Berg Balance Testing

Part of every exam for neuropathy, is asking the question, “so… how are your balance issues? How is your walking gait?” Most patients will indicate that they have, at least some, balance issues. Even more, indicate that they cannot get up out of a chair without arms, at least, without some assistance. (This, is one reason, we don’t have arms on the chairs in our waiting room… they become part of the test!) But, if the patient indicates they “fall over or down a lot, stagger or have difficulty getting up and down,” we will give them what is known as a Berg Balance Test.

Developed by Katherine Berg (of whom it is named) and others, the test tests the static and dynamic balance abilities, of the patient. Scoring will indicate how ‘likely’ the patient is to end up in a wheelchair, or if they need to walk with assistance or can walk without much risk of falling. (Research shows, that if a patient – especially, an elderly one – falls and can get back up on their own within 15 minutes or less, they are more likely to be able to continue to live on their own. The longer it takes for the patient to get up, or if they need assistance, the more likely they will end up in assisted living or convalescent care).

The patient, depending upon their age, is scored on their ability to:

  1. Sitting to standing
  2. Standing unsupported
  3. Sitting unsupported
  4. Standing to sitting (without using arms on a chair or pushing up with hands on knees)
  5. Transfers
  6. Standing with eyes closed
  7. Standing with feet together
  8. Reaching forward with outstretched arm
  9. Retrieving object from floor
  10. Turning to look behind
  11. Turning 360 degrees
  12. Placing alternate foot on stool
  13. Standing with one foot in front
  14. Standing on one foot

Each task must be completed within a certain amount of time; and, is scored accordingly. These scores helps the neuropathist judge, not only what the ‘risk of falling’ is for the patient, but the extent of their neuropathy as well; in other words, the lower the score, the more likely to fall; and, most likely, the more severe the neuropathy.

Taking these scores and combining them with Toronto Clinical Scoring results, as well as examination of other parts of the body and information from Intake, all help determine the type of neuropathy the patient has; and ‘WHAT‘ issues need to be addressed first and foremost! For example, if a patient scores really well on the Berg test, we are not as concerned with treating muscle atrophy as we would someone with a low score. In the same sense, if Intake and examination indicate possible diabetic neuropathy, but the patient has stated he “trips over his own feet and falls a lot,” we might wish to look at drop foot or even send the patient to be checked for MS; if the muscles have not noticeably atrophied.

In other words, if we see a neuropathy with certain symptoms which are not common, we may refer out to neurologists to ‘look’ for other reasons besides, simple neuropathy for the symptoms.

 

Next Blog:  Patient Compliance.

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Intake

Before we start an examination, we require some information just as with any doctor’s office. The neuropathist will, generally, either send by mail or email, a questioner to a new patient (or have them fill it out upon their first visit) in which they will ‘detail’ their medical history.

Often we hear:

“Why do you need to know this information, isn’t it rather ‘personal’ to ask about my medical history and medications; or if I have had any kind of injuries or diseases?” 

Frankly, no… it’s not too personal, when we are attempting to find out “why” the patient hurts!  It is not out of line to ask for a patient’s medical history, or even ask other so-called ‘personal’ questions, if one is trying to determine the type of neuropathy a patient might have… or, even to determine if the patient even HAS a true neuropathy (remember from past blogs, some issues like IBS may actually be autonomic neuropathy, or carpal tunnel, may or may not)!  Patients, most likely, wouldn’t go into a doctor’s office and tell the doctor “guess what is wrong with me,” they are going to give the doctor, hopefully, as much information as possible so he/she can make a good, educated determination as to the problem or disorder. The same is with the neuropathist!

Of course, most patients don’t mind or expect the obvious questions: “Do you have High Blood Pressure, are you a Diabetic, have you had any operations or injuries, and etc.”  But many times, questions don’t seem appropriate to the patient.  What kind of questions do people find ‘objectionable?’  “Have you ever been in the military?” 

“What would that have to do with anything,” we are often asked.  Well, if someone happens to be in their 60’s or so, it can help to determine ‘the reason’ for ones neuropathy.  Was the patient in Viet Nam? “Yes?”  Now, the possibility of exposure to Agent Orange comes into play!  Was the patient a pilot or airplane crew member during the war?  It gets rather cold high up in the sky… frostbite is not unheard of by pilots.

Other questions; “Are you or were you a skier?”  Same thing… possible frostbite at one time.  “Are you or were you a smoker?” Lots of objections on this question. Again, we hear, “what does that have to do with anything?  My lungs are not the issue here… it’s my feet that hurt!”  The issue is, that most peripheral neuropathy is caused by hypoxia, a lack of oxygen to the nerves and tissue via the blood. The hypoxia can have many root causes; but if one is a smoker, oxygen is being depleted to the tissue with every ‘puff’ the patient takes.  This can be easily seen in some smoker’s legs and feet. The tissue takes on a ‘blue’ or ‘purple’ coloration.  This is poor circulation, pure and simple; and poor circulation means less oxygen to the tissue. To reiterate, hypoxia may be the ‘root of the problem’ for the neuropathy; but ‘smoking’ may be the ‘root of the problem’ for the hypoxia!

Questions about legal and illegal drugs, now, need to come into play.  Again, we are not being nosey, nor are we looking to ‘turn in’ anyone one for illegal drug use.  But, we NEED to know about any self-medicating issues, as so many drugs can cause neuropathy; and/or treatment for drug addiction can also be responsible (not surprisingly, with ‘Baby Boomers, doctors and surgeons are finding that some patients still have drug addictions stemming from back in the 1960’s; and those addictions must be taken care of before surgery or treatment can take place. We neuropathists see the same issues… and, the addiction can be the ‘root issue,’ once again.) for many symptoms. 

As an added feature to treatment, however, if we know the patient has a drug addiction, we can possibly help with that as well – or, help the patient find the help they need.  In the same sense, if one is taking legal or prescription drugs, we need to look at the side effects of those compounds to see if they contribute to ones neuropathy.  Statin drugs for high cholesterol are very common culprits of this; but luckily, there are plenty of ‘natural statin’s’ one can take to reduce ones cholesterol.  In addition, depending upon some modalities, they might help to reduce not only cholesterol, but blood sugar or blood pressure as well.  If we know exactly what the patient is taking, again, we can make a more informed determination as to the best modality to use or what issue to address; as well as how to best address nutrition.

One more question that people seem to have an objection to sharing, especially if a younger patient, is:  if one has a pacemaker or defibrillator or not. Older patients don’t seem to mind answering this one, but younger ones do, as they seem to feel there is something of a ‘stigma’ of some kind associated with it.  Of course, there is not; but we do need to know, as there are certain contraindications (meaning it could be unwise to do) that accompany the patients’ device.

Next, is probably the most embarrassing: ‘bathroom habits!’  No, we really don’t want to know… but we may HAVE TO know to make certain determinations. For example, many patients present with, not only, a idiopathic neuropathy diagnosis, but with irritable bowel syndrome as well.  “How long have you had the Neuropathy or diagnosis of Neuropathy” we ask? Then, “how long have you had the Irritable Bowel syndrome?” If their answer is “20 or more years,” then we look at that irritable bowel just a bit differently. We consider the possibility of, the afore mentioned, autonomic neuropathy – in other words, neuropathy of the internal organs; which brings about even more questions for the Intake! “Do you get diarrhea when you go out to eat?  Do things like Thousand Island Salad Dressing bother you?  Does Gluten bother you?”  If the answer is “yes” to those questions, the person is more likely – not definitive, but more likely – to actually have irritable bowel syndrome.  If not, and the diarrhea appears at any time, or after eating just about anything… and/or incontinence is involved, we then start looking towards meds to make sure “loose bowels” are not a side effect from certain medication.

It is only through a complete Intake, and medical history, that we can make proper determinations as to the patients neuropathy and treatment.  It’s not being “nosey”… we have a genuine “need to know!”  And, because of that need to know, we are more likely to find the correct ‘modality of treatment’ for your neuropathy!

 

Next Blog: Examination and Testing