Balance and gait assessment

Balance (equilibrium) is the ability to maintain the centre of mass of the body within the base of support with minimal postural sway.

Balance depends on the integration of proprioception, vestibular input, visual input, central coordination and neuromuscular responses.

When standing, changes in orientation are first perceived by cutaneous proprioceptive sensors in the feet; the vestibular apparatus detects linear and angular acceleration of the head; vision detects motion of the visual field. On a fixed level surface proprioception predominates; when the surface is irregular or moving, vestibular input becomes essential.

Gait is the pattern of trunk and limb movement during locomotion over a solid surface — the “manner of walking” or “sequence of foot movements”.

Gait assessment is a critical part of the comprehensive geriatric assessment. At least one-fifth of community-dwelling older adults report difficulty walking, rising to one-half in those aged 85 and above.

30-second chair stand — number of chair stands completed in 30 seconds with arms crossed on the chest. The most practical tool in a busy clinic; measures both balance and strength. It is one component of the Short Physical Performance Battery (SPPB).

Short Physical Performance Battery (SPPB) — repeated chair stands plus balance testing with side-by-side, semitandem and tandem stands, plus gait speed.

4-Stage Balance Test — side-by-side, semitandem, tandem and one-foot stand. Normal balance = holding each position for 10 seconds.

Berg Balance Scale — a 14-item test of everyday tasks (sitting unsupported, sit-to-stand, stand-to-sit, transfers, standing unsupported, eyes closed, feet together, tandem standing, one-leg stand, turning the trunk, retrieving objects from the floor, turning 360 degrees, stool stepping, reaching forward). Total score 0–56. Interpretation: 0–20 wheelchair bound, 21–40 walks with assistance, 41–56 independent. Validated originally in older stroke patients; predicts functional and motor performance and future falls.

Functional reach test — dynamic standing balance. The subject stands behind a line and reaches the arm as far forward as possible without stepping. Fall risk is suspected if reach is less than 10 inches. It correlates with other balance measures and predicts future decline in ADLs, though it may not reliably predict falls.

Gait speed is the simplest and most standardised global measure of health and function. Measured over a pre-measured 4 metre distance. 0.6–0.8 m/sec identifies a high-risk population and 0.6 m/sec is the generally accepted cut-off for abnormal gait speed.

Get Up and Go Test (GUGT) / Timed Up and Go (TUGT) — rise from a chair, walk a set distance, turn, walk back and sit down. In the inpatient setting sensitivity is 91% but specificity only 22%. Even an untimed GUGT is clinically useful for identifying specific balance and gait problems. Kane recommends a simple “get up and go” test in all patients who have fallen.

Tinetti’s Performance-Oriented Mobility Assessment (POMA) — 14 performance tasks split into balance and gait. Maximum balance score 16, maximum gait score 12, total 28. Score below 19 = high risk of falls; 19–24 = at risk. Mean sensitivity 82%, specificity 65%. Takes 10–15 minutes, so it is harder to use in a busy clinic. Interrater agreement is over 85%.

The Tinetti balance items are: sitting balance, arises, attempts to arise, immediate standing balance (first 5 seconds), standing balance, nudged, eyes closed, turning 360 degrees, sitting down. The gait items are: initiation of gait, step length and height, step symmetry, step continuity, path, trunk, and walking stance.

Kane’s performance-based assessment grades each manoeuvre as normal, adaptive or abnormal: sitting balance, arising from chair, immediate standing balance (first 3–5 seconds), standing balance, Romberg, sternal nudge (examiner pushes with light even pressure over the sternum three times), walking, turning balance through 360 degrees, neck turning, and back extension. This is more useful than the standard neuromuscular examination for identifying remediable problems.

Dual-task testing — walking while counting backwards from 100 by sevens, GUGT while holding a full glass of water, or one-leg stand with eyes closed. Institutionalised older adults who cannot keep up a conversation while walking have a high risk of falls. Both young and old prioritise gait over the secondary cognitive task. Clinical utility is still unclear because of variability across studies.

Expect slower gait, reduced step length, increased time in double limb support, reduced range of motion, and increased anterior-posterior postural sway. Gait speed falls 12–16% per decade.

On perturbation testing, younger people abduct the arms uphill and hinge at hips and trunk to keep the centre of mass away from the tilt; older subjects have reduced compensatory trunk movement and stretch the arms in the direction of the fall.

Recognise disease-specific gaits: Parkinson’s disease — gait initiation failure and freezing, better with external visual cues; post-stroke — decreased hip and knee flexion during the swing phase; cerebellar disease — broad-based ataxic gait; vestibular lesion — veering to the ipsilateral side when walking with eyes closed.

Where to place it in practice: gait, strength and balance assessment forms the core of the CDC STEADI risk assessment using TUGT, 30-second chair stand and 4-stage balance test.