1. Balance Tests and
Measures in Physical
Therapy
Steven Ferro, SPT
JSUMC
Rutgers University
Physical Therapy-South
Presentation Date: 2/19/15
2. Objectives
• Introduction to Balance
• Types of Balance Scales:
• Functional:
• Four Square Step Test (FSST)
• Timed Up & Go (TUG)
• Pediatric Balance Scale (PBS)
• Subjective
• Activities-Specific Balance Confidence Scale (ABCs)
• Dizziness Handicap Inventory (DHI)
3. Balance
• Falls occur in 30% of people over the age of 65
each year and balance is a critical modifiable risk
factor for falls (Gervais et al., 2014).
• The control of your COG over your BOS.
• Somatosensation (CVA, Neuropathy)
• Vision (poor eyesight)
• Vestibular System (BPPV)
• Musculoskeletal system (Strains, Sprains, Joint
Replacements)
5. Balance
• Balance can also be affected by:
• Dehydration (vestibular system)
• Nutrition
• Medications (Polypharmacy)
• Benzodiazepines
• Antidepressants
• Hypnotics
• Diuretics
6. Lacking a “Gold Standard” Test?
• Components of Balance (Gervais et al., 2014)
• Control of dynamics (COG within BOS with walking)
• Biomechanical constraints (ROM, strength, endurance)
• Static stability (COG within BOS static)
• Reactive movement (ability to regain control)
• Anticipatory movement (COG adjustment before
movement)
• Cognitive Processing (Subjective)
• Sensory (visual, vestibular, somatosensory)
• Orientation in space (Processing of sensory inputs)
7. Test Types
Test Types Examples
Self-perception Scales ABC
DHI
Sensory manipulation (surface, visual
conditions
Clinical Test of Sensory Interaction and
Balance (Foam and Dome)
Motor Components FSST
Multidimensional Assessment Berg
PBS
Gait Assessment TUG
8. Four Square Step Test (FSST)
• Measures forward, backward, and lateral mobility.
• Demonstrates the patient’s ability to shift their weight
quickly.
• The FSST involves stepping over 4 canes that are laid
on the ground at 90° angles (forming a plus sign).
• Each cane is to be 90cm in length (Whitney et al.,
2007).
• One practice trial and two timed trials
• Start timer when first foot reaches box 2 and finishes
when last foot contacts box 1 when coming back.
9. Four Square Step Test (FSST)
• Cut off score is >15 seconds
• Sensitivity: 89% (Whitney et al., 2007)
• Sensitivity: 85% (Kisner et al., 2012)
• Percent of fallers correctly identified by the test.
• Specificity: 85% (Whitney et al., 2007)
• Specificity: 88% (Kisner et al., 2012)
• Percentage of non-fallers correctly identified by the
test.
• Interrater Reliability: r=.99 (Whitney et al., 2007)
• **Multiple Raters.
10. Four Square Step Test (FSST)
• “Try to complete the
sequence as fast as
possible without
touching the lines.”
• “Both feet must
make contact with
the floor in each
square and face
forward during the
entire sequence.”
Sequence: 2, 3, 4, 1, 4, 3, 2, and 1.
(Whitney et al., 2007)
11. Timed Up & Go (TUG)
• Stand up from a chair (seat height 46cm, arm height
67cm) and walk 9.8ft (3 meters), turn around and walk
back. (Podsiadlo, 1991)
• Patient is to complete the test 4 times with 2-4 recorded
(1 practice).
• Transfers, gait, neuromuscular mobility.
• Timer starts when the administer says “Go” and
stopped when the patient’s pelvis touches the chair.
12. Timed Up & Go (TUG)
• Cut off reported between 11-13.5 seconds while walking
as fast as possible (Schoene et al., 2013)
• A cut off of 13 seconds (>13) was associated with:
• Sensitivity: 87% (Kisner et al., 2012)
• Percent of fallers correctly identified by the test
• Specificity: 87% (Kisner et al., 2012)
• Percentage of non-fallers correctly identified by the
test.
• Good correlation between TUG and BBS r=0.81
(Cattaneo et al., 2006)
13. Timed Up & Go (TUG)
(O'Sullivan &
Schmitz, 2007)
Definitions
Inter-rater: 2 or more raters
Intra-rater: same rater
Concurrent Val: compared at the
same point and time to a gold
standard
14. Timed Up & Go (TUG)
• Things to Consider:
• Gervais et al. reports that although the TUG is
described as a measure of balance, the use of
a gait aid reduces its balance demands.
• The patient’s upper extremities should not
start on the assistive device, however, the
device is to be close to the patient for use.
(Podsiadlo, 1991)
15. Pediatric Balance Scale (PBS)
• Development of balance
begins in infancy with
the establishment of
head and trunk control.
• By 12 months, most
infants are mastering
standing and walking
(Franjoine et al., 2010).
• Posture
• Increased BMI
• Muscle Strength
• Sensory
16. Pediatric Balance Scale (PBS)
• Modified Berg Scale
• 14 item test used to examine balance in pediatric
patients
• Can be administered in less than 20 minutes (Franjoine
et al., 2010)
• Instructions:
• Demonstrate task to the child
• Test is scored on a scale of 0-56, with 56 being least impaired and
0 being the most impaired.
• Each item is scored on a 0-4 scale
• Scores are based upon the lowest criteria, which
describes the patient’s best performance (Franjoine et
al., 2003).
17. Pediatric Balance Scale (PBS)
• Referenced from Franjoine et al., 2003:
• Points are deducted if:
• Time is not met
• Distance requirements are not met
• Subject requires supervision
• Receives assistance from the examiner
• If the subject touches an external support
• Equipment needed listed in supplement**
• Optional items that may help during test include:
• Footprints
• Flash cards
• Etc.
20. Pediatric Balance Scale (PBS)
• Additional Points (Franjoine et al., 2003):
• On the first trial if the patient scores a 4, then
additional trials are not needed
• If the task asks the patient to use one extremity it is
up to the subject to decide.
• Poor judgment negatively influences scoring.
• For questions 4, 5, 6, 7, 8, 9, 10, & 13 recording time in
seconds is optional.
• Things to consider:
• It is difficult to interpret whether changes are clinically
meaningful, or simply due to maturation.
• Age cut off between PBS vs. Berg?
21. Changes Due to Maturation?
Franjoine et al.,
2010:
N=643 children
administered PBS
22. Pediatric Balance Scale (PBS)
• Evidence:
• Reported by Franjoine et al., 2010:
• Inter-rater Reliability :0.972 (2 or more raters)
• Intra-rater Reliability: 0.895-0.998 (same rater)
23. Subjective Measures
• The fear of falling is a major concern for many patients.
• Assesses cognitive processing abilities and reactive
control components of balance (Gervais et al., 2014)
• Consider the following:
• Perceives a balance deficit decrease in activity
sedentary decreased ROM, decreased
endurance, decreased strength unable to do the
things they used to social isolation, depression.
24. Activities-Specific Balance
Confidence Scale (ABC)
• Self report tool used to gather information about
the patient’s confidence with performing various
activities.
• 16-items
• Percentages are added and divided by 16 to
give an overall confidence %
• 0%=no confidence
• 100%=completely confident
25. Activities-Specific Balance
Confidence Scale (ABC)
• N=51 patients with multiple sclerosis, using a cut off
score of >40% demonstrated a sensitivity of 65% and a
specificity of 77% (Cattaneo et al., 2006).
• Less than 67%= increased fall risk (Kisner et. al., 2012)
• Things to consider:
• Some items on the ABC may not be applicable to
patients, and they may not be able to rate their
confidence.
• Ex: Individuals may be from a sunny climate and may
not have experienced walking on an icy surface in
recent years (Holbein-Jenny et al., 2005).
26. The Dizziness Handicap Inventory
(DHI)
• A 25-question self assessment measure of the functional,
emotional, and physical effects of dizziness and unsteadiness
in individuals >19 years of age (Yorke et al., 2013).
• Graded on a scale of 0-100, with greater scores indicating a
greater perception of handicap due to dizziness.
• Functional (36 points)
• Emotional (36 points)
• Physical (28 points)
• Useful instrument to document the patient perceived
consequences of vestibular and/or balance impairments
(Vereeck et al., 2007)
• Vestibular disorders most appropriate
27. The Dizziness Handicap Inventory
(DHI)
• Scores assigned to each item:
• No=0
• Sometimes=2
• Yes=4
• Reported by Yorke et al., 2013:
• MCID: 18 points
• MDC: 17.18
• SEM: 6.23
• Excellent correlation with the ABC
• Excellent test-retest reliability for vestibular
dysfunction
28. The Dizziness Handicap Inventory
(DHI)
• Cattaneo et al. reports a specific test-retest
reliability=0.97
• The following reported by Vereeck et al., 2007:
• Internal Consistency: The extent of which
items on measure, measure the same
characteristic (perceived dizziness).
• Functional: 0.85
• Emotional: 0.72
• Physical: 0.78
• DHI Total: 0.89
30. Summary
• Balance has multiple components:
• Control of dynamics
• Static stability
• Reactive movement
• Cognitive Processing
• Sensory
• What is the best test for your patient?
• What are you measuring?
• Consider all systems
• Base interventions off measures that are specific to
the patient.
34. References
• Cattaneo, D., Regola, A., & Meotti, M. (2006). Validity of six balance disorders scales in persons
with multiple sclerosis. Disabil Rehabil, 28(12), 789-795.
• Whitney, S. L., Marchetti, G. F., Morris, L. O., & Sparto, P. J. (2007). The reliability and validity of
the Four Square Step Test for people with balance deficits secondary to a vestibular disorder. Arch
Phys Med Rehabil, 88(1), 99-104.
• Yorke, A., Ward, I., Vora, S., Combs, S., & Keller-Johnson, T. (2013). Measurement Characteristics
and Clinical Utility of the Dizziness Handicap Inventory Among Individuals With Vestibular
Disorders. Arch Phys Med Rehabil, 94(11), 2313-2314.
• Holbein-Jenny, M. A., Billek-Sawhney, B., Beckman, E., & Smith, T. (2005). Balance in Personal Care
Home Residents: A Comparison of the Berg Balance Scale, the Multi‐Directional Reach Test, and
the Activities‐Specific Balance Confidence Scale. Journal of Geriatric Physical Therapy, 28(2), 48-
53.
• Schoene, D., Wu, S. M., Mikolaizak, A. S., Menant, J. C., Smith, S. T., Delbaere, K., & Lord, S. R.
(2013). Discriminative ability and predictive validity of the timed up and go test in identifying
older people who fall: systematic review and meta-analysis. J Am Geriatr Soc, 61(2), 202-208.
• O'Sullivan, S. B., Schmitz, T. J., (2007). Physical Rehabilitation (5 ed.): F.A. Davis.
• Vereeck, L., Truijen, S., Wuyts, F. L., & Van De Heyning, P. H. (2007). Internal consistency and factor
analysis of the Dutch version of the Dizziness Handicap Inventory. Acta Otolaryngol, 127(8), 788-
795.
35. References
• Tiedemann, A., Shimada, H., Sherrington, C., Murray, S., & Lord, S. (2008). The comparative ability
of eight functional mobility tests for predicting falls in community-dwelling older people. Age
Ageing, 37(4), 430-435.
• Gervais, T., Burling, N., Krull, J., Lugg, C., Lung, M., Straus, S., . . . Sibley, K. M. (2014).
Understanding approaches to balance assessment in physical therapy practice for elderly
inpatients of a rehabilitation hospital. Physiother Can, 66(1), 6-14.
• Franjoine, M. R., Darr, N., Held, S. L., Kott, K., & Young, B. L. (2010). The performance of children
developing typically on the pediatric balance scale. Pediatr Phys Ther, 22(4), 350-359.
• Franjoine, M. R., Gunther, J. S., & Taylor, M. J. (2003). Pediatric balance scale: a modified version of
the berg balance scale for the school-age child with mild to moderate motor impairment. Pediatr
Phys Ther, 15(2), 114-128.
• Umphred, D. et al (2013) Neurological Rehabilitation. (6th Edition) Elsevier.
• Podsiadlo, D. and Richardson, S. (1991). "The timed "Up & Go": a test of basic functional mobility
for frail elderly persons." J Am Geriatr Soc, 39(2), 142-148.
• Kisner, C., Colby, L. A. (2012). Therapeutic Exercise (6th Edition.) F.A. Davis Company.
• Lewis, C. B., Bottomley, J. M. . (2007). Geriatric Rehabilitation: A Clinical Approach (3rd ed.)
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