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Special Test

Balance Tests & Assessment | Dynamic & Static

Balance Tests is a group of tests used to evaluate the ability of the patient to stand or walk normally. It’s either Static balance tests or Dynamic balance tests.

See Also: Gait Cycle

Dynamic Balance Tests

Dynamic Balance Tests include observation of the patient standing or sitting on an unstable surface, or performing postural transitions and functional activities.

Emery and colleagues recently described a clinical balance measurement tool designed specifically for neurologically intact adolescents. Participants were timed as they balanced on a high density foam pad with eyes open and eyes closed. Easily reproduced clinically, this test may be used to assess the neuromuscular system’s ability to maintain balance on a pliant surface.

Static Balance Tests

Static Balance Tests include observation of the patient maintaining different postures.

Standardized Static Balance tests include:

  1. Single leg balance stance test,
  2. Romberg test;
  3. Sharpened (tandem) Romberg,
  4. Stork stand test,
  5. Timed stance battery.

Foursquare step test

Four walking sticks are placed on the floor at right angles to each other with handles outward so that they form four squares.

The patient starts in square 1, facing square 2, and remains facing in this direction for the duration of the test. The patient steps forward with both feet as quickly as possible into square 2, then sideways to the right into square 3, then backward into square 4, and finally sideways to the left back into square 1.

The patient then reverses the sequence back to the starting position. The trial is recorded to the nearest 10th of a second.

See Also: Foursquare step test
Foursquare step test

Step Test

A step that is 15 cm high is used with a cardboard template 5 cm wide positioned on the floor along the edge of the step to provide a standardized starting position.

As the test is performed, the patient remains on the stance leg the entire time while moving the other leg back and forth from the step to the floor (i.e., the patient places the stepping foot flat up onto the step and then back down flat onto the ground) as many times as possible in 15 seconds without moving the stance leg from the starting position.

The number of whole steps (up onto the step and back down to a flat position on the floor) performed in 15 seconds is recorded for each stance leg.

If the patient overbalances, the test is concluded and the number of completed steps and the time taken are recorded.

See Also: Step Down Test
Step Down Test

Single-leg Balance Stance

Assesses the patient’s ability to stand on one leg without shoes and with the arms placed across the chest without letting the legs touch each other.

Five 30-s trials are performed for each leg, with the maximum possible score of 150 s per leg.

In the acute stage of vestibular loss, a patient will be unable to perform this test; however, patients who have a compensated vestibular loss may test normal. This screening test is not specific to vestibular loss, as patients with other balance disorders may have difficulty performing single leg stance.

Single-leg Balance Stance

Stork Stand

Assesses the patient’s ability to stand on both feet with the hands on the hips, then lift one leg and place the toes of that foot against the knee of the other leg.

On command from the tester, the patient then raises the heel to stand on the toes and try to balance as long as possible without letting either the heel touch the ground or the other foot move away from the knee. Normal adults should be able to balance for 20–30 s on each leg.


Star Excursion Balance

A test of lower extremity reach that challenges an individual’s limits of stability. The patient balances on the involved leg while reaching as far as possible with the uninvolved leg in each of eight prescribed vectors or directions while maintaining balance on the contralateral leg.

The vectors are named in reference to the stance leg. The test intends to demonstrate dynamic balance deficits by comparing the performance of the involved limb to the uninvolved limb as the ability to reach a distant point along a given vector requires a combination of postural stability, strength, and controlled motion on the stance leg.

Pull Test

The clinician stands behind the patient and asks the patient to maintain their balance when pulled backwards. The clinician pulls back briskly to assess the patient’s ability to recover, being careful to prevent the patient from falling.

Backward Release

The patient is asked to stand with feet shoulder width apart. The clinician places their hand between the patient’s scapulae and the patient is asked to lean back against the clinician’s hand.

Once the patient is leaning backwards into the clinician’s hand, the clinician unexpectedly removes the support.

The amount of force created by the patient’s lean should be sufficient to invoke a loss of balance that requires a change in the BOS (i.e., at least one backward step).

Postural Stress Test (PST)

The PST measures an individual’s ability to withstand a series of destabilizing forces applied at the level of
the subject’s waist.

Scoring of the postural responses is based on a nine-point ordinal scale, where a score of 9 represents the most efficient postural response and a score of 0 represents a complete failure to remain upright.

Forward Reach Test

The patient starts in a normal relaxed stance with the dominant arm facing side-on, but not touching, a wall. A leveled measuring tape is mounted on the wall at acromion height.

The patient makes a fist with the dominant hand and elevates the arm to shoulder level. The position of the third knuckle along the tape is recorded as the starting point.

Keeping the contralateral arm by the side and both heels on the floor, the patient reaches as far forward as possible to maintain a maximal reach position for 3 seconds without losing balance. The final reach position of the third knuckle along the tape is recorded as the finishing point.

The mean difference between the starting point and the finishing point across three trials is recorded to the nearest millimeter as the test score.

Forward Reach Test

Clinical Test of Sensory Integration on Balance (foam and dome test)

This test measures the patient’s ability to balance under six different sensory conditions:

  1. Standing on a firm surface with the eyes open.
  2. Standing on a firm surface with the eyes closed.
  3. Standing on a firm surface wearing a dome made from a modified Japanese lantern.
  4. Standing on a foam cushion with the eyes open.
  5. Standing on foam with the eyes closed.
  6. Standing on foam wearing the dome.

For each of these conditions the patient stands with the feet parallel and the arms at the sides or the hands on the hips a minimum of three 30-s trials of each condition are performed.

Patients with vestibulopathy will have difficulty maintaining an upright posture. Individuals who rely heavily on visual input for balance will become unstable or fall in conditions 2, 3, 5, and 6, whereas those who rely heavily on somatosensory inputs show deficits with conditions 4, 5, and 6.

Fukuda stepping test

The test is performed by having the patient stand with the eyes closed and the arms extended forward to shoulder height. The patient is asked to march in place for 50 steps at the pace of a brisk walk.

Progressive turning toward one side of 30 degrees or more is considered a positive test and indicates a unilateral peripheral vestibular deficit.

Dizziness Handicap Inventory

This test assesses a person’s perception of the effects of a balance problem and the emotional, physical, or functional adjustments that the person makes.

Questionnaire consists of 25 items that are divided into functional (nine items), emotional (nine items), and physical (seven items) subscales.

Each item is assigned a value of 4 for a yes, 2 points for a sometimes, and 0 points for a no.

The Berg Balance Scale (BBS)

This 14-item scale was developed to measure balance among older people with impairment in balance function by assessing the performance of functional tasks.

Timed Up and Go (TUG) Test

Patients are timed (in seconds) when performing the TUG under three conditions:

  1. TUG alone: from sitting in a chair, stand up, walk 3 m, turn around, walk back, and sit down.
  2. TUG Cognitive: complete the task while counting backwards from a randomly selected number between 20 and 100.
  3. TUG manual: complete the task while carrying a full cup of water The time taken to complete the task is strongly correlated to level of functional mobility (i.e. the more time taken, the more dependent in activities of daily living).

Tinetti performance-oriented mobility assessment (POMA)

Easily administered task-oriented test that measures an adult’s gait and balance abilities. Rates the ability of an individual to maintain balance while performing activities of daily living-related tasks.

Components include balance, lower and upper extremity strength.


  1. Choi YM, Dobson F, Martin J, Bennell KL, Hinman RS. Interrater and intrarater reliability of common clinical standing balance tests for people with hip osteoarthritis. Phys Ther. 2014 May;94(5):696-704. doi: 10.2522/ptj.20130266. Epub 2014 Feb 20. PMID: 24557648.
  2. Park KM, Cynn HS, Choung SD. Musculoskeletal predictors of movement quality for the forward step-down test in asymptomatic women. J Orthop Sports Phys Ther. 2013;43(7):504-10. doi: 10.2519/jospt.2013.4073. Epub 2013 Jun 11. PMID: 23756380.
  3. Goh EY, Chua SY, Hong SJ, et al. Reliability and concurrent validity of Four Square Step Test scores in subjects with chronic stroke: a pilot study. Arch Phys Med Rehabil. 2013;94(7):1306–1311. doi: 10.1016/j.apmr.2013.01.027. Pubmed
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