| Coverage Policy Manual | |
| Policy #: | 1997175 |
| Category: | Medicine |
| Initiated: | August 1994 |
| Last Review: | March 2024 |
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| Posturography, Dynamic/Static | |
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| Description: |
Complaints of imbalance are common in older adults and contribute to the risk of falling in this population. Falls are an important cause of death and disability in this population in the United States. Maintenance of balance is a complex physiologic process, requiring the interaction of the vestibular, visual, and proprioceptive/somatosensory system, and central reflex mechanisms. Balance is also influenced by the general health of the patient (ie, muscle tone, strength, range of motion). Therefore, identifying and treating the underlying balance disorder can be difficult. Commonly used balance function tests (eg, electronystagmography, rotational chair tests) attempt to measure the extent and site of a vestibular lesion but do not assess the functional ability to maintain balance.
Static platform posturography typically uses a 'force plate,' which senses vertical, and, in some cases, horizontal force exerted by the feet on the ground during upright stance. Patients may be asked to stand with feet at shoulder width, with feet together, with feet in tandem, or on one foot at a time. During standing, a computer monitors the forces briefly and stores the data. Analysis usually includes a computation of the projection of the center of force upon the horizontal plane as a function of time. This computation is straightforward mathematically but can be somewhat misleading in that the position of the center of force may not accurately reflect the projection of the position of the patient's center of mass, especially if the patient's sway is relatively large or of high frequency. The position of the center of force versus time data can be used to compute amplitude, speed, or frequency power spectrum of sway.
Static posturography has not been proven to be of particular value clinically despite many years of research and numerous publications regarding its use. Recently, some physical therapists have used static posturography to monitor a patient's progress during therapy. When used with visual display to provide biofeedback, static posturography can be a treatment tool. Such devices are available commercially, but no literature addresses the efficacy of this treatment.
Dynamic posturography aims to provide quantitative information on a patient’s functional ability to maintain balance. The patient, wearing a harness to prevent falls, stands on an enclosed platform surrounded by a visual field. By altering the angle of the platform or shifting the visual field, the test assesses movement coordination and the sensory organization of visual, somatosensory, and vestibular information relevant to postural control. The patient undergoes 6 different testing situations designed to evaluate the vestibular, visual, and proprioceptive/somatosensory components of balance. In general terms, the test measures an individual’s balance (as measured by a force platform to calculate the movement of the patient’s center of mass) while visual and somatosensory cues are altered. These tests vary by whether eyes are open or closed, the platform is fixed or sway-referenced, and whether the visual surround is fixed or sway-referenced. Sway-referencing involves making instantaneous computer-aided alterations to the platform or visual surround to coincide with changes in body position produced by sway. The purpose of sway-referencing is to cancel out accurate feedback from somatosensory or visual systems that are normally involved in maintaining balance. In the first 3 components of the test, the support surface is stable, and visual cues are either present, absent, or sway-referenced. In tests 4 to 6, the support surface is sway-referenced to the individual, and visual cues are either present, absent, or sway-referenced. In tests 5 and 6, the only accurate sensory cues available for balance are vestibular cues. Results of computerized dynamic posturography have been used to determine what type of information (ie, visual, vestibular, proprioceptive) can and cannot be used to maintain balance. Dynamic posturography cannot be used to localize the site of a lesion.
Posturography tests a patient’s balance control in situations intended to isolate factors that affect balance in everyday experiences. Balance can be rapidly assessed qualitatively by asking the patient to maintain a steady stance on a flat or compressible surface (ie, foam pads) with the eyes open or closed. By closing the eyes, the visual input into balance is eliminated. Use of foam pads eliminates the sensory and proprioceptive cues. Therefore, the only vestibular input is available when standing on a foam pad with eyes closed.
Regulatory Status
In 1985, the NeuroCom EquiTest® (NeuroCom International, Portland, OR; now Clackamas, OR), a dynamic posturography device, was cleared for marketing by U.S. Food and Drug Administration (FDA) through the 510(k) process. Other dynamic posturography device makers include Vestibular Technologies (Cheyenne, WY) and Medicapteurs (Balma, France). Companies that previously manufactured dynamic posturography devices include Metitur (Jyvaskyla, Finland) and Micromedical Technology (Chatham, IL). FDA product code: LXV.
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Policy/ Coverage: |
Effective August 2021
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Dynamic posturography meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness for use in specialized environments dedicated to the analysis and management of vestibular dysfunction only.
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Static posturography does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, static posturography is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Dynamic posturography for physical therapy evaluation or monitoring of progress does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For members with contracts without primary coverage criteria, dynamic posturography for physical therapy evaluation or monitoring of progress is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective Prior to August 2021
Dynamic posturography meets primary coverage criteria for effectiveness and is covered for use in specialized environments dedicated to the analysis and management of vestibular dysfunction only.
Static posturography is not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
Dynamic posturography for physical therapy evaluation or monitoring of progress is not covered based on benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
For contracts without primary coverage criteria, static posturography and dynamic posturography (for physical therapy evaluation or monitoring of progress) are considered investigational. Investigational services are an exclusion in the member certificate of coverage.
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| Rationale: |
This policy originated from an Arkansas Blue Cross Blue Shield Technology Assessment in July 1994.
Computerized dynamic posturography can be used in 3 general settings:
2002 Update
A literature search to identify additional studies published since the 1994 Assessment failed to identify additional studies of note.
However, a literature search of the MEDLINE database for the period of 1998 to May 2002 did not identify any studies that focused on health outcomes related to treatment decisions based on the results of dynamic posturography in any of the above clinical situations or compared the quantitative results of dynamic posturography with the qualitative results of clinical assessment (i.e., history and physical exam alone). Regarding the risk of falling, Girardi and colleagues evaluated the results of computerized dynamic posturography in a group of 65 elderly patients who had a history of falling (Girardi, 2001). 78% of patients had abnormal results on computerized dynamic posturography testing. Baloh and colleagues studied balance control in a group of elderly patients who complained of balance disorders and a group of age-matched controls; the subjects were tested in a variety of situations (i.e., eyes open and closed, while standing on a foam pad to disrupt sensory cues, tilting of the platform, etc.) (Baloh, 1998). The authors concluded that posturography data provided little information about the cause of imbalance and did not correlate with the frequency of reported falls. Other authors have pointed out that there is uncertainty about how results of computerized dynamic posturography may correlate to functional activities, such as gait (Evans, 1999). For example, measurements of gait, frequently gait velocity, are often used in the elderly to assess balance and mobility. A variety of patient questionnaires have been designed to measure self-perceived dizziness or balance. The correlation between the results of these clinical tests, questionnaires, and computerized dynamic posturography are uncertain.
2003 Update
A review of the peer-reviewed literature on MEDLINE from the period of 2002 through June 2003 found 1 study that used posturography in the assessment of post-surgical acoustic neuroma patients (Cohen, 2002) and 3 other studies that used posturography for assessment of fall risk (Sinaki, 2002; Carter, 2002; Girardi, 2001).
2007 Update
A Pubmed search through February 2007 did not identify any randomized or controlled trials using posturography. Several retrospective studies were published describing a customized exercise program based on results of a complete medical and neuro-otologic history and physical examination that included platform posturography. However, the contribution of dynamic posturography to the overall assessment and customization of the exercise program is unclear (Clendaniel, 2000).
2013 Update
A literature search conducted using the MEDLINE database through July 2013 did not reveal any new literature that would prompt a change in the coverage statement.
One study that used both dynamic posturography and another test for assessing balance was published in 2011, a study by Ebersbach and Gunkel in Germany (Ebersbach, 2011). The study aimed to compare clinical tests (i.e., the pull test) with dynamic posturography. A total of 58 successive patients with Parkinson’s disease and 29 healthy age-matched controls were included in the study. Before undergoing dynamic posturography testing, balance was assessed using the pull test (i.e., rater delivered a sudden pull to both shoulders from behind). These test results were used to stratify the Parkinson patients into sub-groups (normal vs. impaired pull tests) for comparison with the healthy controls. Posturography was performed using a stabilometer similar to a seesaw. Dynamic performance was assessed by measuring the linear displacement of the base of the platform on the ground over 60 seconds. Patients with normal pull-test results (n=30) had significantly lower sway values with dynamic posturography than controls (p=0.001). There were no significant differences, however, between patients with impaired pull-test results (n=28) and controls in sway values with dynamic posturography (p=0.43). The authors concluded that dynamic posturography was not useful for identifying patients with impaired pull-tests and “it thus remains doubtful whether sway in this type of dynamic posturography is a valid indicator of clinical disequilibrium.”
Several studies published in 2012 used dynamic posturography as a research tool to study balance e.g., in older individuals or Parkinson’s patients; these studies were not designed to evaluate the technical performance or accuracy of dynamic posturography (Ganesan, 2012; Lee, 2012; Pierchala, 2012).
There is a lack of evidence regarding the clinical utility of this test in identifying patients who are at risk for falls or for evaluation the etiology of balance disorders. The policy statement is unchanged.
2014 Update
A literature search conducted using the MEDLINE database through July 2014 did not reveal any new information to prompt a change in the coverage statement.
2016 Update
A literature search conducted through April 2016 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
Several studies have used both dynamic posturography and another test for assessing balance. A 2015 study by Fritz and colleagues assessed the correlation between dynamic and static posturography and other measures of gait and balance dysfunction in 57 ambulatory patients with multiple sclerosis (MS) (Fritz, 2015). Two dynamic posturography parameters and 4 static posturography parameters were measured. Walking velocity, the alternative test, was measured in 2 ways: (1) in a laboratory using the Optotrak Motion Capture System and (2) using the timed 25-foot walk test. In regression analysis, demographics, 1 of the dynamic posturography parameters (anteroposterior sway) and 1 of the static posturography parameters (eyes open, feet apart) explained 95.3% of the variance in walking velocity. A higher degree of anteroposterior sway, assessed using dynamic posturography was significantly associated with higher walking velocity. Although the study found that dynamic posturography was associated with measures of walking velocity, the utility of this information in terms of impact on patient management is unclear.
A 2015 study by Ferrazzoli and colleagues evaluated dynamic posturography compared with the Berg Balance Scale (BBS) (Ferrazzoli, 2015). The BBS is a 14-item scale that assesses the performance on a variety of functional tasks, each rated on a 0 to 4 scale (maximal score, 56 points). Lower scores indicate higher fall risk. The study included 29 patients with Parkinson disease (PD) not complaining of balance problems and 12 healthy controls matched for age and sex. Scores on the BBS were significantly lower in PD patients than controls (p=0.002). Similarly, results of body sway analysis assessed by posturography were significantly different in PD patients and controls. Specifically, compared with controls, PD patients had higher standard deviation of body sway measurements in the eyes open condition (p=0.005) and the eyes open counting condition (p=0.020). The standard deviation of PD patients as also higher than controls in posturography along the mediolateral axis in the eyes open condition (p=0.019) but results were similar in the eyes open counting condition. The authors noted that posturography can potentially identify early balance disorders in PD patients before they develop clinical symptoms and that rehabilitation programs could possibly be developed to address specific balance issues. As discussed in the next section, there is a lack of prospective studies comparing health outcomes in patients managed with and without dynamic posturography.
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in April 2016 did not identify any ongoing or unpublished trials that would likely influence this review.
2017 Update
A literature search conducted through June 2017 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
Izquierdo-Renau and colleagues reported on the technical performance of testing 1 pressure platform, the S-Plate platform, in a group of 40 healthy subjects\l " (Izquierdo-Renau, 2016). However, that study analyzed plantar pressure, not posturography. There were generally high or moderate intra- and intersession intra-class correlation coefficients.
2018 Update
A literature search was conducted through July 2018. There was no new information identified that would prompt a change in the coverage statement.
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2019. No new literature was identified that would prompt a change in the coverage statement.
2020 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2020. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
Practice Guidelines and Position Statements
The American Academy of Otolaryngology-Head and Neck Surgery
The American Academy of Otolaryngology-Head and Neck Surgery and the Academy’s Foundation have issued 2 guidelines that mention dynamic posturography:
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2021. No new literature was identified that would prompt a change in the coverage statement.
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2022. No new literature was identified that would prompt a change in the coverage statement.
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2023. No new literature was identified that would prompt a change in the coverage statement.
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2024. No new literature was identified that would prompt a change in the coverage statement.
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| References: |
Bhattacharyya N, Gubbels SP, Schwartz SR, et al.(2017) Clinical practice guideline: benign paroxysmal positional vertigo (Update). Otolaryngol Head Neck Surg. Mar 2017;156(3 Suppl) S1-S47. PMID 28248609 American Academy of Otolaryngology-Head and Neck Surgery.(2014) Position Statement: Posturography. 2007 (revised 2014); http://www.entnet.org/Practice/policyPosturography.cfm. Accessed January 20, 2020. Badke MB, Miedaner A, et al.(2005) Effects of vestibular and balance rehabilitation on sensory organization and dizziness handicap. Ann Otol Rhinol Laryngol, 2005; 114:48-54. Badke MB, Shea TA, et al.(2004) Outcomes after rehabilitation for adults with balance dysfunction. Arch Phys Med Rehabil, 2004; 85:227-33. Baloh RW, Jacobson KM, Enrietto JA, et al.(1998) Balance disorders in older persons: quantification with posturography. Otolaryngol Head Neck Surg 1998; 119(1):89-92. Brown KE, Whitney SL, et al.(2006) Physical therapy for central vestibular dysfunction. Arch Phys Med Rehabil, 2006; 87:76-81. Buatois S, Gueguen R, et al.(2006) Posturography and risk of recurrent falls in healthy non-institutionalized persons aged over 65. Gerontology, 2006; 53:345-52. Carter ND, Khan KM, McKay HA, et al.(2002) Community-based exercise program reduces risk factors for falls in 65- to 75-year-old women with osteoporosis: randomized controlled trial. CMAJ 2002; 167(9):997-1004. Clendaniel RA.(2000) Outcome measures for assessment of treatment of the dizzy and balance disorder patient. Otolaryngol Clin North Am 2000; 33(3):519-33. Cohen HS, Kimball KT, Jenkin HA.(2002) Factors affecting recovery after acoustic neuroma resection. Acta Otolaryngol 2002; 122(8):841-50. Ebersbach G, Gunkel M.(2011) Posturography reflects clinical imbalance in Parkinson’s disease. Mov Disord 2011; 26(2):241-6. Evans MK, Krebs DE.(1999) Posturography does not test vestibulospinal function. Otolaryngol Head Neck Surg 1999; 120(2):164-73. Ferrazzoli D, Fasano A, Maestri R, et al.(2015) Balance dysfunction in Parkinson's disease: the role of posturography in developing a rehabilitation program. Parkinsons Dis. 2015;2015:520128. PMID 26504611 Fritz NE, Newsome SD, Eloyan A, et al.(2015) Longitudinal relationships among posturography and gait measures in multiple sclerosis. Neurology. May 19 2015;84(20):2048-2056. PMID 25878185 Ganesan M, Pasha SA, Pal PK et al.(2012) Direction specific preserved limits of stability in early progressive supranuclear palsy: a dynamic posturographic study. Gait Posture 2012; 35(4):625-9. Girardi M, Konrad HR, Amin M, et al.(2001) Predicting fall risks in an elderly population: computer dynamic posturography versus electronystagmography test results. Larynogscope 2001; 111(9): 1528-32. Izquierdo-Renau M, Perez-Soriano P, Ribas-Garcia V, et al.(2016) Intra and intersession repeatability and reliability of the S-Plate(R) pressure platform. Gait Posture. Dec 02 2016;52:224-226. PMID 27936441 Lee JM, Koh SB, Chae SW et al.(2012) Postural instability and cognitive dysfunction in early Parkinson's disease. Can J Neurol Sci 2012; 39(4):473-82. Loughran S, Tennant N, et al.(2005) Interobserver reliability in evaluating postural stability between clinicians and posturography. Clin Otolaryngol, 2005; 30:255-7. Peacock ML, Warren JT, Roses AD, et al.(1993) Therapeutics and Technology Assessments Subcommittee of the American Academy of Neurology. Neurology 1993; 433:1261-1264. Pierchala K, Lachowska M, Morawski K et al.(2012) Sensory Organization Test outcomes in young, older and elderly healthy individuals - preliminary results. Otolaryngol Pol 2012; 66(4):274-79. Reid VA, Adbulhadi H, Black KR, et al.(2002) Using posturography to detect unsteadiness in 13 patients with peripheral neuropathy: a pilot study. Neurol Clin Neurophysiol 2002; 2002(4):2-8. Sinaki M, Lynn SG.(2002) Reducing the risk of falls through proprioceptive dynamic posture training in osteoporotic women with kyphotic posturing: a randomized pilot study. Am J Phys Med Rehab 2002; 81(4):241-6. Whitney SL, Marchetti GF, Schade AI.(2006) The relationship between falls history and computerized dynamic posturography in persons with balance and vestibular disorders. Arch Phys Med Rehabil, 2006; 87:402-7. |
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Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association. |
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