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1. Balance Tests and Measures in Physical Therapy Steven Ferro, SPT JSUMC Rutgers University Physical Therapy- South Presentation Date: 2/19/15

2. Objectives Introduction to Balance Types of Balance Scales: Functional: Four Square Step Test (FSST ) Timed Up & Go (TUG ) Pediatric Balance Scale (PBS ) Subjective Activities-Specific Balance Confidence Scale (ABCs) Dizziness Handicap Inventory (DHI )

3. Balance Falls occur in 30% of people over the age of 65 each year and balance is a critical modifiable risk factor for falls (Gervais et al., 2014 ). The control of your COG over your BOS. Somatosensation (CVA, Neuropathy) Vision (poor eyesight) Vestibular System (BPPV) Musculoskeletal system (Strains, Sprains, Joint Replacements)

4. What Makes U p B alance? (Kisner et al., 2012)

5. Balance Balance can also be affected by: Dehydration (vestibular system) Nutrition Medications (Polypharmacy) Benzodiazepines Antidepressants Hypnotics Diuretics

6. Lacking a “Gold Standard” T est ? Components of Balance (Gervais et al., 2014) Control of dynamics (COG within BOS with walking) Biomechanical constraints (ROM, strength, endurance) Static stability (COG within BOS static) Reactive movement (ability to regain control) Anticipatory movement (COG adjustment before movement) Cognitive Processing (Subjective) Sensory (visual, vestibular, somatosensory) Orientation in space (Processing of sensory inputs)

7. Test Types Test Types Examples Self-perception Scales ABC DHI Sensory manipulation (surface, visual conditions Clinical Test of Sensory Interaction and Balance (Foam and Dome) Motor Components FSST Multidimensional Assessment Berg PBS Gait Assessment TUG

8. Four Square Step Test (FSST) Measures forward, backward, and lateral mobility. Demonstrates the patient’s ability to shift their weight quickly. The FSST involves stepping over 4 canes that are laid on the ground at 90° angles (forming a plus sign). Each cane is to be 90cm in length (Whitney et al., 2007 ). One practice trial and two timed trials Start timer when first foot reaches box 2 and finishes when last foot contacts box 1 when coming back.

9. Four Square Step Test (FSST) Cut off score is >15 seconds Sensitivity : 89% (Whitney et al., 2007) Sensitivity : 85% (Kisner et al., 2012) Percent of fallers correctly identified by the test. Specificity : 85% (Whitney et al., 2007) Specificity : 88% (Kisner et al., 2012) Percentage of non-fallers correctly identified by the test. Interrater Reliability : r=.99 (Whitney et al., 2007 ) **Multiple Raters.

10. Four Square Step Test (FSST) “Try to complete the sequence as fast as possible without touching the lines.” “Both feet must make contact with the floor in each square and face forward during the entire sequence.” Sequence: 2, 3, 4, 1, 4, 3, 2, and 1. ( Whitney et al., 2007)

11. Timed Up & Go (TUG) Stand up from a chair (seat height 46cm, arm height 67cm) and walk 9.8ft (3 meters), turn around and walk back. (Podsiadlo, 1991 ) Patient is to complete the test 4 times with 2-4 recorded (1 practice). Transfers, gait, neuromuscular mobility. Timer starts when the administer says “Go” and stopped when the patient’s pelvis touches the chair.

12. Timed Up & Go (TUG) Cut off reported between 11-13.5 seconds while walking as fast as possible (Schoene et al., 2013 ) A cut off of 13 seconds (>13) was associated with: Sensitivity : 87% (Kisner et al., 2012 ) Percent of fallers correctly identified by the test Specificity : 87% (Kisner et al., 2012 ) Percentage of non-fallers correctly identified by the test. G ood correlation between TUG and BBS r = 0.81 (Cattaneo et al., 2006)

13. Timed Up & Go (TUG) (O'Sullivan & Schmitz, 2007) Definitions Inter-rater : 2 or more raters Intra-rater : same rater Concurrent Val : compared at the same point and time to a gold standard

14. Timed Up & Go (TUG) Things to Consider: Gervais et al. reports that although the TUG is described as a measure of balance, the use of a gait aid reduces its balance demands . The patient’s upper extremities should not start on the assistive device, however, the device is to be close to the patient for use. (Podsiadlo, 1991)

15. Pediatric Balance Scale (PBS) Development of balance begins in infancy with the establishment of head and trunk control. By 12 months, most infants are mastering standing and walking (Franjoine et al., 2010 ). Posture Increased BMI Muscle Strength Sensory

16. Pediatric Balance Scale (PBS) Modified Berg Scale 14 item test used to examine balance in pediatric patients Can be administered in less than 20 minutes (Franjoine et al., 2010 ) Instructions: Demonstrate task to the child Test is scored on a scale of 0-56, with 56 being least impaired and 0 being the most impaired. Each item is scored on a 0-4 scale Scores are based upon the lowest criteria, which describes the patient’s best performance ( Franjoine et al., 2003 ).

17. Pediatric Balance Scale (PBS) Referenced from Franjoine et al., 2003: Points are deducted if: Time is not met Distance requirements are not met Subject requires supervision Receives assistance from the examiner If the subject touches an external support Equipment needed listed in supplement** Optional items that may help during test include: Footprints Flash cards Etc.

18. Pediatric Balance Scale (PBS) (Franjoine et al., 2003)

19. Pediatric Balance Scale (PBS ) vs. Berg (Franjoine et al., 2003 )

20. Pediatric Balance Scale (PBS) Additional Points (Franjoine et al., 2003 ): On the first trial if the patient scores a 4, then additional trials are not needed If the task asks the patient to use one extremity it is up to the subject to decide. Poor judgment negatively influences scoring. For questions 4, 5, 6, 7, 8, 9, 10, & 13 recording time in seconds is optional. Things to consider: It is difficult to interpret whether changes are clinically meaningful, or simply due to maturation. Age cut off between PBS vs. Berg?

21. Changes Due to M aturation? Franjoine et al., 2010: N=643 children administered PBS

22. Pediatric Balance Scale (PBS) Evidence : Reported by Franjoine et al., 2010: Inter-rater Reliability :0.972 (2 or more raters) Intra-rater Reliability: 0.895-0.998 (same rater)

23. Subjective Measures The fear of falling is a major concern for many patients. Assesses cognitive processing abilities and reactive control components of balance (Gervais et al., 2014) Consider the following: Perceives a balance deficit  decrease in activity sedentary decreased ROM, decreased endurance, decreased strength unable to do the things they used to social isolation, depression.

24. Activities-Specific Balance Confidence Scale (ABC) Self report tool used to gather information about the patient’s confidence with performing various activities. 16-items Percentages are added and divided by 16 to give an overall confidence % 0%=no confidence 100%=completely confident

25. Activities -Specific Balance Confidence Scale (ABC) N=51 patients with multiple sclerosis, using a cut off score of >40% demonstrated a sensitivity of 65% and a specificity of 77% (Cattaneo et al., 2006). Less than 67%= increased fall risk (Kisner et. al., 2012) Things to consider: Some items on the ABC may not be applicable to patients, and they may not be able to rate their confidence. Ex: Individuals may be from a sunny climate and may not have experienced walking on an icy surface in recent years (Holbein-Jenny et al., 2005).

26. The Dizziness Handicap Inventory (DHI) A 25-question self assessment measure of the functional, emotional, and physical effects of dizziness and unsteadiness in individuals >19 years of age (Yorke et al., 2013 ). Graded on a scale of 0-100, with greater scores indicating a greater perception of handicap due to dizziness. Functional (36 points) Emotional (36 points) Physical (28 points) Useful instrument to document the patient perceived consequences of vestibular and/or balance impairments (Vereeck et al., 2007 ) Vestibular disorders most appropriate

27. The Dizziness Handicap Inventory (DHI) Scores assigned to each item: No=0 Sometimes=2 Yes=4 Reported by Yorke et al., 2013: MCID: 18 points MDC: 17.18 SEM: 6.23 Excellent correlation with the ABC Excellent test-retest reliability for vestibular dysfunction

28. The Dizziness Handicap Inventory (DHI) Cattaneo et al. reports a specific t est-retest reliability=0.97 The following reported by Vereeck et al., 2007: Internal Consistency : The extent of which items on measure, measure the same characteristic (perceived dizziness). Functional: 0.85 Emotional: 0.72 Physical: 0.78 DHI Total: 0.89

29. The Dizziness Handicap Inventory (DHI) Scores >10 points=balance specialist 16-34 points=Mild handicap 36-52 points= Moderate handicap 54+ points=Severe handicap

30. Summary Balance has multiple components: Control of dynamics Static stability Reactive movement Cognitive Processing Sensory What is the best test for your patient? What are you measuring? Consider all systems Base interventions off measures that are specific to the patient.

31. Summary: Make Interventions Specific to Patient

32. Summary (Kisner et al., 2012)

33. Questions? Steven Ferro, SPT Email: [email protected] Thank you!

34. References Cattaneo , D., Regola, A., & Meotti, M. (2006). Validity of six balance disorders scales in persons with multiple sclerosis. Disabil Rehabil, 28 (12), 789- 795. Whitney, S. L., Marchetti, G. F., Morris, L. O., & Sparto, P. J. (2007). The reliability and validity of the Four Square Step Test for people with balance deficits secondary to a vestibular disorder. Arch Phys Med Rehabil, 88 (1), 99- 104. Yorke, A., Ward, I., Vora, S., Combs, S., & Keller-Johnson, T. (2013). Measurement Characteristics and Clinical Utility of the Dizziness Handicap Inventory Among Individuals With Vestibular Disorders. Arch Phys Med Rehabil, 94 (11), 2313-2314 . Holbein-Jenny, M. A., Billek-Sawhney, B., Beckman, E., & Smith, T. (2005). Balance in Personal Care Home Residents: A Comparison of the Berg Balance Scale, the Multi‐Directional Reach Test, and the Activities‐Specific Balance Confidence Scale. Journal of Geriatric Physical Therapy, 28(2), 48-53 . Schoene, D., Wu, S. M., Mikolaizak, A. S., Menant, J. C., Smith, S. T., Delbaere, K., & Lord, S. R. (2013). Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis. J Am Geriatr Soc, 61 (2), 202-208. O'Sullivan, S. B., Schmitz, T. J. , (2007). Physical Rehabilitation (5 ed.): F.A. Davis . Vereeck, L., Truijen, S., Wuyts, F. L., & Van De Heyning, P. H. (2007). Internal consistency and factor analysis of the Dutch version of the Dizziness Handicap Inventory. Acta Otolaryngol, 127 (8), 788-795.

35. References Tiedemann, A., Shimada, H., Sherrington, C., Murray, S., & Lord, S. (2008). The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing, 37 (4), 430-435 . Gervais, T., Burling, N., Krull, J., Lugg, C., Lung, M., Straus, S., . . . Sibley, K. M. (2014). Understanding approaches to balance assessment in physical therapy practice for elderly inpatients of a rehabilitation hospital. Physiother Can, 66 (1), 6-14 . Franjoine, M. R., Darr, N., Held, S. L., Kott, K., & Young, B. L. (2010). The performance of children developing typically on the pediatric balance scale. Pediatr Phys Ther, 22 (4), 350-359. Franjoine, M. R., Gunther, J. S., & Taylor, M. J. (2003). Pediatric balance scale: a modified version of the berg balance scale for the school-age child with mild to moderate motor impairment. Pediatr Phys Ther, 15 (2), 114-128. Umphred, D. et al (2013) Neurological Rehabilitation. (6 th Edition) Elsevier. Podsiadlo, D. and Richardson, S. (1991). "The timed "Up & Go": a test of basic functional mobility for frail elderly persons." J Am Geriatr Soc, 39(2), 142-148 . Kisner, C., Colby, L. A. (2012). Therapeutic Exercise (6 th Edition.) F.A . Davis Company . Lewis, C. B., Bottomley, J. M. . (2007). Geriatric Rehabilitation: A Clinical Approach (3rd ed. ) Prentice Hall .