Balance Labs

Question 1

What outcome measures are there for balance and give an example of each?

Answer 1

1. BASIC or single activity measurements (Romberg Test EO/EC)- either timed test or reach test.
2. Combined tasks and performance tests (FIST, BBS, Mini-Best): Series of scored activities or tasks.
3. Sensory Integration Tests (Foam and Dome Test): Alter visual, somatosensory, or vestibular feedback to determine impairments in individual systems.
4. Computerized Tests (measure Sway, COM…)
5. Advanced or higher level tests: progressive increase in demands of test (Functional gait assessment or dual task)
6. Self-efficacy scales: client’s self-perceived abilities (ABC scale)
   * Fall efficacy scale for fear of falling. (Clients overestimate their abilities may be overconfident and at increased risk of falling vs clients who underestimate their abilities may develop excessive fear and limits their activities.
7. Vestibular Tests

Question 2

What are the different uses of the FIST, BBS and Mini-BESTest?

Answer 2

FIST: acute, bedside administration or lower functioning patients (non-standing/non-ambulatory), evaluates steady state, proactive and reactive postural control in sitting as well as functional movements like scooting.

BBS: Elderly population and stroke.

Mini-BESTest: systems analysis approach to help id problem areas affecting balance in order to target these areas for treatment.

Question 3

What are the three broad classes of action for balance?

Answer 3

1. Volitional movement
2. Support surface moves unexpectedly
3. Maintain posture against an external interference.

Question 4

What are the components of a balance assessment?

Answer 4

• Interview (What is the chief complaint, frequency of falls, circumstances associated w/ falls, goals or expectations, other health conditions)
• Observation of movement and stability (like head and trunk posture)
• System analysis (ROM, strength….)
• Common outcome measures. (FIST, BBS)

Question 5

What are variables that need to be asked about for falls?

Answer 5

Have you ever had a fall? 
How many times, how often? 
Do you lose balance without falling? 
Where do you fall? 
How did the fall happen? 
What sort of injuries have you had? 
Dizziness? 
Other symptoms?

Question 6

What 3 things need to be considered prior to a balance assessment?

What are 2 important things to remember throughout the session?

Answer 6

1. Consider space
2. Prepare support surfaces
3. Prepare equipment
4. Start at therapist-estimated level of pt’s abilities and work pt to maximal abilities.
5. PT is in control, provide support, lead and ensure safe environment.

Question 7

What are the 4 components of balance and how can they be observed?

Answer 7

1. Static stability: sitting or standing, how much support is needed or sway.
2. Reactive responses: to expected or unexpected COM movement (stepping response)
3. Anticipatory responses: before voluntary mvmts
4. Adaptive: responses due to changes in environmental conditions or task demands.

Question 8

What are the 2 main questions that should be considered?

Answer 8

1. Is the pt able to maintain sitting or standing position unsupported?
   - If Supported Describe: type of support (hand on bed) and posture/sway/position
   - If Unsupported Describe: Posture, time, sway, postural symmetry, not in midline the correct to sit w/ appropriate assistance such as verbal or tactile cue, time to hold a corrected sit tall position.
2. Is the patient able to respond to perturbations?
   - Withstand perturbation
   - Perform internal or self-initiated: Weight-shifts, reaches, LOS. Can they maintain stability when shifting weight within BOS?
   - Manage expected perturbations w/in BOS: External pressure from therapist. ( try to hold your position)
   - Manage unexpected perturbation: Pt is moved out of BOS, how do they respond? Postural response strategies: hip/ankle, grabbing, stepping, arm response.

Does a patient have effective (did therapist need to assist pt?), appropriate (to the type of perturbation), timely, normal (or delayed) and functional/safe responses (at risk of falling?) or postural control strategies?

Question 9

What are the 10 elements in the hierarchies of balance task difficulty?

Answer 9

1. Static to dynamic
2. Proactive to reactive
3. Slower to faster
4. EO to EC
5. Firm to unstable surface
6. Larger to smaller BOS
7. Smaller to larger reach
8. Expected to unexpected perturbations
9. Simpel to more complex environment
10. Single to dual to multi task

Question 10

1. What does FIST stand for?
2. What is its purpose?
3. Who can the FIST be used for?

Answer 10

1. Function in Sitting Test
2. Use in a hospital to quantify patient’s performance for specific functional sitting tasks. Can be used to track progress over time.
3. People with sitting balance deficits, low functioning pts that cannot do other tests.
   May be too simple for people who have no trouble with sitting (standing, walking), also not good for pts who are not medically stable and may not tolerate sitting.

FIST is for pt that do not have any contraindications to sitting and health care provider are responsible for maintaining safety during the test for each pt.

Question 11

1. What equipment is needed for the test?
2. Pt position
3. Therapist position
4. Key Instructions to Pt

Answer 11

1. Step stool, stop watch, small object, tape measure, FIST scoring sheet.
2. Pt should maintain this position throughout the entire test. Examiner should realign pt as needed before each test item. Sit at edge of bed 1/2 femur length supported by mattress. Hip and knees 90 degrees. Feet flat on floor. Thighs in neutral. Hands on lap.
3. PT position: Beside or in front of pt. Ensure safety and assist pt as needed.
4. I am doing a test today to assess your balance in sitting. Sit w/ best posture. I will push you lightly. Try not to use hands. Let me know if you need a break. Do you have any?

Question 12

How is the FIST scored?

Answer 12

4=Independent: Completes task independently and successfully
3=Verbal Cues or Increased Time: Completes task independently and successfully, but may need verbal cues or excessive time.
2= UE support: Unable to complete task w/ out using UE for support. Can use 1 or both hands, it doesn’t matter.
1= Needs Assistance: Unable to complete task w/ out physical assistance from therapist min, mod or max.
0=Dependent: requires complete physical assistance to complete task or is unable to complete the task w/ assistance.

Question 13

What are the 14 FIST items and the criteria for each item?

Answer 13

Anterior nudge: Light pressure at sternum once.

Posterior nudge: Light pressure between scapular spines once.

Lateral nudge: 1 time at dominant/stronger side at acromion.

Static sitting: “Sit w/ your hands on your lap”
-Time for 30 sec

Sitting move head to side: “When tell you to look right, keep sitting straight, but turn your head to the right. Keep looking to the right until I tell you look left, then keep sitting straight and turn your head to the left. Keep your head to the left until I tell you look straight, then keep sitting straight but return your head to the center.”
-Move head through full available ROM.

Sitting eyes closed: “Close your eyes and remain sitting w/ your hands on your lap.”
-30 sec

Sitting lift feet: “sit w/ your hands in your lap; life your (side) foot 1 inch of the floor like this (demonstrate) now do it one more time”
-Do 2 repetitions on stronger side.

Turn and pick up object from behind in preferred direction: “Turn around and pick up the object that I’ve placed behind you”
-Pt can turn in preferred direction and use dominant hand. Place object in midline, one hand posterior to hips.

Reach forward w/ uninvolved hand outstretched at shoulder heigh: “Reach w/ your stronger arm as far as you can while staying balance like this (demonstrate), keep your other hand on your lap”
-Do passively to assess ROM. Pt must move through full available ROM or until abdomen contacts anterior thighs. Available pain free ROM, make note if pt has pain.

Lateral reach w/ hand at shoulder height: “Reach out to the side as far as you can. Be sure to get all your weight off the opposite side of your bottom keeping your feet on the floor like this (demonstrate)”
-Pt must complete full available ROM maintain upright Upper trunk and Upper extremity position. Contralateral truck shortening and clearance of ischial tuberosity. Return to midline. Pt move to preferred side.

Pick up object off the floor: “Pick this object up off the floor”
-Objet btwn feet at the level of the 1st MTP joint. Pt uses preferred hand.

Posterior scooting: “Now move backwards 2 in. try not to use your hands if you can”
-Use tape measure to verify
Anterior scooting: “Now move forward 2 in. try not to use your hands if you can”
-Use tape measure to verify
Lateral scooting. “Now move sideways 2 in. try not to use your hands if you can”
-Use tape measure to verify

Question 14

1. What is the Berg Balance Scale? What types of balance does it assess?
2. What can the total score on the BERG be correlated w/?

Answer 14

1. Assesses performance on movements common to everyday life. Static and dynamic balance. Coordination of the body in completing functional activities.
2. 56-Normal Balance.
   75% probability of falling at a score or 45/56. <45 increase risk of falling.

Question 15

1. What general instructions should be given for the BERG?

2. What equipment is required?

Answer 15

1. Why the test is being done, what pt will have to do. Ask pt to try to maintain balance. Demonstrate each task item and give appropriate instructions.
2. Stopwatch, ruler, chairs, step or stool.

Question 16

1. What are the 14 scale items? Instructions for each item?

2. What is the scoring scale?

Answer 16

1. Sit to Stand: “Please stand up. Try not to use your hands for support”

Standing Unsupported: “Please stand for 2 min w/out holding”

If able to stand unsupported for 2 min, score full points for sitting unsupported and move on to item 4.

Sitting w/ back Unsupported but feet supported on the floor or stool: “Please sit w/ arms folded for 2 min”
d

Standing to sitting: “Please sit down”

Transfers: Arrange chairs for a pivot transfer. Use 2 chair 1 w/ and 1 w/ out armrests or a bed and a chair. “Transfer one way toward a seat w/ armrests and one way towards a seat w/out armrests.

Standing Unsupported E. C.: “Please close your eyes and stand still for 10 sec”

Standing unsupported w/ feet together: “Place your feet together and stand w/ out holding”
- max score 1 min.

Reaching forward w/ outstretched arm while standing: “Lift arms to 90 degrees. Stretch your fingers and reach forward as far as you can”

• Measure the distance the finger reaches forward, while the subject is in the most forward lean position.
• When possible reach w/ both arms to avoid rotation of the trunk.
• 4>25 cm

Pick up object from the floor from a standing position: “ Pick up the shoe/slipper which is placed in front of your feet.”

Turning to look behind over left and right shoulders while standing: “Turn to look directly behind you over towards your left shoulder. Repeat to the right”
-Examiner may pick an object to look at directly behind the subject to encourage a better twist turn.

Turn 360: “Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.

Placing alternate foot on a step or stool while standing unsupported: “Place each foot alternately on the step/stool. Continue until each foot has touched the step/stool 4 times”
-4 is 8 steps in 20 sec

Standing unsupported one foot in front: DEMONSTRATE “Place 1 foot in front of the other. IF you feel you cannot place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot”
-Hold 30 sec

Stand on 1 leg: “Stand on 1 leg as long as you can w/ out holding”
-> 10 sec

2. Each item scored 0-4 based on pt’s independence in performing task and time/distance requirements.

Question 17

1. What does the BESTest stand for?
2. What was the reason for creating the BESTest?
3. What are the 6 systems assessed in the BESTest?

Answer 17

1. Balance Evaluation Systems Test.
2. Other clinical balance assessment tools did not help therapists determine the underlying postural control system responsible for poor functional balance. By id the disordered system contributing to poor balance, a therapist can direct specific types of interventions for different types of balance problems.
3. Biomechanical Constraints, Stability Limits/Verticality, Anticipatory postural adjustments, postural responses, sensory orientation and stability in gait.

Test has good reliability and validity.
Helps to determine type of balance problem to direct specific treatments. Needs further development.

Question 18

1. Why was the Mini-BESTest developed?

2. How does it compare to the BESTest?

Answer 18

1. The BESTest was too long for clinical use.
2. It has 14 items in 4 out of the 6 BESTest sections. It focuses on dynamic balance and takes 10-15 minutes. It still helps differentiate the postural control system that may be contributing to poor functional balance.

Question 19

What 4 balance control systems does the Mini-BESTest include?

Answer 19

Anticipatory
Reactive Postural Control
Sensory Orientation
Dynamic Gait

Question 20

Mini-BESTest Instructions:

1. Subject Conditions
2. Equipment
3. Scoring
4. What happens if a subject needs to use an assistive device?
5. What happens if a subject requires physical assistance?

Answer 20

1. Subject should be tested w/ flat-heeled shoes or shoes and socks off.
2. Toam, chair w/out arm rests or wheels, incline ramp, stop watch, box 9’’, 3 m distance measured out and marked on the floor w/ tape.
3. Highest possible score is 28 for 14 items.
   2-Normal: Highest level of functioning
   1-Moderate
   0-Severe: Lowest level of functioning.
4. Score them one category lower.
5. Score them 0 for that item.

Question 21

What are the anticipatory items on the Mini-Best?

• Pt instructions for each item
• PT instructions for each item

Answer 21

1. Sit to stand.
   “Cross your arms across your chest, try not to use your hands unless you must. Do not let your legs lean against the back of the chair when you stand. Please stand up now”
2. Rise to toes.
   “Place your feet shoulder width apart. Place your hands on your hips. Try to rise as high as you can onto your toes. I will count out loud to 3 seconds. Try to hold this pose for at least 3 seconds. Look straight ahead. Rise now.”
   -Give subject 2 attempts, score the best
   -Make sure they have reached the full height by having subject rise while holding examiner’s hands.
3. Stand on one leg.
   “Look straight ahead. Keep your hands on your hips. Lift your leg off of the ground behind you without touching or resting your raised leg upon your other standing leg. Stay standing on one leg as long as you can. Look straight ahead. Lift now.”
   -Allow subjects two attempts for each leg and record times.
   -stop timing if they take their hands off hips or put their foot down.
   -Choose the best time (of trial 1 and 2) for both L and R leg
   -For sub-scale choose the side w/ the lowest score

Question 22

What are the reactive postural control items on the Mini-Best?

• Pt instructions for each item
• PT instructions

Answer 22

4. Compensatory stepping correction-forward.
   “Stand with your feet shoulder width apart, arms at your sides. Lean forward against my hands beyond your forward limits. When I let go, do whatever is necessary, including taking a step, to avoid a fall.”
5. Compensatory stepping correction- backwards.
   Stand with your feet shoulder width apart, arms at your sides. Lean backward against my hands beyond your backward limits. When I let go, do whatever is necessary, including taking a step, to avoid a fall.”
6. Compensatory stepping correction- lateral.
   “Stand with your feet together, arms down at your sides. Lean into my hand beyond your sideways limit. When I let go, do whatever is necessary, including taking a step, to avoid a fall.”
   -Do for both L and R
   -Use the side w/ the lowest score to calculate sub-score.

Question 23

What are the sensory orientation items on the Mini-Best?

-Pt instructions for each item

Answer 23

7. Stance: Feet together EO, firm surface.
   Place your hands on your hips. Place your feet together until almost touching. Look straight ahead. Be as stable and still as possible, until I say stop.”
   - Up to max of 30 sec
8. Stance: Feet together EC, foam surface.
   Step onto the foam. Place your hands on your hips. Place your feet together until almost touching. Be as stable and still as possible, until I say stop. I will start timing when you close your eyes.”
   - Max 30 sec
9. Incline-EC
   Step onto the incline ramp. Please stand on the incline ramp with your toes toward the top. Place your feet shoulder width apart and have your arms down at your sides. I will start timing when you close your eyes.”
   -Up to 30 sec
   -Note if sway

Question 24

What are the dynamic gait items on the Mini-Best?

-Pt instructions for each item

Answer 24

10. Change in gait speed
    Begin walking at your normal speed, when I tell you ‘fast’, walk as fast as you can. When I say ‘slow’, walk very slowly.”
    -3-5 steps fast, 3-5 slow, stop
11. Walk w/ head turns-horizontal
    “Begin walking at your normal speed, when I say “right”, turn your head and look to the right. When I say “left” turn your head and look to the left. Try to keep yourself walking in a straight line.”
    -Say right or left every 3-5 steps.
12. Walk w/ pivot turns
    “Begin walking at your normal speed. When I tell you to ‘turn and stop’, turn as quickly as you can, face the opposite direction, and stop. After the turn, your feet should be close together.”
    -Demonstrate
    -Count # of steps during pivot turn
13. Step over obstacles
    “Begin walking at your normal speed. When you get to the box, step over it, not around it and keep walking.”
    -Box 10 ft away from pt
14. TUG w/ dual task
    Instruction TUG: “When I say ‘Go’, stand up from chair, walk at your normal speed across the tape on the floor, turn around, and come back to sit in the chair.”
    Instruction TUG with Dual Task: “Count backwards by threes starting at ___. When I say ‘Go’, stand up from chair, walk at your normal speed across the tape on the floor, turn around, and come back to sit in the chair. Continue counting backwards the entire time.”
    -Subject walks a 3 m distance
    -Record the numbers for counting to cross off as you go.
    IF the pt’s gait speed changes by >10% on dual task, decrease score by 1 point.
    -start w/ back against a chair
    -Give 2 different numbers to start from.

Question 25

1. What does it mean to take a task-oriented approach to balance control problems?
2. What are the required elements for retraining functional tasks?

Answer 25

1. After assessment, decide which impairments can be modified through PT interventions by:
   1) Resolve, reduce, prevent impairments that contribute to imbalance.
   2) Develop task-specific sensory and motor strategies for maintaining postural control.
   3) Retrain functional tasks w/ varying postural control demands.
2. • Analysis of the task: Person, Task and environment
   • Identify abnormal or missing component, then train them
   • Practice the whole task.
   • Transfer of learning to different conditions.

Question 26

What are the clinical considerations for treatment in terms of the types of postural control?

Answer 26

1. Static Control:
   -Sitting or standing head and trunk control
   -Posture training
   -ROM
   -Strengthening
   If you are working on the impairments with the rationale that they are essential components for balance, then it is considered balance training.
2. Reactive Control: After a perturbation has occurred.
   - Design activities to elicit a certain response
   - At first it might be helpful to give instructions to do a certain response like step
   - Over time move towards more automatic responses.
3. Proactive or Anticipatory Control: Before perturbation occurs.
   - Hard to train
   - Usually involved postural control muscles from the entire body preparing for a movement.

Question 27

What is essential to the success of balance training?

Answer 27

Do balance training in varying environment with different task demands, for the transferability and adaptability of different skills.

Question 28

What balance training for sitting or standing can you do?

Answer 28

• Hold position or posture to work on stability of the head and trunk.
• Mobility: mvmt eyes, head, trunk
• Reaching (UE) activation: front, sides, high/low
• Increase distance to be reached, vary speed mvmt
• Reduce BOS in sitting (cross legs), standing (narrow, tandem, SLS)
• Balance strategies
• Catch ball
• Pick up objects
• Scooting

Question 29

How can the following sensory systems be altered to train balance?
Visual
Somatosensory
Vestibular

Answer 29

Visual:
N-EO
Enhance- Biofeedback, look in a mirror
Reduce- EC, dim light, glasses

Somatosensory:
N- Firm level surface
Enhance- Velcro, rice, or other substance for plantar stimulation
Reduce- Foam, ball, moving surface

Vestibular:
N- Regular environment
Enhance- EC and on foam (no vision and altered somatosensory will for vestibular system to work)

Question 30

Some other considerations w/ balance training?

Answer 30

• Do not train test tasks
• Make sure ex are challenging, but achievable and fun
• Assess if ex is eliciting response you want

Question 31

What are the categories of balance exercise and some examples?

Answer 31

Postural training: work on maintaining head and trunk control in sitting w/cues from the therapist.
ROM and Strength: Trunk or cores strength (w/ a theraband, sit ups w/ a pillow)
Reactive Balance:
-Internal perturbations (ex voluntary weight shifts in sitting or with a ball),
-External perturbations (in sitting, don’t let me move you-therapist applies nudges)

Sitting balance:

• On a stability ball, make exercise more challenging.
• Throw a ball (can manipulate weight, speed…)
• 2 partners sitting on a stability ball, use theraband to provoke perturbations

Standing Exercises:

• Start in parallel bars
• Change BOS (SLS) or support surface (FOAM)
• Stand on incline (vestibular system if eyes closed)
• Reaching activities in stance
• Tilt board

Gain training:

• Obstacle course
• Tandem stepping on a line

Proactive 
Use of strategies 
-Ankle strategy 
-Hip strategy 
-Stepping Response (nudges) 
Specific Skill Training 
Dual Task

Question 32

What is important to consider w/ a HEP for balance?

Answer 32

SAFETY

• Stand in corner or near a wall
• By a table or chair
• Kitchen counter or chair using support as needed.