BALANCE

INTRODUCTION
 BALANCE IS THE ABILITY TO MAINTAIN THE BODY’S
CENTER OF MASS OVER ITS BASE OF SUPPORT.

 BALANCE IS A COMPLEX MOTOR CONTROL TASK

INVOLVING THE DETECTION AND INTEGRATION OF
SENSORY INFORMATION TO ASSESS THE POSITION
AND MOTION OF THE BODY IN SPACE AND THE
EXECUTION OF APPROPRIATE MUSCULOSKELETAL
RESPONSES TO CONTROL BODY POSITION WITHIN
THE CONTEXT OF THE ENVIRONMENT AND TASK.
 KEY TERMS
• CENTER OF MASS:- THE COM IS A POINT THAT CORRESPONDS TO THE CENTER OF
THE TOTAL BODY MASS AND IS THE POINT AT WHICH THE BODY IS IN PERFECT
EQUILIBRIUM.

• CENTER OF GRAVITY:- THE COG REFERS TO THE VERTICAL PROJECTION OF THE

CENTER OF MASS TO THE GROUND.

• BASE OF SUPPORT:- THE BOS IS DEFINED AS THE PERIMETER OF THE CONTACT

AREA BETWEEN THE BODY AND ITS SUPPORT SURFACE.

• LIMITS OF STABILITY:- “LIMITS OF STABILITY” REFERS TO THE SWAY BOUNDARIES

IN WHICH AN INDIVIDUAL CAN MAINTAIN EQUILIBRIUM WITHOUT CHANGING HIS
OR HER BOS.
PHYSIOLOGY OF BALANCE
What Happens to the postural control, When These
Inputs & Outputs Gets Altered Or Absent ?
I. SENSORY SYSTEMS AND BALANCE CONTROL

i. VISUAL SYSTEM
ii. SOMATOSENSORY SYSTEM
iii. VESTIBULAR SYSTEM

II. Sensory organization for balance control

 III. MOTOR STRATEGIES

i. ANKLE STRATEGY
ii. HIP STRATEGY
iii. STEPPING STRATEGY
 MUSCLE SYNERGIES

• PERTURBATIONS IS ANY SUDDEN CHANGE IN CONDITIONS THAT DISPLACES THE

BODY POSTURE AWAY FROM EQUILIBRIUM.

PERTURBATI
ON

SENSORY PERTURBATION MECHANICAL PERTURBATION

• SENSORY PERTURBATION : IT IS CAUSED BY ALTERING THE VISUAL
INPUT.

• E.G., WHEN A PERSON’S EYES ARE COVERED.

• MECHANICAL PERTURBATION : DISPLACEMENTS THAT INVOLVE

CHANGES IN THE RELATIONSHIP OF BODY’S COM TO THE BOS.
• THE POSTURAL RESPONSES TO PERTURBATIONS ARE CALLED “SYNERGIES OR
STRATEGIES”

MUSCLE SYNERGY /
STRATEGIES

FIXED SUPPORT CHANGE IN SUPPORT HEAD STABILIZING

 FIXED SUPPORT STRATEGIES

• THEY ARE PATTERNS OF MUSCLE ACTIVITY IN WHICH THE BOS

REMAINS FIXED DURING THE PERTURBATION AND RECOVERY OF
EQUILIBRIUM.

• STABILITY REGAINED BY MOVEMENTS OF PART OF THE BODY, BUT

THE FEET REMAIN FIXED ON THE BOS.

• EXAMPLES :- ANKLE AND HIP STRATEGIES.

 ANKLE STRATEGY

• IT CONSISTS OF DISCRETE BURSTS OF MUSCLE ACTIVITY ON

EITHER THE ANTERIOR OR POSTERIOR ASPECTS OF THE BODY
WHICH OCCURS IN A DISTAL TO PROXIMAL PATTERN IN RESPONSE
TO THE FORWARD AND BACKWARD MOVEMENTS OF THE SUPPORT
PLATFORM RESPECTIVELY.
• FORWARD MOTION

PLATFORM RESULTS IN

RELATIVE DISPLACEMENT

OF LOG POSTERIORLY AND IS

SIMILAR TO FALL

BACKWARD IN A FREE-

STANDING POSTURE.
• BACKWARD MOTION OF THE
PLATFORM RESULTS IN
RELATIVE DISPLACEMENT OF
THE LOG ANTERIORLY AND IS
SIMILAR TO THE STARTING TO
FALL FORWARD IN A FREE-
STANDING POSTURE.
 HIP STRATEGY

• THE HIP SYNERGY CONSISTS OF DISCRETE BURSTS OF MUSCLE

ACTIVITY A PROXIMAL TO DISTAL PATTERN OF ACTIVATION.

• MUSCLE ACTIVITY ORDER – ABDOMINALS, QUDRICEPS,

DORSIFLEXORS (FORWARD TRANSLATION)

• MUSCLE ACTIVITY ORDER – BACK EXTENSORS, KNEE FLEXORS &

ANKLE PLANTAR FLEXORS (POSTERIOR TRANSLATION)
 CHANGE IN SUPPORT STRATEGIES

• STRATEGIES INCLUDE STEPPING AND GRASPING IN RESPONSE TO

SHIFTS IN EITHER THE BOS OR THE ENTIRE BODY.

• STEPPING AND GRASPING DIFFER FROM FIXED SUPPORT SYNERGIES

BECAUSE STEPPING / GRASPING EITHER MOVES OR ENLARGES THE
BODY’S BOS SO THAT IT REMAINS UNDER THE BODY’S COM.
• THE STEPPING SYNERGY WAS USED ONLY AS
LAST RESORT, BEING INITIATED WHEN THE
ANKLE AND THE HIP STRATEGIES WERE
INSUFFICIENT TO BRING AND MAINTAIN THE
COM OVER BOS .

• CHANGE IN SUPPORT SYNERGIES ARE THE

ONLY SYNERGIES THAT ARE SUCCESSFUL IN
MAINTAINING STABILITY IN THE INSTANCE
OF A LARGE PERTURBATION
 HEAD STABILIZING STRATEGIES
• TWO STRATEGIES ARE USED TO MAINTAIN THE VERTICAL STABILITY OF
THE HEAD: HEAD STABILIZATION IN SPACE (HSS) AND HEAD
STABILIZATION ON TRUNK (HST).

• DIFFERENCE IS THAT THIS STRATEGY OCCURS IN ANTICIPATION OF THE

INITIATION OF INTERNALLY GENERATED FORCES CAUSED BY CHANGES
IN POSTURE FROM SITTING TO STANDING.

• IT OCCURS DURING DYNAMIC POSTURE.

• THE HSS STRATEGY IS A MODIFICATION OF HEAD POSITION IN
ANTICIPATION OF DISPLACEMENT OF BODY’S COG.

• THE ANTICIPATORY ADJUSTMENTS TO HEAD POSITION ARE

INDEPENDENT OF TRUNK MOTION.
• THE HST STRATEGY IS ONE IN WHICH THE HEAD AND TRUNK
MOVE AS SINGLE UNIT.

• IN STANDING, SUBJECTS ATTEMPTED EITHER TO RECOVER THEIR

BALANCE AFTER A PERTURBATION OR TO RESIST TRYING TO
RECOVER THEIR BALANCE AND INSTEAD TO FALL ON A
PROTECTED SURFACE.
 BALANCE IMPAIRMENTS

• IMPAIRED BALANCE CAN BE CAUSED BY INJURY OR DISEASE TO ANY STRUCTURES

INVOLVED IN THE THREE STAGES OF INFORMATION PROCESSING
a. SENSORY INPUT,
b. SENSORIMOTOR INTEGRATION, AND
c. MOTOR OUTPUT GENERATION.
 SENSORY INPUT IMPAIRMENTS

• REDUCED SOMATOSENSATION IN THE LOWER EXTREMITIES CAUSED BY

PERIPHERAL POLYNEUROPATHIES IN THE AGED AND IN INDIVIDUALS
WITH DIABETES ARE ASSOCIATED WITH BALANCE DEFICITS AND AN
INCREASED RISK FOR FALLS
• VISUAL LOSS OR SPECIFIC DEFICIT S I N ACUITY, CONTRAS T SENSITIVITY
, PERIPHERAL FIELD VISION, AND DEPTH PERCEPTION CAUSED BY DISEAS
E, TRAUMA, OR AGING CAN IMPAIR BALANCE AND LEAD TO FAL
• INDIVIDUALS WITH DAMAGE TO THE VESTIBULAR SYSTEM DUE TO
VIRAL INFECTIONS, TRAUMATIC BRAIN INJURY, OR AGING MAY
EXPERIENCE VERTIGO AND POSTURAL INSTABILITY.
SENSORIMOTOR INTEGRATION IMPAIRMENTS

• E.G. WHEN STANCE IS PERTURBED BY PLATFORM TRANSLATIONS, PATIENTS WITH

PARKINSON’S DISEASE TEND TO HAVE A SMALLER THAN NORMAL AMPLITUDE OF
MOVEMENT DUE TO CO-ACTIVATION OF MUSCLES ON BOTH SIDES OF THE BODY,
WHEREAS PATIENTS WITH CEREBELLAR LESIONS TYPICALLY DEMONSTRATE
LARGER RESPONSE AMPLITUDES.
 BIOMECHANICAL AND MOTOR OUTPUT
IMPAIRMENTS
• DEFICITS IN THE MOTOR COMPONENTS OF BALANCE CONTROL CAN BE CAUSED BY
MUSCULOSKELETAL (I.E., POOR POSTURE, JOINT ROM LIMITATIONS, DECREASED
MUSCLE PERFORMANCE) AND/OR NEUROMUSCULAR SYSTEM (I.E., IMPAIRED MOTOR
COORDINATION, PAIN) IMPAIRMENTS
 DEFICITS WITH AGING

• DECLINES IN ALL SENSORY SYSTEMS (SOMATOSENSORY, VISION, VESTIBULAR)

AND ALL THREE STAGES OF INFORMATION PROCESSING (SENSORY PROCESSING,
SENSORIMOTOR INTEGRATION, MOTOR OUTPUT) ARE FOUND WITH AGING.
• IN COMPARISON TO YOUNG ADULTS, 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.
• ELDERLY INDIVIDUALS WHO HAVE EXPERIENCED ONE OR MORE FALLS MAY
DEVELOP FEAR OF FALLING, WHICH LEADS TO A LOSS OF CONFIDENCE IN A
PERSON’S ABILITY TO PERFORM ROUTINE TASKS, RESTRICTED ACTIVITY, SOCIAL
ISOLATION, FUNCTIONAL DECLINE, DEPRESSION, AND DECREASED QUALITY OF
LIFE.
• THE FEAR OF FALLING ARISES MORE OFTEN FROM A PERSON’S FEAR OF
INSTITUTIONALIZATION THAN A FEAR OF INJURY.
 DEFICITS FROM MEDICATIONS

• THERE IS AN INCREASED RISK OF FALLING AMONG OLDER INDIVIDUALS

WHO TAKE FOUR OR MORE MEDICATIONS AND AMONG THOSE TAKING
CERTAIN MEDICATIONS (IE; HYPNOTICS, SEDATIVES, ANTI-DEPRESSANTS,
ANTI-HYPERTENSIVE DRUGS) DUE TO DIZZINESS OR OTHER SIDE EFFECTS.

• INDIVIDUALS WHO HAVE FALLEN SHOULD HAVE THEIR MEDICATIONS

REVIEWED AND ALTERED OR STOPPED AS APPROPRIATE TO PREVENT
FUTURE FALLS.
 TYPES OF BALANCE CONTROL

a. STATIC BALANCE CONTROL

b. DYNAMIC BALANCE CONTROL
c. ANTICIPATORY BALANCE CONTROL (FEEDFORWARD)
d. REACTIVE BALANCE CONTROL (FEEDBACK)
 ASSESSMENT OF BALANCE
• THE KEY ELEMENTS OF A COMPREHENSIVE EVALUATION OF
INDIVIDUALS WITH BALANCE PROBLEMS INCLUDE THE FOLLOWING.

I. HISTORY.
II. ASSESSMENTS TO IDENTIFY SENSORY INPUT (PROPRIOCEPTIVE,
VISUAL, VESTIBULAR), SENSORY PROCESSING (SENSORIMOTOR
INTEGRATION, ANTICIPATORY AND REACTIVE BALANCE
CONTROL), AND BIOMECHANICAL AND MOTOR IMPAIRMENTS
CONTRIBUTING TO BALANCE DEFICITS.
III. TESTS AND OBSERVATIONS TO DETERMINE THE IMPACT OF BALANCE CONTROL
SYSTEM DEFICITS ON FUNCTIONAL PERFORMANCE
IV. ENVIRONMENTAL ASSESSMENTS TO DETERMINE FALL RISK HAZARDS IN A PERON’S
HOME
ASSESSMENT OF VARIOUS TYPES OF BALANCE
CONTROL WHICH INCLUDES:-

STATIC BALANCE :-

IT CAN BE ASSESSED BY OBSERVING THE PATIENT’S ABILITY TO

MAINTAIN DIFFERENT POSTURES WHICH INCLUDES :
a) ROMBERG TEST.
b) SHARPENED ROMBERG TEST.
c) SINGLE LEG BALANCE STANCE TEST.
d) THE STORK STAND TEST.
Romberg Test:
• IT IS A TEST OF THE PROPRIOCEPTION RECEPTORS AND PATHWAYS
FUNCTION.
• ROMBERG SIGN- PRESENT OR ABSENT
• PRESENT- IF THE SWAY IS CONSIDERABLE AND/OR THE PATIENT
BREAKS POSITION.
• ABSENT- PERFORM TASK WITH NO SWAY OR MINIMAL SWAY
WITHOUT BREAKING POSITION.

Tandem Romberg Test:

• It is a variation of the Romberg test.
• All instructions are same except for the foot position, in this test, the patient has to
place his feet in heel-to-toe position, with one foot directly in front of the other.
 SINGLE LEG BALANCE STANCE TEST:
• THIS TEST IS PERFORMED ON A SINGLE LEG WITHOUT SHOES OR SOCKS
ON THE FOOT AND WITH THE HANDS PLACED ON THE HIPS IN ORDER TO
PREVENT USE OF ARMS FOR BALANCE.
• PERFORM 3 TIMES WITH THE EYES OPEN FOR 40 SEC, THEN 3 TIMES
WITH THE EYES CLOSED FOR 20 SEC.
• THE SLB TEST IS CONSIDERED POSITIVE AND A GOOD PREDICTOR OF A
FUTURE ANKLE SPRAIN IF THE TIME HELD IS LESS THAN 10
SECONDS FOR EITHER EYES OPEN OR EYES CLOSED.
 THE STORK STAND TEST
• PERFORMED BY HAVING PATIENT STAND ON BOTH FEET WITH HANDS ON THE
HIPS, THEN LIFT ONE LEG AND PLACE THE TOE OF THAT FOOT AGAINST THE
KNEE OF THE OTHER LEG.
• ON COMMAND FROM THE TESTER, THE PATIENT THEN RAISES THE HEEL TO
STAND ON THE TOES AND TRIES TO BALANCE FOR AS LONG AS POSSIBLE
WITHOUT LETTING EITHER THE HEEL TOUCH THE GROUND OR THE OTHER FOOT
MOVES AWAY FROM THE KNEE.
• NORMAL ADULTS SHOULD BE ABLE TO BALANCE FOR 20 TO 30 SECONDS ON
EACH LEG.
DYNAMIC BALANCE TESTS:-

• DYNAMIC BALANCE CONTROL CAN BE ASSESSED BY

OBSERVATIONS OF HOW WELL THE PATIENT IS ABLE TO
STAND OR SIT ON UNSTABLE SURFACES (E.G., FOAM OR
SWISS BALL), TRANSITION FROM ONE POSITION TO
ANOTHER (E.G., SUPINE-TO-SIT OR SIT-TO-STAND
TRANSFERS), AND PERFORM ACTIVITIES SUCH AS
WALKING, JUMPING, HOPPING, AND SKIPPING.
 FIVE-TIMES-SIT-TO-STAND TEST (5×STS) :

• THIS TEST IS USED TO EVALUATE BALANCE CONTROL WHEN

MOVING BETWEEN SITTING AND STANDING.
INTERPRETATION:
• GERIATRICS -NEED FOR FURTHER ASSESSMENT OF FALL RISK: ≥ 12
SEC.
• RECURRENT FALLS: > 15 SEC .
• VESTIBULAR DISORDERS -FALL RISK: > 15 SEC.
• PARKINSON’S DISEASE -FALL RISK: > 16 SEC.
ANTICIPATORY POSTURAL CONTROL TESTS:

FUNCTIONAL REACH TEST

• INTERPRETATION:
• NORMAL 15 INCHES.
• < 10 INCHES : INCREASED RISK OF FALL.
• 5 INCHES: 5 X INCREASED RISK OF FALL.
• FOR EVERY INCH <10 X 1 INCREASED RISK OF FALL
• HIGHLY RECOMMENDED IN STROKE, PARKINSON’S, MS AND VESTIBULAR
CONDITIONS.
MULTIDIRECTIONAL REACH TEST:
• THE POPULATION INCLUDED ARE OLDER ADULTS AND
GERIATRIC CARE.
• THE CUT OFF SCORES FOR COMMUNITY DWELLING ELDERS
(NEWTON 2001):
• MEAN SCORE IN EACH DIRECTION OF INDIVIDUALS WHO
REPORTED A TRIP OR FALL IN THE LAST 6 MONTHS :
• FORWARD (IN): 8.38
• BACKWARD (IN): 4.06
• RIGHT (IN):6.12
• LEFT (IN): 5.67
STAR EXCURSION BALANCE TEST:
• IT IS A TEST OF LOWER EXTREMITY REACH THAT CHALLENGES AN INDIVIDUAL’S
LIMITS OF STABILITY.
• 1. ANTERIOR
2. ANTEROMEDIAL
3. MEDIAL
4. POSTEROMEDIAL
5. POSTERIOR
6. POSTEROLATERAL
7. LATERAL
8. ANTEROLATERAL

• OUT OF THIS, THE ANTERIOR, POSTEROMEDIAL AND POSTEROLATERAL DIRECTIONS

APPEAR TO BE IMPORTANT TO IDENTIFY INDIVIDUALS WITH CHRONIC ANKLE
INSTABILITY AND ATHLETES AT GREATER RISK OF LOWER EXTREMITY INJURY.
• WHEN THE PERSON DEMONSTRATES A SIGNIFICANTLY DECREASED REACH WHILE
STANDING ON THE INJURED LIMB COMPARED TO STANDING ON THE HEALTHY LIMB,
THE STAR EXCURSION BALANCE TEST HAS HIGHLIGHTED THE LOSS OF DYNAMIC
POSTURAL CONTROL.
REACTIVE POSTURAL CONTROL TEST:

• AUTOMATIC POSTURAL RESPONSES OR REACTIVE CONTROL CAN BE

ASSESSED BY THE PATIENT’S RESPONSE TO EXTERNAL
PERTURBATIONS.
• PUSHES (SMALL OR LARGE, SLOW OR RAPID, ANTICIPATED AND
UNANTICIPATED) APPLIED IN DIFFERENT DIRECTIONS TO THE
STERNUM, POSTERIOR TRUNK, OR PELVIS ARE USED WIDELY, BUT
THEY ARE NOT QUANTIFIABLE OR RELIABLE. THE CLINICIAN
SUBJECTIVELY RATES THE RESPONSES AS NORMAL, GOOD, FAIR,
POOR, OR UNABLE.
• TEST INCLUDES THE PULL TEST, PUSH AND RELEASE TEST.
 PULL TEST/ RETROPULSION TEST
• IT IS A COMMONLY USED CLINICAL TEST OF POSTURAL STABILITY FOR PATIENTS
WITH PD. THIS TEST EVALUATES THE ABILITY OF PATIENTS TO RECOVER FROM A
BACKWARD PULL ON THE SHOULDERS.
• CUT OFF SCORE FOR PD IS >1= INCREASED RISK OF FALLING.
 PUSH & RELEASE TEST:
• ACCORDING TO THE PUSH AND RELEASE TEST, THE CLINICIAN STANDS BEHIND
THE PATIENT.
• THE PATIENT IS INSTRUCTED TO PUSH BACKWARD AGAINST THE CLINICIAN’S
HANDS, WHICH ARE PLACED ON THE PATIENT’S SCAPULAE.
• THE FORCE OF THE PATIENTS PUSH IS NOT ALLOWED TO BE SO STRONG THAT THE
HEELS ARE LIFTED OFF THE GROUND.
• A BALANCE PERTURBATION IS INDUCED BY SUDDENLY REMOVING THE HANDS,
INEVITABLY FORCING THE PATIENT TO TAKE ONE OR MORE CORRECTIVE
BACKWARD STEPS (PRIOR TO THE TEST, PATIENTS SHOULD BE INSTRUCTED TO DO
WHATEVER NECESSARY TO REGAIN THEIR BALANCE, INCLUDING TAKING ONE OR
MORE STEPS).
• THE PUSH AND RELEASE TEST IS AGAIN RATED BY COUNTING THE NUMBER OF
BALANCE CORRECTING STEPS.
 SENSORY ORGANIZATION TEST:
• THE CLINICAL TEST OF SENSORY INTEGRATION ON BALANCE TEST
(CTSIB), ALSO CALLED THE “FOAM AND DOME” TEST ,MEASURES THE
PATIENT’S ABILITY TO BALANCE UNDER SIX DIFFERENT SENSORY
CONDITIONS.
1. STANDING ON A FIRM SURFACE WITH THE EYES OPEN (VISUAL,
SOMATOSENSORY, AND VESTIBULAR INFORMATION ACCURATE)
2. STANDING ON A FIRM SURFACE WITH THE EYES CLOSED
(SOMATOSENSORY AND VESTIBULAR INFORMATION ACCURATE)
3. STANDING ON A FIRM SURFACE WEARING A DOME MADE FROM A
MODIFIE D JAPANES E LANTER N (SOMATOSENSORY AN D VESTIBULA
R INFORMATION ACCURATE, VISUAL INFORMATION INACCURATE
4. STANDING ON A FOAM CUSHION WITH THE EYES OPEN (VISUAL
AND VESTIBULAR INFORMATION ACCURATE, SOMATOSENSORY
INACCURATE).
5. STANDING ON FOAM WITH THE EYES CLOSED (VESTIBULAR
INFORMATION ACCURATE, SOMATOSENSORY INFORMATION
INACCURATE).
6. STANDING ON FOAM WEARING THE DOME (VESTIBULAR
INFORMATION ACCURATE, SOMATOSENSORY AND VISUAL
INFORMATION INACCURATE).
• THE PATIENT STANDS WITH FEET PARALLEL AND ARMS AT SIDES OR
HANDS ON HIPS. A MINIMUM OF THREE 30-SECOND TRIALS OF EACH
CONDITION ARE PERFORMED.
 INTERPRETATION:
• INDIVIDUALS WHO RELY HEAVILY ON VISUAL INPUTS FOR BALANCE
(I.E., VISUAL DEPENDENT) WILL BECOME UNSTABLE OR FALL IN
CONDITIONS 2, 3, 5, AND 6.
• THOSE WHO RELY HEAVILY ON SOMATOSENSORY INPUTS (I.E.,
SURFACE DEPENDENT) SHOW DEFICITS WITH CONDITIONS 4, 5, AND 6.
• WITH GENERALIZED ADAPTATION PROBLEMS, INDIVIDUALS ARE
UNSTABLE IN CONDITIONS 3, 4, 5, AND 6.
• INDIVIDUALS WITH VESTIBULAR LOSS ARE VERY UNSTABLE IN
CONDITIONS 5 AND 6.
ASSESSMENT OF BALANCE DURING FUNCTIONAL
ACTIVITIES:
• FUNCTIONAL TESTS ARE USED TO DETERMINE ACTIVITY LIMITATIONS AND
PARTICIPATION RESTRICTIONS AND TO IDENTIFY TASKS THAT A PATIENT NEEDS TO
PRACTICE.
• 3 MOBILITY SCALES INCLUDES: TINETTI PERFORMANCE-ORIENTED MOBILITY
ASSESSMENT , TIMED UP AND GO TEST , BERG BALANCE SCALE.
• 2 GAIT SCALES INCLUDES: DYNAMIC GAIT INDEX & FUNCTIONAL GAIT
ASSESSMENT.
• THE COMMUNITY BALANCE AND MOBILITY SCALE AND THE HIGH LEVEL
MOBILITY ASSESSMENT TOOL (HIMAT) CAN BE USED TO EVALUATE BALANCE AND
MOBILITY IN PEOPLE WHO ARE AMBULATORY AND FUNCTIONING AT A HIGH
LEVEL, YET HAVE SOME BALANCE DEFICITS.
 BALANCE TRAINING

• THERE ARE MANY FACTORS TO CONSIDER WHEN DEVELOPING AN

INTERVENTION PROGRAM FOR BALANCE IMPAIRMENTS.
• MOST BALANCE INTERVENTION PROGRAM REQUIRES A MULTISYSTEM
APPROACH.
• WHICH ARE BASED ON THE IDENTIFIED DEFICITS IN STATIC, DYNAMIC,
ANTICIPATORY AND REACTIVE CONTROL AS WELL AS PROBLEM
INVOLVING SENSORY ORGANIZATION, FUNCTION AND SAFETY.
SAFETY PRECAUTION DURING BALANCE TRAINING
• 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 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.
• 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.
 STATIC BALANCE CONTROL
• ACTIVITIES TO PROMOTE STATIC BALANCE CONTROL INCLUDE HAVING THE PATIENT
MAINTAIN SITTING, 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 A 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

PRACTICE ANTICIPATORY BALANCE CONTROL BY PERFORMING THE FOLLOWING.

• 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 THAT INVOLVE MULTIPLE PARTS OF THE BODY TO
INCREASE THE CHALLENGE TO ANTICIPATORY POSTURAL CONTROL BY HAVING
THE PATIENT LIFT OBJECTS OF VARYING WEIGHT IN DIFFERENT POSTURES AT
VARYING SPEEDS, OPEN AND CLOSE DOORS WITH DIFFERENT HANDLES AND
HEAVINESS, OR MANEUVER THROUGH AN OBSTACLE COURSE.
 REACTIVE BALANCE CONTROL

TRAIN REACTIVE BALANCE CONTROL BY USING THE FOLLOWING ACTIVITIES

• HAVE THE PATIENT WORK TO GRADUALLY INCREASE THE AMOUNT OF SWAY WHEN
STANDING IN DIFFERENT DIRECTIONS WHILE 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; OR 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
MANY OF THE ACTIVITIES PREVIOUSLY DESCRIBED CAN BE UTILIZED WHILE
VARYING THE RELIANCE ON SPECIFIC SENSORY SYSTEMS.
• 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, HAVE THE PATIENT 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.
• PERFORM TWO OR MORE TASKS SIMULTANEOUSLY TO INCREASE THE LEVEL OF
TASK COMPLEXITY.
• PRACTICE RECREATIONAL ACTIVITIES THE PATIENT ENJOYS, SUCH AS GOLF, TO
INCREASE MOTIVATION WHILE CHALLENGING BALANCE CONTROL.
 SAFETY DURING GAIT, LOCOMOTION, OR
BALANCE

• TO EMPHASIZE SAFETY, HAVE THE PATIENT 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
THANK YOU