Background and framework

Falls are the leading cause of injury and premature death among community dwelling older adults, with about a third of community-living elderly above 65 years falling every year (1-3). In Denmark, more than 45,000 hospital contacts each year are related to falls and a third of these involves fractures (4). For elderly, the cost of falling includes distress, pain, injury, loss of confidence, and ultimately loss of independence and mortality (3). Prevention of falls is therefore an urgent public health challenge (5). 

Impaired balance alone is associated with a 40% increase in risk of falls but is at the same time modifiable through exercises (6, 7). International consensus states that balance exercise should be structured and individually tailored, but no consensus exist how to tailor an individualized exercise intervention (8). This lack of individualizing may explain why currently applied exercise programs aimed at improving balance only reduce falls by 17 - 20% (5, 7, 9, 10).

Horak and colleagues recently developed the Balance Evaluation System’s Test (BESTest), which groups balance items into six “systems” (11). By measuring each “system” as a separate property of postural control, the BESTest can be applied to guide how to focus the intervention when aiming at improving balance. No other current balance measure offers this applicability (12-14).

Because the execution time of the BESTest is rather extensive a shorter version of the test “the mini-BESTest” was developed applying a Rasch analyses (15, 16). This methodological approach ensures uni-dimensionality of the test, but because the inclusion of items in the Rasch analysis is based on item functioning in relation to the total score the original division in subsystems is jeopardized (15).

A brief version of the original BESTest was developed based on item with total correlation (17). The “Brief BESTest” retains the theoretical framework of the original test, including only a single item to measure each “system” but shows limited sensitivity to change and the item selection is disputable (18).

Consequently, no instruments have until now provided a clinical applicable approach for designing and prescribing individualized balance exercise interventions for individuals who are in risk of falls.

Specific Training According to BaLance Evaluation (STABLE) is developed to meet this demand. STABLE is built on the framework of the BESTest, but essential properties of the two approaches are different. In STABLE, six functional measures are applied to quantify the individuals’ balance ability within six specific domains of balance.

In the following, we briefly explain how these six measures relates to the “systems” of the BESTest and the domains in STABLE. For detailed description of the six tests please refer to the measure section. To learn how the measures are applied to guide exercise prescription please refer to introduction to stable.


The “system” Biomechanical constraints comprises in the original BESTest of items which primarily measure strength of the lower extremities plus a rating of the individual’s alignment, deformities and pain based on the therapist visual assessment. The reliability of these ratings is not satisfactory (11) and it is questionable which exercises (if any) are effective to target these properties when impaired.

In STABLE, this domain is measured applying a sit-to-stand test. Sit to stand tests are generally accepted as a measure of lower extremity strength and basic biomechanical function (19, 20) and the test is an independent predictor of fall risk (21).

Because the sit-to-stand test measures strength by the force developed within a timespan this domain is named Power.

Stability limits

Stability limits/Verticality is evaluated in the BESTest in sitting by leaning bilaterally and in standing applying “the functional reach test” (22) forward and laterally. Limits of stability can be defined as to how far an individual is able to extend their center of mass relative to their base of support without stepping, slipping or falling (23, 24). In STABLE, this domain is measured applying a reach test wherein the individual chose the preferred strategy of exploring the stability limits reaching toward a wall. This approach is chosen to improve the reliability and validity of the original reach test (25-27).

Because of the narrowed focus, this domain is named Stability limits.

Anticipatory turning

Transitions-Anticipatory Postural Adjustments is the third “system” of the BESTest. This property of balance is necessary in almost every daily tasks and has been reported as one of the most frequent cause of falling if ineffective (28). In the BESTest, five subtests are covering this “system”. Our proposal is that, if a single task is to cover this domain meaningfully, this task should be essential for daily living and closely related with the risk of falls.

Turning is a fundamental component of mobility being associated with 35–45% of steps in common everyday tasks and therefore a very frequently performed task requiring effective anticipatory postural adjustments (29). Difficulties in turning and low turning speed has been identified as a predictor of falls (30-33). The risk of falls is proportional to the turning angle and is up to three times higher during turning compared to straight walking (34). Active head or whole-body turning is often included in protocols to evaluate balance and mobility in elderly individuals (35-37). Thus, a measure of turning ability is therefore included in STABLE as the core expression of an individual’s ability of executing anticipatory postural adjustments.

Because of the specified focus in this property of balance, this domain is named anticipatory turning.

Reactive stepping

Reactive balance, the ability to recover from instability through a rapid postural muscle corrective response, step, or grasp (38), is a critical components of balance for fall avoidance (39) and inefficient stepping response is highly correlated with falls (40).

In the BESTest, reactive postural response is evaluated by releasing isometric pressure against the patient in different directions. This “push and release” technique, originally developed for patient´s who has Parkinson´s disease (41), is a clinical version of the lean and release protocol, which has been applied to investigate reactive postural responses (42-44). Applying this approach, stepping strategy among elderly is very adaptable within the same testing session (45, 46) and manually providing pressure and releasing in a consistent manner is very difficult (47-49). Consequently, we propose a different clinical approach for evaluation reactive stepping strategy.

The Four Square Step Test evaluates rapid stepping in multiple directions (31). The original test does not measure reactive stepping per se, because the individual is instructed to repeat a stepping task in a beforehand practiced pattern, enabling the individual to use anticipatory balance strategies. Thus, in STABLE a modified version of the test is applied wherein the individual is stepping in unpredictable directions as commanded by the assessor. In contrary to the push and release technique, observed deficits in this modified test logically translate into exercises for improving reactive stepping strategy which can be performed by the patient without the need for assistance.

Because of the specified focus in this property of balance, this domain is named reactive stepping.

Sensory orientation

The vertical perception and body orientation depend on how spatial information is encoded and how spatial reference frames are selected and weighted. The ability to orient in space and keeping verticality therefore depends on the interaction between allocentric (primary visual), egocentric (primary proprioceptive) and geocentric (primary vestibular) reference frames (50).

In the BESTest sensory orientation is measured with the modified Clinical Test of Sensory Interaction in Balance (CTSIB-m) (51) and an “incline test”. The reliability of the latter is very low (11). The CTSIB-m was developed as a clinical low-cost alternative to the force plate-based gold standard (52-54), but further modifications are warranted to improve the validity of the test (55, 56). Therefore, in STABLE we apply an extended version of the original CTSIB-m, which measures balance in 12 combinations of foot positions, visual and proprioceptive conditions systematically challenging all three reference frames.

Cognitive-motor interaction

Stability in gait is the sixth “system” of the BESTest and is measured with the dynamic gait index and the timed “up and go” test performed with and without a secondary cognitive task (11).

Gait is an inevitable task of daily living and improving stability in gait is often a core goal of any balance exercise program rather than a property of balance. Indeed, some evidence exist that gait is a construct independent from balance (57). Thus, in STABLE we do not regard stability in gait as an isolated domain of balance.

Instead we propose focusing this domain on cognitive-motor interaction in balance. As in the BESTest, we apply the timed “up and go” test with a dual-task paradigm to measure this domain. Dual-task-related changes in gait is highly related with falls and is an accepted measure of cognitive-motor interaction in balance (58, 59). Further, we have modified the test to control how the individual prioritizes between tasks. This modification is essential because when individuals with balance impairment execute dual-task paradigms it is inconsistent whether the primary (i.e. the “up and go” task), the secondary (i.e. the cognitive task) or both tasks are affected. Differences between individuals and change over time can thus only be measured meaningfully when monitoring both tasks (60, 61).

Because of the distinct focus, this domain is named cognitive-motor interaction.


To learn more please refer to introduction to STABLE



  1. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-7.
  2. Kannus P, Sievanen H, Palvanen M, Jarvinen T, Parkkari J. Prevention of falls and consequent injuries in elderly people. Lancet. 2005;366(9500):1885-93.
  3. falls W. [Available from:
  4. Sundhedsstyrelsen. National klinisk retningslinje for forebyggelse af fald hos ældre 2018 [Available from:
  5. Hopewell S, Copsey B, Nicolson P, Adedire B, Boniface G, Lamb S. Multifactorial interventions for preventing falls in older people living in the community: a systematic review and meta-analysis of 41 trials and almost 20 000 participants. Br J Sports Med. 2019.
  6. Muir SW, Berg K, Chesworth B, Klar N, Speechley M. Quantifying the magnitude of risk for balance impairment on falls in community-dwelling older adults: a systematic review and meta-analysis. J Clin Epidemiol. 2010;63(4):389-406.
  7. Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51(24):1750-8.
  8. Shubert TE. Evidence-based exercise prescription for balance and falls prevention: a current review of the literature. J Geriatr Phys Ther. 2011;34(3):100-8.
  9. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56(12):2234-43.
  10. Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, et al. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA. 1995;273(17):1341-7.
  11. Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther. 2009;89(5):484-98.
  12. Pardasaney PK, Slavin MD, Wagenaar RC, Latham NK, Ni P, Jette AM. Conceptual limitations of balance measures for community-dwelling older adults. Phys Ther. 2013;93(10):1351-68.
  13. Mancini M, Horak FB. The relevance of clinical balance assessment tools to differentiate balance deficits. Eur J Phys Rehabil Med. 2010;46(2):239-48.
  14. Sibley KM, Beauchamp MK, Van Ooteghem K, Straus SE, Jaglal SB. Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: a scoping review. Arch Phys Med Rehabil. 2015;96(1):122-32 e29.
  15. Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med. 2010;42(4):323-31.
  16. Leddy AL, Crowner BE, Earhart GM. Utility of the Mini-BESTest, BESTest, and BESTest sections for balance assessments in individuals with Parkinson disease. J Neurol Phys Ther. 2011;35(2):90-7.
  17. Padgett PK, Jacobs JV, Kasser SL. Is the BESTest at its best? A suggested brief version based on interrater reliability, validity, internal consistency, and theoretical construct. Phys Ther. 2012;92(9):1197-207.
  18. Bravini E, Nardone A, Godi M, Guglielmetti S, Franchignoni F, Giordano A. Does the Brief-BESTest Meet Classical Test Theory and Rasch Analysis Requirements for Balance Assessment in People With Neurological Disorders? Phys Ther. 2016;96(10):1610-9.
  19. Csuka M, McCarty DJ. Simple method for measurement of lower extremity muscle strength. Am J Med. 1985;78(1):77-81.
  20. McCarthy EK, Horvat MA, Holtsberg PA, Wisenbaker JM. Repeated chair stands as a measure of lower limb strength in sexagenarian women. J Gerontol A Biol Sci Med Sci. 2004;59(11):1207-12.
  21. Tiedemann A, Shimada H, Sherrington C, Murray S, Lord S. The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing. 2008;37(4):430-5.
  22. Weiner DK, Duncan PW, Chandler J, Studenski SA. Functional reach: a marker of physical frailty. J Am Geriatr Soc. 1992;40(3):203-7.
  23. Juras G, Słomka K, Fredyk A, Sobota G, Bacik BJJoHK. Evaluation of the limits of stability (LOS) balance test. 2008;19:39-52.
  24. Spreitzer L, Perkins J, Ustinova KI. Challenging stability limits in old and young individuals with a functional reaching task. Am J Phys Med Rehabil. 2013;92(1):36-44.
  25. Giorgetti MM, Harris BA, Jette A. Reliability of clinical balance outcome measures in the elderly. Physiother Res Int. 1998;3(4):274-83.
  26. Clark S, Iltis PW, Anthony CJ, Toews A. Comparison of older adult performance during the functional-reach and limits-of-stability tests. Journal of aging and physical activity. 2005;13(3):266-75.
  27. Wallmann HW. Comparison of elderly nonfallers and fallers on performance measures of functional reach, sensory organization, and limits of stability. J Gerontol A Biol Sci Med Sci. 2001;56(9):M580-3.
  28. Robinovitch SN, Feldman F, Yang Y, Schonnop R, Leung PM, Sarraf T, et al. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet. 2013;381(9860):47-54.
  29. Glaister BC, Bernatz GC, Klute GK, Orendurff MS. Video task analysis of turning during activities of daily living. Gait Posture. 2007;25(2):289-94.
  30. Topper AK, Maki BE, Holliday PJ. Are activity-based assessments of balance and gait in the elderly predictive of risk of falling and/or type of fall? J Am Geriatr Soc. 1993;41(5):479-87.
  31. Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil. 2002;83(11):1566-71.
  32. Leach JM, Mellone S, Palumbo P, Bandinelli S, Chiari L. Natural turn measures predict recurrent falls in community-dwelling older adults: a longitudinal cohort study. Scientific reports. 2018;8(1):4316.
  33. Mancini M, Schlueter H, El-Gohary M, Mattek N, Duncan C, Kaye J, et al. Continuous Monitoring of Turning Mobility and Its Association to Falls and Cognitive Function: A Pilot Study. J Gerontol A Biol Sci Med Sci. 2016;71(8):1102-8.
  34. Yamaguchi T, Yano M, Onodera H, Hokkirigawa K. Effect of turning angle on falls caused by induced slips during turning. J Biomech. 2012;45(15):2624-9.
  35. Wrisley DM, Kumar NA. Functional gait assessment: concurrent, discriminative, and predictive validity in community-dwelling older adults. Phys Ther. 2010;90(5):761-73.
  36. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-8.
  37. Berg K. Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada. 1989;41(6):304-11.
  38. Maki BE, McIlroy WE. The role of limb movements in maintaining upright stance: the "change-in-support" strategy. Phys Ther. 1997;77(5):488-507.
  39. Maki BE, McIlroy WE. Postural control in the older adult. Clin Geriatr Med. 1996;12(4):635-58.
  40. Hilliard MJ, Martinez KM, Janssen I, Edwards B, Mille ML, Zhang Y, et al. Lateral balance factors predict future falls in community-living older adults. Arch Phys Med Rehabil. 2008;89(9):1708-13.
  41. Jacobs JV, Horak FB, Van Tran K, Nutt JG. An alternative clinical postural stability test for patients with Parkinson's disease. Journal of neurology. 2006;253(11):1404-13.
  42. Hsiao-Wecksler ET. Biomechanical and age-related differences in balance recovery using the tether-release method. J Electromyogr Kinesiol. 2008;18(2):179-87.
  43. Do MC, Breniere Y, Brenguier P. A biomechanical study of balance recovery during the fall forward. J Biomech. 1982;15(12):933-9.
  44. Singer ML, Smith LK, Dibble LE, Foreman KB. Age-related difference in postural control during recovery from posterior and anterior perturbations. Anat Rec (Hoboken). 2015;298(2):346-53.
  45. Carty CP, Cronin NJ, Lichtwark GA, Mills PM, Barrett RS. Mechanisms of adaptation from a multiple to a single step recovery strategy following repeated exposure to forward loss of balance in older adults. PLoS One. 2012;7(3):e33591.
  46. Barrett RS, Cronin NJ, Lichtwark GA, Mills PM, Carty CP. Adaptive recovery responses to repeated forward loss of balance in older adults. J Biomech. 2012;45(1):183-7.
  47. El-Gohary M, Peterson D, Gera G, Horak FB, Huisinga JM. Validity of the Instrumented Push and Release Test to Quantify Postural Responses in Persons With Multiple Sclerosis. Arch Phys Med Rehabil. 2017;98(7):1325-31.
  48. Smith BA, Carlson-Kuhta P, Horak FB. Consistency in Administration and Response for the Backward Push and Release Test: A Clinical Assessment of Postural Responses. Physiother Res Int. 2016;21(1):36-46.
  49. Carty CP, Mills P, Barrett R. Recovery from forward loss of balance in young and older adults using the stepping strategy. Gait Posture. 2011;33(2):261-7.
  50. Borel L, Lopez C, Peruch P, Lacour M. Vestibular syndrome: a change in internal spatial representation. Neurophysiol Clin. 2008;38(6):375-89.
  51. Cohen H, Blatchly CA, Gombash LL. A study of the clinical test of sensory interaction and balance. Phys Ther. 1993;73(6):346-51; discussion 51-4.
  52. Ford-Smith CD, Wyman JF, Elswick RK, Jr., Fernandez T, Newton RA. Test-retest reliability of the sensory organization test in noninstitutionalized older adults. Arch Phys Med Rehabil. 1995;76(1):77-81.
  53. Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction of balance. Suggestion from the field. Phys Ther. 1986;66(10):1548-50.
  54. Di Fabio RP, Emasithi A, Paul S. Validity of visual stabilization conditions used with computerized dynamic platform posturography. Acta oto-laryngologica. 1998;118(4):449-54.
  55. Wrisley DM, Whitney SL. The effect of foot position on the modified clinical test of sensory interaction and balance. Arch Phys Med Rehabil. 2004;85(2):335-8.
  56. Park MK, Kim KM, Jung J, Lee N, Hwang SJ, Chae SW. Evaluation of uncompensated unilateral vestibulopathy using the modified clinical test for sensory interaction and balance. Otol Neurotol. 2013;34(2):292-6.
  57. Horak FB, Mancini M, Carlson-Kuhta P, Nutt JG, Salarian A. Balance and Gait Represent Independent Domains of Mobility in Parkinson Disease. Phys Ther. 2016;96(9):1364-71.
  58. Al-Yahya E, Dawes H, Smith L, Dennis A, Howells K, Cockburn J. Cognitive motor interference while walking: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2011;35(3):715-28.
  59. Muir-Hunter SW, Wittwer JE. Dual-task testing to predict falls in community-dwelling older adults: a systematic review. Physiotherapy. 2016;102(1):29-40.
  60. Boisgontier MP, Beets IA, Duysens J, Nieuwboer A, Krampe RT, Swinnen SP. Age-related differences in attentional cost associated with postural dual tasks: increased recruitment of generic cognitive resources in older adults. Neurosci Biobehav Rev. 2013;37(8):1824-37.
  61. Plummer P, Eskes G, Wallace S, Giuffrida C, Fraas M, Campbell G, et al. Cognitive-motor interference during functional mobility after stroke: state of the science and implications for future research. Arch Phys Med Rehabil. 2013;94(12):2565-74 e6.