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Modified Clinical Test of Sensory Interaction on Balance

Modified Clinical Test of Sensory Interaction on Balance

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

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Instrument Details

Acronym CTSIB-M

Area of Assessment

Balance – Vestibular
Balance – Non-vestibular

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil



Cost Description

Free non-instrumented
$10,000-$30,000 instrumented


  • Brain Injury Recovery
  • Cerebral Palsy
  • Multiple Sclerosis
  • Parkinson's Disease & Neurologic Rehabilitation
  • Pediatric + Adolescent Rehabilitation
  • Stroke Recovery
  • Vestibular Disorders

Key Descriptions

  • The CTSIB-M is a modification of the CTSIB that eliminates the use of the visual conflict dome (Cohen et al 1993). It includes conditions 1,2,4,and 5 of the original CTSIB.
  • To perform the test the patient stands with their hands at their side and performs the following 4 conditions:
    1) Stand on firm surface with the eyes open (CTSIB condition 1)
    2) Stand on firm surface with the eyes closed (CTSIB condition 2)
    3) Stand on compliant surface (foam) with the eyes open (CTSIB condition 4)
    4) Stand on compliant surface (foam) with the eyes closed (CTSIB condition 5)
  • Patient performance is timed for 30 seconds (10 seconds for instrumented CTSIB-M). 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.
  • Research has shown that neither the position of the feet nor the footwear influence the scores (Whitney and Wrisley 2004, Wrisley and Whitney 2004).
  • Can be performed on a force plate for an instrumented CTSIB-M. (i.e. NeuroCom Balance Master).
  • Has been modified for children as Pediatric Clinical Test of Sensory Interaction on Balance.
  • Total score (Modified CTSIB) =
    -Average Time Cond 1 (if > 1 trial required) +
    -Average Time Cond 2 (if > 1 trial required) +
    -Average Time Cond 3 (if > 1 trial required) +
    -Average Time Cond 4 (if > 1 trial required)

Number of Items


Equipment Required

  • Stopwatch
  • 40.64 x 40.64 x 7.62cm piece of medium density viscoelastic (Temper) foam

Time to Administer

Less than 10 minutes

Required Training

Reading an Article/Manual

Age Ranges

Preschool Child

2 - 5



6 - 13



13 - 17



18 - 64


Elderly Adult

65 +


Instrument Reviewers

Reviewed by Diane Wrisley, PT, PhD, NCS and Elizabeth Dannenbaum, MScPT for APTA Neurology Section Vestibular EDGE Group.

ICF Domain


Measurement Domain


Professional Association Recommendation

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:




Highly Recommend




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


Not Recommended

Recommendations for use based on acuity level of the patient:



(CVA < 2 months post)

(SCI < 1 month post) 

(Vestibular < 6 weeks post)


(CVA 2 to 6 months)

(SCI 3 to 6 months)


(> 6 months)

(Vestibular > 6 weeks post)

Vestibular EDGE




Recommendations based on vestibular diagnosis




Benign Paroxysmal Positional Vertigo (BPPV)


Vestibular EDGE





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)

Vestibular EDGE






  • Reliability for people with vestibular dysfunction was established using the CTSIB.
  • CTSIB-M was developed to assess sensory contributions to balance not to measure change over time.
  • Stance (feet together versus feet apart) did not result in significantly different mCTSIB scores. (Wrisley and Whitney, 2004) 
  • There is likely a maturation effect on the P-CTSIB, as older children perform better than younger children (Richardson et al, 1992; n = 40 preschool and kindergarten children) and adults perform better than children (Kluenter et al, 2008)
  • 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. 

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Alzheimer's Disease and Progressive Dementia

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Standard Error of Measurement (SEM)

Alzheimer’s Disease:

(Suttanon et al, 2011; = 14 patients with mild to moderate Alzheimer’s Disease; mean age = 79.57(6.19) years, Alzheimer's Disease)

  • SEM = 0.17 (deg/sec)

Minimal Detectable Change (MDC)

Alzheimer’s Disease:

(Suttanon et al, 2011, Alzheimer's Disease)

  • Relatively high MDC₅ (MDC = 0.34) 
  • Large changes are needed in order to ensure a significant clinical change in people with Alzheimer’s disease

Test/Retest Reliability

Alzheimer’s Disease:

(Suttanon et al, 2011, Alzheimer’s Disease)

  • Excellent test-retest reliability in mCTSIB (ICC = 0.91)

Pediatric Disorders

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Normative Data

Geldhof et al, 2006 determined normative scores with 99 children aged 9-10 years. Means and Standard deviations are presented in the table below.





Composite deg/site

0.712 + 0.181

0.679 + 0.186

0.873 + 0.155

Firm EO

0.323 + 0.095

0.303 + 0.085

0.351 + 0.101

Firm EC

0.424 + 0.137

0.395 + 0.127

0.469 + 0.142

Foam EO

0.686 + 0.183

0.641 + 0.184

0.751 + 0.162

Foam EC

1.463 + 0.408

1.376 + 0.412

1.591 + 0.370

(Kluenter et al, 2008; n = 65; mean age = 7 years for children born full-term and children born pre-term with low birth weight, Pediatrics)

Modified CTSIB domain

Healthy full-term (sway: degrees/s)

Pre-term (sway: degrees/s)

Firm: eyes open 

0.70 (0.32) 

0.86 (0.47) 

Firm: eyes closed 

0.91 (0.39) 

1.05 (0.50) 

Foam: eyes open 

1.25 (0.47) 

1.30 (0.42) 

Foam: eyes closed 

2.01 (0.66) 

1.98 (0.61)



(Gagnon et al, 2006; n = 16; mean age = 9.8 (3.5) years, Healthy Pediatrics)


Tandem (s)

Single leg (s)

Eyes open

29.4 (2.4)

26.5 (7.6)

Eyes closed

23.0 (9.3)

9.4 (6.9)

Altered vision

18.6 (11.0)

7.4 (6.9)

Eyes open with altered support

28.6 (4.5)

23.5 (8.9)

Eyes closed with altered support

14.9 (11.3)

6.0 (4.4)

Altered vision with altered support

9.6 (9.3)

3.9 (2.5)

Test/Retest Reliability


Pediatric (Mild TBI):

(Gagnon et al, 1993; n = 38; mean age = 12.2 (2.8) years; mean Glasgow Coma Scale score = 14.8, used Pediatric-CTSIB-tandem standing added for total of 12 conditions, Pediatric Mild TBI)

  • Excellent test-retest reliability in P-CTSIB (ICC = 0.79 - 0.82, across 12 sensory conditions)



(Geldhof et al, 2006; n = 20, 9 to 10 year old children; mean age = 10.1 (0.7) years, Pediatric)

  • Poor to adequate intersession test-retest reliability in mCTSIB (ICC = 0.37-0.77 for four sensory conditions)

Interrater/Intrarater Reliability

Pediatrics with Cerebral Palsy

(Lowes et al, 2004; n = 14; age not given, Pediatrics with CP)

  • Excellent overall interrater reliability (r = 0.88, range 0.60-1.00)

Criterion Validity (Predictive/Concurrent)

(Gagnon et al, 2006, Healthy Pediatric)

  • P-CTSIB scores and SOT scores on domains measuring proprioceptive alteration differ
  • On domains measuring visual integration, they are related
  • These two tests are not interchangeable

Construct Validity

Pediatric (Hearing Impairments):

(De Kegel et al, 2010; n = 76; mean age = 9 (3.0 years); children with bilateral hearing impairment vs typically developing children, Pediatric - Hearing Impairments)

  • Modified CTSIB (mCTSIB) scores were able to illustrate a strong, significant amount of postural sway when two types of sensory information were disturbed in children with hearing impairments when compared to typical children

Pediatric (SMD):

(Su et al, 2010; n = 31; mean age = 6.75 (2.25 years); n = 17 children with SMD vs. n = 14 typically developing children, Pediatric (SMD))

  • CTSIB scores showed that children with Sensory Modulation Disorder (SMD) had poorer stance control than typically developing children for all visual input types (p < 0.05), except for the condition of reliable somatosensory input with sway-referenced vision. Results revealed that body sway of the child with SMD was greater than that of the typically developing child for all visual input types under the condition of unreliable somatosensory input (p < 0.05)

Non-Specific Patient Population

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Test/Retest Reliability

Healthy adults:

Hageman et al, 1995, in a pilot study of 12 healthy subjects aged 24-68 years tested 1 week apart found high test-retest reliability for the first 2 conditions of the instrumented CTSIB-M (NeuroCom Balance Master).  ICC  = 0.91 for firm surface eyes open and ICC = 0.97 for firm surface eyes closed.



Criterion Validity (Predictive/Concurrent)

Healthy women:

Nitz et al, 2013 found that the inability to maintain standing on foam with eyes closed predicted future multiple falls (Odds Ratio 4.21 95% confidence interval 1.79-9.92) based on a 10 year prospective study involving 449 women aged 40-80.


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Test/Retest Reliability


Liston and Brouwer, 1996, found poor to moderate reliability for patients with stroke (= 20, mean age 64 ± 8.5 years, time since stroke 6 months to 17 years, all ambulatory patients with hemiparesis) for the first 2 conditions of the instrumented CTSIB-M (NeuroCom Balance Master),  ICC = 0.56 for firm surface eyes open and ICC = 0.63 for firm surface eyes close

Vestibular Disorders

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Interrater/Intrarater Reliability

Adults with Imbalance:

In 81 patients with a complaint of imbalance, Loughran et al, 2005 found good agreement between 2 clinicians scoring the CTSIB-M and the scores on instrumented CTSIB-M (NeuroCom Balance Master) for conditions 2, firm surface eyes closed (kappa = 0.57); condition 3, foam surface eyes open (kappa = 0.72) and condition 4, foam surface eyes closed (kappa =0.72).  Agreement between the 2 clinicians ranged from kappa = 0.31 (condition 1 firm surface eyes open) to 0.81 (condition 3 foam surface eyes open).

Criterion Validity (Predictive/Concurrent)

Patients with complaints of dizziness or imbalance

Wrisley and Whitney, 2004 found significant but small correlations between CTSIB-M scores and SOT condition 2, firm surface with eyes closed (r = 0.48), condition 4, sway referenced surface, eyes open (r = 0.30), and condition 5, sway-referenced surface with eyes closed (r = 0.51)


Patients with complaints of dizziness or imbalance:

Weber and Cass, 1993, used the Sensory Organization Test (SOT) as the gold standard for the CTSIB-M with patients with complaints of dizziness or imbalance.  The CTSIB-M condition 4, standing on foam with the eyes closed had a sensitivity of 95%, and a specificity of 90% compared to SOT condition 5.


Vestibular dysfunction

Loughran et al, 2005 found weak correlations between scores on the instrumented CTSIB-M (NeuroCom Balance Master) firm surface conditions and the Dizziness Handicap Inventory (r = 0.262 and r = 0.370) in patients with vestibular dysfunction but no correlation between DHI Scores and the foam conditions of the CTSIB-M.  Weak correlations were also found between the Health Utilities Index and the scores on the CTSIB-M.


Unilateral Vestibulopathy:

Park et al 2013 explored the relationship between the Sensory Organization Test (SOT) and the instrumented CTSIB-M in subjects with uncompensated unilateral vestibulopathy.  Correlations between the 4 conditions of the CTSIB-M and the corresponding conditions of the SOT and the composite score ranged from -0.23 to -0.65 (all statistically significant).  The agreement between the SOT and CTSIB-M in classifying subjects who were normal or abnormal on the tests resulted in a sensitivity of 42% and a specificity of 68% (using SOT as the gold standard).

Construct Validity

Vestibular dysfunction:

Whitney and Wrisley, 2004 found significant difference between patients with vestibular dysfunction with or without normal scores on CTSIB-M for self-perception (ABC, DHI) and functional balance scales (DGI, TUG, Gait Speed. Five times sit to stand and sensory organization test) (p < 0.05)

Unilateral vestibular dysfunction:

Giray et al, 2009 demonstrated significant differences on the instrumented CTSIB-M (NeuroCom Balance Master) between subjects with unilateral vestibular dysfunction who received vestibular rehabilitation and those who did not (p < 0.05 for all conditions and composite.

Older Adults and Geriatric Care

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Construct Validity

Community dwelling older adults:

Boulgarides et al, 2003, found that the instrumented CTSIB-M did not accurately predict falls in community dwelling older adults who were active and independent.


Boulgarides, L. K., McGinty, S. M., et al. (2003). "Use of clinical and impairment-based tests to predict falls by community-dwelling older adults." Phys Ther 83(4): 328-339. Find it on PubMed

De Kegel, A., Dhooge, I., et al. (2010). "Construct validity of the assessment of balance in children who are developing typically and in children with hearing impairments." Phys Ther 90(12): 1783-1794. Find it on PubMed

Gagnon, I., Swaine, B., et al. (2006). "Exploring the comparability of the Sensory Organization Test and the Pediatric Clinical Test of Sensory Interaction for Balance in children." Phys Occup Ther Pediatr 26(1-2): 23-41. Find it on PubMed

Gagnon, I., Swaine, B., et al. (2004). "Children show decreased dynamic balance after mild traumatic brain injury." Arch Phys Med Rehabil 85(3): 444-452. Find it on PubMed

Geldhof, E., Cardon, G., et al. (2006). "Static and dynamic standing balance: test-retest reliability and reference values in 9 to 10 year old children." Eur J Pediatr 165(11): 779-786. Find it on PubMed

Giray, M., Kirazli, Y., et al. (2009). "Short-term effects of vestibular rehabilitation in patients with chronic unilateral vestibular dysfunction: a randomized controlled study." Archives of Physical Medicine and Rehabilitation 90(8): 1325-1331. Find it on PubMed

Kluenter, H., Roedder, D., et al. (2008). "Postural control at 7 years of age after preterm birth with very low birth weight." Otol Neurotol 29(8): 1171-1175. Find it on PubMed

Liston, R. A. and Brouwer, B. J. (1996). "Reliability and validity of measures obtained from stroke patients using the Balance Master." Archives of physical medicine and rehabilitation 77(5): 425-430.

Loughran, S., Gatehouse, S., et al. (2006). "Does patient-perceived handicap correspond to the modified clinical test for the sensory interaction on balance?" Otology & Neurotology 27(1): 86-91.

Loughran, S., Tennant, N., et al. (2005). "Interobserver reliability in evaluating postural stability between clinicians and posturography." Clinical Otolaryngology 30(3): 255-257.

Lowes, L. P., Westcott, S. L., et al. (2004). "Muscle force and range of motion as predictors of standing balance in children with cerebral palsy." Phys Occup Ther Pediatr 24(1-2): 57-77. Find it on PubMed

Nitz, J., Stock, L., et al. (2013). "Health-related predictors of falls and fractures in women over 40." Osteoporosis International 24(2): 613-621.

Park, M. K., Kim, K. M., Jung, J., Lee, N., Hwang, S. J., & Chae, S. W. (2013). Evaluation of uncompensated unilateral vestibulopathy using the Modified Clinical Test for Sensory Interaction and Balance. Otology & Neurotology, 34(2), 292-296. doi: 10.1097/MAO.0b013e31827c9dae 

Su, C. T., Wu, M. Y., et al. (2010). "Impairment of stance control in children with sensory modulation disorder." Am J Occup Ther 64(3): 443-452. Find it on PubMed

Suttanon, P., Hill, K. D., et al. (2011). "Retest reliability of balance and mobility measurements in people with mild to moderate Alzheimer's disease." International Psychogeriatrics 23(7): 1152-1159. Find it on PubMed

Weber, P. C., & Cass, S. P. (1993). Clinical assessment of postural stability. The American journal of otology14(6), 566–569.

Whitney, S. L. and Wrisley, D. M. (2004). "The influence of footwear on timed balance scores of the modified clinical test of sensory interaction and balance." Arch Phys Med Rehabil 85(3): 439-443. Find it on PubMed

Wrisley, D. and Whitney, S. (2004). "The effect of foot position on the modified clinical test of sensory interaction and balance." Archives of physical medicine and rehabilitation 85(2): 335-338. Find it on PubMed