Journal of Geriatric Physical Therapy:
Impairments in Static Standing Balance Are Highly Prevalent Among Older Adults Receiving Home-Based Physical Therapy
Bohannon, Richard W. PT, NCS, EdD, DPT, FAPTA, FAHA, FASNR, CEEAA
Physical Therapy Program, Department of Kinesiology, NeagSchool of Education, University of Connecticut, Storrs, Connecticut
Address correspondence to: Richard W. Bohannon, PT, NCS, EdD, DPT, FAPTA, FAHA, FASNR, CEEAA, Department of Kinesiology, University of Connecticut, Storrs, CT 06269 (firstname.lastname@example.org).
The author declares no conflict of interest.
Background and Purpose: Measures of balance are an important component of the physical therapist examination. This study investigated the usefulness of timed static stance durations for identifying balance impairments among patients receiving home-based physical therapy.
Methods: This study involved the retrospective retrieval of data from the records of 48 patients at least 60 years of age. Their balance was measured under 3 foot configurations; that is, feet apart, feet together, and on each foot.
Results: Every patient demonstrated impaired standing balance. Most, but not all could balance 30 seconds with the feet apart or together. Only 19 could maintain balance on each of both feet. Of those who could so balance, none was able to achieve the average time of normal individuals of comparable age.
Discussion and Conclusions: Although not able to identify all aspects of balance, timed durations of stance under different configurations demonstrate a high prevalence of balance impairments among patients receiving home-based physical therapy. As the tests are objective, fast, and require little space, they can be advocated in such a setting.
In the Guide to Physical Therapist Practice, balance is described as the “ability to maintain the body in equilibrium with gravity both statically (ie, while stationary) and dynamically (ie, while moving).”1 There are many methods by which balance impairments can be identified,2 but the timing of stance duration under different static foot configurations is a compelling alternative that is objective, simple, and fast. Balance so measured correlates with performance at functional activities such as transfers and gait.3,4 Timed measures of static stance are also useful for discriminating between individuals with different fall histories,5,6 disease states,7,8 and health scores.9
The configurations under which static stance can be timed include, but are not limited to, feet apart, feet together, and 1 foot (unipedal). Clinicians considering whether to measure balance by timing stance duration under these configurations need to know if doing so will help them to identify and grade impairments in the settings where they practice. Timed stance durations under feet apart, feet together, and unipedal conditions have been shown to be informative of patient status in an acute rehabilitation setting.4,5 Whether timed stance durations under different foot configurations are useful for identifying balance impairments in a home care setting has not been established. This descriptive study was undertaken to investigate this issue.
This study involved the retrospective retrieval of data from records maintained by the author on his personal patients. Use of the records without patient consent was approved by the Institutional Review Board of the University of Connecticut. Information was retrieved from the initial examination records of all patients who were ambulatory, able to stand, had no weight-bearing restrictions, and were at least 60 years of age. The information included basic descriptors of the patients (ie, gender, age, primary diagnosis) and timed measurements of balance performance under 3-foot configurations in a standard order: (1) feet apart, (2) feet together, and (3) on each foot. By convention, balance testing was performed with eyes opened while patients wore socks or shoes with firm soles and little or no heel and stood on a firm surface (vinyl, tile, wood). During feet apart testing, the heels were separated about 1-foot length. During feet together testing the heels were touching. During unipedal testing, the contralateral limb was lifted but not touching the stance limb. Up to 3 trials were allowed for patients to achieve a 30-second stance under each configuration. Timing, which was achieved with a stopwatch, ceased when a foot was displaced (or returned to the floor during unipedal testing), when a patient grabbed something with a hand, or a patient's loss of control required the tester's assistance to prevent a fall. The number of patients able to balance under the 3 configurations was documented as was the best (maximum) time that they could maintain balance. For those patients able to balance on one foot, the time was compared with age-matched reference values published by Bohannon.10 Descriptive statistics and Wilcoxon matched pairs analysis was used for this purpose.
Forty-eight patients were included in this study. Thirty-two were women. Their age ranged from 60 to 93 years (mean [SD] = 78.2 [8.7]). There were 21 different primary diagnoses among the patients, but patients tended to have multiple comorbidities. Primary diagnoses possessed by more than 2 patients were (in descending order): stroke (5), fall (5), fracture (5), infection (4), and cancer (3).
The Figure tallies the number of patients able to balance under various foot configurations. Five patients were unable to balance 30 seconds with the feet apart. Another 5 patients were unable to balance with the feet together. Seventeen patients were unable to balance on the left foot and 19 patients were unable to balance on the right foot. Of those able to balance on 1 foot, none balanced as long as expected on the basis of published norms (14.6 seconds). The mean (SD) time was 3.0 (3.8) seconds on the left and 3.2 (4.0) seconds on the right. These times were significantly less than age-relevant norms (P < .001).
Figure. Line diagram...Image Tools
This retrospective study demonstrates that tests involving timed stance durations under different foot configurations are useful for identifying balance impairments in a home care setting. Balance so measured was impaired in every patient. As balance is related to function, falls, disease, and health, the adequacy of such tests for identifying impairments is important.3–9
Many aspects of balance are not captured by static tests. It is not surprising, therefore, that balance indexes such as those of Berg and Tinetti contain both static and dynamic elements.11,12 That said, timed balance tests under ever more challenging stance configurations are objective and can be performed quickly in almost any setting. They require little space, which in a home care setting is often quite limited.
This study includes several potential limitations. First, a small heterogeneous sample of patients from a single home-care practice was involved. Consequently, the results may not generalize to other practices or settings or to large groups of diagnostic specific patients. Second, only the results from the patients' initial examinations are presented. The prevalence in static balance impairments might not be as high during a later examination. Third, there was some variability in footwear and floor surfaces. Some of this could be avoided by testing all patients in bare feet, but this is often not a good idea. Moreover, studies have shown no difference in standing balance under shoes on and off conditions.13 So limitations notwithstanding, my findings in combination with previous research4,5 suggest that timed durations of stance under different foot configurations are useful for identifying patients whose balance is impaired.
For patients receiving home-based physical therapy, balance impairments are highly prevalent. Tests involving the timing of stance under different foot configurations are able to identify such impairments.
1. Guide to Physical Therapist Practice (ed 2). Phys Ther. 2001;81:72.
2. Smithson F, Morris ME, Iansek R. Performance on clinical tests of balance in Parkinson's disease. Phys Ther. 1998;78:577–592.
3. Bohannon RW, Walsh S, Joseph MC. Ordinal and timed balance measurements: reliability and validity in patients with stroke. Clin Rehabil. 1993;7:9–13.
4. Bohannon RW, Leary KM. Standing balance and function over the course of acute rehabilitation. Arch Phys Med Rehabil. 1995;76:994–996.
5. Hurvitz EA, Richardson JK, Werner RA, Ruhl AM, Dixon MR. Unipedal stance testing as an indicator of fall risk among older outpatients. Arch Phys Med Rehabil. 2000;81:587–591.
6. Thomas JI, Lane JV. A pilot study to explore the predictive validity of 4 measures of fall risk in frail elderly patients. Arch Phys Med Rehabil. 2005;86:1636–1640.
7. Richardson JK, Ashton-Miller JA, Lee SG, Jacobs K. Moderate peripheral neuropathy impairs weight transfer and unipedal balance in the elderly. Arch Phys Med Rehabil. 1996;77:1152–1156.
8. Stankovic I. The effect of physical therapy on balance of patients with Parkinson's disease. Int J Rehabil Res. 2004;27:53–57.
9. Manckoundia P, Buatois S, Gueguen R, et al. Clinical determinants of failure in balance tests in elderly subjects. Arch Gerontol Geriatr. 2008;47:217–228.
10. Bohannon RW. Single limb stance times. A descriptive meta-analysis of data from individuals at least 60 years of age. Top Geriatr Rehabil. 2006;22:70–77.
11. Berg KO, Wood-Dauphinee S, Williams JI, Maki BE. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83:S7–S11.
12. Tinetti ME. Performance-oreiented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34:119–126.
13. Briggs RC, Gossman MR, Birch R, Drews JE, Shaddeau SA. Balance performance among noninstitutionalized elderly women. Phys Ther. 1989;69:748–756.
© 2012 Academy of Geriatric Physical Therapy, APTA
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