Balance and Coordination Tests
Balance is the ability to maintain the center of gravity over the base of support, usually while in an upright position. Coordination is the capacity to move through a complex set of movements that requires rhythm, muscle tension, posture, and equilibrium. Balance and coordination depend on the interaction of multiple body organs and
systems including the eyes, ears, brain and nervous system, cardiovascular system, and muscles. Tests or examination of any or all of these organs or systems may be necessary to determine the causes of loss of balance, dizziness, or the inability to coordinate movement or activities.
Tests of balance and coordination, and the examination of the organs and systems that influence balance and coordination, can help to identify causes of dizziness, fainting, falling, or incoordination.
Tests for balance and coordination should be conducted in a safe and controlled area where patients will not experience injury if they become dizzy or fall. The practitioner should first evaluate the patient's static and dynamic balance before leaving the patient unattended.
Assessment of balance and coordination can include discussion of the patient's medical history and a complete physical examination including evaluation of the heart, head, eyes, and ears. A slow pulse or heart rate, or very low blood pressure may indicate a circulatory system problem, which can cause dizziness or fainting. During the examination, the patient may be asked to rotate the head from side to side while sitting up or while lying down with the head and neck extended over the edge of the examination table. If these tests produce dizziness or a rapid twitching of the eyeballs (nystagmus), the patient may have a disorder of the inner ear, which is responsible for maintaining balance.
An examination of the eyes and ears may also provide clues to episodes of dizziness or incoordination. The patient may be asked to focus on a light or on a distant point or object, and to look up, down, left, and right moving only the eyes while the eyes are examined. Problems with vision may, in themselves, contribute to balance and coordination disturbances, or may indicate more serious problems of the nervous system or brain function. Hearing loss, fluid in the inner ear, or ear infection might indicate the cause of balance and coordination problems.
Various physical tests may also be used. A patient may be asked to walk a straight line, stand on one foot, or touch a finger to the nose to help assess balance. The patient may be asked to squeeze or push against the doctor's hands, to squat down, to bend over, or stand on tiptoes or heels. Important aspects of these tests include holding positions for a certain number of seconds, successfully repeating movements a certain number of times, and repeating the test accurately with eyes closed. The patient's reflexes may also be tested. For example, the doctor may tap on the knees, ankles, and elbows with a small rubber mallet to test nervous system functioning. These tests may reveal muscle weakness or nervous system problems that could contribute to incoordination.
As ergonomics becomes a major emerging practice area in occupational therapy, balance and coordination is increasingly analyzed in workplace evaluations. Good balance and coordination, such as finger dexterity, may be needed for a worker to properly complete a specific task in his or her job. Assessments used to determine coordination include the Crawford Small Parts Dexterity Test, Bennettt Hand-Tool Dexterity Test, Purdue Pegboard, and the Minnesota Rate of Manipulation Test.
|SOURCE: O'Sullivan, S.B. and T.J. Schmitz. Physical Rehabilitation: Assessment and Treatment. 3rd ed. Philadelphia: F.A. Davis Co., 1994.|
|Alternate heel to knee and heel to toe||While lying down, the patient is asked to touch his or her knee and big toe alternately with the heel of the opposite|
|Alternate nose to finger||The patient alternately touches the tip of his or her nose and the tip of the therapist's finger with the index finger. The|
|therapist may move his or her finger during testing to assess ability to change distance, direction, and force of|
|Drawing a circle||While sitting, standing, or lying down, the patient alternately draws an imaginary circle in the air, or on a table or|
|floor, with either upper or lower extremity. Instead of a circle, a figure-eight pattern may be used.|
|Finger to finger||With both shoulders abducted to 90° and the elbows extended, the patient is asked to bring both hands toward the|
|midline and approximate the index fingers from opposing hands.|
|Finger to nose||With the shoulder abducted to 90° and the elbow extended, the patient is asked to bring the tip of the index finger to|
|the tip of the nose. The initial starting position may be changed to assess performance from different planes of|
|Finger opposition||The patient touches the tip of the thumb to the tip of each finger in sequence. Speed may be gradually increased.|
|Finger to therapist's finger||The patient and therapist sit opposite each other. The therapist holds his or her index finger in front of the patient,|
|and the patient is asked to touch the tip of the index finger to the therapist's index finger. The position of the thera-|
|pist's finger may be altered during testing to assess ability to change distance, direction, and force of movement.|
|Fixation or position holding||Upper extremity: The patient holds arms horizontally in front.|
|Lower extremity: The patient holds the knee in an extended position.|
|Mass grasp||The patient alternately opens and closes the fist (finger flexion to full extension). Speed may be gradually increased.|
|Pronation/supination||With elbows flexed to 90° and held close to body, the patient alternately turns his or her palms up and down. This|
|test also may be performed with shoulders flexed to 90° and elbows extended. Speed may be gradually increased.|
|The ability to reverse movements between opposing muscle groups can be assessed at many joints, including the|
|knee, ankle, elbow, fingers, etc.|
|Rebound test||The patient is positioned with the elbow flexed. The therapist applies sufficient manual resistance to produce con-|
|traction of biceps. Normally when resistance is suddenly released, the opposing muscle group (triceps) will contract|
|and "check" movement of the limb. Many other muscle groups can be tested for this phenomenon, such as the|
|shoulder abductors or flexors, and elbow extensors.|
|Tapping||Foot: The patient is asked to "tap" the ball of one foot on the floor without raising the knee; heel maintains contact|
|Hand: With the elbow flexed and the forearm pronated, the patient is asked to "tap" his or her hand on the knee.|
Standardized tests that evaluate gross motor coordination include the Bruinlinks-Oseretsky Test of Motor Proficiency, which evaluates gross and fine motor coordination, muscle strength, balance, and visual motor control; the Devereux Test of Extremity Coordination, which assesses static balance, motor attention span, and sequential motor activity; the Lincoln-Oseretsky Motor Development Scale, which assesses motor tasks such as walking backwards and one-foot standing; and the Miller Assessment for Preschoolers, which assesses gross motor function in young children.
Balance testing instruments
The Berg Balance Scale. This widely-used instrument identifies balance impairment. Functional activities such as reaching, bending, transferring, and standing are used as items on the test to measure balance. The test items are graded on a five-point scale to determine extent of impairment.
Clinical Test of Sensory Interaction and Balance (CTSIB). This test, also known as the Sensory Organization Test, assesses static balance under six combinations of sensory conditions. For example, visual conditions vary by testing while the eyes are closed, open, and also when peripheral vision is restricted. The test also includes having the subject balance while standing on a hard floor and while standing on foam. The effect on posture and balance is graded and scored.
Functional Reach Test. This test measures a person's stability while leaning forward and reaching as far as possible with arm outstretched and parallel to the floor in front of the body. A normal reach is at least six inches, measured from the distance the fist has traveled during the reach.
The Tinetti Balance Test of the Performance-Oriented Assessment of Mobility Problems. This test measures balance and gait while performing typical daily activities. The activities are graded as normal, adaptive, or abnormal to determine the severity of balance impairment.
The Timed Up and Go Test. This test measures the time it takes a person to rise from a standard armchair and stand, walk three meters, turn around, and walk back to the chair and sit down.
The Physical Performance Test. This test evaluates a person's physical functional capabilities. The person performs nine separate activities, such as feeding and writing,
and is scored on each of the activities based on speed from 0-4.
No special preparation is required prior to administration of balance and coordination tests. The patient may be asked to disrobe and put on an examination gown to make it easier for the doctor to observe muscles and reflex responses.
No special aftercare is generally required. However, some of the tests may cause episodes of dizziness or incoordination. Patients may need to use caution in returning to normal activities if they are experiencing any symptoms of dizziness, lightheadedness, or weakness.
These simple tests of balance and coordination are generally harmless.
These tests do not normally cause dizziness, loss of balance, or incoordination.
The presence of dizziness, lightheadedness, loss of coordination, unusual eye movements, muscle weakness, or impaired reflexes are abnormal results and may indicate the problem causing the loss of balance or incoordination. In some cases, additional testing may be needed to diagnose the cause of balance or coordination problems.
Incoordination—Uneven, inaccurate movement.
Meniere's disease—An abnormality of the inner ear that causes dizziness, ringing in the ears, and hearing loss.
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American Academy of Otolaryngology-Head and Neck Surgery. One Prince Street, Alexandria, VA 22314. (703) 836-4444.
Ear Foundation. 2000 Church Street, Box 111, Nashville, TN 37236. (615) 329-7807 or (800) 545-HEAR.
Vestibular Disorders Association (VEDA). P.O. Box 4467, Portland, OR 97208-4467. (800) 837-8428 or (503) 229-7705. Fax: (503) 229-8064.