Balance disorders in geriatric population, assessment and management, various Balance tests

1. BALANCE DISORDERS IN
GERIATRIC POPULATION,
ASSESSMENT AND MANAGEMENT
Dr. Usha (PT)
Assistant Professor

2. CONTENTS
• Aging and age related changes
• Balance related disorders in Geriatric Patients
• Balance definition and balance system
• Motor Strategies for Balance Control
• Balance Impairment In Elderly
• Assessment of balance
• Management of balance disorders and Balance training

3. • Aging is a fundamental process that affects all of our systems and
tissues. The rate and magnitude of change in each system may
differ person to person, but total body decline is an inevitable
part of life for everyone.

4. • Approximately half of the decline in physiological functions with age has a
genetic basis and the remainder of age-related change is the consequence of
lifestyle, primarily physical inactivity that can account for the other half of
the decline with age.
• Coupling sedentary lifestyle with inadequate nutrient intake, excess body
weight (which puts stresses on tissues, increases inflammation, predisposes
toward disease), and variables such as smoking and excessive alcohol intake,
the biological decline is more precipitous and greater in magnitude

5. BALANCE
• Balance- Balance refers to an individuals ability to maintain
their line of gravity within their Base of support (BOS).
• It can also be described as the ability to maintain equilibrium,
where equilibrium can be defined as any condition in which all
acting forces are cancelled by each other resulting in a stable
balanced system.

6. BALANCE CONTROL
• The following systems provides input regarding the body's equilibrium and
thus maintains balance.
• Somatosensory / Proprioceptive System
• Vestibular System
• Visual System

7. THE BALANCE SYSTEM
https://en.wikibooks.org/wiki/Sensory_Systems/Control_Systems accessed on 12/04/2020

8. MOTOR STRATEGIES FOR BALANCE CONTROL
• Three strategies
– Ankle Strategy (Anteroposterior Plane)
– Hip Strategy
– Stepping Strategy

9. Ankle Strategy (Anteroposterior
Plane)
• In quiet stance and during small perturbations movements
at the ankle act to
– Restore a person’s COM to a stable position.
• For small external perturbations that cause loss of balance in a
forward direction
– Muscle activation usually proceeds in a distal to proximal
sequence
– i.e. activation begins in gastrocnemius followed by the hamstrings and
finally paraspinal muscle.

10. • In response to backward instability
– muscle activity begins in the anterior
tibialis
– followed by the quadriceps and abdominal
muscles.

11. Hip Strategy
• Hip strategy is employed for
– rapid and/or large external perturbations
– movements executed with the COG near the
limits of stability
• The hip strategy uses rapid hip flx or ext
– to move the COM within the BOS.

12. • In response to a forward body sway
– Muscles are typically activated in a proximal to distal
sequence
• Abdominals followed by activation of the
quadriceps.
• Backward body sway results in
– Activation first of the paraspinals followed by the
hamstrings.

13. Stepping Strategy
• If a large force displaces the COM beyond
the limits of stability
– A forward or backward step is used to
enlarge the BOS and regain balance control
• Example of a stepping strategy
– The uncoordinated step that follows a
stumble on uneven ground

14. Factors Influencing Selection of Balance
Strategies
• Speed and intensity of the displacing forces
• Characteristics of the support surface
• Magnitude of the displacement of the Centre of mass
• Subject’s awareness of the disturbance
• Subject’s posture at the time of perturbation
• Subject’s prior experiences

15. Balance Impairment In Elderly
• It is estimated that 13% of adults self-report imbalance from ages
65 to 69 and this proportion increases to 46% in those aged 85
and older.
• Impairments of balance and gait have been associated with
increased risks of falls.

16. • In adults aged 65 and older, the estimated prevalence of falls is
28% per year.
• Patients who have fallen or have a gait or balance problem are at
higher risk of having a subsequent fall and losing independence.
• An assessment of fall risk should always be integrated into the
history and physical examination of all geriatric patients.

17. Causes for Falls in Elderly
• The causes of falls in the elderly are usually multifactorial, with a
combination of intrinsic factors, including the physiological
changes of ageing, frailty, pathologies, and extrinsic,
environmental and situational factors.

18. Age Related Changes To Balance Components
• Changes To Sensory Component of Balance
• Decreasedvisual,vestibular, somatosensory (bodyawareness),and auditory
(hearing)function
• Decreasedabilityto adaptresponses(e.g.usingyour innerearandyour feet)
• Changes To Motor Component of Balance
• Decreasedmagnitudeofmuscle response
• Increasedrelianceof arms
• Changes To Cognitive Component of Balance
• Decreasedoverallattentioncapacity
• Decreasedabilityto multitask(e.g.carryingacupofwaterwhilewalking)

19. Altered Balance/ Fall
Leads to slowed and weakened postural control and muscle responses
Changes in elderly with Age
Decrease in depth
perception and dark-
light discrimination,
A high
prevalence(≤40%) of
decreased vibration and
position sense and
frequent vestibular
impairment.
Central processing
is slower, both in
the interpretation
and weighting of
sensory
information and in
motor output and
co-ordination
Peripheral nerve
conduction is
slower, there is a
decrease in the
number of motor
units in the spinal
cord
Progressive and
generalised loss of
skeletal muscle mass
and strength
(Sarcopenia)

20. FALL RISK FACTORS IN ELDERLY
Classification I
• Intrinsic (internal) Risk factors
• Extrinsic (external) Risk factors
• Acquired Risk factors
Classification II
• Modifiable Risk Factors
• Non-Modifiable Risk Factors

21. • e.g. Age, Dizziness, Orthostatic hypotension,
confusion, muscle weakness, osteoporosis, vision loss,
dementia
Intrinsic Risk
factors
• e.g. Médications, foot wear, assistive devices, floor
surface if unstable
Extrinsic Risk
factors
• e.g. Facility or hospital admission due to health
change or decline (new environment),
delirium due to disease, increased frailty due to
injury
Acquired Risk
factors

22. Non-Modifiable Risk
Factors
• e.g. Age, chronic
conditions, disability,
dementia, vision loss
Modifiable Risk Factors
• e.g. Muscle weakness,
poor balance, exercise
level, medications,
environmental lighting,
footwear

23. ASSESSMENT IN ELDERLY
• The assessment and management of a patient who is at risk of
falls, or who has fallen, require a multidisciplinary approach to
identify and address factors that contribute to a fall. Such an
assessment should be considered for elderly persons who
• have sustained injuries after a fall,
• have had a single fall,
• have an abnormal gait, or
• have had ≥2 unexplained falls in a 12-month period.

24. BALANCE ASSESSMENT
• There are three approaches to the assessment of balance:
1. A systems approach,
2. Functional assessment and
3. Quantitative posturography.

25. BALANCE ASSESSMENT
• The systems approach to the assessment of balance seeks to
identify impairments in the various subcomponents of postural
control and compensatory strategies used to compensate for
these impairments.

27. FUNCTIONAL ASSESSMENT TOOLS
• Functional assessment seeks to establish whether there is a
balance problem and predict the risk of falls, while the systems
approach tries to identify which of the elements of postural
control are impaired.
• Functional assessment tools seek to rate performance across
various tasks requiring balance control to identify functional
limitations or the capacity to perform various tasks.

28. FUNCTIONAL BALANCE ASSESSMENT TESTS OR
TOOLS
• Balance Outcome Measure for Elder Rehabilitation (BOOMER)
• Functional Reach Test (FRT)
• Timed Get Up and Go Test (TUG)
• Romberg’s test (identifies vestibular and proprioception impairments by removing visual
compensation),
• Postural sway (with eyes open and closed- slowed postural reflexes),
• The sternal nudge (postural response to external force)
• Tinetti Performance Oriented Mobility Assessment (POMA)
• Berg Balance Scale (BBS)

29. BALANCE OUTCOME MEASURE FOR ELDER
REHABILITATION (BOOMER)
• The BOOMER assesses standing balance and functional mobility
in the elderly population. A global multi-item static, dynamic and
functional balance measure throughout all settings of elder
rehabilitation.
• Collaboration of 4 test scores used to measure balance, mobility
and perceived confidence in geriatric population.

30. The BOOMER consists of the following four tests:
Test Description
Step Test One foot is repeatedly placed on top of a 7.5cm step and
returned back down to the ground as many times as able in 15
sec. The average between legs is then calculated for scoring.
Timed Up and Go From a seated position, individual stands, walks 3m, turns 180°,
walks 3m back to chair and sits down with back resting against
backrest.
Functional Reach Individual reaches as far forward as possible in a standing
position without losing balance.
Timed Static Stance Standing with feet together and eyes closed.

31. BOOMER Scoring
Test Scoring
0 1 2 3 4
Step test (average number
of steps)
Unable 0 - 5 5 - 8 8 - 12 >12
TUG (seconds) Unable ≥ 30 29 - 20 19 - 10 <10
FR (centimetres) 0 1 - 15 16 - 20 21 - 30 > 30
Timed Static Stance
(seconds)
Unable 0 - 30 30 - 60 60 - <90 90

32. FUNCTIONAL REACH TEST
 Developed to predict fall risk in the elderly and Frail
adult
 Procedure
• The patient stands near a wall with feet parallel
• A yard stick is attached to the wall 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.
• The client is then asked to lean forward as far as
possible, & the examiner notes the end point.

34. • Beginning position is subtracted from end position of the fist
on the yardstick.
 Interpretation (FRT):
 Score of 6 or less indicates a significant increased risk for
falls (>70% fall in 3 months)
 Score between 6-10inches indicates a moderate risk for falls

35. TIMED GET UP AND GO TEST (TUG)
• To determine fall risk and measure the progress of balance, sit to
stand and walking.
• Materials Needed: One chair with armrest, Stopwatch, Tape (to
mark 3 meters)

36. Procedure:
• The patient starts in a seated position
• The patient stands up upon therapist’s
command: walks 3 meters, turns around,
walks back to the chair and sits down.
• The time stops when the patient is
seated.
• The subject is allowed to use an assistive
device. Be sure to document the assistive
device used.

37. Interpretation (TUG)
• If time taken 14 seconds or longer- high-risk for falling
• Normal healthy elderly- usually complete the task in 10 seconds
or less.
• Very frail or weak elderly with poor mobility- may take 2 minutes
or more.

38. ROMBERG TEST & SHARPENED ROMBERG TEST
• Measure of balance maintenance or equilibrium with a narrowed base of support
• ROMBERG TEST
1) Feet together, eyes open, 60 sec (R-EO)
2) Feet together, eyes closed, 60 sec. (R-EC)
• SHARPENED ROMBERG TEST
1) Feet heel-to-toe (dominant foot behind non-dominant foot), eyes open, 60 sec. (SR-EO)
2) Feet heel-to-toe (dominant foot behind non-dominant foot), eyes closed, 60 sec. (SR-EC)

39. SHARPENED ROMBERG TEST

40. TINETTI PERFORMANCE ORIENTED MOBILITY
ASSESSMENT (POMA)
 Description: The Tinetti assessment tool is an easily
administered task-oriented test that measures an older adult’s
gait and balance abilities.
 Equipment needed: Hard armless chair Stopwatch or
wristwatch 15 ft walkway
 Completion:
Time: 10-15 minutes

41. TINETTI
PERFORMANCE
ORIENTED
MOBILITY
ASSESSMENT
(POMA)

42. TINETTI
PERFORMANCE
ORIENTED
MOBILITY
ASSESSMENT
(POMA)

43. Scoring: A three-point ordinal scale, ranging from 0-2. “0”
indicates the highest level of impairment and “2” the individuals
independence.
• Total Balance Score = 16
• Total Gait Score = 12
• Total Test Score = 28
• Interpretation (POMA):
• 25-28 = low fall risk
• 19-24 = medium fall risk
• < 19 = high fall risk

44. BERG BALANCE SCALE
• The Berg balance scale is used to objectively determine a patient's ability
(or inability) to safely balance during a series of predetermined tasks. It is a
14 item list with each item consisting of a five-point ordinal scale ranging
from 0 to 4, with
• 0 indicating the lowest level of function and
• 4 the highest level of function and
• takes approximately 20 minutes to complete. It does not include the
assessment of gait.

45. BERG
BALANCE
SCALE

46. • Interpretation (BBS)
• 41–56 = low fall risk
21–40 = medium fall risk
0–20 = high fall risk
<36 fall risk close to 100%

47. Management of Balance Disorders
Management of balance disorders in elderly requires a multifactorial
approach
• Muscle strengthening exercises (specific to proximal muscles and core area)
• General flexibility or Stretching exercises
• Joint ROM exercises
• Visual biofeedback training
• Balance training

48. BALANCE TRAINING
• Static balance control
• Reactive balance control
• Sensory organization
• Balance during functional activities

49. STATIC BALANCE CONTROL
• Activities to promote static balance control include
having the patient maintain sitting, half-kneeling, tall
kneeling, and standing postures on a firm surface. More
challenging activities include practice in the tandem and
single-leg stance, lunge, and squat positions.

50. Standing activities:
• Static Double limb stance (feet apart then feet together, open eyes then closed eyes)
• Single leg stance (open eyes then closed eyes)
• Tandem position
• Toe or heel standing
• Looking up at the ceiling
• Turning to look behind without moving the feet

51. Sequence of Progression In Static Balance
Hard surfaces
• Maintainstatic balance.
• Move some part(s)ofbody and
try to maintainhis balance.
• Open thenclosed eyes.
• NarrowingBOS
• Externalchallengefrom therapist
(perturbations).
• Throw andcatchexerciseswith
ball.
Soft surfaces
• Maintainstatic balance.
• Move some part(s)ofbody and
try to maintainhis balance.
• Open thenclosed eyes.
• NarrowingBOS
• Externalchallengefrom therapist
(perturbations).
• Throw andcatchexerciseswith
ball.

52. DYNAMIC BALANCE CONTROL
• To promote dynamic balance control, interventions
may involve the following.
– Maintain equal weight distribution and upright trunk
postural alignment while on moving surfaces, such as
• Sitting on a therapeutic ball
• Standing on wobble boards
• Bouncing on a minitrampoline

53. Standing activities:
• Marching in one place
• Standing on wobble board or rocker board

54. Walking-
• Walking Forward (Stable then Unstable
Surface)
• Walking Backward
• Walking Sideways
• Tandem walking
• Toe or heel walking
• Walking on a circle
• Walking on ramp
• Stair climbing up and down
• Walking by clearing obstacles

55. Anticipatory Balance Control
• Reach in all directions (Forward reach, Lateral reach, Backward
reach, Diagonal reach) to touch or grasp object- Use different
postures for variation (e.g., sitting, standing, kneeling)
• Reaching down to a chair or stool and touching floor
• Catching or throwing an object (e.g. a ball)
• kicking a ball

56. REACTIVE BALANCE CONTROL
Have the patient train reactive balance control with the following
activities.
• Have the patient work to gradually increase the amount of sway when
standing in different directions while on a firm stable surface.
• To emphasize training of the ankle strategy, have the patient practice
while standing on one leg with the trunk erect.
• For hip strategy- have the patient walk on balance beams or lines
drawn on the floor; perform tandem stance and single-leg stance with
trunk bending; stand on a mini-trampoline, rocker balance, or sliding
board.

57. • For stepping strategy, have the patient practice stepping up onto a stool or
stepping with legs crossed in front or behind other leg (e.g., weaving or
braiding).
• To increase the challenge during these activities, add anticipated and
unanticipated external forces.
• For example, have the patient lift boxes that are identical in appearance but
of different weights; throw and catch balls of different weights and sizes; or
while on a treadmill, suddenly stop/start the belt or increase/decrease the
speed.

58. References
• Osoba MY, Rao AK, Agrawal SK, Lalwani AK. Balance and gait in the elderly: A contemporary
review. Laryngoscope Investigative Otolaryngology. 2019 Feb;4(1):143-53.
• De Villiers L, Kalula SZ. An approach to balance problems and falls in elderly persons. South
African Medical Journal. 2015;105(8):695.
• Kloos AD, Heiss DG. Exercise for Impaired Balance. In: Kishner C, Colby LA editors. Therapeutic
exercise foundations and technique. 5th ed. Philadelphia. F.A. Devis Company. 2007; 251-266.
• Brown M. The Physiology of Age-Related and Lifestyle-Related Decline. In: Falk K, Jackson C
editors. Geriatric Physical Therapy. 3rd ed. Elsevier Mosby. 2012; 27-37. ISBN: 978-0-323-
02948-3

59. Thank You