Coverage Policy Manual
Policy #: 1997175
Category: Medicine
Initiated: August 1994
Last Review: August 2018
  Posturography, Dynamic/Static

Description:
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 uses a force plate like that found in static posture platforms except that the force plate is mounted in a device that can translate horizontally and/or rotate about an axis collinear with the ankles.  In some cases, the rotational movement of the platform is matched to the measured movements of the subject such that the angle between the foot and the lower leg remains relatively constant.  Dynamic platforms may be surrounded by specialized visual environments as well.  These environments may present moving visual scenes that are disorienting.  In this way the nervous system is provided with unreliable somatosensory and visual information regarding the orientation of the body.  Broadly speaking, dynamic posturography tests can be divided into two types:
    • Those that record responses to small brief movements of the support surface; and
    • Those that record responses during various combinations of sensory inputs that are or are not useful.
 
Posturography is considered safe when performed under strict supervision by an experienced technician while the patient wears a harness secured overhead.
 
The most widespread application of dynamic posturography is in the evaluation of patients with dizziness and disequilibrium wherein a vestibular disorder is considered likely.
 
Dynamic posturography provides a functional assessment of upright balance that may be useful, especially in the evaluation of patients with suspected vestibular system abnormalities, but more research is required for comparing responses across patient groups.  Posturography is a technology that is still evolving and the literature that addresses the usefulness of posturography is sparse.
 
Regulatory Status
The NeuroCom EquiTest® is a dynamic posturography device that received 510(k) marketing clearance from the U.S. Food and Drug Administration (FDA). Other dynamic posturography device makers include Micromedical Technology, Metitur, and Vestibular Technologies.
 

Policy/
Coverage:
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.

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:
    • to further evaluate the etiology of balance disorders;
    • to provide a risk assessment for falling; or
    • to assess improvement after a program of vestibular rehabilitation.
 
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.   

CPT/HCPCS:
92548Computerized dynamic posturography

References: 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.


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.
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