Balance and Postural Control Assessment After Stroke

Original Editor - Stacy Schiurring based on the course by Mike Studer

Top Contributors - Stacy Schiurring and Jess Bell  

Introduction

Balance is often treated as a single construct, but it is better understood as a collection of interacting skills: awareness, vision, somatosensation, perception, motor control, and neuromuscular endurance. Following stroke, these skills are frequently affected asymmetrically, since most strokes damage one hemisphere of the brain more than the other. Brainstem and cerebellar strokes are exceptions, often affecting both sides of the body, though in different ways. Regardless of the pattern of damage, the clinical task is the same: to identify precisely which component of balance is limited, so that assessment findings translate directly into a targeted plan of care.

The assessment should distinguish between feedforward control (the anticipatory postural adjustments a person makes in preparation for a self-initiated movement, such as reaching) and feedback control (the reactive postural response to an unexpected external perturbation). Both must be assessed, as an individual can present with a deficit in one and relative preservation of the other.

Fear of falling, which is common after stroke, also needs to be measured and included in clinical reasoning rather than treated as a side issue. A recent meta-analysis confirmed that fear of falling, even when captured with a single self-report question, is significantly associated with future falls after acute stroke. This reinforces the value of including patient-reported measures alongside performance-based testing.

This page summarises the core clinical measures used to assess sitting and standing balance after stroke, moving from basic to more advanced assessment, and outlines how these assessments can be graded and dosed to extract additional clinical information.

Core and Complementary Outcome Measures

Several measures have sufficient psychometric evidence in stroke populations to be considered core to any balance assessment. The Academy of Neurologic Physical Therapy (American Physical Therapy Association) endorsed clinical practice guideline recommends the core measures listed in Table 1 for adults with neurologic conditions undergoing rehabilitation. The complementary tools listed in Table 2 add further detail, particularly around fear of falling and task-specific instability. Used together, the measures from both tables give an objective score alongside the person's own experience of instability, though the two do not always align.

Table 1. Core Measures

Measure	Type	What it Assesses	Practical Note
Berg Balance Scale (BBS)	Performance-based	Static and dynamic balance across sitting, standing, and transitional tasks (14 items)	One of the most extensively validated balance measures in stroke Widely used as a general screen
Activities-specific Balance Confidence (ABC) Scale	Patient-reported	Balance confidence during 16 progressively demanding ambulatory activities	Captures perceived risk, which does not always match performance-based scores
Functional Gait Assessment (FGA)	Performance-based	Postural stability during walking and gait-related tasks	Sits at the intersection of balance and gait

Table 2. Complementary Measures

Measure	Type	What it Adds
Modified Falls Efficacy Scale–International	Patient-reported	Fear of falling across a broad range of daily activities
Rate of Perceived Stability (RPS)	Patient-reported, single item	Real-time rating of how unstable the patient felt during a specific task
Balance Challenge (rater/therapist version)	Clinician-rated	A therapist's structured rating of the difficulty of a balance task
Patient-Specific Functional Scale (PSFS)	Patient-reported	The individual's own nominated balance-related priorities, rated over time

Assessing Sitting Balance

Sitting balance is frequently under-assessed relative to standing balance, yet it provides an efficient, lower-risk starting point for individuals with more significant impairment. It also reveals feedforward and feedback deficits that may not otherwise be apparent.

Table 3. Sitting Balance Assessments

Measure	Type	What it Assesses	Practical Note
Function in Sitting Test (FIST)	Performance-based	14 items, scored 0–4, including feedforward tasks (reaching side-to-side, behind, and to the floor; scooting) and feedback tasks (tolerating an external nudge), plus items removing vision and adding head rotation	Because it captures such a broad range of sitting sub-skills, the item-level score can be used diagnostically to identify which specific component most needs addressing, rather than only giving a summary score
Timed unsupported sitting	Performance-based	Time an individual can maintain an unsupported sitting position under standardised conditions (e.g. a set seat height, feet unsupported, etc)	A simple alternative or supplement to the FIST where a fuller battery is not required; straightforward to re-test and document change over time

Assessing Standing Balance

Standing balance assessment is conventionally divided into static and dynamic categories, though many higher-level tools combine both.

Table 4. Static Standing Measures

Measure	Type	What it Assesses	Practical Note
Berg Balance Scale (BBS)	Performance-based	See core measures table above	Also functions as a standing measure, not only a general screen
Clinical Test of Sensory Interaction on Balance (CTSIB)	Performance-based	Four conditions systematically manipulating vision and surface compliance	Useful for identifying which sensory system a person relies on most Also see the modified CTSIB (m-CTSIB)
Four-Stage Balance Test	Performance-based	Progresses through feet-together, semi-tandem, tandem, and single-leg stance	Quick to administer Good screening picture of overall standing stability

Table 5. Dynamic Standing Measures

Measure	Type	What it Assesses	Practical Note
Functional Reach / Multidirectional Reach	Performance-based	Quantifies limits of stability during a self-initiated forward or multidirectional lean	Simple, equipment-light measure of anticipatory control
Four Square Step Test	Performance-based	Rapid stepping over low objects in four directions	Captures dynamic postural control, coordination, and reactive stepping together
Fullerton Advanced Balance Scale	Performance-based	10-item scale, originally developed for community-dwelling older adults	Psychometric properties recently established in stroke Useful where a higher ceiling than the BBS is needed for a higher-functioning individual

Higher-Level and Hybrid Measures

Higher-level tools challenge balance under more demanding conditions than the standard static and dynamic tests above (e.g. greater speed, agility, or complexity), and are appropriate once basic static and dynamic standing balance has been established. These assessments are, therefore, well suited to individuals returning to higher-functioning recreational, vocational, or community roles. Hybrid refers to measures that combine multiple balance components (such as static and dynamic control, or anticipatory and reactive strategies) within a single tool, or that assess balance and gait together rather than in isolation.

Table 6. Higher-Level and Hybrid Measures

Measure	Type	What it Assesses	Practical Note
Balance Evaluation Systems Test (BESTest) / Mini-BESTest	Performance-based	Separates balance into component systems: biomechanical constraints, anticipatory postural adjustments, reactive postural control, sensory orientation, and stability in gait	A low subscale score points directly to the underlying deficit, rather than only an overall level of impairment
High-Level Mobility Assessment Tool (HiMAT)	Performance-based	Skipping, hopping, running-based tasks	Appropriate for higher-functioning individuals returning to demanding recreational or occupational roles
Functional Gait Assessment (FGA)	Performance-based	Postural stability during walking and gait-related tasks	Also listed as a core measure above
Dynamic Gait Index (DGI)	Performance-based	Gait-focused hybrid balance measure, predecessor to the FGA	Sits at the intersection of balance and gait

Adaptability, Fatigue, and Distraction Tolerance

The capacity to adapt balance strategies to changing conditions is a clinically important, and frequently under-assessed, dimension of recovery. This is particularly relevant given that dual-task and cognitive-motor interference is now well established as a feature of post-stroke balance and gait impairment.

In practice, adaptability can be assessed by comparing a balance score obtained at rest with one obtained immediately after a standardised fatiguing task (such as a six-minute walk test, a bout of sit-to-stand repetitions, or use of a stepper). It can also be assessed by comparing a balance score obtained with and without a concurrent distraction task (e.g. manual, cognitive, auditory, or visual). The difference between rested and fatigued performance measures endurance-related consistency. The difference between the distracted and undistracted scores is called a dual-task cost. Both are readily documented, clinically meaningful, and directly relevant to real-world function, since most activities are performed under some degree of fatigue or distraction.

Assessing Fall Risk

Balance and fall-risk assessments are related but not identical. A 2024 scoping review found the Berg Balance Scale to be the most extensively studied single indicator of fall risk after stroke, with cut-off scores of 46.5–50.5 (area under the curve 0.72–0.81). The Timed Up and Go test and Falls Efficacy Scale-International showed consistent but less accurate cut-offs, and no single tool reliably distinguished fallers from non-fallers. This supports pairing a performance-based measure such as the BBS with a patient-reported measure such as the ABC Scale, plus a structured fall-history interview.

It is also worth considering not just how much risk a person carries, but how appropriately they respond to it. Stroke survivors can be broadly grouped as appropriate non-avoiders (suitably active), inappropriate avoiders (more fearful and inactive than their risk warrants), appropriate avoiders (correctly limiting high-risk activity given severe impairment), or inappropriate non-avoiders (taking on more risk than their impairment allows). This is a useful reminder that overly cautious fall-prevention messaging can itself cause harm, by shifting someone from appropriate activity into inappropriate inactivity.

Dosing and Grading a Balance Assessment

A balance test need not be treated as fixed. The measures above can be systematically graded for more precise clinical information:

1. Removing a sensory condition. Re-administer with vision removed, on a compliant surface, or with head rotation added; progressing from least to most destabilising, and only as tolerated. The gap between baseline and modified performance is a sensory cost, and shows which sensory system the person relies on most.
2. Adding a load. Re-measure after adding an external challenge (e.g. an inclined or uneven surface, removing foot or arm supports, a perturbation, or resistance towards the person's typical direction of loss), then re-test once the load is removed. This unloaded–loaded–unloaded sequence shows whether performance returns to, or exceeds, baseline.
3. Layering a secondary task or fatigue. Distraction and fatigue can each be quantified as a cost relative to an undistracted, rested baseline.

Dosage should be collaborative rather than imposed. Asking a person how unstable they felt during a task (captured by the RPS), or how effortful or difficult they found it, lets the next test or intervention be calibrated to their tolerance rather than a generic protocol. Framing assessment around a person's goals and preferred level of challenge (e.g. tracking a "personal best" for unsupported sitting time) also improves engagement, which is important as disengagement can under-represent true capacity.

Additional Resources

• Matsumoto D, Fujita T, Kasahara R, Tsuchiya K, Iokawa K. Screening cutoff values to identify the risk of falls after stroke: A scoping review. Journal of rehabilitation medicine. 2024 Oct 24;56:40560.
• Moore JL, Potter K, Blankshain K, Kaplan SL, O'Dwyer LC, Sullivan JE. A core set of outcome measures for adults with neurologic conditions undergoing rehabilitation: a clinical practice guideline. Journal of neurologic physical therapy. 2018 Jul 1;42(3):174-220.
• Tamis WP, Winser SJ, Wayne LS, Bolton CH, Shamay NG, Thomson WO, Margaret MA, Marco PA. Association between fear of falling and falls following acute and chronic stroke: a systematic review with meta-analysis. Journal of rehabilitation medicine. 2024 Jan 16;56:18650.