BALANCE

BALANCE
• Definition : Balance or postural stability is the
dynamic process by which the body’s position is
maintained in equilibrium

• State of equilibrium is when

the sum of forces acting on a
body equals zero

 Static
 Dynamic
Equilibrium
Center of Mass (COM) –
• A point that corresponds to the center of the total body mass
• The point at which the body is in perfect equilibrium
• Determined by the weighted average of the COM of each
body segment
Center of Gravity (COG) –
• Center of gravity is the point in a body or object
where the force of gravity can be considered to
act. It is the point through which the
gravitational force passes

• The vertical projection of the COM to the ground

• In the anatomical position, the COG is located slightly

anterior to the 2nd sacral vertebra or approx. 55% of a
person’s height
Base of Support :
• The BOS is defined as the perimeter of the
contact area between the body and its
support surface.

• A wide stance increases stability.

• A narrow BOS reduces stability.

Line of gravity :
• It is an imaginary line that
extends from the COG to the
base of support.
Limits of stability :
• Limits of stability refers to the sway boundaries in which an
individual can maintain equilibrium without changing his or
her BOS.

• The anteroposterior sway limit is approximately 12° from

the most posterior to most anterior position.

• Lateral stability varies with foot spacing and height; adults

standing with 4 inches between the feet can sway
approximately 16° from side to side.
Ground Reaction Force :

• The contact between our bodies and the

ground due to gravity is always
accompanied by a reaction called the
ground reaction force.
 Balance Control
• 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. Thus balance control
requires the interaction of the nervous and
musculoskeletal systems and contextual effects.
• Even if all the elements of the neurological
and musculoskeletal systems are operating
effectively a person may fall if the contextual
effects force the balance control demands to be
so high that the person’s internal mechanisms
are overwhelmed.
Physiology of Balance
 Sensory Systems
A combination of information from peripheral
receptors in multiple sensory systems, including;
• The visual
• The somatosensory
• The vestibular
 Visual system
• It provides information regarding :

 the position of the head relative to the

environment;
 the orientation of the head to maintain level
gaze;
 the direction and speed of head movements,
because as your head moves, surrounding
objects move in the opposite direction.
 Somatosensory System
• It provides information about the position and motion of
the body and body parts relative to each other and the
support surface.

• Maintain balance when the support surface is firm, flat,

and fixed.

• Muscle proprioceptors, including muscle spindles and Golgi

tendon organs
• Joint receptors
• Skin mechanoreceptors
 Vestibular System
• It provides information about the position and movement
of the head with respect to gravity and inertial forces.

• Receptors in the semicircular canals detect angular

acceleration of the head - sensitive to fast head
movements.

• Receptors in the otoliths (utricle and saccule) detect

linear acceleration and head position with respect to
gravity - slow head movements.
• The vestibular system uses motor pathways originating from
the vestibular nuclei for postural control and coordination of
eye and head movements.

• The vestibulospinal reflex brings about postural changes to

compensate for tilts and movements of the body through
vestibulospinal tract projections to antigravity muscles at all
levels of the spinal cord.

• The vestibulo-ocular reflex stabilizes vision during head and

body movements through projections from the vestibular
nuclei to the nuclei that innervate extraocular muscles.
• Incoming sensory information
is integrated and processed in
the
cerebellum,
basal ganglia, and
supplementary motor area.

• Somatosensory information
has the fastest processing
time for rapid responses,
followed by visual and
vestibular inputs.
 Sensory Organization

• When sensory inputs from one system are

inaccurate owing to environmental conditions
or injuries that decrease the information-
processing rate, the CNS must suppress the
inaccurate input and select and combine the
appropriate sensory inputs from the other two
systems. This adaptive process is called
sensory organization.
 Types of Balance Control-
1. Static balance control to maintain a stable
antigravity position while at rest ( standing , sitting.)
2. Dynamic balance control to stabilize the body when
the support surface is moving or when the body is
moving on a stable surface.
3. Automatic Postural Reactions to maintain balance in
response to unexpected external pertubations, such as
standing on a bus that suddenly accelerates forwards.
 Motor Strategies for Balance Control
• The CNS uses 3 movement systems to regain
balance after the body is perturbed-
 Reflex, Automatic and Voluntary systems

• Ankle strategy
• Hip strategy
• Stepping strategy
• Others :
1. Weight shift strategy
2. Suspension strategy
3. Combined strategy
 Impaired Balance
• Impaired balance can be caused by injury or
disease to any structures involved in the 3
stages of processing :
1. sensory input
2. sensorimotor integration
3. motor output generation
 Sensory Input Impairments
Proprioceptive deficits or increased postural
sway -
• Lower extremity and trunk injuries
• Recurrent ankle sprains
• Knee ligamentous injuries
• Degenerative joint diseases
• Low back pain
 Somatosensory deficits-
• Peripheral polyneuropathies (aged, diabetic)
• Rely more on hip strategy

 Visual deficits-
• Visual loss
• Specific deficits in acuity, contrast sensitivity , peripheral
field vision, depth perception.

 Vestibular System deficits-

• Viral infections
• Traumatic brain injuries
• Aging
 Sensorimotor Integration
• Damage to Basal Ganglia, Cerebellum or
supplementary motor area .
 Biomechanical and motor output deficits-

• Musculoskeletal system :
poor posture
joint ROM limitations
decreased muscle performance

• Neuromuscular system :
impaired motor coordination
 pain
• Deficits with aging -
 Muscle weakness
 Gait deficit
 Use of assistive device
 Arthritis
 Depression
 Cognitive impairment

• Deficits from medications -

 Hypnotics, sedatives, tranquilisers etc.
 Examination and Evaluation of Impaired
Balance
• A thorough history of falls :
 onset of falls - sudden Vs gradual;
 frequency of fall
 direction of falls
 the environmental conditions,
 activities
 presence of dizziness, vertigo, or light headedness at the
time of fall
 current and past medications
 presence of fear of falling.
• Assessments to identify sensory input, sensory
integration, and biomechanical and motor
impairments contributing to balance deficits.
• Tests and observations to determine the
impact of balance control system deficits on
functional performance.
• Environmental assessments to determine fall
risk hazards in a person’s home.
 Tests and measures to assess the various
types of balance control
• Static Balance Tests :
 The Romberg Test
 The sharpened Romberg
 The Single-Leg Balance Stance Test
 The Stork Stand Test
The Stork Stand
Test
• Dynamic Balance Tests :
 Dynamic Gait index (DGI)
 The Five-times-sit-to-stand test (5*STS)
• Anticipatory Postural Control Tests :
 The Functional Reach Test

• Reactive Postural Control Tests :

 Pushes

• Sensory Organization Tests :

 The Clinical Test of Sensory Integration on Balance
Test (CTSIB)
CTSIB
• Functional Tests :

 Three mobility scales –

1. Tinetti Performance Oriented Mobility Assessment [POMA]
2. Timed Up and Go Test [TUG]
3. Berg Balance Scale
4. Four Square Step Test

 Two gait scales -

1. Dynamic Gait Index
2. Functional Gait Assessment
• Most balance intervention programs require multisytems approach.

• Precautions-
1. Use of gait belt
2. Proper support, stand slightly behind patient.
3. Perform exercises near railing or in parallel bars to allow patient to grab when
necessary
4. Do not perform exercises near sharp edges of equipments or objects.
5. 2 people can assist with patients having high risks of falls.
6. Check equipment functioning before use.
7. Guard patients when getting on and off equipments
8. Ensure clean floors.
 Static Balance Control

• Activities to promote static balance control include having the

patient maintain-
 sitting, half-kneeling, tall kneeling and standing postures on a
firm surface.
• More challenging activities include –
 Practice in the tandem and single leg stance, lunge and squat
positions.
• Progression –
1. Performing these activities on soft surfaces eg foam, sand,
grass.
2. Narrowing BOS
3. Moving arms, or closing eyes.
• Providing resistance via handheld weights or elastic resistance
• Add secondary tasks.( catching a ball, mental calculations).
 Dynamic Balance Control

• 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 mini
trampoline.

• 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 .

• Stepping exercises—then mini lunges—then full lunges.

• Progress– hopping , skipping, hopping down from a small height.

• Progress—normal stance—tandem stance—single leg stance.

 Anticipatory Balance Control

• Reach in all directions to touch or grasp objects , catching a

ball or kicking a ball.

• Use of different postures for variation (eg. Sitting, standing)

and throwing or rolling balls at different speeds and heights.

• Use of functional tasks that involve multiple parts of the

body.
 maneuver through obstacle courses,
 lift objects of varying heights and weights etc.}
 Reactive Balance Control
• Have the patient work to gradually increase the amount of sway
when standing in different directions while on a firm stable surface.

• Emphasize training of ankle strategy

• Emphasize training of hip strategy-[ walk on balance beams,

tandem and single stance with trunk bending]

• Emphasize stepping strategy

• Increase challenge by applying external forces, changing

environment, weights etc.
 Sensory Organization

• To reduce or destabilize the visual inputs –

 have the patient close eyes, wear prism
glasses, or move eyes and head together
during balance activity

• To decrease reliance on somatosensory cues –

 patients can narrow the BOS , stand on foam
or stand on incline board.
 Balance during Functional Activities
• 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
Thank you