Balance & Postural Equilibrium

Factors

impacting balance

Muscular

weakness Proprioceptive deficits ROM deficits

Terminology

Balance - Process of maintaining bodys CoG within base of

support

Bodys CoG rests slightly above the pelvis Ability to align body segments against gravity to maintain or move the body within the available base of support without falling (Kisner &
Colby, 2002, 4th ed.)

Postural equilibrium - broader term that incorporates

alignment of joint segments

Strength is emphasized before proprioception in rehab because strength influences balance

Proprioception bodys ability to transmit position sense,

Maintaining CoG (Center of Gravity) within the limits of stability (LOS)

interpret info & respond consciously/unconsciously to stimulation

Coordination smooth pattern of activity is produced through a combo of muscles acting together with appropriate intensity & timing Agility ability to control the direction of a body or segment during rapid movement

Postural Control System

3 Components of the system

Sensory detection of body motions

Visual Vestibular Somatosensory inputs

Integration of sensorimotor information within the CNS Execution of musculoskeletal responses

Balance is both a static & dynamic process

Control of Balance

Tall body vs. Small base of support

Balance relies on network of neural connections

Postural control relies on feedback

CNS involvement

Sensory organization

Determines timing, direction & amplitude of correction based on input System relies on one sense at a time for orientation Collection of processes that determine temporal sequencing & distribution of contractile activity

Muscle coordination

Sensory Input

Vision

Measures orientation of eyes & head in relation to surrounding objects Helps maintain balance

Vestibular

Provides info dealing with gravitational, linear & angular accelerations of the head with respect to inertial space Minor role when visual & somatosensory systems are operating correctly
Provides info concerning relative position of body parts to support surface & each other

Somatosensory

Somatosensation = Proprioceptive system

Specialized variation of the sensory modality of touch, encompassing joint sense (kinesthesia) & position Process

Input from mechanoreceptors Stretch reflex triggers activation of muscles about a joint because of perturbation Results in muscle response to compensate for imbalance and postural sway Muscle spindles sense stretch in agonist, relay information afferently to spinal cord Information is sent back to fire muscle to maintain postural control

Body position in relation to gravity is detected by sensory input

Balance movements involve a number of joints

Ankle Knee Hip Coordinated movement along kinetic chain

Prentice, 2004, 4th ed.

Balance relating to the CKC

Kinetic chain

Each moving segment transmits forces to every other segment Maintaining equilibrium involves the closed kinetic chain
(foot = distal segment fixed beneath base of support)

Automatic postural movements

Determined via indirect forces created by muscles on neighboring joints Series of joint strategies are involved to coordinate movement

Injury to joints or corresponding muscles can result in loss of appropriate feedback

Steadiness - Ability to keep body as motionless as

possible

Measure of postural sway

Postural sway

Deviation from Center of Pressure, Balance & Vertical Force (CoP, CoB, or CoF) Determined using mean displacement, length of sway path, length of sway area, amplitude, frequency and direction relative to CoP

Symmetry - Ability to distribute weight evenly between 2 feet in upright stance. Measures: Center of Pressure (CoP) Center of distribution of the total force applied to the supporting surface Center of Balance (CoB) Point between feet where the ball & heel of each foot has 25% of the body weight Relative weight positioning Center of Vertical Force (CoF) Center of vertical force exerted by the feet against the support surface

Balance Deficiencies - Inappropriate interaction

among 3 sensory inputs

Balance Disruption

2 Factors that Disrupt Balance

Position of CoG relative to base of support is not accurately sensed Automatic movements required to maintain the CoG are not timely/effective

In the event of contact, the body must be able to determine what to do in order to control CoG

Joint mechanoreceptors initiate automatic postural response

Selecting Movement Strategies during Balance Disruption

Joints (Ankle, Knee & Hip) involved allow for a wide variety of postures that can be assumed in order to maintain CoG

Forces exerted by pairs of opposing muscles at a joint to resist rotation (joint stiffness) Resting position & joint stiffness are altered independently due to changes in muscle activation Myotatic or Stretch Reflex is earliest mechanism for activating muscles due to externally imposed joint rotation

Ankle Strategy

Hip Strategy

Shifts CoG by maintaining feet & rotating body at a rigid mass about the ankle joints

Gastrocnemius or tibialis anterior are responsible for torque production about ankle Anterior/posterior sway is counteracted by gastrocnemius & tibialis anterior, respectively

Effective for slow CoG movements when base of support is firm & within LOS Also effective when CoG is offset from center

Relied upon more heavily when somatosensory loss occurs & forward/backward perturbations are imposed or support surface lengths are altered Aids in control of motion through initiation of large & rapid motions at the hip with anti-phase rotation of ankle Effective when CoG is near LOS perimeter & when LOS boundaries are contracted by narrower base of support

Stepping Strategy

Utilized when CoG is displaced beyond LOS Step or stumble is utilized to prevent a fall

Instance of musculoskeletal abnormality

Damaged tissue result in reduced joint ROM causing a decrease in the LOS & placing individual at a greater risk for fall Research indicates that sensory proprioceptive function is affected when athletes are injured

Subjective Assessment

Assessment of Balance

Romberg Test traditional assessment

Balance Error Scoring System (BESS)

Google Images

Prentice, 2004, 4th ed.

Semi-dynamic & dynamic tests

functional reach tests timed agility tests carioca hop test Timed T-band kicks Timed balance beam walks (eyes open & closed)

Objective Assessment

Balance systems

Provide for quantitative assessment & training static & dynamic balance Easy, practical & cost-effective Utilize to assess:

Possible abnormalities due to injury Isolate various systems that are affected Develop recovery curves based on quantitative measures in order to determine readiness to return Train injured athlete Vertical position of CoG is calculated Vertical position of CoG movement = indirect measure of postural sway

Computer interfaced force-plate technology

Force plate measures Steadiness, symmetry, dynamic stability Total force applied to the platform fluctuates due to body weight and inertial effects of body movement Forces based on motion of CoG Allows for static & dynamic postural assessment Single or double leg stance, eyes opened or closed Moving visual surround for sensory isolation & interaction

Prentice, 2004, 4th ed.

Dynamic stability - Ability to transfer

vertical projection of CoG around a stationary supporting base

Perception of safe limit of stability Some are systematic while others are unpredictable & determined via changes in subject sway

Utilization of external perturbation

Athlete should maintain their CoP near A-P and M-L midlines

Injury & Balance

Stretched/damaged ligaments fail to provide adequate neural feedback, contributing to decreased balance & proprioception

May result in excessive joint loading Could interfere with transmission of afferent impulses Alters afferent neural code conveyed to CNS Decreased reflex excitation

Caused via a decrease in proprioceptive CNS input May be the result of increased activation of inhibitory interneurons within the spinal cord

All of these factors may lead to progressive degeneration of joint & continued deficits in joint dynamics, balance & coordination

Ankles

Joint receptors believed to be damaged during injury to lateral ligaments

Less tensile strength when compared to ligament fibers Results in deafferentation and signaling via afferent pathways Articular deafferentation reason behind balance training in rehabilitation

Orthotic & bracing intervention

Enhancement of joint mechanoreceptors to detect perturbations & provide structural support for detecting & controlling sway

Modify movement strategies to enhance proprioceptive input Altered biomechanical alignment alters somatosensory transmission

Knee Injuries

Ligamentous injury has been shown to alter joint position detection

ACL deficient subjects with functional instability exhibit this deficit which persist to some degree after reconstruction May also impact ability to balance on ACL deficient leg

More dynamic testing may incorporate additional mechanoreceptor input results may be more definitive

Head Injury

Balance has been utilized at a criterion variable Additional testing is necessary in addition to balance & sensory techniques Postural stability deficits

Deficits may last several days post-injury Result of sensory interaction problem - visual system not used effectively

Objective balance scores can be used to determine recovery curves for making return to play decisions

Balance Training

Vital for successful return to competition from lower leg injury

Possibility of compensatory weight shifts and gait changes resulting in balance deficits

Functional rehabilitation should occur in the closed kinetic chain nature of sport Adequate AND safe function in the open chain is critical = first step in rehabilitation

Rules of Balance Training

Exercise must be safe & challenging Stress multiple planes of motion Incorporate a multisensory approach Begin with static, bilateral & stable surfaces & progress to dynamic, unilateral & unstable surfaces Progress towards sports specific exercises Utilize open areas Assistive devices should be in arms reach early on Sets and repetitions

2-3 sets, 15 30 repetitions or 10 of the exercise for 15 30 seconds later on in the program

Classification of Balance Exercises

Static

CoG is maintained over a fixed base of support, on a stable surface Person maintains CoG over a fixed base of support while on a moving surface Person transfers CoG over a fixed base of support to selected ranges and or directions within the LOS, while on a stable surface Maintenance of CoG within LOS over a moving base of support while on a stable surface (involve stepping strategy) Same as dynamic with inclusion of sports specific task

Semi-dynamic

Dynamic

Functional

Phase I

Non-ballistic types of drills Static balance training Bilateral to unilateral on both involved & uninvolved sides Utilize multiple surfaces to safely challenge athlete & maintaining motivation With & without arms/counterbalance Eyes open & closed Alterations in various sensory information ATC can add perturbations Incorporation of multiaxial devices Train reflex stabilization & postural orientation
Prentice, 2004, 4th ed.

Phase II

Transition from static to dynamic Running, jumping and cutting activities that require the athlete to repetitively lose and gain balance in order to perform activity Incorporate when sufficient healing has occurred Semi-dynamic exercised should be introduced in the transition

Involve displacement or perturbation of CoG Bilateral, unilateral stances or weight transfers involved Sit-stand exercises, focus on postural

Bilateral Stance Exercises

Prentice, 2004, 4th ed.

Unilateral Semidynamic exercises

Emphasize controlled hip flexion, smooth controlled motion Single leg squats, step ups (sagittal or transverse plane) Step-Up-AndOver activities Introduction to Theraband kicks Balance Beam Balance Shoes
Prentice, 2004, 4th ed.

Phase III

Dynamic & functional types of exercise Slow to fast, low to high force, controlled to uncontrolled Dependent on sport athlete is involved in Start with bilateral jumping drills straight plane jumping patterns Advance to diagonal jumping patterns

Increase length and sequences of patterns Pain & fatigue should not be much of a factor

Progress to unilateral drills

Can also add a vertical component to the drills Addition of implements

Tubing, foam roll

Final step = functional activity with subconscious dynamic control/balance

Phase III Exercises

Prentice, 2004, 4th ed.

References

Prentice, W.E. (2004). Rehabilitation Techniques for Sports Medicine and Athletic Training, 4th ed., McGraw-Hill Houglum, P.A. (2005). Therapeutic Exercise for Musculoskeletal Injuries, 2nd ed., Human Kinetics. Kisner, C. & Colby, L. (2002). Therapeutic Exercise Foundations & Techniques, 4th ed., F.A. Davis. http://www.google.com - Images