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.7 Notably, 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)
Balance Test Procedure Mean Value (range) Cutoff/

Risk Value

Sensitivity, Specificity for fall prediction Pros Cons
Functional Reach Test10

 

Individual is asked to reach forward farther than arm’s length without changing the base of support in standing,

1-2 minutes to complete.

13.2”: older M

10.5”: older  F living in community

<7 inches

Predicting falls in older adults

73%/88.5%, others report inconsistent results Can be done in a small room Only assessing static balance
Short Physical Performance Battery (SPPB)11 Balance, Gait Speed, Chair Stand Tests

Measures lower extremity function

Score range 0-12 (higher score is better balance)

11-12: healthy elderly

 

10: 4x risk for mobility disability

Risk of falls in older adults

<7: x3

7-9: x2

81%/52% for frailty in older adults12 Separate component of mobility can be tested. Space to perform walking (4m)
Timed Up and Go test (TUG)13

 

Individual stands up from an arm chair, walks a distance of 3 m, turns, walks back, and sits down again in the chair (higher score indicating worse balance) 7-11: older M

7-12: older F living in community

>13.5 sec in older adults for fall risk 87%/87% for falls in older adults14 Dynamic balance Space to perform TUG
Detailed Balance Test
Berg Balance Scale15 14 items with each item scoring from 0 to 4 (total score range 0-56), higher score indicating better balance) 50-55 for living in community <45-49: high risk for falls 53%/96% for falls in older adults High specificity

Dynamic balance

>15-20 min to perform, low sensitivity for fall prediction
Performance Oriented Mobility Assessment (POMA) Scale by Tinetti16 Total score range 0-28 (higher score is better balance), consisting of

POMA-balance subscale

POMA-gait subscale

25-27: 65-79 of age <19:  high risk of falling

10-11: POMA-B

20-68%/

63-95%

No better than the simple test in discriminating fallers Time consuming

(15 min to complete)

 

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 Test Description, Advantage, Disadvantages
Computerized Dynamic Posturography (CDP)
  • Assessment technique to quantify and differentiate among possible sensory, motor, and central adaptive impairments to balance control.
  • The cost of the equipment can be substantial.
Posturography utilizing force plates18
  • Monitor the trajectory of the center of pressure (CoP).
  • 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.
Trunk sway measured by Angular Velocity Sensors (AVS)19
  • 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 environment.
  • Unlike motion analysis, the AVS can only measure changes relative to 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

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Author Disclosure

Mooyeon Oh-Park, MD
Nothing to Disclose

Natasha Mehta, MD
Nothing to Disclose

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