Balance
Review
 Theoretical Background of the balance system
 Assessment
 Objective Measures
 Treatment Strategies
Theoretical Background
 Balance consists of the ability to:
 Actively hold a position
 Move oneself in a position
 React to externally produced forces
Balance
 The Sensory System
 The Motor System
 Central Integration
Sensory System
 Visual Input
 Provides information about body relative to environment
 Very important when support surface is unstable or there is
proprioception deficit
 Is susceptible to incorrect interpretation of reality (Sensory
conflict)
Sensory System
 Somatosensory/Proprioceptive Input
 Involves muscle spindles and receptors in feet
 Provides information of body parts with respect to each other
and with respect to surface
 Can give false information from a compliant surface (not as
conflicting as inaccurate visual information)
Sensory System
 Vestibular Input
 Provides information about position of head with respect to
gravity, linear acceleration and angular acceleration
 Primary role is precise control of head and eye movements
 Not affected by changes in support surface or visual conflict
 More reliable information than other senses, resolves conflicts
of other sensory systems when dynamic visual environment or
challenging support surfaces present
Motor System
 Ankle Strategy
 Most effective when: surface is solid, non-compliant
 base of support is large (at least size of feet)
 perturbations are small and slow
 Muscle activation is distal to proximal
 Forward perturbation activates gastrocs, hamstrings, paraspinals
 Backward perturbation activates tib ant, quads, and abdominals
Motor System
 Hip Strategy
 Most effective when compliant surface; narrow base; large
perturbations
 Muscle activation is proximal to distal
 Forward perturbation activates abdominals and quads
 Backward perturbation activates paraspinals and hamstrings
Motor System
 Stepping Strategy
 Activated if large or fast perturbations that can’t be dealt with
by hip, ankle or combination of these strategies
 Central Integration
 The body needs to know where the centre of gravity is at any
given time
Assessment
 General guidelines
 gradually increase the degree of difficulty by
 Progressing from static to dynamic balance
 From wide base to narrow base
 From minimal displacement to maximal
Assessment
 Subjective
 questions re falls history (frequency, cause etc.)
 awareness of falling
 dizziness, footwear, vision
 questions to eliminate VBI, hypotension
 medications
Assessment
 Objective
 SITTING BALANCE
 Alignment
 Hold position –time
 Head movements
 Turn body
 Touch quadrants
 Touch toes
 Touch floor at side
 Lift leg
 Moving base
 External displacement
Assessment
 Static Standing Tests
 Alignment
 Feet apart, eyes open – time
 Feet together, eyes open
 Stride stance
 Feet apart, eyes closed
 Feet together, eyes closed
 Single leg stance, L) & R) – time
Assessment
 Dynamic Standing Test
 Head movements
 Turn body
 Touch head
 Touch quadrants
 Step and touch L) & R)
 Pick up object from floor
 Turn 360 degrees
 Walk on a mat
 Stand on a balance board
Objective Measures
 Static Tests
 Not useful for predicting fallers
 Single Limb stance normative data :
 Mean age 75 years: Eyes open - 14 seconds
 Eyes closed – 4 seconds
 79 years – 2-3 seconds
 Has a significant correlation with hip strength
 No significant difference between fallers and non-fallers
Objective Measures
 CTSIB (Clinical Test for Sensory Interaction on
Balance)
 Condition 1: Eyes open, firm surface
 Condition 2: Eyes closed, firm surface
 Condition 3: Visual conflict dome, firm surface
 Condition 4: Eyes open. Foam surface
 Condition 5: Eyes closed. Foam surface
 Condition 6: Visual conflict dome, foam surface
Objective Measures
 Self Generated Perturbations
 Functional Reach
 Need to standardize foot position
 Significant difference between fallers and non-fallers
 25cms for healthy elderly
 15cms for fallers
Objective Measures
 Functional Step Test
 Number of steps up onto a small block in 15 seconds
 Usually 7.5cm block
 Must get whole foot onto block and back down again
 CVA average – 4 in 15 seconds (harder to load affected leg)
 Healthy elderly average – 19 in 15 seconds
 Also depends on co-ordination of non-stance leg, and strength
of hip abductors in stance leg
Objective Measures
 Functional Performance Tests
 Timed up and Go Test
 Normative data 75 years – 8.5 seconds
 Fallers – 20 – 30 seconds
 Fukuda Stepping Test
 Abnormal: Rotate > 45o in direction of peripheral vestibular
problem, travel > 1.5m
Objective Measures
 External Perturbations
 Sternal Push and Thoracic Push Test
 Pastor Day and Marsden Scale
 0 staying upright, without taking a step
 1 one step backwards
 2 more than one step
 3 several steps backward plus the need to be caught
 4 falling backwards without attempting to step
Retraining/ Treatment Strategies
 tailored to the individual deficit
 functional retraining
 Practice motor strategies
 Must use outcome measures
 Home exercise programmes
 Frequency of exercise is at least once daily, 4-5 exercises, 20-30
repetitions
 Usually need to do over several months before improvements
noticed.
 Balance retraining must provide a challenge to the balance
system. Use of hand support negates this.