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Huxham et al: Theoretical considerations in balance assessment

Theoretical considerations in balance assessment

Frances E Huxham1,2, Patricia A Goldie2 and Aftab E Patla3


1
Kingston Centre, Melbourne 2La Trobe University, Melbourne 3University of Waterloo, Canada

Although balance control is an integral component of all daily activities, its complex and flexible nature
makes it difficult to assess adequately. This paper discusses balance by examining it in relation to
function and the physical environment. Balance is affected by both the task being undertaken and the
surroundings in which it is performed. Different tasks and environments alter the biomechanical and
information processing needs for balance control. These issues are discussed and a modification of
Gentile’s taxonomy of tasks is suggested for analysis of clinical balance tests, some of which are used
as examples. [Huxham FE, Goldie PA and Patla AE (2001): Theoretical considerations in balance
assessment. Australian Journal of Physiotherapy 47: 89-100]

Key words: Biomechanics; Equilibrium; Locomotion; Motor Skills

Introduction 1987) to examine a number of common balance tests,


suggesting some reasons why existing methods may
fail to predict falls effectively. This will enable
As health professionals, physiotherapists have a physiotherapists to evaluate balance assessment
specific interest in recognising and treating balance methods and interpret test results in light of their
problems (Berg et al 1997). People with balance relevance to functional ability.
difficulties constitute a large proportion of all
neurological, rehabilitation and geriatric workloads.
To be effective, physiotherapists therefore need ways Balance and function are inextricable
to assess patients, measure the outcome of treatment
and predict which people, particularly amongst the Balance is not an isolated quality, but underlies our
older population, are at risk of falling. However, capacity to undertake a wide range of activities that
selecting an appropriate test is difficult, particularly constitute normal daily life. Activities such as sitting
to predict falls. Although many tests discriminate in an armchair, carrying a struggling child, cleaning a
between levels of performance or even between high window or running across a busy road require
fallers and non-fallers, very few have been shown to different and complex changes in muscle tone and
predict future falls. Even the carefully documented activity within the balance control system. Balance
Berg Balance Scale (Berg et al 1989) may miss one- cannot be separated from the action of which it is an
third of future fallers (Riddle and Stratford 1999), integral component, or from the environment in
despite good sensitivity (Shumway-Cook et al which it is performed (Carr and Shepherd 1998).
1997a). The difficulty of test selection is increased by Balance therefore forms the “foundation for all
the complex and multi-factorial nature of balance voluntary motor skills” (Massion and Woollacott
(Woollacott and Tang 1997) allowing different 1996, p.1).
emphases by different therapists.
What constitutes balance control?
This paper treats balance as an integral component of
function, stressing how balance is a product of the
task undertaken and the environment in which it is Normal balance requires control of both gravitational
performed. It will discuss how the biomechanical and forces to maintain posture and acceleration forces to
information-processing aspects of both task and maintain equilibrium (Massion and Woollacott 1996).
environment impact on balance control. Finally, it will Acceleration forces may be generated from within the
use the framework of the taxonomy of tasks (Gentile body as the consequence of voluntary movement or

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Huxham et al: Theoretical considerations in balance assessment

Biomechanical Biomechanical
aspects aspects

Environmental
Task constraints BALANCE context

Information Information
processing processing
aspects aspects

comprising

Postural control Equilibrium control

achieved by

Proactive mechanisms Predictive mechanisms Reactive mechanisms

Figure 1. Determinants of functional balance.

from outside as the result of an unexpected instruction constrain or regulate the walk.
disturbance, such as a push. Central to balance
control is the need to maintain the body’s centre of
Similarly, the environment in which the activity takes
mass (COM) within manageable limits of the base of
place constrains the manner in which it is performed.
support (BOS) as in standing, or on track to a new
For example, walking in a darkened unfamiliar room
BOS, as in walking or running (Winter 1995a).
will result in shorter, more cautious steps; stepping
Together, the postural and equilibrium components of
off the footpath onto a major road will use different
balance control ensure stability of the body during
patterns of eye and head movement than stepping
widely differing activities. The exact demands on the
down the same height from a familiar stair.
balance control system are determined both by the
task itself and the environment in which it is
performed. The constraints from task and environment affect
motor performance in two ways (Gentile 1987) and
Balance depends on task characteristics consequently alter balance demands. First, they alter
and environmental context the biomechanical features of the activity. Second,
they affect the amount of information that must be
processed in order to achieve both balance and the
The characteristics of a task may increase or decrease motor goal. The first part of the remainder of this
the difficulty of its balance component. For example, paper will consider the effects of task and
balance is challenged less during normal walking than environment on the biomechanics of balance control;
walking on tip-toes, in high heels or when instructed the second part will examine how the information
to walk very slowly, because the smaller BOS or the coming from both task and environment impacts on

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Huxham et al: Theoretical considerations in balance assessment

balance (see Figure 1 for schematic overview). the body part being moved. Thus raising the arm fast
or with a weight in the hand requires greater control
Biomechanical aspects of than slow movement (Horak et al 1984). Regaining
balance control control of the trunk following a stumble is more
difficult than controlling the momentum of the
swinging arm because it has greater mass and inertia.
As mentioned, both postural and equilibrium control Similarly, it is easier to recover from a trip if walking
of the body (Massion and Woollacott 1996) are slowly than if walking at maximum speed.
necessary to maintain the stability of the body against
the forces of gravity and acceleration impacting upon So complex and intertwined are these forces that
it. As this paper will discuss, these forces are stronger sometimes the postural demand to control COM and
and more complex during walking than when the equilibrium demand to maintain intersegmental
standing, because the BOS is moving (Winter 1995a). relationships may actually conflict (Eng et al 1992).
The normal control system reconciles these
Postural component of balance control There are conflicting demands, even managing to minimise
two elements to the need for postural control imposed energy expenditure by utilising intersegmental
by the Earth’s gravitational pull. First, even a dynamics. During the swing phase of walking, for
stationary body must do work to remain upright under instance, the inertia of the swinging thigh and shank
the force of gravity, particularly the tall human frame is used to extend the knee, rather than quadriceps
with its small BOS (Winter 1995b). In walking, there action (Winter 1991). Similarly, the effort required to
must always be net extensor activity in the stance limb clear an obstacle is reduced at the hip and ankle by
to prevent collapse, even though one or two joints active knee flexion and utilisation of passive forces
may be flexing (Winter 1995b). Second, postural (Patla and Prentice 1995). Thus the normal balance
control is necessary to counterbalance any movement mechanism simultaneously meets complex, changing
which alters the projection of the COM of the body to and sometimes conflicting demands and maximises
the ground (the centre of gravity or COG) (Massion energy efficiency.
1992). If the shape of the body is changed, such as by
raising an arm or bending forward, the position of the
COM will move closer to or beyond the boundaries of Task influences on the biomechanical parameters of
the BOS unless preventative action is taken. balance control The activity undertaken determines
the magnitude, direction and combination of the
forces of gravity and acceleration, changing its
Equilibrium component of balance control
biomechanical parameters throughout the task.
Equilibrium control relates to maintaining
Further, the biomechanical challenges in standing and
intersegmental stability of the body and its parts
walking are very different because the COM lies
despite the forces acting on it (Massion and
outside the BOS for 80% of the gait cycle during
Woollacott 1996). Forces such as linear and angular
walking (Winter 1995a) instead of within it as in quiet
accelerations affect the relationship between body
standing. The acceleration forces which act on the
parts. For example, the angular acceleration acting at
trunk are minimal in quiet standing, increase as a
the shoulder when raising an arm creates reactive
result of arm movement or manipulation and become
moments on the trunk which must be countered by
much greater again with walking, turning and
opposing postural moments before and during the
running, with or without arm movements.
movement (Eng et al 1992). Similarly, horizontal
acceleration forces occur at the hip during walking.
Because they act some distance from the COM, they These differences in biomechanical challenge may be
cause unbalancing moments that would, if unopposed, used to classify clinical balance tests. After
cause flexion of trunk at initial contact and extension categorising the BOS as stationary or moving, this
during push-off (Winter 1995a). To prevent this, the model sub-divides tasks in accordance with the
balance system produces almost equal and opposite stresses superimposed on the body. These may result
hip moments, effectively reducing antero-posterior from self-generated movements, such as waving or
movement of the trunk to near zero (Winter 1995a). reaching, or be imposed on the body from outside, for
The amount of intersegmental stabilisation or example by a push in a crowd or movement of the
equilibrium control necessary is determined by the BOS in a bus. Refer to Table 1 for examples using this
speed of the focal movement and also by the mass of type of classification (test details in Appendix).

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Huxham et al: Theoretical considerations in balance assessment

Table 1. Classification of some clinical balance tests according to biomechanical demands.

Stationary Base of Support Moving Base of Support


Unperturbed Timed standing 10m walk, whether timed or qualitative
Steadiness in standing
Self-generated Performance-Oriented Assessment - Performance-Oriented Assessment
perturbations balance (most items) - mobility
Berg Balance Scale (most items) Timed Up and Go
Step Test Dynamic Gait Index
Functional Reach Performance-Oriented Assessment
Reach Test – balance (turn item)
Berg Balance Scale (turn item)
Sensory-Oriented Mobility Assessment
Instrument
Functional Obstacle Course
External perturbation Performance-Oriented Assessment
– balance (sternal thrust item)
Postural Stress Test
Shoulder Tap Test
Sensory manipulation Clinical Test of Sensory Integration Sensory-Oriented Mobility Assessment
or perturbation and Balance Instrument

Classifying balance tests in this way highlights some performance and hence balance may be seen in
of the biomechanical differences in balance control avoidance strategies such as walking around an
involved in perturbed and non-perturbed activities. It obstacle, running to avoid an oncoming car or
should be noted that some tests do not fall entirely in increasing stride to step over a puddle. In detailing the
one class because they have a number of components, roles of vision for locomotor control, Patla recognises
eg Berg Balance Scale (BBS) (Berg et al 1989) and the importance of environmental context in balance
Performance-Oriented Assessment (B-POMA) control during walking (Patla 1997) and suggests that
(Tinetti 1986). However, this classification has balance is achieved via two main essentials. The first
significant limitations because it fails to recognise and more major essential utilises two types of learned
that the environmental context of a task will influence proactive mechanisms to reduce or counteract
its biomechanical parameters. It further neglects the stresses acting on the body. The second essential
role played by the amount of information to be consists of largely automatic reactive mechanisms
processed from the task itself, and from its that respond to failures of proactive components or to
environmental context. unexpected external perturbation.

How environmental context influences the The first category of proactive balance mechanisms
biomechanical parameters of balance The is based on the visual system. Information about
environmental context of a task can alter its environmental conditions and changes is constantly
biomechanical parameters in two ways (Patla 1997). received through the eyes and interpreted in the light
Walking patterns are likely to demonstrate different of experience for its impact on stability (Patla 1997).
kinematics and kinetics to accommodate to walking Thus we step around or over perceived obstacles,
on sand, in water or over slippery surfaces. The size or reduce our walking speed if the surface appears to be
compliance of the support surface in standing has slippery, and maintain a higher degree of alertness in
been demonstrated to alter the balance strategies used potentially hazardous situations such as rough terrain
(Nashner 1989) and the ability to stand independently or cluttered areas. These appropriate adjustments
(Cohen et al 1993). generally prevent the need to recover from the
stronger forces that would be imposed by a stumble,
The second type of environmental effect on motor slip or trip.

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Huxham et al: Theoretical considerations in balance assessment

As well as visually-based proactive balance control minor perturbation frequently requires only the
evaluating the external environment, a second form of response of an ankle strategy, a distal-to-proximal
proactive control considers the forces acting on and synergy of either anterior lower limb muscles for
within the body. Sometimes referred to as predictive posterior destabilisation or posterior limb muscles for
balance control, this maintains intersegmental anterior destabilisation. Stronger perturbation or a
stability within the body and between the body and narrow support surface may require a hip strategy in
the support surface (Patla 1995). It is dependent upon which much larger multi-joint movements are used to
an accurate internal representation of the body and a bring the COM back within the BOS (Nashner 1989).
learned awareness of how any movement or muscle It was believed that a step strategy, in which the BOS
action will alter these relationships (Nashner 1989). is actually shifted by taking a step away from the
perturbation, only occurred with very marked
Predictive control of the forces acting on the body is instability or strong perturbation. However earlier
largely achieved by anticipatory postural adjustments works describing these responses had actually
(Patla 1995). These patterns of muscle activity constrained the foot position, either implicitly or
commence prior to most voluntary or focal explicitly. Recent research suggests that a step
movements (Massion and Woollacott 1996). The type strategy may often be preferred for even minor
and magnitude of anticipatory postural adjustments perturbation (Maki and McIlroy 1997).
are determined by the direction and speed of focal
movement (Aruin and Latash 1996). The initial In summary, the biomechanical demands on balance
response is not based on sensory input but rather on are a product of factors relating to the motor task
what experience has taught will be the amount and itself and to aspects of its environmental context. The
direction of destabilisation produced by the focal normal balance system is believed to meet these
movement (Patla 1995). Other postural varied demands by a mixture of proactive visual and
accompaniments (Frank and Earl 1990) or reactional predictive mechanisms, with reactive processes
adjustments (Bouisset and Zattara 1987) act to playing an important role when proactive ones fail or
reinforce the anticipatory postural adjustments perturbation is unexpected.
accompanying and following on the voluntary
movement. Unlike anticipatory postural adjustment,
they utilise somatosensory and kinaesthetic input to It is apparent from Table 2 that the vital proactive
guide the extent and type of their actions, thereby balance mechanisms used to navigate and plan to
compensating for any inadequacies in anticipatory avoid obstacles are scarcely assessed. This suggests
control. They act both to steady body parts for that the tests listed are likely to be limited in their
movement and to stabilise the body against gravity ability to predict how well people will perform in the
(Massion 1992). In walking, the anticipatory postural world outside the physiotherapy department. As
adjustments include the commencement of COM emphasised by Patla, stability is particularly
movement towards the new BOS provided by the new maintained by accommodating to or avoiding
stance leg before the swing leg is moved (Massion potential stresses, with reactive mechanisms
1992). constituting the backup system (Patla 1997).
Although predictive control of forces is assessed by
clinical balance tests that use self-generated
In these ways, the balance system proactively perturbations such as the Berg Balance Scale (BBS)
monitors the external environment and predicts the (Berg et al 1989) and the Dynamic Gait Index
effects of forces generated by voluntary movement on (Shumway-Cook and Woollacott 1995), these require
the body, making the adjustments necessary to little or no use of the visual component of proactive
maintain posture and equilibrium in anticipation of balance control. Two tests do include this component
need. It is only when these adjustments fail or an to some extent by requiring the subject to plan a
unexpected destabilisation occurs that the emergency course and to traverse surfaces of different
back-up system of reactive balance responses is compliance. The Functional Obstacle Course (FOC)
called in for crisis management (Patla 1995). (Means et al 1996) includes obstacles to be stepped
over or around, necessitating visual evaluation of the
Reactive balance control consists of both short and size and location of the obstacles and planning of how
long latency postural reflexes of a type appropriate to best to negotiate them. The Sensory-Oriented
the particular stimulus (Nashner 1980). In standing, Mobility Assessment Instrument (SOMAI) course

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Huxham et al: Theoretical considerations in balance assessment

(Tang et al 1998) is repeated a second time with light of experience to establish its importance or
peripheral vision occluded by goggles. This relevance and an appropriate motor response
challenges and assesses the person’s ability to use including balance reactions be selected and
other sensory modalities to compensate for reduced implemented. Importantly, the capacity of the central
vision. Although both tests represent advances in the processing regions is not infinite. This is
use of vision for proactive balance, the environments demonstrated by reduced performance of secondary
in which they are performed are still static and so the tasks shown by dual-task paradigms (Abernethy
degree of challenge for visual proactive control is less 1988). Further limitations may appear with ageing
than in open and dynamic situations such as a (Chen et al 1996) or pathology (Morris et al 1995).
crowded supermarket. Conditions such as those in a
supermarket are more complex because of both the Balance control, although performed at an
amount and changing nature of sensory information unconscious level, is not a fully automatic process
present. It is probable that failure to recognise the (Ebersbach et al 1995, Teasdale et al 1993). The level
impact of this on the balance control system of attention required to maintain postural control in a
contributes to the limited predictive ability of balance challenging position increases from sitting to
tests. standing to walking and in the elderly (Chen et al
1996, LaJoie et al 1996, Teasdale et al 1993) and in
Having discussed how the task and the environment those with a history of falls (Shumway-Cook et al
affect the biomechanical aspects of balance control, 1997b). Older people also choose to respond to a
consideration will now be given to how the need to secondary auditory task at the more stable initial
process information from these areas also impacts on contact phase of the gait cycle, unlike young subjects
the control of balance. who respond close to the stimulus regardless of the
phase (LaJoie et al 1996). It is therefore important to
Information processing aspects of consider other competing processing demands of the
environment when analysing the ability of an
balance control
individual to balance effectively.

In order to meet the biomechanical challenges of task Environmental influences on information


and environment, the balance mechanism requires processing for balance control The amount of
adequate sensory input, efficient central processing information processing required depends on the
and a strong effector system of muscles and joints complexity of the environment and whether it
(Horak et al 1989). A redundancy of sensory changes throughout the activity. Walking along a
information is normally available. Visual information carpeted, well-lit and empty corridor requires less
about the near and far environment allows us processing than walking in a similar corridor filled
proactively to avoid obstacles (Patla 1997). Visual with chairs and pillars, and with several different
information from the environment combines with floor surfaces. Despite greater initial processing
memory in a process called cognitive-spatial mapping demand in the second condition, the information
to enable us to plan a route to places out of sight present is stable over time and allows monitoring to
(Patla 1997). Peripheral visual information about reduce during task performance. This means the
limb position assists obstacle clearance (Patla 1997). attentional demand of a task in such stable or closed
Finally, optic flow, information from peripheral vision environments reduces (Gentile 1987). Furthermore,
as we move, tells us about our movement in walking because the surroundings are fixed, the motor activity
(Patla 1997). In addition, vestibular information does not have to fit in with external timing but can be
concerning our relationship with vertical, and done at preferred speed.
proprioceptive and somatosensory messages detailing
the relative positions of our body parts to themselves
and the support surface make up the sensory input to However, most environments comprise both fixed and
the balance control mechanism. varying elements. If the above-mentioned empty
corridor were to fill with a number of people walking
towards the subject, information processing demand
This wealth of sensory information streams into the would increase enormously. In order to prevent
central processing regions of the central nervous collisions, the subject must now calculate other
system. Here it must be integrated and weighted in people’s paths and plan their own to avoid them. It is

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Huxham et al: Theoretical considerations in balance assessment

Table 2. Ability of some balance tests to recognise constraints from task and environmental context.

Balance test Task conditions Environmental conditions Balance mechanisms used


Berg Balance Scale closed simple and stable predictive; some use of vision proactively to
locate object to pick up
Clinical Test of closed simple and stable predictive
Sensory Integration (items 1 & 2)
and Balance simple and active
(items 3-6)
Dynamic Gait Index closed simple and stable proactive to locate stairs and obstacles;
predictive
Functional Reach closed simple and stable some use of vision; mainly predictive
Functional Obstacle closed complex but stable proactive to evaluate obstacles and surface
Course changes; predictive
Performance-Oriented closed simple and stable mainly predictive; proactive to locate object to
Assessment – balance pick up; one item tests reactive balance
and mobility
Reach Test closed simple and stable some use of vision; mainly predictive; repetitive
timed nature of reach increases degree of
challenge relative to Functional Reach test.
Sensory-Oriented closed complex but stable within proactive to evaluate obstacle and surface
Mobility Assessment trials; visual condition changes; predictive
Instrument changes between trials
Step Test closed simple and stable some use of vision; mainly predictive
10 metre walk closed simple and stable predictive
Timed standing closed simple and stable predictive

probable that such complex central calculations Task influences on information processing for
distract attention from maintaining balance. This may balance control The central processing area handles
be seen clinically when stroke patients undergoing complex information not only from the environmental
rehabilitation can walk in a quiet and closed context but also from the task itself. Like
environment but lose their balance if distracted. Not environments, complicated tasks require more
only is more attention required but the ongoing nature information processing than simple ones. As with
of path calculations and predictions means the closed environments, closed tasks whose
demand on central processing does not decrease characteristics do not change from one trial to another
(Gentile 1987). Thus open contexts changing in time require less information processing with practice
differ markedly from stable or fixed environments, (Gentile 1987). The intimate relationship between
however complex. task and environment that occurs when the task must
be timed to environmental factors has been noted
above. When performance depends on external
Many activities depend even more intimately on the timing, demand for central processing increases
environment for their performance. These are tasks in because success depends on predicting future spatial
which the timing of the task is directly linked to the relationships of, for example, a bat and a ball or the
environment, such as catching a ball, moving about hand reaching for a suitcase on a revolving carousel
on a crowded bus or stepping onto an escalator. The (Gentile 1987).
timing constraint requires more complex calculations
and predictions and further increases the central In summary, the need to process information related
processing load. to task and environment may compete for limited

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Huxham et al: Theoretical considerations in balance assessment

central resources and hence impact adversely on changing aspects of the environmental context or the
balance control. Frail elderly or patient groups may be task, the motor skill that develops is more flexible and
unable to walk and concurrently talk or carry objects generative in type (Gentile 1987). Generative motor
without impairing their balance (Lundin-Olsson et al skill learning resembles a kind of motor problem
1997, Morris and Iansek 1997). Similarly, they may solving ability. The difference between the two types
be unable to manage in new or dynamic of skill learning is particularly significant clinically.
environments. Externally paced activities, dual task As balance is a flexible and varying integral of all
performance and complex or changing environments movement, it would seem appropriate that it should be
provide greater challenge in information processing. retrained in a generative manner. For example,
practice for a stroke patient reaching to a target to
Understanding the biomechanical and information improve balance can be broadened by changes in
processing demands imposed by task and speed, instruction, support surface compliance, hand
environmental context allows us to evaluate their position, foot configuration and target size, shape and
probable impact on motor performance and balance. position. These changes incorporate different
Applying Gentile’s framework of task and biomechanical and information processing
environmental demands (Gentile 1987) to some components of task and environment. The benefit of
existing balance tests helps to evaluate their strengths varied balance practice has been demonstrated in a
and limitations (see Table 2). Utilising this model, randomised controlled study of training sitting
Table 2 provides a more comprehensive method of balance in chronic stroke (Dean and Shepherd 1997).
classifying balance tests. It can be seen that although Subjects who were challenged by varied reaching
several of the tests include more complex tasks showed improvement in not only sitting balance
environments (eg FOC (Means et al 1996), SOMAI but also sit-to-stand, an action with a similar
(Tang et al 1998)), there are as yet no methods that biomechanical component. These results demonstrate
include moving or open environments. It appears the ability of balance skills gained through flexible
likely that our current inability to evaluate this highest practice to generalise to other activities.
level of balance objectively contributes to the poor
predictive value of available tests. Unless or until Conclusion
some test can incorporate open environments,
clinicians should be aware that the balance
assessments they are using for objective measurement The inextricability of balance, function and the
have limitations. As clinical assessment is a tool for environment has been clearly demonstrated in recent
treatment and not an end in itself, this knowledge years. Physiotherapists frequently assess and treat
reinforces the need to practise mobility in open people unable to maintain adequate stability for all
environments. Examples of open tasks in an active the goal-directed motor tasks of a normal active life.
environment include: pushing a loaded trolley in the The original taxonomy of tasks (Gentile 1987)
supermarket; pulling different coins out of a purse provides a structure to examine the complexity of
while crossing the road; walking while having a these tasks and criteria for normal balance
conversation and putting on sunglasses. performance. Some common balance measures have
been evaluated as examples of using these criteria.
Type of practice affects motor learning Consideration of these criteria during assessment will
help the clinician establish the functional level of
patients’ balance and guide treatment to maximise
Assessment, as stated, is only a component of functional recovery.
treatment. As well as the biomechanical and
information processing aspects of task performance,
another aspect of task has important implications for Authors Frances Huxham, Geriatric Research Unit,
treatment - the manner in which it is learnt. Practice Kingston Centre, Cheltenham, Victoria 3192. E-mail:
type affects motor learning (Gentile 1987). If each f.huxham@southernhealth.org.au (for corres-
trial is practised in the same way, the resulting skill, pondence). Patricia Goldie, School of Physiotherapy,
probably with its underlying balance adjustments, La Trobe University, Bundoora, Victoria 3083. Aftab
will be fine-tuned to a single skilled production and Patla, Professor, Department of Kinesiology,
motor learning of a reproductive nature will occur University of Waterloo, Waterloo, Ontario N2L3G1,
(Gentile 1987). However, when practice is varied by Canada.

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Huxham et al: Theoretical considerations in balance assessment

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Pastor M, Day B and Marsden C (1993): Vestibular induced Winter DA (1995b): Human balance and posture control
postural responses in Parkinson’s Disease. Brain during standing and walking. Gait and Posture
116: 1177-1182. 3: 193-214.
Patla AE (1995): A framework for understanding mobility Wolfson LI, Whipple R, Amerman P and Kleinberg A (1986):
problems in the elderly. In Craik RL and Oatis CA (Eds): Stressing the postural response - a quantitative method
Gait Analysis: Theory and Application. St Louis: Mosby, for testing balance. Journal of the American Geriatrics
pp. 436-449. Society 34: 845-850.
Patla AE (1997): Understanding the roles of vision in the Woollacott MH and Tang P-F (1997): Balance control during
control of human locomotion. Gait and Posture 5: 54-69. walking in the older adult: research and its implications.
Patla AE and Prentice SD (1995): The role of active forces Physical Therapy 77: 646-660.
and intersegmental dynamics in the control of limb
trajectory over obstacles during locomotion in humans.
Experimental Brain Research 106: 499-504. Appendix
Podsiadlo D and Richardson S (1991): The timed “Up &
Go”: a test of basic functional mobility for frail elderly
persons. Journal of the American Geriatrics Society Listed below are many of the methods of assessing
39: 142-148. balance commonly used in the clinics, with brief
Riddle DL and Stratford PW (1999): Interpreting validity descriptions of how they are performed and scored.
indexes for diagnostic tests: An illustration using the Berg
Balance Test. Physical Therapy 79: 939-948. Berg Balance Scale (BBS) (Berg et al 1989)
Shumway-Cook A and Horak FB (1986): Assessing the
influence of sensory interaction on balance: suggestions Task: There are 14 items performed in standing and
from the field. Physical Therapy 66: 1548-1550. graded from 0 (unable) to 4 (independent), with a
Shumway-Cook A and Woollacott M (1995): Assessment maximum score of 56. Items are: sitting unsupported;
and treatment of the patient with mobility disorders. In rising from and sitting down in a chair; transfer from
Shumway-Cook A and Woollacott M (Eds): Motor Control: chair to chair; standing unsupported; standing eyes
Theory and Practical Applications. Baltimore: Williams
and Wilkins, pp. 315-318. closed; standing feet together; tandem standing;
single leg stand; turning trunk with feet flexed and
Shumway-Cook A, Baldwin M, Polissar NL and Gruber W
(1997a): Predicting the probability for falls in community also turning 360 degrees; picking up an object off the
dwelling older adults. Physical Therapy 77: 812-819. floor; stepping one foot up and down off a step and a
Shumway-Cook A, Woollacott M, Kerns KA and Baldwin M forward reach. The scale has sensitivities of 53%
(1997b): The effects of two types of cognitive tasks on (Thorbahn and Newton 1996) and 91% when used
postural stability in older adults with and without a history with history of imbalance (Shumway-Cook et al
of falls. Journal of Gerontology: Medical Sciences 1997a).
52A: M232-240.
Tang P-F, Moore S and Woollacott MH (1998): Correlation Clinical Test of Sensory Integration and Balance
between two clinical balance measures in older adults:
functional mobility and sensory organization test. Journal (CTSIB) (Shumway-Cook and Horak 1986)
of Gerontology: Medical Sciences 53A: M140-M146. Task: The subject is tested for ability to stand still
Teasdale N, Bard C, LaRue J and Fleury M (1993): On the under six permutations of sensory input so that the
cognitive penetrability of posture control. Experimental capacity to compensate for missing or misleading
Aging Research 19: 1-13.
input can be assessed. The conditions are: eyes open,
Thorbahn LD and Newton RA (1996): Use of the Berg firm surface; eyes closed, firm surface; eyes open but
Balance Test to predict falls in elderly persons. Physical
Therapy 76: 576-583. visual conflict provided through a hood, on firm
Tinetti ME (1986): Performance-oriented assessment of
surface; eyes open, compliant surface; eyes closed,
mobility problems in elderly patients. Journal of the compliant surface; visual conflict, compliant surface.
American Geriatrics Society 34: 119-126. Subjects are timed to a maximum of 30 seconds in
Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, each condition.
Rubenstein LZ and Garry PJ (1997): One-leg balance is
an important predictor of injurious falls in older persons. Dynamic Gait Index (DGI) (Shumway-Cook and
Journal of the American Geriatrics Society 45: 735-738. Woollacott 1995)
Winter DA (1991): The Biomechanics and Motor Control of
Human Gait: Normal, Elderly and Pathological. (2nd ed.)
Task: The subject is asked to walk continuously on a
Waterloo, Ontario: University of Waterloo Press, pp. 75-85. level surface. Self-initiated perturbations are
Winter DA (1995a): ABC (Anatomy, Biomechanics and performed on command approximately every five feet
Control) of Balance During Standing and Walking. as follows: walk normally; walk fast; walk slowly;
Waterloo, Ontario: Waterloo Biomechanics, pp. 41-53. walk with head turns from side to side; then neck

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Huxham et al: Theoretical considerations in balance assessment

flexion/extension; walk and then pivot turn and stop; response (2 points) or abnormally (3 points). Thus the
walk and step over a shoebox and ‘slalom’ around two score for a completely normal performance is 13 and
cones. The final item is assessment of walking up and higher scores represent poorer balance. The items are:
down stairs. All items are scored from 1 (severely sitting balance; rising from a chair; immediate
affected) to 3 (normal), to a total of 24 points. Clear standing balance; standing balance with feet together
definitions are given for scoring each item. eyes open and then eyes closed; ability to turn 360
Discriminates between fallers and non-fallers but degrees on the spot and withstand a nudge on the
predictive ability not known. sternum; head turning with feet together; single leg
balance; back extension; reaching up and bending
Functional Obstacle Course (FOC) (Means et al down and sitting down.
1996)
Performance-Oriented Mobility Assessment – gait
Task: The FOC involves walking at preferred speed
(M-POMA) (Tinetti 1986)
and with an aid, if normally used, over four different
surfaces (artificial turf, shagpile carpet, pinebark and Task: The mobility section of Tinetti’s problem-
sand) up and down a standard 1:12 ramp and up and oriented assessment is a qualitative evaluation of
down two sets of steps. One set of steps has 7.6cm mainly unperturbed walking. The subject walks at
risers and the other 15.2cm risers. Subjects must also preferred pace with a walking aid, if used, while the
rise from a soft, armless chair, open a door, perform a examiner observes the gait for nine qualities:
slalom course around eight large plastic cones initiation of gait; step height; step length; step
without stepping outside a boundary line and step symmetry; step continuity; path deviation; trunk
over three cylindrical bolsters of 10.2, 15.2 and 20.3 stability; walk stance and turning while walking.
cm diameter. These are aligned parallel and 61cm Scores are 1 for normal and 2 for abnormal or
apart. Subjects cover approximately 106m in the test compensatory and the criteria for scoring are clearly
and are timed for the whole test. Qualitative defined.
assessments are also made of each of the 12
component manoeuvres, following clear guidelines. Postural Stress Test (PST) (Wolfson et al 1986)
Each item is scored 0 (unable or refuses) to 3 (smooth Task: The subject stands with feet apart wearing a
motion and no assistance from neighbouring support padded waistband that is attached at the back to a
or person). Shown to discriminate between fallers and wall-mounted pulley system, such as found in most
non-fallers but predictive ability not assessed. physiotherapy departments. An unexpected backward
perturbation is applied by one of a graded series of
Functional Reach (FR) (Duncan et al 1990) weights standardised to a percentage of body weight.
Task: In comfortable barefoot stance, the subject is The weight is applied abruptly. Results consider not
asked to raise the right arm, fist closed, to only the weight used but the resultant strategy used by
approximately 90 degrees and then to reach forwards the patient. Able to discriminate between fallers and
as far as possible without losing balance or moving non-fallers but predictive ability not investigated.
the feet. The distance between the position of the third
metacarpal in each position is the Functional Reach. Reach Test (Goldie et al 1990)
Reduced ability to reach has shown increases in Task: Developed for hemiplegic subjects, this test
future falls with odds ratios of 8.2 if unable to reach requires that the subject repetitively reaches from a
at all and 4 if able to reach < 15.2cm (Duncan et al target close to the ipsilateral greater trochanter to
1992). touch a second target positioned at waist level in front
of the opposite hip. This second target is placed 15cm
Performance-Oriented Mobility Assessment – beyond the length of the extended arm. The number of
balance (B-POMA) (Tinetti 1986) repetitions achieved in 60 seconds constitutes the
Task: Tinetti’s original performance-oriented score.
assessment has both a balance and mobility or gait
section. However, as some projects use the sections Sensory-Oriented Mobility Assessment
separately, they will be discussed separately here. The Instrument (SOMAI) (Tang et al 1998)
balance section examines the ability of subjects in 13 Task: The SOMAI incorporates the following
tasks and requires a judgment as to whether they are mobility items: rise from chair; unperturbed walk;
performed normally (1 point), using an adaptive reach high to remove a piece of tape off the wall and

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Huxham et al: Theoretical considerations in balance assessment

then low to place it on the wall at knee level; turn 180 Step Test (Hill et al 1996)
degrees and walk along a carpeted walkway which Task: The subject stands on one leg then steps the
incorporates two foam cushions underlying it and other on then off a 7.5cm block placed 5cm in front of
return to the chair. The SOMAI is performed twice, the feet, as many times as possible in 15 seconds. The
once with normal vision and once with peripheral task is then repeated using the other leg.
vision occluded. Performance on each component is
qualitatively evaluated and rated from 0 (normal) to 3 Timed standing with the feet in different
(required assistance for safety), consequently a configurations (Bohannon et al 1984)
perfect score would be 0. The test is not timed. Ability Task: The task difficulty progresses from standing
to discriminate or predict fallers not investigated. with feet apart through feet together, step stance and
tandem stance to single leg stance. Each position is
Shoulder Tap Test (Pastor et al 1993) timed, usually to a maximum of 30 seconds. The one
legged stance component has shown a positive
Task: The subject stands facing away from the predictive value for injurious falls of 31% (Vellas et al
examiner, who advises: “I am going to tap you 1997).
backwards; I won’t let you fall” and then applies a
quick tug to both shoulders of sufficient force to Timed ‘Up and Go’ (TUG) (Podsiadlo and
destabilise the subject. The test is graded according to Richardson 1991)
whether an ankle strategy, a step response or no Task: On the command “Go”, the subject rises from
postural response (‘plank’ reaction) is evoked. Failed a standard chair, walks three metres, turns and walks
to discriminate people with Parkinson’s disease who back to the chair. Timing starts when the command is
fell from those who did not (Bloem et al 1998). given and ceases when the subject is again sitting in
the chair.

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