Balance is achieved and maintained by a complex set of sensorimotor control systems. (check What is Balance?) When any of these systems is injured or deficient, balance can markedly be affected. Therefore, it is important to have tools that can help health professionals identify if there is a balance problem and the specific nature and/or the cause of the problem. Several conditions like stroke, Parkinson’s disease, multiple sclerosis, vestibular dysfunctions, knee and foot lesions, among many others will affect balance.
Nowadays, there is technology that can quantify sway data, for example, using force and pressure plates. With those it is possible to accurately measure balance and thus establish objective baselines that are reproducible, practical and reliable, so that progress can be monitored. Using such tools, it can help differentiate balance deficits using different sensory perturbations, identify weight bearing asymmetries (for example in case of stroke there is more weight in non-paretic leg or in case of knee/foot lesion) and muscle weakness. In addition, it can help guide and evaluate the effectiveness and efficiency of rehabilitation programs to reduce risk of falling or injury.
Sensing Future has a software dedicated to assist physiotherapy activities, physical and vestibular rehabilitation and neurorehabilitation, the PhysioSensing Balance. At the moment, it has twelve protocols for balance assessment (Figure 1), which allow the identification of balance disorders and muscle strength problems in the lower limbs, using the PhysioSensing pressure plate or force plate.
Figure 1 – Protocols interface of PhysioSensing Balance software.
Brief description of the protocols available:
1- Modified Clinical Test of Sensory Interaction on Balance (mCTSIB)
This protocol allows the sway velocity measurement in a comfortable stance in four sensorial conditions: stable surface with eyes open, stable surface with eyes closed, unstable surface with eyes open, and unstable surface with eyes closed. Each condition has three trials of 10 seconds.
Figure 2 – Report example of mCTSIB.
2- Romberg Test
Use this protocol to evaluate static balance with feet together on two different surfaces (stable and unstable) with eyes open and closed for a predefined time (30s, 60s, 120s, ...). Romberg’s test helps uncover any disordered proprioception that may have been masked by vision. This test presents the Romberg’s quotient for several parameters obtained from the center of pressure oscillations.
Figure 3 – Report example of Romberg Test.
3- Body Sway
Use Body Sway to create a personalized posturography. Define initial conditions and obtain center of pressure variation, mediolateral and anteroposterior variables over time. It also includes more than 30 parameters derived from a posturographic examination including Fourier analyses.
Figure 4 – Report example of Body Sway.
4- Limits of Stability (LOS)
Perhaps the most used protocol for balance assessment in a dynamic task. This protocol quantifies the directional control and the maximum distance that the patient can reach with its center of pressure in 8 different directions – front, front/right, right, back/right, back, back/left, left and front/left, without losing balance and taking a step.
Figure 5 – Report example of LOS.
5- Fall Risk
Use Fall Risk to measure the static balance in four conditions: comfortable stance with eyes open and eyes closed, narrow stance with eyes open and closed. After performing the protocol, the value of the sway velocity index appears which allows the identification of potential elderly people at risk of falling. You can find more information about fall risk at Do you know how to assess the Fall Risk?.
Figure 6 – Report example of Fall Risk.
6- Rhythmic Weight Shift (RWS)
Use the Rhythmic Weight Shift protocol to evaluate the transfer capacity of the center of pressure rhythmically between two targets in the sagittal and anteroposterior plane, at three different velocities: slow, moderate and fast.
Figure 7 – Report example of RWS.
7- Unilateral Stance (US)
Use this protocol to measure the balance in four conditions: left foot lifted up with eyes open, left foot lifted up with eyes closed, right foot lifted up with eyes open and right foot lifted up with eyes closed. Each condition has three trials of 10 seconds.
Figure 8 – Report example of US.
8- Balance Error Scoring System (BESS)
The BESS protocol allows the measurement of postural stability for 20s with eyes closed in three different positions – two feet together, one leg standing (non-dominant foot) and tandem position (non-dominant foot behind), on two types of surfaces (firm and unstable). Read more about BESS here.
Figure 9 – Report example of BESS.
9- Static Analysis*
This protocol allows the plantar pressure distribution analysis on the sagittal and anteroposterior planes of a single pressure image, dividing the pressure image into four quadrants. You can find more about this analysis at Static Analysis 👣 What is it? Why is it so important?.
Figure 10 – Report example of Static Analysis.
10- Weight Bearing Squat (WBS)*
This protocol allows observation of weight distribution in the sagittal plane with the patient standing up with different knee flexion angles (0°, 30°, 60° and 90°), as well as the plantar pressure distribution map.
Figure 11 – Report example of WBS.
11- Sit-to-Stand (STS)*
Use this protocol to quantify the ability of the patient to lift from a sitting position to a standing position as quickly as possible, in three trials of 15s.
Figure 12 – Report example of STS.
12- Total Balance Pro (TBP)*
Use this protocol to analyze the balance integration through six key parameters - proprioception, vestibular & visual input, postural stability, lower limb strength, reflexes & response time and motor control. This protocol consists of the execution of three consecutive protocols. Read more about this combination at Get a perfect balance assessment.
Figure 13 – Report example of Total Balance Pro summary results.
* Only available in the Pressure Plate solution
As mentioned, those protocols allow the evaluation of several characteristics of balance. The mCTSIB, LOS, RWS, WBS, STS, US, Fall Risk and TBP protocols have normative values according to the patient's age. For these protocols, except Fall Risk, the normative values are for patients in the age group of 20 to 79 years. While the Fall Risk is for patients over the age of 50 years.
At the end of each protocol an interface with the center of pressure trace and the results of each condition appears. In this interface the health professional can save the results and generate a clinical report in PDF format. In case the patient has previous sessions with the selected protocol it will also appear the option to view the progress between sessions through graphs and tables. Moreover, a description of each parameter calculated in the protocol and their units can be found, and some scientific articles about the clinical application and scientific evidence of the protocol are listed.
When faced with all these protocols can sometimes be confusing, with all the different stances and parameters. To help health professionals use the right one we created a table with all the protocols available and the main conditions (Figure 14) in which they are used. This table is a suggestion of balance assessment applications based on the scientific community articles and is also displayed in the software.
Figure 14 – Table with main applications for each protocol. The protocols indicated with five dots are the best ones for that condition.
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Cláudia Tonelo
Sensing Future Technologies