What is the appropriate workup for a patient with poor balance?

Comprehensive Workup for Poor Balance

A comprehensive balance assessment should include standardized functional tests such as the Timed Up and Go (TUG) test, 4-Stage Balance Test, and evaluation of the P-SCHEME risk factors to identify the underlying causes of poor balance. 1

Initial Assessment

Standardized Balance Tests

1. Timed Up and Go (TUG) Test:

   • Patient rises from a chair, walks 3 meters at normal pace, turns around, returns to chair, and sits down
   • Score ≥12 seconds indicates increased fall risk 1

2. 4-Stage Balance Test:

   • Patient holds four increasingly difficult positions for 10 seconds each:
     • Feet side by side
     • Semitandem stand (instep of one foot touching big toe of other foot)
     • Tandem stand (one foot in front of other, heel touching toe)
     • Single-foot stand
   • Inability to hold tandem stand for 10 seconds indicates increased fall risk 1

3. 30-Second Chair Stand Test:

   • Patient stands fully and sits back down as many times as possible within 30 seconds
   • Age-specific norms determine if score is below average 1

Key Screening Questions

• Have you fallen in the past year?
• Do you feel unsteady when standing or walking?
• Are you worried about falling? 1

Comprehensive Evaluation Framework (P-SCHEME)

The P-SCHEME framework helps identify common factors contributing to balance impairment 1:

1. P - Pain (axial or lower extremity)

   • Assess for musculoskeletal pain that may alter gait patterns
   • Evaluate for arthritis, neuropathic pain, or other pain syndromes

2. S - Shoes (suboptimal footwear)

   • Evaluate footwear for appropriate support, fit, and stability

3. C - Cognitive impairment

   • Screen for dementia, delirium, or mild cognitive impairment using tools like Mini-Cog
   • Assess for depression using PHQ-2/PHQ-9 1

4. H - Hypotension (orthostatic or iatrogenic)

   • Check for orthostatic hypotension by measuring blood pressure lying, sitting, and standing
   • Review medications that may cause hypotension

5. E - Eyesight (vision impairment)

   • Assess visual acuity, depth perception, and peripheral vision
   • Check for cataracts, macular degeneration, or other visual disorders

6. M - Medications (centrally acting)

   • Review medications, particularly:
     • Benzodiazepines
     • Antidepressants
     • Antipsychotics
     • Antihistamines
     • Anticonvulsants
     • Other sedating medications 2

7. E - Environmental factors

   • Assess home safety and environmental hazards

Additional Specialized Testing

For patients with persistent or severe balance issues, consider:

1. Neurological Examination:

   • Cerebellar function testing (finger-to-nose, heel-to-shin)
   • Proprioception assessment
   • Motor strength and coordination testing
   • Sensory examination (particularly lower extremities)

2. Vestibular Assessment:

   • Dix-Hallpike maneuver for positional vertigo
   • Head impulse test
   • Dynamic visual acuity testing 3

3. Advanced Balance Testing:

   • Berg Balance Scale (14-item scale with scores 0-56; higher scores indicate better performance) 1
   • Functional Ambulation Classification (assesses physical support needed during walking) 4

Laboratory and Imaging Studies

Based on clinical findings, consider:

1. Laboratory Tests:

   • Complete blood count (anemia)
   • Comprehensive metabolic panel (electrolyte abnormalities)
   • Vitamin B12 and folate levels (deficiencies)
   • Thyroid function tests (hypothyroidism)
   • Hemoglobin A1c (diabetes/neuropathy)

2. Imaging:

   • Brain MRI if central neurological causes suspected
   • Cervical spine imaging if cervical myelopathy suspected

Management Recommendations

Once assessment is complete, management should be tailored to identified causes:

1. Exercise Interventions:

   • Balance-specific training programs
   • Tai Chi (particularly effective for older adults)
   • Progressive resistance training focusing on lower extremity strength 1

2. Physical Therapy Referral:

   • For creating individualized exercise programs
   • Evaluating need for walking aids
   • Gait training 1

3. Medication Review and Adjustment:

   • Reduce or eliminate medications that impair balance
   • Consider alternatives for necessary medications with fewer balance-affecting side effects

4. Environmental Modifications:

   • Home safety assessment
   • Installation of grab bars, improved lighting, removal of trip hazards

Common Pitfalls to Avoid

1. Attributing balance problems solely to aging - Balance disorders are not a normal part of aging and should be thoroughly investigated

2. Missing vestibular disorders - Vestibular problems are common but frequently overlooked causes of balance impairment

3. Overlooking medication effects - Many medications can affect balance, and polypharmacy increases this risk

4. Focusing only on one system - Balance requires integration of multiple systems (visual, vestibular, proprioceptive, musculoskeletal)

5. Neglecting psychological factors - Fear of falling can significantly impact balance performance and mobility

By following this systematic approach to balance assessment, clinicians can identify specific underlying causes of poor balance and implement targeted interventions to improve stability and reduce fall risk.