Rating scales to inform balance exercise difficulty during rehabilitation for individuals with neurological disorders

Appropriate exercise dosing is essential for optimizing functional outcomes in rehabilitation for individuals with neurological disorders. While guidelines for aerobic and resistance training intensity are well established, comparable standards for balance exercise remain limited, despite its central role in reducing falls and promoting safe mobility. Clinically feasible approaches to quantifying balance exercise difficulty are needed to support safe progression and individualized prescription. This exploratory study explored the relationship between participants perceived balance difficulty and clinician-rated assistance during progressive balance training. Sixteen adults (68.1 ± 8.0 years old; 69% female) with balance disorders (peripheral vestibular hypofunction, peripheral neuropathy, or age-related balance impairment) completed an 18-session balance rehabilitation program over 6-weeks. Participants and clinicians rated each exercise using standardized scales, yielding 1,658 rating comparisons. Agreement between participant-perceived difficulty and clinician-rated assistance was moderate [Cohen's kappa (k) = 0.42, 59% exact agreement, p < 0.001], with higher agreement observed using weighted analysis (linear weighted k = 0.58; quadratic weighted k = 0.74, both p < 0.001). Most rating discrepancies (85%) differed by only one category, suggesting clinically minor disagreements. These preliminary findings indicate that participant-perceived difficulty may provide a clinically accessible indicator of balance exercise challenge. However, validation in larger samples with independent rating procedures and examination of relationships between difficulty ratings and functional outcomes are needed before clinical implementation. This work provides initial evidence for incorporating participant feedback into balance exercise prescription as part of individualized, patient-centered rehabilitation approaches.