Balance define
A state whereby the projection of the COM falls within the stability limits of the BOS
Postural control define
control of posture and movement in attaining a state of balance
Aims of postural control
– Postural equilibrium/ stability (maintain upright position and maintain COM within stability limits of BOS during internally and externally initiated movement)
– Postural orientation (gravity, vertical, internal references, the environment)`
Balance =
sensory input, integration of input and motor output
sensory input
Vestibular
visual
proprioceptive
integration of input
the cerebellum
the cerebral cortex
the brainstem
motor output
vertibular ocular relfex
motor impulses to control eye movements
motor impulses to make postural adjustments
movement strategies
ankle
hip
step
outstretched arm
Common impairments in neurological patients - motor dysfunction
musculoskeletal - decr muscle strength, trunk instability, decr ROM, altered muscle tone
Biomechanics- decr stability limits, decr balance response (magnitude and velocity), altered movement strategies
Common impairments in neurological patients - Sensory Dysfunctions
Altered Sensation-
↓ ankle proprioception, vestibular system damage, dizziness, visual deficits
Altered Sensory Integration-
Difficulty dividing attention between tasks, impaired ability to use sensory weighting, delayed or inadequate anticipatory response, altered perceived stability limits, abnormal perception of vertical via somatosensory systems
Setting an appropriate balance task
- Create a safe situation (environment, assistance)
- Incorporate various environmental contexts and tasks
- Challenge their behaviour (↓BOS, raise COM, displace COM towards stability limits, unstable surface, alter visual input)
- Assess all aspects of balance responses (posture and movement, balance strategies/ reactions, planes of movement
Observe the patient performing the balance task
- Can they balance in a specific posture?
- Can they balance during movement?
- If they can balance, what strategies do they use to achieve balance?
- Does the patient use compensatory strategies to maintain balance?
- Are these compensations effective?
- Is the goal completed successfully?
- Do they interact with their BOS during their movement?
- What happens to the balance if sensory input is reduced?
Outcome measures for balance
- Tinetti balance
- Berg balance scale
- BOOMER
- Romberg’s test/ Sharpened Romberg’s
- CTSIB
- Functional reach test
- Functional activities
- Sitting: supported sitting, sitting arm raise, sitting forward reach
- Standing: supported standing, standing arm raise, standing forward reach, static tandem standing, weight shift
- Walking; timed 5m walk, tap and step
Balance training
• Trained simultaneously as part of functional motor actions
– Sitting, standing, mobility and transfers
– Control and stability of the COM is specific to each task and the conditions in which it is carried out
• Increasing evidence that challenging balance in standing, with the aim of reducing the BOS and practicing controlled movements of the COM is the optimal way to improve balance during performance of everyday actions
• Mobility requires accurate sense of balance, sufficient lower limb strength, and sufficient soft tissue extensibility and joint flexibility
• Training programmes should include exercises that require a fast build of force and propulsive muscle activity (power)
• Strength relates directly to functional motor control and both can be improved by intensive and functional based training that is challenging for the individual
– Progress to extend capabilities of patient
– Functional tasks strengthen muscles concentrically and eccentrically
– Increase intensity by increasing repetitions, increasing step height, lowering chair height, reducing hand support etc
• Maximise skill through progressively challenging the tasks according to destabilising effects (e.g. complex environments, unpredictable demands)
