Balance

Balance components and Balance Training

1. Balance and Fall Prevention
By,
SankariNedunsaliyan
Physiotherapist
Dip In PT (MAL), BscHonsApplied Rehab (UK)

2. Balance Defined
•Balance: Control of center of mass over
base of support (Shumway–Cook, 2001)
14
•Center of mass: Center point of each body
segment combined
•Center of gravity: Vertical projection of
center of mass
•Base of support: Area of object that is in
contact with the ground

3. Base of Support

4. Center of Mass
Balance: Control of center of mass
over base of support

5. Balance: control of center of mass
over base of support

6. Vicious Cycle
Fall
↗ ↘
Imbalance← Inactive

7. Indications/Needs
Gait and balance difficulties regardless of the
underlying neurologic or orthopedic cause
Medical conditions that can cause mobility
difficulties include Parkinson’s disease, multiple
sclerosis, stroke, neuropathies, and head trauma
Vestibular disorders that cause dizziness
Patients with osteoporosis or elderly can
benefit from specific balance training to prevent
falls and decrease risk of fractures.

8. Precautions
High Fall Risk
Co morbidities
Recent Surgery
Injuries

9. Types of Balance
•Steady state (static) balance
•Reactive balance (Dynamic Balance)
•Proactive (anticipatory) balance

10. Steady state (static) balance:
Maintain stable position in standing or
sitting
This happens when the objects centre of
gravity is on the axis of rotation.

11. Reactive balance:
Recovering from an unexpected perturbation.
Reactive balanceis defined as automatic
movement patterns, or strategies, that occur
when balanceis disturbed.
They are faster responses than movements
under voluntary control. If the response is
appropriate no loss of balancewill occur.

12. Proactive (anticipatory) balance
To develop a device which provides safe,
controlled, simple, and inexpensive.
reactive balancetraining for adults
Anticipatory -Body recognize that
something is going to happen that will
disturb its balanceand make the
adjustments before it happens

13. A Systems Model of Balance
1
1
Courtesy of Sandra Rader, PT, Clinical Specialist

14. Stability & Balance
Result of interaction of many variables (see
model)
Limits of Stability -distance in any direction
a subject can lean away from mid-line
without altering the BOS
Determinants:
◦Firmness of BOS
◦Strength and speed of muscular responses
◦Range: 8
0
anteriorly; 4
0
posteriorly

15. Limits of Stability

16. Model Components
Musculoskeletal System
ROM of joints
Strength/power
Sensation
◦Pain
◦Reflexive inhibition
Abnormal muscle
tone
◦Hypertonia (spasticity)
◦Hypotonia

17. Model Components
Goal/Task Orientation
What is the nature of
the activity or task?
What are the goals or
objectives?

18. Model Components
Central Set
Past experience may
have created “motor
programs”
CNS may select a
motor program to
fine-tune a motor
experience

19. Model Components
Environmental Organization
Nature of contact
surface
◦Texture
◦Moving or stationary?
Nature of the
“surrounds”
◦Regulatory features of
the environment
(Gentile)

20. Model Components
Motor Coordination
Movement strategies
◦Based on repertoire of
existing motor
programs
Feedback &
feedforward control
Adjustment/tuning of
strategies

21. Strategies to Maintain/Restore
Balance
Ankle
Hip
Stepping
Suspensory
Strategies are automaticand occur 85 to
90 msec after the perception of instability
is realized

22. Ankle Strategy
Used when
perturbation is
◦Slow
◦Low amplitude
Contact surface firm,
wide and longer than
foot
Muscles recruited
distal-to-proximal
Head movements in-
phase with hips

23. Ankle Strategy

24. Hip Strategy
Used when
perturbation is fast or
large amplitude
Surface is unstable or
shorter than feet
Muscles recruited
proximal-to-distal
Head movement out-
of-phase with hips

25. Hip Strategy

26. Stepping Strategy
Used to prevent a fall
Used when
perturbations are fast
or large amplitude -
or-when other
strategies fail
BOS moves to “catch
up with” BOS

27. Suspensory Strategy
Forward bend of
trunk with hip/knee
flexion -may progress
to a squatting position
COG lowered

28. Model Components
Sensory Organization
Balance/postural
control via three
systems:
◦Somatosensory
◦Visual
◦Vestibular

29. Somatosensory System
Dominant sensory
system
Provides fast input
Reports information
◦Self-to-(supporting)
surface
◦Relation of one
limb/segment to
another
Components
◦Muscle spindle
Muscle length
Rate of change
◦GTOs (NTOs)
Monitor tension
◦Joint receptors
Mechanoreceptors
◦Cutaneous receptors

30. Visual System
Reports information
◦Self-to-(supporting)
surface
◦Head position
Keep visual gaze parallel
with horizon
Subject to distortion
Components
◦Eye and visual tracts
◦Thalamic nuclei
◦Visual cortex
Projections to parietal
and temporal lobes

31. Vestibular System
Not under conscious
control
Assesses movements
of head and body
relative to gravity and
the horizon (with
visual system)
Resolves inter-sensory
system conflicts
Gaze stablization
Components
◦Cerebellum
◦Projections to:
Brain stem
Ear

32. Sensory-Motor Integration
Somatosensory
Vestibular
Visual
Eye Movements
Postural Movements
1
0
Processor
2
0
Processor
Cerebellum
Motoneurons
Sensory Input Processing Motor Response

33. Body response to sensory input
Normal body response to perturbation(deviation)
(pushing patient forward and back)
A)Mild perturbation: Ankle response (push patient
forward, the calf muscles engage)
B)Moderate perturbation: Hip response (push patient
forward, patient leans back)
C)Large perturbation: Stepping response (patient
steps forward to avoid falling)

34. BALANCE COMPONENTS
VS
AGE

35. Age related changes to motor
components of balance
Decreased magnitude of muscle response
Increased reliance of arms

36. Age related changes to sensory
components of balance
Decreased visual, vestibular,
somatosensory (body awareness), and
auditory (hearing) function
Decreased ability to adapt responses (e.g.
using your inner ear and your feet

37. Age related changes to cognitive
components of balance
Decreased overall attention capacity
Decreased ability to multitask (e.g.
carrying a cup of water while walking)

38. BALANCE COMPONENTS
VS
DISEASE

39. Abnormal balance
As the balance system declines, so does
the ability of the system to respond
correctly
Individuals with an increased fall rate did
not use an ankle strategy

40. Abnormal balance
Cerebrovascular accident (CVA)—Stroke
A) Synergistic pattern: Groups of muscles
work together in a “stuck” pattern
B) Increased muscle tone
C) Cognition (e.g. impulsive behavior)
D) Impaired body awareness

41. Abnormal balance
Parkinson’s Disease
A) Dynamic balance problem
B) Difficulty initiating gait
C) Moments of freezing during movement
D) Altered gait cycle

42. Abnormal balance
Benign Paroxysmal Positional Vertigo (BPPV)
A) Calcium crystals stuck in the semicircular
canals in the inner ear.
B) Dependent on head position.
C) Vertigo –sensation that the room is
spinning.

43. Abnormal balance
Orthopedic cases: (Hip or knee replacement)
A) Impaired joint range of motion (alters
center of mass during gait and stance)
B) Altered body awareness (new body part)

44. HOW TO TEST YOUR
BALANCE

45. Valid tools to measure balance
Berg’s Balance scale
Timed up and go test
Functional reach test
Nudge test
Other tests: Hallpixe –Dix Test

46. Balance Tests –Berg Balance Scale
14 item scale for possible 56 points total
•Decrease in Berg score = increased fall risk
14
•Score of 56-54, 1 point drop = 3-4% inc. fall risk
•Each point drop from 54-46, = 6-8% increase
•Below 36, fall risk = 100%
•Limitations: does not test reactive balance;
ceiling effect

47. Balance Tests
Timed up and go test
12
•Get up from seated position, walk 3 meters,
turn around, walk back to chair
•Adults who took > 30 sec were dependent
in activities of daily living
Functional reach test
•Standing reaching forward with hand
•Highly predictive of falls among older adults
3

48. Balance Tests
Nudge test:
•Moving patient forward, back, sideways
•Ankle vship, vsstepping strategy
•Test under different conditions: soft surface,
eyes closed, with head movements
Other tests:
•Hallpike-Dix (testing for vertigo),
observational gait analysis, dynamic gait index

49. Treatment of balance
Exercise examples
A) Calf stretch
B) Heel / toe raises
D) Soft surface stance in corner
E) Sitting to standing

50. Resources
Active Life Physical Therapy Port Ludlow:
www.activelifetherapy.com
Home Instead Senior Care
www.homeinstead.com/650/Pages/HomeInsteadSeniorCare.aspx
Olympic Area Agency on Aging: www.o3a.org/
ECHHO: http://echhojc.org/
Boeing Bluebills Olympic Peninsula:
www.bluebills.org/olympic.html
Centers for Disease Control and Preventionwww.cdc.gov/
National Osteoporosis Foundation»http://www.nof.org/
American Physical Therapy Association: www.apta.org
WA State Dept. Of Health www.doh.wa.gov/
Washington State Falls Prevention web site
www.fallsfreewashington.org

51. References
1. American Geriatric Society, British Geriatric Society, American Academy of Orthopedic
Surgeons Panel on Falls Prevention. Guidelines for the Prevention of Falls in Older Persons. JAGS
49: 664-672, 2001.
2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Web–based Injury Statistics Query and Reporting System (WISQARS)[online]. Accessed
November 30, 2010.

3. Duncan P, StudenskiS, Chandler J, Prescott B. Functional Reach: a new clinical measure of
balance. J Gerontol1990; 45M192-M197.

4. Englander F, HodsonTJ, TerregrossaRA. Economic dimensions of slip and fall injuries. Journal of
Forensic Science 1996;41(5):733–46.trial. The Gerontologist 1994;34(1):16–23.

5. HausdorffJM, Rios DA, EdelberHK. Gait variability and fall risk in community–living older adults:
a 1–year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.
6. HornbrookMC, Stevens VJ, WingfieldDJ, Hollis JF, GreenlickMR, OryMG. Preventing falls
among community–dwelling older persons: results from a randomized trial. The Gerontologist
1994:34(1):16–23
7. Issue Brief (Public Policy Inst (Am Assoc Retired Pers) 2002 Mar;(IB56):1-14.
8. KocheraA. Public Policy Institute, American Association of Retired Persons, Washington, DC,
USA. Falls among older persons and the role of the home: an analysis of cost, incidence, and
potential savings from home modification. 2002.

52. References
9. Morrison, C. Northwest Orthopaedic Institute. Proven Best Practices: Assessment and
Treatment of Patients Who are at Risk for Falls. Gentiva Seminar. Attended October 20,
2006.

10. National Hospital Discharge Survey (NHDS), National Center for Health Statistics.
Available at: www.cdc.gov/nchs/hdi.htm.Assessed September 14, 2011.

11. National Fire Safety Council, Inc., Michiagan Center, MI 49254-0378. Falls Prevention:
Protecting Your Active Lifestyle.
12. Podsiadlo D, Richardson S. The timed “Up and Go” test: a test of basic functional
mobility for frail elderly persons. J Am Geriatr Soc 1991; 39:142-148.
13. Roudsari BS, Ebel BE, Corso PS, Molinari, NM, Koepsell TD. The acute medical care costs
of fall-related injuries among the U.S. older adults. Injury, Int J Care Injured 2005;36:1316-22.
14. Shumway-Cook A, Woollacott M. Motor Control Theory and Practical Applications, 2
nd
Ed. Lippincott Williams & Wilkins. Baltimore, MD 2001.
15. Tinetti ME. Clinical Practice. Prevention Falls in Elderly Persons. N Eng J Med 2003;
348:42-49

53. References
16. Washington State Department of Health: Senior Falls Prevention Study 2006
17. York, S. Northwest Orthopaedic Institute. Proven Best Practices: Assessment and
Treatment of Patients Who are at Risk for Falls. Gentiva Seminar. Attended October 20,
2006.

55. Static balance control
◦Maintaining sitting.
◦Half-kneeling,
◦Tall kneeling,
◦Standing postures on a firm surface,
Balance Training
◦Tandem, Single-leg stance.
◦Working on soft surfaces (e.g., foam, sand, grass),
◦Narrowing the BOS, moving the arms, or closing the eyes.

56. Dynamic Balance Exercises Using
Movable Surfaces:
1.Swiss Ball
1.Tilt Boards
Balance Training

57. Hard surfaces.
Maintain static balance.
Move some part (s) of body and try to maintain his
balance.
Open then closed eyes.
External challenge from therapist.
Throw and catch exercises with ball.
Soft surfaces.
Maintain static balance.
Move some part (s) of body and try to maintain his
balance.
Open then closed eyes.
External challenge from therapist.
Throw and catch exercises with ball.