Workup for Impaired Balance
The comprehensive workup for a patient with impaired balance should include standardized balance assessments, evaluation of sensory systems (visual, vestibular, somatosensory), gait analysis, and targeted neurological examination to identify the underlying cause and guide appropriate treatment interventions. 1
Initial Assessment
Standardized Balance Tests
- Timed Up and Go (TUG) Test: Patient rises from a chair, walks 3 meters, turns, returns to chair, and sits down. A time >12 seconds indicates increased fall risk 1
- Four-Stage Balance Test: Progressively challenging standing positions held for 10 seconds each (feet side-by-side, semi-tandem, tandem, single-foot). Inability to hold tandem stand for 10 seconds indicates fall risk 1
- Berg Balance Scale: Comprehensive assessment of balance during various functional tasks 2
- Single Leg Stance Test: Simple but effective predictor of fall risk 2
Sensory System Evaluation
Visual System:
- Visual acuity testing
- Dynamic visual acuity test (assesses gaze stability during head movement) 3
- Assessment of visual field deficits
Vestibular System:
- Dix-Hallpike maneuver (for BPPV)
- Head impulse test (for vestibular hypofunction)
- Fukuda stepping test (for asymmetric vestibular function) 3
- Consider referral for formal vestibular testing if indicated
Somatosensory System:
- Proprioception testing (joint position sense)
- Vibration sense testing
- Light touch sensation
- Cervical joint position error sense test (if cervical issues suspected) 3
Gait Analysis
- Observe for abnormal patterns: ataxic, antalgic, parkinsonian, etc.
- Note use of assistive devices
- Assess for specific gait deviations that may indicate neurological or musculoskeletal issues 1
Neurological Examination
- Cranial nerve assessment (particularly CN III, IV, VI, and VIII)
- Cerebellar testing (finger-to-nose, heel-to-shin, rapid alternating movements)
- Motor strength testing
- Deep tendon reflexes
- Coordination testing 1
Additional Assessments
- Functional Impact Assessment: Dizziness Handicap Inventory to evaluate daily life impact 3, 2
- Cognitive Screening: If cognitive impairment is suspected as contributing to balance issues 1
- Medication Review: Identify medications that may contribute to balance problems (e.g., sedatives, antihypertensives) 1
- Fall Risk Assessment: "Three key questions" approach 1:
- Have you fallen in the past year?
- Do you feel unsteady when standing or walking?
- Are you worried about falling?
Advanced Testing (When Indicated)
- Computerized Dynamic Posturography: Quantifies sensory and motor components of balance control 4
- Imaging Studies: Based on clinical suspicion:
- Laboratory Testing: Consider based on clinical presentation:
- CBC, metabolic panel, vitamin B12, thyroid function
- Specialized vestibular testing (VNG, VEMP)
Common Pitfalls to Avoid
- Attributing all balance problems to aging: Balance impairment is not a normal part of aging and should be thoroughly investigated
- Missing multifactorial causes: Balance problems often have multiple contributing factors
- Overlooking medication effects: Many medications can impair balance
- Failing to assess fall risk: Balance impairment significantly increases fall risk
- Neglecting the impact on quality of life: Balance problems can lead to activity restriction and social isolation
Special Considerations
- For stroke patients, balance training has been shown to be effective and should be incorporated into rehabilitation 1
- For patients with ataxia, specific postural training and task-oriented therapy may be beneficial 1
- Consider dual-task training approaches for older adults with balance impairment to improve functional outcomes 5
By systematically evaluating these components, clinicians can identify the underlying causes of balance impairment and develop targeted treatment strategies to improve patient outcomes and reduce fall risk.