BALANCE

Postural orientation –The control of relative

positions of the body parts by skeletal muscles
with respect to gravity and each other.

Postural stability :the condition in which all the

forces acting on the body are balanced such
that the center of mass (COM)is with in the
stability limits or boundaries of BOS
 DEFINITION

Balance is the ability to maintain the equilibrium

or
It is the ability to maintain center of gravity (COG)
over the base of support (BOS)

Overall goal of balance

control system to give
Stability and function ,
achieved through integrated CNS system of
control
 Balance
 Foundation of coordination
 Center of gravity (COG) constantly shifts over
base of support (BOS)
 If sway exceeds limits of stability = compensation
 If sway is within limits of stability = postural
stability
 Musculo-
skeletal
Neuro- Components Body
muscular Schema
Synergies

BALANCE
Sensory Reactive
Systems Mechanisms

Proactive Anticipatory
Mechanisms Mechanisms
(external) (internal)
 postural stability
 Ability to maintain the COG within stability
limits.
 Normal anterior/posterior sway – 12 degrees
from most posterior-anterior position.
 Lateral sway 16 degrees from side to side.
 If sway exceeds boundaries, compensation is
employed to regain balance. A smaller
envelope is created and tolerated
Envelope of Sway
The maintenance of balance is based
on an intrinsic cooperation between
the
 Vestibular system
 proprioceptive,
 tactile information
 vision
not only depends on the integrity of the
systems but also on the sensory
integration with in the CNS, visual and
spatial perception, effective muscle
strength and joint flexibility
 Triad of balance
• Somatosensory
 Free nerve endings
 Golgi ligament endings
 Muscle spindles
 Difference

Visual Vestibular
Provides sensory information Provides information
regarding the position of the regarding orientation of
the head in space and
head relative to the
acceleration.
environment, and orients
the head to maintain level
gaze.
 Response Strategies
• Ankle Strategy
 Used when displacements are
small.
 Displaces COG by rotation
about the ankle joint.
 E.g., Posterior displacement of
COG – Dorsiflexion at ankle,
contraction of anterior tibialis,
quadriceps, abdominals.
 Anterior COG displacement –
Plantar flexion at ankle,
contraction of gastrocnemius,
hamstring, trunk extensors.
• Hip Strategy
 Employed when ankle motion is
limited, displacement is greater,
when standing on unstable surface
that disallows ankle strategy.
 Preferred when perturbation is
rapid and near limits of stability.
 Post. Displacement COG –
Backward sway, activation of
hamstring and paraspinals.
 Ant Displacement COG – Forward
sway, activation of abdominal and
quadricep muscles.

Stepping Strategy If displacement is large

enough, a forward or backward step is used to
regain postural control
• Hip Strategy
 Employed when ankle motion is limited, displacement is
greater, when standing on unstable surface that disallows
ankle strategy.
 Preferred when perturbation is rapid and near limits of
stability.
 Post. Displacement COG – Backward sway, activation of
hamstring and paraspinals.
 Ant Displacement COG – Forward sway, activation of
abdominal and quadricep muscles.

Stepping Strategy
 If displacement is large enough, a forward or
backward step is used to regain postural
control
In the normal individual, balance is maintained
almost completely at a subconscious level.

In retraining a patient’s balance ,the patient

trained to react to stimuli rather than to make a
conscious, voluntary effort to maintain
equilibrium

Balance, therefore, is the basis of all static or

dynamic postures and should be considered
when planning any exercise or rehabilitation
programme
 Balance reaction can also be used to facilitate
the contraction of selected muscle groups and
as part of a muscle-strengthening programme

 Static balance and dynamic balance

 Treatment of balance impairment requires a

detail examination to determine the system
at fault.
Causes of balance impairment

 Injury to or diseases of the structures (e.g.

eyes, inner ear, peripheral receptors, spinal
cord, cerebellum, basal ganglia, cerebrum)

 Damage to Proprioceptors

 Injury to or pathology of hip, knee, ankle, and

back have been associated with increases
postural sway and decreased balance

 Lesions produced by tumor , CVA, or other

insults that often produced visual field losses
 Assessments of posture can Provide useful
information about functional balance

 Observe balance during quite standing

 During movt from one posture to another
 Assess the amount of help subject need to maintain
the position
 Apply pressure to the trunk in various direction
,encourage subjects to hold the position (or say don’t
let me move you )
 Test subject ‘Automatic reaction' to balance
disturbance by moving them.
 Clinical evaluation of balance
Functional balance test

Traditional Test for balance is

Static balance

Dynamic balance

•Static balance - Double limb stance,

Single limb stance,
Tandem stance
Romberg test
Sharpened Romberg test.
Standing in tandem position with eye open to eye closed
Dynamic balance – Standing Up
Walking
Turning
Stopping

Subjective grading Scales are

Normal Absent
Good Impaired
Fair present
Poor
Absent
Standardized tests and measures of balance

Functional reach test

Berg balance scale

Functional reach test : (Duncan et al.)
Test of dynamic standing balance
Def : The maximal distance one can reach
forward beyond arm’s length while maintaining
a fixed BOS in standing position.
Reference scale
20 to 40 yrs: 14-17 inches
41 to 69yrs: 13 to 16 inches
70to 87yrs : 10-13
 Berg balance scale

Test for both static and dynamic balance

Scale consists of 14 functional task commonly performed
in everyday life
 Ranging from sitting to standing , standing to sitting.

Variation in standing position

( Eyes closed, feet together,reaching forward,
- Retrieving an object from the floor
- Turning
- Standing on one foot
- Place foot on the stool.)

Scoring by 5 point ordinal scale ranging from 0 to 4

The Performance –oriented mobility test by

Tinetti et al

Assessment for

 position changes,

response to perturbations and

Gait movement during ADL

` Scales range fro 0-2

Get Up and Go (GUG) test by Mathias et al

Measures basic mobility and balance

Scored using 5-point ordinal scale with

scores from
1 - Normal(no risk of falling)

2 - Very slightly abnormal

3 - Mildly abnormal

4 - Moderately abnormal

5 - Severely abnormal (high risk of

falling)
Equilibrium reactions 

Ensures body posture when a change occurs in

supporting surface there are two components

Place the subject supine or standing or on a tilting

table.,

the initial observation is a stretching out of the

extremities to the side which the tipping is occurring,
accompanied by slight abduction . gradually ,
compensatory abduction of the leg and the arms to
opposite side takes place .
 ACTIVTIES FOR TREATING BALANCE
IMPAIRMENT

To determine the cause of the impairment

Mode a variety of mode can be used to treat

balance impairment
 Begin with weight shifts on a stable
surface
Gradually increase sway
Increase surface challenges (mini-tramp,
etc.)
Any cause of impairment such as

Weakness
Decreased mobility
Pain should be treated first .
Rehabilitation balls ,foam rollers ,foam
surfaces are often used to
• Provide uneven or unstable surface for
exercise
• Sitting balance ,trunk stability, and weight
distribution can be trained on a chair,table
,or therapeutic ball

 Pool is an ideal palace for training balance

Posture Awareness of posture and the position of
the body in space
is fundamental to balance training
Begin in supine or seated position
Over sessions, use a variety of arm positions,
unstable surfaces, single leg stances, etc.

Mirrors can provide postural feedback –Visual

feedback
Movement

Training for both Static posture & Dynamic posture

Environment -the environment for balance training

depends on the Patient's situation

For the frail elderly or those with significant

balance impairment , most of the training activity
takes place in clinic

For athletes or other active individual with

Musculoskeletal cause of balance impairment,
balance activity can be carried at home
 movt
 Adding movement patterns to acquired stable
static postures increases balance challenge.
 Add ant./post. sway to increase stability
limits.
 Trunk rotations and altered head positions
alter vestibular input.
 PNF techniques during trunk rotation.
 Stepping back/forward assists in re-
stabilization exercises.
Sequence –Progression of exercise from simple to
complex involves
BOS – Advance from wide to narrow base
Posture – Stable to unstable posture (sway)
Visual – Closing of the eyes
COG – Greater disruption to elicit hip or stepping
strategy
Progress to more dynamic activities, unstable
surfaces, and complex movement patterns

Frequency,intensity,and duration – It of less issue

PRECAUTIONS

Patients safety
A gait belt
Parallel bars

CONTRAINDICATION

Cognitive impairment

Patients education