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Summary of Balance Measures

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  • Summary of Balance Measures

    What is the gold standard test for measuring static and dynamic balance in healthy, young and older adults?
    >From the responses received, there is seemingly no consensus of opinion as to which particular measure of balance would be regarded the 'gold standard' under either static or dynamic conditions or for either age group. In terms of static balance assessment, normally a combination of testing quiet-stance with eyes open and closed, on a flat surface and foam surface is performed.
    The Berg Balance Test was frequently cited as an appropriate measure in older adults, as it provides an assessment of both static and dynamic functional tasks beginning with sit-to-stand, progressing to one-legged stance. In most items, the subject is asked to maintain a given position for a specific time. Progressively more points are deducted if the time or distance requirements are not met, if the subject's performance warrants supervision, or if the subject touches an external support, or receives assistance from the examiner. Subjects should understand that they must maintain their balance while attempting the tasks. Poor judgment will adversely influence the performance and the scoring.
    Tinetti's Balance Test provides a similar measure to the Berg Balance Test and is suitable for use in older adults. Again, this test is based on functional tasks, although perhaps less testing than the Berg Balance Test, ranging from un-supported sitting balance to the execution of the sitting down movement. Both the Berg Balance Test and Tinetti's Balance Test are seemingly the most universally acceptable balance measures for older adults, largely because of their clinical feasibility, low-cost, high reliability and sensitivity.
    The Single-Leg Stance Test or Flamingo Balance Test were recommended for use in young adults, although some indicated its application to an older client group, suggesting the results produced were good for both age groups, depending upon the researcher/clinician's aims. Timed Single Leg Stance, conducted with eyes open and eyes closed, has been correlated with amplitude and speed of sway in people without disease, with the ability to maintain single leg stance generally decreasing with increasing age. The criteria indicated to stop timing the test relates to the point at which the legs touch each other, the feet move on the floor, the eyes open during the test (for the eyes closed variant), the foot touches the ground, or the arms move from their crossed starting position. The usefulness of this test is somewhat jaded by the limited knowledge of what would be regarded as the 'normal duration of time' for which this position could be held, suggesting it's clinical use would be elicited from repeated measures over a period of time to detect improvement or deterioration of conditions. Further variants on the Single Limb Stance Test include the Romberg Balance Test and Sharpened Romberg Balance Test, which adopt the same eyes open/eyes closed principle, but different initial foot positions, with both ankle bones touching each other (Romberg), or with the feet placed in tandem, directly in front of one another (Sharpened Romberg).
    Posturography is becoming increasingly popular given that it generates quantitative data. EquiTest by NeuroCom ( ) is a comprehensive assessment that can provide a balance measure for healthy subjects ranging from young athletes to an 80 year old person who has recently suffered a stroke. The EquiTest provides an objective assessment of balance control and postural stability under dynamic test conditions designed to reflect the challenges of daily life: this includes the full battery of tests that comprise Computerized Dynamic Posturography (CDP). CDP is a unique assessment technique used to objectively quantify and differentiate among the wide variety of possible sensory, motor, and central adaptive impairments to balance control. The interactive technology and clinically proven protocols allow the clinician to objectively and systematically manipulate somatosensory and visual information. The precise test data accurately identifies and differentiates underlying sensory and motor impairments, and enhances the ability to diagnose and treat problems of imbalance and postural instability, especially for those patients who previously proved difficult to diagnose. Whilst NeuroCom is a recognised leader in balance assessment, the equipment is large and expensive. Other posturography systems, which provide a more portable and economic option, include the Bertec BalanceCheck ( ).
    Further instrumentation for use in both young and older adults includes the Biodex Balance System ( .). The Biodex Balance System SD will allow testing and training in both static and dynamic variants. Accurate Fall Risk Assessments and Conditioning can be generated for older adults plus closed-chain, weight-bearing assessments and training for lower extremity patients. Biodex Balance System enables clinicians to assess neuromuscular control by quantifying the ability to maintain dynamic bilateral and unilateral postural stability on a static or unstable surface. Four test protocols are available including fall risk, athletic single leg stability, limits of stability and postural stability.
    Suggestions for numerically quantifying dynamic balance included calculating the distance of total centre of mass (projected to the ground) to the centre of the base of support. To enhance this view, the projection of this distance can also be calculated to medial/lateral and anterior/posterior directions. However, these are not standardised procedures.
    Useful References:
    Black FO, Wall C, Rockette H, Kitch R. Normal subject postural sway during the Romberg test. Am J Otolaryngol 1982; 3:309-18
    Newton R. Review of tests of standing balance abilities. Br Injury 1989; 3:335-43
    Functional Reach:
    Duncan P, Weiner K, Chandler J, Studenski S. Functional
    Reach: A new clinical measure of balance. Journal of Gerontology 1990; 45:

    Timed Up and Go test
    Podsiadlo D, Richardson S. "The timed "Up & Go": A test of
    basic functional mobility for frail elderly persons." J Am Geri Soc 1991; 39: 142-8.

    Step test
    Hill K, Bernhardt J, McGann A, Maltese D, Berkovits D. A new test of dynamic standing balance for stroke patients: Reliability, validity, and comparison with healthy elderly. Phys Canada 1996; 48: 257-62.

    Clinical test of sensory integration of balance
    Shumway-Cook A, Horak F. Assessing the influence of Sensory Interaction on Balance: suggestion from the field. Physical Therapy 1986; 66: 1548-50.

    Four square step test
    Dite W, Temple V. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med 2002; 83: 1566-71.
    Anna Hatton
    Research Assistant / PhD Student (Rehabilitation Sciences)
    Centre for Rehabilitation Science
    University of Teesside
    School of Health & Social Care
    Middlesbrough TS1 3BA
    Telephone: 01642-342934