BALANCE ASSESSMENT .pptx

ASSESSMENTOFBALANCE
PRESENTED BY: GUNDEEP SINGH

Balance
◻ Definition
� Balance is defined as a “complex process
involving the reception and integration of
sensory inputs, planning and execution of
movements, to achieve a goal requiring
upright posture.” (Nashner L, 1994)
� It is the ability to control the COG over the
BOS in a given sensory environment. (Nashner
L, 1994)

Posture
◻ Posture
� The term posture is often used to describe both
Biomechanical alignment of the body as well as
Orientation of the body to environment
◻ Balance impairment may resulting from,
� Neurological conditions
� Musculoskeletal conditions
� Psycological conditions.

OBJECTIVES OF TESTING
◻ A comprehensive evaluation of balance includes both functional
and impairment tests. “There is currently no one single test of
balance that adequately covers the many multidimensional aspects
of balance.”
◻ There is no single, simple test for balance because balance is a
complex sensorimotor process. Many balance tests exist, but not all
tests are appropriate for all clients. For example, several good tests
have been developed to determine the risk of falls in elderly people
but clinicians should understand the advantages and limitations of
different balance tests to be able to select appropriate evaluative
tools.
◻ In general, a balance test will not be useful unless it sufficiently
challenges the postural control system being tested. Tests for
stability (“static balance”) are appropriate for clients who are having
difficulty just finding midline and/or holding still in sitting or standing.
They are of much less value for clients with higher-level abilities.
Conversely, single-leg stance tests or sensory tests using a foam
surface may be far too difficult for clients with lower-level abilities to
perform.

◻ Because there are so many balance tests from which to
choose, several questions must be asked to determine
whether a test is appropriate for use or not.
⮚ For what purpose and population was the test designed?
⮚ Is it appropriate to use that test for a different purpose or with
a different population?
⮚ Is it valid?
⮚ Is it repeatable by different examiners or by the same
examiner multiple times?
⮚ Are results reliable?
⮚ Are there any normative data for comparison?
◻ Most of these questions have not been answered yet as they
relate to the clinical balance tests commonly used by
therapists.

TYPES OF BALANCE TESTS
◻ Balance tests can be grouped or classified as different type of tests
measure different facets of postural control.
•Self-report measures
•The Activities-specific Balance Confidence (ABC) Scale
• Quiet standing
•Romberg
•Sharpened Romberg
•Postural sway
•Postural stress test
•Motor control test
•One Legged Stance Test (OLST)
• Active standing
•Functional reach
•Limits of stability
• Sensory manipulation
•Sensory organization test
•CTSIB
•Nystagmus
•Visual acuity
•Occulomotor tests
•Fukuda stepping test
• Functional scales
•Berg Balance Scale
•Get Up and Go
•Timed Get Up and Go
•Extended Get up and Go

◻ Quiet standing (static) refers to tests where the client is
standing and the movement goal is to hold still. Disturbances
to balance, called perturbations, may or may not be applied.
◻ Active standing (dynamic) tests also position the patient
standing, but the movement goal involves voluntary weight
shifting.
◻ Sensory manipulation tests use various body and head
positions, eye movements, or stepping to stimulate or restrict
visual, vestibular, and somatosensory inputs.
◻ Functional balance, mobility and gait scales involve the
performance of whole-body movement tasks, such as sit-to-
stand, walking, and stepping over objects.
◻ Finally, a few test batteries offer a combination of the
preceding tests. A commonly accepted test for sitting balance
in adults is not yet available, although clients with
neurological problems may often need sitting balance
retraining in early stages.

Self-report measures
THE ACTIVITIES-SPECIFIC BALANCE CONFIDENCE (ABC) SCALE
Time to administer: 5-10 minutes to administer.
Clinical Comments: This test, along with a functional balance test, such as the
Berg, will tell the clinician if their client is over confident or under confident
about falling.
◻ Populations Tested
◻ Elderly
◻ Multiple Sclerosis
◻ Parkinson's Disease and Parkinsonism
◻ Stroke
◻ Unilateral Transtibial Amputation
◻ Vestibular Disorders
Psychometric property (Salbach, 2006)
◻ Reliability- test –retest , inter-rater and intra-rater well established. Excellent
internal consistency.
◻ Validity – content, construct, criterion well established

For each of the following activities, please indicate your level of self-confidence by
choosing a corresponding number from the following rating scale:
0% 10 20 30 40 50 60 70 80 90 100%
no confidence completely confident
“How confident are you that you will not lose your balance or become unsteady when you . .
.
1. . . . walk around the house? %
2. . . . walk up or down stairs? %
3. . . . bend over and pick up a slipper from front of a closet floor? %
4. . . . reach for a small can off a shelf at eye level? %
5. . . . stand on tip toes and reach for something above your head? %
6. . . . stand on a chair and reach for something? %
7. . . . sweep the floor? %
8. . . . walk outside the house to a car parked in the driveway? %
9. . . . get into or out of a car? %
10. . . . walk across a parking lot to the mall? %
11. . . . walk up or down a ramp? %
12. . . . walk in a crowded mall where people rapidly walk past you? %
13. . . . are bumped into by people as you walk through the mall? %
14. . . . step onto or off of an escalator while you are holding onto a railing? %
15. . . . step onto or off an escalator while holding onto parcels such that you cannot hold onto the

Quiet standing
◻ The classic Romberg test was originally developed to
“examine the effect of posterior column disease upon
straight stance”.
◻ The client stands with feet parallel and together and
then closes the eyes for 20 to 30 seconds. The
examiner subjectively judges the amount of sway.
Quantification of sway can be accomplished with a
video tape or force plate. Excessive sway, loss of
balance, or stepping during this test is abnormal.
◻ The Sharpened Romberg also known as the Tandem
Romberg, requires the client to stand with feet in a
heel-to-toe position and arms folded across the chest,
eyes closed for 60 secs. Often 4 trials of this test are
timed with a stopwatch, for a maximum score of 240
secs (4 mins).

Quiet standing
◻ One-legged-stance test (OLST) also called as Timed- single limb
stance, Unipedal Balance test, are commonly used in elderly
population and also with clients suffering with Parkinson's disease.
Both legs must be alternately tested, and differences between are
noted.
◻ The client stands on both feet and crosses the arms over the chest,
then picks up on leg and holds it with the hip in neutral and the knee
flexed to 90 degrees. This test is scored with a stopwatch.
◻ Five 30 second trials are performed for each leg (alternating legs),
with a maximum possible score of 150 seconds per leg. According
to a study done in Saudi Arabia, an older adult of age ranging from
60-64 can stand for maximum 20secs (eyes open) and 7 secs (eyes
closed).
◻ In both Romberg test and the OLST, problems in sensory
organization processes can be observed. To determine how much
of the stability is achieved through visual stabilization, each test can
be repaeted with eyes closed. The client with visual dependency for
balance will often have an immediate loss of balance when the eyes
are closed.

Quiet standing
❑ Objective postural sway measures can also be
obtained through the use of computerized
forceplates. It is widely used among elderly
population, clients with Parkinson's disease.
❑ The client is asked to stand quietly on a
standardized foot placement with arms at
sides or hands on hips for 20 or 30 secs. Sway
with both eyes open and eyes closed is
commonly measured and graphical and
numerical quantification is provided.

Quiet standing
◻ The Postural Stress Test was developed to examine elderly
people and determine the risk for falls. It is essentially a
quantifiable, repeatable nudge/push test that is known to be
reliable with trained raters.
◻ The client stands wearing a waist belt attached posteriorly to
a line that travels through a pulley and is attached on the
other end to one of the three weights. The weights are 1.5%,
3.0% or 4.25% of the client’s body weight. Each of these wt is
dropped from a standard height, pulling the line that displaces
the client backward. The expected response is a
compensatory forward adjustment.
◻ Clients are videotaped, and the video tape is reviewed to
assign scores to the balance responses, from 0(no
response/fall) to 9(appropriate response). If a videotape
cannot be made, a second examiner may be asked to
observe the responses during the test.

+ and ++ symbols indicate very frequently visible and invariably visible synergistic
responses respectively.
+_ refers to less frequently seen components.
Frames 2 to 0 show essentially absent coordinated activity followed by a fall.

Quiet standing
◻ Now, in case of vestibular loss, the sense of
body position in space can be lost. Postural
reflexes triggered by a perturbation may not be
appropriate for the actual circumstance and
therefore cause destabilization. Clients with
vestibular deficits often hold the Cog in a
posterior position during quiet stance. When
perturbed, they each the posterior limits of
stability before appropriate postural
adjustments can be made. This can result in a
fall backward.

Quiet standing
◻ The Motor Control Test
perturbs the client through
surface displacement. The
client stands on the
forceplate, which is movable,
with feet parallel and arms at
sides. The support surface
very rapidly rotates toes up or
toes down or slides forward
or backward. Both of these
surface displacements result
in a rapid shift in the
relationship between the
COG and the BOS.
◻ The expected responses are
directionally specific forces
generated against the surface
to bring the COG back to the
center.
Surface perturbations during the motor
control test using computer dynamic
posturography. Forceplate measures
include latency and amount of response,
and adaptation of the response to

Active standing
❑ “ Volitional control of the COG is evaluated by asking
the client to make voluntary movements that require
weight shifting.”
◻ The FUNCTIONAL REACH TEST: This was
developed for use with older adults to determine risk
for falls. Later on was also used in stroke clients.
◻ Procedure
� The client stands near a wall with feet parallel
� A yard stick is attached to the walls in shoulder (acromion)
height
� The client is asked to make a fist & raise the arm nearest
the wall (without touching) to 90° of shoulder flexion
� The examiner notes the fist (3ird MC head) on the yard
stick.

Active standing
◻ The client is then asked to lean forward as far
as possible, and the examiner notes the end
position of the fist on the yardstick.

Active standing
◻ Beginning position is subtracted from end position of the
fist on the yardstick to obtain a change unit in inches.
Three trials are performed. If the feet move, that trial
must be discarded and repeated. Guard the subject as
the task is performed to prevent a fall.
◻ Scoring: Scores less than 6 or 7 indicate limited
functional balance. Most healthy individuals with
adequate function balance can reach 10 inches or more.
◻ Population tested
■ Community Dwelling Elderly
■ Elderly Parkinson's Disease
■ Spinal Cord Injury
■ Stroke
■ Vestibular Disorders

Active standing
◻ MODIFIED FUNCTIONAL REACH TEST (Adapted for
individuals who are unable to stand):
◻ Performed with a levelled yardstick that has been mounted
on the wall at the height of the patient’s acromion level in the
non-affected arm while sitting in a chair
◻ Hips, knees and ankles positioned are at 90 degree of
flexion, with feet positioned flat on the floor. The initial reach
is measured with the patient sitting against the back of the
chair with the upper-extremity flexed to 90 degrees, measure
was taken from the distal end of the third metacarpal along
the yardstick.
◻ Consists of three conditions over three trials
o Sitting with the unaffected side near the wall and leaning
forward
o Sitting with the back to the wall and leaning right
o Sitting with the back to the wall leaning left.

Active standing
◻ Comments:
■ Simple single task test,
easy to administer, Quick
screen
■ High degree of agreement
rates (reliability inter .98
intra .92)
■ FR is affected by age and
height (i.e. anthropometric
characters).
■ Studies shown that this
test is useful for fall
prediction
■ Limitation: it measures
sway in only 0ne direction.
■ Less sensitive to illustrate
the clinical improvement.

Active standing
◻ The MULTI DIRECTIONAL REACH TEST is
conceptually equivalent but measures sway anteriorly,
posteriorly and laterally to both sides. This test should
provide a more comprehensive picture of volitional COG
control limitations.
Area of Assessment : Balance Vestibular; Balance Non-
Vestibular; Functional Mobility; Vestibular
◻ Population tested
■ Community Dwelling
■ Elderly Parkinson's Disease
■ Spinal Cord Injury
■ Stroke
■ Vestibular Disorders
◻ Stroke: (Katz-Leurer et al, 2009, Acute Stroke)
Excellent test-retest reliability (ICC = 0.90 to 0.95)

Active standing
◻ Vestibular pathology can produce an abnormal internal
representation of self-position in space. This may, in turn,
cause the client’s perceived limits of stability to be different
from their actual physical limits of stability. Poor motor
strategy selection may thus follow when the client attempts
to perform this test. For clients with vestibular deficits, eye
and head movements during this test may disturb
equilibrium sense and lead to abnormal postural
responses.
◻ For vestibular signals, the head orientation relative to the
trunk must be taken into account to control posture.
Orientation of the eyes appears to change the organization
of the whole-body posture, as well as the integration of
body space with extra personal space. When the CNS is
unable to manage the input from each of the visual and
vestibular systems, misperception of verticality may occur.

Sensory manipulation
◻ Sensory inputs play a critical role in postural control, but
tests to measure their use to produce a a balance
performance outcome have only recently been
develepoed.
◻ The Sensory Organization Test (SOT) uses a
computerized, movable force plate and movable visual
surround to systematically alter the surface and visual
environments.
◻ The client stands with feet parallel and arms at the sides
on the forceplates. It examines body sway during three
20-second trials under each of six sensory conditions
are performed.
◻ In conditions 1, 2 & 3 the support surface (forceplate) is
fixed. In conditions 4, 5 & 6 the support surface is sway
referenced to the sway of the client.

◻ It is used to determine the effectiveness of an individual to
utilize different sensory inputs.
◻ Components:
� Moving platform (sliding or tilting)
� A moving visual surround screen
◻ Test conditions are,
� C1: Eyes Open, Stable Surface (EOSS)
� C2: Eyes Closed, Stable Surface (ECSS)
� C3: Visual Conflict with Moving Surround, Stable Surface (VCSS)
� C4: Eyes Open, Moving Surface (EOSS)
� C5: Eyes Closed, Moving Surface (ECSS)
� C6: Visual Conflict with Moving Surround, Moving Platform
(VCSS)
■ Test condition 1 provides accurate somatosensory, visual, and
vestibular information & is the baseline reference
■ Each of the other 5 conditions increasing the level of sensory
conflict & postural difficulty.

◻ Under condition 1, all the three senses (vision, vestibular, and
somatosensory) are available and accurate. Body sway is
measured by means of forceplate; this initial measurement
forms the baseline against which subsequent measures are
compared.
◻ Under condition 2, the eyes are closed, so only the
somatosensory and vestibular inputs will dominate in this
condition. By comparing sway during condition 2 to sway
during condition 1, it is possible to detect how well the client
is using somatosensory inputs for balance control.
◻ Under condition 4, the support surface is sway referenced
(somatosensory cues are available but are inaccurate), so
only visual and vestibular cues remain. In a normal subject,
the visual inputs will dominate in this condition. Comparing
sway during condition condittion 4 to sway during condition 1
indicates how well the client is using visual inputs for balance
control.

◻ Under condition 5, the eyes are closed (visual cues are
absent) and the support surface is sway-referenced
(somatosensory cues are inaccurate), leaving the vestibular
inputs as the only remaining sense that is both available and
accurate. Comaprison of sway during condition 5 to sway
during condn 1indicates how well the client is using vestibular
inputs for balance control.
◻ Under both conditions 3 & 6, the visual surround is sway-
referenced (visual cues are available but inaccurate). By
comparing sway during these two conditions to sway in the
absence of vision (conditions 2 &5, with eyes closed), it is
possible to determine how well the client can recognize and
subsequently suppress inaccurate visual inputs when they
conflict with somatosensory and vestibular cues. Some
clients with CNS lesions like head injury, stroke, tumor may
have difficulty with this condition.

Postural sway measures from each of the six SOT conditions are compared and the
ratios are used to identify impairments in the use of sensory inputs for postural
control. Ref: Jacobson GP, Newman CW: handbook of balance Function testing,
Mosby, 1993.

◻ The SOT is valid and reliable in the absence of
motoric problems, which increase sway for reasons
unrelated to sensory reception and perception.
◻ The CLINICAL TEST FOR SENSORY INTERACTION
ON BALANCE (CTSIB) is a clinical version of the SOT
that does not use computerized forceplate technology.
The concept of the six conditions remain intact.
◻ Components: Instead of the sway measures, the
examiner uses a stop watch and visual observation. A
thick foam pad substitutes for moving forceplate
during conditions 4, 5 and 6. a modified japanese
lantern substitutes for the moving visual surround in
conditions 3 and 6.

◻ Procedure: the client is asked to stand with feet
parallel and arms at sides or hands on hips. Five
30 sec trials of each condition are performed. The
watch is stopped if the client steps, reaches, or
falls during the 30 secs.
◻ A max score for five trials of each condition is 150
secs.
◻ In normal subjects and clients with peripheral
vestibular lesions, measures using foam to
correlate to moving forceplate measures. The
CTSIB may not be a reliable measure in clients
with hemiplegia.

◻ Interpretation
� By using a stop watch.
� SCORING:
■ SCORE 1 : Minimal
sway
■ SCORE 2 : Mild sway
■ SCORE 3 : Moderate
sway
■ SCORE 4 : Fall

◻ MODIFIED CLINICAL TEST OF SENSORY
INTERACTION AND BALANCE
◻ Assesses patient’s balance under a variety of conditions
to infer the source of instability.
◻ Readily used with clients suffering from stroke.
◻ Involves the observation of a patient's attempt to
maintain balance in standing with feet together hands on
hips or with hands across waist for 30 seconds under
conditions 1-4 below (m-CTSIB):
� Eyes open on firm surface
� Eyes closed on firm surface
� Eyes open on compliant surface
� Eyes closed on compliant surface

◻ Test is terminated when a subject's arms or feet change
position:
◻ Conditions 1 thru 4:
� Record the time (in seconds) the patient was able to
maintain the starting position (maximum of 30
seconds)
� SCORING:

◻ Tests of sensory integration or organization can be of
benefit to the clinician working with the clients with
vestibular dysfunction.
◻ Often individuals with compensated vestibular system
deficiencies will select visual or somatosensory
information as the primary input for balance, to
decrease the sense of sensory conflict. Vestibular
input does not appear to play its normal role during
certain activities, and vestibular deficits may be
difficult to detect. Eg., when testing the individual with
chronic vestibular insufficiency, standing balance on
foam may appear normal with eyes open and a static
head position but not when the head is quickly turned
and visual inputs for balance are disrupted.

◻ TESTS OF NYSTAGMUS: assessment of the eye
movement control can help to diagnose
dysfunction of the peripheral and central
vestibular pathways through the medial
longitudinal fasciculus.
◻ In particular, tests for a specific type of abnormal
eye movement called nystagmus should be
performed as the client with nystagmus will also
ususally complain of vertigo.
◻ There is more than one type of nystagmus;
identification of the particular type of nystagmus;
identification of the particular type can direct the
clinician toward the area of dysfunction.

◻ SPONTANEOUS NYSTAGMUS: it results from
imbalance in the vestibular signals through their
transmission to the oculomotor neurons.
◻ This imbalance produces a constant drift of the eyes
in one direction interrupted by brief fast movement in
the opposite direction. This type of nystagmus usually
occurs after acute lesions and usually lasts about 24
hrs.
◻ Peripheral versus central lesions may be
distinguished by asking the patient to fix his or her
gaze on a stable target. ‘Nystagmus from peripheral
vestibular lesions is easily inhibited with visual fixation
whereas Nystagmus due to central lesions of the
brainstem or cerebellum is not easily inhibited with
visual fixation.’

◻ POSITIONAL NYSTAGMUS: is induced by a
change in head position. Paroxysmal
nystagmus due to stimulation of the canals
lasts only secs and then dissipates. Central
nystagmus due to central vestibular system
damage lasts mins or longer. Static nystagmus
occurs with lesions to the otolith system
through connections in the vestibular nuclei
and cerebellum. It is provoked with change of
head position in relation to gravity and
continues as long as the position is
maintained, although it can fluctuate in
frequency and amplitude.

◻ GAZE EVOKED NYSTAGMUS: occurs when clients
shift their eyes from a primary central position to a
second location. It is caused by the inability to
maintain stable gaze position and the eye drifts back
toward the center or primary position. Usually
indicative of a CNS problem, it is commonly seen in
stroke, head injury and congenital lesions.
◻ HEAD SHAKING NYSTAGMUS is generally seen in
clients with vestibular dysfunction and also among
healthy community dwelling elderly according to a
study. The test for it is performed by the examiner
passively moving the client’s head. Starting with the
head anteriorly flexed to 30 degrees, the head is
moved side to side 45 degrees in each direction for 30
cycles with a velocity of 360 degrees per second.
Normal individuals do not have Nystagmus after this
stimulus, but Nystagmus occur in clients with

◻ TESTS OF SEMICIRCULAR CANAL FUNCTION
Tests that attempt to stimulate the vestibular
semicircular canals are usually called vertiginous
positions and monitor for vertigo, dizziness, nausea
and nystagmus.
The Hallpike- Dix maneuver is a vertiginous position test
to stimulate the posterior semicircular canal.
◻ Procedure
� Moving the patient from a sitting to a supine position with
the head turned so that the affected ear is 30-45° below
the horizontal post. Canal and may produce Nystagmus &
vertigo
� A +ve result leads to a diagnosis of Benign positional
vertigo (BPV)

◻ The critical hallmark
of BVP is that the
vertigo usually starts
after 5 to 10 secs
and resolves or
fatigues within 20 to
40 secs.

◻ The FUKUDA STEPPING TEST was developed to assess
labyrinth function. A grid is drawn on the floor with two
concentric circles (1 & 2 m in diameter, respectively) divided
into 30 degree sections.
◻ Procedure: The client is placed standing in the center of the
circles, is blindfolded and raises the arms outstretched to
shoulder height. The examiner instructs the client to take 100
marching steps in place, then observes for postural sway and
deviations of position of the head, arms and body.
◻ Once the client has stopped, the examiner quantitatively
measures the angle of rotation, angle of displacement, and
the distance of displacement.
◻ Interpretation: according to Fukuda, normal subjects are able
to take 100 steps without travelling more than 1 m and
without rotating more than 45 degrees, whereas clients with
peripheral vestibular dysfunction deviate outside this range
toward the side of the deficit.

◻ According to a study done by A. L. Adkin et al in 2001, trunk
sway measures of postural stability during clinical balance
tests were done and their effects were seen in clients
suffering from unilateral vestibular deficit.
◻ In this, the author used a light weight easy to attach, body
worn apparatus to measure trunk angular velocities during a
number of stance and gait tasks similar to those of the Tinetti
and CTSIB protocols in 15 patients suffering from UVL
(having well defined acute balance deficit) and 26 clients
having severe chronic balance problems caused by CPAT
prior to surgery.
◻ The tasks included standing on one or two legs both eyes
open and closed on a foam or firm support surface, semi-
stance tasks and gait tasks.

◻ Results: The CPAT patients had more sway than that of normals,
but less than that of UVL subjects.
◻ The eyes closed two legged stance task on foam caused UVL
subjects to fall most. Some UVL subjects also fell before 20 sec for
the eys open foam and eyes closed normal surface two legged
stance. For very short duration the UVL subjects could maintain one
legged stance eyes closed(almost all of them fell towards the side
of their deficit).
◻ Walking tasks that involved more difficult sensory and motor control
conditions lead to an increase in trunk sway in vestibular deficit
subjects compared to that of the normals.
◻ It was seen that the UVL subjects had larger trunk sway and there
was no significant difference between the trunk sway amplitudes of
the CPAT patients and normal subjects. (CPAT patients required
only a longer duration for the walking with head rotation task.)five
steps with eyes

Functional scales
◻ A comprehensive balance evaluation must
include both impairment measures and
disability measures. Functional scales help to
address the latter. By asking the client to
perform functional tasks that demand balance
skills, the clinician can determine the presence
of disabilities and identify the tasks the client
needs to practice.
◻ Functional balance, mobility, and gait scales
involve the performance of whole-body
movement task.

Functional scales
◻ BERG BALANCE SCALE
The BBS quantitatively assesses balance in older
adults.
The BBS measures a number of different aspects of
balance, both static and dynamic.
◻ Items of the measure:
In this 14-item scale, patients must maintain positions
and complete moving tasks of varying difficulty.
◻ In most items, patients must maintain a given position
for a specified time.
◻ Scoring:
Patients receive a score from 0-4 on their ability to
meet these balance dimensions. A global score can
be calculated out of 56.

ITEM DESCRIPTION- SCORE
(0-4)
1. Sitting to standing ________
2. Standing unsupported ________
3. Sitting unsupported ________
4. Standing to sitting ________
5. Transfers ________
6. Standing with eyes closed ________
7. Standing with feet together ________
8. Reaching forward with outstretched arm ________
9. Retrieving object from floor ________
10. Turning to look behind ________
11. Turning 360 degrees ________
12. Placing alternate foot on stool ________
13. Standing with one foot in front ________
14. Standing on one foot _________

Functional scales
◻ A score of 0 represents an inability to complete the item, and
a score of 56 represents the ability to independently complete
the item.
◻ 0-20 on the BBS represents balance impairment;
◻ 21-40 on the BBS represents acceptable balance;
◻ 41-56 on the BBS represents good balance.
◻ Time: The scale takes approximately 10-15 minutes to
complete.
Psychometric property
◻ Reliability – test –retest , intra-rater and internal consistency
well established
◻ Validity - content, construct and criterion validity well
established
◻ It does so with minimal space and equipment requirements
(Whitney et al. 1998, Zwick et al. 2000).
◻ (Hiengkaew et al, (Chronic Stroke): Excellent test-retest

◻ TINETTI PERFORMANCE ORIENTED MOBILITY
ASSESSMENT
Purpose : The Tinetti assessment tool is an easily
administered task-oriented test that measures an older
adult’s gait and balance abilities.
Task : Two subtask
1. Balance
2. Gait
◻ Total POMA consists of 16 items: 9 balance (POMA-B)
and 7 gait (POMA-G) items
◻ 3 point ordinal scale, ranging from 0-2, where highest
score indicates independence with each test item

◻ Focused on
� Maintenance of position
� Postural response to perturbation
� Gait mobility
◻ Requirements: able to stand & walk
independently
◻ Time: 10-15 minutes
◻ Score: The maximum score for the gait
component is 12 points. The maximum score
for the balance component is 16 points. The
maximum total score is 28 points.

Interpretation: 25-28 = low fall risk
19-24 = medium fall risk
< 19 = high fall risk
Psychometric Property
Canbek, Jennifer et al (march 2013) -Test-
Retest Reliability and Construct Validity of the
Tinetti Performance-Oriented Mobility
Assessment in People With Stroke
Content Validity, Construct Validity, & Test
Retest Reliability – Excellent in stroke patent

◻ POSTURAL ASSESSMENT SCALE FOR STROKE
PATIENTS(PASS)
◻ PASS was developed to examine the postural abilities
of the acute stroke patient.
◻ It include 12 item and scored using an ordinal scale (0
to 3) with description ranging from cannot perform to
perform with little help , to perform without help.
◻ It demonstrate good construct validity and high inter
rater and intra rater reliability.
◻ PASS is one of the most valid and reliable clinical
assessments of postural control in stroke patients
during the first 3 months after stroke. (Stroke.

Maintaining a Posture
1. Sitting without support
2. Standing with support
3. Standing without support
4. Standing on non paretic leg
5. Standing on paretic leg
Changing Posture
6. Supine to affected side lateral
7. Supine to non affected side lateral
8. Supine to sitting up on the edge of the table
9. Sitting on the edge of the table to supine
10. Sitting to standing up
11. Standing up to sitting down
12. Standing, picking up a pencil from the floor
Scoring is 0 to 3 for each sub item.
Maximum score is 36.

◻ GET UP AND GO TEST
◻ Instructions:
◻ Ask the patient to perform the following series of
manoeuvres:
1. Sit comfortably in a straight-backed chair.
2. Rise from the chair.
3. Stand still momentarily.
4. Walk a short distance (approximately 3 meters).
5. Turn around.
6. Walk back to the chair.
7. Turn around.
8. Sit down in the chair.

◻ Scoring: Observe the patient's movements for any deviation
from a confident, normal performance. Use the following
scale:
1 = Normal
2 = Very slightly abnormal
3 = Mildly abnormal
4 = Moderately abnormal
5 = Severely abnormal
◻ "Normal" indicates that the patient gave no evidence of being
at risk of falling during the test or at any other time. "Severely
abnormal" indicates that the patient appeared at risk of falling
during the test. Intermediate grades reflect the presence of
any of the following as indicators of the possibility of falling:
undue slowness, hesitancy, abnormal movements of the
trunk or upper limbs, staggering, stumbling.
◻ A patient with a score of 3 or more on the Get-up and Go
Test is at risk of falling.

◻ TIMED UP AND GO TEST
◻ The TUG is a general physical performance test used to
assess mobility, balance and locomotor performance in
elderly people with and other clients balance disturbances.
◻ More specifically, it assesses the ability to perform sequential
motor tasks relative to walking and turning (Schoppen,
Boonstra, Groothoff, de Vries, Goeken, & Eisma, 1999)
◻ TUG is one of the most valid and reliable clinical
assessments of balance in stroke patients
◻ PROCEDURE:
⮚ Begin the test with the subject sitting correctly in a chair with
arms, the subject’s back should resting on the back of the
chair. The chair should be stable and positioned such that it
will not move when the subject moves from sitting to
standing.
⮚ Place a piece of tape or other marker on the floor 3 meters
away from the chair so that it is easily seen by the subject.

⮚ Instructions :
⮚ “On the word GO you will stand up, walk to the line on the
floor, turn around and walk back to the chair and sit down.
Walk at your regular pace.
⮚ Start timing on the word “GO” and stop timing when the
subject is seated again correctly in the chair with their back
resting on the back of the chair.
⮚ The subject wears their regular footwear, may use any gait
aid that they normally use during ambulation, but may not be
assisted by another person. There is no time limit. They may
stop and rest (but not sit down) if they need to.
⮚ Normal healthy elderly usually complete the task in ten
seconds or less. Very frail or weak elderly with poor mobility
may take 2 minutes or more.
⮚ The subject should be given a practice trial that is not timed
before testing.
⮚ Results correlate with gait speed, balance, functional level,
the ability to go out, and can follow change over time.

⮚One practice trial is permitted to allow the individual to
familiarize him/herself with the task.
⮚The individual wears their regular footwear and is
permitted to use their walking aid (cane/walker) with its
use indicated on the data collection form. No physical
assistance is given.
⮚the TIMED UP AND GO test eliminates “standing
steady” segment and uses a stopwatch to time the

Scoring:
Performance of the TUG is rated on a scale from 1 to 5
where 1 indicates "normal function" and 5 indicates "severely
abnormal function" according to the observer's perception of
the individual's risk of falling (Podsiadlo & Richardson, 1991).
◻ The score consists of the time taken to complete the test
activity, in seconds.
Interpretation
◻ < 10s Completely independent
With or without walking aid for ambulation and transfers
◻ < 20s Independent for main transfers
With or without walking aid, independent for basic tub or
shower transfers and able to climb most stairs and go outside
alone
◻ > 30s Requires assistance
Dependent in most activities

◻ EXTENDED TIMED GET UP AND GO TEST
Each of the subtasks of the TUG is relevant for daily life
functioning. However, when only focusing on the one score
based on the combined tasks, problems in performing
separate subtasks may be camouflaged. Furthermore, such a
score may not give sufficient information to guide the choice
of intervention, even though it can be useful in assessing the
effect of such treatment. Therefore, a test that includes the
same subtasks as the TUG, but that scores each subtask
separately, can possibly add information of relevance for
clinical decision making in rehabilitation and geriatric
medicine and in evaluating changes over time.
◻ The ‘Expanded Timed Get Up and Go’ (ETGUG) was
developed to answer these shortcomings of GUG and TUG
(Wall et al.,2000). In the ETGUG, a combined task similar to
the one used in GUG and TUG was applied, but each part of
the test, such as turning, was timed separately. In addition,
the total time was reported. As opposed to GUG and TUG,
the ETGUG used a longer walkway (10 m) and an armless

◻ What is common to all three tests is that they were
completed as one continuous task. This made it
difficult to determine when certain subtasks had been
completed. For example, the subject was instructed to
stand up and walk, which posed the problem of
determining when the subject was standing. This was
particularly difficult when subjects started walking
before becoming fully upright. Although the
multimemory stopwatch used to time parts of the
ETGUG is an inexpensive, reliable and valid
instrument, it does require manual transcription of the
data to a results sheet as well as certain calculations,
such as walking speed, to be made.
◻ To overcome these problems, a modified version of
the ETGUG was developed (Expanded Timed Up-
and-Go [ETUG]), where subjects perform each of the
subtasks of TUG in a series, but with a stop and a

◻ Scoring the ETUG
◻ Each subtask was instructed in the same way: ‘After I have
counted three, two, one, I want you to start. Are you ready?
Three, two, one, start’.
◻ Subtask 1: sit-to-stand
The subjects sat on a 46-cm high chair with armrests with their
back against the back of the chair. The instruction was to rise to
an upright position and stand still. There was no instruction on
the use of armrests, but whenever used, it was recorded. The
time was started at the instruction ‘start’ and stopped when the
subject was standing upright and still.
◻ Subtask 2: 3-m walk at preferred speed
The subjects were asked to walk a distance of 6 m at their
preferred gait speed and then stop without turning. Time was
recorded for the middle 3 m. Start and stop times were
registered when the subject’s hips/body passed two lines on the
floor, one at the beginning and the other at the end of the central

◻ Subtask 3: 180° turn
At the start of the 180° turn, the subjects stood with their
back against the walkway. Time was taken from the
instruction ‘start’ until the subjects had turned 180° and were
standing still, facing the walkway and the chair.
◻ Subtask 4: 3-m walk at fast speed
The subjects were asked to walk a distance of 6 m at their
fast but safe speed and then stop without turning. Time was
recorded for the middle 3 m. Start and stop times were
registered when the subject’s hips passed two lines on the
floor, one at the beginning and the other at the end of the
central 3-m region of the walkway.
◻ Subtask 5: turn and sit down
The subjects stood in front of and facing the chair and were
instructed to turn and sit down. Time was registered from the
instruction ‘start’ until the subjects were sitting on the chair.

◻ Total time
◻ The ETUG total time was calculated by adding
up the time for all five subtasks: sit to-stand,
walking at preferred speed, 180° turn, walking
at fast speed, and turn and sit down.

◻ FICSIT-4 (Frailty and Injuries: Cooperative
Studies of Intervention Techniques)
◻ INSTRUCTIONS: Demonstrate each position to
the subject, then ask them to perform and time.
◻ F-1. FEET CLOSELY TOGETHER,
UNSUPPORTED, eyes open (ROMBERG
POSITION)
◻ INSTRUCTIONS: Stand still with your feet
together as demonstrated for 10 seconds. [Berg
#7 = 60 seconds]
◻ 4 able to stand 10 seconds safely
◻ 3 able to stand 10 seconds with supervision
◻ 2 able to stand 3 seconds
◻ 1 unable to stand 3 seconds but stays steady
◻ 0 needs help to keep from falling If subject is able

◻ F-2. FEET CLOSELY TOGETHER, UNSUPPORTED, eyes closed
(ROMBERG POSITION)
◻ INSTRUCTIONS: Please close your eyes and stand still with your
feet together as demonstrated for 10 seconds.
◻ 1 unable to keep eyes closed 3 seconds but stays steady
◻ 0 needs help to keep from falling If subject is able to do this,
proceed to the next position, if not, stop.
◻ F-3. SEMI-TANDEM: eyes open HEEL OF 1 FOOT PLACED TO
THE SIDE OF THE 1ST TOE OF THE OPPOSITE FOOT
(SUBJECT CHOOSES WHICH FOOT GOES FORWARD)
◻ INSTRUCTIONS: Please stand still with your feet together as
demonstrated for 10 seconds.

◻ F-4. SEMI-TANDEM: eyes closed HEEL OF 1 FOOT PLACED TO
THE SIDE OF THE 1ST TOE OF THE OPPOSITE FOOT
(SUBJECT CHOOSES WHICH FOOT GOES FORWARD)
◻ INSTRUCTIONS: Please close your eyes and stand still with your
feet together as demonstrated for 10 seconds.
◻ 1 unable to keep eyes closed 3 seconds but stays steady
◻ F-5. FULL TANDEM: eyes open HEEL OF 1 FOOT DIRECTLY IN
FRONT OF THE OTHER FOOT (SUBJECT CHOOSES WHICH
FOOT GOES FORWARD) [Berg #14 = 30 seconds]

◻ F-6. FULL TANDEM: eyes closed HEEL OF 1 FOOT DIRECTLY
IN FRONT OF THE OTHER FOOT (SUBJECT CHOOSES WHICH
FOOT GOES FORWARD)
proceed to the next position, if not, stop
◻ F-7. STANDING ON ONE LEG: eyes open [Same as Berg #13]
◻ INSTRUCTIONS: Stand on one leg as long as you can without
holding.
◻ 4 able to lift leg independently and hold >10 seconds
◻ 3 able to lift leg independently and hold 5-10 seconds
◻ 2 able to lift leg independently and hold = or >3 seconds
◻ 1 tries to lift leg unable to hold 3 seconds but remains standing
independently
◻ 0 unable to try or needs assist to prevent fall
◻ Total FICSIT-4 Static Balance score = ____ / 28

◻ RIVERMEAD MOBILITY INDEX
◻ The Rivermead Mobility Index (RMI) was developed
from the Rivermead Motor Assessment Gross
Function subscale as a means to quantify mobility
disability in clients with stroke.
◻ The RMI is clinically relevant in testing functional
abilities such as gait, balance, and transfers
(Forlander & Bohannon, 1999).
◻ The RMI includes fifteen mobility items: 14 self-
reported and 1 direct observation (standing
unsupported). The 15 items are hierarchically
arranged and suggesting all items are ordered
according to ascending difficulty.

ITEM OF SCALE
1. Turning over in bed
2. Lying in sitting
3. Sitting balance
4. Sitting to standing
5. Standing unsupported
6. Transfer
7. Walking inside
8. Stair
9. Walking outside (even ground)
10. Walking inside, with no aid:
11. Picking up off floor:
12. Walking outside
13. Bathing
14. Up and down four steps
15. Running:

◻ Scoring: Each item is coded 0 or 1, depending on whether
the client can complete the task according to specific
instructions.
◻ A score of 0 = a 'no' response; a score of 1 = a 'yes'
response.
◻ A total score is determined by summing the points allocated
for all items.
◻ A maximum score of 15 is possible: higher scores
indicate better mobility performance. (Franchignoni et
al., 2003; Hsueh, Wang, Sheu & Hsieh, 2003).
◻ Time: The RMI takes 3 to 5 minutes to administer (Hsieh et
al., 2000).
◻ Psychometric property
◻ Reliability- test –retest , intra-rater well established.
◻ Validity – content, construct, criterion well established

◻ FIVE TIMES SIT TO STAND TEST
◻ Description: Assesses functional lower extremity strength,
transitional movements, balance, and fall risk.
◻ Equipment: Stopwatch; standard height chair with straight
back (16 inches high);
◻ Therapist Instructions: Have the patient sit with their back
against the back of the chair. Count each stand aloud so that
the patient remains oriented. Stop the test when the patient
achieves the standing position on the 5th repetition.
◻ Patient Instructions: “Please stand up straight as quickly as
you can 5 times, without stopping in between. Keep your
arms folded across your chest. I’ll be timing you with a
stopwatch. Ready, begin.”
◻ Interpretation:
◻ Lower times = better scores

◻ Age-Matched Norms
◻ Age Bracket Time (sec)
◻ 60‐69 yR 11.4
◻ 70‐79 yR 12.6
◻ 80‐89 yR 14.8
◻ Fall Risk:
◻ Cerebral Palsy, COPD, Healthy elderly, Knee osteo-
arthritis, Low back pain, Multiple Sclerosis,
Parkinson's Disease, Patients with functional mobility
impairment in sit to stand transfers, Peripheral arterial
disease, Renal transplant, Rheumatoid arthritis,
Stroke, TKA, Vestibular Disorders
◻ Excellent Test-retest, interrater and intrarater
reliability in stroke, parkinson’s disease and

◻ MULTIPLE TASK TEST
◻ It was basically developed to determine be used
in high functioning community dwelling elderly.
◻ The MTT is a relatively new balance test that
simultaneously assesses multiple components of
postural control, representing everyday situations.
Performance is quantitatively graded as normal,
hesitation or block.
◻ Materials used: 56 cm height chair with armrests,
predefined 8 m course, stopwatch, 3 shoe boxes,
empty tray, 2 hard boiled eggs, cup, shoe covers.

◻ PROCEDURE:
◻ 1. stand up from chair, walk undisturbed along a predefined 8 m
course, turn 180 degrees and sit down. This task is repeated seven
times, each time an extra component was added to the earlier and
otherwise identical task.
◻ 2. as above- the subject was asked to count backwards from 96 by
3’s. this was done prior to the test to determine a baseline for the
subject’s speed in performance.
◻ 3. + while avoiding 3 obstaclles( shoe boxes) placed at varying
distances on the floor (1-2 m).
◻ 4. + while carrying an empty tray.
◻ 5. + while carrying a tray with two hard boiled eggs in a cup and one
loosely rolling.
◻ 6. + while wearing shoe covers over shoes. All subjects use the
same covers.
◻ 7. + touching finger tips to floor, halfway through the obstacle
course.
◻ 8. + wearing sunglasses with illumination moderately reduced.

◻ SCORING
◻ Each task is rated as:
◻ Normal- rapid performance of all components with a
task.
◻ Hesitation- obvious slowing of one or more
components within a task.
◻ Block- a complete stop or inability to perform one or
more components within a task.
◻ A gait belt was placed around the subject's waist for
safety during the MTT. However, no contact is made
with the subjects unless he is judged to be in danger.
Subjects sit while each task described and
demonstrated. Each task performed was recorded on
a tape

◻ According to a study done in 2004, MTT was correlated to BBS. It
was basically developed to determine be used in high functioning
community dwelling elderly.
◻ If a relationship existed between the performance of multiple tasks
and the potential loss of balance resulting in falls, then the MTT
would be more appropriate than the BBS at predicting falls in higher
functioning individuals.
◻ There were a significant negative correlation between the total BBS
score and the MTT ties at each task. This indicated that individuals
requiring more time to complete a cognitive task were likely to score
lower on the BBS.
◻ The study hypothesized that the correlation would be high initially
between these two instruments and would then drop.
◻ Also according to the results of the study, it was indicated that when
the MTT is compared to the BBS, the BBS is highly correlated to the
MTT through the entire eight tasks. This was unexpected since
there was no dual task in the BBS. Furthermore, others have found
the BBS less sensitive to differences in balance abilities with higher
functioning adults.

◻ Another prospective study done by Mau-Roung Lin et al in JUL 2004,
compared the practicality, reliability, validity, and responsiveness of the
timed up and go (TUG), one-leg stand (OLS), functional reach (FR), and
Tinetti balance (TB) performance measures in people aged 65 and older in
which Twelve hundred community-dwelling older people participated.
◻ Measurements: During an initial assessment at their residences,
participants were interviewed for demographics, cognition, fall history, use
of a walking aid, and activities of daily living (ADLs), in addition to
completing the four balance tests. Falls were ascertained by telephone
every 3 months for a 1-year follow-up; the four balance measures and
ADLs were also reassessed at the end of the follow-up year.
◻ Results: Of the four balance measures, the OLS had the lowest
participation rate, and participation of people who were cognitively impaired
had fallen in the previous year, used a walking aid, or suffered from an ADL
disability was lower than for their counterparts. The time to complete the
tests ranged from 58 seconds for OLS, to 160 seconds for the TB. All four
balance measures exhibited excellent test-retest reliability and discriminant
validity but poor responsiveness to fall status. The TB showed better
discriminant, convergent, and predictive validities and responsiveness to
ADL changes than the other three tests.
◻ Conclusion: According to psychometric properties, the most suitable
performance measure for evaluating balance in community-dwelling older

◻ In another study done in 2004 Jan-Feb, by Lajoie Y, Simple
reaction time, the Berg balance scale, the Activities-specific
Balance Confidence (ABC) scale and postural sway were studied in
order to determine cut-off scores as well as develop a model used
in the prevention of fallers within the elderly community.
◻ One hundred and twenty-five subjects, 45 fallers and 80 non-fallers
were evaluated throughout the study and results indicated that non-
fallers have significantly faster reaction times, have higher scores
on the Berg balance scale and the ABC scale as well as sway at
slower frequencies when compared to fallers. Furthermore, all risk
factors were subsequently entered into a logistic regression
analysis and results showed that reaction time, the total Berg score
and the total ABC score contributed significantly to the prediction of
falls with 89% sensitivity and 96% specificity. A second logistic
regression was carried out with the same previous variables as well
as all questions of the Berg and ABC scales. Results from the
logistic analysis revealed that three variables were associated with
fall status with 91% sensitivity and 97% specificity. Results from the
following study would seem rather valuable as an assessment tool
for health care professionals in the identification and monitoring of
potential fallers within nursing homes and throughout the

◻ THE BALANCE EVALUATION SYSTEMS TEST
◻ Dr. Horak has developed a Balance Evaluation Systems Test
(BESTest) for clinicians to differentiate balance into 6
underlying systems that may constrain balance:
Biomechanical, Stability Limits, Postural Responses,
Anticipatory Postural Adjustments, Sensory Orientation, and
Dynamic Balance during Gait and Cognitive Effects.
◻ This unique evaluation tool is appropriate for ambulatory
patients with Parkinson’s Disease, Cerebellar Ataxia,
Vestibular Disorders, Neuropathy, Head Injury, Multiple
Sclerosis, Stroke, Cerebral Palsy, Cognitive Deficits, and
other balance disorders. The BESTest is a sensitive,
quantitative balance assessment that will improve third party
reimbursement by identifying subtle deficits and changes with
therapy.
◻ Description:
◻ Consisits of 36 items, Grouped into 6 systems (biomechanical
constraints, stability limits/verticality, anticipatory postural
adjustments, postural responses, sensory orientation, stability
in gait). Score of 108 points total, calculated in to a
percentage score (0-100%). Also total sub-scores for each
above listed system. Ordinal scale from 0-3

◻ Equipment Required
⮚ Stop watch
⮚ Measuring tape mounted on wall
⮚ 60 cm x 60 cm block of 4 inch, medium density, Tempur®
foam
⮚ 10 degree incline ramp (at least 2 x 2 ft)
⮚ Stair step, 15 cm (6 inches) in height
⮚ 2 stacked shoe boxes (for 9 inch obstacle height)
⮚ 2.5 kg (5-lb) free weight
⮚ Firm chair with arms with 3 meters in front marked with tape
⮚ Masking tape to mark 3 m and 6 m lengths on the floor
◻ Excellent Test-retest Reliability, Inter-rater/Intra-rater
Reliability, Internal Consistency in Community dwelling adults
with and without balance deficits and clients with Parkinson's
disease.
◻ BESTest.pdf

◻ MINI BALANCE EVALUATION SYSTEMS TEST
◻ The Mini-BESTest was developed by Franchignoni et al,
2010. it is a Shortened version of the Balance Evaluation
Systems Test (BESTest), a clinical balance assessment tool
that aims to target and identify 6 different balance control
systems so that specific rehabilitation approaches can be
designed for different balance deficits. The BESTest was
shortened based on factor analysis to include dynamic
balance only and to improve clinical utilization.
◻ Description
◻ Revised version of BESTest based on psychometric
properties of items, item scoring, and Rasch analysis
designed to improve the measurement qualities of the original
test. Mini BESTest assesses dynamic balance and includes
14 items addressing 4 of the 6 sections of the original
BESTest (anticipatory postural adjustments, reactive postural
control, sensory orientation, dynamic gait).
◻ The Mini BESTest is a 14 item test scored on a 3 level ordinal
scale. For the Mini BESTest, the original BESTest 4 level (0 -
3) scoring was revised to 3 levels (0 - 2) due to redundancy.
Total score = 28 points per test directions. Two items have
right and left assessment in which the lower score is used

◻ Equipment Required
⮚ 60 cm x 60 cm block of 4" medium density Tempur foam
(T41)
⮚ Incline ramp of 10 degree slope (2 x 2 foot recommended)
⮚ Standard chair without arm rests or wheels
⮚ Firm chair with arms
⮚ Box that is 9 inches (23 cm) in height (~2 stacked shoeboxes)
⮚ Stopwatch
⮚ Masking tape marked on floor at 3 meters from front of chair
◻ Age-Related Balance Disorders ,Ataxia, Cervical Myelopathy,
CNS Neoplasm, Multiple Sclerosis, Neuromuscular Disease,
Nontraumatic Brain Injury, Parkinson’s Disease, Peripheral
Vestibular Disorders, Stroke, Traumatic Brain Injury

◻ Excellent Test-retest Reliability, Inter-rater/Intra-rater
Reliability, Internal Consistency in Community
dwelling adults with and without balance deficits and
clients with chronic Stroke and Parkinson's disease.
◻ Considerations
◻ The Mini-BESTest appears to have strong test
psychometrics across neurologic populations with
good clinical utility as a revised version of BESTest.
One discrepancy noted across research however, was
the total score (28 vs. 32 points) which depended on
whether researchers counted both right/left sides on
two test items.
◻ MiniBEST_revised_final_3_8_13.pdf

◻ According to a study which was to explore the usefulness of the
Mini-BESTest compared to the Berg Balance Scale in evaluating
balance in people with PD of varying severity. We evaluated (1) the
distribution of patients scores to look for ceiling effects, (2)
concurrent validity with severity of disease, and (3) the
sensitivity/specificity of separating people with or without postural
response deficits. Subjects. Ninety-seven people with PD were
tested for balance deficits using the Berg, Mini-BESTest, Unified
Parkinson’s Disease Rating Scale (UPDRS) III and the Hoehn &
Yahr (H&Y) disease severity classification. Setting. Clinical
research facility at Oregon Health & Science University.
◻ Results. The Mini-BESTest is highly correlated with the Berg (r =
0.79, P < 0.001), but avoids the ceiling compression effect of the
Berg for mild PD (skewness −2.30 Berg, −0.93 Mini-BESTest).
◻ Consequently, the Mini-BESTest is more effective than the Berg for
predicting UPDRS Motor score (P < 0.001 Mini-BESTest versus P =
0.86 Berg), and for discriminating between those with and without
postural response deficits. Conclusion. The Mini-BESTest is a
promising tool for discerning balance deficits in patients with PD,
most importantly those with more subtle deficits.

◻ Recent advances:
◻ The Nintendo Wii is becoming an increasingly popular
technology for the training and assessment of balance in
older adults.
◻ Recent studies have shown promising results for its use in
fall prevention. However it is not clear how scores on the
WiiFit balance games relate to current standardized tests
of balance and mobility.
◻ According to a study, which aimed to evaluate the
relationship between WiiFit™ Plus balance tests, and
standardized tests of older adult fitness, balance, mobility,
self-reported balance confidence, and visual attention and
processing.
◻ Assessment of the older adult participants included a
combination of fitness tests to assess muscular strength
and cardiovascular endurance, an obstacle course to
assess functional mobility, Nintendo WiiFit balance tests to
assess balance, the Useful Field of View (UFOV) test for

◻ The functional assessment included grip dynamometry
(isometric upper-body muscular strength); 30-second chair
stand and 30-second arm curl tests (lower- and upper-body
muscular endurance); 6-minute walk test (cardiovascular
fitness); and 8-ft Timed Up-and-Go (TUG) test (motor agility
and dynamic balance). Performance on the 30-second chair
stand and 30-second arm curl tests was defined as the
maximum number of repetitions achieved in 30 seconds.
Cardiovascular fitness performance was defined as the
maximum distance (in yards) walked in 6 minutes. Finally, the
least amount of time (in seconds) required completing the 8-ft
Timed Up-and-Go test defined motor agility.
◻ Additional physical performance tests were included to further
assess muscular power. The ramp-walk power test assessed
lower limb power. Two different ramp sizes were used to
assess both short and endurance bursts. The short ramp had
a 5.53 m walking distance at 4.1 degrees angle, and the long
ramp had a 19.05 m walking distance at 7.9 degree angle.
Assessment of upper body muscular power included the
Gallon-Jug Shelf-Transfer Test (GJSTT) and medicine ball
chest-press throw test.

◻ Two balance tests were performed on the Nintendo WiiFit Plus™
with Balance Board. Both tests are included in the WiiFit basic body
test. The Basic Balance Test involved shifting weight
mediolaterally to direct center of pressure to target areas on the
display. The Wii instructions were “Spread your feet apart; lean left
and right to keep the red bar in the blue area for 3 seconds” . The
test had five possible levels with a time limit of 30 seconds to
complete all levels. Outcome score included the number of levels
that were successfully completed (Wii Level) and the time taken to
complete each level (Wii Level Time). Each participant performed
the test twice on each test day. The Prediction Test involves
shifting COP to avoid obstacles, a blue area appears after the first
20 seconds that blocks the view of the next immediate obstacle and
therefore the player must predict where the obstacle is to
appropriately direct COP.
◻ Instructions for the Prediction Test were “Shift your center of
balance to the right or left to avoid hitting the walls or obstacles”.
Outcome score for this test was the time from “start” until the first
obstacle was contacted (Wii Obs Time). Participants performed this
test three times and the best time was taken for analysis.
◻ The Useful Field of View test (Visual Awareness Inc., Birmingham,
AL) was used to measure visual processing speed, divided visual
attention, and selective visual attention. The UFOV is the area from
which one can extract useful visual information at a brief glance
without movement of the head or eyes. The UFOV test provides

◻ Participants completed the Activities-specific Balance Confidence
(ABC) scale. The ABC scale is a 16 item questionnaire that allows
participants to rate their confidence when performing certain daily
activities such as walking in a crowded place and picking up an
object off the floor. The scale is rated from 0% (no confidence) to
100% (absolute confidence).
◻ Results from 34 older adult participants indicate that WiiFit™
balance tests do not correlate well with standardized functional
balance, mobility and fitness tests. However, the Wii balance score,
as measured by the Basic Balance Test of the WiiFit™, does
correlate with visual processing speed as measured by the Useful
Field of View (UFOV(®)) test. These results indicate that WiiFit™
balance tests may provide advantageous information
supplementary to information obtained through standard
functional mobility and balance tests; however, caution should
be used when using the WiiFit™ balance tests in isolation.
Further research is necessary as these technologies become widely
used in clinical and home settings for balance training and
assessment.

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