Assessment and Treatment of Balance Impairments

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. Static balance involves the ability to maintain a stable position, while dynamic balance is the ability to maintain postural stability and orientation while individual move from one position to another. 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 (Diagram 1) are

• 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, decreased peripheral sensation)
• Pain syndrome
• Age-related vestibular losses can be unilateral or asymmetric though are typically bilateral as the exposures related to aging (e.g., cumulative toxic, metabolic, ischemic, infectious exposures) are typically systemic²
• Impaired vestibular function:³
  • Ototoxicity due to gentamicin
  • Meniere’s disease
  • Infectious causes (e.g., meningitis)
  • Neurodegenerative and inherited syndromes (CANVAS Syndrome)
  • Autoimmunity (Cogan’s Syndrome)
  • Trauma
• 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
  • Peripheral Nervous System 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. The velocity at which high muscular forces can be generated may be the critical determinants to maintain balance and prevent a fall.⁴ Ankle range of motion particularly ankle eversion declines with aging and is associated with reduced postural control.⁵ 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.⁶ 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.^7,8 There have been studies investigating obesity as a potential risk factor for postural instability or falls; however, the results are diverging.

Relevance to Clinical Practice

Center for Disease Control and Prevention (CDC) data in the past few years have demonstrated that each year approximately one in four individuals over the age of 65 will experience a fall. More importantly, they report that often every one out of 10 falls will result in an injury that will restrict these individuals in their daily living.⁹ 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.²⁰ 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). Studies have demonstrated that individuals with concerns about falling and balance difficulties were associated with increased risk of injurious falls.²¹ More importantly, one in four of those with balance impairment had difficulty in activities of daily living (ADLs).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.

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. Due to the increase of population age, age-related mobility limitations become more prevalent. Mobility limiting factors have been studied to be an early predictor of physical disability and fall risk. When obtaining history from patients, knowing the modifiable and non-modifiable determinants of mobility will be fundamental in addressing management.²²

• Acute and chronic medical problems (recent illness, surgery, hospitalization)
• Medication history including number of medications, new medications, over the counter medications, herbal supplements 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, sleep disorders)
• 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 (e.g., arrhythmia, murmurs, orthostatic hypotension)
• Peripheral neuropathy related to medical conditions (e.g., endocrine disorders, infectious, renal insufficiency)
• Central nervous system disorders (e.g., cerebellar dysfunctions or degeneration, multiple sclerosis, normal pressure hydrocephalus, Parkinson Disease, stroke, etc.)
• Vestibular disorders
• Spine disorders (e.g., cervical myelopathy, lumbar spinal stenosis)
• Sensory abnormalities (hearing or visual impairment, peripheral neuropathy)
• Frailty

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
• Musculoskeletal examination
  • Standing posture for kyphosis of spine, loss of lumbar lordosis
  • Range of motion of hips, knees, ankle, and foot (e.g., tightness of hip flexors, knee flexors, and gastrocnemius muscles)
  • Joint swelling and any deformity or instability.
  • Strength assessment (e.g., isometric hand grip, knee extensor strength)
• Footwear
  • Look 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
• Evaluate gait mechanics noting
  • 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.^1,23

Summary of Clinical Balance Tests

A meta-analysis conducted by Jepsen and Robinson et al. In 2022 demonstrated that no single gait, balance or functional mobility assessment in isolation can be used to predict fall risk in older adults with high certainty. Moderate evidence suggests gait speed can be useful in predicting falls and might be included as part of a comprehensive evaluation for older adults. ²⁴

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

Smartphone-based mobile posturography applications²⁵

• Easy-to-use and affordable solutions but are limited to one sensor lumbar level posturography and offer only basic clinical evaluation (e.g., Timed Up and Go Test (TUG) and limited biofeedback capabilities
• More research is needed to develop solutions to provide continuous monitoring, improve biofeedback necessary to implement these solutions into home rehabilitation regimens and to decrease the number of false alarms.

 Vestibular tests²⁶

• The Caloric Test:  The most widely used vestibular test. It assesses horizontal semicircular canal function. Only measures relative function between the right and left side and does not measure absolute vestibular function)
• Torsion swing test: Rotatory chair testing is another test that has good reproducibility, although it only measures horizontal semicircular canal function and cannot disambiguate between right and left vestibular impairment
• Video Head Impulse Test vHIT): Newer measure that can assess the function of all semicircular canals (horizontal, anterior, and posterior separately for each side). It is a powerful, portable test; however, testing artifacts can limit the validity of the vHIT
• Vestibular-Evoked Myogenic Potentials: Vestibular-evoked myogenic potential tests are the mainstay of otolith function testing; however, vestibular-evoked myogenic potential inter-rater reliability and reproducibility can be low, given that test performance relies on patient effort and examiner factors that can vary across test.

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 (e.g., stroke, myelopathy), brain and/or spinal cord (cervical/thoracic spine) pathology 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.

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 plans 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 separate article Fall Prevention in the Elderly)
• Explore the patients’ perceptions of the causes of balance impairments (and falls) as well as  the patient’s willingness to make recommended 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 medications and supplements) considering 20% of unsteadiness in older adults may have pharmacologic etiology. A careful review may reveal medications triggering the unsteadiness
  • Common examples include pain medications, anti-spasticity, 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.
• A 2015 study from the Journal of Geriatrics Gerontology International demonstrated that “walking among community-dwelling older adults can be more effective for fall prevention than balance training.”
• 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 (e.g., PT, community programs, home programs)²⁷
• Strengthening exercise, three dimensional exercise (e.g., Tai Chi, qi gong, dance, yoga),
• Virtual balance training (therapy, serious games)
• Vitamin D 800 IU per day for those at risk of fall and suspected vitamin D deficiency.
• Offer ongoing monitoring and follow-up
• For certain conditions, such as MS, studies have found that training including backwards walking had a positive impact on gait and balance. ²⁸
• Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program designed to promote vestibular adaptation and substitution
  • It promotes vestibular adaptation, substitution by vision, somatosensory cues and habituation
  • Exercises include eye movements with a variety of body posture and activities, maintaining balance with a reduced base of support, provoking vertigo and exposing patients gradually to varieties of sensory and motor environments²⁹

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. A 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.³⁰  But a recent study regarding Turning training vs. Balance training in elderly adults examined the effects of both training regiments on factors such as balance performance, mobility, turning, as well as the fear of falling itself. Both were effective in improving all factors,  turning training improved turning and functional balance when compared to simple balance training.³¹

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 (e.g., ambulatory monitoring device, high tech glasses enhancing foot placement, virtual reality). For specific disease population (such as Parkinson’s disease), trials of neurosurgical tools (e.g., subthalamic or pallidal deep brain stimulation) are ongoing for balance improvement.³² Newer studies have also been studied using haptic vibrotactile trigger technology which targets the neural pathways to assist in improving balance and stability. Posture and balance are controlled by mechanisms of the sensory and motor modules in the spinal cord, brainstem, and cerebellum. As we age, the changes in our sensory systems result in increased risk of falling due to postural control and balance issues. Using haptic trigger technology has been shown to influence neuromuscular balance.³³

Robotic assisted gait training with individuals with neurological disorders showed some additive benefit in balance and ambulation when combined with conventional rehabilitation.  More clinical research needs to be done to determine optimal timing and protocol design for maximum benefit and long-term outcomes . Recent studies have been performed assessing the use of exoskeletons to train individuals to maintain balance. These exoskeletons will react to physiologic stimuli to maintain balance. However, they have been found to occasionally react too quickly and even faster than the body’s only physiologic response. This may actually hinder the response and lead to increased risk of falls. While studies are still ongoing, this highlights an emerging field in robotic balance training.³⁴

Creative dancing in elderly showed improvement in gait, dynamic balance, fall risk, reaction time. It encouraged participants to move and change gait patterns while responding to a variety of unexpected external stimuli including music and people by using multiple senses simultaneously. Furthermore, auditory stimuli of music and training to respond to rhythm, tempo, and melody lead to highly automated gait patterns and improved balance.²⁴

Virtual reality game systems used for balance training in elderly showed statistically significant improvement in balance by stimulating vision and vestibular pathway.  It increased their confidence and decreased fear of falls.^35,36 More recent studies regarding virtual reality have demonstrated decreased risk of falling following 8 weeks of consistent and targeted virtual reality exercises.³⁷

Balance in the Athlete

Athletes are a unique population which need to be addressed as balance and falls play a pivotal role in the well being of the athlete. Movements in sports require a complex coordination between balance, strength, and agility. With deficits in any of these factors, movement and performance are heavily impacted. A study was performed which looked at potential differences in postural control between different types of sports based on their level of contact. It found that postural control characteristics were significantly different for athletes that participate in collision sports as relative to non-contact sports.³⁸ For sports such as marital arts, a large aspect of their performance relies on maintaining postural balance and control. Posture is related to the ability to coordinate movements and maintain balance, and those who succeed are those athletes with higher level of postural balance.³⁹ It is important to maintain balance and resistance training in athletes to improve on their fitness and performance. Use of resistance training, balance, training, K-taping, and stability exercises have all demonstrated efficacy in improving the stability and postural control of athletes.^40,41

Gaps in Knowledge/Evidence

The major pitfalls in the literature and clinical practice in management of balance impairment include not determining the underlying pathology, lumping balance disabilities together 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 needed, particularly during the transition of care from the hospital or clinic to the community. There are also certain groups of populations in where the studies of balance and falls have been limited, including those of lower limb prosthetic users.⁴²

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Original Version of the Topic

Mooyeon Oh-Park, MD, Natasha Mehta, MD. Assessment and Treatment of Balance Impairments. 4/13/2016

Previous Revision(s) of the Topic

Mooyeon Oh-Park, MD, Deepthi Ganta, MD. Assessment and Treatment of Balance Impairments. 7/7/2021

Author Disclosure

Mooyeon Oh-Park, MD
Nothing to Disclose

Bassem Hanna, MD
Nothing to Disclose

Muhammad Sheheryar Rizwan, DO
Nothing to Disclose