3.6 Balance, Coordination, & Vestibular Basics
Key Takeaways
- The Berg Balance Scale scores 14 functional tasks for a maximum of 56 points; lower scores indicate worse balance, and a score of 45 or below is commonly associated with increased fall risk.
- The Timed Up and Go (TUG) test times a sit-to-stand, 3-meter walk, turn, and return; a time greater than about 13.5 seconds in community-dwelling older adults is commonly linked to elevated fall risk.
- The Romberg test screens proprioceptive contributions to standing balance; a patient who is steady with eyes open but sways or falls with eyes closed has a positive Romberg sign, and the sharpened (tandem) Romberg increases the challenge.
- Coordination is screened with tests such as finger-to-nose, heel-to-shin, and rapid alternating movements (dysdiadochokinesia), which help identify cerebellar dysfunction.
- Benign paroxysmal positional vertigo (BPPV) canalith repositioning maneuvers are performed by the physical therapist; the PTA implements habituation, gaze-stabilization, and balance exercises within the established plan of care.
Why Balance Measures Matter
Balance depends on the integration of three systems — visual, vestibular, and somatosensory (proprioceptive) — processed centrally with help from the cerebellum. PTAs deliver large volumes of balance and fall-prevention training, and the NPTE-PTA expects you to know the standardized measures, their cutoff scores, and where PTA scope ends in vestibular care.
Standardized Balance Outcome Measures
Berg Balance Scale (BBS)
The Berg Balance Scale (BBS) rates 14 functional tasks (sitting, standing, transfers, reaching, turning, single-leg stance) on a 0-4 scale, for a maximum of 56 points. Higher is better.
- A score of 45 or below is commonly used as a marker of increased fall risk.
- The BBS is widely used to track progress across a plan of care; the PTA can administer it as a data-collection task when the PT includes it.
Timed Up and Go (TUG)
The Timed Up and Go (TUG) test times the patient as they stand from a chair, walk 3 meters, turn, walk back, and sit down.
- A time greater than roughly 13.5 seconds in community-dwelling older adults is commonly associated with elevated fall risk.
- The TUG is quick, requires minimal equipment, and is a strong PTA progress-tracking tool.
Other Common Measures
| Measure | What It Assesses |
|---|---|
| Functional Reach Test | Forward reach distance in standing; shorter reach links to higher fall risk |
| 30-Second Chair Stand | Lower-extremity strength and sit-to-stand endurance |
| Dynamic Gait Index / Functional Gait Assessment | Gait under varied task demands (head turns, obstacles, speed changes) |
Romberg and Sharpened Romberg
The Romberg test isolates the proprioceptive (somatosensory) contribution to standing balance. The patient stands with feet together:
- Eyes open: vision, vestibular, and proprioception all contribute.
- Eyes closed: vision is removed, so the patient must rely on proprioception and the vestibular system.
- A positive Romberg sign — steady with eyes open but significant sway or loss of balance with eyes closed — suggests a proprioceptive (sensory) deficit, such as in peripheral neuropathy or posterior-column disease.
The sharpened (tandem) Romberg narrows the base of support by placing one foot directly in front of the other, increasing the challenge for higher-functioning patients.
Coordination Screening
Coordination tests help identify cerebellar dysfunction. Common screens a PTA may observe or assist with:
- Finger-to-nose and finger-to-therapist's finger — tests for dysmetria (over- or undershooting).
- Heel-to-shin — lower-extremity coordination.
- Rapid alternating movements (e.g., forearm pronation/supination) — impaired performance is dysdiadochokinesia.
- Observation for intention tremor, ataxic gait (wide-based, unsteady), and nystagmus.
Vestibular Rehabilitation Basics and PTA Scope
Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo, produced by displaced otoconia (calcium crystals) in a semicircular canal. It is identified with positional tests such as the Dix-Hallpike and treated with canalith repositioning maneuvers (for example, the Epley maneuver).
Scope boundary — high-yield for the NPTE-PTA: the diagnostic positional testing and the canalith repositioning maneuvers are performed by the physical therapist, who evaluates the patient and establishes the plan of care. Within that plan of care, the PTA implements:
- Habituation exercises — repeated, controlled exposure to provoking movements to reduce the symptom response over time.
- Gaze-stabilization exercises — vestibular-ocular reflex training such as maintaining focus on a target during head movement.
- Balance and gait training, postural strategies, and fall-prevention activities.
If a patient develops new or worsening vertigo, new neurological symptoms, or unexpected responses, the PTA stops the activity and reports to the supervising PT rather than performing or modifying a repositioning maneuver.
A PTA is treating a patient who was evaluated by the PT and diagnosed with benign paroxysmal positional vertigo (BPPV). The plan of care lists habituation and gaze-stabilization exercises. The patient asks the PTA to "do the maneuver that fixes the crystals." What is the MOST appropriate PTA action?
A PTA administers the Timed Up and Go test to a community-dwelling 78-year-old patient as a data-collection task within the plan of care. The patient completes the test in 19 seconds. How should the PTA interpret and act on this result?