Perhaps one of the most popular video courses from our catalog is from Ray Hedenberg, PT. His course “Keeping Your COG over Your BOS” focuses on the guiding principles of balance control and maintaining center of gravity. His 5 hour course discusses working definitions of mobility and balance, delves into motor and sensory components of upright posture, and gives insight on the role of balance assessment and treatment in the medical management process. In this blog Ray explains the importance of identifying impairments that may lead to balance problems and recommends several of tests for doing so.
Keeping Your COG Over Your BOS
Balance, keeping your center of gravity (COG) over your base of support (BOS), is a complex sensorimotor process involving intricate central nervous system processing and proficient musculoskeletal functioning. Balance embraces reflexes, automatic postural responses, anticipatory postural control and voluntary movements. Therefore, it is obvious that there is no single test that will assess balance.
In order to effectively assess balance, the clinician must look at the components of the sensorimotor process. There are categories of balance tests to guide the clinician in evaluating a patientís ability to control their COG while performing normal activities of daily living as well as higher level tasks such as skilled athletic maneuvers. Basic test categories are: standing at rest (sometimes referred to as static stance), postural strategy tests, moving over an-in-place base of support, sensory impairment testing, and functional tests.
Functional tests such as the Timed Up and Go (TUG), Berg Balance Scale (BBS), Tinetti Performance Oriented Mobility Assessment (POMA), Fullerton Advanced Balance Scale, Gait Abnormality Rating Scale (GARS) and Dynamic Gait Index are a few evaluation instruments allowing the examiner to quantify a patientís COG stability during functional tasks. These functional tests provide valuable information pertaining to fall risk and degree of functional limitation. More commonly used functional tests with a brief description are listed below.
- The Timed Up and Go Test (TUG) requires minimal equipment and is easy to administer. The subject stands up from a seated position, walks 10 feet, turns around, walks back to the chair and sits down. The TUG is a screening tool used to identify mobility and balance impairments in older adults. Normative and fall risk data are available.
- The Berg Balance Scale (BBS) was originally designed to evaluate older adultsí falling risk. It consists of 14 items and uses 5 point ordinal scale. It is a reliable and valid assessment and has a positive correlation to the TUG and the Tinetti Assessment Tool.
- The Tinetti Performance Oriented Mobility Assessment (POMA) is a task-oriented test that consists of balance and gait components. It is intended to scale the ability of an individual to maintain balance while performing common daily activities. It provides a 2 or 3 point ordinal scale and offers a range of scores for fall risk.
- The Fullerton Advanced Balance Scale (FAB) is a clinical balance assessment tool that provides valid and reliable measures of balance in higher functioning older adults. It is a predictive measure of faller status when used with independently functioning older adults. Community dwelling older adults who score lower than 25 are considered to be at high risk for falls and are candidates for timely balance intervention.
- The Gait Abnormality Rating Scale (GARS) rates abnormal aspects of gait which are commonly seen in elderly people who fall. It was developed to assess quality risk for falls in the elderly and focuses on parameters of postural control during gait. Lower numbers are better i.e. less abnormal. Perfect score is 0.
- The Dynamic Gait Index (DGI) was developed to assess gait, balance and fall risk. It has high reliability and demonstrates validity with other balance and mobility scales. Although it contains gait items that may help to identify patients with vestibular disorders, the interrater reliability with this patient population is moderate. It is a useful clinical tool for evaluating dynamic balance in ambulatory people with chronic stroke.
It is important to realize that with many patients the ability to maintain the COG over the BOS is not fully addressed because attention is directed toward their symptoms and functional limitations. For that reason, in addition to functional testing, the clinician MUST identify impairments that may lead to balance problems. Impairments in peripheral sensory input, central nervous system processing, ocular-motor performance, musculoskeletal deficits, automatic postural responses, and COG control can affect balance leading to postural instability and falls.
Demo Video: “Keeping Your COG Over Your BOS”
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About the Author: Ray Hedenberg
Ray Hedenberg is a licensed Physical Therapist with over 34 years of experience. Since graduating from the University of Pennsylvania, Mr. Hedenbergís career has included private practice ownership, clinical applications development for several rehabilitation products and clinical education in balance and mobility programs both domestically and abroad. He has directed physical therapy programs in various institutional settings, ranging from acute care hospitals and extended care facilities to outpatient rehabilitation centers and fitness facilities.