Balance Exercise in Physiotherapy: From Berg/TUG Assessment to VR Protocol in Your Practice (+ 2.29 s Gained on the TUG)
Postural balance is a transversal clinical issue: knee trauma, chronic low back pain, neurological sequelae, vestibular disorders… In all these situations, your initial assessment determines the relevance of the protocol. A meta-analysis published in 2025 (Cui et al.) covering 14 randomised trials shows that virtual reality (VR) significantly improves the Berg Balance Scale (BBS) score with an SMD = 0.55, and up to 0.89 when combined with conventional therapy. On the Timed Up and Go (TUG), a 2024–2025 meta-analysis reports an average reduction of 2.29 seconds in favour of VR versus control. These figures do not describe a technology: they describe what your patients can regain in functional independence.
The clinical challenge of balance assessment and progression in practice
Postural balance is not an isolated symptom. It is a complex system, continuously fed by three sensory channels: musculoarticular proprioception, the vestibular system, and vision.
When one of these channels is impaired — following an ankle sprain, chronic low back pain, a neurological episode, or knee surgery — the entire system reorganises. Sometimes poorly.
The physiotherapist's role is twofold: objectively measure this deficit, then correct it through targeted, progressive, and documented balance exercises. This dual imperative — assessment + protocol — is at the heart of this article.
💡 Discover what KineQuantum can change in your practice.
Balance assessment tools: Berg, TUG and objective measures
Before prescribing any balance exercise in physiotherapy, you need to know where your patient is starting from. Two validated tools structure this clinical assessment.
The BBS (Berg Balance Scale) is a 14-task functional scale, scored from 0 to 56 points. It evaluates static and dynamic balance in everyday situations: transfers, single-leg stance, pivoting, functional reach. A score < 45 signals a significant fall risk.
The TUG (Timed Up and Go Test) measures the time needed to stand up from a chair, walk 3 metres, turn around, and sit back down. Simple, reproducible, it documents functional mobility and dynamic postural reactivity. A TUG > 12 seconds in an active adult is a clinical warning sign.
These two tools are not mutually exclusive: they complement each other. The BBS photographs static balance and transitions; the TUG captures integrated mobility and postural response speed. Together, they define the starting point of your protocol.
Parameter | Clinical value |
|---|---|
Tool | Berg Balance Scale (BBS) |
Scoring | 0 – 56 points |
Vigilance threshold | < 45 points |
Complementary tool | TUG (Timed Up and Go Test) |
TUG alert threshold | > 12 seconds (active adult) |
Reassessment frequency | Every 4 to 6 sessions |
Why VR transforms balance exercises in physiotherapy into precision clinical tools
VR balance rehabilitation does not consist of "making the patient move in a game". It is based on documented neurophysiological mechanisms.
1. Controlled multisensory stimulation: The immersive environment simultaneously manipulates visual, proprioceptive inputs and, depending on the exercises, virtual postural perturbations. This is not possible with a Freeman board or a balance cushion alone. The therapist precisely controls which sensory channel is being challenged.
2. Real-time feedback: The patient immediately sees, hears, and feels the consequence of each postural adjustment. This instant feedback accelerates implicit motor learning mechanisms — what science calls "motor learning" through sensory reinforcement.
3. Parameterisable challenge progression: Unlike conventional exercises, VR allows precise adjustment of stimulus speed, environmental complexity, task duration, and perturbation tolerance — without changing equipment or reconfiguring the room.
4. Cognitive-motor engagement: VR balance exercises couple the motor task with an attentional or perceptual task. This dual-task closely mirrors real-life situations, which promotes functional transfer of acquired skills.
A recent meta-analysis confirms that this goal-oriented feedback improves anticipatory postural adjustments (APAs) and cognitive-motor coupling, particularly for weight transfers and step strategies.
Which populations benefit from VR balance exercises?
Balance exercises in physiotherapy with VR are not reserved for a single profile. Here are the most documented indications in private practice.
Knee and ankle trauma (sprain, ACL, chronic instability)
Chronic low back pain with altered lumbopelvic postural control
Neurological conditions: stroke sequelae, multiple sclerosis (MS), Parkinson's disease
Vestibular disorders with a proprioceptive component
Post-operative recovery from hip or knee arthroplasty
Athletes in post-traumatic rehabilitation aiming for return to play
For each of these populations, recent literature identifies measurable effects on the BBS and TUG — the two tools of your initial assessment.
Building the VR balance exercise protocol: from session 1 to session 12
A good physiotherapy balance exercise protocol is built like a pedagogical progression. VR allows this progression to be structured in a rigorous and traceable manner.
1. Initial assessment (session 1): Conduct the BBS and TUG before any session. Also note tolerance to immersion (potential cybersickness), single-leg balance level, and tandem gait quality. These data define the starting profile.
2. Familiarisation phase (sessions 2–3): Exercises take place in stable bipedal stance, low-complexity visual environment, short duration (10–15 min). The aim is to calibrate the patient's postural response within the virtual environment, without causing discomfort.
3. Proprioceptive strengthening phase (sessions 4–7): Progressive introduction of challenge: simulated unstable surface, reduced visual information, postural reactivity exercises (perturbation correction), combined upper limb movements. This is where musculoarticular proprioceptive work is most intensive.
4. Dynamic reactivity phase (sessions 8–10): Rapid weight transfers, cognitive-motor dual-task, complex visual perturbations (optokinetic), step and reactive stepping exercises. Conditions approach real functional demands.
5. Reassessment and consolidation (sessions 11–12): New BBS and TUG. Progress is objectified, communicated to the patient, and if necessary, forwarded to the referring physician. Progression towards independence or return to sport is planned.
Protocol parameter | Recommended value |
|---|---|
Number of sessions | 10 to 15 sessions |
Duration per session | 30 to 45 minutes |
Frequency | 2 to 3 sessions per week |
Supervision | Systematic (physiotherapist present) |
BBS / TUG reassessment | Sessions 1 and 12 (minimum) |
Challenge adaptation | Session by session, based on data |
💡 Key takeaway: Challenge progression is not a matter of subjective perception. In VR, it relies on objective parameters: postural response time, amplitude of centre of pressure oscillations, cognitive-motor task scores. Your clinical decision is informed by data, not by impression.
What research measures: figures to support your practice
Recent studies are convergent, and the results are clinically significant.
In a meta-analysis published in 2025 by Cui et al. analysing results from 14 randomised trials on stroke patients, VR significantly improves the BBS score (SMD = 0.55; 95% CI: 0.23–0.88; p < 0.05), with an even more pronounced effect (SMD = 0.89) when VR is combined with conventional rehabilitation.
A systematic review and meta-analysis published in the Journal of Medical Internet Research (2025) shows that VR therapy significantly improves the BBS (mean difference: +3.29 points; 95% CI: 0.52–6.06; p = 0.02) and TUG (mean difference: −1.67 s; 95% CI: −2.89 to −0.46; p = 0.007) compared with conventional therapy in stroke survivors.
In the chronic low back pain population, a 2024–2025 meta-analysis (PMC12564781) shows that VR training reduces the TUG by an average of 2.29 seconds (95% CI: −2.91 to −1.66; I² = 0%) compared with controls — suggesting that VR can positively improve dynamic and functional aspects of balance in these patients.
For knee trauma, a meta-analysis covering nine randomised trials and 330 post-ACL (anterior cruciate ligament) reconstruction patients concludes that VR has a significant positive effect on proprioception, muscle strength, and dynamic balance.
A randomised controlled trial conducted in chronic low back pain patients reports significant large effect size improvements (Cohen's d > 0.69) in pain, range of motion, function, and balance — with a session adherence rate of 98.75%.
⚠️ Key point: These results are not achieved with "consumer-grade" VR. They come from clinical tools designed for rehabilitation, configured by a healthcare professional, with integrated tracking metrics. Recreational VR does not replace a structured physiotherapy protocol.
How KineQuantum translates this science into concrete results
From research to your daily practice
KineQuantum is a clinical virtual reality rehabilitation tool designed for private physiotherapists and rehabilitation centres. It integrates the mechanisms described above within a structured clinical environment.
1. Integrated balance assessment — From the very first session, KineQuantum enables objective postural balance evaluations, with recorded metrics that can be compared across sessions. Your VR physiotherapy assessments become exploitable clinical documents.
2. Profile-calibrated balance exercises — The exercise library covers postural balance, lower limb proprioception, postural reactivity, and dual-tasks. Each exercise can be parameterised in terms of difficulty, duration, and sensory complexity.
3. Traceable session-by-session progression — Performance data is recorded automatically. You visualise BBS and TUG evolution, and adjust the protocol based on objective data — not intuition alone.
4. A tool adapted to neurology and complex conditions — For your patients in neurological rehabilitation (stroke, MS, Parkinson's) or vestibular rehabilitation, KineQuantum offers specific modules, consistent with validated clinical protocols.
5. Real time savings in practice — The initial assessment, exercise prescription, and session report are generated directly by the tool. Less administrative workload, more clinical contact time.
Conclusion: balance can be measured, trained, and proven
Balance exercises in physiotherapy are no longer an intuitive practice reserved for the end of an assessment. They represent a rigorous clinical approach, beginning with an objective assessment (BBS, TUG), built on documented neurophysiological mechanisms, and validated by progression data.
Virtual reality does not replace your clinical expertise. It gives it a framework of precision: calibrated exercises, traceable metrics, and results that can be communicated to your patients, their physicians, and their payers.
That is what practising VR balance rehabilitation looks like in 2025.
FAQ
What are the most effective balance exercises in physiotherapy? The most effective exercises combine proprioceptive stimulation (unstable surfaces, visual restriction), postural reactivity (triggered perturbations), and cognitive-motor dual-tasks. In VR, these three dimensions can be integrated into a single progressive, parameterisable protocol. The literature converges on the superiority of multimodal protocols over classic unimodal exercises.
How is a balance assessment conducted in physiotherapy? The standard balance assessment relies on two validated tools: the BBS (Berg Balance Scale, scored out of 56 points) and the TUG (Timed Up and Go Test, expressed in seconds). These two tests are complementary: the BBS evaluates transitions and static balance, while the TUG captures dynamic functional mobility. In VR, additional metrics (centre of pressure oscillations, response time) complete this clinical picture.
Is virtual reality indicated for all patients with balance disorders? VR is suitable for the vast majority of profiles presenting with balance disorders: lower limb trauma, chronic low back pain, neurological conditions, post-surgical recovery. A few relative contraindications exist: photosensitive epilepsy, severe oculomotor disorders, severely reduced visual acuity. An initial evaluation of immersion tolerance is systematically recommended at the first session.
How many VR balance exercise sessions are needed to observe results? Studies identify significant improvements in BBS and TUG from 8 to 12 sessions, at a rate of 2 to 3 sessions per week. Effects are more pronounced when VR is combined with conventional rehabilitation. An intermediate reassessment at session 6 allows the difficulty level to be adjusted and motivates the patient through objectified progress.
Are VR balance exercises reimbursed in private physiotherapy practice? Rehabilitation sessions conducted with a clinical VR tool are billed as standard physiotherapy acts, according to the condition being treated and the medical prescription. KineQuantum is a Class I CE-marked medical device, used within the framework of a standard physiotherapy care pathway. For any questions regarding billing, please refer to your regional health insurance body.
💡 Would you like to integrate virtual reality balance exercises into your practice or centre?
📚 References
[1] Cui X., Tang J., Ying Y. et al. (2025). Effect of virtual reality technology on balance ability intervention in stroke patients: a systematic review and meta-analysis. PubMed. View article →
[2] Fernandes J.V.A., Figueiredo V.L.F.A., Oliveira A.B. et al. (2025). Virtual reality in Parkinson's disease: a systematic review and meta-analysis. Dementia & Neuropsychologia. View article →
[3] Garcia-Rudolph A., Saurí J., Guitart M. et al. (2025). Effect of Virtual Reality–Based Therapies on Lower Limb Functional Recovery in Stroke Survivors: Systematic Review and Meta-Analysis. Journal of Medical Internet Research. View article →
[4] Jiménez-García J.D. et al. (2025). Virtual Reality Training for Balance in Patients with Chronic Low Back Pain: A Systematic Review and Meta-Analysis. PMC. View article →
[5] Rodríguez-Almagro D. et al. (2024). Efficacy of virtual reality balance training on rehabilitation outcomes following anterior cruciate ligament reconstruction: A systematic review and meta-analysis. PLOS ONE. View article →
[6] Hussein H. et al. (2024). Effectiveness of Virtual Reality on Rehabilitation of Chronic Non-Specific Low Back Pain Patients. Healthcare (Basel), 12(13):1312. View article →
Comments