How to assess impaired balance?

Assessment of Impaired Balance

Use the Timed Up and Go (TUG) test as your primary screening tool—a time >12 seconds indicates increased fall risk and warrants comprehensive balance evaluation. 1

Initial Screening Approach

Start with rapid screening questions to identify balance impairment 1:

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

A "yes" to any question requires formal balance testing 1.

Standardized Clinical Balance Tests

Primary Assessment Tools

The 4-Stage Balance Test provides quick, objective measurement 1:

• Stand with feet side by side (10 seconds)
• Semitandem stand (10 seconds)
• Tandem stand (10 seconds)
• Single-foot stand (10 seconds)

Inability to hold tandem stand <10 seconds indicates significant fall risk 1.

The Timed Up and Go (TUG) measures functional mobility 1:

• Patient rises from chair, walks 3 meters, turns, returns, and sits
• Time >12 seconds = increased fall risk 1
• Simple, reliable, and validated across multiple populations 1

Comprehensive Balance Assessment

Berg Balance Scale for detailed evaluation 1, 2:

• 14-item criterion-based assessment
• Evaluates static and dynamic balance
• Scores 0-56 (higher = better performance)
• Takes approximately 15 minutes 1
• Score <41 indicates need for assistive device 1

Functional Reach Test measures dynamic stability 1:

• Single-item test of forward reach distance in standing
• Quick (<5 minutes) with normative data available 1

Neurological Examination Components

Essential elements to assess 1:

• Gait evaluation: Observe for speed, symmetry, assistive device use 1
• Motor examination: Strength, reflexes, Babinski signs 1
• Sensory testing: Vision, proprioception, distal sensation 1
• Vestibular function: Nystagmus, head impulse test, positional testing 3

Walking speed categories 1:

• <0.4 m/s = household ambulation only
• 0.4-0.8 m/s = limited community ambulation

• 0.8 m/s = community ambulation

Context-Specific Assessments

Post-Stroke Patients

Use the Postural Assessment Scale for Stroke Patients (PASS) 2:

• Specifically validated for recent stroke
• Easy to administer
• Captures stroke-specific balance deficits 1

Geriatric Patients

30-Second Chair Stand Test assesses lower extremity strength 1:

• Patient stands and sits repeatedly for 30 seconds
• Age and sex-specific normative values available 1
• Scores below average predict fall risk 1

Vestibular Disorders

Videonystagmography enables precise monitoring 3:

• Characterizes peripheral vs. central vestibular dysfunction
• Identifies benign paroxysmal positional vertigo (BPPV) 3
• Cost-effective for serial monitoring 3

Risk Factor Assessment (P-SCHEME)

Systematically evaluate modifiable contributors 1:

• Pain (axial or lower extremity)
• Shoes (inappropriate footwear)
• Cognitive impairment
• Hypotension (orthostatic or medication-induced)
• Eyesight (visual impairment)
• Medications (centrally acting agents)
• Environmental hazards

Advanced Assessment Tools

Computerized posturography for complex cases 4, 2:

• Differentiates sensory contributions (visual, vestibular, somatosensory)
• Provides objective, quantifiable data 4
• More sensitive than clinical scales alone 4

Wearable inertial sensors offer continuous monitoring 4:

• Captures real-world balance performance
• Identifies subtle deficits missed by clinical testing 4

Documentation Requirements

Record the following for comprehensive assessment 1:

• Subjective symptoms and onset timing
• Vital signs including orthostatic blood pressure 1
• Specific balance test scores with dates 5
• Gait aid requirements 1
• Fall history with circumstances 1

Common Pitfalls to Avoid

Do not rely on single assessment 4, 2:

• Most functional scales assess fall risk but don't differentiate underlying mechanisms 4
• Combine screening tools with targeted neurological examination 1

Recognize central vs. peripheral causes 3:

• Central findings: direction-changing nystagmus, dysmetria, dysarthria 1
• Peripheral findings: unidirectional nystagmus, positive head impulse test 3

Consider vestibular migraine in differential 1:

• ≥5 episodes lasting 5 minutes to 72 hours
• Migraine symptoms during ≥50% of dizzy episodes 1
• Distinguishable from BPPV by spontaneous (not positional) nature 1

Monitoring Over Time

Use MCQ-Balance approach for serial assessment 5:

• Measures progression between sessions
• Classifies improvement, stability, or decline 5
• Accuracy 83.4% compared to clinical expert assessment 5