How To Do the Unterberger Test in Balance and Vestibular Rehabilitation

Learn how to do the Unterberger Test, interpret results, and enhance your balance assessments with data-driven balance assessment devices.

The Unterberger Test (also known as the Unterberger Stepping Test, or Fukuda Stepping Test) is a vestibular assessment that examines individual’s labyrinthine function by triggering vestibulospinal reflexes^1,2. Performing the Unterberger Test in vestibular rehabilitation tells us important information about our patients’ stability, balance, and vestibular function.

Understanding how to administer the Unterberger Test is key to gathering accurate data and tailoring treatment plans effectively. In this guide, I’ll walk you through the steps of performing the Unterberger Test, explain what it measures, and discuss rehabilitation equipment that can enhance your vestibular assessments.

Balance is a multifaceted aspect of mobility. It relies on the interplay between visual input and the vestibular system.  As rehabilitation professionals, we pay close attention to each patient’s unique balance and vestibular challenges with care, but also scrutiny. In vestibular rehabilitation, we must take a nuanced approach in our assessments to understand the full picture. Let’s dive in!

What Is the Unterberger Test?

The Unterberger Test is one of many balance assessments that can be used in vestibular rehab, balance physical therapy, and occupational therapy. A positive Unterberger Test can indicate peripheral vestibular dysfunction and balance instability². Performing the Unterberger Test involves blind-folding a patient and having them step in-place while their occupational therapist or physical therapist observes their movement^1,3. We use this evaluation primarily in outpatient or skilled nursing settings, and it is the most useful in individuals that don’t have multiple confounding factors that could contribute to vestibular dysfunction.

This balance assessment is best implemented as a diagnostic method to isolate peripheral labyrinthine dysfunction in ambulatory individuals that don’t require significant physical assistance to mobilize^3,4,5. By this token, it will naturally have limitations in certain populations, such as those with spinal cord injury or brain injury.

Nonetheless, the Unterberger test remains valuable for patients at an advanced stage of vestibular rehabilitation. When patients are operating at a high level, I find it necessary to focus on isolating the more nuanced, detailed balance mechanisms. This test provides quick results that help occupational therapists and physical therapists structure our treatment approaches moving forward.

How To Do the Unterberger Test

Now let’s get into exactly how to do the Unterberger Test. Performing the Unterberger test involves a few detailed steps:

1. Have your patient stand in a designated area delineated with .5m and 1.0m concentric circles, divided by 30 degree angles¹.
2. Blindfold your patient, and instruct them hold both arms out straight anteriorly.
3. Instruct the patient to step in place for 50 or 100 paces*^1,2.
4. While your patient steps in place, watch for body sway, deviations in rotations during steps, and how much deviation your patient exhibits.

*The general recommendation is to use the 50-step Unterberger variation due to its higher sensitivity^1,2,3. The 100-step variation can lend some advantage as it gives you more information to work with over time and can help identify vestibular dysfunction that has a delay in onset.

The Unterberger test is appropriate for adult and elderly adult populations and takes only a few minutes to administer. However, it is not recommended as a sole diagnostic test for those with existing confounding factors that limit vestibular function (such as stroke or benign paroxysmal positional vertigo), or peripheral motor patterns and ambulation (such as CVA or spinal cord).¹ If your patient has other confounding factors, you should include additional balance-related assessments for a more complete picture. For example, the Romberg test will assess proprioception, balance, and sensory ataxia.

What Is a Positive Unterberger Test?

A positive Unterberger test indicates a level of peripheral labyrinthine dysfunction.

While the results of this test are generally a negative or positive, there are some control values and standard error of measurements that can be helpful during interpretation¹. Whether your patient completed 50 or 100 steps, you can interpret the results as follows:

• In the 50-step variation of the Unterberger Test, a rotation over 30 degrees, or a displacement of .5m indicate an asymmetrical labyrinthine function¹.
• In the 100-step variation, rotation over 45 degrees or displacement of 1.0m indicate an asymmetrical labyrinthine function¹.

But how do we interpret these results if we see that our patient has a more significant deviation? If there is deviation out of the “normal” reference (with overt loss of balance clearly signifying dysfunction) we can assume there is peripheral vestibular dysfunction. This contributes to an increased risk of falls or other balance issues. While it can be difficult to quantify these results manually, the Unterberger helps us determine what other evaluations to administer and how we can start addressing these deficits in our plan of care.^1,3

Advanced Unterberger Test with Alfa

As an occupational therapist, I can get a little frustrated when I feel like I can’t reliably quantify my testing results for documentation or to track progress. However, with some serious advancement in technology and innovation from BTE, the Alfa system enhances the benefits of balance assessments like the Unterberger exponentially.

BTE’s Alfa is an advanced stabilometric platform designed for objective, data-driven balance assessments and gamified exercise. The Alfa makes balance assessments objective, detailed, and reliable with BTE’s cutting-edge measurement technology.

The Alfa is automatically set up to help administer a number of balance assessments, including the Unterberger. Its physical platform has highly sensitive force plates that establish boundaries and detect deviations in real-time. It not only allows you to digitize your balance assessment findings, but it measures the Unterberger’s metrics much more accurately than I ever could as a human.

The Alfa measures the following metrics for the Unterberger Test:

• Body sway – The degree of sway laterally and forward-backward while standing
• Rotation or deviation angle – Angle of rotation or deviation from the starting position.
• Trajectory length – The total path traveled by the body’s center of pressure
• Area of sway – The area covered by the patient’s sway, calculated from the displacement of the body’s center of pressure.

While the Alfa isn’t solely for use with the Unterberger, these metrics are also valuable in holistic vestibular rehab. In particular, deviation angle lends a lot of information as to the severity of dysfunction, and a patient’s area of sway is a general marker for stability.

Can You Diagnose Vertigo with the Unterberger Test Using Alfa?

The Alfa’s balance assessment protocols can be used for a variety of vestibular dysfunctions, including vertigo. The key is to know how to use the tool. The Alfa’s Unterberger test provides objective data about a patient’s postural instability and overall proprioceptive awareness. Because it calculates these deviances in real-time, it can quickly identify balance issues that may stem from a variety of sources such as concussion or vertigo.

Vertigo is a collection of symptoms, rather than a specific condition, as it can happen for a variety of reasons. While the Unterberger should not be used as a stand-alone test to diagnose vertigo, it can be a helpful assessment in addition to more specific vertigo tests or maneuvers that target inner ear structures.

For those with vertigo, the vestibular system isn’t really doing what it should, which can lead to symptoms of nausea, dizziness, and loss of balance, to name a few. What we can decipher, though, is what vestibular structures may be affected based on a patient’s movement while their eyes are closed. For instance, while stepping with the eyes closed, a person rotates to the left, they likely have issues in the left ear drum/ear canal⁶.

What To Do If Unterberger Test Is Positive

The Unterberger Test gives us information about a patient’s vestibular status. We must then use that information to structure our plan of care to address vestibular dysfunctions.

Some of my favorite ways to do this are by systematically challenging the vestibular system through functional exercise and reflex conditioning. Functional exercises and movements that engage the trunk, head, and neck through different planes, as well as integrating cross-body and rotational movement⁷ are good intervention choices for vestibular rehab.

The Alfa is another incredible tool that acts as an all-in-one balance system that helps screen, evaluate, track, and provide interventions throughout a patient’s vestibular rehab journey. The Alfa has a slew of fun, personalized games that not only motivate patients to participate, but appropriately challenge them based on real-time measures.

When it comes to balance, organic and genuine tasks, games, and situations are the best at challenging and improving such a nuanced system. The Unterberger may tell us what our patients need to work on, but it’s up to us to develop a treatment plan to follow, These sessions are some of the hardest to work through, however, which means our interventions need to be high-value and engaging for our patients to keep their follow up sessions and continue to make progress toward their goals.

 

Mary Vieregge, OTR/L is an Occupational Therapist and freelance writer based in Eastern North Carolina. She has experience in a range of settings, from inpatient rehabilitation to long-term care, with a concentration in neurorehabilitation and spinal cord injury populations. Mary is passionate about patient education and innovative practices, is constantly searching for the latest and greatest to add to her clinical toolbox.