Balance Training

1. BALANCE TRAININGBALANCE TRAINING

2. DefinitionDefinition
Balance is defined as the ability to Balance is defined as the ability to
control the body mass or center of control the body mass or center of
gravity to the base of support in gravity to the base of support in
order to maintain a upright posture order to maintain a upright posture
or a functional equilibrium in or a functional equilibrium in
dynamic activitiesdynamic activities

3. Normal Balance MaintenanceNormal Balance Maintenance

Human balance is a complex process which Human balance is a complex process which
involves the integration of sensory information involves the integration of sensory information
from peripheral end organs to detect body from peripheral end organs to detect body
position in relation to environment.position in relation to environment.

Integration of this information by CNS to Integration of this information by CNS to
produce adequate and proper motor output in produce adequate and proper motor output in
the form of automatic postural responsesthe form of automatic postural responses. .

4. The Sensory factorsThe Sensory factors

Somato Sensory Inputs Somato Sensory Inputs
(Proprioceptors) (Proprioceptors)

Visual Inputs Visual Inputs

Vestibular InputsVestibular Inputs

5. Somato sensory receptors:Somato sensory receptors:
Proprioceptors located in Muscles , Proprioceptors located in Muscles ,
Ligaments and Joints.Ligaments and Joints.
Visual Inputs:Visual Inputs:
Perception of verticality, object motion and Perception of verticality, object motion and
motion of self in relation to environment.motion of self in relation to environment.
Vestibular InputsVestibular Inputs::
Position of head in relation to gravity and Position of head in relation to gravity and
linear and angular acceleration of head linear and angular acceleration of head
during movement. during movement.

7. StrategiesStrategies

Ankle strategyAnkle strategy
Describes postural sway control from ankle Describes postural sway control from ankle
musculature level. This strategy act when the musculature level. This strategy act when the
sway is small, slow and near midline.sway is small, slow and near midline.

Hip StrategyHip Strategy
It is the postural sway from pelvis and trunk. It is It is the postural sway from pelvis and trunk. It is
seen when the sway is large, fast and nearing seen when the sway is large, fast and nearing
the limits of stability.the limits of stability.

8. 
Suspensary strategySuspensary strategy
It describes lowering of COG by flexing both the It describes lowering of COG by flexing both the
knees. Commonly seen in windsurfing.knees. Commonly seen in windsurfing.

Stepping strategyStepping strategy
It describes steps with feet or reaches with arms It describes steps with feet or reaches with arms
in an attempt to re-establish a new base of in an attempt to re-establish a new base of
support when COG has exceeded the original support when COG has exceeded the original
base of support.base of support.

9. What is a balance disorder?What is a balance disorder?
A balance disorder is a A balance disorder is a
disturbance that causes an disturbance that causes an
individual to feel unsteady, giddy, individual to feel unsteady, giddy,
or have a sensation of movement, or have a sensation of movement,
spinning, or floating.spinning, or floating.

10. Causes of balance disordersCauses of balance disorders
Sensory system disordersSensory system disorders

Sensory ataxia (dorsal column degeneration)Sensory ataxia (dorsal column degeneration)

Vestibular neuronitisVestibular neuronitis

Benign paroxysmal positional vertigoBenign paroxysmal positional vertigo

Neuropathic jointsNeuropathic joints

11. CNS disordersCNS disorders

Cerebro vascular accidentsCerebro vascular accidents

Parkinson’s diseaseParkinson’s disease

Cerebellar dysfunctionCerebellar dysfunction

Vertibro basilar insufficiencyVertibro basilar insufficiency

Brain injuryBrain injury
Motor disordersMotor disorders

Gross poliomyelitis involving both lower limbsGross poliomyelitis involving both lower limbs

Motor neuron diseaseMotor neuron disease

12. Biomechanical ProblemsBiomechanical Problems

WeaknessWeakness

Limitation of joint rangeLimitation of joint range
Environmental risk factorsEnvironmental risk factors

General risk factors like Furniture, Bathroom, General risk factors like Furniture, Bathroom,
Toilet, Stairs, Outdoor curbsToilet, Stairs, Outdoor curbs
Falls in the ElderlyFalls in the Elderly

13. Symptoms of balance disordersSymptoms of balance disorders

When balance is impaired, an individual has When balance is impaired, an individual has
difficulty maintaining orientationdifficulty maintaining orientation

An individual may experience the "room An individual may experience the "room
spinning" and may not be able to walk without spinning" and may not be able to walk without
staggeringstaggering

May not even be able to arise May not even be able to arise

A sensation of dizziness A sensation of dizziness

Falling or a feeling of falling Falling or a feeling of falling

LightheadednessLightheadedness

Visual blurring Visual blurring

Disorientation Disorientation

14. ASSESSMENTASSESSMENT
1. 1. Visual system:Visual system:
Check visual acuity, depth perception, visual Check visual acuity, depth perception, visual
field defects.field defects.
2. 2. Somatosensory:Somatosensory:
Check proprioception, cutaneous sensation Check proprioception, cutaneous sensation
(touch, pressure), lower extremities and trunk, (touch, pressure), lower extremities and trunk,
especially feet and ankle.especially feet and ankle.

15. 3. Vestibular:3. Vestibular:
Check motor responses to positional and Check motor responses to positional and
movement testingmovement testing

Righting reactions: Move or position the body, observe automatic adjustments Righting reactions: Move or position the body, observe automatic adjustments
that restore normal alignment of the head position (face vertical, mouth that restore normal alignment of the head position (face vertical, mouth
horizontal).horizontal).

Equilibrium reactions: Alter the body’s center of mass or base of support, Equilibrium reactions: Alter the body’s center of mass or base of support,
observe automatic postural adjustments that serve to maintain balance (keep observe automatic postural adjustments that serve to maintain balance (keep
centre of mass within the BOS).centre of mass within the BOS).

Protective reactions: Alter the body’s centre of mass outside of the BOS, Protective reactions: Alter the body’s centre of mass outside of the BOS,
observe the automatic adjustments of the arms or legs to extend and support observe the automatic adjustments of the arms or legs to extend and support
the body weight in anticipation of a fall.the body weight in anticipation of a fall.
Testing considerations: Can use a displacing manual Testing considerations: Can use a displacing manual
force against the Centre Of Mass (a perturbation or force against the Centre Of Mass (a perturbation or
push) or displace the BOS using a moveable surface push) or displace the BOS using a moveable surface
(platform, gymnastic ball, equilibrium board). (platform, gymnastic ball, equilibrium board).

16. 4. Assessment of Musculoskeletal 4. Assessment of Musculoskeletal
ElementsElements

Determine musculoskeletal strength Determine musculoskeletal strength
and ROM especially in the lower and ROM especially in the lower
extremities and trunkextremities and trunk

Tightness, contracturesTightness, contractures

SpasticitySpasticity

Determine limits of stability: maximum Determine limits of stability: maximum
sway in any direction.sway in any direction.

17. 5. CHECK STATIC BALANCE5. CHECK STATIC BALANCE
A. Standing tests:A. Standing tests:

Double limb supportDouble limb support

Single limb supportSingle limb support

20. 6.Dynamic Balance:6.Dynamic Balance:

Standing upStanding up

SteppingStepping

StoopingStooping
7. Scoring: 7. Scoring:
A. Three point scale: absent, impaired, A. Three point scale: absent, impaired,
presentpresent
B. Functional balance grades: 0, poor, B. Functional balance grades: 0, poor,
fair, good, normal (with descriptive fair, good, normal (with descriptive
criteria for each)criteria for each)

21. 
Berg’s Balance ScaleBerg’s Balance Scale
0 – No Balance0 – No Balance
1 – Able to maintain balance with support1 – Able to maintain balance with support
2 – Able to maintain balance with hands 2 – Able to maintain balance with hands
offoff
3 – Able to maintain balance with hands 3 – Able to maintain balance with hands
off, accepts minimal challengesoff, accepts minimal challenges
4 – Able to maintain support with hands 4 – Able to maintain support with hands
off, accepts maximal challengesoff, accepts maximal challenges

25. 
Romberg test: Romberg test:
Standing with feet in normal stance Standing with feet in normal stance
position, first with eyes open, then with position, first with eyes open, then with
eyes closed: used to detect posterior eyes closed: used to detect posterior
column ataxiacolumn ataxia

Sharpened or Tandem Romberg:Sharpened or Tandem Romberg:
Have patient stand in a tandem heel to Have patient stand in a tandem heel to
toe position, first with eyes open, then toe position, first with eyes open, then
eyes closed; increases sensitivity of eyes closed; increases sensitivity of
Romberg testRomberg test

27. TREATMENT SUGGESTIONS FOR TREATMENT SUGGESTIONS FOR
BALANCE DISORDERSBALANCE DISORDERS

Cognitive impairment treatment Cognitive impairment treatment
suggestionssuggestions

Reduce confusionReduce confusion

Improve motivationImprove motivation

Improve attentionImprove attention

Encourage consistencyEncourage consistency

Start with simple task increase the complexity Start with simple task increase the complexity
graduallygradually

28. 
Managing sensory problemsManaging sensory problems
(Vestibular, Proprioceptive, Visual)(Vestibular, Proprioceptive, Visual)
Facilitating demand system, encourage Facilitating demand system, encourage
remaining system remaining system

Managing strategy selection problemsManaging strategy selection problems
(Parkinson’s disease)(Parkinson’s disease)
Appropriate sensory demands Appropriate sensory demands
(Pertubations)(Pertubations)
Hip strategy – Stand on foam surface, Hip strategy – Stand on foam surface,
narrow surface, Treadmillnarrow surface, Treadmill

29. 
Managing preparatory problemsManaging preparatory problems
(Bradykinesia)(Bradykinesia)
Strategy trainingStrategy training

Managing sequencing and timing Managing sequencing and timing
problemsproblems
(CP, Hemiplegia)(CP, Hemiplegia)
Facilitate normal sequential muscle Facilitate normal sequential muscle
contraction from distal to proximal in contraction from distal to proximal in
response to pertubation (EMG response to pertubation (EMG
Biofeedback, Balance master)Biofeedback, Balance master)

30. 
Managing scaling problemManaging scaling problem
(Cerebellar dysfunctions)(Cerebellar dysfunctions)
Correct faulty amplitude of contraction Correct faulty amplitude of contraction
(Visual Biofeedback, Balance master, (Visual Biofeedback, Balance master,
Wobble board, weighted cuffs)Wobble board, weighted cuffs)

Managing musculoskeletal problemsManaging musculoskeletal problems
(Muscle weakness, ROM restriction, (Muscle weakness, ROM restriction,
Spasticity)Spasticity)
Muscle strengthening exercises, Electrical Muscle strengthening exercises, Electrical
stimulation, Stretchingstimulation, Stretching

31. Functional Sequence in Functional Sequence in
Balance TrainingBalance Training
Balance activities starts from lying, Balance activities starts from lying,
kneeling, sitting, then progressed to static kneeling, sitting, then progressed to static
and dynamic standing and walking.and dynamic standing and walking.
NOT NECESSARY TO FOLLOW NOT NECESSARY TO FOLLOW
THE STEP LADDER PATTERNTHE STEP LADDER PATTERN

32. 
LyingLying
Prone lying – Neck ExtensionProne lying – Neck Extension
Prone on elbowsProne on elbows
Prone on handsProne on hands

SittingSitting
High sitting with foot on ground, with arm High sitting with foot on ground, with arm
support on the sidessupport on the sides
Weight shiftsWeight shifts
Without arm supportWithout arm support
Without feet touching the groundWithout feet touching the ground
Sit walkingSit walking
Long sittingLong sitting

33. 
KneelingKneeling
4 point kneeling4 point kneeling
Kneel sittingKneel sitting
2 point kneeling2 point kneeling
Half kneelingHalf kneeling
(with and without support, challenges)(with and without support, challenges)

34. 
Sit to StandSit to Stand

StandingStanding
# Static# Static
Double limb stanceDouble limb stance
Single leg stanceSingle leg stance
Tandem positionTandem position
# # DynamicDynamic
Static marchingStatic marching
Wobbling boardWobbling board

35. 
WalkingWalking
ForwardForward
BackwardBackward
SidewaysSideways
TandemTandem
BraidingBraiding
TreadmillTreadmill

36. 
Steps Steps

RampsRamps

Rough terrainRough terrain

CurbsCurbs

ObstaclesObstacles

Community ambulationCommunity ambulation

37. TasksTasks

Looking up at the ceilingLooking up at the ceiling

Turning to look behind without moving the Turning to look behind without moving the
feetfeet

Reaching forward to take an objectReaching forward to take an object

Reaching sidewaysReaching sideways

Reaching backwards Reaching backwards

Reaching down to stool and floorReaching down to stool and floor

Ball catching and throwingBall catching and throwing

38. 
Environmental modificationsEnvironmental modifications

Low chairs, low beds - leg modificationsLow chairs, low beds - leg modifications

Unstable furniture - repair immediatelyUnstable furniture - repair immediately

Ladders and step ladders - avoid themLadders and step ladders - avoid them

Lack of grab rails - installation of grab Lack of grab rails - installation of grab
railsrails

39. 
Hand rails not present or inadequate – Hand rails not present or inadequate –
installation of appropriate handrailsinstallation of appropriate handrails

Stairs too steep, tread too narrow Stairs too steep, tread too narrow
-modification of stairs-modification of stairs

Foot wear - thin, flat, broad, made up of Foot wear - thin, flat, broad, made up of
firm material, textured sole, ankle firm material, textured sole, ankle
supportsupport

Avoid – high heeled shoes, shoes with Avoid – high heeled shoes, shoes with
soft and slippery soles. soft and slippery soles.

40. THANK YOUTHANK YOU