With the advancement of modern medicine, we are seeing people live longer and longer lives, however the quality of that life can vary widely from person to person. In the United States, there is an increasing number of people who adopt a sedentary lifestyle which can affect their health in many ways. The way it has most manifested throughout the course of my physical therapy career is a decline in balance. Oftentimes, this decline will eventually result in a fall… which is what led them to me in the first place.
Just as quality of life can be multi-factorial, there can be a multitude of factors that influence a person’s balance. These can include ROM, strength, the vestibular system, proprioception, just to name a few. The good news is once you’ve isolated the primary sources for a patient’s loss of balance, you can often work to correct it and thereby reduce a person’s risk for falls.
Physical Therapy Balance Assessment
So let’s look at what your physical therapist may be looking for when they perform their balance assessment on you.
1. Range of Motion (ROM)
If someone is limited in the available ROM of key joints, it can influence a person’s risk for falls. For example, you want to have enough ankle dorsiflexion (motion at the ankle that brings the toes towards your shins) to properly transfer your weight over your ankle and leg as you walk. Without sufficient ROM at this joint, you could trip by stubbing your toes on the ground as you walk since they couldn’t clear the floor.
Other key motions for improved balance include:
- Hip extension as you push off while walking
- Lumbar (back) extension to have better posture and in turn, a better center of gravity while upright
- Pelvic rotation since your pelvis moves in a figure-S shape whenever you step
- Lumbar rotation to counterbalance the pelvic rotation
- Knee extension in order to have a better heel strike during the gait cycle
- Knee flexion to swing the leg through the air just before heel strike
2. Strength | Muscle Testing
Strength plays a primary role in our ability to stay balanced, and I have found over the years that weakness in the hip muscles is the primary culprit causing people to fall. As you’ll soon see, however, it’s not the only cause. A physical therapist can do a brief muscle testing assessment, but isolating the muscle groups will provide more insight as to where to focus treatment:
- Hip extensors– One of the first muscle groups to atrophy are muscles like the gluteus maximus which extends your leg back behind you. When these muscles are weak, it will often cause low back pain as well. You will often see people bend forward to keep themselves balanced, since your extensor muscles keep your posture erect.
- Hip abductors– These are the muscles on the side of your hips. They may be tiny compared to the rest, but they are mighty! Your abductor muscles keep your pelvis level, so you may notice after a hip replacement, that the non-surgical hip may hang lower than the one operated on (known as a Trendelenburg sign). This is because your abductors have become weak after surgery. Because the pelvis is not level, you may find the toes on your non-surgical leg catching on the floor or the bottoms of that shoe wearing out faster than the surgical side.
- Ankle dorsiflexors– Just as limitations in ankle dorsiflexion ROM can contribute to falls, weakness in the dorsiflexor muscles (those located towards the front and outer part of the shins) can cause people to fall backwards.
- Ankle plantarflexors– Also known as your calf muscles. These do the opposite of the dorsiflexors and prevent you from falling forward.
- Quadriceps- These are the muscles in the front of your thighs. Their primary responsibility is to straighten your knees. Quad strength is important for tasks such as standing up from a chair, so you don’t fall backwards. However, they are also crucial to prevent your knees from buckling when you eventually come to stand.
- Abdominals– Your abdominal muscles promote trunk flexion, but they are also responsible for isometrically holding your trunk forward. What this means in laymen’s terms is that with weak abdominals, you will most likely find yourself falling backwards.
Again, this list is by no means exhaustive, but these are the key players I assess in my patients with balance issues. Sometimes, I don’t even have to do a formal assessment if I’m short on time. For example, a Trendelenburg sign will visually tell me that a patient’s hip abductors are weak, and I proceed to incorporate strengthening into my treatment.
Proprioception is when the sensors in your joints and tendons relay information to your brain regarding joint position. It allows you to know whether you are standing erect, where your arm is in space, or the placement of your feet, all without looking. Events such as joint sprains and strokes can decrease the effectiveness of the body’s ability to decipher proprioception accurately.
Proprioception can be tested formally at each joint as in when a therapist moves the joint in an up or down direction- with the patient’s eyes closed- then asks the patient to tell which direction their body part was moved.
Typically in balance, we are concerned with proprioception of the lower limbs, specifically at the ankles and hips. We can informally test proprioception by removing the firmness of the surface a patient stands on, having them stand on a pillow or foam pad, so that the patient must heavily rely on their body’s ability to tell where they are in space.
Decreased sensation of the feet, such as neuropathy commonly associated in those with diabetes, is a risk for falls. The individual would not be able to feel objects on the floor that could trip them, nor know if their toes had cleared the floor during gait.
Visual acuity (or the sharpness of vision) is not the only risk factor for falls. Other degenerative diseases such as macular degeneration, glaucoma, or cataracts can diminish your central or peripheral vision, which ultimately can put you at risk for tripping over objects.
6. Vestibular System Impairments
There are 3 canals in the inner ear that relay information regarding balance, especially in relation to the head. A dysfunction in the inner ear can often lead to dizziness and decreased balance. A condition known as BPPV is the most common vestibular dysfunction treated by therapists.
More and more there is an emphasis in therapy towards evidenced-based practice to demonstrate the effectiveness of certain interventions. As it relates to balance, more therapists are conducting specialized tests to assess patient’s abilities pre and post interventions.
There are a multitude of tests that can be chosen, and it is up to the therapist to determine which is the most appropriate to assess their patient. The following list includes the specialized tests I have more commonly used during my career:
BERG Balance Scale
Looks primarily at stationary balance such as ability to stand with and without eyes closed, standing tandem, etc. It does, however, have some dynamic components such as sit to stand and vice-versa.
Dynamic Gait Index
Assesses a patient’s balance during walking while performing various tasks such as altering speed or stepping around an object.
Tinetti Balance Assessment
Combines components from the Berg and the Dynamic Gait Index by looking at stationary and walking components.
Function in Sitting Test
This test is more appropriate for those patients who cannot stand.
Time Up and Go
Assesses speed of rising from a chair, walking about 10 ft, turning, and returning to sitting. The greater the time to accomplish this task, the greater the risk of falling.
Putting Together the Balance Assessment
While I have listed a lot of considerations during a physical therapy evaluation, I don’t typically have the time, nor do patients always have the ability to get into the necessary positions, for me to conduct an in-depth assessment. Below, I will lay out my thinking process for how I conduct a typical exam.
A patient’s past medical history or intake form is where I start when assessing a person’s balance. I am looking for diagnoses such as stroke, diabetes, hypertension, hypotension, orthopedic surgeries or injuries. I make a mental note of anything I should assess further such as blood pressure in supine, sitting, and standing if they report a blood pressure issue.
When I worked in an outpatient clinic, after reviewing the medical history, I analyzed a patient’s posture and gait as they walked from the waiting room to my examination room. In inpatient settings where patients are typically too weak to walk long distances or may even be too weak to stand on their own, I will proceed to assess their posture in sitting and note their sitting balance with and without support.
Strength will usually be assessed in the hips, knees, and ankles, and I can grossly assess for limitations in range of motion at the same time I assess their strength. In inpatient facilities, I am more general in my testing, but I can be more specific in grading and measuring in my outpatient population.
The balance assessment usually ends with a special test of some kind. If the individual cannot stand, I will perform the FIST. If they have decreased endurance or difficulty walking, I will perform the BERG. If I want to assess the static and gait aspects of their balance, I will conduct the Tinetti. These multi-step tests are helpful in assessing various aspects of sitting and standing balance.
Final Thoughts on Balance
Contrary to popular belief, we do not have to just expect to lose balance or fall as we age. While it is typical to lose certain aspects of our functional performance as we get older, this can be related to our decreased levels of activities. Even in advanced age, individuals can improve posture, can increase strength, and can reduce their risk for falling. As physical therapists, it is our job to guide these individuals towards their goals so that they can continue to have a great quality of life for the rest of their days.