Balance Training

BALANCE TRAININGBALANCE TRAINING

DefinitionDefinition

Balance is defined as the ability Balance is defined as the ability to control the body mass or to control the body mass or

center of gravity to the base of center of gravity to the base of support in order to maintain a support in order to maintain a upright posture or a functional upright posture or a functional

equilibrium in dynamic activitiesequilibrium in dynamic activities

Normal Balance MaintenanceNormal Balance Maintenance

Human balance is a complex process which Human balance is a complex process which involves the integration of sensory information involves the integration of sensory information from peripheral end organs to detect body from peripheral end organs to detect body position in relation to environment.position in relation to environment.

Integration of this information by CNS to Integration of this information by CNS to produce adequate and proper motor output in produce adequate and proper motor output in the form of automatic postural responsesthe form of automatic postural responses. .

The Sensory factorsThe Sensory factors

Somato Sensory Inputs Somato Sensory Inputs (Proprioceptors) (Proprioceptors)

Visual Inputs Visual Inputs

Vestibular InputsVestibular Inputs

Somato sensory receptors:Somato sensory receptors:Proprioceptors located in Muscles , Proprioceptors located in Muscles , Ligaments and Joints.Ligaments and Joints.

Visual Inputs:Visual Inputs:Perception of verticality, object Perception of verticality, object motion and motion of self in relation motion and motion of self in relation to environment.to environment.

Vestibular InputsVestibular Inputs::Position of head in relation to gravity Position of head in relation to gravity and linear and angular acceleration and linear and angular acceleration of head during movement. of head during movement.

StrategiesStrategies

Ankle strategyAnkle strategy

Describes postural sway control from ankle Describes postural sway control from ankle musculature level. This strategy act when musculature level. This strategy act when the sway is small, slow and near midline.the sway is small, slow and near midline.

Hip StrategyHip Strategy

It is the postural sway from pelvis and It is the postural sway from pelvis and trunk. It is seen when the sway is large, trunk. It is seen when the sway is large, fast and nearing the limits of stability.fast and nearing the limits of stability.

Suspensary strategySuspensary strategy

It describes lowering of COG by flexing both It describes lowering of COG by flexing both the knees. Commonly seen in windsurfing.the knees. Commonly seen in windsurfing.

Stepping strategyStepping strategy

It describes steps with feet or reaches with It describes steps with feet or reaches with arms in an attempt to re-establish a new arms in an attempt to re-establish a new base of support when COG has exceeded base of support when COG has exceeded the original base of support.the original base of support.

What is a balance disorder?What is a balance disorder?

A balance disorder is a A balance disorder is a disturbance that causes an disturbance that causes an individual to feel unsteady, individual to feel unsteady, giddy, or have a sensation of giddy, or have a sensation of movement, spinning, or floating.movement, spinning, or floating.

Causes of balance disordersCauses of balance disorders

Sensory system disordersSensory system disorders

Sensory ataxia (dorsal column Sensory ataxia (dorsal column degeneration)degeneration)

Vestibular neuronitisVestibular neuronitis Benign paroxysmal positional vertigoBenign paroxysmal positional vertigo Neuropathic jointsNeuropathic joints

CNS disordersCNS disorders

Cerebro vascular accidentsCerebro vascular accidents Parkinson’s diseaseParkinson’s disease Cerebellar dysfunctionCerebellar dysfunction Vertibro basilar insufficiencyVertibro basilar insufficiency Brain injuryBrain injury

Motor disordersMotor disorders

Gross poliomyelitis involving both lower limbsGross poliomyelitis involving both lower limbs Motor neuron diseaseMotor neuron disease

Biomechanical ProblemsBiomechanical Problems

WeaknessWeakness Limitation of joint rangeLimitation of joint range

Environmental risk factorsEnvironmental risk factors

General risk factors like Furniture, General risk factors like Furniture, Bathroom, Toilet, Stairs, Outdoor curbsBathroom, Toilet, Stairs, Outdoor curbs

Falls in the ElderlyFalls in the Elderly

Symptoms of balance disordersSymptoms of balance disorders

When balance is impaired, an individual When balance is impaired, an individual has difficulty maintaining orientationhas difficulty maintaining orientation

An individual may experience the "room An individual may experience the "room spinning" and may not be able to walk spinning" and may not be able to walk without staggeringwithout staggering

May not even be able to arise May not even be able to arise A sensation of dizziness A sensation of dizziness Falling or a feeling of falling Falling or a feeling of falling LightheadednessLightheadedness Visual blurring Visual blurring Disorientation Disorientation

ASSESSMENTASSESSMENT

1. 1. Visual system:Visual system:Check visual acuity, depth perception, Check visual acuity, depth perception, visual field defects.visual field defects.

2. 2. Somatosensory:Somatosensory:Check proprioception, cutaneous sensation Check proprioception, cutaneous sensation (touch, pressure), lower extremities and (touch, pressure), lower extremities and trunk, especially feet and ankle.trunk, especially feet and ankle.

3. Vestibular:3. Vestibular:

Check motor responses to positional and Check motor responses to positional and movement testingmovement testing

Righting reactions: Move or position the body, observe automatic Righting reactions: Move or position the body, observe automatic adjustments that restore normal alignment of the head position (face adjustments that restore normal alignment of the head position (face vertical, mouth horizontal).vertical, mouth horizontal).

Equilibrium reactions: Alter the body’s center of mass or base of Equilibrium reactions: Alter the body’s center of mass or base of support, observe automatic postural adjustments that serve to support, observe automatic postural adjustments that serve to maintain balance (keep centre of mass within the BOS).maintain balance (keep centre of mass within the BOS).

Protective reactions: Alter the body’s centre of mass outside of the Protective reactions: Alter the body’s centre of mass outside of the BOS, observe the automatic adjustments of the arms or legs to BOS, observe the automatic adjustments of the arms or legs to extend and support the body weight in anticipation of a fall.extend and support the body weight in anticipation of a fall.

Testing considerations: Can use a displacing Testing considerations: Can use a displacing manual force against the Centre Of Mass (a manual force against the Centre Of Mass (a perturbation or push) or displace the BOS using perturbation or push) or displace the BOS using a moveable surface (platform, gymnastic ball, a moveable surface (platform, gymnastic ball, equilibrium board). equilibrium board).

4. Assessment of Musculoskeletal 4. Assessment of Musculoskeletal ElementsElements

Determine musculoskeletal Determine musculoskeletal strength strength

and ROM especially in the lower and ROM especially in the lower

extremities and trunkextremities and trunkTightness, contracturesTightness, contracturesSpasticitySpasticityDetermine limits of stability: Determine limits of stability: maximum maximum

sway in any direction.sway in any direction.

5. CHECK STATIC BALANCE5. CHECK STATIC BALANCE

A. Standing tests:A. Standing tests:

Double limb supportDouble limb support

Single limb supportSingle limb support

6.Dynamic Balance:6.Dynamic Balance: Standing upStanding up SteppingStepping StoopingStooping

7. Scoring: 7. Scoring:

A. Three point scale: absent, A. Three point scale: absent, impaired, impaired, presentpresent

B. Functional balance grades: 0, B. Functional balance grades: 0, poor, poor, fair, good, normal (with fair, good, normal (with descriptive criteria for each)descriptive criteria for each)

Berg’s Balance ScaleBerg’s Balance Scale

0 – No Balance0 – No Balance 1 – Able to maintain balance with support1 – Able to maintain balance with support 2 – Able to maintain balance with hands 2 – Able to maintain balance with hands offoff 3 – Able to maintain balance with hands 3 – Able to maintain balance with hands off, accepts minimal challengesoff, accepts minimal challenges 4 – Able to maintain support with hands 4 – Able to maintain support with hands off, accepts maximal challengesoff, accepts maximal challenges

Romberg test: Romberg test: Standing with feet in normal Standing with feet in normal

stance position, first with eyes open, stance position, first with eyes open, then with eyes closed: used to detect then with eyes closed: used to detect posterior column ataxiaposterior column ataxia

Sharpened or Tandem Romberg:Sharpened or Tandem Romberg: Have patient stand in a tandem Have patient stand in a tandem heel to toe position, first with eyes heel to toe position, first with eyes open, then eyes closed; increases open, then eyes closed; increases sensitivity of Romberg testsensitivity of Romberg test

TREATMENT SUGGESTIONS FOR TREATMENT SUGGESTIONS FOR BALANCE DISORDERSBALANCE DISORDERS

Cognitive impairment treatment Cognitive impairment treatment suggestionssuggestions Reduce confusionReduce confusion Improve motivationImprove motivation Improve attentionImprove attention Encourage consistencyEncourage consistency Start with simple task increase the Start with simple task increase the

complexity graduallycomplexity gradually

Managing sensory problemsManaging sensory problems(Vestibular, Proprioceptive, Visual)(Vestibular, Proprioceptive, Visual)

Facilitating demand system, Facilitating demand system, encourage remaining system encourage remaining system

Managing strategy selection Managing strategy selection problemsproblems

(Parkinson’s disease)(Parkinson’s disease) Appropriate sensory demands Appropriate sensory demands

(Pertubations)(Pertubations) Hip strategy – Stand on foam Hip strategy – Stand on foam

surface, narrow surface, Treadmillsurface, narrow surface, Treadmill

Managing preparatory problemsManaging preparatory problems (Bradykinesia)(Bradykinesia) Strategy trainingStrategy training

Managing sequencing and timing Managing sequencing and timing problemsproblems

(CP, Hemiplegia)(CP, Hemiplegia) Facilitate normal sequential muscle Facilitate normal sequential muscle

contraction from distal to proximal in contraction from distal to proximal in response to pertubation (EMG response to pertubation (EMG Biofeedback, Balance master)Biofeedback, Balance master)

Managing scaling problemManaging scaling problem (Cerebellar dysfunctions)(Cerebellar dysfunctions) Correct faulty amplitude of contraction Correct faulty amplitude of contraction

(Visual Biofeedback, Balance master, (Visual Biofeedback, Balance master, Wobble board, weighted cuffs)Wobble board, weighted cuffs)

Managing musculoskeletal Managing musculoskeletal problemsproblems

(Muscle weakness, ROM restriction, (Muscle weakness, ROM restriction, Spasticity)Spasticity)

Muscle strengthening exercises, Muscle strengthening exercises, Electrical stimulation, StretchingElectrical stimulation, Stretching

Functional Sequence in Balance Functional Sequence in Balance TrainingTraining

Balance activities starts from lying, Balance activities starts from lying, kneeling, sitting, then progressed to kneeling, sitting, then progressed to static and dynamic standing and static and dynamic standing and walking.walking.

NOT NECESSARY TO FOLLOW NOT NECESSARY TO FOLLOW THE STEP LADDER PATTERNTHE STEP LADDER PATTERN

LyingLying Prone lying – Neck ExtensionProne lying – Neck Extension Prone on elbowsProne on elbows Prone on handsProne on hands

SittingSitting High sitting with foot on ground, with arm High sitting with foot on ground, with arm

support on the sidessupport on the sides Weight shiftsWeight shifts Without arm supportWithout arm support Without feet touching the groundWithout feet touching the ground Sit walkingSit walking Long sittingLong sitting

KneelingKneeling

4 point kneeling4 point kneeling

Kneel sittingKneel sitting

2 point kneeling2 point kneeling

Half kneelingHalf kneeling

(with and without support, (with and without support, challenges)challenges)

Sit to StandSit to Stand

StandingStanding

# Static# StaticDouble limb stanceDouble limb stance

Single leg stanceSingle leg stance

Tandem positionTandem position

# # DynamicDynamic

Static marchingStatic marchingWobbling boardWobbling board

WalkingWalkingForwardForwardBackwardBackwardSidewaysSidewaysTandemTandemBraidingBraidingTreadmillTreadmill

Steps Steps

RampsRamps

Rough terrainRough terrain

CurbsCurbs

ObstaclesObstacles

Community ambulationCommunity ambulation

TasksTasks

Looking up at the ceilingLooking up at the ceiling Turning to look behind without Turning to look behind without

moving the feetmoving the feet Reaching forward to take an objectReaching forward to take an object Reaching sidewaysReaching sideways Reaching backwards Reaching backwards Reaching down to stool and floorReaching down to stool and floor Ball catching and throwingBall catching and throwing

Environmental modificationsEnvironmental modifications

Low chairs, low beds - leg Low chairs, low beds - leg modificationsmodifications

Unstable furniture - repair Unstable furniture - repair immediatelyimmediately

Ladders and step ladders - avoid Ladders and step ladders - avoid themthem

Lack of grab rails - installation of Lack of grab rails - installation of grab railsgrab rails

Hand rails not present or inadequate Hand rails not present or inadequate – installation of appropriate handrails– installation of appropriate handrails

Stairs too steep, tread too narrow -Stairs too steep, tread too narrow -modification of stairsmodification of stairs

Foot wear - thin, flat, broad, made Foot wear - thin, flat, broad, made up of firm material, textured sole, up of firm material, textured sole, ankle supportankle support

Avoid – high heeled shoes, shoes Avoid – high heeled shoes, shoes with soft and slippery soles. with soft and slippery soles.

THANK YOUTHANK YOU