A Study of the Clinical Test of Sensory Interaction

and Balance
Helen Cohen, Cathleen A Blatchly and Laurie L
Gombash
PHYS THER. 1993; 73:346-351.

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 Research Report

A Study of the Clinical Test of Sensory Interaction

and Balance

Background and Purpose. The ability to maintain a n upright position dun'ng Helen Cohen
quiet standing is a usefil motor skill. The Clinical Test of Sensory Interaction and Cathleen A Blatchly
Balance is a n inexpensive, easily administered test that provides information Laurle L Gombash
about the ability to stand upright under several sensory conditions. Subjects.
Three groups of neurologically asymptomatic (AS) adults, divided by age into
younger, middle-aged, and older groups, participated in the study. A fourth group
comprked subjects diagnosed with vestibular disorders. Metbods. Timed perjor-
mances under six dzrerent conditions were compared across groups. Results.
Subjects with vestibular disorders were signifcantly impaired o n perjormance
when compared with age-matched AS subjects. Older AS and vestibularly impaired
subjecrs had greater variation in their scores than did younger AS subjects. Con-
cluston and Dlscussfon. This test is a usehl screening tool for examining
static standing balance. [Coben H, Blatchly GI,Gombash LL. A study of the Clini-
cal Test o f Sensory Interaction and Balance. Phys Ther. 1993;73:346354..]

Key Words: Balance, Equilibrium, Posture, Tests and measurements, Vestibular

system.

A
Successful performance of some daily ment of balance.' These sophisticated Therefore, a simpler, less expensive,
life tasks, such as reading the titles of systems, however, are expensive and valid, and reliable test is needed.
books on a shelf, requires the ability often impractical for use by a thera-
to maintain an upright position. For pist in a typical hospital or private The Clinical Test of Sensoq Interac-
this reason, many physical therapists practice. They require considerable tion and Balance (CTSIB) is a timed
are concerned with their patients' floor space, special training, and com- test that was developed for systemati-
ability to perform this motor skill. We puters. These resources may be un- cally testing the influence of visual,
will refer to the ability to maintain an available to the clinician who would vestibular, and somatosensoq input on
upright position during quiet standing like to be able to test patients' bal- standing balance.2 This test is inexpen-
as "balance." Force platforms, electro- ance, but who lacks funds to purchase sive, requires minimal equipment, and
myography, and motion analysis sys- sophisticated equipment or who must is currently in use by some clinicians.
tems have all been used for assess- carry equipment from place to place. Conditions 1,2, and 3 involve standing
on the floor with eyes open, eyes
closed, and wearing a visualconflict
H Cohen, EdD, OTR, is Assistant Professor, Department of Otorhinolaryngology and Communica- dome. The dome provides a sensoq
tive Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 (USA). She was conflict by depriving the subject of
Assistant Professor, Program in Rehabilitation Science, and Assistant Professor, Departrnent of Oto- peripheral vision and introducing a
laryngology, Medical College of Ohio, Toledo, OH 43699, at the time of this study. Address all
correspondence to Dr Cohen. sway-referenced image. Use of the
conflict dome results in a discrepancy
CA Blatchly, PT, is Assistant Professor, Program in Physical Therapy, Medical College of Ohio between vestibular input stimulated by
LL Gombash, PT, is Physical Therapist, Medical College Hospital, and Clinical Lecturer, Departrnent postural sway and visual flow.' Thus,
of Otolaryngology, Medical College of Ohio. conditions 2 and 3 should examine
This study was approved by the Institutional Rwiew Board of the Medical College of Ohio. different aspects of sensoq organiza-
tion of visual information that may
This article was submitted February 18, 1992, and was accepted January 29, 1993.

Physical Therapy/Volume 73, Number 6/June 1993 346 / 9

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require different postural adjustments.3
That is, condition 2 examines how
well subjects maintain balance in the
absence of any vision, and condition 3
examines how well subjects maintain
balance when vision is present but that
information conflicts with vestibular
information.
Conditions 4, 5, and 6 involve stand-
ing on foam and repeating the visual
conditions described for conditions 1
through 3. For each condition, the
length of time the subject can main-
tain standrng and the amount of body
sway that occurs are assessed.
Although norms for this test have
been established for children and
young adults, norms for performance
on the CTSIB have not been estab-
lished for older adults and patients
with vestibular deficits.4.5 Currently,
the CTSIB requires performance of at
least one trial on each of the six con-
ditions. Some investigators have ques-
tioned whether the eyes-closed and
the visuab'vestibular-conflict condi-
tions produce different performance.
Billek-Sawhney5 found no differences
on measures of duration and sway
amplitude in the eyes-closed and
visual-conflict conditions in neurologi-
cally asymptomatic (AS) young adults.
No studies in the literature address
these issues in older adults and indi-
viduals with vestibular disorders.
It is unclear whether patients improve
on repeated trials on the CTSIB, be-
cause different investigator+ have
used different methods for calculating
performance times and amount of
sway. Physical therapists have advo-
cated the use of balance retraining
that involves repeated exposure to
different sensory conditions when
standing,7 but no studies have distin-
guished between motor performance
on this test and motor learning as a
result of practice. Determining the
need for repeated trials during assess-
ment would be useful.
'Alimed Inc, 68 Harrison Ave, Boston, MA 02111.
10 / 347
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These findings suggest that the CTSIB
should be studied further. Previous
findings suggest that therapists using
the CTSIB should expect performance
on this test to vary with respect to age
and health status.6.S10This study had
several goals: (1) to determine
whether healthy adults of different
ages had different timed balance
scores on the CTSIB, (2) to determine
whether healthy subjects performed
differently on each of the six condi-
tions, (3) to learn whether individuals
diagnosed with vestibular disorders
performed differently than AS sub-
jects, and (4) to determine whether
subjects' performance improved over
trials.
Method
Subjects
Pilot data were collected from 22 sen-
ior physical therapy students (9 men,
13 women), aged 20 to 24 years
@=21.3, SD=0.85). Subjects in the
experiment were divided into four
groups. Groups 1,2, and 3 each com-
prised 15 AS subjects. Group 1 com-
prised 5 men and 10 women, aged 25
to 44 years @=39.3, SD=5.5). Group
2 comprised 4 men and 11 women,
aged 45 to 64 years @=52.1, SD=6.2).
Group 3 comprised 1 man and 14
women, aged 65 to 84 years @=75.1,
SD=5.9). No subjects were obese.
Subjects were screened for major
health problems, and only individuals
with no history of "dizziness," balance
disorders, or recent orthopedic prob-
lems were included. Subjects in
groups 1 and 2 were recruited from
among the physical therapy students,
SUE,and faculty at the Medical College
of Ohio, Toledo, Ohio. Group 3 sub-
jects were retired elderly people living
in the community.
Group 4 comprised 17 patients (7
men, 10 women), aged 30 to 87 years
@=59.8, SD= 18.9), diagnosed with
vestibular disorders by a board-
certified otolaryngologist specializing
in vestibular disorders. In addition to
Physical Therapy /Volume 73, Number 6/June 1993
the clinical evaluation, diagnostic tests
included computerized harmonic
acceleration tests of the vestibulo-
ocular reflex, optokinetic nystagmus,
ocular pursuit and saccades, and ca-
loric tests, during which eye move-
ments were recorded with electroocu-
lography. Patients' diagnoses included
benign paroxysmal positional vertigo,
vestibular neuronitis, cupulolithiasis,
labyrinthitis, and vestibular disorder
of idiopathic origin. Their initial com-
plaints included vertigo, disequili-
brium, and blurred vision. The physi-
cian referred all patients for physical
therapy at the Medical College Hospi-
tal. All subjects gave informed consent
before participating in this study.
Equipment
The materials for this test included a
40.64 x 40.64 x 7.62-cm piece of
medium-density Sunmate* foam,2 a
visuaUvestibular-conflict dome made
from a Chinese lantern attached to a
plastic sun visor, and a stopwatch. (A
sun visor is a hatless brim attached to
an elastic band covered in terry cloth,
which holds the brim over the fore-
head to shade the eyes.) We used a
sun visor that could be detached from
its elastic band, so that ditferent bands
could be used with each subject. -ILp
Between test sessions, the elastic
bands were washed. This detail elimi-
nated any concerns subjects might
have had about hygiene. The dome
was constructed according to the
description by Shumway-Cook and
Horak2 so that the subject saw a fixa-
tion point, a large black cross, cen-
tered in visual field. The total cost for
materials was approximately $40.
Because the materials needed for this
test are inexpensive, even clinics with
small budgets can afford to obtain the
necessary equipment.
Procedure
All subjects were tested for three trials
on each of the six conditions, in
stocking feet. The conditions were
(1) quiet standing on the floor, look-
ing straight ahead; (2) quiet standing
on the floor with eyes closed; (3)
quiet standing on the floor wearing
the conflict dome; (4) quiet standmg
 on the foam, with eyes open; (5)
quiet standing on the foam, with eyes
closed; and (6) quiet standing on the
foam wearing the conflict dome. Be-
tween trials for conditions 4 through
6 , the foam was turned over and
rotated 90 degrees to prevent the
foam from wearing unevenly over
many trials. Subjects rested between
trials, for 30 to 60 seconds, to elimi-
nate the confounding effect of fatigue.
Pilot work showed no effect of order
of conditions, with subjects who un-
derstooci the nature of the task, when
conditions 1 through 3 were given
before or after conditions 4 through
6. Similarly, no daerences were
found when the orders of conditions
2 and 3 and conditions 5 and 6 were
reversed. Performance is known to be
aEected by the performer's level of
understanding of the skdl.ll Although
the postural control aspect of the test
is presumably automatic, assuming
the correct position of the feet and
hands could require some practice to
understand the nature of the task.
Therefore, the experimental paradigm
was always administered using condi-
tions 1 through 3 first to give the
subjects the idea of the position re-
quired. For that reason, condition 1,
the least complicated condition, al-
ways preceded all other conditions,
and condition 4 always preceded
conditions 5 and 6.
b
- Prior to testing in each condition, the
investigator demonstrated the task.
The test was administered with the
conditions in the same order each
time. For all conditions, the subject
was instructed to stand quietly, with
arms comfortably across the waist,
feet together, for as long as possible,
up to 30 seconds. This period of time
had been specified in the original
description of the test.2 The instruc-
tions given by all investigators were
standardized and were changed
slightly for each condtion.
Prior to starting the test, subjects were
told that each trial would last for up
to 30 seconds. For condition 1, the
investigator told the subject, "Stand
with your feet together, hands across
your waist, and look straight ahead.
Physical Therapy /Volume 73, Number 6/June 1993
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Do this until I tell you to stop." The
instructional set for the other condi-
tions included the instruction to
"close your eyes" for condition 2 and
"Now I'd like you to wear this hat and
look at the cross" for condition 3. For
conditions 4 through 6 , subjects were
given the same instruction regarding
visual conditions and were also asked
to stand on the center of the foam.
The length of time the subject could
maintain balance was recorded. A trial
was terminated when the subject's
arms or feet changed position. For
subjects who were able to perform all
18 trials for 30 seconds, the test took
approximately 20 minutes. All subjects
were tested in a quiet, well-lighted
room with a linoleum floor.
Data Analysis
The data were analyzed using the
mean time performing the test, over
the three trials for each condition.
Test-retest reliability and interrater
reliability were determined using
Pearson Product-Moment Correlation
Coefficients. Differences among exper-
imental groups were determined
using an analysis of variance (ANOVA)
for repeated measures. Significant
differences were then subjected to
post hoc Tukey's tests. Differences
between AS subjects and age-matched
vestibularly impaired subjects were
examined with t tests using the Bon-
ferroni correction.
Results
Both test-retest and interrater reliabil-
ity were high (r=.99, Pc.01). These
measures were taken with the pilot
group. Interrater reliability was evalu-
ated by having two investigators at a
time test five subjects simultaneously,
using identical digital stopwatches.
Values were rounded to the nearest
half second. Test-retest reliability was
tested by having the same investigator
test five subjects twice.
The ANOVA showed no significant
differences among groups for condi-
tions 1 through 3. That is, all subjects
could stand on the floor for 30 sec-
onds with eyes open, eyes closed, and
wearing the conflict dome, for all
three trials.
The results were somewhat different
for conditions 4 , 5, and 6 (eyes open,
eyes closed, and wearing the conflict
dome, respectively, while standing on
the foam). As shown in Figure 1, and
confirmed with the ANOVA, subjects
in groups 1, 2, and 3 performed con-
dition 4 for significantly longer than
condition 5 (F[16,34]= 11.35, P < ,001).
This difference stemmed from differ-
ences across conditions among the
older subjects. Group 3 showed a
performance decrement on cond-
tions 5 and 6 , and their scores on
conditions 5 and 6 did not differ sig-
nificantly. Performance of the subjects
in group 4 was slightly different. As
with the AS subjects, their perfor-
mance on condition 4 was signifi-
cantly better than on condition 5, but
unlike AS subjects their performance
on condition 6 was significantly
poorer than on condition 4. Figure 1
shows that their scores on conditions
5 and 6 did not d 8 e r significantly.
When the data were evaluated by
conditions (Fig. 2), no sigmficant dif-
ferences were found between the
scores of groups 1 and 2, on any con-
ditions. On condition 4 (eyes open on
the foam), no differences were found
among scores of subjects in groups 1,
2, and 3. Subjects in group 4, however,
scored significantly lower than subjects
in the other groups (F[16,34]=2.12,
P < .04). On condition 5 (eyes closed
on the foam), group 3 had scores
significantly lower than those of
groups 1 and 2, but not significantly
different from those of group 4. Al-
though group 3 performed signifi-
cantly worse than groups 1 and 2 on
condition 6 (foam and dome), the
scores of group 3 were significantly
higher than those of group 4, as
shown in Figure 2. As the figure indi-
cates, both groups 3 and 4 had consid-
erable variabihty in their scores.
When subjects were matched by age
and mean scores were compared with
related-measures t tests, no differ-
ences were found between AS and
vestibularly impaired subjects on
condition 4. Figure 3 shows that
348/ 11
 groups 1 , 2 , and 3 performed signifi-
cantly better than group 4 on condi-
tions 5 and 6 (condition 5: t[l6]=4.17,
40 Condition P<.001; condition 6: t[l6]=5.58;
P < .001). Under these conditions,
vision was eliminated or conflicted
with vestibular input. Group 4 also
30 had much more variability than did
n
J the other groups. In general, these
-
.-8 data show that older AS subjects
(group 3) and subjects with vestibular
impairments (group 4) had consis-
n 20
8 tently lower scores on conditions 5
-5m and 6.
m
10 The data were also analyzed by trials
to look for a practice effect. Groups 1
and 2 had no significant differences
across trials for any condition. Simi-
0 larly, for groups 3 and 4, no d8er-
1 2 3 4 ences were found across trials on
condition 4. On conditions 5 and 6,
however, groups 3 and 4 had differ-
Group
ences between scores on trials 1 and
2 (F(3,58,8,24]=7.22, PC ,001) (Table).
Figure 1. Mean duration of balance in each group, by condition. Error bars repre- Some subjects in both groups im-
sent standard deviations. Condition 4=standing on foam with eyes open, condition proved their performance on both
5=standing on foam with eyes closed, condition 6=standing on foam wearing visual/
vestibular-conflictdome. Group I =asymptomatic subjects aged 25 to 44 years, group conditions. The importance of this
2=asymptomatic subjects aged 45 to M years, group 3=asymptomatic subjects aged 65 finding, however, is unclear because
to 84 years, group 4=uestibukarly impaired subjects. both of these groups had such great
variability in their scores. The means
and standard deviations of these data
are shown in the Table.

Group

40 The CTSIB is an inexpensive, easily

1 I
administered test of standing balance
8 2 that is useful in the typical physical
therapy clinic. These results suggest
n
30 3 that it can b e modified for even easier
42 .4 administration. Because no differences
C
0 were found among groups on the first
4
0 20
three conditions, these conditions
could be eliminated for subjects with
8 only peripheral vestibular disorders.
5 Norre et a112 and other investigators
3 (CA Blatchly, SL Whitney, and JMRF
10 Furman; unpublished data) have re-
ported differences in conditions 1 and
2, but these differences may be attrib-
uted to the use of different foot posi-
0
4 5 6 tions in each study, as well as to the
presence of central neurological
problems.
Condition
Asymptomatic older adults can per-
Figure 2. Mean duration of balance in each condition, by group. Error bars repre- form condition 4 as well as younger
sent standard deviations. See Fig. I legend for desn'ptons of groups and conditions. subjects, although people with vestib-

12 / 349 Physical Therapy/Volume 73, Number 6June 1993

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 ular disorders cannot. Therefore, this
condition may serve as a useful base-
line, particularly when assessing older
patients with vestibular disorders and
other balance problems.
VesUbulady
Impaired Subjects
On condition 5, both the older group
and the vestibularly impaired group
performed more poorly than did the
younger AS groups. These findings
are consistent with those of previous
work.10 The vestibularly impaired
group performed at the same level as
the older AS group, regardless of age.
On the measure reported in this
study, younger subjects with vestibu-
lar impairments performed as if they
were older people.

On condition 6, although the elderly

AS subjects had lower scores than did
their younger counterparts, they were
better able to perform this condition
than subjects with vestibular disor-
ders. These data suggest that a score
1 Condition 1 of 20 seconds on conditions 4, 5, and
6 with the feet together is within

-
Flgure 3. Dz$wences in balance duration between vestibularly impaired subjects
and age-matched asymptomatic subjects. Ewor bars represent standard deviations. See normal limits for older subjects. Con-
Fig. 1 legend for descriptions of conditions. dition 6 may also be useful in dis-
criminating between older people
with and without vestibular disorders.
When a therapist suspects a vestibular
disorder in a patient without such a
diagnosis, these data may help the
physical therapist make a referral to
the appropriate physician for evalua-
Table 1. Mean Balance Scores (in Seconds)" for Each Group by Trial tion. Such a difference may also be
useful in reassessing patients after a
Condttlon 4' Condltlon 5" Condttlon 6. course of physical therapy.
Groupb Trlal 1 Trlal 2 Trlal 3 Trlal 1 Trlal 2 Trlal 3 Trlal 1 Trlal 2 Trlal 3
Older AS and vestibularly impaired
subjects tended to show higher scores
with successive trials on the two con-
ditions in which vision was eliminated
o r not useful. This finding suggests
that these subjects may have used an
unsuccessful movement strategy ini-
tially, but were able to mod* their
motor plans with practice. This find-
ing may indicate that these subjects
took longer than younger AS subjects
to understand the motor require-
*Standard deviations shown in parentheses
ments of the task. Because the sub-
b ~ r o u pl=asymptomatic subjects (n=15) aged 25 to 44 years, group 2=asymptomatic subjects jects with vestibular lesions had more
(n=15) aged 45 to 64 years, group 3=asymptomatic subjects (n=15) aged 65 to 84 years, group
variability than other subjects, and
4=vestibularly impaired subjects (n = 17).
because those subjects did improve
'Condition 4=standing on foam with eyes open
over trials, it might be useful to ad-
d~ondition5=standing on foam with eyes closed. minister this test using three or more
"Condition 6=standing on foam wearing visuaVvestibular-conflictdome.

Physical Therapy/Volume 73, Number 64une 1993

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trials and take the mean of those
trials.
This study examined subjects' ability
to maintain quiet upright standing
when sensory inputs were systemati-
cally altered. Measures of sway could
provide further insight into perfor-
mance abilities of individuals in differ-
ent age groups, but that issue was not
examined in this study because ob-
seming sway in the clinic would have
required two observers or more so-
phisticated, expensive equipment.
One purpose of this study was to
make it easy for a single physical
therapist to administer this test.
Although the CTSIB does not spec@
the exact nature of a subject's balance
problem, it is useful in difFerentiating
between individuals with and without
vestibular disorders. The test is also
useful for obtaining data about pa-
tients' performance before and after
therapy, and thus in documenting the
efficacy of treatment, for the benefit of
Commentary
The development of effective methods
for assessing and treating adults with
vestibular deficits is a prominent issue
for physical therapists and occupa-
tional therapists involved with "vestibu-
lar rehabilitation." The article by Co-
hen et al provides a vehicle for the
kind of dialogue that is needed about
this important topic. I would consider
their study preliminary, however, in
view of several issues related to the
broad generalization of their results,
the inconsistency of age-matched com-
parisons, the recommendation to de-
lete various aspects of the Clinical Test
of Sensory Interaction on Balance
(CTSIB), and the absence of a docu-
mented relationship between stance
duration and functional status in pa-
tients with vestibular impairments.
14 / 351
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third-party payers. Because the CTSIB
is inexpensive, it is a useful option for
clinics in which expensive dynamic
posturography testing equipment is
unavailable, but where the therapists
still need objective data about balance.
Acknowledgments
We thank Rebecca Koch, FT, and Milli-
cent Branch, FT,for their assistance.
References
1 Horak FB. Clinical measurement of pos-
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1881-1885.
2 Shumway-Cook A, Horak FB. Assessing the
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The primary conclusion reported by
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1. Subjects with and without active
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to spontaneous displacements of
the subject's center of force.2 Pos-
turography provides a more sensi-
tive measure of balance compared
with the CTSIB because manipula-
tion of the sensory environment is
precisely controlled and equilib-
rium scores are derived from verti-
cal floor reaction forces. It is un-
likely, therefore, that the CTSIB
will identify sensory integration
deficits in many patients with ver-
tigo, because more sensitive mea-
sures d o not detect deficits related
to this symptom.
Subjects with compensated (chron-
ic) unilateral peripheral vestibular
impairments often have normal
balance responses when tested
 A Study of the Clinical Test of Sensory Interaction
and Balance
Helen Cohen, Cathleen A Blatchly and Laurie L
Gombash
PHYS THER. 1993; 73:346-351.

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