1. Hernandez, Brian PT, DPT

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Annually in the United States, there are 3 million emergency room visits, $50 billion in medical costs, and 34,000 deaths associated with falls (Centers for Disease Control and Prevention, 2022). This is an obvious strain on the health system and quality of life. There is room for (amicable) debate among practitioners who treat older adults, about the best way to achieve accurate measures of fall risk. One area for debate is precision of measurement. Two options are 1) collect more precise, postural sway measurements with specialized equipment but limiting accessibility, or 2) collect less sensitive stability measurements requiring little equipment but increasing accessibility, perhaps even to family caregivers. One could call these two groups instrumented measures of balance (IMB) and noninstrumented measures of balance (NIMB). This article presents pros and cons of each.


The IMB category is a useful one, especially for purposes of research. Levy et al. (2018) state the gold standard for measuring balance is a force plate. These authors measured the validity and reliability of the Balance Tracking System (BTrackS), a portable force plate specially designed for clinical field measurement of balance. Though the evidence was mixed for validity, the authors did conclude BTrackS was reliable and valid in measuring balance through postural sway in older adults. Levy et al. also provided minimal detectable change at 95% confidence level (MDC95) for BTrackS, which demonstrated agreement trends with traditional force plates, though caution is advised in interpretation given the bias toward higher outputs found with BTrackS (Table 1). Ultimately, the portability of this device could provide a middle ground in balance measurement-accessibility in the field while maintaining sensitive data collection from the gold standard technology of a force plate.

Table 1 - Click to enlarge in new windowTable 1. MDC

On the other hand, as accessible as a portable force plate is compared to a traditional force plate, it remains less so than NIMBs. Rossiter-Fornoff et al. (1995) found the FICSIT-4, commonly known as the 4-stage balance test (4SBT), is reliable and valid for measuring balance in older adults. The test consists of four standing positions (feet together, semi-tandem, tandem, and single leg stance), and uses a stopwatch to measure length of time each position is maintained. Each position is then assigned incomplete (1-9 seconds) or complete (10 seconds), and further assigned a point value based on number of completed positions, as seen in Table 2. This test proves useful as a NIMB given that it was found to correlate with more dynamic measures of balance, such as the Tinetti test and Berg balance scale. This test is easy to administer, only requires a stopwatch, and typically takes 5 to 10 minutes, making it much more available to assess balance in older adults. This availability lends toward use in a wider range of environments, such as community health fairs, senior centers, or patient residences.

Table 2 - Click to enlarge in new windowTable 2. 4SBT Point Value Assignments

These two examples, BTrackS and the 4SBT, provide context for a broader comparison between IMBs and NIMBs. The 4SBT would be a good solution for those seeking quick, easy assessments of balance, such as a screening event at a senior center, or perhaps even a family caregiver wanting to assess the balance of their aging loved one. Unfortunately, NIMBs, like the 4SBT, can have lower sensitivity than the gold standard of force plates, as reported by Saunders et al. (2015). Thus, if a properly trained individual is available, it could prove more beneficial to utilize an IMB, such as the BTrackS. This portable force plate remains relatively accessible, while providing more sensitive balance data. This could serve in a clinical or research setting where more thorough assessment is important for the progression of a treatment plan. Ultimately, the decision is left to skilled clinicians based on setting, accessibility, and availability of resources, perhaps even using a combination of both IMBs and NIMBs, to best assess balance in older adults.


Risk of developing heart failure much higher in rural areas vs. urban

Researchers from NHLBI and Vanderbilt University Medical Center analyzed data from The Southern Community Cohort Study, a long-term health study of adults in the southeastern United States. They compared the rates of new onset heart failure among rural and urban residents in 12 states (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia). A total of 27,115 adults without heart failure at enrollment were followed for about 13 years. Nearly 20% of participants lived in rural areas; the remainder lived in urban areas. At the end of the study, the researchers found living in rural America was associated with an increased risk of heart failure among both women and Black men, even after adjustment for other cardiovascular risk factors and socioeconomic status. Overall, the risk of heart failure was about 19% higher in rural residents than their urban counterparts. However, Black men living in rural areas had the highest risk of all - a 34% higher risk of heart failure compared to urban-dwelling Black men. The study showed white women living in rural areas had a 22% increased risk of heart failure compared to white women in urban areas, and Black women had an 18% higher risk compared to Black women in urban areas. No association was found between rural living and heart failure risk among white men. The exact reasons behind these rural-urban health disparities are unclear and are still being explored. Researchers said a multitude of factors may be at play, including structural racism, inequities in access to health care, and a dearth of grocery stores that provide affordable and healthy foods, among others.




Centers for Disease Control and Prevention. (2022). Older adult fall prevention.[Context Link]


Levy S. S., Thralls K. J., Kviatkovsky S. A. (2018). Validity and reliability of a portable balance tracking system, BTrackS, in older adults. Journal of Geriatric Physical Therapy, 41(2), 102-107.[Context Link]


Rossiter-Fornoff J. E., Wolf S. L., Wolfson L. I., Buchner D. M. (1995). A cross-sectional validation study of the FICSIT common data base static balance measures. The Journals of Gerontology: Series A, 50(6), M291-M297.[Context Link]


Saunders N. W., Koutakis P., Kloos A. D., Kegelmeyer D. A., Dicke J. D., Devor S. T. (2015). Reliability and validity of a wireless accelerometer for the assessment of postural sway. Journal of Applied Biomechanics, 31(3), 159-163.[Context Link]


Scaglioni-Solano P., Aragon-Vargas L.F. (2014). Validity and reliability of the Nintendo Wii Balance Board to assess standing balance and sensory integration in highly functional older adults. International Journal of Rehabilitation Research, 37(2), 138-143.