assessment of balance and management of balance

 The dynamic process by which the
body’s position is maintained in
equilibrium.
Balance is greatest when the body’s
center of mass (COM) or center of
gravity (COG) is maintained over its
base of support (BOS).

COM
 point that corresponds to the
center of the total body mass
,where the body is in perfect
equilibrium.
 It is determined by finding the
weighted average of the COM of
each body segment.

COG
 the vertical projection of the
center of mass to the ground.
In the anatomical position, the
COG of most adult humans is
located slightly anterior to the
second sacral vertebra or
approximately 55% of a person’s
height.42

MOMENTUM
 product of mass times velocity.
 Linear momentum relates to the
velocity of the body along a straight
path, for example in the sagittal or
transverse planes.
Angular momentum relates to the
rotational velocity of the body.

BASE OF SUPPORT
 the perimeter of the contact area
between the body and its support
surface;
 foot placement alters the BOS and
changes a person’s postural
stability.
 A wide stance Vs narrow BOS.

Limits of stability.
the sway boundaries in which an
individual can maintain equilibrium
without changing his or her BOS.

GROUND REACTION FORCE AND
CENTER OF PRESSURE
 the contact between our bodies and the ground
due to gravity (action forces) is always
accompanied by a reaction from it, the so-called
ground reaction force.
 The center of pressure (COP) is the location of the
vertical projection of the ground reaction force.
 It is equal and opposite to the weighted average of
all the downward forces acting on the area in
contact with the ground.

 COP – SINGLE FOOT Vs DOUBLE FOOT?
 To maintain stability, a person produces
muscular forces to continually control the
position of the COG, which in turn changes
the location of the COP.
 Thus the COP is a reflection of the body’s
neuromuscular responses to imbalances of
the COG.
 A force plate - to measure ground reaction
forces [in newtons (N)] and COP
movements [in meters (m)].

BALANCE CONTROL
 complex motor control task
 Involves
- the detection and integration of sensory
information to assess the position and
motion of the body in space
- execution of appropriate musculoskeletal
responses to control body position within
the context of the environment and task.
 Thus, balance control requires the
interaction of the nervous and
musculoskeletal systems and contextual
effects

ROLE OF NERVOUS SYSTEM
 The nervous system provides the
(1) sensory processing for perception of body
orientation in space provided mainly by the visual,
vestibular, and somatosensory systems;
(2) sensorimotor integration essential for linking
sensation to motor responses and for adaptive and
anticipatory (i.e., centrally programmed postural
adjustments that preceed voluntary movements)
aspects of postural control;
(3) motor strategies for planning, programming, and
executing balance responses.

MUSCULOSKELETAL
CONTRIBUTIONS
postural alignment,
 musculoskeletal flexibility such as
joint range of motion (ROM), joint
integrity, muscle performance (i.e.,
muscle strength, power, and
endurance),
sensation (touch, pressure, vibration,
proprioception, and kinesthesia).

CONTEXTUAL EFFECTS
 that interact with the two systems are the
environment whether it is,
 closed (predictable with no distractions)
 or open (unpredictable and with distractions),
 the support surface (i.e., firm versus slippery, stable
versus unstable, type of shoes)
 the amount of lighting,
 effects of gravity
 inertial forces on the body,
 task characteristics (i.e., well learned versus new,
predictable versus unpredictable, single versus
multiple tasks).

SENSORY SYSTEMS AND BALANCE
CONTROL
Visual System
 The visual system provides information regarding
(1) the position of the head relative to the environment;
(2) the orientation of the head to maintain level gaze
(3) the direction and speed of head movements.
 Visual stimuli - improve a person’s stability when
proprioceptive or vestibular inputs are unreliable.
 visual inputs sometimes provide inaccurate information for
balance control, such as when a person is stationary and a
large object such as a nearby bus starts moving, causing the
person to have an illusion of movement

SOMATOSENSORY SYSTEM
 provides information about the position and motion of the
body and body parts relative to each other and the support
surface.
 Information from
-muscle proprioceptors including muscle spindles and
Golgi tendon organs (sensitive to muscle length and
tension),
- joint receptors (sensitive to joint position, movement,
and stress),
-skin mechanoreceptors (sensitive to vibration, light touch,
deep pressure, skin stretch) are the dominant inputs for
maintaining balance when the support surface is firm, flat,
and fixed.

PERSON STANDING ON MOVING
SURFACE ?
JOINT PROPRIOCEPTORS?
SENSORY INPUTS?

VESTIBULAR SYSTEM
 provides information about,
 the position and movement of the
head with respect to gravity and
inertial forces.
 Receptors in the semicircular
canals (SCCs) detect angular
acceleration of the head,
 receptors in the otoliths (utricle
and saccule) detect linear
acceleration and head position
with respect to gravity.
 The SCCs - sensitive to fast head
movements, such as during
walking or during episodes of
imbalance (slips, trips, stumbles)
 otoliths respond to slow head
movements, such as during
postural sway.

VESTIBULAR SYSTEM
 By itself, the vestibular system can give no information about the
position of the body. For example, it cannot distinguish a simple head
nod (head movement on a stable trunk) from a forward bend (head
movement in conjunction with a moving trunk).
 mechanoreceptors in the neck + central nervous system (CNS) GIVE
true picture of the orientation of the head relative to the body.
 The vestibular system uses motor pathways originating from the
vestibular nuclei for postural control and coordination of eye and head
movements.
 The vestibulospinal reflex brings about postural changes to
compensate for tilts and movements of the body through
vestibulospinal tract
 The vestibulo-ocular reflex stabilizes vision during head and body
movements through projections from the vestibular nuclei to the
nuclei that innervate extraocular muscles.

SENSORY ORGANIZATION FOR
BALANCE CONTROL
 Incoming sensory information is integrated and processed in the
cerebellum, basal ganglia, and supplementary motor area.
 Somatosensory information has the fastest processing time for
rapid responses, followed by visual and vestibular inputs.
 When sensory inputs from one system are inaccurate owing to
environmental conditions or injuries that decrease the
information-processing rate, the CNS must suppress the
inaccurate input and select and combine the appropriate
sensory inputs from the other two systems.
 This adaptive process is called sensory organization. Most
individuals can compensate well if one of the three systems is
impaired; therefore, this concept is the basis for many treatment
programs.

Types of balance control
 (1) static balance control to maintain a stable
antigravity position while at rest such as when
standing and sitting;
 (2) dynamic balance control to stabilize the body when
the support surface is moving or when the body is
moving on a stable surface such as sit-to-stand
transfers or walking;
 (3) automatic postural reactions to maintain balance
in response to unexpected external perturbations,
such as standing on a bus that suddenly accelerates
forward.

 Feedforward, or open loop motor control-
Used in reactive responses) or for anticipatory aspects
of postural control. Doesnt rely on sensory feedback.
e.g,Like activation of postural muscles in advance of
performing skilled movements,activation of posterior
leg and back extensor muscles prior to a person
pulling on a handle when standing or planning how to
navigate to avoid obstacles in the environment.
 Closed loop control –
Utilized for precision movements that require sensory
feedback
(e.g., maintaining balance while sitting on a ball or
standing on a balance beam).

ROLE OF MOVEMENT SYSTEM FOR BALANCE
CONTROL FOLLOWING PERTUBATION.

Motor Strategies for Balance
Control

Ankle Strategy (Anteroposterior
Plane)
 In quiet stance and during small perturbations
 movements at the ankle act to restore a person’s COM
to a stable position
 For forward instability, muscle activation usually
proceeds in a distal to proximal sequence:
gastrocnemius activity begins, followed by the
hamstrings later, and finally paraspinal muscle
activation.
 In response to backward instability, muscle activity
begins in the anterior tibialis, followed by the
quadriceps and abdominal muscles.

Weight-Shift Strategy (Lateral
Plane)
 utilized to control mediolateral perturbations
 involves shifting the body weight(COM) laterally from
one leg to the other.
 key control points - HIP.
 activation of hip abductor and adductor muscles, with
some contribution from ankle invertors and evertors

SUSPENSION STRATERGY
 Observed when a person quickly lowers his or her
body COM by flexing the knees, causing associated
flexion of the ankles and hips.
 The suspension strategy can be combined with the
ankle or the weight-shift strategy to enhance the
effectiveness of a balance movement.

Hip Strategy
 For rapid and/or large external perturbations
 movements executed with the COG near the limits of
stability.
 The hip strategy uses rapid hip flexion or extension to
move the COM within the BOS.
 In response to a forward body sway, muscles are typically
activated in a proximal to distal sequence: Abdominals ,
followed by activation of the quadriceps.
 Backward body sway results in activation of paraspinals
followed by the hamstrings.
 A person cannot use the hip strategy to restore balance
while walking on slippery surfaces because the large
horizontal forces generated cause the feet to slip.

Stepping Strategy
 If a large force displaces the COM beyond the limits of
stability, a forward or backward step is used to enlarge
the BOS and regain balance control.
 The uncoordinated step that follows a stumble on
uneven ground is an example of a stepping strategy.

Combined Strategies
 Research - movement response patterns to postural
perturbations are more complex and variable.
 Most healthy individuals use combinations of strategies to
maintain balance depending on the control demands.
 Balance control requirements vary depending on the task
and the environment. For example, standing on a bus that
is moving has higher control demands than standing on a
fixed surface.
 Therefore, it is important during treatment of balance
disorders to vary the task and environment so the person
develops movement strategies for different situations.

CAUSES OF IMPAIRED BALANCE
 injury or disease to any structures involved in the three
stages of information processing (i.e., sensory input,
sensorimotor integration, motor output generation).

Sensory Input Impairments
 Proprioceptive deficits following lower extremity and
trunk injuries or pathologies.
 Decreased joint position sense has been reported in
individuals with recurrent ankle sprains,knee
ligamentous injuries,degenerative joint disease,and
low back pain.
 Reduced somatosensation in the lower extremities
caused by peripheral polyneuropathies in the aged and
in individuals with diabetes impair balance and
increase risk for falls.
 These individuals tend to rely more heavily on a hip
strategy to maintain balance .

 Visual loss or specific deficits in acuity, contrast
sensitivity, peripheral field vision, and depth
perception caused by disease, trauma, or aging can
impair balance and lead to falls.
 damage to the vestibular system due to viral infections,
traumatic brain injury (TBI), or aging may experience
vertigo (a feeling of spinning) and postural instability

Sensorimotor Integration
 Damage to the basal ganglia, cerebellum, or
supplementary motor area - disruption of
anticipatory and reactive postural adjustments.
 Individuals who rely heavily on visual inputs (visually
dependent) or somatosensory inputs (surface
dependent) become unstable or fall under conditions
where the preferred sense is either absent or
inaccurate

Motor Output Deficits
 musculoskeletal (i.e., poor posture, joint ROM
limitations, decreased muscle performance) and/or
neuromuscular system (i.e., impaired motor
coordination, pain)
 Postural malalignment, such as the typical thoracic
kyphosis of the elderly.
 For example, restriction of ankle motion or ankle
dorsiflexor weakness eliminates ankle strategy,
resulting in increased hip and trunk muscles for
balance control
 neurological conditions (e.g., stroke, traumatic brain
injury, Parkinson’s disease) - abnormal tone, or
impaired coordination of motor strategies ,

Deficits with Aging
 Declines in all sensory systems (somatosensory, vision,
vestibular) and all three stages of information
processing (i.e., sensory processing, sensorimotor
integration, motor output)
 older adults have more difficulty maintaining balance
when sensory inputs from more than one system are
greatly reduced, particularly when they must rely
solely on vestibular inputs for balance control

 older adults have demonstrated -
 Slower-onset latencies.
 More frequent use of a hip strategy for balance control.
 Limitations in the ability to maintain balance when
challenged with perturbations of increasing
magnitude and velocity.

Deficits from Medications
 certain medications (i.e., hypnotics, sedatives,
tricyclic antidepressants, tranquilizers,
antihypertensive drugs) due to dizziness or other side
effects

EXAMINATION AND
EVALUATION OF
IMPAIRED BALANCE

history of fall - sudden versus gradual;
the frequency and direction of falls
the environmental conditions,
activities, and
presence of dizziness, vertigo
current and past medications;
 presence of fear of falling)

Assessments to identify
 sensory input (proprioceptive, visual,
vestibular), sensory processing
(sensorimotor integration, anticipatory and
reactive balance control), and
biomechanical and motor (postural
alignment, muscle strength and endurance,
joint ROM and flexibility, motor
coordination, pain
 functional performance
 Environmental assessments to determine
fall risk hazards in a person’s home.

ACTIVITIES OF TREATING
IMPAIRED BALANCE
 Impaired balance can be treated by foll
ways:
 1. Gradual intervention (mode)
 2. Posture for COG control
 3. Movement

MODE-GRADUATED
INTERVENTION
 Begin with weight shifts on a stable
surface.
 Gradually increases sway
 Increase surface challenges (mini-tramp)

POSTURE
 Often includes “core stability training” to
improve COG control and sense of trunk
posture.
 Begin in supine or seated position.
 Over sessions, use a variety of arm
positions, unstable surfaces, single leg
stances etc.

 1. Use a gait belt - practices exercises or activities that
challenge or destabilize balance.
 2. Stand slightly behind and to the side of the patient
with one arm holding or near the gait belt and the
other arm on or near the top of the shoulder (on the
trunk, not the arm).
 3. Perform exercises near a railing or in parallel bars to
allow patient to grab when necessary.
 4. Do not perform exercises near sharp edges of
equipment or objects.
Safety During Balance Exercises

 5. Have one person in front and one behind when
working with patients at high risk of falling or during
activities that pose a high risk of injury.
 6. Check equipment to ensure that it is operating
correctly.
 7. Guard patient when getting on and off equipment
(such as treadmills and stationary bikes).
 8. Ensure that the floor is clean and free of debris

Safety During Gait, Locomotion, or
Balance
 To emphasize safety - practice postural sway
activities within the person’s actual stability
limits and progress dynamic activities with
emphasis on promoting function.
 If balance deficits cannot be changed,
environmental modifications, assistive
devices, and increased family or external
support may be required to ensure safety

Static Balance Control Activities
 include having the patient maintain sitting, half-kneeling,
tall kneeling, and standing postures on a firm surface.
 More challenging activities include practice in the tandem
and single-leg stance (, lunge, and squat positions.
 Progress these activities by working on soft surfaces (e.g.,
foam, sand, grass), narrowing the base of support, moving
the arms, or closing the eyes.
 Provide resistance via handheld weights or elastic
resistance.
 Add a secondary task (i.e., catching a ball or mental
calculations) to further increase the level of difficulty

Dynamic Balance Control
 To promote dynamic balance control, interventions
may involve the following.
 Have the patient maintain equal weight distribution
and upright trunk postural alignment while on moving
surfaces, such as sitting on a therapeutic ball, standing
on wobble boards , or bouncing on a minitrampoline

 Progress the activities by superimposing movements
such as shifting the body weight, rotating the trunk,
moving the head or arms.
 Vary the position of the arms from out to the side to
above the head

 Practice stepping exercises starting with small steps,
then mini-lunges, to full lunges.
 Progress the exercise program to include hopping,
skipping, rope jumping, and hopping down from small
stool while maintaining balance,
 Have the patient perform arm and leg exercises while
standing with normal stance, tandem stance, and
single leg stance

Anticipatory Balance Control
 Reach in all directions to touch or grasp objects,
catching a ball, or kicking a ball.
 Use different postures for variation (e.g., sitting,
standing, kneeling) and throwing or rolling the ball at
different speeds and heights.
 Use functional tasks .
Ex. Using multiple parts of the body, having the
patient lift objects of varying weight in different
postures at varying speeds,
Ex. open and close doors with different handles and
heaviness, or maneuver through an obstacle course.

Reactive Balance Control
 gradually increase the amount of sway when standing
in different directions on a firm stable surface.
 To emphasize training of the ankle strategy, have
the patient practice while standing on one leg with the
trunk erect.
 To emphasize training of the hip strategy, have the
patient walk on balance beams or lines drawn on the
floor; perform tandem stance and single-leg stance
with trunk bending; stand on a mini-trampoline,
rocker balance, or sliding board

 To emphasize the stepping strategy, have the patient
practice stepping up onto a stool or stepping with legs
crossed in front or behind other leg (e.g., weaving or
braiding).
 To increase the challenge during these activities, add
anticipated and unanticipated external forces.
 For example, have the patient lift boxes that are
identical in appearance but of different weights; throw
and catch balls of different weights and sizes; or while
on a treadmill, suddenly stop/start the belt or
increase/decrease the speed.

Sensory Organization
 To reduce or destabilize the visual inputs,
have the patient close the eyes, wear prism
glasses, or move the eyes and head together
during the balance activity.
 To decrease reliance on somatosensory cues,
patients can narrow the BOS, stand on
foam, or stand on an incline board.

Balance During Functional
Activities
 focus on activities similar to the functional limitations
identified in the evaluation.
 For example, if reaching is limited, the patient should
work on activities such as reaching for a glass in a
cupboard, reaching behind (as putting arm in a
sleeve), or catching a ball off center.
 Having the patient perform two or more tasks
simultaneously increases the level of task complexity.
 Practicing recreational activities the patient enjoys,
such as golf, increases motivation for practice while
challenging balance control

Exercises for Elderly with Low
Physical Functioning
Exercises While Sitting in a Chair
Set 1 (for the lower extremities) Extend leg up
then back down
 Raise up and down on toes then heels
 March in place
 Bring leg out to the side then back to the
middle
 Bring leg back toward the chair then
forward again

Set 2 (for the upper extremities)
 Bend arms towards shoulders then back down
again
 Push arms out away from chest then back again
 Push arms up from shoulders then back down
again
 Raise shoulders up toward ears then back down
again
 Roll shoulders forward then backward
 Raise arm to shoulder level and extend forearm
upward toward ceiling then back down again
 Bring elbows in then back out from chest

Standing Exercises for Balance
 Bring leg in toward the middle then back
out again
 Rise up and down on heels and then toes
 March in place
 Keeping the trunk and hip straight, bend leg
toward buttocks then back down
 Squat down by bending at the knees and
keeping back straight

 Kick leg straight back behind body while
not bending the knee
 Kick leg in front of body while not bending
the knee
 Lunge leg out to the side then back toward
the middle again
 Lunge leg in back of the body then toward
the front again
 Practice standing on one leg, then the other,
without holding onto the counter

Multisystem Program
Incorporating a Circuit of Activities
Tai chi exercises

PRECAUTIONS FOR BALANCE
EXS
 Pain should not occur during exercises.
 Do not initiate exercises at maximum level.
 Avoid uncontrolled, ballistic movements as
they compromise safety & effectiveness.
 Avoid exercises that creates stress on back.
 Discontinues exercises if patient experiences
pain, dizziness or unusual shortness of breath.
 Eliminate obstacles or unsafe instruments from
exercise area.

CONTAINDICATONS
 Persons who are inheritently in balance-
challenged positions.
 Pain or muscle pain.
 Inflammatory neuromuscular disease.
 Severe cardio-pulmonary diseases.

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