BALANCE

AIBEL JOHNSON
MPT 1ST YEAR
Balance or postural stability is a generic term used to describe the
dynamic process by which the body's position is maintained in
equilibrium.
Balance is defined  as the ability to control the body mass or centre
of gravity to the base of support in order to maintain a upright
posture or a functional equilibrium in dynamic activities.
But recent researches have change this definition emphasizing on
various factors affecting balance.
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.
Key terms
 Center of mass
 Center of gravity
 Momentum
 Base of support
 Limits of stability
 Ground reaction force
 Center of pressure
1)Center of mass
 The COM is a point that corresponds to the center of the total body mass and
is the point at which the body is in perfect equilibrium.

2)Center of gravity
 The COG refers to the vertical projection of the center of mass to the ground.
 COG of most adult humans is located slightly
anterior to the second sacral vertebra or
approximately 55% of a person's height
3)Momentum
 It is the product of mass times velocity.
 Linear momentum relates to the velocity of the body along a straight path.
 Angular momentum relates to the rotational velocity of the body.
4)Base of support 
 It refers to the area beneath an object or person that includes every point of
contact that the object or person makes with the supporting surface. These
points of contact may be body parts e.g. feet or hands, or they may include
things like crutches or the chair a person is sitting in.
5)Limits of stability
 It refers to the sway boundaries in which an individual can maintain
equilibrium without changing his or her BOS .
 The normal sway angle in the antero-posterior direction and medio-lateral
direction is approximately 12.5° and 16° respectively.
 This area of stable swaying is often referred to as the 'Cone of Stability'.
 The limits of this cone of stability keep changing constantly depending on the
task being performed.
6)Ground reaction force
 It is the force exerted by the ground on a body in contact with it.
 When a person is just standing, the GRF corresponds with the person’s
weight.
 When the body is moving, the GRF increases due to acceleration forces.
 For example, while running, the GRF increases to up to two or three times the
body weight.
7) Center of pressure
 It is the location of the vertical projection of the ground reaction force.
 It is equal and opposite to the weighted average of all the downward forces
acting on the area in contact with the ground.
COP is a reflection of the body's neuromuscular responses to imbalances of
the COG. A force plate is traditionally used to measure Ground reaction
forces (in Newtons [N]) and COP movements (in meters [m]).
Balance is the greatest when the bodys center of mass or center of gravity
is maintained over its base of support.
Equilibrium is a state of balance in which all forces are equal.
It means the body is either at rest(static equilibrium) or in steady state
motion(dynamic equilibrium)
BALANCE CONTROL 
It is defined as the act of maintaining, achieving or restoring a state
of balance during any posture or activity.
Balance control requires the interaction of the nervous and musculoskeletal
systems and contextual effects.
NERVOUS SYSTEM
It provides;
(1) sensory processing for perception of body position/Movement orientation in space 
(2) sensorimotor integration the capability of the CNS to integrate different sources of
stimuli, and parallelly, to transform such inputs in motor actions. 
(3) motor strategies for planning, programming, and executing balance responses. 
MUSCULOSKELETAL SYSTEM
It include postural alignment, musculoskeletal flexibility such as ROM, joint integrity,
muscle performance and sensation.
CONTEXTUAL EFFECTS
It interact with the two systems are the environment (closed or open) and support
surface the amount of lighting, effects of gravity and inertial forces on the body, and
task characteristics.
• MECHANISM OF BALANCE CONTROL
SENSORY SYSTEMS AND BALANCE CONTROL
Perception of one’s body position and movement in space require a
combination of information from peripheral receptors in multiple sensory
systems, including the visual, somatosensory and vestibular system
VISUAL SYSTEM
The visual system provides information regarding
(1) the position of the head relative to the environment
(2) the orientation of the head to maintain level gaze
(3) the direction and speed of head movements
Visual stimuli can be used to improve a person’s stability when
proprioceptive or vestibular inputs are unreliable by fixating the gaze on an
object.
SOMATOSENSORY SYSTEM
The somatosensory system provides information about the position
and motion of the body and body parts relative to each other and the
support surface.
 Muscle spindles and Golgi tendon organs (sensitive to muscle
length and tension).
 Joint receptors (sensitive to joint position, movement, and stress).
 Skin mechanoreceptors(sensitive to vibration, light touch, deep
pressure, skin stretch).
These are the dominant sensory inputs for maintaining balance when
the support surface is firm, flat, and fixed.
VESTIBULAR SYSTEM
• The vestibular system uses motor pathways originating from the vestibular
nuclei for postural control and coordination of eye and head movements.
• The vestibular system generates compensatory responses to head motion via:
• Postural responses (Vestibulo-Spinal Reflex) - keep the body upright and
prevent falls when the body is unexpectedly knocked off balance.
• Ocular-motor responses (Vestibulo-Ocular Reflex) - allows the eyes to
remain steadily focused while the head is in motion.
• Visceral responses (Vestibulo-Colic Reflex) - help keep the head and neck
centred, steady, and upright on the shoulders.
• To achieve this the vestibular system measures head rotation and head
acceleration through semicircular canals and otolith organs (utricle and
saccule).
The vestibular system provides information about the position and
movement of the head with respect to gravity and inertial forces. 
Receptors in the semicircular canals (SCCs) 
- 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.
- Responds to slow head movements.
SENSORY ORGANIZATION FOR BALANCE CONTROL
Somatosensory information has the fastest processing time for
rapid responses followed by visual and vestibular inputs.
When sensory inputs from one system are inaccurate owing to
environmental conditions or injuries→ decrease the information
processing rate →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. 
Incoming sensory information is integrated and processed in the
cerebellum, basal ganglia, and supplementary motor area.
Types of Balance Control 
(1)Static balance control 
to maintain a stable antigravity position while at rest such as when
standing and 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 such as sit-to-stand transfers or walking. 
(3)Automatic or Reactive postural reactions 
to maintain balance in response to unexpected external perturbations,such
as standing on a bus that suddenly accelerates forward. Four common
postural strategies(ankle strategy,hip strategy,suspensory strategy,stepping
strategy)
(4)Anticipatory postural control 
Similar to automatic but occur before an actual stimulus.
Involve a postural set to offset forces.
Functioning anticipatory reactions limit need for rapid reactive responses.
e.g., maintaining balance while sitting on a ball or standing on a balance
beam
(5)Volitional postural movements
Under conscious control
Weight shifts
Trained responses,like those in gymnastics or advanced sport activities.
Motor Strategies for Balance Control 
Ankle Strategy (Anteroposterior Plane)
Hip Strategy
Stepping Strategy
Suspensory strategy
(1)Ankle Strategy (Anteroposterior Plane) 
Used when displacements are small. 
Displaces COG by rotation about the ankle joint.
Example,
Posterior displacement of COG
• Dorsiflexion at ankle
→ contraction of anterior tibialis, quadriceps, abdominalis.
Anterior COG displacement 
• Plantarflexion at ankle
• →contraction of gasterocnemius, hamstring, trunk extensors. 
(2)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 paraspinalis
 Ant. Displacement COG-
→ forward sway, activation abdominal and quadriceps
muscles. 
(3)Weight-Shift Strategy (Lateral Plane)
The movement strategy utilized to control mediolateral
perturbations involves shifting the body weight laterally from one
leg to the other.
The hips are the key control points of the weightshift strategy.
They move the COM in a lateral plane primarily through
activation of hip abductor and adductor muscles, with some
contribution from ankle invertors and evertors.
(4)Stepping Strategy 
If a large force displaces the COM beyond the limits of stability  a forward
or backward step is used to enlarge the BOS and regain balance control .
Example of a stepping strategy 
→ The uncoordinated step that follows a stumble on uneven ground
(5)Suspensory strategy
It includes bending knees during standing or ambulation for the purpose of
maintaining a stable position during a perturbation.
Bending of the knees usually lowers the COG to be closer to the BOS,
thereby enhancing postural stability.
For example cricketer uses this strategy while catching the ball.
Factors Influencing Selection of
Balance Strategies 
1. Speed and intensity of the displacing forces 
2. Characteristics of the support surface 
3. Magnitude of the displacement of the COM 
4. Subject's awareness of the disturbance 
5. Subject's posture at the time of perturbation 
6. Subject's prior experiences
IMPAIRED BALANCE 
Impaired balance can be caused by injury or disease to any
structures involved in the three stages of information
processing.
i.e.
→ sensory input
→ sensorimotor integration
→ motor output generation
SENSORY INPUT 
Proprioceptive deficits have been implicated as contributing to
balance impairments following lower extremity and trunk injuries or
pathologies 
Decreased joint position sense has been reported in individuals
with 
 recurrent ankle sprains 
 knee ligamentous injuries 
 degenerative joint disease 
 low back pain.
It is unclear whether decreased joint position sense is due
to changes in joint receptors or in muscle receptors.
Somatosensory, visual, or vestibular deficits may impair
balance and mobility.
Reduced somatosensation in the lower extremities caused
by 
• Peripheral polyneuropathies. 
• In the aged and in individuals with diabetes are associated
with balance deficits and an increased risk for falls.
Visual loss or specific deficits in acuity, contrast sensitivity,
peripheral field vision, and depth perception caused by disease,
trauma, or aging → can impair balance and lead to falls.
Individuals with damage to the vestibular system due to viral
infections, traumatic brain injury (TBI), or aging may
experience vertigo (a feeling of spinning) and postural
instability. 
Patients with severe bilateral loss of vestibular function are
unable to use hip strategies, although ankle strategies are
unaffected.
Sensorimotor Integration 
Damage to the basal ganglia, cerebellum, or supplementary motor
area 
Impair processing of incoming sensory information resulting in
difficulty adapting sensory information in response to environmental
changes.
When stance is perturbed by platform translations, patients with 
→Parkinson's disease tend to have a smaller than normal amplitude of
movement due to co-activation of muscles on both sides of the body, 
→ cerebellar lesions typically demonstrate larger response amplitudes
Biomechanical and Motor Output Deficits 
Deficits in the motor components of balance control can be caused by 
→Musculoskeletal  system impairments
Poor posture, joint ROM limitations, decreased muscle performance 
→ Neuromuscular system impairments 
Impaired motor coordination, pain
Postural malalignment such as the typical thoracic kyphosis of the elderly,that
shifts the COM away from the center of the BOS increases a person's chance
of exceeding his or her limits of stability 
Impaired ROM or muscle strength at one joint can alter posture
and balance movements throughout the entire limb
In individuals with neurological conditions (e.g., stroke,
traumatic brain injury, Parkinson's disease) failure to generate
adequate muscle forces due to 
→abnormal tone 
→impaired coordination of motor strategies 
It may limit the person's ability to recruit muscles required for
balance. 
Deficits with Aging 
In persons over age 65, falls are common and are a major cause of 
→ morbidity
→ mortality
→ reduced functioning
→ premature nursing home admissions.
Declines are found with aging in all sensory system(somatosensory,
vision, vestibular) and three stages of information processing (sensory
processing, sensorimotor integration, motor output).
Anatomical lesions leading to balance
dysfunction: 
1. Lesions of the motor cortex. 
2. Lesions of corticospinal tract. 
3. Lesions of sensory pathways including cerebellum 
4. Lesions of vestibular system. 
5. Loss of compensatory pathways such as vision.
Diagnostic conditions manifested by balance
dysfunction: 
1. Stroke. 
2. Guillain Barré syndrome. 
3. Multiple scelerosis. 
4. Peripheral lesions-receptors in the ear, vestibular nerve. 
5. Ataxia. 
6. Head injury  
Most Common Risk Factors for Falls Among the Elderly
■ Muscle weakness
■ History of falls
■ Gait deficit
■ Balance deficit
■ Use of assistive device
■ Visual deficit
■ Arthritis
■ Impaired activities of daily living
■ Depression
■ Cognitive impairment
■ Age >80 years
Examination and Evaluation of
Impaired Balance
It is important to determine the which component of balance is the cause of
dysfunction
Evaluating the cause of balance of dysfunction guides the therapist in
development of treatment.
The key elements of a comprehensive evaluation of individuals with balance
problems include
1) A thorough history of falls
→ onset of falls is sudden versus gradual;
→ the frequency and direction of falls;
→ The environmental conditions and mode of activities,
→ presence of dizziness, vertigo, or lightheadedness at time of the
fall;
→ current and past medications;
→ presence of fear of falling
(2)Assessments to identify sensory input (proprioceptive,
visual,vestibular)
(3) Assessments to identify sensory processing
(sensorimotor integration, anticipatory and reactive balance control),
(4) Assessments to identify biomechanical
components(postural alignment)
(5) Assessments to identify motor output
(muscle strength and endurance,joint ROM and flexibility, motor
coordination,pain).
(6) Assessments to identify gait and fuctional
performance.
(7) Environmental assessments to determine fall risk
hazards in a person’s home.
• Tests and observations to determine the impact of balance control system.
deficits on functional performance
Vestibular domain-head shaking test,hallpike-dix test,rotatory chair test,DVA
test
Oriention in space-Fukuda step test
Cardiopulmonary domain –six minute walk test,vertebral artery compression
test
Cognitive domain-TUG with dual tasking
Emotional domain-Balance confidence scale dizzness inventory
FICSIT trials
Videonystagmography or balance test (ENG)
→ Electronystagmography is a test used to evaluate the balance portion of the
inner ear and some parts of the brain involved in the balance system. which
provides hearing and helps with balance. The test is used to help determine
what may be the cause of dizziness or vertigo.
Standing Balance
• Flamingo Balance — stand on one leg while balancing on a beam.
• Stork Stand Test — stand on the toes of one leg for as long as possible with the free leg resting on the inside of the
opposite knee.
• Standing Balance Test — stand on one leg for as long as possible.
• One Leg Stand— the US sobriety test, stand with one foot off the ground for 30 seconds.
• Stick Lengthwise Test — balance on a stick for as long as possible, standing side-on on the balls of both feet.
Walking Balance
• Beam Walk
• Balance Beam Test
• Walk and Turn Field Sobriety Test
Dynamic Balance
• Balance Board Test
• Bass Test
• Star Excursion Balance Test
• Y Balance Test
• Multiple Single-Leg Hop-Stabilization Test (MSLHST)
Balance training
It refers to exercises that are designed to improve and maintain balance.
Most balance intervention programs require a multisystem approach.
Goals and outcomes of intervention for patients or clients with balance
problems could include
(1) resolve or prevent impairment;
(2) improve functional balance, particularly during gait;
(3)decrease the risk of falls;
(4) improve the ability to see clearly and focus during head movement or when in
a moving environment;
(5) improve overall general physical condition and activity level;
(6) reduce social isolation caused by fear of falling;
(7) decrease the patient’s disequilibrium and oscillopsia.
Safety During Balance Training
1. Use a gait belt any time the patient practices exercises or activities that challenge
or destabilize balance.
2. Stand slightly behind and to the side of the patient with one arm holding or near
the gait belt and the other arm on or near the top of the shoulder (on the trunk, not the
arm).
3. Perform exercises near a railing or in parallel bars to allow patient to grab when
necessary.
4. Do not perform exercises near sharp edges of equipment or objects.
5. Have one person in front and one behind when working with patients at high risk
of falling or during activities that pose a high risk of injury.
6. Check equipment to ensure that it is operating correctly.
7. Guard patient when getting on and off equipment (such as treadmills and stationary
bikes).
8. Ensure that the floor is clean and free of debris.
BALANCE EXERCISES 

(1)Exercises for weakness-The muscles which are responsible for postural

instability, needs to be strong. This can be achieved by variety of therapeutic
exercises. Such as 
• Active exercises 
• PNF (Proprioceptive Neuromuscular facilitation. 
• PRE (Progressive resistive exercise) 
• Isokinetic etc.
(2)Exercises for movement strategies
If patient exhibits weakness or prior control in a particular strategy, he
should practice positions which facilitate the activation of muscles require
for that strategy. 
For e.g. Patient having poor dorsiflexors finds difficulty in using ankle
strategy for balance.
He should practice following positions to facilitate the dorsiflexors.
a. Sitting on therapeutic ball with feet on the floor, ball is rolled posteriorly by
the therapist, dorsiflexors get activated (equilibrium response).
b. Standing in parallel bar or walker, patient practices leaning posteriorly with
small range in starting and then gradually increasing the range. Same
facilitation is achieved.
(3)Static balance exercises
These are performed to improve control in sitting and standing positions. 
Patient follows the following sequence for developing sitting or standing control (he may skip any step
in which he has good control).
a. Sitting: 
o sitting with two hands support 
o sitting with one hand support 
o sitting unsupported 
o change the sitting surface (hard to soft)
b. Standing: 
o standing in parallel bar with two hands support
o standing with one hand support
o standing unsupported
o change the base of support (wider to narrower) 
o tandem standing (one foot in front of other)  
o standing on one leg
(4)Dynamic balance exercises 
After achieving unsupported sitting, patient is asked to look up and down,
and  from side to side, which activate the vestibular system. 
Reaching activities on same side and then contralateral side both in sitting
and standing position. 
Sitting to standing with both hands support then one hand and then without
any support. Equal weight bearing on both lower extremity should be
facilitated by visual and verbal feedback
Stepping forward and backward can be practised first in parallel bar with one
or two hands then without parallel bar. 
Standing to supine on mat and then move back to standing. Same may be
practised by going to prone position from standing. Each movement activates
the vestibular system in addition to challenging the patient's dynamic balance
 
Trunk dynamic balance and strength can be achieved by throwing and
catching (at head level, overhead and either side) by therapy balls of various
sizes and weights in a variety of positions such as kneeling, half-kneeling,
sitting and standing.
Gait activities should be practised in parallel bar then with assistive devices
(walker - cane) and then without any device.
Patient should practice:
→side stepping
→ walking forward
→ crossing legs
→ walking backward
→ walking on heels
→ walking on toes
Balancing on vestibular board or wobble board may be practised to facilitate
weight-shift in backward/forward and side to side direction (In star ting this
activity may be performed between the parallel bars).
Ball kicking activities should be incorporated to improve stability on one leg
and dynamic movement with other leg.
→ Walking through obstacles.
→ Walking on different surfaces (hard to soft)
→ Walking with various speed (slow to fast). 
(5)Aerobic exerciser
Patient with balance dysfunction become deconditioned because of self
imposed immobility arising from the fear of loosing balance. 
Following acrobic exercise can be performed: 
o Static cycling
o Upper extremity bicycle ergometer
o Walking 
o Jogging 
o Rowing  
o Trampoline etc.
(6)Balance exercises for vestibular dysfunction habituation exercises-
are those which habituate the patient in positions of eliciting symptoms of
vertigo and nystagmus. 
Patient is gradually brought to the desired position, with every change in
position symp toms might reappear. Positions are main tained at every
change until the symptoms disappear. As the symptoms are gone,
the change towards the desired position is again made. Moving through
the full range without symptoms is the ultimate goal of treatment. Patient
may also be moved through the full range if they can tolerate the intensity
of treatment. 
During the first week, only two movements or positions that elicit
symptoms should be addressed. Patient should perform movements and
positioning activities 5 to 10 times and repeat them at atleast 3 times a day
.Gradually, other movements and positions that elicit vertigo can be
added, until all symp toms diminish and patient is free of vertigo.
(7)Exercises for muscle imbalance
Patients with vestibular dysfunction develop muscle imbalance due to strategies to
minimize head and trunk movement that may cause vertigo. 
→For e.g. Sternocleidomastoid, latissimus dorsi might become tight.
(8)Exercises for vestibular-ocular reflex
The vestibular-ocular reflex may be impaired in patients with vestibular dysfunction.
The following exercises may be used to increase vestibular-ocular reflex
a. Visual tracking exercise: Instruct the patient to follow tip of pencil/pen moving in
various direction with head still. Start with small displacement of the pen/pencil, gradually
increase the range. First per form the exercise in sitting then in standing position .Further
the exercise may be performed during walking ascending/descending stairs.
b. In sitting position: Eyes are fixed while the head is moved passively by the thera pist.
First perform slowly, then with increasing speed, progressing to active movement of head. 
Once patient can perform actively, exercise may be performed during standing, walking,
and walking while reading a magazine.
(9)Management for somatosensory loss 
o Modification of external environment. 
o Compensation by visual feedback. 
o Standing and walking barefoot on different textured surfaces. 
o Use of weighted belts, and back support in chairs to improve trunk alignment
which is impaired because of somatosensory loss. 
o Walking with weight tied on knee and ankle joints
o Overuse of visual compensation should be discouraged.
(10)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.
 Progress these activities by working on soft surfaces (e.g.,foam, sand,
grass), narrowing the base of support, moving the arms, or closing the eyes
(11)Dynamic Balance Control
To promote dynamic balance control, interventions may involve the following.
■ 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 a minitrampoline.
■ 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 from out to the side to above the head .
■ Practice stepping exercises starting with small steps, then mini-lunges to full lunges.
■ Progress the exercise program to include hopping, skipping, rope jumping, and
hopping down from a small stool while maintaining balance.
■ Have the patient perform arm and leg exercises while standing with normal stance,
tandem stance, and single-leg stance.
(12)Anticipatory Balance Control
■ Reach in all directions to touch or grasp objects, catching a ball, or kicking a
ball.
■ Use different postures for variation (e.g., sitting, standing,kneeling) and
throwing or rolling the ball at different speeds and heights
■ Use functional tasks that involve multiple parts of the body to increase the
challenge to anticipatory postural control by having the patient lift objects of
varying weight in different postures at varying speeds, open and close doors
with different handles and heaviness, or maneuver through an obstacle course
(13)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.
■ To emphasize training of the ankle strategy, have the patient practice while standing
on one leg with the trunk erect.
■ To emphasize training of the hip strategy, have the patient walk on balance beams or
lines drawn on the floor; perform tandem stance and single-leg stance with trunk
bending;or stand on a mini-trampoline, rocker balance, or sliding board.
■ To emphasize the stepping strategy, have the patient practice stepping up onto a
stool or stepping with legs crossed in front or behind other leg (e.g., weaving or
braiding).
■ To increase the challenge during these activities, add anticipated and unanticipated
external forces. For example, have the patient lift boxes that are identical in
appearance but of different weights; throw and catch balls of different weights and
sizes; or while on a treadmill, suddenly stop/start the belt or increase/decrease the
speed.
(14)Sensory Organization
Many of the activities previously described can be utilized while varying the reliance on specific
sensory systems.
■ To reduce or destabilize the visual inputs, have the patient close the eyes, wear prism glasses, or move
the eyes and head together during the balance activity.
■ To decrease reliance on somatosensory cues, patients can narrow the BOS, stand on foam, or stand on
an incline board.
(15)Balance During Functional Activities
Focus on activities similar to the functional limitations identified
in the evaluation. For example:
■ 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
(16)Health and Environmental Factors 
• Low Vision 
• Sensory Loss 
• Medications 
• Low Vision - encourage regular eye examinations
- Wearing a hat and sunglasses in bright sunlight.
- making sure lights are on when walking about the house at night.
- avoid using bifocal glasses when walking because ,single lens glasses are
safest for improving depth perception and contrast sensitivity, especially on
stairs 
Sensory Loss 
- For individuals with sensory loss in the legs 
• caution them to take extra care when walking on soft carpet or uneven ground .
• use a cane or other device if necessary
- wear firm rubber shoes with low heels
Medications 
Regular medical examinations 
• blood glucose levels - Seek medical attention if they experience any symptoms
of dizziness. 
- Patients should be educated about the influence of certain medications such as
sedatives and antidepressants 
- if such medications are used at night as a sleep aid patients should take extra
precautions when getting up to use the bathroom