Background/ Aim: Measuring balance is often part of the start of a treatment, especially when we are talking about “fall Prevention” programs, and of course we need to know the state of balance and how the treatment is taking effect.  But are we aware that we actually know nothing after these tests? 

Design: Looking at a number of balance tests, the conclusion is that many exist and that they can indicate when the values deteriorate to the point that balance is at risk.

Result: Balance measurements can serve as an indicator of balance and of the treatment, but they cannot indicate why the balance is reduced and therefore cannot show what should be done about it.

Discussion and conclusion: Measuring balance is a foundation for identifying deterioration, but once the influence of the tests has been exerted, it becomes essential to examine and test all the indirect and direct systems that control balance. All systems influence each other, but there is only one system that is fast enough to detect and respond in time, and the focus and treatment should be directed there. Such a treatment must comply with training rules but also requires the understanding that not every older adult can meet them, so for some older adults, falls cannot be prevented through training.

Balance is one of the greatest problems that threatens the health care in many countries where the population is aging. In all those countries their goes a lot of money to the treatment of accidents after a balance collapse and therefore there is now also a lot of money needed to “prevent” older people from falling and especially falling with severe impacts. [1,2.,3.4.5.]  The effects of this Fall prevention aren’t clear when we look at the numbers of people that are going to hospital after a fall and with a fracture, but is that the right way of interpretation and is the word “prevention” right? [6]. Prevention suggests that it can prevent something, which is actually a utopian idea in the case of falls among the elderly. Delaying fall problems is actually the primary goal, but if training is no longer possible or no longer effective, there is a significant risk if such a person still attempts to exercise. Fries J. [6] conducted a study into how dependent people are on their basic health in order to function optimally in old age, and it became clear that people with less ability, but also less training, clearly have a poorer prognosis, and that progress can still be made in the preliminary phase. We know, for example, that the risk of falling is greater in people with neurological disorders [8,9,10] than in people of the same age without neurological disorders.

Figure 1: Study between athletes (runners) and a control group who did not participate in sports. Both groups were monitored during the final period of their lives to determine what level they could maintain and how healthy they remained.

It is clear that people who participate in sports maintain their abilities for much longer and at a much higher level compared to a control group. However, both groups experience a decline in ability, which is an important factor. Both groups are eligible for fall prevention programmes, with the control group starting much earlier and continuing for longer, but in the end, it will become increasingly difficult to maintain fitness at the desired level and the risk of falling will only increase. This means that there is a limit, but just before that limit there is a lot that can be done, provided we know what the problem is and whether it can be trained or treated. That is why it is very important to go further than just doing a balance test, because then we still do not know much and very often do not know at all why someone falls.

Examples of balance measurements test.

The first example is the Berg Balance Test. 

Figure 2: A test consisting of 14 items that start with sitting to standing and continue up to standing on one leg. Basically, it covers everything except that for someone who has had a stroke, it matters which leg is used for the test.

The cut-off point is 45 points, which is a score where there may be a risk of falling.

An increase or decrease of 6 points is a sign of significant change [11-14].

Figure 3: Reaching forward in a standing position requires a certain amount of control, and this control partly determines the distance that can be reached. By reaching along a measuring stick, one can immediately see the achieved distance. By conducting many tests at all ages, an average value emerges that can serve as a standard. This made it possible to identify people who were vulnerable and would decline fairly quickly. Reduced ability to reach has shown increases in future falls with odds ratios of 8.2 if unable to reach at all and 4 if able to reach < 5>

Table 1

So, both tests indicate a limit, with a warning that there is a risk of falling, but do they also say something about the cause?

Up and Go-test. Tinetti One-leg St.

Figure 3, 4, and Photo 1: Up and Go test, Test de Tinetti, one leg standing with at the top with closed eyes [17-22].

Again, testing where you can read from the result what the balance power is; once again there is a cutoff point indicating: 'this is where it can/becomes dangerous!'

Special attention for the Senior fitness test (Rikli and Jones [23,24], because it is much more comprehensive and indicates the level of both men and women of different ages.  Here we can see differences and it becomes possible to identify deficiencies and therefore better target treatment. Certainly, the combination of various tests therefore makes the other tests redundant, especially since the aforementioned tests are included. Because of the results for different ages, the threshold is much clearer and fairer for each person in terms of gender and age, but this still represents the average. And although we have come closer to understanding the why, we still do not really know why balance ability is lower and near the threshold, nor do we know which treatment is best.

Figure 5: Standing up as fast as possible in 30 seconds. Figure 6: Bend the elbow with a weight as much as possible.

Figure 7: Mobility for the shoulders and important for the ADL.

Figure 8. 6: Minutes walking test (cardio-pulmonal) Figure 9. Step-test, one leg standing item.

Figure 10: Reach test to the feet, an item to observe the mobility. Figure 11. Up and Go test.

Figure 12 and 13: The results by man and woman is thus an average number what the tests are, of course, a clear indication of where a person scores lower, and they certainly provide some clues about where someone scores less well, but again, it is not possible to clearly determine after testing where the problem lies and what can be done about it. That means the investigation needs to go in-depth to find the right cause. Guidelines consistently highlight a number of essential elements that need to be tested to obtain a complete picture, but the equilibrium system has various mechanisms that can trigger the system, yet these mechanisms are unable to restore balance within the required time [25-27]. 

Items that always must be assessed by balance training/assessment are:

1. Eyes /ears. The scanning ability of the eyes to the environment is important for building alertness, but in older adults, we often see that this scanning ability is used primarily to observe where the feet should be placed, which means that objects further away are not seen. This is therefore an adjustment to another issue, namely that the sensation and perception in the feet are not optimal.   

2. Dizziness. Dizziness presents an additional problem, as it causes the vestibular system to provide incorrect information, requiring the brain to perform extra work to recalibrate the body in space, whereas the process should ideally occur the other around. 

3. Mobility and Balance sec. At the end of this list.

4. Incontinence. The tension and increased attention cause risks to be taken more quickly, and also the phenomenon that the pressure on the sphincter muscles rises rapidly compared to a lying position.

5. Medication. It is clear that careful consideration must be given to their effects, as low blood pressure can cause dizziness, but also delay reactions or even reduce muscle tension [28].

6. Home and environment factors [29]. These factors often indicate that balance checking has become more difficult and that an update of the home and environment is necessary, and the aids are already is use.

7. Pain [30]. The impact of pain on movement is significant and can therefore hinder balance recovery.

8. Inflammations [31]. Inflammation also has a negative effect on our balance ability. 

9. Tone, especially pathological tone [32,33]. We see pathological tone in neurological disorders, and measuring this tone is therefore essential to know what influence it has, especially on movement speed. Particularly in balance recovery, speed is an essential element and can thus be decisive. The measurement is performed passively and often in an “rest”-position, and then it appears that this increase in not so necessary. The difference between measurement in the sitting or standing position of the elbow was significant higher [33]. Higher tonus in elbow is a sign of higher tonus in the entire back of the torso and one of the reasons why walking backward often can end in a fall [35]. 

Ad.3. Mobility and Balance sec. [27] This is the central system capable of detecting and responding well within time. The detection involves weight shift and approaching limits, and the reaction of muscles patterns creates a counter-movement to correct it. All other systems require more time and are therefore actually used to detect danger and make correction unnecessary and/or to keep the system extra alert. This system monitors the borers and intervenes, but at the same time, the system is at its sharpest when things “almost” go wrong at the border and everything must be brought out to restore balance on the spot or with an excursion- step. 

Figure 14: This figure shows how the information about weight change is transmitted from bottom to top, and the times are indicated when the information and reaction reach the specific points. The weight shift and especially the perception under the feet are therefore essential information for this system, so testing that input is essential.

The limit of balance is monitored by applying an inhibitory strategy with the possibility of a stepping strategy. Here, we already see the first adjustments with aging (around 40). A simple ankle strategy is no longer sufficient and both the hip (back) strategy must be employed to enable a stepping strategy [36,37].

Figure (15 -22): At or beyond the boundary, a reaction is required in trunk and fee. Falling forward: trunk backward and on the toes. Falling backward; trunk forward and forefeet up. Falling sideways; an elongation in the trunk/hip beyond the lateral limit of the foot. These actions are necessary to gain time for a weight shift to one leg. Falling forward: place free leg to the forward, backward fall free leg to the back, and sideways, cross and then shorten trunk/hip to place the free leg far outside.  Here we see the first problems in the adaptation process due to various changes in body and muscle patterns. This element, which is fundamental for optimal balance control, will never be clearly revealed in all balance tests.

Balance adjustments. This starts much earlier than most people realize, and that is possible because the balance system has so many possibilities, but more frequent falls can also be related to reaching the limit of the adjustments. Every change can affect balance, and the system will immediately seek a solution, which ranges from- more eyes on the ground, walking with an aid, etc. 

Figure 23: A body that “collapses” and changes shape due to aging. A fairly normal process and not an immediate reason for balance problems.

Of course not, because these people actually still perform reasonably well on all balance tests since they adapted their system. However, this adaptation does have consequences for muscle patterns and muscle power. Observe the red line starting at the ear and then going vertically downward. Normally, it falls in or behind the heel, but if the trunk flexes more due to changes in the spine, such as lumbar stenosis (44-49% of older adults between 60 and 70 years old [40]), this line first ends in the middle of the foot and, in the last figure, even in the toes. This has major consequences for the posture and, in particular, muscle activity. If the left side in figure 23 is actually relatively relaxed, the back of the neck, from the calf to the back, will have to work much harder and more consistently to prevent a forward fall. Walking in this position will therefore require a quick foot placement with immediate power in the plantar flexors to regain control, and heel strike and roll-off will no longer occur because there is no time for it. This means that the muscles in the back are trained, but the muscles in the front will lose their power. Postural control is back under control, but balance control, and especially control at or beyond the limit, becomes a major challenge.

Falling forward, for example, when stumbling, is almost impossible to prevent because so much of the torso is already in front of the hip. Falling backward becomes very difficult, but if it does happen, dorsiflexion strength is negligible, and especially with neurological conditions, the back is too stiff to expect more flexion. Falling sideways is precisely the compensation because the spine can barely achieve optimal extension and shortening due to the flexion. Therefore, care is taken to remain within the base of support while maintaining independence, and they perform quite well in tests as long as they are allowed to remain within the base of support. This is where the problems arise when muscle patterns are no longer complete, or perception is impaired, and/or selectivity (pathological tone) is impaired, in which case we see a lower score on balance tests.

Photo 2: The gentleman still scores well on the Berg Balance Scale, but the woman is around the cutoff point. His confidence in movement is also clearly much higher. She has difficulty with proper positioning and a static examination [Statiek 41-44] clearly showed “gaps” in her muscle patterns, preventing her from building the same stability as her husband, who, despite his posture, had full control. He was asked often asked to let go of his arms, but that is poor advice, as this technique makes posture and balance control easier.

So, when the tests become more difficult, we may be “too late” to still do anything to improve the muscle pattern for balance, as shown the research by Robinovitch et al., [45]. That research showed that people living in long-term care facilities usually fell due to incorrect weight shifting (41%) with stumbling in second place (21,1%). Of course, treatment is still possible here, but the effect will be poor. Therefore, in addition to these balance tests, we should actually check everything, but especially the muscle patterns. By testing these muscle patterns, it becomes possible timely identify where a “mistake” occurs in detection and reaction, and nit makes it possible to train this according to the training rules [46-48]. Thus, balance tests can never find the reason why balance deteriorates.

How then to test the muscle patterns and how to train?

The practical technique “statiek” developed by G. Worm [41] requires practical training before investigative ability is optimal and can actually be used immediately as a training possibility. Muscle pattern training should comply as much as possible with task-specific [50] training and with training rules where fatigue of the muscle pattern is an essential stimulus to improve coordination and power. And task-specific training therefore requires, in balance training, situations in which limits are explored and even exceeded, and practicing in water [51-57] should actually be the first option. And this actually applies to everyone who needs training. The group that still notices that they sometimes fall, up to people who are able to maintain their balance with aids, and especially the group with pathological tone.

Picture 1 and 2: “Statiek technique” at the front at hip and shoulder height. To keep the situation safe, there is a table behind, yet this can again have a disadvantage because sometimes people focus too much on it. Of course, this can also be done by the therapist in a standing position, but from a seated position it often provides more safety.

Picture 3 and 4: “Statiek Technique from behind”. The same safe situation applies here, and the handling (front, back, and sideways) must be never “comprehensive”. So, no thumb on the front when pulling forward, because this gives everyone information, and everyone will very quickly use that point as an extra “stabilization point”, which will cause the entire test to fall.

Ask the person to respond immediately and appropriately to a light pressure(pull). Clearly show that your hands (lumbrical grip) go to the hip, and often someone will already start responding, which gives us an indication that he/she understands the task. The pressure is very slight, so notice what happens: adjusted counterpressure-immediate, too late, too much, or a combination- and whether it is the same on the left and right. Also, how does that counterpressure feel? Is it a “board”, completely under control, and if so, let the pressure (pull) increase and feel and observe?

Does the reaction increase properly and are there indications that measures are taken when the limit reached?   Reaction for: dorsiflexion of both feet (is it the same in terms of time, speed, and strength) and simultaneously flexion in the trunk n (left and right equally fast and equally far), furthermore at the limit there is a weight shift to one leg and is it always the same leg. And is the stepping strategy optimal.  Reaction behind: plantar flexion and trunk/hip extension, and what is the reaction at the end and is the stepping strategy optimal. The phenomena that a reaction to light pressure can be addressed with an optimal “board” response, but any hesitation is a sign that something is functioning less well somewhere, which can be in detection and/pr response. Through repetition, it is also possible to feel whether the person has reserve and improves their reaction, or if there is clearly something missing. For example, if one leg is consistently later or too late, this can be a sign of a joint problem, incomplete muscle pattern, leg length difference, or pathological tone. A consistently delayed but still good “board” reaction may indicate a perception problem. The “brake” reaction at the limit, if there are differences, calls for further investigation of, among other things, muscle pattern and tone. Pathological tone often does not seem to test task-specific, but test (photo 3) provides best insight.

Photo 3: Lifting one leg requires stabilization and control of the other leg and its corresponding diagonal [59,60].

When the neurological system is damaged, extension from the hip to the heel with dorsiflexion is often no longer optimal, and we see a pathological extension synergy with less control and plantar flexion. With maximum resistance, this also indicates how severely the system is damaged.

Pathological synergies will usually show a weight shift away from the leg and, of course, the characteristic extension synergy movement of adduction and internal rotation, starting in the hip.  “Statiek technique” sideways, as show in the figures 5 and 6, perform this with one hand on one side and do not use the other hand on the opposite side for safety, because almost everyone will use that hand, makes the test meaningless. Again, start with the movement toward the hip/shoulder and observe the reaction: usually, there is already movement before any pressure is applied. Start with light pressure and keep in mind that the hip (greater trochanter) is at or even outside the lateral edge of the foot, so the reaction should occur immediately at that level. If that “board” is not immediately there, this points to a perception problem, but if it has been there for an while, it is also a muscular inability and is resolved by the other leg. So immediately band above the lateral edge of the foot, after that the pressure can be increased up to limit.

Picture 5 and 6: The “statiek technique” sideways with one hand.

The sideways reaction must immediately from a “board” at the height of the lateral edge of the foot. At the moment the sideways pressure becomes so high that the limit is reached, the hip extends far over the lateral edge and the foot tilts, the torso lengthens, and the free leg crosses to then become the support point for an additional sideways step.

NBpow we know how complete the muscle patterns are and we can also train in an adapted way to bring coordination and power up to level or improve them. Task=specificity is essential in balance training, so ensure optimal safety and consider practicing in water. This is necessary for people with neurological disorders because, due to gravity, the damaged brain must make this adjustment, and thus an essential component of balance control and balance recovery is speed, which is not possible with high muscle tone. In water, this high muscle tone is no longer necessary, and some of the speed can also be incorporated into task-specific training, and water will respond with resistance at increased speed, which can again be used for power training, fall training, but also perception training.

Rolling out some form of training for the elderly to better protect them against the consequences of falls requires the right timing and reaching the right people at the right moment. It is clear that this is very difficult, which is why the idea of using balance tests to indicate to people that they are at risk, as well as asking about their history of falls, is very logical. From there, one can start training to improve balance.

Unfortunately, the name “fall prevention” suggests that these programs are capable of preventing falls, which is a bit of an overstatement. Balance tests indicate that there may be a problem, but they do not reveal what that problem is, which means that the balance assessment has only really just begun, and the balance tests are only able to indicate that it is not optimal and whether training has produced results or not.  A good treatment examines everything (including all the senses), but the essential elements are the muscle patterns that are fundamental for maintaining/restoring balance, and this system has often been working for years to optimally adapt to the changing and aging body and “learn” from these adaptations. Because that also provides the first signal that there is a limit to that balance control/restoration. Particularly the detection and the response b (muscle patterns) remain the foundation for reacting in time, and that requires training  that adheres to training principles and also honesty toward the person if this is no longer achievable.