Balance Assessment

Balance
A generic term used to describe the dynamic process by which the bodys position is maintained
in equilibrium.
Equilibrium means that the body is either at rest (static equilibrium) or in steady-state motion
(dynamic equilibrium).
Balance is greatest when the bodys center of mass (COM) or center of gravity (COG) is
maintained over its base of support (BOS).
Sensory Systems and Balance Control
1. Visual System
The position of the head relative to the environment;
The orientation of the head to maintain level gaze
The direction and speed of head movements because as your head moves, surrounding
objects move in the opposite direction.
Note: Compensates in the (-) of vestibular and proprioceptive inputs BUT sometimes
inaccurate
2. Somatosensory System
It provides information about the position and motion of the body and body parts
relative to each other and the support surface.
3. Vestibular System
It provides information about the position and movement of the head with respect to
gravity and inertial forces.
Only vestibular system can detect high velocities of head motion.
4. Sensory Organization for Balance Control
Vestibular, visual, and somatosensory inputs are normally combined seamlessly to
produce our sense of orientation and movement.
What is the Role of Vestibular System in Balance?
Allows for the perception of self-motion (acceleration & deceleration), head position and spatial
orientation in relation to gravity.
Verticality orientation
Postural control during movement
Stabilize gaze by coordinating head and eye motion
Allows differentiation between motions of self vs. environment.


I- Anatomy of Vestibular System

1. Peripheral Vestibular system
3 primary functions
Gaze stabilization
Postural stability esp. with head movement
Spatial orientation

A. Semicircular Canals(3 SCC on each TEMPORAL bone)
Responds to angular acceleration through the movement of endolymph
slightly > density with water.
Endolymph deflects the gelatinous barrier cupula inside the ampulla-
cupula has sensory hair cells kinocillia and stereocilia- deflection of
stereocilia towards kinocilia leads to excitation(depolarization) STKex.
Opposite direction leads to inhibition (hyperpolarization).
E.g. Head turned to right right horizontal SCC is excited and Left
horizontal is inhibited.-send signals to brain that head moves towards
right.
Orthogonal in respect to one another and has coplanar mate contra-
laterally.

ii. Anterior/Superior ( coplanar pair with contralateral posterior SCC)
iii. Posterior/ inferior (coplanar pair with contralateral posterior SCC)
iv. Horizontal (coplanar pair with contralateral horizontal SCC)

B. Otolith organs
With sensory hair cells that projects into gelatinous material with
otoconia (calcium carbonate crystals)

ii. Saccule - occurs excitation during vertical linear acceleration.
iii. Uttricle- occurs excitation during horizontal linear acceleration and or static
head tilt
2. Central Vestibular System
A. Brainstem- contains the vestibular and reticular nuclei
B. Thalamus-
C. Cerebellum maintain calibration of Vestibulo-ocular reflex
D. Vestibular Cortex-parietal and insular lobes( evidence through fMRI-functional
magnetic resonance imaging)
- With brainstem and thalamus contributes to
integration of arousal and conscious awareness of the
body as well as discriminate between movement of
self and environment.
II- Physiology and Motor Control
1. Tonic firing rate high tonic firing rate of vestibular afferents @ 70-100 spikes/s resting rate
efficiently detects movement through excitation and inhibition.
2. VOR- is responsible for maintaining stability of on the fovea of the retina during rapid head
movements. Its mechanism generates rapid compensatory eye movements opposite the head
rotation.

3. Push pull mechanism- if the ipsilateral is excited the contralateral coplanar plain is inhibited.
the brain detects head movement & direction through inputs of two vestibular systems.
- A faulty interpretation can lead to difficulties with
gaze stabilization, postural stability, and motion
perception.
4. Inhibitory cut off the hyperpolarization of the hair cells in the opposite labyrinth can only
decrease the firing rate to zero at which point the inhibition is cut off.( 70-100spikes/s resting)
5. Velocity storage system(VSS)- vestibular inputs last longer than 10secs during low frequency
head rotation to allow the brain in detecting low frequency head rotation.

III- Examination
SUBJECTIVE
1. History is the most important part of the evaluation.
a. 3 key items in history
i. Tempo
ii. Symptoms
iii. Circumstances of complaint

b. Identification of symbols
i. Dizziness- vaguely defined as sensation of whirling or feeling of a tendency to
fall.
ii. Vertigo is an illusion of movement( spinning)
iii. Lightheadedness- feeling of fainting
iv. Dysequilibrium- sensation of being of balance
v. Oscillopsia- is the subjective of experience of motion of objects in the visual
environment that are known to be stationary. Inadequate compensatory eye
velocity during the head movement(vestibular hypofunction)
c. Onset
d. Intensity (VAS)
e. Duration
f. Frequency
g. Precipitating and alleviating factors
h. Associated symptoms-tinnitus, hearing loss, ear pain, infection.
i. Past medical & Medical history
j. Family history
k. Medications sedatives, anti -hypertensive, antidepressants
l. Falls History
m. Functional status
n. Social status
o. Psychological status
p. Treatment sought
q. Goals of patient
r. Dizziness Handicap Inventory (DHI) Scale

2. Tests & Measures
a. Visual Analogue Scale
i. Intensity rating of vertigo, lightheadedness, disequilibrium and oscillopsia.
b. Dizziness Handicap Inventory
i. Is a popular tool used to measure a patients self perceived handicap as a
result to vestibular disorders.
ii. It has 25 questions sub grouped into functional, emotional and physical
components.
c. Functional Disability Scale
i. Determines patients response to PT, tests is done before rehabilitation and
after rehabilitation.
d. Motion Sensitivity Quotient
i. Developed to provide a subjective score of an individuals dizziness
ii. Place patients into various head and body positions.
iii. 0- no symptom; total number of 100 means severe dizziness.
e. Eye movement
i. Nystagmus
Rhythmic, quick, oscillatory, back and forth movement of the eyes.
Is the primary diagnostic indicator used in identifying most peripheral
and central vestibular lesions
a. Peripheral Vestibular Lesions- nystagmus is composed of
- Slow component (excitation on the healthy side of the
vestibular system opposite the lesion)
- fast component ( brainstem compensatory
repositioning of the eye to the center of the orbit)
Note: Vestibular lesion is opposite to the fast
component.
e.g.- The eye moves slowly to the right (VOR) and the
resetting eye movement to the left (fast component).
Therefore: Left beating nystagmus and right vestibular
lesion.










Name of Test Position Procedure Positive Negative Indications
Oculomotor
Examination in
room light
Note: This is
used for initial
observation
only.
Sitting A. Ask the
patient to look
ahead; do not
allow to visually
fixating on any
target.
PT observes for
nystagmus.
+ Spontaneous
Nystagmus
No Nystagmus Initial
examination to
confirm that the
patient has
vestibular
lesion(peripheral
or central)
B. Let the
patient fixate
on a visual
target(PTs
Nose)
(-)Spontaneous
nystagmus
(suppressed
after visual
fixation)
Peripheral
Vestibular lesion
c. Let the
patient fixate
on a visual
target(PTs
Nose)
(+)Spontaneous
nystagmus
(not inhibited
after visual
fixation)
Central
Vestibular lesion
Vestibular-
ocular-reflex
cancellation
test (VORc
Test)
Sitting Flexed subjects
head forward
by 30deg. ask
subject to Flex
shoulder 90deg
with elbow
extended,
hands clasped
together with
one thumb in
front of the
other. Ask
subject to
visually fixate
at his thumb
and move side
to side 30deg.
(+) Saccadic eye
movement
Central lesion
Head Thrust
Test
( Horizontal
SCC)


Sitting -Examine
cervical ROM
-Explain the
procedure that
there will be
quick
unpredictable
head turning
(5-15degs.)
-Flex head and
neck to 30deg.
The eyes fall off
the target and
move with the
head and
undershoot
upon return to
midline.
(Returns eyes
towards the
examiner nose
through
The eyes fixate
on examiners
nose.
Malfunction of
Horizontal SCC/
Unilateral
Vestibular
Hypofunction
( Peripheral
lesion)


and stabilize.
- Instruct
patient to
fixate vision at
the nose of the
examiner while
testing.
- Begin from
midline and
thrust the head
rapidly to
testing side and
back to midline.
Observe the
eyes. Test both
side.

Corrective
saccade from
the lesion side)




Pt. has difficulty
maintaining
gaze upon
return to
midline
Central Lesion
( Vestibular
nuclei same side
lesion)
Corrective
saccades on
either side
Bilateral
Head Shaking
Induced
Nystagmus
Standing or
sitting with
patient and
examiners
eyes on the
same level
Examine
cervical ROM
-Explain the
procedure that
there will be
quick
unpredictable
head turning.
-Flex head and
neck to 30deg.
and stabilize.
- Instruct the
patient to close
eyes.
Examiner
oscillate the
head of the
patient
20cycles at a
frequency of of
2 reps/sec. (
Approx. 5-10
degs. rot .
-Open eyes and
check for
nystagmus
+ Horizontal
Nystagmus (
Fast Beating
opposite the
lesion)
Unilateral
Vestibular
Hypofunction
+ Vertical
Nystagmus
Central Lesion
Hallpike-Dix
T0est (Supine)
Position the
patient long
Head position
horizontally
+ Nystagmus on
tested side
No nystagmus Benign-
paroxysmal
sitting on
the
treatment
table with
the head
and neck
exceeds the
treatment
table upon
supine.
rotated to
45deg on the
tested side,
hold and
maintain head
position while
quickly position
the pt. to
supine with the
neck extended
to 30deg from
the horizon.
Observe
nystagmus
Return to
sitting, test
other side.
Return to siting
where the head
is rotated( fast
beating
nystagmus
towards the
tested side)

*nystagmus
within 15secs
after provoking
position.
positional
vertigo( BPPV)
(+ Nystagmus
towards the
floor-testing side
where the head
is rotated)
Ant. & Post SCC
Hall pike- Dix
Test(Side lying)
Position the
patient long
sitting on
the edge of
treatment
table.
Head position
horizontally
rotated to
45deg on the
tested side,
maintain head
position while
quickly position
the pt. to
sidelying
opposite the
head rotation.
Return to siting
and test other
side.
-nystagmus &
vertigo
Benign
paroxysmal
positional
vertigo( BPPV)
Roll Test for
Horizontal SCC
Supine Position the
neck flexion to
20deg. The
head is quickly
turn to 90deg
on tested side
and observe for
nystagmus and
vertigo. Return
to neutral and
test the other
side
+ Nystagmus
with same
direction
towards rotated
side.

BPPV
(canalithiasis)
+ nystagmus
opposite the
rotated side
BPPV
(cupulolithiasis)







Dynamic Visual
Acuity
Test(DVA)
-is a
measurement
of visual acuity
during
horizontal
motion of the
test.
Sitting or
Standing
Ask the patient
the smallest
line they can
see and read
(static visual
acuity).
Oscillate head
5-10 deg. and
instruct the
patient to read
the letters as
able.
3 or more line
decrement of
visual acuity.
2 or less
decrement of
visual acuity
Vestibular
hypofunction

F. Gait & Balance Testing
test both static and dynamic balance.
See Table for Common Balance Tests and expected results related to specific diagnosis.

G. Vestibular Tests
Semicircular Canal Tests
1. Caloric testing
Involves infusing the external auditory canal with air or water.
Temperature gradient results to convective flow of endolymph that
deflects scapula and create nystagmus in the horizontal SCC.
+ nystagmus on the side tested
2. Rotary chair testing
Rotates subject in the dark to stimulate vestibular system (horizontal
SCC) and abruptly stop and observe for nystagmus.
Compare nystagmus in both sides by rotating the chair towards the
opposite direction.
H. Otolith Tests

The otolithic organs (see above) in the vestibular system sense gravity. Both the utricle and
saccule (see figure above) contribute to the sense of verticality. After injury to the otoliths, or to
the nerve that transmits impulses from the otoliths and other parts the ear to the brain,
judgment of vertical may be altered. The inner ear may falsely suggest that the head is tilted
while the eyes and somatosensory systems suggest that one is upright. Thus there is a sensory
conflict.

1. Vestibular evoked myogenic potential(VEMP)
Exposes patient to series of loud noise clicks(95dB) simultaneously test
the ipsilateral SCM( head postural mm) for myogenic potentials.
Patients with vestibular hypofunction have absent excitatory myogenic
potentials.
2. Subjective Visual Vertical(SVV)
Examine otolith function
Patients are asked to align a dimly lit luminous bar in a darkened room
with what they perceive as vertical.( sensory conflict with visual and
vestibular)
Tilts toward the lesion( peripheral vestibular lesion) >2deg.( normal
<2deg) to the true vertical
3. Subjective Visual Horizontal
Patients are asked to align a dimly lit luminous bar in a darkened room
with what they perceive as horizontal.
Tilts toward the lesion( peripheral vestibular lesion) >2deg.( normal
<2deg) to the true horizontal.



References:

1. Sullivan & Schmitz, Rehabilitation Medicine 5
th
Edition
2. Balance, Equilibrium and Dizziness Center,Inc., Cebu City
3. Principle of the head impulse (thrust) test or Halmagyi head thrust test (HHTT)
Wuyts Antwerp University Research centre for Equilibrium and Aerospace (AUREA), Antwerp
University Hospital, University of Antwerp, Antwerp, Belgium
4. Timothy C. Hain, MD, Subjective Horizontal and Vertical Testing, http://www.dizziness-and-
balance.com/testing/subjective_vertica.htm