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How to evaluate balance disorders in patients in the primary care setting

Balance and gait problems may contribute to significant morbidity. A thorough evaluation increases the likelihood of an accurate diagnosis, proper treatment, and reduced risk of falls.

John E. Lopes, Jr, DHSc, PA-C

John Lopes practices at the Fall and Balance Center for Assessment and Rehabilitation, Carls Center for Clinical Care and Education, Mount Pleasant, Michigan, and is assistant professor at the Central Michigan University PA program. He has indicated no relationships to disclose relating to the content of this article.

Balance requires an ability to integrate sensorineural, vestibular, and musculoskeletal inputs and react with coordinated muscle responses.¹ Balance problems are common, and as many as 8 million patient visits to a primary care provider per year are attributed to difficulty maintaining balance.² An estimated 50% of patient referrals to ear, nose, and throat surgeons are related to balance problems.³ Additionally, balance disorders and falls contribute significantly to morbidity in the elderly. One-third of community-dwelling adults older than 65 years and half of those older than 80 years fall each year; the rate of falls is similar among the institutionalized elderly.⁴ Although only 10% to 15% of falls result in significant injury, many patients are hospitalized for evaluation or treatment after a fall, and falls are listed as a precipitating factor in up to 40% of nursing home admissions.²

Tinetti and colleagues identified a number of factors that contribute to increased risk of falls in the elderly.^5,6 The physiologic effects of aging on the musculoskeletal system, visual problems, medication side effects, and environmental factors can increase the prevalence of balance problems and the risk of falls. Tinetti’s team also noted that routine physical examinations may not adequately identify balance problems and their causes.⁷

Dizziness may be a symptom of diabetes, chronic obstructive pulmonary disease (COPD), stroke, dementia, or traumatic brain injury.^8-11 The assessment of fall risk can significantly reduce morbidity and mortality in patients with these diseases and conditions. In addition, patients with diabetes are at increased risk of having skeletal abnormalities such as Charcot’s joint that interfere with normal gait and mobility. Patients with diabetes and neuropathy or retinopathy have altered sensorineural and proprioceptive sensation, further increasing their risk of falls.⁸ The chronic hypoxia of COPD reduces exercise tolerance, increases fatigability, and reduces muscle mass, all of which can increase fall risk.⁹ Changes in the biomechanics of the neck in patients with whiplash- associated disorders alters sensorineural inputs that result in difficulty with balance and complaints of dizziness.¹² Patients suspected of being at increased risk for falls should be asked if they have balance problems, experience falls, or have a fear of falling.

SELF-REPORT EVALUATIONS

Balance problems can be readily evaluated in the office setting using the clinical history, a physical examination, a self-report questionnaire, and several clinical evaluation techniques. Routine physical examinations include general neurologic and musculoskeletal assessments; however, including one or more additional clinical evaluation techniques will enhance the assessment of a patient who has a balance problem or is at increased risk of falling. The most commonly used questionnaires are described below. A high score on the Dizziness Handicap Inventory (DHI) or the Survey of Activities and Fear of Falling in the Elderly or a low score on the Activities-Specific Balance Confidence Scale should prompt a more in-depth clinical evaluation.

The Dizziness Handicap Inventory is a 25-item questionnaire developed to quantify the effect of dizziness on quality of life¹³ (see Figure 1). The perception of a heightened fall risk can cause a person to alter his or her behavior. For example, a patient may avoid some physical or social activities because of a fear of falling. The DHI questions rate quality of life in three categories: emotional (9 items), functional (9 items), and physical (7 items). The patient responds to each item with one of three responses: Yes (4 points), Sometimes (2 points), and No (0 points). The point values are totaled, and the higher the score, the greater the likelihood that balance problems are having a negative impact on the patient’s quality of life. The DHI can be administered before and after a therapy regimen to determine the effectiveness of therapy.

The Activities-Specific Balance Confidence Scale asks the patient to rate his or her perceived balance confidence when performing 16 different tasks on a scale of 0% to 100% (0% = no confidence; 100% = totally confident)¹⁴ (see Figure 2). The items on the scale represent varying levels of difficulty. The total score is an average of the scores of the 16 items. Lower scores are associated with a greater perceived risk of falling.

The Survey of Activities and Fear of Falling in the Elderly is a questionnaire that asks the patient to rate his or her avoidance of 11 activities of daily living (ADL) based on the person’s fear of falling.¹⁵ ADLs include personal care, mobility, and social activities. A series of questions is posed for each ADL:

Do you currently perform this activity?
If yes, how worried are you about falling when performing this activity?
If no, do you avoid this activity because you are worried about falling?
If you are not worried about falling, what are your reasons for not performing this activity?

A 4-point Likert scale is used to generate the total score. Higher scores are associated with a greater fear of falling and increased risk of falls.

CLINICAL EVALUATION

The evaluation starts with a comprehensive history that includes a detailed description of the nature of the complaint. The presence of comorbidities is significant. For example, patients with diabetes who are taking insulin and sulfonylureas are at risk for hypoglycemia, which can cause dizziness. The ability to be attentive to surroundings is required to maintain balance; therefore, patients with dementia and its concomitant attention deficits may have difficulty with balance. Additional comorbidities to consider are anemia and cardiac arrhythmias.

A medication review is especially important. The Beers Criteria identify medications that should be avoided in the elderly because of their potential for increased toxicity and drug-related adverse effects, including dizziness, in this patient group.¹⁶ Many of the psychoactive medications used to treat depression and other mood disorders list dizziness as a side effect.⁶ Medications that affect visual acuity also increase the risk for falls.

Observation is probably the most overlooked evaluative component of the physical examination.⁷ The PA should attempt to observe the patient with a balance problem and/or complaint of falls as he or she enters the examination room. Is the patient able to rise from a chair without assistance? Does the patient move to the edge of the chair and use his or her arms to push up? Does the patient require assistance when turning or bending to pick up something on the chair or floor? At this time, the PA should observe the patient’s posture and gait; take note of whether the patient uses a cane or walker; and assess stride length, symmetry, and whether the patient shuffles or stubs the toes when walking. Note whether the patient is able to walk along a straight path without significant deviation. As the patient enters the examination room and sits down, does the patient flop down or end up off center on the seat?

Visual acuity should be assessed because poor vision is a contributor to balance problems and increased risk of falls.² Loss of depth perception and poor contract sensitivity are also associated with increased fall risk.

Additional assessments include orthostatic BP measurements and heart rate and rhythm. The neurologic examination should assess the presence of spontaneous nystagmus, symmetry of deep tendon reflexes, and sensation in the lower extremities. Positioning tests of the great toe are used to assess proprioception. Anteroposterior stability is assessed with Romberg’s test performed with the patient’s feet together (a narrow base) and eyes closed.

BALANCE AND GAIT TESTS

Several easy-to-administer tests are validated for evaluating balance problems and fall risks. These tests can be administered in the examination room or at the bedside. They provide additional information on the extent of the patient’s balance problems. The equipment needed to administer these tests are a timing device (a watch with a second hand will do; a stopwatch is better), a line on the floor, and a standard chair with arms.

The sharpened Romberg’s test (tandem stance) assesses lateral stability. In the tandem stance, the patient places one foot in front of the other, heel touching toe, with his or her eyes closed.^17-19 A patient who is not able to maintain this position for more than 10 seconds is at increased risk for falls.

The unipedal balance test is used to detect subtle balance impairments.²⁰ The patient is asked to stand on one foot with the other foot raised 2 inches off the floor and not touching the other ankle or foot. Increased fall risk is associated with an inability to remain in that position for at least 5 seconds.

The timed 360-degree turn test assesses dynamic balance.^18,20 The patient is asked to turn in a circle while taking steps. An inability to complete the maneuver in less than 4 seconds indicates an increased risk of falling. A similar test is the 180-degree turn test, where the number of steps the patient needs to turn halfway around is counted.²¹ Staggering during the turn, an inability to pivot during the turn, using five or more steps to complete the turn, or taking 3 seconds or longer to accomplish the turn are indicative of problems in turning while walking.

The five times sit to stand test is used to assess lower extremity strength.²² The patient is asked to rise from a standard chair, with arms folded across the chest, five times consecutively. The ability to rise from a chair requires vision, proprioception, balance, and sensorimotor skills. An inability to complete the maneuver, standing and sitting back down in less than 14 seconds, indicates an increased level of disability.

The tandem walk test can be administered if space allows.²⁰ The patient walks heel-to-toe in a straight line and the number of missed steps is counted. Typically a measured distance is used, varying from 3 to 10 meters. A missed step is defined as heel not touching toe, stepping off the line, loss of balance, or requiring support. Fall risk increases with a higher number of missed steps or an inability to complete the test.

Gait tests should be administered to test slow and fast gait speed.²³ The patient is asked to walk a measured distance at his or her usual pace, using a cane or walker if necessary. The patient is then asked to walk the same distance as fast as he or she can. The patient’s ability to increase gait speed indicates an ability to respond to environmental changes and task demands such as crossing the street or reacting to the sudden appearance of an obstacle.

CONCLUSION

A comprehensive history is an important component of the initial evaluation of balance problems. Self-report questionnaires help to further assess the patient’s condition and its effects on quality of life. A thorough physical examination should include simple observation of the patient entering the examination room. One or more gait and stability tests are administered to further evaluate the patient’s risk of falling. A self-report questionnaire score that indicates an increased risk of falls or a heightened fear of falling or any abnormal finding on a clinical evaluation of balance should prompt a referral to a physical therapist who specializes in gait and balance rehabilitation. JAAPA

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