How do you assess balance in a patient?

How to Assess Balance in a Patient

Use the Berg Balance Scale, Timed Up and Go test, or 4-Stage Balance Test as your primary standardized assessment tools, selecting based on the clinical context and time available.

Rapid Screening Tests (Under 5 Minutes)

Timed Up and Go (TUG)

• Instruct the patient to rise from a chair, walk 3 meters, turn around, walk back, and sit down 1
• A time ≥12 seconds indicates increased fall risk 1
• This test is the simplest and most reliable quick assessment, taking less than 5 minutes 1, 2
• It quantifies more than straight walking by including sit-to-stand transitions and turning 1

4-Stage Balance Test

• Progress through 4 increasingly difficult standing positions, each held for 10 seconds 1:
  1. Feet side by side
  2. Instep of one foot touching the big toe of the other foot (semi-tandem)
  3. Tandem stance (heel-to-toe, one foot directly in front of the other)
  4. Single-leg stance
• Stop the test if the patient cannot maintain position without moving feet or requiring support 1
• Inability to hold tandem stand for 10 seconds indicates increased fall risk 1

Single-Leg Stance Test

• Have the patient stand on one leg with eyes open, then repeat with eyes closed 1, 3
• The non-dominant leg should be held at approximately 30 degrees hip flexion and 45 degrees knee flexion 1
• Maintain for 20 seconds with hands on hips 1
• This test is widely used (79.1% of physical therapists use it regularly) and serves as a good predictor of falls 2, 3

Comprehensive Balance Assessment (15-20 Minutes)

Berg Balance Scale

• This 14-item criterion-based assessment evaluates both static and dynamic balance 1
• Each item is scored 0-4, with total scores ranging from 0-56 1
• Interpretation 1:
  • 41-56: Independent
  • 21-40: Walking with assistance required
  • 0-20: Wheelchair-bound
• Tasks include position changes, transfers, standing balance tests, reaching, turning 360°, and retrieving objects from the floor 1
• This scale is widely used across multiple clinical settings and has excellent reliability 1, 2

Functional Reach Test

• Single-item test measuring how far a patient can reach forward while standing 1
• Takes less than 5 minutes and has normative data available for comparison 1

Additional Functional Tests

30-Second Chair Stand

• Patient crosses arms over opposite shoulders, keeps feet flat, and stands/sits as many times as possible in 30 seconds 1
• Age and sex-specific cutoffs identify below-average performance 1
• For example, men aged 60-64 scoring <14 or women <12 are below average 1

Walking Speed Assessment

• Measure speed over 5 or 10 meters 1
• Interpretation 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 Considerations

For Concussion/Sports Medicine

• Use the balance examination component of the SCAT assessment with three 20-second trials 1:
  • Feet together, eyes closed
  • Single-leg stance (non-dominant foot), eyes closed
  • Tandem stance (non-dominant foot back), eyes closed
• Count the number of times the patient moves out of position 1

For Stroke Patients

• The Berg Balance Scale remains the primary tool 1
• Consider the Activities-Specific Balance Confidence Scale (16 questions, 20 minutes) to assess balance confidence during routine activities 1
• Scores range 0-100, with higher scores indicating greater confidence 1

For Cardiac Rehabilitation Patients

• Use the assessment tools to identify frailty and fall risk as part of comprehensive rehabilitation 1
• Combine balance testing with strength assessment (1-repetition maximum testing) 1

Critical Red Flags Requiring Urgent Evaluation

If balance impairment presents acutely with any of the following, immediate neuroimaging is required 4:

• Vertical diplopia, head tilt, or subjective visual tilt
• New nystagmus or ocular motor abnormalities
• Ataxia, dysmetria, or limb incoordination
• Associated vertigo, nausea, or vomiting
• New weakness, sensory changes, or dysarthria

Common Pitfalls to Avoid

• Do not rely on a single test—the Tinetti test, while widely used in older adults, is quite approximate and less reliable than other options 2
• Ensure proper footwear removal and adequate space for accurate testing 1
• Test reliability improves when using the best result of multiple attempts rather than the mean 5
• Eyes-open testing has better reliability than eyes-closed testing 5
• Remember that many standardized measures have ceiling effects in high-functioning individuals—consider single-leg stance protocols for these populations 6