Postural control is the ability to maintain our body in space achieving both

goals of stability and orientation [1]. through the process of rehabilitation, we

aim to train patients on various tasks according to their activity limitations
and participation restrictions to achieve independence in their daily activities
and this independence can be achieved only when we put the various factors
affecting each postural task into consideration
Balance  emerges from the interaction of the individual, the task, and the
environment; Functional tasks require three types of balance control, steady-
state, reactive, and proactive. Environmental constraints such as type of
support surface, sensory cues, and cognitive demands. Individual variations
such as motor, sensory and cognitive abilities. Also, impact the control of
balance.
Activates of daily living require 3 types of balance control :

1. Steady-state balance is the ability to control our balance in fairly

predictable and nonchanging conditions.
2. Reactive balance control is the ability to recover a stable position
following an unexpected perturbation.
3. Proactive or anticipatory balance is the ability to activate muscles
in the legs and trunk for balance control in advance of potentially
destabilizing voluntary movements.

Reactive balance control relies on feedback mechanisms; on the other hand,

proactive balance utilizes the feedforward mechanisms. Feedback
control refers to postural control that occurs in response to sensory feedback
from an external perturbation by ⠀⠀the postural control system⠀⠀ the
postural control system  from an external perturbation. Feedforward
control refers to anticipatory postural adjustments that are made ahead of a
voluntary movement that is potentially destabilizing to maintain stability
during the movement.

Most functional tasks require all three aspects of balance control. For
example, reaching for a heavy object while standing requires steady-state
balance to maintain a stable position before reaching for the object,
anticipatory balance control to prevent loss of stability during the reach and
lift, reactive balance control if the object is heavier than expected, and lifting
it causes us to lose balance, and after that steady-state balance again after the
completion of the task.
Steady-state balance

stability required for tasks like sitting or standing is called "static balance" but
when we examine the amount of postural sway during these tasks and how
our center of mass is controlled within the base of support despite it, we can
see how steady-state balance, in this case, can be quite dynamic

Several factors contribute to our ability to maintain steady-state

stability

1. Alignment of the body can minimize the effect of gravitational forces

that tend to pull us off-center.
2. Postural tone to counteract the force of gravity the activity of the
antigravity muscles increases during upright standing. Sensory inputs
from the postural control system  are critical to postural tone.
Researchers have found that many muscles in the body are active during
a quiet stance including
1. the soleus and gastrocnemius , because the line of gravity falls
slightly in front of the knee and ankle.
2. the tibialis anterior, when the body sways in the backward
direction
3. Gluteus Medius  and tensor fasciae latae  but not the gluteus
maximus
4. the iliopsoas , which prevents hyperextension of the hips, but not
the hamstrings  and quadriceps
5. the thoracic erector spinae  in the trunk (along with intermittent
activation of the abdominals), because the line of gravity falls in
front of the spinal column. [3]
3. Movement strategies are not enough because both quiet stance and
sitting are characterized by body sway, passive skeletal alignment, and
postural tone; rather, movement strategies are needed to maintain
stability even when standing or sitting quietly. for this we use one of two
strategies during steady-state balance control; the hip strategy and the
ankle strategy[4]

Clinical tests and measures that examine a patient's ability to sit or stand
independently, such as the Berg Balance Scale  (BBS), are examining steady-
state balance.

Reactive Balance Control

Movement strategies used to recover stability in response to brief
displacements can be categorized into two categories:

1. Fixed support strategies the previously mentioned ankle and hip

strategy
2. Change in support strategies the step strategy and the reach to
grasp strategy.

Movement patterns used to recover stability following perturbations are

selected by the central nervous system (CNS) based on several factors, such as
characteristics of the perturbation (e.g., direction and magnitude).

In both standing and sitting most of the postural sway occurs in the
Anteroposterior direction, so here are some examples of muscle
activity patterns (synergies) used to maintain Anteroposterior
stability

1. Ankle strategy restores stability through body movement centered

primarily on the ankle joint. Activation of the gastrocnemius produces a
plantarflexion torque that slows and then reverses, the body's forward
motion. Activation of the hamstrings and paraspinal muscles maintains
the hip and knees in an extended position. Without the synergistic
activation of the hamstrings and paraspinal muscles, the indirect effect
of the gastrocnemius ankle torque on proximal body segments would
result in the forward motion of the trunk mass relative to the lower
extremities. It appears to be used most commonly in situations in which
the perturbation to equilibrium is small and the support surface is firm.
[2]

2. Hip strategy This strategy controls motion by producing large and

rapid motion at the hip joints, the hip strategy is used to restore
equilibrium in response to larger, faster perturbations or when the
support surface is compliant or smaller than the feet
3. Step strategy A step strategy realigns the base of support under the
falling center of mass by placing the feet in the direction of the
perturbation
4. Reach to grasp strategy relies on extending the BOS by using the
arms to grasp an external object for stability.

Research has demonstrated that during recovery of stability, we continuously

change and add multiple synergies, depending on the context of the task at
hand. This suggests that when retraining balance, it will be important not to
limit training to the activation of a single strategy (e.g., ankle vs. hip vs. step
vs. reach) but to create conditions in which strategies are continuously
modulated. For example, The use of an ankle strategy (legs and trunk moving
in-phase) is predominant when standing on a firm surface; however, there is a
shift to using a hip strategy (legs and trunk out of phase) when standing on a
foam surface [5]

reactive balance control can be tested by various tests that aim to challenge
[6]

the patient to regain balance after a challenging task, the following videos are
an example of such tests

Environmental Constraints

Changes in support surfaces affect the organization of muscles and forces

needed for balance as we previously mentioned. Differences in visual and
surface conditions affect the way sensory information is used for balance
control. Finally, daily life often requires that we perform multiple tasks,
affecting the way cognitive systems like attention are used for balance and
adding more cognitive load to the task at hand. [2]

Summary

 Postural control emerges from the interaction between the task, the
individual, and the environment
 Tasks can demand more than one form of control0; steady-state,
proactive, or reactive
 Steady-state control is needed when we want to maintain balance in
predictable and nonchanging conditions
 proactive postural control is needed to get our bodies ready to maintain
our balance during a predictably destabilizing task
 reactive postural control is needed to maintain our balance in response
to an unexpected perturbation
 Reactive postural control is achieved by using the feedback mechanism,
while proactive postural control is using the feedforward mechanism.
 the environmental conditions at which the task is performed such as the
differences in visual and surface conditions, and cognitive load.

Introduction
Postural control is a term used to describe the way our central nervous
system (CNS) regulates sensory information from other systems in order to
produce adequate motor output to maintain a controlled, upright posture. The
visual, vestibular, and somatosensory systems are the main sensory systems
involved in postural control and balance [1][2].

 Postural orientation and equilibrium are two main functional goals of

postural control [3].
 Postural orientation is the ability to maintain an appropriate
relationship between body parts (alignment) and between the body and
the environment (using multiple sensory inputs) for the purpose of
performing a certain task [4].
 The coordination of sensorimotor strategies to stabilise the body’s
center of mass during both self-initiated and externally triggered stimuli
constitutes postural equilibrium [5].
 Postural equilibrium and Postural orientation are different but also can
be interdependent. for example patients with camptocormia
(involuntary forward flexion of the hips) can have excellent control over
their center of mass (postural equilibrium). in contrast, other patients
can have excellent postural orientation in terms of alignment and
multisensory orientation to the external environment and still be at risk
of falling due to poor postural control. they also can be interdependent
as studies have shown that a flexed postural orientation of the legs and
trunk compromises the ability to recover equilibrium in response to
perturbations[4].

Proper postural control is when an individual is able to engage in various

static and dynamic activities, such as sitting, standing, kneeling, quadruped,
crawling, walking, and running with the ability to contract the appropriate
muscles required for a controlled midline posture, as well as the ability to
make small adjustments in response to changes in position and movement,
without the use of compensatory motions.  

If even one of the three abovementioned systems is not working the way it is
supposed to, it can affect postural control and balance.  However, when one
system is affected the other two can be trained to compensate.  If more than
one system is affected in combination with CNS involvement, postural control
will be more greatly affected. For example, a study published in 2021 found
that persons with a history of a concussion responded more strongly to visual
and vestibular stimuli during upright stance than the control ground (no
history of a concussion). This suggests persons with a history of concussion
may have abnormal dependence on visual and or vestibular feedback. The
study found no differences related to somatosensory feedback. These findings
may help guide targeted rehabilitation interventions. [6]

There are important reflexes involved in postural control known as the

Cervicocollic Reflex (CCR), the Vestibulo-ocular reflex (VOR) and the
Vestibulospinal Reflex (VSR) that work in conjunction with the vestibular
nuclei and cerebellum, discussed in the last module (The vestibular system).
The visual, vestibular and somatosensory are our three balance systems which
are closely linked to control posture.

The Visual System

The visual system is the primary receiver of sensory information to maintain
postural balance, and as such our postural stability increases with the
improvement of the visual environment. The vestibular system is poor at
detecting very slow rotational movements, at speeds <0.1 Hz. Therefore the
visual system will often compensate for dysfunction of the vestibular system. [7]

Rehabilitation interventions which adjust the sensory contributions to

balance control system is referred to as sensory reweighting. [8]
Figure 1: Flow diagram of classification of eye movement systems [9]

There are two functional classes of eye movements: those that stabilize the eye
when the head moves or appears to move (gaze stabilization) and those that
keep the image of a visual target focused on the fovea of the eye when the
visual target changes or moves (gaze shifting).

Gaze Stabilization

Two gaze stabilization systems operate during head movement, namely the
vestibulo-ocular [10] and the optokinetic systems. For gaze stabilisation to be
effective there are conjugate movements in which both eyes move in the same
direction.

Gaze Shifting
Three gaze shifting systems function to focus the image on the fovea.

 Smooth pursuit uses the eyes to track the movement of a visual target.
Essentially, it enables us to stabilise the image of this moving target
on / near the fovea. [11] Pursuit movements are described to be voluntary,
smooth, continuous, conjugate eye movements with velocity and
trajectory determined by the moving visual target.
 Vergence alters the angle between the two eyes to adjust for changes in
distance from the visual target. Accommodation is the mechanism by
which the eye changes focus from distant to near images. When shifting
one's view from a distant object to a nearby object, the eyes converge
(are directed nasally) to keep the object's image focused on the foveae of
the two eyes.
 Saccades consist of short, rapid, jerky (ballistic) movements of
predetermined trajectory that direct the eyes toward some visual target.
Eye movements are initiated to bring an object-of-interest into view.

 The Vestibular System

 The vestibular system  helps regulate body posture and eye
position [12] and, orientates the trunk to vertical using sensory orientation
and weighting appropriate sensory cues under different sensory
environments, for example, the patient stands on an inclined surface, or
on foam, or with their eyes closed. It also controls the body’s centre of
mass (COM) both for static and dynamic positions via postural
responses (patient stands or walks on a beam) and stabilises the head
during postural movements vis-à-vis the patient leans or is tilted.
 The Somatosensory System
 The somatosensory system is a complex system of sensory neurons and
pathways that responds to changes at the surface or inside the body. It
is also involved in maintaining postural balance by relaying information
about body position to the brain, allowing it to activate the appropriate
motor response or movement. 
 Somatosensory input is the primary source of sensory input to maintain
balance in healthy adults. The somatosensory system plays a role vital
in balance and postural control by integrating into the central nervous
system with the purpose of producing motor responses and maintaining
balance. Changes in sensory systems may lead to disturbances in the
balance and postural control. [13]
 Mechanoreceptors are specific sensory receptors located in the muscle
spindles. They provide the nervous system with information about the
muscle’s length and velocity of contraction, thus contributing to the
 individual’s ability to discern joint movement and position sense [14]. The
muscle spindles also provide afferent feedback that can be translated
into appropriate reflexive and voluntary movements [15].
 A very high amount of mechanoreceptors in muscle spindles are found
in the suboccipital area, and are responsible for receiving and sending
information to and from the CNS [16]. Mechanoreceptor impulses from the
occiput to C3 (particulary upper cervical spine muscles) have direct
access to vestibular nuclear complex (VNC) - a reflex centre that
coordinates vision and neck movement.This same mechanoreceptor
input also converges on the central cervical nucleus (CCN). The CCN is
effectively a pathway to the cerebellum that integrates vestibular, ocular
and proprioceptive information.The VNC also connects with the CCN,
so there are interrelated pathways between all the systems. In a
nutshell, mechanoreceptor input from the upper cervical region helps to
coordinate vision, balance and movement of the neck [16] for effective
postural control.
 More sensorimotor dysfunction occurs with injury or whiplash
associated disorders (WAD)  to the upper cervical region than the lower
cervical region because the upper region contains more muscle spindles,
has a greater connection to the visual and vestibular systems, and more
reflex activity[16][17].
 For a more in depth analysis and understanding of the role of
sensorimotor impairment in neck pain, please see  Chris Worsfold’s
course on Sensorimotor integration .
 Summary
 The vestibular system, somatosensory system and visual system do not
act in isolation but are a complex postural control system that work
together to achieve balance. 
 Postural stability happens with good sensorimotor integration between
the upper cervical spine, visual and vestibular structures. Poor postural
control occurs if there is a sensory mismatch, in other words the CNS is
unable to distinguish between accurate and inaccurate sensory
information from one or more of these systems, resulting in feelings of
dizziness/unsteadiness/poor balance [16], and disruption in predictive
timing of sensory input [18][19].
 These patients often complain of headaches, dizziness, blurry vision,
frontal headaches, eye strain and balance problems. These patients
often have difficulty reading (horizontal deficits), they become
headachey/dizzy when looking up at the board and down at the desk
during note-taking (vertical deficits). These patients can also experience
neck pain, as they may have an increase in muscle activity/stiffness as
the body tries to compensate for a loss of balance [16]. They can even be
symptomatic while running and trying to focus on a target such as a
 ball. Some patients complain of feeling disoriented/overwhelmed when
driving in an unfamiliar city, driving in tunnels or pushing a trolley in
the grocery aisles.


 Figure 2: The complex interactions of the Postural Control System

(www.semanticscholar.org accessed 7/9/2019)

  Mancini M, Nutt JG, Horak FB. How is balance controlled by the

nervous system. Balance Dysfunction in Parkinson&s Disease , Nutt JG,
Horak FB, eds. Academic Press/Elsevier. 2020:1-24.
 ↑ Jump up to:2.0 2.1 2.2 2.3 Shumway-Cook A, Wollacott M. Motor control:
translating research to practice. Lippincott Williams and Wilkins,
Philidelphia USA. 2016.
 ↑ Basmajian JV. Muscles alive. Their functions revealed by
electromyography. Academic Medicine. 1962 Aug 1;37(8):802.
 ↑ Creath R, Kiemel T, Horak F, Peterka R, Jeka J. A unified view of quiet
and perturbed stance: simultaneous co-existing excitable modes .
Neuroscience letters. 2005 Mar 29;377(2):75-80.
 ↑ Runge CF, Shupert CL, Horak FB, Zajac FE. Ankle and hip postural
strategies defined by joint torques . Gait & posture. 1999 Oct 1;10(2):161-
70.
 ↑ PaulPotterPT. Berg Balance Test. Available
from: http://www.youtube.com/watch?v=babsE0f8Hys
 ↑ Catalyst University. Reactive Postural Adjustments | Strategies For
Maintaining Balance. Available from: http://www.youtube.com/watch?
v=m678T_r62G
 ↑ Dr. Dania Qutishat. Reactive Postural Control Test/ Pushes (External
perturbations). Available from: http://www.youtube.com/watch?
v=2BxJKgrByfU