As you age, it is common for your balance to change and become more unsteady. These changes typically happen very gradually over time.
It’s essential to be aware of how your own balance system is doing and areas/circumstances where you may be less steady to help prevent future falls. Many diagnostic testing methods can be done in a clinic, but did you know there are easy ways to test your balance at home?
Understanding how the human balance system works, how balance can get worse with age, and how you can test (or be tested) can help you prevent falls and maintain outstanding balance well into old age.
What Causes Loss of Balance?
Three central systems help you with balance:
your inner ear (the vestibular system)
your vision (the ocular system)
and your ability to feel (the somatosensory system)
While these systems interact, your environment determines how much information your brain needs from each.
For example, suppose you are walking in a dark room. In this case, the brain will need more information from the inner ear and the somatosensory system since you can also not see.
Age-Related Balance Changes
As you age, changes can occur in each of the three systems.
First, the vestibular system, which helps your brain to coordinate balance via tiny structures in the inner ear, may become less effective due to the loss of neurons due to normal aging. Vestibular balance testing by a professional can help to identify problems with this system.
The somatosensory system can also change for multiple reasons. Your history of injuries or surgeries can lead to reduced proprioception — your body’s perception of movement or location in space. Physical sensation to touch can also decrease due to conditions such as neuropathy.
Finally, it is common for vision to change, leading to blurring vision or decreased depth perception. Eye conditions like macular degeneration, cataracts, or glaucoma can often worsen these problems.
Tests that record eye movements when following moving objects on a screen show that younger people display a faster reaction time. In comparison, older people tend to lag, indicating a general, age-related decline in eye coordination. (1)
Specific Causes of Loss of Balance
Loss of balance can be caused by multiple factors, many of which are preventable.
One common cause for losing balance while walking involves tripping over an object or obstacle. Trips or stumbles may be due to vision change (such as poor depth perception), a simple lack of attention, or loss of coordination. All of these problems can be attributed to age-related cognitive decline.
To recover from a trip or stumble, having a quick-stepping reaction to catch yourself is critical. There is a much higher chance you will fall if your natural stepping reaction is too small, slow, or absent.
Dizziness is another major cause of balance loss. Dizziness can be associated with changes to the vestibular system or balance disorder. It can also be caused by other conditions such as dehydration, low blood sugar or pressure, or heart conditions.
A common dizziness condition related to the inner ear is called benign paroxysmal positional vertigo — often just called vertigo — characterized by a spinning sensation with a turning movement of the head.
New bouts of dizziness should always be discussed with your doctor to determine the cause and proper treatment.
Consequences of Not Knowing About Your Balance
The risk of falling is the primary concern for balance-challenged seniors.
Falls are the leading cause of head injuries in older adults and can commonly result in other serious injuries, such as broken bones.
The Centers for Disease Control reports that 20% of older adults who fall will experience a severe injury, such as a broken bone. In addition to head injury, 95% of hip fractures result from a fall. (2)
Falls often result from balance problems, many of which can be prevented with simple testing and regularly practiced exercises to keep your balance healthy.
Being more aware of your strengths and weaknesses can help you be proactive regarding your health and safety in your home. If you know your weaknesses, you will likely make the necessary modifications to reduce your risk of falls.
Let’s dive into some simple at-home tests that can aid your balance journey and prevent falls or other injuries.
Balance Testing at Home
For safety, set yourself up for fall prevention before practicing any balancing test. It is best to be near a stable surface, such as a countertop, if you need sudden support with one or both hands.
The following tests target different aspects of your balance and can help determine what areas you need to work on.
If you need assistance completing the following tests, consult your doctor or a physical therapist to learn how to improve your balance safely.
Balance Test #1: The Rhomberg Test
This is one of the most basic balance tests. The “Rhomberg position” refers to standing up straight with your feet together and your arms crossed over your chest.
Hold this position for sixty seconds, standing as still as possible. If this feels relatively easy, you can try the next progression, which is the same position but with your eyes closed.
This can be further progressed to the sharpened Rhomberg test:
Instead of standing with your feet together, you will stand with one foot in front of the other so your heel touches the opposite toes like you’re standing on a balance beam.
Both tests require you to stand as still as possible without holding onto a support surface or moving your feet.
Passing this test means standing relatively still in the position for sixty seconds.
Failing the test refers to moving your feet, touching the countertop, or catching your balance in these positions. (3)
Balance Test#2: The Five-Time Sit-to-Stand Test
This test addresses your safety level with “transfers,” or the ability to get up and down from a chair. It requires both balance and strength in your lower legs.
For this test, you will need a standard-height chair (such as a dining room chair) and a stopwatch.
Start by sitting in the chair with your arms crossed over your chest. Try to stand up and sit back down five times in a row.
The goal is to do this as fast as you can. Have someone start the timer as soon as you begin to stand during the first repetition and stop the timer when you are sitting after the fifth repetition.
If you cannot complete this test or it takes more than fifteen seconds, you are considered at higher risk of falling. If so, consider talking to your healthcare provider. (4)
Balance Test #3: The Functional Reach Test
This test looks at your ability to keep your balance when reaching forward.
For the functional reach test, you will need something to measure with, such as a meter stick or measuring tape. It may be helpful to have someone nearby to help you measure.
You will start standing with your feet at a comfortable distance and your arm straight out in front of you. With your measuring device, mark where the tips of your fingers are when your arm is lifted.
Now reach forward as far as you can without taking a step or losing your balance. Mark the furthest reaching position.
Any noticeable difficulty, inability, or imbalance with reaching beyond seven inches indicates you are at a higher risk of falling, and a professional screen may be a good idea. (5)
Balance Testing by a Professional
If you are having trouble with the above home balance assessments, follow up with a medical provider, such as a physical therapist, for a more in-depth evaluation.
Physical therapists are trained to assess and treat various balance disorders and problems.
What to Expect
Your physical therapist will likely repeat some of the above tests to watch your balance and analyze areas where you are having difficulty. More advanced balance assessments can better illustrate your abilities.
Advanced tests will include a combination of static and dynamic balance — or balance when you are still versus moving.
Various tests may include turning, closing your eyes, or using varied surfaces to better assess how different systems interact or any areas needing improvement.
Clinical Test of Sensory Interaction of Balance (CTSIB Test)
This test looks at static balance and eye movements. Your PT can tell a great deal about your overall balance by how well your vestibular and visual systems work to tell your brain where you are in space. (6)
The first two positions will be identical to the Rhomberg test, standing as still as you can with your feet together. You will first complete this with your eyes open, then repeat with your eyes closed.
Next, you will repeat the same test twice on a squishy foam surface, both with eyes open and closed.
The unstable foam surface makes balance more challenging by reducing your ability to use proprioceptive information — information relayed from the body’s balance systems — back to the brain.
In some clinics, two other positions will be performed with a specialized dome over your head to obstruct your vision, providing visual “conflict.”
In this case, you will be asked to balance with your eyes open and feet together both on and off the foam.
Due to the repetition and the different conditions necessary in this test, it is common for testers to only have you hold each position for thirty seconds instead of sixty seconds at a time. Each condition will be repeated three times. (6)
Timed Up & Go (TUG Test)
The Timed Up & Go test is one of the most common functional balance tests due to the minimum amount of equipment and time it takes to complete.
This test requires you to stand from a chair, walk three meters, turn around, and return to sitting in the same chair while timed.
The goal is to do this test as quickly as you can safely. A time of more than 13.5 seconds would indicate a higher risk of falls. (7)
Balance Evaluation Systems Test (Mini-BEST Test)
This test is a little longer and encompasses fourteen movements to fully understand your balance. It will look at static balance, walking balance, transfers, balance on different surfaces, and reactions.
A benefit of this test is it already includes many components of the tests mentioned above.
Each of the fourteen items is ranked 0-2 based on how well you complete them, for a total score out of 28. A score of less than 19 indicates a higher risk of falls. (8)
Balance Test Results & Next Steps
Further training will likely be recommended if you perform poorly on some home balance assessments or your physical therapist notices difficulty on specific tests.
For clinical tests, a physical therapist will use the information gathered to design a program specific to your needs to help you improve your balance.
Suppose you performed reasonably well on the tests but want to be proactive regarding your balance. In that case, finding ways to stay active and moving can significantly improve your balance. Many local community centers or gyms will even offer balance training classes or classes such as yoga or Tai Chi, both of which build balance and spatial awareness.
Since balance is dynamic and requires multiple systems and parts of your brain, it’s best to find types of exercises or classes that encourage you to move your whole body. Talk to your physical therapist to determine what types of exercise are appropriate for you.
Summary:
Working on your balance is one of the best things you can do to stay active and prevent serious injury. Testing and practicing balance can help you stay safe when you are active or simply moving around the house.
Some tests, like the ones listed above, can be practiced at home, while other more complex tests are safest with medical support.
If you notice a change in your stability, talk with your doctor or physical therapist to ensure you remain safe in your home and daily activities.
References
Remaud, A., Thuong-Cong, C., & Bilodeau, M. (2016). Age-Related Changes in Dynamic Postural Control and Attentional Demands are Minimally Affected by Local Muscle Fatigue. Frontiers in aging neuroscience, 7, 257. https://doi.org/10.3389/fnagi.2015.00257
Centers for Disease Control and Prevention. Facts About Falls. https://www.cdc.gov/falls/facts.html
Forbes J, Munakomi S, Cronovich H. Romberg Test. [Updated 2022 Nov 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563187/
Shirely Ryan Ability Lab. June 2013. https://www.sralab.org/rehabilitation-measures/five-times-sit-stand-test
Shirley Ryan Ability Lab. Functional Reach Test. December 2013. https://www.sralab.org/rehabilitation-measures/functional-reach-test-modified-functional-reach-test
Shirley Ryan Ability Lab. Clinical Test of Sensory Interactions on Balance. November 2013. https://www.sralab.org/rehabilitation-measures/clinical-test-sensory-interaction-balance#:~:text=The%20CTSIB%20was%20developed%20as,patient’s%20attempt%20to%20maintain%20balance.
Shirley Ryan Ability Lab. Timed Up and Go. November 2013. https://www.sralab.org/rehabilitation-measures/timed-and-go
Shirley Ryan Ability Lab. Balance Evaluation Systems Test. August 2018. https://www.sralab.org/rehabilitation-measures/balance-evaluation-systems-test
