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CHAPTER 10 Neuromuscular Examination
reflexive or automatic responses acquired in normal development.80 However, disease, injury, or the effects of aging can
slow, alter, or eliminate these strategies, greatly increasing an
individual’s risk for falls.
The ankle strategy is typically utilized in the event of
small perturbations and involves activation of the gastrocnemius and hamstrings (if the body’s COM has shifted
anterior to the BOS) or tibialis anterior and quadriceps
(if the body’s COM has shifted posterior to the BOS).74,81
The hip strategy is invoked with larger perturbations or
when an individual is standing on a support surface that
is smaller than the length of the feet (envision a gymnast
attempting to recover upright stance after a loss of balance
on the balance beam). In this case, the hips rapidly flex
and/or extend in an attempt to move the body’s COG back
within the BOS.82 The stepping strategy is used when the
body’s COG moves too quickly or too far outside the BOS
for any other strategy to be successful. In this case, one
foot is quickly moved forward, backward, or to the side
in response to a perturbation. When this happens, a new
BOS is created by the altered position of the foot, leading
some to call this a “change-in-support” strategy.83 These
strategies also may be used in combination or in series
(e.g., the hip strategy performs the major correction and
the ankle strategy fine tunes the correction). In addition,
most people also invoke arm movements to assist with balance correction.83
The Role of Cognition
The preceding systems function with little conscious input
once successful strategies have been learned.75 It should not
be difficult to understand, however, that cognition plays an
important role in balance. Deficits in cognition may prevent an individual from paying attention to surroundings,
making appropriate decisions, or remembering how certain situations can be dangerous. Individuals with dementia
and other cognitive impairments have been shown to have
a significantly higher risk for falls as compared to persons
with normal cognition.84–86 In addition, individuals with
cognitive deficits may not be able to learn or relearn balance strategies,87 which may have a significant impact on
rehabilitation planning and implementation.
In any given situation, when an individual experiences a loss of balance, one of two things will happen: he or
she will either invoke a strategy to correct the problem, or
the individual will fall. Falls can lead to serious injury, such
as hip, pelvic, humeral, or wrist fractures, head trauma,
or lacerations. If serious enough, these injuries can lead
to a loss of independence, decreased overall mobility, and
an early risk of death.88,89 Of all hip fractures in persons
over the age of 65 years, 95% are caused by a fall.90 Falls
are the primary cause of injury leading to hospitalization
in persons over the age of 55;91 they are also are the leading cause of injury-related deaths among older adults.92 In
addition, 40% of nursing home admissions are fall related,
and nearly one quarter of those individuals die within
1 year.89
Impaired balance has been identified as the second
largest risk factor for falls in older individuals, behind
muscular weakness.93 While older adults seem to have the
greatest risk for balance-related falls, persons of any age are
susceptible. Many balance problems are quite treatable, and
numerous studies have shown that improvements in balance
can be significant if the underlying source is identified and
remedied.94–99 What follows are various types of tests and
measures that examine an individual’s ability to achieve or
maintain balance. Because balance has so many interrelated
components that can be influenced by the desired task, by
the environment, or by the individual’s cognitive or physical
status, the choice of which assessment tools to use will vary
from patient to patient. It is suggested that several different
aspects of balance be examined with each patient.
PROCEDURE
When performing physical tests and measures of balance,
consideration of the patient’s safety is paramount. While
skilled patient handling and proper guarding can correct
many postural faults and provide support during moments
of instability, safety equipment (e.g., gait belt, parallel bars)
should be utilized when assessing balance in the presence
of any fall risk. In some cases, the use of an assistant is also
appropriate.
Confidence in Balance
As mentioned previously, individuals who have a fear of falling tend to avoid participating in functional activities that
require mobility and balance.56,57,100 These fear and avoidance behaviors may be important factors in prediction of
frailty and disability.57,100 Therefore, it may be helpful to
assess a patient’s self-perceptions of his or her ability to perform various activities that require some level of controlled
balance. Two standardized questionnaires that have proven
clinically useful are the 16-item Activities-specific Balance
Confidence (ABC) scale101 and the 10-item Falls Efficacy
Scale.102 Both of these scales ask the patient to rate his or her
confidence in performing activities such as housecleaning,
getting in and out of a car, and walking in community settings. One study showed that a score of less than 67% on the
ABC (100% indicates full self-confidence in balance during
the stated activities) could predict persons classified as “fallers” 84% of the time.103
Seated Balance
In many acute care and rehabilitation settings, patients may
begin physical therapy at a very low functional level, and
balance assessment may not proceed beyond the seated
position. If a patient is able to achieve and maintain static
sitting, an assessment of dynamic (moving) sitting balance
may be initiated. This can be accomplished by asking the
patient to perform side-to-side or front-to-back weight
shifts, to reach in various directions with one upper extremity, or to move both upper extremities simultaneously. Difficulty may be increased by having the patient close his or
her eyes while performing any of these activities.
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Procedure
Static Standing Balance Tests
Romberg Test
This test was originally developed in the nineteenth century
to assess for the presence of tabes dorsalis (demyelination
of the nerves in the posterior columns that results from an
untreated syphilis infection).104 Since that time, the test has
been described in a variety of ways.105–108 For simplicity, the
test will be described here as a four-step progression. If a
patient is unable to safely perform one step, progression to
further steps is not advised.
Equipment required: timer
Performing the test:
1. Romberg position (eyes open)
a. The patient is asked to stand on a firm, flat surface,
without shoes, feet placed together, arms at the sides.
i. Variations include standing with shoes on or
having arms crossed over the chest.
b. The patient stands unsupported for up to 30 seconds.
i. Variations include the use of multiple trials or a
requirement to stand for 60 seconds.
c. Observation of a loss of balance (patient steps out
of the stance position), use of the upper extremities
to stabilize the body, or significant sway would be
considered a failed test.
2. Romberg position (eyes closed)
a. The patient assumes the same position as described
in Step 1, but eyes are closed (see FIGURE 10-51).
b. The patient stands unsupported for up to 30 seconds.
c. A loss of balance as previously described is considered a failed test.
i. A “positive Romberg test” is classically described
as the ability to stand in this position with eyes
open but not with eyes closed.104 This indicates
that the patient is relying heavily on vision to
maintain balance.
3. Sharpened Romberg position (eyes open)
a. This is also known as the Tandem Romberg stance
position (see Figure 10-49 in the previous section).
b. The patient is asked to stand with one foot directly
in front of the other (heel touching toe), arms at
sides or crossed over chest.
i. The test may be performed with either foot forward as long as it is properly documented; it is
often helpful to compare performance by performing one trial with the right foot forward
and one trial with the left foot forward.
c. The patient stands unsupported for up to 30 seconds.
d. A loss of balance as previously described is considered a failed test.
4. Sharpened Romberg position (eyes closed)
a. Identical to Step 3, but with eyes closed.
Although the Romberg test is used clinically to assess
balance in a variety of patient populations, it is not a highly
functional assessment. While these positions are progressively challenging, and inability to complete the tests indicates probable balance dysfunction, the test positions do
not mimic positions used during typical daily activity. Thus,
balance assessment using the Romberg positions should
also include more functional postures or activities.
Single-Limb Stance Test
Any person who engages in walking is required to assume
a single-limb support posture. As one limb advances, the
other must support and stabilize the body. Thus, although
the Single-Limb Stance Test (SLST) is a static test and
walking is a dynamic activity, assessing a patient’s ability
to achieve and maintain this position may be more functionally informative than the variations of the Romberg
test. Several studies have shown that inability to maintain
a SLS position for even a short period of time indicates a
fall risk109–111 and may be a marker of frailty in older persons.112,113 As with the Romberg test, the SLST has been
studied using varied methods.112,114
Equipment required: timer, alternate surfaces (as needed)
Performing the test:
1. Single-Limb Stance Test (eyes open)
a. The patient is asked to stand comfortably on a
FIGURE 10-51 Position for the basic Romberg test for
static balance.
firm, flat surface, arms at sides, without shoes (see
FIGURE 10-52).
i. Variations include having the arms crossed over
the chest or with shoes on.
b. The patient then is asked to raise one foot from the
floor.
c. This position is maintained for up to 30 seconds.
i. Variations include use of multiple trials.
d. Results may be compared to age-matched norms
(see TABLE 10-3).
e. Persons unable to maintain a SLS position for 5 or
more seconds have been shown to have a fall risk
that is two times greater than those who could balance for more than 5 seconds.111
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CHAPTER 10 Neuromuscular Examination
may not be paying close attention to his or her surroundings. Individuals with good reactive balance function are
able to recover from the bump. Someone with poor reactive
balance may experience a fall. The Nudge/Push test mimics
such situations.115
Equipment required: none
Performing the test:
1. Ensure the patient’s safety, asking another individual to
guard the patient as needed.
2. Ask the patient to stand quietly with eyes open, feet a
FIGURE 10-52 Position for the basic Single-Limb Stance
test.
2. Single-Limb Stance Test (eyes closed)
a. The procedure is identical to that outlined above
but with the patient’s eyes closed.
b. Patients who are able to maintain the SLS position
with eyes open but not with eyes closed rely heavily
on vision to maintain balance.
3. Single-Limb Stance Test (varied surfaces)
a. The procedure is identical to that outlined above,
but the patient stands on less stable surfaces, such
as a stack of towels, a pillow, or a foam square.
comfortable distance apart, and arms comfortably at
the sides.
a. It is also possible to perform this test with the patient seated if standing is not safe or possible.
b. Testing with the patient’s eyes closed may be performed if deemed safe.
3. Inform the patient that you will be randomly giving
him or her a “nudge” in various directions and the goal
is to maintain an upright stance.
4. At random intervals, quickly but gently push the patient
from the front, back, or side (see FIGURE 10-53).
a. The sternum, pelvis, and shoulder are common
sites to push.
b. Begin with light force and increase as the patient is
safely able to tolerate.
c. Vary the direction and location of the push, as well
as the timing.
5. Assess the patient’s ability to recover from the perturbations, if difficulty was specific to a direction or location
of force, or if there was a side-to-side difference in ability to recover from the perturbation.
Reactive Balance Tests
Anticipatory Balance Tests
Nudge/Push Test
Functional Reach Test
Consider a situation in which a person is standing on a busy
sidewalk or in a shopping mall. In situations like these, it is
not uncommon to be bumped into by another person who
Reaching for objects is a common functional activity but
may lead to falls if the object is out of an individual’s safe
range. The Functional Reach test is easy to perform and
TABLE 10-3 Age-Predicted Norms for the
Single-Limb Stance Test
Age Group
Eyes Open
Eyes Closed
(mean of three (mean of three
trials)
trials)
18–39 years
43 seconds
9 seconds
40–49 years
40 seconds
7 seconds
50–59 years
37 seconds
5 seconds
60–69 years
27 seconds
3 seconds
70–79 years
15 seconds
2 seconds
80–99 years
6 seconds
1 second
Total (all ages)
30 seconds
5 seconds
Data from Springer B, Marin R, Cyhan T, Roberts H, Gill N.
Normative values for the unipedal stance test with eyes open and
closed. J Geriatr Phys Ther. 2007;30(1):8–15.
FIGURE 10-53 The Nudge/Push test.
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Procedure
has proven reliable and valid in a variety of patient populations.116–118 It has also been shown to be predictive of falls
in older adults.117
Equipment required: yardstick attached to a wall at the
height of the patient’s shoulder.
Performing the test:
1. The patient stands next to the wall with the yardstick
attached to it, standing with the feet shoulder width
apart.
2. Ask the patient to make a fist with the hand and flex his
or her shoulder to 90°.
a. The number on the yardstick that corresponds to
the position of the distal head of the third metacarpal should be recorded.
3. Ask the patient to reach forward along the yardstick as
far as possible without moving the feet or touching the
wall (see FIGURE 10-54).
4. The number on the yardstick that corresponds to the
position of the distal head of the patient’s third metacarpal should be recorded.
5. Calculate the number of inches the patient was able
to reach, and compare to published norms (see
TABLE 10-4).
6. Reaching also may be done in the lateral direction,
backward (shoulder flexed to 90° but patient instructed
to lean backward),107,119 or while seated (considered the
Modified Functional Reach test).120,121
Catching
Catching an object while maintaining balance is another
example of an anticipatory balance activity. Compared to
the functional reach test, catching is a far less predictable
and generally more difficult activity. Catching also has
inherent variability because it involves the skill of the person
tossing the object. This method of assessment will require
one person to guard the patient if there is any concern for a
loss of balance or fall.
Equipment required: any item that is safe for the patient to
catch, such as a ball or beanbag (the smaller the item, the
more challenging the test).
FIGURE 10-54 The Functional Reach test.
TABLE 10-4 Age-Related Norms for the
Functional Reach Test
Age Group
Women
Men
20–40 years
14.6 (± 2.2) inches
16.7 (± 1.9) inches
41–69 years
13.8 (± 2.2) inches
14.9 (± 2.2) inches
70–87 years
10.5 (± 3.5) inches
13.2 (± 1.6) inches
Data from Duncan P, Studenski S, Chandler J. Functional
reach: predictive validity in a sample of elderly male veterans.
J Gerontol. 1992;47:M93–98.
Performing the test:
1. The patient should stand on a firm surface that is clear
of any obstacles.
2. While standing directly in front of the patient
(5–10 feet away), gently toss the object to the patient
(see FIGURE 10-55).
a. The first several tosses should be easily catchable to
determine if difficulties are present before proceeding to more difficult tosses.
3. Progressively vary the trajectory of the object.
a. Aim for the patient’s right or left side.
b. Aim high or low.
c. If the patient is performing well, aim slightly outside his or her base of support to encourage an anticipatory stepping action.
4. Vary the speed of the toss if you feel the patient can
respond appropriately.
5. A high level of challenge may also be introduced by
asking the patient to stand on a soft or unstable surface
(e.g., pillow, layers of towels, balance board, mini trampoline) while catching.
a. This should only be used if it is deemed safe for the
patient.
Dynamic Balance Tests
The ability to maintain balance while engaged in dynamic
activities can allow for a relatively high level of function.
However, significant functional restrictions can result if
FIGURE 10-55 Tossing a ball to assess anticipatory
reactions.
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CHAPTER 10 Neuromuscular Examination
one’s ability to maintain balance while active and moving is
impaired. Physical balance impairments coupled with fear
of falling can lead to activity and social avoidance behaviors
that can be detrimental to overall health and well-being.57,58
There are a number of standardized balance measures that
require dynamic activity. Use of these measures often helps
a clinician determine the extent of the overall problem, as
well as the degree to which fear contributes.
The Berg Balance Scale (BBS) is one of the best known
and most widely used clinical tools for assessing balance
and functional mobility in a wide variety of patient populations.122–124 The BBS is a 14-item test designed to assess an
individual’s ability to maintain certain positions or to perform particular motions of increasing difficulty, progressing
from sitting to bipedal stance to tandem stance to singlelegged stance.125 The test has demonstrated good to excellent reliability, validity, and internal consistency.123,124,126–128
The one clinical drawback of the BBS is that it takes 15–20
minutes to administer.
Other functional measures of balance and mobility that
have been shown to be clinically useful, reliable, and valid
include the Tinetti Performance-Oriented Mobility Assessment (POMA),129 the modified Dynamic Gait Index,64,130
and the BESTest.131 Each of these tests provides an excellent,
broad-based view of a patient’s ability to perform a number
of varied tasks. However, similar to the BBS, each takes at
least 15 minutes to perform.
One clinical screening measure of balance and mobility that does not take considerable time (typically less
than 3 minutes) is the Timed Up and Go (TUG).132 In this
test, patients are asked to rise from an armchair, walk 3
meters straight forward, turn, walk back to the chair, and
sit down (see FIGURE 10-56). Adults without impairment
BOX 10-1
FIGURE 10-56 Patient performing the Timed Up and Go
(TUG) test.
can typically perform this test in less than 10 seconds. Individuals with a neurologic condition who take longer than
30 seconds to complete the test are typically dependent in
most daily activities.132 The TUG has been shown to be reliable and valid with a number of conditions123,133–136 and also
predictive of fall risk in select populations.137,138
Numerous and varied dynamic activities can be
assessed independent of standardized measurement tools.
The activities you opt to assess should relate to the patient’s
required or desired functional activities. While the patient’s
confidence, physical ability, and safety will dictate your
choice of activities, the list of possibilities is only limited by
your creativity (see BOX 10-1). Recall that the patient’s safety
is of primary concern, so activities beyond the patient’s
capabilities should not be attempted, and all chosen activities should be appropriately guarded.
Activities to Assess Dynamic Balance
> Walking on a straight line taped to the floor
> Walking on a curved line taped to the floor
> Walking in a heel-to-toe pattern
> Sideways stepping
> Walking backward
> Marching in place (eyes open or closed)
> Marching while walking
> Reaching for an object on a high shelf
> Standing or marching on a mini trampoline (see FIGURE 10-57)
> Walking on heels or toes
> Walking with random, unexpected directional changes
> Walking with changes in gait speed
> Walking while carrying an object (e.g., laundry basket)
> Walking while talking
> Walking while stepping over small objects in the path
> Walking on grass or gravel
> Picking small objects up from the floor (see FIGURE 10-58)
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