What is the next step in managing a patient with loss of balance while walking?

Management of Loss of Balance When Walking

The next step in managing a patient with loss of balance while walking should be to perform standardized balance and mobility assessments, including the Timed Up and Go (TUG) test and the 4-Stage Balance Test, followed by a comprehensive fall risk assessment and referral to physical therapy for those with positive screening results. 1

Initial Assessment

Standardized Balance and Mobility Tests

• Timed Up and Go (TUG) test: Have the patient rise from a chair, walk 3 meters, turn around, walk back to the chair, and sit down. A time >12 seconds indicates increased fall risk. 1
• 4-Stage Balance Test: Have the patient stand in 4 increasingly challenging positions for 10 seconds each: feet side by side, semitandem stand, tandem stand, and single-foot stand. Inability to hold tandem stand for 10 seconds indicates increased fall risk. 1
• Three key screening questions: 1
  1. Have you fallen in the past year?
  2. Do you feel unsteady when standing or walking?
  3. Are you worried about falling?

Any positive answer to these questions, a TUG score >12 seconds, or inability to hold a tandem stand for 10 seconds should trigger a broader fall risk assessment. 1

Fall Risk Assessment

Evaluate Common Risk Factors (P-SCHEME): 1

• P: Pain (axial or lower extremity)
• S: Shoes (suboptimal footwear)
• C: Cognitive impairment
• H: Hypotension (orthostatic or iatrogenic)
• E: Eyesight (vision impairment)
• M: Medications (especially centrally acting)
• E: Environmental factors

Intervention Plan

Physical Therapy Referral

For patients with positive screening results, refer to a physical therapist to: 1

• Create a tailored exercise program
• Evaluate the need for walking aids
• Address specific balance and gait impairments

Exercise Interventions

Recommend a multicomponent exercise program including: 1, 2

• Balance and functional exercises: These reduce falls by 24% (high-certainty evidence) 2
• Multiple exercise types: Combining balance, functional, and resistance exercises reduces falls by 34% (moderate-certainty evidence) 2
• Tai Chi: May reduce falls by 19% (low-certainty evidence) 2

For optimal results, exercise should include: 1, 3

• Balance training (both voluntary and reactive control)
• Strength training (particularly lower extremity)
• Gait training
• Aerobic exercise

Medication Review

Review and potentially modify medications that may contribute to balance problems: 1

• Focus on centrally acting medications
• Consider polypharmacy (≥5 medications) as a risk factor
• Evaluate for drug-drug interactions
• Consider deprescribing when appropriate

Special Considerations

For Elderly Patients

• Frail elderly patients benefit from a multicomponent approach including exercise, nutritional support, and medication review 3
• Consider a complete geriatric assessment for those with significant balance issues 3

For Patients with Neurological Conditions

• Stroke survivors require specialized balance training approaches 1
• Consider both voluntary and reactive balance control within assessment and treatment 1

Monitoring and Follow-up

• Schedule follow-up visits to monitor progress and adjust interventions
• Reassess balance and gait periodically using standardized tests
• Evaluate the effectiveness of interventions and modify as needed

Prevention Strategies

• Educate patients on home safety modifications 1
• Encourage consistent participation in balance and strength exercises 1, 2
• Consider patient activation strategies to improve engagement in fall prevention 4

By following this structured approach to managing loss of balance while walking, you can effectively reduce fall risk and improve patient outcomes. The evidence strongly supports early assessment and intervention, with physical therapy and tailored exercise programs forming the cornerstone of management.