Balance

BALANCE
BALANCE SYSTEM
TYPES OF BALANCE
MECHANISM
CORRELATION
BALANCE TRAINING
MANAGEMENT
STRATEGIES
PHYSIOTHERAPY INTERVENTION
BALANCE TRAINING IN ELDERLY
OUTCOME MEASURES

1. BALANCE
Dr. SUMAIYA BANU. I
MPT (Cardio)

2. BALANCE
Balancereferstoanindividualsabilitytomaintaintheir
lineofgravitywithintheirBaseofsupport(BOS).Itcanalso
bedescribedastheabilitytomaintainequilibrium,where
equilibriumcanbedefinedasanyconditioninwhichallacting
forcesarecancelledbyeachotherresultinginastable
balancedsystem.

3. BALANCE SYSTEMS
Thefollowingsystemsprovidesinputregardingthebody's
equilibriumandthusmaintainsbalance.
•Somatosensory/ProprioceptiveSystem
•VestibularSystem
•VisualSystem
TheCentralNervousSystemreceivesfeedbackaboutthebody
orientationfromthesethreemainsensorysystemsandintegratesthis
sensoryfeedbackandsubsequentlygeneratesacorrective,stabilizing
torquebyselectivelyactivatingmuscles.Innormalcondition,healthy
subjectsrely70%onsomatosensoryinformationand20%Vestibular&
10%onVisiononfirmsurfacebutchangeto60%vestibular
information,30%Vision&10%somatosensoryonunstablesurface.

4. SOMATOSENSORY SYSTEM
Proprioceptiveinformationfromspino-cerebellarpathways,
processedunconsciouslyinthecerebellum,arerequiredtocontrol
posturalbalance.Proprioceptiveinformationhastheshortesttime
delays,withmonosynapticpathwaysthatcanprocessinformationas
quicklyas40–50msandhencethemajorcontributorforpostural
controlinnormalconditions.

5. VESTIBULAR SYSTEM
Thevestibularsystemgeneratescompensatoryresponsesto
headmotionvia:
•Posturalresponses(Vestibulo-SpinalReflex)-keepthebodyupright
andpreventfallswhenthebodyisunexpectedlyknockedoff
balance.
•Ocular-motorresponses(Vestibulo-OcularReflex)-allowstheeyes
toremainsteadilyfocusedwhiletheheadisinmotion.
•Visceralresponses(Vestibulo-ColicReflex)-helpkeeptheheadand
neckcentred,steady,anduprightontheshoulders.

6. VISUAL SYSTEM
•Fornon-impairedindividuals,undernormalconditionsthecontribution
ofvisualsystemtoposturalcontrolispartiallyredundantasthevisual
informationhaslongertimedelaysaslongas150-200ms.
•Friedrichetal.observedthatadultswithvisualdisorderswereableto
adaptperipheral,vestibular,somatosensoryperceptionandcerebellar
processingtocompensatefortheirvisualinformationdeficitandto
providegoodposturalcontrol.
•Inaddition,Peterkafoundthatadultswithbilateralvestibulardeficits
canenhancetheirvisualandproprioceptiveinformationevenmore
thanhealthyadultsinordertoreacheffectiveposturalstability.
•Theinfluenceofmovingvisualfieldsonposturalstabilitydependson
thecharacteristicsofthevisualenvironment,andofthesupport
surface,includingthesizeofthebaseofsupport,itsrigidityor
compliance.

7. TYPES OF BALANCE
Balancecanbeclassifiedinto:
•StaticBalance:Itistheabilitytomaintainthebodyinsomefixed
posture.Staticbalanceistheabilitytomaintainposturalstabilityand
orientationwithcentreofmassoverthebaseofsupportandbodyat
rest.
•DynamicBalance:Definingdynamicposturalstabilityismore
challenging,Dynamicbalanceistheabilitytotransferthevertical
projectionofthecentreofgravityaroundthesupportingbaseof
support.Dynamicbalanceistheabilitytomaintainposturalstability
andorientationwithcentreofmassoverthebaseofsupportwhile
thebodypartsareinmotion.

8. THE MECHANISMS INVOLVED IN STATIC BALANCE
1.Sufficientpowerinthemusclesofthelowerlimbsandtrunkto
maintainthebodyerect.
2.Normalposturalsensibilitytoconveyinformationconcerning
position.
3.Normalimpulsesfromthevestibularlabyrinthconcerning
position.
4.Acentralcoordinatingmechanism,thechiefpartofwhichis
thevermisofthecerebellum.
5.Theactivityofhighercentersconcernedinthewilled
maintenanceofposture.

9. THE MECHANISMS INVOLVED IN DYNAMIC BALANCE
1.Sufficientpowerinthemusclesofthebodytomaintainmovement
andstability.
2.Normalposturalsensibilitytoconveyinformationregarding
movement.
3.Normalimpulsesfromthevestibularsystemandvisualsystem
concerningmovementandenvironment.
4.Centralcoordinatingmechanismincludingcerebellumandbasal
ganglia
5.Theactivityofhighercentersconcernedinthewilled/involuntary
maintenanceofmovementandstability.

10. CORRELATION BETWEEN STATIC AND DYNAMIC
BALANCE
•Maintenanceofposturalstabilityduringbothdynamicand
staticconditionsinvolvesestablishinganequilibrium
betweendestabilizingandstabilizingforcesandrequires
sensoryinformationderivedfromvision,thevestibular
systems,andsomatosensoryfeedback.

11. BALANCE TRAINING

12. Balance training involves doing exercises that strengthen the muscles
that help keep upright, including muscles of legs and core. These kinds
of exercises can improve stability and help prevent falls.
Balance training programs aim to:
•Strengthen balance control in everyday activities leading to improved
fall-related self-efficacy, reduced fear of falling and increased walking
speed
•Improve physical function
•Improvequality of life

13. Examplesofbalanceexercisesinclude:
•Standingwithweightononelegandraisingtheotherlegtotheside
orbehind,
•Puttingheelrightinfrontofyourtoe,liketandemwalking,
•Standingupandsittingdownfromachairwithoutusinghands,
•Walkingwhilealternatingkneeliftswitheachstep,
•Doingtaichioryoga,
•Usingequipment,likeaBosu,whichhasaninflatabledomeontopof
acircularplatform,whichchallengesyourbalance.

14. Overtime,thebalancetrainingcanimprovebalancewiththeseexercisesby:
•Holdingthepositionforalongeramountoftime
•Addingmovementtoapose
•Closingeyes
•Lettinggoofchairorothersupport
Balanceexercisescanbedoneasoftenaswelike,eveneveryday.Addingin
twodaysaweekofstrengthtraining,whichalsohelpsimprovebalanceby
workingthemusclesthatkeepstable.

15. AREAS IT TARGETS
•Core:Yes.Weneedstrongcoremusclesforgoodbalance.Many
stabilityexerciseswillworkwithabsandothercoremuscles.
•Arms:No.Mostbalanceexercisesareaboutbalancingonfeet.So
unlesswearedoingmovesthatinvolveourarms,orholdingweights,
wedon’tworkforarms.
•Legs:Yes.Exercisesinwhichwebalanceononelegandthensquator
bendforwardalsoworkthelegmuscles.
•Glutes:Yes.Thesamebalanceexercisesthatworkthelegsalsotone
theglutes.
•Back:Yes.Ourcoremusclesincludesomeofourbackmuscles.

16. TYPE
•Flexibility:No.Balancetrainingismoreaboutstrengtheningmusclesand
improvingstabilitythangainingflexibility.
•Aerobic:Itcanbe,butoftenisnot.Itdependsonhowintensetheactivity
is.Ifitinvolvesmovingfast,thenitmaybeaerobic.Slowerbalance
exercisesdonotmakebreathefasterormakeheartpumpharder.
•Strength:Yes.Manyoftheseexerciseswillworkonthemuscles,especially
themusclesoflegsandcore.Somemovesmayalsousechest
andshouldermuscles,liketheplankposition.

17. MANAGEMENT OF BALANCE IN SPECIFIC
CONDITIONS
Parkinson’s disease:
Physiotherapy for Parkinson’s disease focuses on: transfers,
posture, upper limb function, balance, gait, and physical capacity. The
therapist uses cueing strategies, cognitive movement strategies and
exercise to maintain or increase independence, safety, and quality of
life. Sensory cueing strategies such as auditory, tactile, and visual cues
have often been used to help walking in PD.

18. COGNITIVE MOVEMENT STRATEGIES
•Cognitivemovementstrategiesareusedtoimprovetransfers.Complexand
automaticactivitiesaredividedintoseparateelementsconsistingof
relativelysimplemovementcomponents.
•Bydoingthis,thepersonhastothinkconsciouslyabouthismovements.
TrytoavoiddualtaskingduringcomplexautomaticADL.Furthermore,the
movementoractivitywillbepracticedandrehearsedinthemind.
•Itisimportantthatmovementsarenotperformedautomatically;
performancehastobeconsciouslycontrolled.

19. EXAMPLE:Sittostand
•Handsonchair
•Placefeetcorrectly
•Moveforward
•Flextrunk
•Riseupfromchair

20. Cueing strategies
•Theperformanceofautomaticandrepetitivemovementsofis
disturbedinsomepatientsasaresultoffundamentalproblemsof
internalcontrol.That’swhycuesareusedtocompleteorreplace
thisreducedinternalcontrol.Cuescanbegeneratedinternallyor
externally.Rhythmicalrecurringcuesaregivenasacontinuous
rhythmicalstimulus,whichcanserveasacontrolmechanismfor
walking.
•Auditory(movesonmusic,singing,counting,...)
•Visual(patientfollowsanotherperson,walksoverstripeson
thefloor,heprojectshimselfwithalaserpen,...)
•Tactile(patienttapshishiporleg)

21. THE PHYSICAL THERAPEUTIC INTERVENTION
GOALS APPLY TO THE PHASE ADDRESSED:
Early phase-patients have no or little limitations. Goals of the
therapeutic intervention are:
•Prevention of inactivity
•Prevention of fear to move/to fall
•Preserving/ improving physical capacity

22. Mid phase-more severe symptoms; performance of activities
become restricted, problems with balance and an increased
risk of falls.
Problems:
•Body Transfers
•posture
•Reaching and grasping
•Balance
•Gait

23. •Latephase-patientsareconfinedtoawheelchairorbed.
Thetreatmentgoalinthisphaseistopreservevitalfunctions
andtopreventcomplications,suchaspressuresoresand
contractures.

24. BALANCE TRAINING IN ELDERLY
Balancetrainingcanalsobeusedintheelderly.RiskofFallsinelderly,
isverycommonduetopoorbalance.Forthisreason,theuseofbalance
trainingmightbeveryhelpfultothem.
Thetrainingincludes:
•Gaitpattern
•Balancecontrol
•Co-ordinationandfunctionaltasks
•Strengtheningexercise
•Computerizedbalanceprogramsorvibrationplates.

25. Tokeepthetherapyadherenceupitisbesttolookforanapproach
witha‘funfactor’.Someexamples:
•Music-basedmultitaskexerciseprogram-basicexercisesconsistedof
walkingintimetothemusicandrespondingtochangesinthemusic’s
rhythmicpatterns.Exercisesinvolvedawiderangeofmovementsand
challengedthebalancecontrolsystemmainlybyrequiring
multidirectionalweightshifting,walk-and-turnsequences,and
exaggeratedupperbodymovementswhenwalkingandstanding.
•Taichihasbeenproventobeaneconomicandeffectivewayfor
trainingbalanceinolderpeople.

26. •Toamelioratebalanceintheelderlyitisn’tenoughtojustfollowaconventional
exerciseintervention(includingmusclestrengthening,stretchingandaerobic
exercises,andhealtheducation).Itisbettertoalsoincludestatic,anddynamic
balanceexercises.
•Staticbalanceexercises:squats,two-legstanceandone-legstance.
•Dynamicexercises:joggingendtoend,sidewayswalkingorrunningwith
crossovers,forwardwalkingorrunninginazigzagline,backwardwalking,or
runninginzigzagline.
•UseofBalanceBoards.
•Corestrengthtraining:Neverthelesstoimprovebalancecorestrengthtrainingis
animportantelement.Thebenefitisthistherapycanbebothgiveninagroup
settingorinindividualfallpreventiveinterventions

27. OUTCOME MEASURES
Many exists some commonly used test are:
•4 Stage Balance Test
•Berg Balance Scale to evaluate static and dynamic balance, the
•Falls risk assessment tool
•Timed Up and Go Test to assess a patient's mobility
•The Balance Outcome Measure for Elder Rehabilitation
•Functional Reach

28. THANK YOU…