Fall risk assessments are an important part of outpatient physical therapy. Many patients referred to physical therapy have conditions that increase their risk of falling, such as joint replacements, strokes, or neurological disorders. Physical therapists use several tests to evaluate patients' balance, stability, and proprioception, including the Berg Balance Scale, Tinetti Performance-Oriented Mobility Assessment, Dynamic Gait Index, and Timed Up and Go test. However, some patients may "ceiling out" or not show enough change on these basic tests to continue receiving therapy despite still being at risk for falls. The Balance Evaluation Systems Test (BESTest) was developed to better identify functional balance issues and justify continued care for high-risk patients.

1. Running Head: Fall Risk 1
Fall Risk Assessment
Denise Winters
Pima Medical Institute
PTA-490 Professional Capstone
Mary Jo Rodriquez
April 26, 2015

2. Fall Risk 2
In outpatient physical therapy a variety of patients are referred for rehabilitation from a
variety of different injuries. Injuries such as spine surgery, joint replacements, broken bones,
sports related sprains/strains, chronic pain, falls, trips, stroke, to more sever neurological
disorders. Every one of the reasons a patient is referred to therapy it is a guarantee that they will
require balance and proprioceptive rehabilitation along with strength and endurance training.
A physical therapist will assess a patients balance, stability, and proprioception first
based off the initial evaluation questions and then during the physical examination. A patient
may be determined to be a fall risk if they are mentally incapable of determining if their
performance is unsafe or if they physically are unable to perform simple daily activities without
a loss of balance.
According to a report by the CDC on Morbidity and Mortality Surveillance for Fatal and
Nonfatal Injuries in the United States, Vyrostek (2004, September), “The leading cause of
nonfatal injuries was unintentional falls; however, leading causes vary substantially by sex and
age. For non-fatal unintentional injury, the highest rates were falls predominantly falls (63%) for
persons aged >65 years of age. “
The table below is information drawn from the ten leading causes of nonfatal injury, by
sex and age – United States, 2001.
Males: Unintentional Falls
Age: 65-74 Age: 75-84 Age: >85
168,369 196,573 119,797
Females: Unintentional Falls
Age: 65-74 Age: 75-84 Age: >85
326,598 445,894 384,738

3. Fall Risk 3
Based from this information, it is obvious that patients need to be assessed using a variety
of fall risk standards. Physical Therapist are educated and taught how to perform the standard
Berg Balance, Tenetti Performance-Oriented Mobility Assessment Gait Test, Dynamic Gait
Index, the Timed “Up & Go (TUG) test, and the Rhomberg Test; however, depending on the
severity of the disorder being tested, a patient may test out or not show enough objective change
during treatment and then be denied physical therapy from the insurance company or doctor for
lack of justification, despite the obvious necessity for therapy.
Physical Therapist, Doctors, and other trained medical personnel are not confluent and
cannot predict the probability of a patients fall risk. Shumway-Cook (1997, August) researched
the prediction and probability of older adults living alone based off a questionnaire provided at
evaluation day. The questionnaire tested the degree in which an individual felt safe performing
ADL's. The examination questionnaire was called a Balance Self-Perceptions Test. The patient is
to rate their degree of confidence while performing 12 basic and instrumental activities of daily
living without fear and loss of balance. The higher the score indicate the perception that balance
and fear of falling do not limit them from performing tasks. This particular test is a modification
developed by Tinetti et. al.
Nonfatal, >65 years
Falls
Overexertion
Struck by or against
Cut/pierced

4. Fall Risk 4
This test would be instrumental with identifying mental and emotional capabilities when
it comes to determining the appropriate exercises and activities to practice during therapy.
The goal in therapy is the suggestion to the aging adult to stay active and maintain as
much of their previous lifestyle as possible; however, modification will be required to prevent a
fall injury secondary to the patients inability to recognize their own declining cognitive state. A
research article authored by Barabara Fischer, (2014, March) collected data to which indicate
that with aging come the risk of falls.
They examined 245 individuals with a mean age of 79 years of age that still lived
independently in their own homes. There were a total of 500 individuals selected for the study;
they were divided in half (controlled group and an intervention group). They used tools such as
interviewing and in-home assessment data to determine if the individuals were a fall risk while
performing mobility-related activities of daily living. This research data was collected over a one
year span.
The focus of the research was to determine that with the aging process, cognition
declines, therefore, mobility and activities of daily living become a hazard and the aging
individual becomes a greater fall risk. They indicate in the study that aging adults are unaware
and overestimate their abilities to perform risky behaviors in daily living. They are unaware of
their diminishing physical skills and this leads to poor judgement and decision making and
creating a dangerous situation, ultimately leading to a fall.
There were limiting factors to this research, however, not detrimental. The only limiting
factor was that the test only examined mobility issues related to fall risk. They also used a
relatively insensitive tool to examine cognition; the tool has probably not been tested for validity
or continuity.

5. Fall Risk 5
The examining tests that were performed during the examination were a Depression
Scale, Rhomberg Test, relative balance, Modified clinical test of sensory interaction, and a
balance portion of the Berg Balance Scale, Tinetti Performance-Oriented Mobility Assessment-
gait test, Dynamic Gait Index, and a Timed "Up & Go" test with and without a cognitive task.
This study supports suggesting modifications to aging adults how to maintain an active
lifestyle, however, do those activities in a safe manner. This study feels that older adults with
even a mild declining cognitive state should be assessed as a fall risk.
The Dynamic Gait Index has been proven to be a fall risk test with validity and
specificity. Wrisley al. et. (2003) tested if the dynamic gait index test would help tease out a
patient who has vestibular issues. In fact it does, because of the dynamic tests with head turns
and vertical lifts; however it also identifies that a patient is a fall risk. This test may provide as a
good tool if the therapist feels a patient has a vestibular issue.
An in-depth look into the basic balance system was performed by Mancini (2010, June).
The research of Mancini et. al. discusses the basic balance system of maintenance of postural
alignment in all positions, activation of voluntary movement when transitioning between
postures, and reactive time when an external force is applied.
The primary reasons for a clinical evaluation of balance are: 1) does a balance problem
exists; 2) determine the underlying cause of the balance issue. While identifying these two issues
the clinician will need to reflect the practicality, sensitivity, validity, expense, and reliability of
the tools required to assess the impairments. Included in this research document the author
provided a quick to reference table providing a brief look at common balance tests that are used
in the clinical setting already.

6. Fall Risk 6
SCALES ADVANTAGES DISADVANTAGES
Activities-Specific Balance
Confidence Scale (ABC;
Powell and Meyers, 1995)
16-item questionnaire in
which respondents rate their
confidence that they can
maintain their balance in the
course of daily activities.
Items are rated from 0% (no
confidence) to 100%
(complete confidence) and
averaged.
- Relates to activities subjects
actually perform
- Only 15 minutes
- Good test-retest reliability
(ICC ranging from 0.7 to 0.92)
- Not objective
- No identification of the type
of balance problem
- Not related to falls
Berg Functional Balance
Scale
(Berg, et al, 1992, 1996)
Clinicians rate 14-item
functional activities including
sitting, standing, and postural
transitions. Items scored from
0 to 4 points with a maximum
score of 56. A score less than
45 is associated with increased
risk of falling.
- Only 15 minutes to perform
- High inter-rater reliability
(98% agreement)
- Good specificity (96% of
non-fallers were classified
correctly
Poor sensitivity (only 53% of
fallers were identified)
- Ceiling effect
- No identification of the type
of balance problem
- No dynamic balance during
gait or sensory conditions
Tinetti Balance and Gait
Assessment (Tinetti, 1986)
Clinicians rate a 14-item
balance and 10-item gait test.
Predicts elderly individuals
who will fall at least once
during the following year.
Maximum score is 40.
Individuals scoring less than
36 are at greater risk of
falling.
- Only 20 minutes to perform
- Good inter-rater reliability
(85% agreement)
- Good sensitivity (93% of
fallers were identified)
- Poor specificity (only 11%
of non-fallers were identified)
- Ceiling effect
- No identification of the type
of balance problem
Timed up and go (TUG)
(Mathias, 1986)
A stop-watch is used to
measure the duration of
functional task performed at a
comfortable rate: from sitting
in a chair, stand up, walk 3 m,
turn around, walk back, and sit
down. Participants taking
longer than 13.5 to complete
- Only 3 minutes to perform
- Widely used because simple
- Excellent inter-rater
(ICC=0.99) and test-retest
(ICC=.99) reliability.
- Predicts falls
- Correlated with the Berg
Balance Scale (r=−.72) and
the Barthel Activities of Daily
Living Index (r=−.51)
- Ceiling effect
- Not comprehensive, only 1
functional task
- No identification of the type
of balance problem

7. Fall Risk 7
the TUG are at increased risk
for falls.
One-leg stance (Fregly,
1968)
Performed with eyes open and
arms on the hips, the
participants must stand
unassisted on one leg and is
timed in seconds from the
time one foot is flexed off the
floor to the time when it
touches the ground or the
standing leg or an arm leaves
the hips. Participants unable to
perform the one-leg stand for
at least 5 s are at increased
risk for injurious fall.
- Only one minute to perform
and score
- Good Inter-rater reliability
(ICC=0.75 in older without
disability and ICC=0.85 in
older with disability.
- Inter-subject reliability
ICC=0.73.
- Only one task of static
balance is evaluated
- No identification of the type
of balance problem
- Not continuously related to
falls
Functional reach
(Duncan, et al 1992)
Objectively assesses limits of
stability by measuring the
maximal distance a person can
reach beyond the length of
their arm while maintaining a
fixed base of support in the
standing position. A reach less
than or equal to 6 inches
predicts fall.
- Only one minute to perform
and score
- Excellent predictive validity
of subjects at risk of falls
- Good inter-rater reliability
(ICC=0.98) and test-retest
reliability (ICC=0.92).
- Only one task is evaluated
- Not related to CoM or CoP
limits of stability
- No identification of the type
of balance problem
Balance Evaluation Systems
Test (BESTest; Horak et al.,
2009, 2010)
Consists of 36 items, grouped
into 6 systems:
“Biomechanical Constraints,
"Stability Limits/Verticality,”
“Anticipatory Postural
Adjustments,” “Postural
Responses,” “Sensory
Orientation,” and “Stability in
Gait.” Each item is scored on
a 4-level, ordinal scale from 0
(worst performance) to 3 (best
performance). Scores for the
total test, as well as for each
section, are provided as a
percentage of total points.
- Determines the underlying
causes of balance deficits,
focusing on systems
- Focuses treatment based on
different types of balance
problems
- Good inter-rater reliability
(ICC=0.91
- Correlation with ABC Scale
was r=.636, P<.01
- Long to perform: 30 min
- No studies of fall risk
- Equipment is needed
- Short version (10 min,
miniBESTest) now available

8. Fall Risk 8
Physiological Profile
Approach
(PPA) (Lord, 1996)
Consists of simple, clinical
tests of vision, cutaneous
sensation of the feet, leg
muscle force, step reaction
time, and postural sway.
Composite PPA scores below
0 indicate a low risk for
falling, scores between 0 and 1
indicate a mild risk for falling,
scores between 1 and 2
indicate a moderate risk for
falling, and scores above 2
indicate a high risk for falling.
- Determine the underlying
physiological causes of the
balance deficits
- Accuracy of 75% in
classifying subjects into a
multiple falls group
- Test-retest reliability 0.51 to
0.97 (ICC)
- Inter-rater reliability OK
(ie; 0.70 for proprioception
and 0.81 for tactile sensitivity)
- Long to perform: 30 min
- Equipment is needed
- Imprecise measure of
physiological mechanisms
- Not measuring functional
tasks or balance control
systems
All of the tests above have been tested to be valid, sensitive, reliable, and practical. The
only test in the graph above that may not be recognizable is the Balance Evaluation Systems Test
(BESTest). This research article identifies a common complaint that Physical Therapists have
when testing a patients' balance and the patient clearly needs continued balance therapy to be
safe, however, they "ceiling" out on the basic balance tests. This makes it difficult for a therapist
to validate to the doctor or insurance company that continued care is needed. Without incurring
the expensive cost of purchasing a Posturography for advanced testing, Mancini et. al. developed
the BESTest balance test. There is a short and long version to the test.
The ceiling affect was depicted in a study performed by Leddy (2011, January) where she
evaluated the reliability, validity, sensitivity, and specificity for identifying individuals with
Parkinsons Disease who fall. Leddy et. al. details the ceiling effect of most tests and identifies
how the BESTest test can identify functional balance instability beyond the normal balance tests.
Leddy et. al. is targeting the population of Parkinsons Disease (PD) in her research article;

9. Fall Risk 9
however, the basics of her data research gathering can be applied to most if not all aging adults
that are a fall risk.
Leddy et. al. tested the Berg (BBS), Functional Gait (FGA), and the BESTest on 80
individuals with Parkinsons Disease (PD). They concluded that the FGA and FGA were the most
reliable and indicated the most validity for assessing patients with PD. They indicated that PD
comes in all stages and degrees of progression and is no different than most with any kind of
balance/proprioception issues. They determine that these two specific tests can validate the need
for early intervention with a patient that is a risk for falls, however, is in early stages of PD.
Leddy et. al. also discusses how the BBS can ceiling out with patients that are low level
indicators for fall risk. To maximize the sensitivity and specificity of the BBS the cutoff value on
the BBS when testing was chosen to be 47/56. This would indicate the difference between a
faller and non-faller. According to a reference listed in this research article Stefeen and Seney,
the BBS score must change at least 5 points to show a true change in balance. This means that
43% of those studied in this test would not even be able to show any balance progress using the
BBS.
In conclusion it would be fair to say based off the supporting evidence listed above that
poor balance can and will result in a fall. The fall may or may not be fatal and the evidence
indicates that the risk increases as a person ages. Human beings are all different and suffer from
balance or proprioception loss in varying degrees, therefore, Physical Therapist should be
prepared with the as many tools necessary to examine and re-examine a patient, be able to
clearly identify gains, and justify with objective measures the need for continued care.
Outpatient therapy needs the introduction of the BESTest balance test when a patient is
not showing signs of improvement in a BERG test or when the patient “ceilings” out of a

10. Fall Risk 10
common balance test and continues to pose as a fall risk in their environment while completing
activities of daily living.

11. Fall Risk 11
References
Abigail L. Leddy, B. E. (2011, January). Functional Gait Assessment and Balance Evaluation
System Test: Reliability, Validity, Sensitivity, and Specificity, for Identifying Individuals
With Parkinson Disease Who Fall. Journal of the American Physical Therapy
Assosication, pp. Vol 91, No. 1, pgs. 102-113.
Anne Shumway-Cook, M. B. (1997, August). Predicting the Probability for Falls in Community-
Dwelling Older Adults. Physical Therapy, Journal of the American Physical Therapy
Association, pp. Vol. 77 No. 8 pgs. 812-819.
Barbara L. Fischer, C. E. (2014, March). Declining Cognition and Falls: Role of Risky
Performance of Everyday Mobility Activities. Journal of the American Physical Therapy
Association, pp. Vol. 94, No. 3, pgs 355-362.
Diane M. Wrisley, M. L. (2003, October). Reliability of the Dynamic Gait index in People with
Vestibular Disorders. Physical Medicine and Rehabilitation, pp. Vol. 84, Issue 10, pgs.
1528-1533.
Horak, M. M. (2010, June). The relevance of clinnical balance assessment tools to differentiate
balance deficits. NIH Public Access. Eur J Phys Rehabil Med., pp. vol 46 No. 2: pgs 239-
248.
Sara B. Vyrostek, J. L. (2004, September). Surveillance for Fatal and Nonfatal Injuries - United
States, ,2001. Morbidity and Mortality Weekly Report - Surveillance Summaries -MMWR,
pp. Vol. 53/ SS-7 1-57.
Steffen T, Seney M. Test-retest Reliability and minimal detectable change on balance and
ambulation tests, the 36-item short-form health survey, and the unified Parkinsons
disease rating scale in people with parkinsonism [erratum in Phys Ther. 2010;90:462].
Phys Ther. 2008;88:733-746