Balance and

and Falls
Falls
Balance
Nancy V. Karp, Ed.D., P.T.
Nvkarp@gmail.com

Normal Postural Control

Postural control involves controlling the
bodys position in space for:
Stability
Orientation

Falls

Falls in the elderly are a major cause of:

morbidity
Mortality

The underlying causes of falls is a complex

interaction of:

Biomedical factors
Physiological factors
Psychosocial factors
Environmental factors

Incidence and Cost of Falls in the

Elderly

Falls of people 65+

One third of people 65+ fall each year.

Elders > 75 account for 60% of fall-related deaths.
25% of elders who fracture their hip in a fall will die
within a year.

Costs

Falls account for 70% of all injury-related costs for

the elderly,
The average cost for a fall injury is $20,000.

Falls in the Elderly

Most falls result in minor or no injury.

Repeat fallers tend to fall in the same manner as

they did in the previous fall.

A single fall results in:

Fear of falling and loss of confidence

Restriction in activities
Social isolation
Dependence on others

Identification of Fall Risk Factors

Risk factors for falls are divided into two categories:

Intrinsic Risk Factors

Dizziness, weakness, gait abnormalities, poor balance,
confusion, poor coordination, ROM, cognitive impairment

Extrinsic Risk Factors

Floor surface, poor lighting, cluttered furniture, obstacles,
non-level surface, poor shoes

Falls are a result of loss of

postural control.

Normal Postural Control

(Balance)

Balance requires keeping the Center of Mass

(COM) over the Base of Support (BOS) during
static and dynamic situations.
Neural components of postural control:

Sensory processes
visual, vestibular, somatosensory

Central processing
a higher-level integrative process

Effector component

sometimes referred to as the neuromuscular component

postural alignment, ROM, muscle force, power & endurance

Normal Postural Control

Adaptive postural control requires
modifying sensory and motor systems
to changing tasks and environmental
demands.

Postural Control During Quiet

Stance

Body aligned to minimize the effect of gravitational forces.

Muscle tone

Postural tone

Quiet Stance

Limits of Stability (LOS)

The maximum angle (from vertical) that

can be tolerated.
How far you can shit from front to back and
side to side without loosing balance? This
is often called your Cone of Stability.

Postural Sway refers to small postural

shifts from front to back and side to
side, during quiet stance.

Limits of Stability

Cone of
Stability

Cone of
Stability with
Assistive
Device

Postural Sway

The larger the sway path, the greater

the postural unsteadiness.

Romberg Test- Closing eyes will

decrease visual input. Standing
Postural Sway may increase,
decreasing balance.

Postural Control During

Perturbed Balance

The recovery of stability requires

movement strategies that control the
COM over the BOS.

Limits of Stability is defined as the

distance a person can move, without
losing balance or taking a step.

Perturbed Balance
Movement Strategies

The ankle strategy occurs

with minimal perturbance of
balance.
Control is distal- to-proximal

Perturbed Balance
Movement Strategies

Moderate instability leads to

the hip strategy.
Control is proximal-to-distal

Perturbed Balance
Movement Strategies

The stepping strategy is

used with greater
perturbance.

Perturbed Balance
Central Nervous System

The response can either be protective

or corrective.

Anticipatory Postural Control refers to

postural adjustments that are made
before voluntary movements to
minimize disturbances in balance (feed
forward).

Perturbed Balance
Central Nervous System
Reactive control is the response to a
disturbance in balance (feedback).

Corrective Strategy, such as the ankle strategy

Protective Strategy, such as covering your head

when you fall
This does not correct the fall, but controls the effects of
the fall.

Perturbed Balance
Movement Strategies

The CNS activates muscle synergies in

related joints.

Force in one part of the body does not cause

instability in another part of the body.

Leaning over in a chair to pick up a pen, you do not fall

out of the chair.
Neck extension during the hip strategy prevents the
body from falling forward.

Central Processing Tests

Manual Test of Postural Perturbance
Therapist pulls patient, at waist level,
several times with varying degrees of
force.
See Guccione, p. 287

Normal Postural Control

Sensory System

During perturbance of balance:

Adults rely on somatosensory inputs.
Children rely more on visual input.

The interaction of the senses allows the

modification needed to maintain stability
in a variety of environments.

Normal Postural Control

Sensory System

The three different parts of the sensory

system provide different sources of
information about the bodys position
and movement in space.

Each sense provides a different frame

of reference for postural control.

Normal Postural Control

Sensory System
The Postural Dyscontrol Test will be
performed in class.
Foam and Dome Test
OSullivan, p. 193

Normal Postural Control

Sensory System
Vision provides information about the position and
motion of the head in the environment.

Acuity- detects subtle differences in shapes

Snellen Eye Chart (min 20/200)

Depth perception
Finger Test, Guccione p. 286

Peripheral vision
Finger Test, Guccione p. 286

Normal Postural Control

Sensory System

The somatosensory system

provides information about the
body with reference to supporting
surfaces.

The somatosensory system

receives information from muscle
spindles, joint receptors, tendon
organs, and mechanoreceptors.

The Somatosensory system

Gross Tests of Proprioception

Detecting the subtle movement of the big

toe (< 5mm).

Vibration- Placing a tuning fork at the first

metatarsal head.

Normal Postural Control

Sensory System
The Vestibular System

Provides information about the position and

movement of the head, in reference to gravity and
inertial forces.
Information is received from the vestibule
responsible for position and linear acceleration.
Information is received from the semi-circular
canal responsible for rotational movement.

The Vestibular System

Gross Functional Tests
Guccione, p. 286
Looking at a object while turning head
Reading a book while walking
Marching in place with eyes closed

Postural Control

Controlling the bodys position in space

is an essential part of functional skills.

Postural control requires all three:

Sensory system
Central processing
Effector components

Postural Control
The three systems in postural control
are complex and multifaceted. A
problem or impairment in one area may
affect several other areas, resulting in a
greater affect than the loss of the single
impairment.

The Effect of Aging on

Postural Control
The Sensory System
With aging, vision may decrease in acuity,
contrast sensitivity, and depth perception
With aging, the vestibular system may
undergo age-related changes, resulting in
dizziness and unsteadiness.
With aging, there may be a decrease in
proprioception and vibration.

Aging Effects on Postural

Control
The Central Processing System

Aging may result in a slowing of sensory information.

Aging may result in a slowing of nerve conduction
velocity.
Aging may result in increased postural sway.
Aging may result in an increased incidence of cocontractions
Aging may result in an increased use of proximal-todistal control for balance.

Aging Effects on Postural

Control
The Effector System
Aging may result in decreased muscle
strength.
Aging may result in decreased ROM and
flexibility.
Aging may result in increased stiffness of
connective tissue
Aging may result in cardiovascular
changes

Functional Tests

Progressive Mobility Skills Assessment Task

Guccione, p. 288

Berg Balance Scale (note that the Functional

Reach Test is part of this test)
OSullivan, p. 208

Performance-Oriented Assessment of
Mobility I (Tinetti)
OSullivan, p. 210

Other Assessments

Environmental Assessments
Chapter 12, OSullivan

Psychosocial Assessment
Cognitive assessments
Social work assessments

Interventions

Interventions should be based on assessment results.

The ultimate goal will is to maximize independence in

mobility and function.

The therapist needs to identify and treat modifiable

deficits.

The therapist needs to identify and help the patient

compensate for deficits that cannot be modified.

Some balance exercises for

older people.

Exercises - National Institute on Agingl

Tandem
Walking

Fall Prevention

The purpose of assessment and

intervention is to prevent the next fall.

Balance and
and Falls
Falls
Balance
The End