Balance deficits One of the most common problems treated by physical therapists Are thought to be common after stroke,

e, and they have been implicated in the poor recovery of activities of daily living (ADL) and mobility and an increased risk of falls Balance - The ability to maintain the bodys center of gravity over its base of support with minimal sway or maximal steadiness - A complex process involving the reception and organization of sensory inputs and the planning and execution of movement to achieve a goal requiring upright posture - Is the set of functions which maintains mans upright during stance and locomotion by detecting and correcting displacement of the line of gravity beyond the BOS Postural control involves controlling he bodys position in space for the dual purposes of stability and orientation Postural orientation the control of relative positions of the body parts by skeletal muscles with respect to gravity and each other Postural stability the condition which all the forces acting on the body are balanced such that the center of mass (COM) is with in the stability limits or boundaries of BOS Normal anterior/posterior sway -12 degrees from most posterior-anterior position Lateral sway 16 degrees side to side Static balance BOS remains stationary and only the body center of mass (COM) moves. The balance task in this case is to maintain the COM within the BOS or the limit of stability (the maximal estimated sway angle of the COM)

Maintaining a stable antigravity position while at rest such as when standing and sitting

Automatic postural reactions maintaining balance in response to unexpected external perturbations, such as standing on a bus that suddenly accelerates forward. Dynamic balance maintaining balance when a person is moving from point A to point B, where both the BOS and COM are moving, and the COM is never kept within the BOS Is stabilizing 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 Reactive control in response to external forces (perturbation) Proactive control in anticipation of internal forces imposed on the bodys own movements Systems model Balance controls is very complex and involves many different underlying systems Postural control results from a set of interacting systems

Musculoskeletal Joint ROM Spinal flexibility Muscle properties Biomechanical relationships among linked body segments Body schema Reactive mechanisms Anticipatory mechanisms (internal) Proactive mechanisms (external) Sensory systems Neuromuscular synergies

Neural components Motor processes (neuromuscular response synergies) Sensory processes (visual, vestibular, and somatosensory) Higher lvel integrative processes - Mapping sensation to action - Ensuring anticipatory and adaptive aspects of postural control Adaptive vs. Anticipatory Adaptive postural control - Involves modifying sensory and motor systems in response to changing task and environmental demands Anticipatory postural control - Involves preparing the sensory and motor systems for postural demands based on previous experience and learning Factors that contribute to stability Body alignment - Minimize the effect of gravitational forces, which tends to pull of Muscle tone Postural tone Standing alignment - Head balanced on level shoulders - Upper body erect, shoulders over hips - Hips in front of ankles - Feet few cm (10 cm) apart Sitting alignment - Head balanced on level shoulders - Upper body erect - Shoulders over hips - Feet and knees a few cm apart Muscle tone The force with which a muscle resists being lengthened Keeps the body from collapsing in response the pull of gravity

Postural tone Increased level of activity in antigravity muscles Activation of antigravity muscles during quiet stance Muscles that are tonically active during quiet stance: gastrocsoleus, tibialis anterior, gluteus medius, TFL, ilipsas, and erector spinae Ankle strategy Used when displacements are small Displaces COG by rotation about the ankle joint Posterior displacement of COG Anterior COG displacement Employed when ankle motion is limited, displacement is greater, when standing on unstable surface that disallows ankle strategy Preferred when perturbation is rapid and near limits of stability Post. Displacement COG backward sway, activation of paraspinals then hamstrings Ant displacement COG forward sway, activation of abdominal then quadriceps muscles Stepping strategy If displacement is large enough, a forward or backward step is used to regain postural control Sensory processes The maintenance of balance is based on an intrinsic cooperation between the Vestibular system Proprioceptive Vision - Postural control does not only depends on the integrity of the systems but also on the sensory integration with in the CNS, visual and spatial perception Visual inputs Provides information regarding:

The position of the head relative to the environment The orientation of the head to maintain level gaze The direction and speed of head movements because as your head moves, surrounding objects move in the opposite direction Provide a reference for vertically Visual stimuli can be used to improve a persons stability when proprioceptive or vestibular inputs are unreliable by fixating the gaze on an object

Sensitive to fast head movments (those that occur during gait or imbalance such as slips, trips, and stumbles)

Otolith organs Signal linear position and acceleration Source of information about head position with respect to gravity Respond to slow head movements (those that occur during postural sway) Sensory organization Vestibular, visual, and somatosensory inputs are normally combines seamlessly to produce our sense of orientation and movement 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 the CNS must suppress the inaccurate in put and slect and combine the appropriate sensory inputs from the other two systems Motor control model Individual, task, environment Causes of balance impairments Injury or diseases of the structures (e.g. eyes, inner ear, peripheral receptors, spinal cord, cerebellum, basal ganlia, cerebrum) Damage to proprioceptors Injury to or pathology of hip, knee, ankle, and back have been associated with increases postural sway and decreased balance Lesions produced by tumor, CVA, or other insults that often produced visual field losses

No Since most individuals can keep their balance when vision is occluded In addition, visual inputs are not always an accurate source of orientation information about self motion Visual system has difficulty distinguishing between object motion, referred to as exocentric motion, and self motion, referred to as egocentric motion

Somatosensory inputs... Provides the CNS with position and motion information about the body with reference to supporting surfaces Report information about the relationship of body segments to one another Receptors: muscle spindles, golgi tendon Vestibular inputs... A powerful source of information for postural control Provides the CNS with information about the position and movement of the head with respect to gravity and intertial forces Semicircular canal Sense angular acceleration of the head

Following a stroke Patients with muscle weakness and poor control lack effective anticipatory, onging, and reactive postural adjustments and therefore experience difficulty in: - Supporting the body mass over the paretic lower limb - Voluntarily moving the body mass from one lower limb to another - Responding rapidly to predicted and unpredicted threats to balance Spatiotemporal adaptations Changing the base of support Restricting movement of body mass Using hands for support Changing the base of support Wide BOS Shuffling feet with inappropriate stepping Shifting on the stronger leg Restricting movement of body mass Stiffening the body with altered segmental alignment Moving slowly Changing segmental alignment to avoid large shifts in COG - Standing reaching forward (flexing at ips instead of dorsiflexing ankles) - Standing reaching sideways (flexing trunk sidewas instead of moving body laterally at hips and feet) - Sitting reaching sideways (flexing forward instead of to the side) - In standing (not taking a step when necessary) Using the hands for support Holding on to support Grabbing Guidelines

Balance cannot be trained in isolation from the actions which must be relearned. In training walking, standing up and sitting down, reaching and manipulation... postural adjustments are also trained, since acquiring skill involves in large part the fine tuning of postural and balance control Postural adjustments are specific to each action and the conditions under which it occurs It cannot be assumed that practice of one action will transfer automatically into improved performance in another

Guidelines Progressive complexity is added by increasing the difficulty under which goals must be achieved, keeping in mind the various complex situations in which the patients will find themselves in the environment in which they live, both inside and outside their homes, and the precarious nature of balance As control over balance and confidence improves, tasks are introduced which require a stepping response, and responses to external constraints such as catching a thrown object and standing on a moving support surface Use a gait belt any time the patient practices exercises or activities that challenge or destabilize balance 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). Perform exercises near a railing or in parallel bars to allow patient to grab when necessary Do not perform exercises near sharp edges of equipment or objects Have on 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. Check equipment to ensure that it is operating correctly Guard patient when getting on and off equipment (such as treadmills and stationary bikes) Ensure that the floor is clean and free of debris

Trunk rotations and altered head positions alter vestibular input Stepping back/forward assists in restabilization exercises

Techniques to improve balance A variety of mode can be used to treat balance impairment Begin with weight shifts on a stable surface Gradually increase sway Increase surface challenges (mini tramp etc.) Rehabilitation balls, foam rollers, foam surfaces are often used to Provide uneven or unstable surface for exercise Sitting balance, trunk stability, and weight distribution can be trained on a chair, table, or therapeutic ball Pool is an ideal place for training balance Awareness of posture and the position of the body in space is fundamental to balance training Begin in supine or seated position Over sessions, use a variety of arm positions Unstable surfaces, single leg stances, etc Training both static posture and dynamic posture Mirrors can provide postural feedback visual feedback

Progression From simple to complex involves - BOS: advance from wide to narrow base - Posture: stable to unstable posture (sway) - Visual: closing of the eyes - COG: greater disruption to elicit hip or stepping strategy Progress to more dynamic activities, unstable surfaces, and complex movement patterns Frequency, intensity, and duration Specific techniques Bobath Normal postural activity forms necessary background for normal movement and for functional skills Flaccid stage balance exercises in sitting Stage of spasticity practice symmetrical weight bearing in standing, weight shifting, bending of knees and hips PNF techniques For stability Combination of isotonics Stabilizing reversals Rhythmic stabilization Motor relearning program Analysis of task - Individual - Task - Environment Practice of missing components - Strategy training - Impairment and strategy level Practice of whole task - Functional level

Movement - Adding movement patterns to acquired stable static postures increases balance challenge - Add ant./post. Sway to increase stability limits

Transference of learning

Static balance Vary postures Vary support surface Incorporate external loads Dynamic balance Moving support surfaces Move head, trunk, arms, legs Transitional and locomotor activities Anticipatory (feedforward) Reaching Catching Kicking Lifting Obstacle course Reactive (feedback) Standing sway Ankle strategy Hip strategy Stepping strategy Perturbations Sensory organization Reduce visual inputs Reduce somatosensory cues Sitting balance Acute stage post stroke Head and trunk movements Reaching actions To progress: Increasing distance to be reached Varying speed Reducing thigh support Increasing object weight and size to involve both upper limbs Adding an external timing constraint such as catching or bouncing a ball Standing balance Head and body movements

Reaching actions Single limb support Sideways walking Picking up objects

Paediatrics The following main aspects should be developed: Antigravity support or weight bearing on the feet Postural fixation of the head on the trunk and on the pelvis in the vertical Counterposing Control of anteroposterior weight shift of the childs COG Control of lateral sway from one foot to the other Tilt reactions in standing Saving from falling (strategies) Training should neck: Equal distribution of weight on each foot Correction of abnormal postures Building up of the childs stability by decreasing support Delay training in standing and walking if the child is not ready Weight shift leading to stepping Training lateral sway Training on different surfaces Define balance Assignment: Red kisners chapter 8: exercise for impaired balance, to enhance learning on this topic