a new base of support when the center of gravity has exceeded the original base of support

• When is it appropriate to use a stepping strategy?– When the other strategies are not sufficient

enough to maintain equilibrium

Body Functions and Structure

• Modified CTSIB• Single Leg Stance• Romberg/Sharpened Romberg

Clinical Test for Sensory Interaction in Balance

• Clinical version of the Sensory Organization Test that does not require computerized force plate

• Designed to assess the patient’s ability to select and combine sensory information in different environments

• Does not measure the integrity of the three sensory systems

Sensory Weighting

Firm Surface•70% somatosensory•20% vestibular•10% vision

Unstable Surface•10% somatosensory•60% vestibular•30% vision

Peterka et al, 2004

Clinical Test for Sensory Interaction in Balance

• Condition 1: Firm surface, eyes open• Condition 2: Firm surface, eyes closed• Condition 3: Firm surface, dome• Condition 4: Foam surface, eyes open• Condition 5: Foam surface, eyes closed• Condition 6: Foam surface, dome

Single Leg Stance

• Person stands with knee flexed 90° (legs should not be touching each other)

• Arms crossed around shoulders• Norms• Document – Number of attempts – Time– Visual observation during trial

Romberg/Tandem Romberg

• Person stands with feet together (Romberg) and eyes open

• Repeat the test with eyes closed• Person stands with one foot directly in front of the other

(Tandem Romberg)• Normal is the ability to hold the test position for 30

seconds• Document

– Number of attempts– Time– Visual observation during trial

Activity and Participation

Activity Balance Measures• Berg• Tinetti• Functional Reach

Participation Balance Measures

• Activities Based Confidence Scale

Berg

• 14 test items intended to assess a person's ability to perform common ADLs safely

• Items are scored from 0 to 4, maximum score is 56

• Scores < 36 indicate a fall risk close to 100%

Tinetti

• Consists of 2 subscales to screen for balance and mobility skills in older adults and determine likelihood of falls– Balance– Gait

• Score 19-24 are at moderate risk of falls• Score <19 are considered high risk for falls

Functional Reach

• Define maximum distance one can reach forward beyond arm’s length while maintaining fixed base of support in standing

• Examines limits of stability in forward direction• Person stands near wall with feet parallel, raises

arm nearest wall to 90° of shoulder flexion, makes a fist and leans as far forward as possible

• < 6 inches predicative of increased risk of falls

Activities Based Confidence Scale

• 16 item questionnaire that is a measure of balance self-efficacy in which subjects rate their confidence performing a variety of in home and community based functional activities such as walking in a variety of environments, reaching, picking things up from the floor.

• Scores range from 0-100 where higher scores indicate greater balance confidence

Review

• Examination of a patient with balance disorder can happen at the level of Body Structure/Function, Activity, and Participation

• Numerous objective tools to use to examine balance• No single test of balance is available that covers the

multiple dimensions of balance• Need to select a test that sufficiently challenges the

patient being tested• SAFETY

– Gait belt– Closely guarded

Lab

• Video clips of balance examination• Paper patient cases– Select the correct test– Practice performing and documenting balance

examination