0 General Balance Tests



General Balance Tests

This section describes a variety of balance tests that can be performed to assess and quantify an individual's ability to maintain balance. Tests are noted to be for static or dynamic balance, or both. With the exception of the Romberg, Fregly Graybiel and clinical tests for sensory interaction for balance, most of these tests are functionally based. The Romberg test and clinical tests for sensory interaction for balance can he used to identify impairments. The remaining tests can be used to quantify the patient's ability to maintain static and dynamic postures and perform the movements required for daily activities.

Many of the tests described below require scoring on several activities, which, as suggested by their authors, can be totaled to determine some measure of balance. Because data collected in the majority of these tests consist of ordinal data (i.e. a ranking, such as normal, good, fair, poor, trace and zero), the summation of test items is not reflective of the patient's ability to balance. Adding up various items on a test that uses ordinal scales will not provide a measurement, reflective of the patient's ability to balance. The summation of item scores on an ordinal test cannot be compared to normative data of a population or to other patients because the total value is meaningless. Comparing items within the test can be useful in demonstrating the patient's progress but should not be used as an aggregate score for balance. Clinical tests that use ordinal data are noted.

Romberg test (Static)

Test positions, described above, are repeated here for convenience. Patients stand with their medial malleoli touching and arms folded across their chest and eyes closed. If they maintain this position for 30 seconds, the test is normal. The response is not normal if patients open their eves or unfold their arms before 30 seconds has passed. Assessing sagas can be difficult, so videotaping is recommended.

The inability to achieve positions with eyes open suggests a cerebellar lesion; the inability to achieve positions with eyes closed suggests a somato-sensory lesion. The Romberg test is a good example of the interrelatedness of the systems. Eyes open enables balance to be maintained (in the absence of a cerebellar lesion), with feedback processed from the visual field and somato-sensory system. Closing the eyes forces the patient to rely only on the somato-sensory system and may result in a positive test if this system is deficient. Therefore, if the Romberg test suggests a somato-sensory lesion, further testing of somato-sensory pathways (e.g. position sense) is indicated.

Clinical test for sensory interaction in balance (Static)

This test uses a progressive sequence of standing on a firm surface with the eyes open and closed; the eyes are open for the last sequence, but the visual input is distorted. The same progression is repeated while the patient stands on a foam surface, which distorts somato-sensation during the three testing procedures. The visual conflict dome can be any type of dome-such as a Japanese lantem- that covers the head to distort the visual input with movement of the body. Body sway is used to test sensory components of the postural control and was used by Romberg as a measurement of balance in his test.

Assessing sensory components requires that patients maintain standing for 30 seconds under the six different conditions (Fig. 5). Each square in Figure (5) is referred to as a cell, and the impairment tested in a cell is described below. These six conditions alter somato-sensory information entering the CNS. In all six testing procedures patients stand with feet either together or in tandem, with arms folded across the chest:

On firm surface:

Cell 1- eyes open; all three sensory systems assessed.

Cell 2- eyes closed; somato-sensation assessed (Romberg test).

Cell 3- visual conflict dome; visual integration of distorted information assessed.

On foam surface:

Cell 4- eyes open; assesses distorted somato-sensory.

Cell 5- eyes closed, referred to as the classical test for vestibular since eyes are closed and somato-sensation is distorted.

Cell 6-eyes closed; distorted somatosensation and vision.

Each condition alters the availability and accuracy of visual and somato-sensory information for postural orientation. Amounts of body sway in the six different conditions are recorded.

A scale to quantify amounts of sway may include:

* Subjective assessment based on a numerical ranking system (e.g. 1 = minimal sway, 2 = mild sway, 3 = moderate sway and 4 = fall).

* Time standing erect in each position and condition.

* Use of grids and plumb lines to record body displacement.

Any report by patients of nausea or dizziness should be recorded, as well as movement strategies used to maintain stability.

Berg balance scale (Static and dynamic):

This ordinal scale evaluates patient performance on 14 tasks commonly performed in everyday life. Each task is scored from 0 to 4, with 0 = unable to perform, and 4 = able to perform the task safely and independently. Inability to perform all of these movements may be an indicator that patients are at risk for falls.

Items tested on the scale include:

* Sitting to standing.

* Standing unsupported.

* Sitting unsupported.

* Standing to sitting.

* Transferring.

* Standing with eyes closed.

* Standing with feet together.

* Reaching forward with outstretched arm.

* Retrieving object from floor.

* Turning to look behind.

* Turning 360°.

* Placing alternate foot on ". stool

* Standing with one foot in front

* Standing on one foot

"Get up and go" test (Static and dynamic):

This test evaluates the patient's ability to rise from a chair, walk, and return to sitting. The starting position is in a high-back chair with armrests. Patients rise from the chair, stand still momentarily, walk toward a wall, turn without touching the wall, walk back to the chair, turn around, and then sit down. Examiners observe this activity and score patient balance using a 5-point scale:

1 = normal.

2 = very slightly abnormal.

3 = mildly abnormal.

4 = moderately abnormal.

5 = severely abnormal.

To be assigned a score of "normal" patients must not display any risk of falling (i.e. no postural sway or excessive movement to maintain balance). Patients who appear at risk of falling during testing procedures receive a 5 (severely abnormal).

Timed "Up and go" test (Dynamic):

This is a modified version of the "Get Up and Go" test. In this test, patients walk to a line placed 10 feet away from a .chair, turn, walk back to the chair, and sit down. Patients are timed in this test. The score assigned is the time required (in seconds) to complete the test. Time starts at the examiner's command of "go" and ends when patients sit back in the chair.

Clinical balance assessment (Static):

This assessment is based on five items, one of which is self-report by patients. Items and criteria for scoring the balance test are:

7. Number of falls in the past 2 weeks

0 = more than two

1 = one to two

2 = none

2. Stance tests: standard-eyes open and closed; tandem-eyes open and closed.

0 = unable to maintain for 5 seconds.

1 = presence of unsteadiness, swaying, or deviation even if position is maintained for 5 seconds or more.

2 = maintains steady position for more than 5 seconds.

3. Standing without support.

0 = cannot stand without support

1 = can stand erect for less than 1 minute, or can stand for a longer time but sways somewhat.

2 = good standing balance, can maintain balance for more than 1 minute without insecurity

4. Standing on one lower extremity

0 = position cannot be maintained for more than a few unstable seconds.

1 = can stand in balanced position between 4 to 9 seconds.

2 = can maintain balanced position for more than 10 seconds.

5. Tilting reactions in standing. Tilting reactions are defined as either lateral trunk and neck flexion toward the side being pushed, rotation of trunk and neck toward the side being pushed or abduction of the arm and leg on the side being pushed. Ordinal data are used throughout this test.

0 = no reaction observed

1 = delayed or incomplete reactions

2 = normal reactions

Functional reach (Dynamic):

This test uses a leveled yardstick mounted onto a wall at the height of the patient's acromion process. The patient stands without shoes and socks in a normal, relaxed stance beside the wall where the yardstick is mounted (foot tracings are made to reproduce standing position). The patient then extends one arm, with the hand made into a fist. Placement of the third metacarpal along the yardstick is recorded. The patient then reaches forward as far as possible without losing balance or taking a step forward. Placement of the third metacarpal is again recorded. The upper extremity is not allowed to touch the wall during the procedure. The measurement at rest is subtracted from the measurement at the farthest point of reach to obtain, the value.

Three trials of the functional reach are performed, with an .average of the three measurements reported. Age-related changes in functional reach have been reported:

- In the 20- to 40-year-old range, reach was 16.73 inches for men and 14.64 for women.

- In the 41- to 69-year-old range, reach was 14,98 inches for men and 13.8T for women.

- For those aged 70 to 87, reach was 13.16 inches for men and 10.47 for women.

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