Elizabeth Perez

3/13/21

Measures of balance are commonly used in the physical therapy world. Balance

impairments are often seen in older adults, so common that there are several kinds of balance

outcome measures. In the clinic, many older adults come in due to their gait and balance

impairments. The way that they are determined to be at a high fall risk is by having the patients

perform a series of outcome measures. The one often used outcome measure in my clinic is the

4-stage balance test. It is used on all patients who come in with balance impairments. I have not

seen the outcome measure be performed alone without the integration of other balance measures.

In older adults with balance impairments, should the four-stage balance test be used as an

assessment tool alone for balance, compared to using it in combination with other outcome

measures?

Falls in older adults are very common and can lead to serious injury. Falls are a big

reason why older adults can lose their independence and even double the chance of falling again

CDC (2017). According to the CDC (2017, 2020) billions of dollars are spent annually on

patients due to falls and less than half are known not to report it to their doctor. There are several

fall prevention programs that one may follow that have shown effectiveness. Patients who I have

gotten to know very well, are often in therapy from an injury caused by a fall. Falling is very

dangerous and really can lead to bad outcomes. That is why it is important that therapist use as

many resources as possible to help prevent this.

I chose the four-stage balance test as my outcome measure because it is a measure

commonly used by my CI. Not only was it commonly used by my CI, but articles found through

Pub Med, a study by Franchignoni (1998) suggested that single-leg stance and tandem stance

were reliable and valid when it came to assessing balance. The study chose 4 different outcome
Elizabeth Perez
3/13/21
measures to assess balance, tandem stance, single-leg stance, functional reach, and sit-to-stand

test. Specific to tandem stance and single-leg stance, the interrater reliability provided enough

consistency that both stances scored well using KAPPA values. However, Hile (2012) questions

validity due to individuals who require support during the stance. “Even when considering only

individual performance as part of clinical decision making, providing upper-limb support could

inflate the hold time and lead to the inaccurate characterization of ability, including failure to

recognize subtle deficits” (Hile 2012). I agree with Hile, providing support would completely

alter any score, however, Franchignoni's (2018) study did not mention anything about upper limb

support but instead provided information in the age range of the participants being over the age

of 55.

There were no large barriers when trying to find evidence regarding this outcome

measure. However, there are no constructive articles or study’s that prove that the four-stage

balance test is enough to be used alone. This outcome measure appears to be used with other

assessments for balance. One article by Tisher et al. (2018) used the four-stage balance test as a

home exercise program for patients and did a pre- and post-assessment using the Timed Up and

Go and Berg Balance Scale. The patients who performed the home exercise program had made

improvements on their score resulting in the reduction of fall risk. This article helps state that

performing the four-stage balance test, does indeed help progression, however, does not state that

it can be used alone. Another article by Mols et al. (1970) came to the conclusion that balance

training helped improve a patient’s functional status. The article was based on patients who had

undergone chemotherapy and resulted in impaired balance. However after a series of exercises

involving the stance position, functional improvement in patients were noticed.

Elizabeth Perez
3/13/21
The patient population that I selected for the outcome measure of the four-stage balance

test where patients with high fall risk. I did the test with 2 patients who fell into the category of

older adults. Both patients came into the clinic about 2 to 3 times a week, for three weeks. Week

one- patient one held tandem stance for 3 seconds, patient 2 was able to hold tandem stance for 5

seconds. This was performed on the left and right lower extremity and with no support following

all CDC guidelines. The CDC (2017) suggests that, if a patient is under 10 second’s they are

considered to be fall risk.

With the results from week one, my CI was able to make adjustments to the plan of care

for each patient due to their scores on a variety of balance measures. Also taking into

consideration their differences in medical history. Each patient had a significant difference in

medical history however fell into both category of older adult and fall risk. Over the remaining

two and a half weeks, I was able to practice this test over and over with patients along with other

balance outcome measures. The patients at the start needed guidance and cueing and occasional

breaks due to how weak they were. At the end of week 3, both patients had shown progress,

patient one was able to hold tandem stance for 7 seconds and patient two was able to hold

tandem stance for 9 seconds. Over the course of their treatment sessions, there were many gait

and balance implications to their plan of care. They were also given a home exercise program to

help their progression, patient one reported practicing the stance and exercises at home during

their spare time. Patent two had also reported the same however had difficulty due to

experiencing fatigue.

The results of the patient's scores from the 4-stage balance test made the indication that

they were at a high fall risk. However, at the very end of week 3, their time was significantly

increased indicating that they were now at less of a chance of falling. I believe that the test
Elizabeth Perez
3/13/21
cannot be used alone because although it can be a helpful indicator of fall risk, it does not take

any differences between patients into consideration. This test is better when used with other

outcome measures to be able to help patient progression. Combining this test with others will

help indicate what a patient needs in terms of care. If the test was used alone without any other

outcome measures, Validity would be in question. Patient’s medical histories range from a wide

variety and even if they fall in the category of fall risk, and older adult, the test alone would be

insufficient. Patients need more than one outcome measure to perform to help their progression,

because the more information provided, the better it is to improve patient care.
Elizabeth Perez
3/13/21
Centers For Disease Control And Prevention . (2017). 4 stage balance test .
https://www.cdc.gov/steadi/pdf/4-Stage_Balance_Test-print.pdf. 

Centers for Disease Control and Prevention. (2017, February 10). Important Facts about Falls.
Centers for Disease Control and Prevention.
https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. 

Centers for Disease Control and Prevention. (2020, July 9). Cost of Older Adult Falls. Centers
for Disease Control and Prevention. https://www.cdc.gov/falls/data/fall-cost.html. 

Centers for Disease Control and Prevention. (2020, October 8). Older Adult Falls. Centers for
Disease Control and Prevention. https://www.cdc.gov/falls/index.html. 

F. Mols, T. B., M. Seretny, G. L. C., CT. Pike, H. G. B., KM. Winters-Stone, F. H., Schie, C. H.
M., JC. Brown, M. O. H., … CMI. Beijersbergen, U. G. (1970, January 1). It's never too
late - balance and endurance training improves functional performance, quality of life,
and alleviates neuropathic symptoms in cancer survivors suffering from chemotherapy-
induced peripheral neuropathy: results of a randomized controlled trial. BMC Cancer.
https://doi.org/10.1186/s12885-019-5522-7. 

Franchignoni, F., Tesio, L., Martino, M. T., & Ricupero, C. (1998). Reliability of four simple,
quantitative tests of balance and mobility in healthy elderly females. Aging Clinical and
Experimental Research, 10(1), 26–31. https://doi.org/10.1007/bf03339630 

Hile, E. S., Brach, J. S., Perera, S., Wert, D. M., VanSwearingen, J. M., & Studenski, S. A.
(2012, October 1). Interpreting the Need for Initial Support to Perform Tandem Stance
Tests of Balance. OUP Academic.
https://academic.oup.com/ptj/article/92/10/1316/2735160. 

Tisher, K., Mann, K., VanDyke, S., Johansson, C., & Vallabhajosula, S. (2018). Functional
measures show improvements after a home exercise program following supervised balance
training in older adults with elevated fall risk. Physiotherapy Theory and Practice, 35(4),
305–317. https://doi.org/10.1080/09593985.2018.1444116