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Better Balance

Posted on June 27, 2017 by

Want to know more about balance and how to improve it? Check out this balance inservice article and learn ways to assess your balance and reduce the risk of falls through various exercises.



Evaluation and

Treatment of Balance Inservice

What is Balance?

  • A state of equilibrium
  • Always changing, dynamic
  • Coordination and stability of the body in space
  • Normal balance depends on information from the vestibular system in the inner ear, sight, touch, proprioception, muscles, and from the integration of sensory data by the cerebellum


Causes of Falls/Loss of Balance

There are many different reasons why a person could lose their balance and fall down.  Here are a few reasons:

  • Weakness
  • Decreased vision/hearing
  • Impaired reaction time
  • Temperature changes
  • Neuropathy
  • Medications
  • Environment
  • Low blood pressure
  • Parkinson’s disease, Ménière’s disease
  • Poorly controlled diabetes, epilepsy
  • Brain disorders, stroke
  • Osteoporosis, arthritis, decreased conditioning


Prevalence of Falls

  • One out of three elderly people fall (AAOS, Aging in the Know)
  • More than a third of adults aged 65 years or older fall each year (CDC)
  • 21-61% of elderly people report ‘fear of falling’ (Fear of Falling in the Elderly)
  • Fear of falling affects confidence in performing daily activities, causing self-limitation and a less active lifestyle (Hawk).
  • Direct and indirect costs associated with falls total $75–100 billion in the U.S. annually (Hawk).


Assessing Balance (see attached)


The Berg Balance Scale is mainly used in an in-patient setting, such as hospitals and in-patient rehabilitation clinics.  It assesses balance through 14 items in sitting and standing.  Each item is scored on an ordinal scale (0-4): 0 indicating inability to perform the skill and 4 indicating the ability to perform the skill at the highest level described.  The maximum score is 56.   The items range in difficulty from sitting unsupported for 2 minutes to standing on 1 foot for more than 10 seconds.  It does not include a gait component.



  • 41-56 = low fall risk
  • 21-40 = medium fall risk
  • 0-20 = high fall risk


Tinetti’s Balance and Mobility Assessment is used for higher-level patients and is the most widely used measure of balance and gait.  It includes 8 components of balance and 8 components of gait.  The 8 components of balance are sitting balance, arising from a chair, immediate and prolong standing balance, withstanding a nudge at the sternum, turning 360˚, balance with eyes closed, and sitting down.  The 8 components of gait are initiation, step length, height, and continuity, symmetry, path deviation, trunk sway, and walking stance.



  • ≥ 24 low risk for falls
  • 19-23 moderate risk for falls
  • ≤ 18 high risk for falls    


Timed Up and Go Test (TUG): is a timed walking test (including sit to stand transfer) that is used to assess balance with transitional movements, speed of walking and risk for falls. 



  • <12 seconds = normal
  • >16 seconds = increased fall risk in community dwelling elderly


Timed single leg stance (SLS) has been correlated with amplitude and speed of sway in people without disease.  Single leg stance has been shown to improve over the course of 6 months of rehabilitation.  Rossiter and Wolf found that older adults in the community could maintain SLS for 10 sec about 89% of the time and nursing home residents for 45% of the time.  


Interpretation (Berg Balance Scale)

  • 4= able to lift leg independently and hold › 10 seconds
  • 3 = able to lift leg independently and hold 5-10 seconds
  • 2= able to lift leg independently and hold ≥3 seconds
  • 1 = tries to lift leg unable to hold 3 seconds but remains standing I
  • 0= unable to try and needs assistance to prevent falls


Other Things to Assess

  • Functional Reach
    • Using a yardstick attached to a wall at approximately shoulder height, measure how far a person can reach forward without losing their balance
  • ROM necessary for normal gait (Perry):
    • Dorsiflexion= 10˚
    • Knee Flexion = 60-70˚
    • Hip Flexion= 30-40˚
  • Patient’s home environment (rugs, doorways, etc.)
  • Strength, especially trunk stabilizers and LE muscles (quadriceps, gluteals, hamstrings, gastrocs, tibialis anterior, peroneals)


What’s the Best Way?

There isn’t one!  The Timed Single Leg Stance and The Timed Up and Go are quick and easy to set up and are also repeatable and measurable.  Tinetti’s Balance and Mobility Assessment is a measure that’s widely used for higher-level patients and doesn’t require much set-up.  The Berg Balance Scale is slightly more complicated and requires more set-up but is easy to score.

Perhaps a combination of the assessments or their components would be best, depending on what your patient presents with.


Treatment of Balance Problems/ Fall Prevention

Most of the time, balance problems and falls aren’t due to just one thing, they happen because of a variety of things.

  1. Ask about medications and past/current medical history (Koski)
    • Sedatives: Ambien, Valium
    • Diuretics: Lasix, Lozol, Diuril
    • Psychotropic drugs: Haldol, Lithium, Prozac, Xanax
    • Calcium channel blockers: Diltazium, Cardizem, Dilacor, Tiazac
    • Anti-inflammatory drugs: Advil, Motrin, Aleve, Celebrex

*According to Koski, calcium channel blockers and anti-inflammatory drugs are both associated with slow walking speeds and muscles weakness, in particularly iliopsoas weakness with anti-inflammatory drugs.

  1. Test ROM and strength of lower extremity and trunk
  2. Evaluate (or have a family member, friend or co-worker evaluate) the person’s home/work environment


Strength Training vs. Balance Training:  Study # 1

Effect of intense strength training on standing balance, walking speed, and sit-to-stand performance in older adults

  • 8-week, 3-day/week intense strength training program
  • 24 Subjects aged 61-87
  • Strength Training group: 12 subjects performed 2 sets of 10 , 6 lower body exercises
  • Control Group: 12 subjects had no intervention
  • Tested pre, mid and post- intervention using SLS and 5-rep sit-to- stand (as per Berg Balance Scale)


  • Post intervention strength was significantly better for all 12 strength training subjects  
  • No difference between groups for the SLS or 5-rep sit-to-stand tests
  • Schlicht J, et al.  found that strength training alone does not improve standing balance


Strength Training Combined with Balance Training:  Study #2

A Randomized Control Trial of a General Practice Program of home based exercise to prevent falls in elderly women

  • Control Group: 117 subjects received usual care, no physical therapy  
  • Exercise group: 116 subjects received a physical therapy program
    • Strength training component: ankle cuff weights for
      • Hip extensor and abductor muscles
      • Knee flexor and extensor muscles
      • Quadriceps
      • Ankle plantar and dorsiflexor muscles
    • Balance Training component:
      • Standing with one foot directly in front of the other
      • Walking placing one foot directly in front of the other
      • Walking on the toes and walking on the heels
      • Walking backwards, sideways, and turning around
      • Stepping over an object
      • Bending and picking up an object
      • Stair climbing
      • Rising from a sitting position to a standing one
      • Knee squat
  • Main Outcome Measures:
    • Number of falls and injuries related to falls
    • Time between falls during one year of follow up
    • Changes in muscle strength
    • Balance measures after six months
  • Assessment tests used: Functional Reach, Berg Balance, knee extensor strength, “Chair stand” test (time taken to rise from a chair and return to the seated position five times), time to walk 8 feet, stair climbing (4 steps), distance walked in 6-minutes using AD



  • After 1 year there were 152 falls in the control group and 88 in the exercise group
  • After 6 months balance had improved in the exercise group
  • Campbell J, et al. found that a home exercise program of strength training and balance training improved physical function as well as reduced falls and injuries.




“A Tool Kit to Prevent Senior Falls: The Costs of Fall Injuries Among Older Adults.” National Center for Injury Prevention and Control. 2006. 24 Sept.2006.


Abbruzzese, LD.  The tinetti performance-oriented mobility assessment tool. Am J Nur.  1998:98(12):16J-16L


Campbell  J, Robertson MC, Gardner MM, et al.  A randomized control trial of a general practice programme of home based exercise to prevent falls in elderly women.  BMJ. 1997;315:1065-1069


     Colby, Lynn Allen S, PT and Carolyn Kisner, MS, PT.  Therapeutic Exercise Foundations         

     and Techniques  4th Edition.  Philadelphia: F.A. Davis Company, 2002


“Don’t Let a Fall Be Your Last Trip: Who’s At Risk?” American Academy of Orthopaedic    Surgeons. 2000. 24 Sept. 2006. Thread_ID=74&topcategory=Prevent%20Fall.htm


“Falls.” Aging in the Know. 2005. 24 Sept. 2006. know/chapters_ch_trial.asp?ch=21


Farrell, MK. Using functional assessment and screening tools with frail older adults. T Ger Rehab 2004:20(1):14-20


Gagnon, Nadine, MD, FRCP(C) and Alastair Flint, MB, ChB, CRCP (C), FRANZCP.  Fear of falling in the elderly. Geri & Aging.  July/August2003:6(7)


Hawk C, Hyland JK, Rupert R, Colonvega M. Assessment of balance and risk for falls in a sample of community-dwelling adults aged 65 and older.  Chiropr Osteopat.2006; 14: 3


Koski K, Luukinen H, Laippala P, Kivela S.  Physiological factors and medications as predictors of injurious falls by elderly people: a prospective population-based study.  Age and Ageing 1996;25:29-38


Lusardi, M.M. Berg balance scale.  Jou Geriatric PT, 26(3), 14-22


Perrry, J.  Gait Anaylsis: Normal and Pathological Function.  Accessed at:,M1.  Accessed on December 3, 2007


Schilcht J, et al.  Effect of intense strength training on standing balance, walking speed, and sit-to-stand performance in older adults .  Ger Soc Am. 2001;56:281-286


    “Strength and balance exercises.” Geriatrics. 2006.24 Sept. 2006.


Tinetti ME, Williams TF, Mayewski R, Fall risk index for elderly patients based on number of chronic disabilities. Am J Med 1986:80:429-434


“What You Need To Know About Balance And Falls.” Balance and Falls. 2006. 24 Sept. 2006.



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