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Balance
1. Balance and Fall Prevention
By,
Sankari Nedunsaliyan
Physiotherapist
Dip In PT (MAL), Bsc Hons Applied Rehab (UK)
2. Balance Defined
• Balance: Control of center of mass over
base of support (Shumway – Cook, 2001)14
• Center of mass: Center point of each body
segment combined
• Center of gravity: Vertical projection of
center of mass
• Base of support: Area of object that is in
contact with the ground
7. Indications/Needs
Gait and balance difficulties regardless of the
underlying neurologic or orthopedic cause
Medical conditions that can cause mobility
difficulties include Parkinson’s disease, multiple
sclerosis, stroke, neuropathies, and head trauma
Vestibular disorders that cause dizziness
Patients with osteoporosis or elderly can
benefit from specific balance training to prevent
falls and decrease risk of fractures.
9. Types of Balance
• Steady state (static) balance
• Reactive balance (Dynamic Balance)
• Proactive (anticipatory) balance
10. Steady state (static) balance:
Maintain stable position in standing or
sitting
This happens when the objects centre of
gravity is on the axis of rotation.
11. Reactive balance:
Recovering from an unexpected perturbation.
Reactive balance is defined as automatic
movement patterns, or strategies, that occur
when balance is disturbed.
They are faster responses than movements
under voluntary control. If the response is
appropriate no loss of balance will occur.
12. Proactive (anticipatory) balance
To develop a device which provides safe,
controlled, simple, and inexpensive.
reactive balance training for adults
Anticipatory - Body recognize that
something is going to happen that will
disturb its balance and make the
adjustments before it happens
13. A Systems Model of Balance1
1Courtesy of Sandra Rader, PT, Clinical Specialist
14. Stability & Balance
Result of interaction of many variables (see
model)
Limits of Stability - distance in any direction
a subject can lean away from mid-line
without altering the BOS
Determinants:
◦ Firmness of BOS
◦ Strength and speed of muscular responses
◦ Range: 80 anteriorly; 40 posteriorly
18. Model Components
Central Set
Past experience may
have created “motor
programs”
CNS may select a
motor program to
fine-tune a motor
experience
19. Model Components
Environmental Organization
Nature of contact
surface
◦ Texture
◦ Moving or stationary?
Nature of the
“surrounds”
◦ Regulatory features of
the environment
(Gentile)
20. Model Components
Motor Coordination
Movement strategies
◦ Based on repertoire of
existing motor
programs
Feedback &
feedforward control
Adjustment/tuning of
strategies
21. Strategies to Maintain/Restore
Balance
Ankle
Hip
Stepping
Suspensory
Strategies are automatic and occur 85 to
90 msec after the perception of instability
is realized
22. Ankle Strategy
Used when
perturbation is
◦ Slow
◦ Low amplitude
Contact surface firm,
wide and longer than
foot
Muscles recruited
distal-to-proximal
Head movements in-
phase with hips
24. Hip Strategy
Used when
perturbation is fast or
large amplitude
Surface is unstable or
shorter than feet
Muscles recruited
proximal-to-distal
Head movement out-
of-phase with hips
26. Stepping Strategy
Used to prevent a fall
Used when
perturbations are fast
or large amplitude -
or- when other
strategies fail
BOS moves to “catch
up with” BOS
27. Suspensory Strategy
Forward bend of
trunk with hip/knee
flexion - may progress
to a squatting position
COG lowered
29. Somatosensory System
Dominant sensory
system
Provides fast input
Reports information
◦ Self-to-(supporting)
surface
◦ Relation of one
limb/segment to
another
Components
◦ Muscle spindle
Muscle length
Rate of change
◦ GTOs (NTOs)
Monitor tension
◦ Joint receptors
Mechanoreceptors
◦ Cutaneous receptors
30. Visual System
Reports information
◦ Self-to-(supporting)
surface
◦ Head position
Keep visual gaze parallel
with horizon
Subject to distortion
Components
◦ Eye and visual tracts
◦ Thalamic nuclei
◦ Visual cortex
Projections to parietal
and temporal lobes
31. Vestibular System
Not under conscious
control
Assesses movements
of head and body
relative to gravity and
the horizon (with
visual system)
Resolves inter-sensory
system conflicts
Gaze stablization
Components
◦ Cerebellum
◦ Projections to:
Brain stem
Ear
33. Body response to sensory input
Normal body response to perturbation(deviation)
(pushing patient forward and back)
A) Mild perturbation: Ankle response (push patient
forward, the calf muscles engage)
B) Moderate perturbation: Hip response (push patient
forward, patient leans back)
C) Large perturbation: Stepping response (patient
steps forward to avoid falling)
35. Age related changes to motor
components of balance
Decreased magnitude of muscle response
Increased reliance of arms
36. Age related changes to sensory
components of balance
Decreased visual, vestibular,
somatosensory (body awareness), and
auditory (hearing) function
Decreased ability to adapt responses (e.g.
using your inner ear and your feet
37. Age related changes to cognitive
components of balance
Decreased overall attention capacity
Decreased ability to multitask (e.g.
carrying a cup of water while walking)
39. Abnormal balance
As the balance system declines, so does
the ability of the system to respond
correctly
Individuals with an increased fall rate did
not use an ankle strategy
40. Abnormal balance
Cerebrovascular accident (CVA)—Stroke
A) Synergistic pattern: Groups of muscles
work together in a “stuck” pattern
B) Increased muscle tone
C) Cognition (e.g. impulsive behavior)
D) Impaired body awareness
41. Abnormal balance
Parkinson’s Disease
A) Dynamic balance problem
B) Difficulty initiating gait
C) Moments of freezing during movement
D) Altered gait cycle
42. Abnormal balance
Benign Paroxysmal PositionalVertigo (BPPV)
A) Calcium crystals stuck in the semicircular
canals in the inner ear.
B) Dependent on head position.
C)Vertigo –sensation that the room is
spinning.
43. Abnormal balance
Orthopedic cases: (Hip or knee replacement)
A) Impaired joint range of motion (alters
center of mass during gait and stance)
B) Altered body awareness (new body part)
45. Valid tools to measure balance
Berg’s Balance scale
Timed up and go test
Functional reach test
Nudge test
Other tests: Hallpixe – Dix Test
46. Balance Tests – Berg Balance Scale
14 item scale for possible 56 points total
• Decrease in Berg score = increased fall risk14
• Score of 56-54, 1 point drop = 3-4% inc. fall risk
• Each point drop from 54-46, = 6-8% increase
• Below 36, fall risk = 100%
• Limitations: does not test reactive balance;
ceiling effect
47. Balance Tests
Timed up and go test12
• Get up from seated position, walk 3 meters,
turn around, walk back to chair
• Adults who took > 30 sec were dependent
in activities of daily living
Functional reach test
• Standing reaching forward with hand
• Highly predictive of falls among older adults3
48. Balance Tests
Nudge test:
• Moving patient forward, back, sideways
• Ankle vs hip, vs stepping strategy
• Test under different conditions: soft surface,
eyes closed, with head movements
Other tests:
• Hallpike - Dix (testing for vertigo),
observational gait analysis, dynamic gait index
49. Treatment of balance
Exercise examples
A) Calf stretch
B) Heel / toe raises
D) Soft surface stance in corner
E) Sitting to standing
50. Resources
Active Life PhysicalTherapy Port Ludlow:
www.activelifetherapy.com
Home Instead Senior Care
www.homeinstead.com/650/Pages/HomeInsteadSeniorCare.aspx
Olympic Area Agency on Aging: www.o3a.org/
ECHHO: http://echhojc.org/
Boeing Bluebills Olympic Peninsula:
www.bluebills.org/olympic.html
Centers for Disease Control and Prevention www.cdc.gov/
National Osteoporosis Foundation » http://www.nof.org/
American Physical Therapy Association: www.apta.org
WA State Dept. Of Health www.doh.wa.gov/
Washington State Falls Prevention web site
www.fallsfreewashington.org
51. References
1.American Geriatric Society, British Geriatric Society,American Academy of Orthopedic
Surgeons Panel on Falls Prevention.Guidelines for the Prevention of Falls in Older Persons. JAGS
49: 664-672, 2001.
2. Centers for Disease Control and Prevention,National Center for Injury Prevention and Control.
Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed
November 30, 2010.
3. Duncan P, Studenski S, Chandler J, Prescott B. Functional Reach: a new clinical measure of
balance. J Gerontol 1990; 45M192-M197.
4. Englander F, HodsonTJ,Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of
Forensic Science 1996;41(5):733–46.trial.The Gerontologist 1994;34(1):16–23.
5. Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–living older adults:
a 1–year prospective study.Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.
6. Hornbrook MC, StevensVJ,Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls
among community–dwelling older persons: results from a randomized trial.The Gerontologist
1994:34(1):16–23
7. Issue Brief (Public Policy Inst (Am Assoc Retired Pers) 2002 Mar;(IB56):1-14.
8. Kochera A. Public Policy Institute,American Association of Retired Persons,Washington, DC,
USA. Falls among older persons and the role of the home: an analysis of cost, incidence, and
potential savings from home modification. 2002.
52. References
9. Morrison, C. Northwest Orthopaedic Institute. Proven Best Practices:Assessment and
Treatment of Patients Who are at Risk for Falls. Gentiva Seminar.Attended October 20,
2006.
10. National Hospital Discharge Survey (NHDS), National Center for Health Statistics.
Available at: www.cdc.gov/nchs/hdi.htm. Assessed September 14, 2011.
11. National Fire Safety Council, Inc., Michiagan Center, MI 49254-0378. Falls Prevention:
Protecting Your Active Lifestyle.
12. Podsiadlo D, Richardson S.The timed “Up and Go” test: a test of basic functional
mobility for frail elderly persons. J Am Geriatr Soc 1991; 39:142-148.
13. Roudsari BS, Ebel BE, Corso PS, Molinari, NM, Koepsell TD.The acute medical care costs
of fall-related injuries among the U.S. older adults. Injury, Int J Care Injured 2005;36:1316-22.
14. Shumway-Cook A,Woollacott M. Motor Control Theory and Practical Applications, 2nd
Ed. Lippincott Williams & Wilkins. Baltimore, MD 2001.
15.Tinetti ME. Clinical Practice. Prevention Falls in Elderly Persons. N Eng J Med 2003;
348:42-49
53. References
16.Washington State Department of Health: Senior Falls Prevention Study 2006
17.York, S. Northwest Orthopaedic Institute. Proven Best Practices:Assessment and
Treatment of Patients Who are at Risk for Falls. Gentiva Seminar.Attended October 20,
2006.
54.
55. Static balance control
◦ Maintaining sitting.
◦ Half-kneeling,
◦ Tall kneeling,
◦ Standing postures on a firm surface,
Balance Training
◦ Tandem, Single-leg stance.
◦ Working on soft surfaces (e.g., foam, sand, grass),
◦ Narrowing the BOS, moving the arms, or closing the eyes.
56. Dynamic Balance Exercises Using
Movable Surfaces:
1. Swiss Ball
1. Tilt Boards
Balance Training
57. Hard surfaces.
Maintain static balance.
Move some part (s) of body and try to maintain his
balance.
Open then closed eyes.
External challenge from therapist.
Throw and catch exercises with ball.
Soft surfaces.
Maintain static balance.
Move some part (s) of body and try to maintain his
balance.
Open then closed eyes.
External challenge from therapist.
Throw and catch exercises with ball.
