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RehabMeasures Instrument

Clinical Test of Sensory Interaction on Balance

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Purpose

The CTSIB provides the clinician with a means to quantify postural control under various sensory conditions.

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Instrument Details

Acronym CTSIB

Area of Assessment

Balance – Vestibular
Balance – Non-vestibular

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Brain Injury
  • Multiple Sclerosis
  • Parkinson's Disease + Neurologic Rehabilitation
  • Stroke Recovery
  • Vestibular Disorders

Key Descriptions

  • The CTSIB was developed as a clinical version of the Sensory Organization Test and was developed to assess sensory contributions to postural control and involves the observing a patient's attempt to maintain balance.
  • Patients stand with their hands at their sides, feet together and perform the following 6 sensory conditions:
    1) Stand on firm surface, eyes open
    2) Stand on firm surface, eyes closed
    3) Stand on firm surface, visual conflict dome
    4) Stand on foam surface, eyes open
    5) Stand on foam surface, eyes closed
    6) Stand on foam surface, visual conflict dome
  • Patient performance is timed for 30 seconds. The test is terminated when a subject's arms or feet change position. If a patient is unable to maintain the position for 30 seconds they are provided with 2 additional attempts. The scores of the 3 trials are averaged (Shumway-Cook & Horak, 1986).
  • Conditions and Dysfunctions:
    1) Patients dependent on vision become unstable in conditions 2,3, 5 & 6 with either eyes closed or a conflict between vision and the vestibular system
    2) Patients dependent on surface/somatosensory inputs become unstable in conditions 4,5 & 6 because they stand on a soft surface (foam)
    3) Patients with vestibular loss become unstable in conditions 5 &6 because they can’t rely on vision or surface / somatosensory function
    4) Patients with sensory selection problems become unstable in conditions 3-6
  • If one or both knees flex condition 1 is a baseline, and changes in sway direction and amount are noted in conditions 2-6 (if unable to maintain 30 seconds on 1st trial, given 2nd trial, and 3rd if needed), then trials are averaged.
  • Conditions 1 thru 4:
    -Record the time (in seconds) the patient was able to maintain the starting position (maximum of 30 seconds)
  • Equilibrium Score: quantifies the center of gravity (COG) sway or postural stability under each of the three trials of each of six sensory conditions (higher scores indicative of better balance).
  • Composite equilibrium scores and the weighted averages of the scores are computed for each of six conditions.
  • Ratios are also computed to identify impairments of individual sensory systems.
  • Center of Gravity (COG) Alignment computed for individual’s COG position relative to center of base of support at the start of the trial.
  • A pediatric version has been developed.

Number of Items

6

Equipment Required

  • Stopwatch
  • 40.64 x 40.64 x 7.62cm piece of medium density viscoelastic (Temper) foam, visual conflict dome: a modified 16” Japanese lantern with horizontal ribs, holes are cut for the patient’s neck and head leaving about 270° circumference (for instructions see Shu

Time to Administer

20 minutes

9 MINUTES FOR TESTING ALL CONDITIONS (6 CONDITIONS * 3 TRIALS * 30 SECONDS), WITH ADDITIONAL TIME FOR SETUP AND EXPLANATION; 3 TRIALS OF FULL TEST IN 20 MIN (COHEN, BLATCHLY ET AL, 1993)

Required Training

Reading an Article/Manual

Age Ranges

Child

6 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Diane Wrisley, PT, PhD, NCS and Elizabeth Dannenbaum, MScPT for the Vestibular EDGEtask force of the Neurology section of the APTA.

ICF Domain

Body Function
Activity

Measurement Domain

Motor
Sensory

Professional Association Recommendation

Measure: Clinical Test of Sensory Interaction in Balance

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post) 

(Vestibular < 6 months post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

Vestibular EDGE

LS

LS

LS

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

UR

UR

UR

UR

UR

TBI EDGE

LS

LS

LS

LS

LS

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

LS

LS

LS

NR

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

UR

UR

UR

NR

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

Vestibular EDGE

LS

LS

LS

LS

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

No

No

No

Yes

TBI EDGE

Yes

Yes

No

Not reported

Vestibular EDGE

Yes

Yes

Yes

Yes

Considerations

  • CTSIB was developed to evaluate the relative contributions of sensory systems involved in the maintenance of balance, not to evaluate change over time.
  • For test batteries, Bernhardt et al, 1998 recommend one component of the CTSIB
    • The Repetitive Reach (RR, step stance)
    • Step Test (ST) and 
    • Gait velocity assessments
  • The CTSIB initially required participants to remove their shoes prior to administration. However, research suggests that CTSIB scores with low-heeled shoes are not significantly different from no-shoe administrations (Whitney & Wrisley, 2004).
  • Some research evaluates performance on the scale in terms of sway (e.g., degrees/second) instead of the time the subject maintains the starting position. 
  • The modified Clinical Test of Sensory Interaction on Balance is more commonly used currently.

 

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Older Adults and Geriatric Care

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Cut-Off Scores

Community-Dwelling Elderly

(Di Fabio and Anacker, 1996; = 47 adults with falls = 16 vs. no falls = 31; mean age = 80.5(9.0); fall group had > 2 falls in past 6 months, Community-Dwelling Elderly)

  • A composite score < 260 seconds (summing all 3, 30sec trials for each of 6 conditions) has specificity of 90% and sensitivity of 44% for identifying fallers
  • If average score below 81s in compliant surface conditions, relative risk of falling is 8.67 (age adjusted odds ratio)

Normative Data

Elderly Adults


(Ricci et al, 2009; n = 96 independent elderly; mean age = 74.81 (7.25), 75.19 (7.32) and 74.47 (6.39) years for groups 1 (no falls),2 (one fall), and 3 (recurrent falls), respectively, Elderly Adults)

Mean Scores for Elderly Adults Depending on Individual Fall History:

 

 

 

 

CTSIB Domain

Groups

Time (s)

 

 

anova p-value

Firm; eyes open

Group 1 (no falls)

30 (0)

 

0.5

 

Group 2 (one fall)

29.9 (0.56)

0.5

 

Group 3 (recurrent falls)

29.7 (1.68)

0.5

Firm; eyes closed

Group 1 (no falls)

29.74 (1.05)

0.079

 

Group 2 (one fall)

29.57 (2.38)

0.079

 

Group 3 (recurrent falls)

27.93 (5.44)

0.079

Firm; dome

Group 1 (no falls)

29.21 (4.36)

0.177

 

Group 2 (one fall)

28.76 (5)

0.177

 

Group 3 (recurrent falls)

26.53 (8.25)

0.177

Foam; eyes open

Group 1 (no falls)

30 (0)

0.043

 

Group 2 (one fall)

29.27 (4.08)

0.043

 

Group 3 (recurrent falls)

26.85 (4.95)

0.043

Foam; eyes closed

Group 1 (no falls)

26.22 (8.38)

0.042

 

Group 2 (one fall)

25.96 (7.45)

0.042

 

Group 3 (recurrent falls)

20.97 (11.38)

0.042

Foam; dome

Group 1 (no falls)

26.86 (7.65)

0.052

 

Group 2 (one fall)

25.15 (8.86)

0.052

 

Group 3 (recurrent falls)

21.09 (11.8)

0.052

Test/Retest Reliability

Community dwelling adults: 

(Anacker and Di Fabio, 1992; = 47 adults with falls = 16 vs no falls n = 31; mean age = 80.5 (9.0); fall group had > 2 falls in past 6 months, Community Dwelling Elderly)

  • Excellent test-retest reliability (r = 0.75)

Criterion Validity (Predictive/Concurrent)

Community-Dwelling Elderly:

(Di Fabio and Anacker, 1996, Community-Dwelling Elderly)

  • Cross validation analyses predicted 75% fallers and 60% of non-fallers 

Construct Validity

Older adult fallers:

Ricci et al 2009 found significant differences between older adults who fell 2 or more times in the past year, 1 time in the past year and did not fall in the past year on conditions 4-6 of the CTSIB p < 0.05

 

Community-Dwelling Elderly

(Di Fabio and Anacker, 1996, Community-Dwelling Elderly)

  • Discriminant functions classified 63% of fallers and 77% of non-fallers

Stroke

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Normative Data

(Bernhardt et al, 1998; n = 29; mean age = 71.8 (10.5) years; < 4 weeks post onset, Acute Stroke)

CTSIB domain

Week 4: mean (SD)

Week 8: mean (SD)

Firm; eyes open

25.2 (10.7)

28.5 (6.1)

Firm; eyes closed

24.0 (11.3)

28.1 (6.4)

Firm; dome

23.2 (11.9)

26.7 (8.8)

Foam; eyes open

23.5 (11.9)

27.0 (7.7)

Foam; eyes closed

19.8 (13.3)

24.3 (10.7)

Foam; dome

18.5 (13.6)

23.2 (11.9)

Interrater/Intrarater Reliability

Hemiplegia:

(DiFabio & Badke, 1990; tested on subset of subjects: n = 5, mean age = 58 (12) years, hemiparesis, Chronic Stroke)

  • Excellent interrater reliability: kappa = 0.77 (tested on a different sample of individuals with hemiparesis

Construct Validity

Stroke:

Significant positive correlations were found by DiFabio and Badke, 1990 between the CTSIB and Fugl-Meyer Sensorimotor Assessment (FMSA) sensory subscore (r = 0.55), the FMSA balance subscores (r = 0.77), and the FMSA lower extremity recovery score (r = 0.69) in 10 subjects post stroke.

Anacker and DiFabio, 1992, found a significant group by surface interaction (p = 0.048) when comparing CTSIB scores between 16 older adults with a history of falling and 31 older adults without a history of falling.  Older adults with a history of falling demonstrated a reduction in stance duration on a compliant surface compared to non-fallers.

Floor/Ceiling Effects

Stroke:

(Bernhardt et al, 1998, Acute Stroke) 

Floor effects at 4 weeks & ceiling effects at 8 weeks:

CTSIB domain

Week 4: mean (SD)

% Floor

Week 8: mean (SD)

%Ceiling

Firm; eyes open

25.2 (10.7)

10

28.5 (6.1)

93

Firm; eyes closed

4.0 (11.3)

14

28.1 (6.4)

90

Firm; dome

23.2 (11.9)

17

26.7 (8.8)

86

Foam; eyes open

23.5 (11.9)

14

27.0 (7.7)

83

Foam; eyes closed

19.8 (13.3)

21

24.3 (10.7)

72

Foam; dome

18.5 (13.6)

24

23.2 (11.9)

72

Responsiveness

Stroke:

(Bernhardt et al, 1998, Acute Stroke)

Standard Responsiveness Measures (SRM)

CTSIB domain

SRM

Firm; eyes open

0.38

Firm; eyes closed

0.48

Firm; dome

0.45

Foam; eyes open

0.34

Foam; eyes closed

0.46

Foam; dome

0.44

Vestibular Disorders

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Normative Data

(Cohen et al, 1993, n = 17, mean age 59.8 (18.9), Vestibular Impairment):

  • Condition 1: 30 seconds
  • Condition 2: 30 seconds
  • Condition 3: 30 seconds
  • Condition 4: 25.7 (8.8), 27.6 (7.3), 26.6 (8.4) seconds across trials
  • Condition 5: 11.4 (12.6), 14.0 (13.0), 16.1 (13.3) seconds across trials 
  • Condition 6: 8.0 (11.1), 12.9 (13.5), 12.5 (13.7) seconds across trials

Criterion Validity (Predictive/Concurrent)

Vestibular Disorders:

El-Kashlan et al (1998) compared scores on CTSIB with scores on the Sensory Organization Test (SOT) in adults with vestibular disorders.  They found significant correlations between total scores on both tests r-values ranged from 0.41 to 0.89 depending on the time period during rehabilitation the tests were performed.  When the SOT is used as the gold standard, the CTSIB demonstrates a Cohen’s k (measure of agreement) of 0.80; specificity of 87% and sensitivity of 60%, positive predictive value was 89% and negative predictive value was 55%.  When comparing response patterns elicited by the SOT and CTSIB in 21 patients who demonstrated abnormalities in both tests, the CTSIB was significantly less sensitive in identifying more subtle patterns of balance dysfunction (p < 0.05)

Construct Validity

Vestibular Disorders:

 

(Cohen et al, 1993, n = 17, mean age 59.8 (18.9), Vestibular Impairment):

People with vestibular disorders scored significantly lower than 45 healthy adults aged 25-84 years on conditions 5,and 6. Subjects with vestibular disorders had greater variability than the healthy adults.

Non-Specific Patient Population

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Normative Data

Healthy Adults: 

Normative data for the CTSIB were determined by El-Kashlan et al, 1998, using 69 healthy adults aged 20-79 years.  Normative scores are listed below, maximum score is 180, 30 seconds for each condition.  Scores of < 180 are recommended for ages 20-49 even though the 5% is 176.5.

 

 

Age 20-49

Age 50-59

Age 60-69

Age 70-79

Mean

179.7

180

179.9

177.4

SD

1.6

0

0.5

8.7

5%

176.5 (180)

180

178

151.3

 

Cohen et al, 1993; pilot study with n = 22 healthy adults; mean age = 21.3 (0.85); experiment compares neurologically asymptomatic adults to adults diagnosed with vestibular disorders, Healthy Adults)

Mean Balance Scores

 

 

 

Age

Time

Conditions

25-44 yrs

30 secs

4,5 & 6

45-64 yrs

30 secs

4 & 5

45-64 yrs

28-30 secs

6

65-84 yrs

26-28 secs

4

65-84 yrs

13-19 secs

5

65-84 yrs

14-24secs

6

Test/Retest Reliability

Healthy young adults:

Test-retest reliability was reported as high by Cohen et al, 1993 based on their pilot study (r = 0.99).  Healthy young adults were tested twice by the same investigator.

Interrater/Intrarater Reliability

Healthy Young Adults:

(Cohen et at, 1993, Healthy Young Adults)

  • Excellent interrater reliability (r = 0.99)

Criterion Validity (Predictive/Concurrent)

Healthy Young Adults:

(Cohen et al, 1993, Healthy Young Adults)

  • CTSIB scores for healthy adults compared to those with vestibular impairments were found to be significantly different

Bibliography

Anacker, S. L. and Di Fabio, R. P. (1992). "Influence of sensory inputs on standing balance in community-dwelling elders with a recent history of falling." Phys Ther 72(8): 575-581; discussion 581-574. Find it on PubMed

Bernhardt, J., Ellis, P., et al. (1998). "Changes in balance and locomotion measures during rehabilitation following stroke." Physiother Res Int 3(2): 109-122. Find it on PubMed

Cohen, H., Blatchly, C. A., et al. (1993). "A study of the clinical test of sensory interaction and balance." Phys Ther 73(6): 346-351; discussion 351-344. Find it on PubMed

Di Fabio, R. P. and Badke, M. B. (1990). "Relationship of sensory organization to balance function in patients with hemiplegia." Phys Ther 70(9): 542-548. Find it on PubMed

El-Kashlan, H. K., Shepard, N. T., et al. (1998). "Evaluation of clinical measures of equilibrium." Laryngoscope 108(3): 311-319. Find it on PubMed

Horak, F. B. (1987). "Clinical measurement of postural control in adults." Physical Therapy 67(12): 1881-1885. 

Ricci, N. A., de Faria Figueiredo Goncalves, D., et al. (2009). "Sensory interaction on static balance: a comparison concerning the history of falls of community-dwelling elderly." Geriatr Gerontol Int 9(2): 165-171. Find it on PubMed

Shumway-Cook, A. and Horak, F. B. (1986). "Assessing the influence of sensory integration on balance. Suggestions from the field." Physical Therapy 66: 1548-1549.

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