 Balance: General Concepts &

Considerations
 Balance in the Elderly: Special Concerns
• Age Related Changes

• Assessment

• Intervention Strategies
 Definition
• Balance is defined as a “complex process
involving the reception and integration of
sensory inputs, planning and execution of
movements, to achieve a goal requiring upright
posture.” (Nashner L, 1994)

• It is the ability to control the COG over the BOS

in a given sensory environment. (Nashner L,
1994)
 Posture
• The term posture is often used to describe both

Biomechanical alignment of the body as well

as Orientation of the body to environment
 Balance impairment may resulting from,
• Neurological conditions

• Musculoskeletal conditions

• Psycological conditions.
 Earlier studies are,
• Based on neurophysiologic principles.
• Focused on Reflexive & Reactive equilibrium
responses .

 Recent studies
• Incorporated other relevant systems
 In a Systems model or system approach
to dynamic equilibrium.
 “…Balance is the result of
interactions between the
PERSON
individual, task and
environment”
ENVIRON
MENT TAS
K
  Within the PERSON…
 Sensory inputs & processing system. (b/w E & P)
 Motor planning & execution system. (b/w P & T)
 Influence of other systems.

• Sensory Person • Execution

input • Sensory of task
processing &
motor planning
Environment Tas
k
VISION VESTIBULAR SOMATO SENSORY

CENTRAL NERVOUS SYSTEM

MUSCULOSKELETAL
SYSTEM

PHYSICAL EQUILIBRIUM
It includes…
A. Peripheral sensory reception.
i. Somatosensory
ii. Visual
iii. Vestibular
 Dysfunction leads to impaired rendering of sensory
information's to brain.
B. Central sensory perception.
• Multi Sensory reweighting - “Upweightage”
&“Downweightage” of sensory information(s).
 Dysfunction result in to “sensory conflict”
It includes…
 Central motor planning & control
• Depends on
 Attention, Intention & Motivation
 Peripheral motor execution- through bilateral
Joints & muscles.
• Factors influencing are,
 ROM
 Muscle strength
 Endurance
 Musculoskeletal evaluation is significant here.
Cognitive & behavioral factors…
• Attention
• Cognition
• Judgment
• Memory
• Depression
• Emotional liability
• Agitation
• Denial of impairment.
 Balancing is always accomplished in an
environmental context.
 Some environmental factors influencing
balance are,
• Gravity
• Surface conditions
• Visual environment
• Intention
• Task choice
 Postural Control Inputs
 Somatosensory systems
• - cutaneous receptors in soles of the feet
• - muscle spindle & Golgi tendon organ information
• - ankle joint receptors
• - proprioreceptors located at other body segments
 Vestibular system
• - located in the inner ear
• - static information about orientation
• - linear accelerations, rotations in the space
 Visual system
• - the slowest system for corrections (200 ms)
 This includes…
A. Reflexes
 Vestibulo-occular Reflex (VOR)
 Allows the coordination of eye & head movements.

 Vestibulospinal Reflex (VSR)

It helps to control movement & stabilize the body. (via.
Righting like labyrinthine, optical, body on head righting)
The VSR permits stability of the body when the head
moves and is important for the co ordination over
the trunk over the extremities in upright posture.
16
B. Automatic postural
 Ankle strategy
responses
 Hip strategy
 Suspensory strategy
 Stepping & reaching strategy
• When the COG is outside of the BOS, a strategy is
required (shift, step or stumble) is required to
prevent a fall. (INHERENT FALL PREVENTION)
• Strategies are automatic
• Occur 85 to 90 msec after the perception of
instability is realized
 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
 Used when perturbation is:
• fast
• large amplitude
 Surface is unstable or
shorter than feet
 Muscles recruited proximal-
to distal
 Head movement out-of
phase with hips
 Forward bend of trunk with
hip/knee flexion
 May progress to a Squatting
position
 COG lowered
 Used to prevent a fall
 Used when
 Perturbations are:
• Fast
• Large amplitude
• Or when other strategies fail
• Base of Stability (BOS)
 Moves to “catch up”
C. Anticipatory postural adjustments
 Aim: to counteract the destabilizing
consequences of a Voluntary movement.
 Failure to produce this adjustment –
increases the risk of falling
D. Volitional Postural Movements
 Self initiated disturbance of the
COG to accomplish a goal.
Basic Principles of Postural Control - Summery
The Sensory System

 With Aging:
• Vision may decrease in acuity, contrast
sensitivity, and depth perception.
• The vestibular system may undergo age-
related changes, resulting in dizziness and
unsteadiness.
• There may be a decrease in proprioception
and vibration.
The Central Processing System
 Aging may result in:
• Slowing of sensory information
• Slowing of nerve conduction velocity
• Increased postural sway
• Increased incidence of co-contractions
 Cognitive Area
• High level Sensory Adaptation
 Decreased ability to shift from the use of one sensory
input to other for poster control
• Attention
 Increased attention required for the Postural Control
 Poorer performance in Dual Tasks (in Cognitive &
postural tasks)
 The Effector System

 Aging may result in:

• Decreased muscle strength
• Decreased ROM and flexibility
• Increased “stiffness” of connective tissue
• Aging may result in cardiovascular changes
  20% - 30% fear falling1
 35%-40% of people 65+ fall each year
2 Those who fall are 2-3 times more likely to fall

again3
 10%-20% of falls cause serious injuries4
 In India,
• Incidence of fall is 14% (History of
a single fall in the last 6 months)
• M:F = 68%:32%
1. Vellas BJ, Age & Aging, 1997; Friedman SM, JAGS, 2002
2. Hornbrook, Gerontologist, 1994; Hausdorff, Arch Phys Med & Rehab,
2001
3. Tinetti, New Eng J Med, 1988; Teno, JAGS,1990
4. Sterling, J Trauma-Inj Infection & Critical Care, 2001
 2 classifications,
• Classification 1
1. Intrinsic (internal) Risk factors
2. Extrinsic (external) Risk factors
3. Acquired Risk factors

• Classification 2
1. Modifiable Risk Factors
2. Non-Modifiable Risk Factors
 Intrinsic (internal) risk factors
• Examples- Age, osteporosis, vision loss, dementia

 Extrinsic (external) risk factors:

• Examples- Medications, footwear, assistive
devices, environment

 Acquired risk factors:

• Examples- Facility or hospital admission due to
health change or decline (new environment),
delirium due to illness, increased disability due
to injury
Modifiable risk factors
• Examples: Muscle weakness, poor
balance, exercise level, medications,
environmental lighting, footwear

Non-modifiable risk factors

• Examples: Age, chronic
conditions, disability, dementia,
vision loss
 Assessment is “an appraisal or evaluation of a
patient’s condition, based on clinical &
laboratory data, medical history, and the
patient’s account of symptoms”
 Taber’s cyclopedic medical dictionary., 18th ed. p 16
 The system approach is a useful approach for the
assessment of balance in elderly
• A comprehensive assessment of balance function from
the system perspective would include examining the
older adult performing a range of balance tasks under a
variety of contexts.
 Underlying Components of balance control to be assessed
include,
• Muskuloskeletal
• Sensory
• Motor &
• Cognitive
 Balance tasks to be assessed includes
• Self Report Measures
• Quiet standing (static)
• Active standing (dynamic)
• Sensory manipulation
• Vestibular
• Functional scales
• Dual task & Multiple Task
The Activities-specific Balance
Confidence (ABC) Scale
• Description of the Instrument
 The Activities-specific Balance Confidence (ABC)
Scale is a 16-item scale; each item is rated from 0%
(no confidence) to 100% (complete confidence).
• Form of instrument:
 Questionnaire/ Survey
• Reliability Validity = Good
 Refers to test in which the client is standing
and the movement goal is to hold still. (i.e.
Static Balance)
 Perturbations may or may not be applied.
 Examples are,
• Double Limb Standing
• Single Limb Stance (SLC)/ Unilateral standing
• Tandem Stance
• Romberg Test
• Sharpened / tandem Romberg
• One legged stance tests (OLSTs)
 Procedure
• Both legs must be alternatively tested
• Difference b/w sides are noted
 The client stands on both feet and crosses the arms
over the chest, then picks up one leg and hold it in
neutral and the knee flexed to 900.
 The lifted leg may not be pressed in to the stance
leg.
 Five 30 sec trials are performed for each leg
 Max. score is 150 for each leg
 Interpretation
• Normal young subject are able to stand for 30 sec
• Gehlsen and Whaley found that a one-legged stance
test distinguished elderly fallers from non-fallers. 39
 Refers to test in which the client is standing and
the movement goal involves voluntary weight
shifting.
 Examples are,
• Functional reach test
• Multidirectional reach
• Sit-to-stand, Sit down
• Reaching movement
• Different walking tasks (turning, head rotation, on
beam, stop and start etc)

• Limits of stability : it is the farthest distance in any

direction a person can lean (away from the mid line)
with out altering the original BOS by stepping,
reaching, or falling
 This was developed for use with older adults to
determine risk for falls.
 Procedure
• The client stands near a wall with feet
parallel
• A yard stick is attached to the walls in
shoulder (acromion) height
• The client is asked to make a fist & raise the arm
nearest the wall (without touching) to 90° of shoulder
flexion
• The examiner notes the fist (3ird MC head) on the
yard stick.
• The client is then asked to lean forward as far as
possible, & the examiner notes the end point.
 • Beginning position is subtracted from end position
of the fist on the yardstick.
 Interpretation: Score is available
 Comments:
 Simple single task test, easy to administer, Quick screen
 High degree of agreement rates (reliability inter .98 intra
.92)
 FR is affected by age and height (i.e.
anthropometric characters).
 Studies shown that this test is useful for fall
prediction
 Limitation: it measures sway in only 0ne direction.
 Less sensitive to illustrate the clinical improvement.
 This test measures how far an individual
can reach in the forward, backward,
and lateral directions.
 Procedure
• For backward reach, the test position is the
same as FR
• For lateral reach, the client faces away from the
wall and reaches to sides (to right and left
side)
• 1 practical trial is allowed before the start of 3
trial
 Uses altered surface & visual conditions to
determine how well the CNS is using and
reweighting sensory input from postural control.
 Examples are,
• Sensory organization test

• Clinical Test of Sensory Interaction on Balance

(CTSIB)
 The SOT uses a computerized, movable force
plate and movable visual surround to alter the
surface and visual environment
 systematically.
It is used to determine the effectiveness of an
individual to utilize different sensory inputs.
 It examines body sway during three 20-second
trials under each of six sensory conditions are
performed
 Components:
• Moving platform (sliding or tilting)
• A moving visual surround screen
 Test conditions are,
• C1: Eyes Open, Stable Surface (EOSS)
• C2: Eyes Closed, Stable Surface (ECSS)
• C3: Visual Conflict with Moving Surround, Stable
Surface (VCSS)
• C4: Eyes Open, Moving Surface (EOSS)
• C5: Eyes Closed, Moving Surface (ECSS)
• C6: Visual Conflict with Moving Surround, Moving
Platform (VCSS)
 Test condition 1 provides accurate somatosensory,
visual, and vestibular information & is the baseline
reference
 Each of the other 5 conditions increasing the level of
sensory conflict & postural difficulty.
46
 Interpretation
• Posturography equipment provides a
printed result
• Ratio comparison provide information
regarding reliance on one system over another
• EMG – to know about muscle activity
& recruitment.
 Comments
• SOT is reliable and valid scale
• Normative data is available.

47
 It is a clinical version of the SOT that does not
use computerized force plate.
 The concept of 6 condition is remain intact.
 A thick foam pad substitutes for moving force
plate.
 Interpretation
• By using a stop watch
• Visual gradations.
 SCORE 1 : Minimal sway
 SCORE 2 : Mild sway
 SCORE 3 : Moderate sway
 SCORE 4 : Fall
48
 These tests use various • Visual acuity

body & head positions, • Nystagmus

eye movement, or • Visual-vestibular
stepping to stimulate or interaction
restrict visual, vestibular • Oculomotor
or somatosensory inputs. tests
 Examples are, • Vertigous

• Hallpike-Dix Maneuver
positions
• Fukuda
Stepping Test
• Dizziness 49
 It is a vertiginous position test
to stimulate the post
semicircular canal
 Procedure
• Moving the patient from a sitting
position with the head turned
so that the affected ear is 30-
45° below the horizontal
stimulate post. Canal and may
produce nystagmus & vertigo
• A +ve result leads to a diagnosis
of Benign positional vertigo (BPV)
50
 Functional balance, mobility, and gait
scales involve the performance of whole-
body movement task.
 Examples are
• Berg Balance Scale
• Tinetti performance oriented assessment of gait.
• Timed Up and Go Test
• Gait Assessment Rating Scale (GARS)
• Dynamic Gait Index
• Functional Gait Assessment
51
 It is a multi task test of 14 balance task (6 static &
8 dynamic)
 Focused on,
• Maintanance of position
• Postural adjustment to volountry movement
 Reliability (inter=.98 intra=.99)
 Scoring : 5 point ordinal scale with specefic task criteria
 Comments
• Simple, easy to administer
• Client should able to stand
• Provide baseline & outcome data; score of 45 or below
are predictive of falls in the elderly
52
53
 It is a multi task test: have 2 parts
• Balance sub test: 9 items (4 static & 5 dyanamic)
• Gait sub test : 8 test
 Focused on
• Maintenance of position
• Postural response to perturbation
• Gait mobility
 Equipment needed
• Chair, walk way; patient can use usuan walking
aid
54
 Scoring
• Some items graded can/cannot perform; some 3 point
scale with specific criteria
 Reliability : inter=.85
 Requirements: able to stand & walk independently
 Comments
• Simple, easy to administer
• Provide baseline data; predictive of falls in elderly
 > 24 low risk
 19-24 mod risk
 18> high risk
• Limitation: some scoring criteria vague; difficult to
detect small changes
 It is a single task test: stand up, walk 3 meter,
turn around and return to chair
 Focuses on = Functional mobility
 Scoring
• Timed test uses 1 practice/3 trials for average score
 Reliability : inter=.99, intra = .98
 Requirements : able to stand & walk
independently
 Comments
• Simple, easy to administer
• Provides baseline & outcome data: predictive of falls in
elderly
 These are developed to examine the
concurrent activities (i.e. cognitive &
postural control demands)and divided
attention on balance and mobility
 performance.
Examples are,
• Stops Walking When Talks (SWWT) & Walking While
Talking (WWT)
• Multiple Tasks Tests (MTT)
 In these tests, clinician asks the client 1 or
more questions and observe if the client must
stop walking to answer the question(s).

If so the test is positive. i.e. patient have
to stop walking to reallocate attention to
the cognitive task
 This is a more formalize test
 It include 8 items involving gait plus other
cognitive and motor tasks such as carrying
a try and avoid obstacle.
 Comments for Dual task tests
• Reliability & validity are not well established
• Disagreement in the literature exist regarding their
usefulness.
• In clinical use, these are helpful to detect clients
with major problems (Sensitivity ?).
 This topic will be discuss under the
following headings

• Preventive Exercises

• Recent Advanced techniques used for balance

intervention in elderly from Literatures.

 CDC Fall Prevention Recommendations

 Regular exercise
 Medication review
 Vision exams
 Home safety evaluation

(Circulation. 2007;116:000-000.)
Downloaded from www.circ.ahajournals.org by on May 16, 2010
1. Individual risk assessment
2. Regular strength & balance exercise
3. Gait & assistive device training
4. Medication review & management
5. Management of chronic conditions
6. Vision correction
7. Education
8. Home safety improvements
WA State Dept. of Health, Falls Among Older Adults: Strategies for Prevention (2002)
Centers for Disease Control
 The intervention strategies that were evaluated for their
effectiveness in preventing falls were classified as single or
multifactorial strategies and as generic or individually
designed. JAGS 49:664–672 MAY 2001–VOL. 49, NO. 5
,


)
 Among community-dwelling older persons (i.e.,
those living in their own homes), multifactorial
interventions should include:
• Gait training and advice on the appropriate use of
assistive devices (B);
• Review and modification of medication,
especially psychotropic medication (B);
• Exercise programs, with balance training as one
of the components (B);
• Treatment of postural hypotension (B);
• Modification of environmental hazards (C); and
• Treatment of cardiovascular disorders, including
cardiac arrhythmias (D).
 In long-term care and assisted living settings
multifactorial interventions should include:
• Staff educationprograms (B);
• Gait training and advice on the appropriateuse of
assistive devices (B); and review and
• Modification of medications, especially
psychotropicmedications (B).

 The evidence is insufficient to make

recommendations for or against multifactorial
interventions in acute hospital settings
 Exercise

1. Although exercise has many proven benefits,

the optimal type, duration and intensity of
exercise for falls prevention remain unclear (B).
2. Older people who have had recurrent falls
should be offered long-term exercise and
balance training (B).
3. Tai Chi C’uan is a promising type of
balance
exercise,although it requires further evaluation
before it can be recommended as the preferred
balance training (C)
Environmental Modification
• When older patients at increased risk of falls are
discharged from the hospital, a facilitated
environmental home assessment should be
considered (B).
• In a subgroup of older patients, a facilitated home
modification program after hospital discharge
was effective in reducing falls (Class I).
• Otherwise, modification of home environment
without other components of multifactorial
intervention was not beneficial (Class I).
 Medication

Patients who have fallen should have their

medications reviewed and altered or stopped as
appropriate in light of their risk of future falls.
Particular attention to medication reduction should
be given to older persons taking four or more
medications and to those taking psychotropic
medications. (C)
 Assistive Devices
• Studies of multifactorial interventions that have
included assistive devices (including bed alarms,
canes, walkers (Zimmer frames), and hip protectors)
have demonstrated benefit. However, there is no direct
evidence that the use of assistive devices alone will
prevent falls. Therefore, while assistive devices may be
effective elements of a multifactorial intervention
program, their isolated use without attention to other
risk factors cannot be recommended (C).

• Among hospitalized patients there is insufficient

evidence for or against the use of bed alarms (Class I).
 Behavioral and Educational Programs
 Although studies of multifactorial interventions that have
included behavioral and educational program have
demonstrated benefit, when used as an isolate
intervention, health or behavioral education does not
reduce falls and should not be done in isolation (B)
 A structured group educational program among
community- dwelling older people did not reduce the
number of falls but did achieve short-term benefits in
attitudes and self-efficacy (Class I).
 Practice guidelines in the emergency department did not
alter documentation of falls risk factors, causes of falls,
consequences of falls, or the implementation of practice
guidelines (Class I).
 Bone Strengthening Medications
• It reduce fracture rates. But not reduce the rates of falls.
 Visual Intervention
• Fall-related hip fractures were higher in patients with
visual impairment.
 Footwear Interventions
• For Women: Static and dynamic balance were better in
low-heeled rather than high-heeled shoes or than the
patient’s own footwear.
• For men: foot position awareness and stability were
best with high midsole hardness and low mid-sole
thickness. Static balancewas best in hard-soled (low
resistance) shoes.
 Sensory-Specific Balance Training in Older Adults:
Effect on Position, Movement, and Velocity Sense at
the Ankle
• Results suggest that short-term improvements in velocity
sense, but not movement and position sense, may be
achieved following a balance exercise intervention
PHYS THER Vol. 87, No. DOI: 5, May 2007,Vol. 87, No. 5, May 2007, pp. 560-568

 Effects of ballates, step aerobics, and walking on

balance in women aged 50-75 years
• All three training programs improved dynamic balance,
however, step aerobics be better improvements in
postural stability or static balance when compared to the
Ballates program.
 Effects of High-Intensity Strength Training on
Multiple Risk Factors for Osteoporotic Fractures A
Randomized Controlled Trial
• High-intensity strength training exercises are an effective
and feasible means to preserve bone density while
improving muscle mass, strength, and balance in
postmenopausal women.
JAMA. 1994;272(24):1909-1914. Vol. 272 No. 24, December 28,
1994

 An Objective Approach for Assessment of Balance

Disorders and Role of Visual Biofeedback
Training in the Treatment of Balance Disorders : A
Preliminary Study.
• Study suggests that visual biofeedback training
facilitates appropriate balance strategies and enables in
achieving improved postural control.
IJPMR 12, April 2001; 25-30
 Dual task training
 Evidence shows that “in physically fit elderly people,
cognitive dual tasks influence balance control during
walking directly as well as indirectly through decreased
velocity” Marianne B et. al
 This shows the significance of dual task intervention in
this area
 The efficacy of Tai Chi Chuan in older adults:a
systematic review
• There is limited evidence that TCC is effective in
reducing falls and blood pressure in the elderly.
Family Practice Vol. 21, No. 1 © Oxford University Press
2004
 Beneficial effect of proprioceptive physical
activities on balance control in elderly human
subjects
• Proprioceptive exercise therefore appears to have the
best impact on balance control.
Neuroscience Letters Volume 273, Issue 2, 1 October 1999, Pages
81-84
 Community-based group exercise improves
balance and reduces falls in at-risk older people: a
randomised controlled trial
• participation in a weekly group exercise programme with
ancillary home exercises can improve balance and
reduce the rate of falling in at-risk community dwelling
older people.
Age and Ageing 2003; 32: 407-
 Randomised controlled trial of a general practice
programme of home based exercise to prevent falls
in elderly women
• An individual programme of strength and balance retraining
exercises improved physical function and was effective in
reducing falls and injuries in women 80 years and older
BMJ 1997;315:1065-1069 (25
October)
 The Effect of Multidimensional Exercises on Balance,
Mobility, and Fall Risk in Community-Dwelling Older
Adults
• Exercisecan improve balance and mobility function and
reduce the likelihood for falls among community-dwelling
older adults with a history of falling. The amount of exercise
needed to achieve these results, however, could not be
determined from this study.
PHYS THER Vol. 77, No. 1, January 1997, pp. 46-
 Training Elderly People in Martial Arts
Could Cut Their Risk of Injuries from Falls
• Training older people in martial arts could cut their
chances of suffering broken bones or fractures when
they fall, according to experts.
Health & Fitness, Science & Technology News April 22nd, 2010 at
10:10 am
 Effect of a Gentle Iyengar Yoga Program on Gait
in the Elderly: An Exploratory Study
• …. yoga programs tailored to elderly adults may offer a
cost-effective means of preventing or reducing age-
related changes in these indices of gait function.
Arch Phys med Rehabil Volume 86, Issue 9, Pages 1830-1837 (September
2005)
And remember, falls
can be prevented,
except
falling in love.