Balance Assessment and Treatment

7/29/2019 Balance Assessment and Treatment

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Introduction:

Balance: Control of center of mass over base of support (1)

Center of mass: Center point of each body segment combined(1)

Center of gravity: Vertical projection of center of mass(1)

Base of support: Area of object that is in contact with the ground(1)

Postural control:involves controlling the bodys position in space

for the dual purposes of stability and orientation.(1)

Postural orientation:

Is defined as the ability to maintain an appropriate relationship between the

body and the environment for a task.(1)

stability limits (during quit stance)are defined as:

the area encompassed by the outer edges of the feet in contact with the

ground. These are the boundaries in which the body can maintain its

position without changing the base of support. Stability limits are not

fixed boundaries but change according to the task, the individuals

biomechanics, and various aspects of the environment.(2)

Prerequests for balance:

I)Musculoskeletal components:

include such things as joint range of motion,

spinal flexibility, muscle properties, and biomechanical relationship

among linked body segment.


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II)Neural components essential to postural control encompass: (a)motor processes,

including neuromuscular response synergies; (b)sensory

processes, including the visual, vestibular, and somatosensory systems;

and (c) higher-level integrative processes essential for mapping sensation

to action and ensuring anticipatory and adaptive aspects of postural

control.(2)

strategies for postural control:

Postural motor strategies are the organization of movement appropriate for controlling the body'sposition in space.Sensory strategies organize sensory information from visual, somatosensory,

and vestibular system for postural control. Finally,sensorimotor strategies reflect the rules for

coordinating sensory and motor aspects of postural control.

I)Motor mechanisms for postural control:

A number of factor contribute to our stability in quit stance .First, body alignment can minimize

the effect of gravitational forces, which tend to pull us off center. Second, muscle tone keeps the

body from collapsing in response to the pull of gravity.Three main factor contribute to our

background muscle tone during quiet stance: (a) the intrinsic stiffness of the muscles themselves,

(b) the background muscle tone, which exists normally in all muscles because of neural

contributions,and (c) postural tone, the activation of antigravity muscles during quiet

stance.(5,6,7,8)

I I)Sensory mechanisms related to postural control:

The CNS must organize information from sensory receptorsthroughout the body before It can

determine the bodys position in space.Normally, peripheral inputs from visual, somatosensory

(proprioceptive,cutaneous,and joint receptors), and vestibular systems are available todetect the

body's position and movement in space with respect to gravityand the environment.

(A)Visual inputs:

Visual inputs report information regarding the position and motion of the head with respect tosurrounding objects.visual inputs are not always an accurate source of orientation information

aboutself-motion. Thus, visual information may be misinterpreted by the brain. The

visualsystem has difficulty distinguishing between object motion, referred to as exocentric

motion, and self-motion, referred to as egocentric motion.(3)


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(B)Somatosensory inputs:

The somatosensory system provides the CNS with position and motion information about the

body with reference to supporting surfaces. In addition, somatosensory inputs throughout thebody report information about the relationship of body segments in one another. Somatosensory

receptors include muscle spindles and Golgi tendon organs (sensitive tomuscle length and

tension), joint receptors (sensitive to joint movement and stress), and cutaneous

mechanoreceptors, including Pacinian corpuscles (sensitive to vibration), Meissner's corpuscles

(sensitive to light touch and vibration), Merkel's discs (sensitive to local pressure) and Ruffini

endings (sensitive to skin stretch).(2)

(C)Vestibular inputs:

Information from the vestibular system is also a powerful source of information for postural

control. The vestibular system provides the CNS with information about the position and

movement of the head with respect to gravity and inertial forces, providing a gravitoinertial

frame of reference for postural control.(2, 4).

(III)Central processing systems for postural control:

(A)Vestibular nuclear complex:

The vestibular nuclear complex in the medulla and pons is an important center for the

integration of vestibular, somatosensory, andvisual information and plays a large part in the

control of posturalorientation and equilibrium.(4).

(B)Basal ganglia:

The basal ganglia play an important role in postural alignment and control of stability.(4).

(C)Cerebellum:

The cerebellum plays several roles in the control of posture involving sensory-motor

integration.The most profound deficits in dynamic postural control occur with damage to the

anterior lobe of the cerebellum, which receives somatosensory inputs from throughout the body

and projects to the spinal cord via the red nucleus and reticular formation.(4).

(D)Cerebral cortex:

Cerebral Cortex is most important in the anticipatory postural adjustments that accompany

voluntary movement.(4)


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The role of postural reactions in maintenance of balance:

The postural reactions (righting, equilibrium, and protective reactions) have been identified as

the underlying responses that are related, most functionally; to motor milestones. Posturalreactions provide automatic support and stability to the head, trunk and extremities; and facilitate

normal weight shifts and mobility.(5,6,7,8)

The different postural responses controlling balance:

(a) Automatic postural responses:There are three commonly identified automatic postural

responses, or strategies:

1) Ankle strategy:restores the center of mass (COM) to a position of stability through

bodymovement centered primarily about the ankle joints. Muscle activity begins afterperturbation onset in the gastrocnemius, followed by activation of the hamstrings and finally by

activation of the paraspinal muscles. The ankle movement strategyappears to be used commonly

in situations in which the perturbation to equilibrium is small and the support surface is

firm.(8,10)

2) Hip strategy:controls motion of the COM by producing large and rapid motion at the hip

joints with antiphase motions of the ankles. The hip strategy is used to restore equilibrium in

response to larger, faster perturbations or when the support surface is smaller than the feet.(8,9)

3) Stepping and reaching strategies:describe steps with the feet or reaches with the arms inan attempt to reestablish a new BOS with theactive limb(s) when the COG has exceeded the

original BOS. Stepping strategy is used to bring the support base back into alignment under the

COM when in-place strategies such as the ankle and hip strategies are insufficient to recover

balance(8,9) .


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(b) Antcipatory postural responses:These responses are similar to automatic postural

responses, but they occur before the actual disturbance. If a balance disturbance is predicted, the

body will respond in advance by developing a "postural set" to counteract the coming

forces.(8,9,10,16)

(c) Volitional postural responses:These responses are under conscious control. Volitionalpostural movements can range from simple weightshifts to complex balance skills of skaters and

gymnasts.(9,10,16).

The systems model of postural control(16).

ASSESSMENT

A task-oriented approach assesses postural control on three levels:

(a)the functional skills requiring posture control, (b) the sensor and

motor strategies used to maintain posture in various contexts and


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tasks, and (c) the underlying sensory, motor, and cognitive

impairments thatconstrain posture control.

Safety First Concern

During the course of evaluating postural control, patients will be asked

to perform a number of tasks that will likely destabilize them. Safety is

of paramount importance. All patients should wear an ambulation belt

during testing, and be closely guarded at all times.

A-Functional Assessment

A task-oriented approach to evaluating postural control begins with afunctional assessment to

determine how well a patient can perform avariety of skills that depend on postural control.

1-GET UP AND GO TEST

The Get Up and Go test (1) was developed as a quick screening tool for detecting balance

problems in elderly patients. The test requires that subjects stand up from a chair, walk 3 meters,

turn around, and return. Performance is scored according to the following scale: 1 normal; 2 very

slightly abnormal; 3 mildly abnormal; 4 moderately abnormal; 5 severely abnormal. An

increased risk for falls was found among older adults who scored 3 or higher on this test. The

Get Up and Go test modifies the original test by adding a timing component to performance (2).

Neurologically intact adults who are independent in balance and mobility skills are able to

perform the test in less than 10 seconds.(13,15).

2-FUNCTIONAL REACH TEST

The Functional Reach Test is another single item test developed as a quick screen for balance

problems in older adults. subjects stand with feet shoulder distance apart, and with the arm raised

to 90 flexion. Without moving their feet, subjects reach as far forward as they can while still

maintaining their balance (Fig. 1). The Functional Reach Test has established inter-rater

reliability, and is shown to be highly predictive of falls among older adults (12).


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Figure (1 ) The functional reach test. A, Subjects begin by standing with feet shoulder

distance apart, arm raised to 90 flexion, and reach as far forward as they can while

still maintaining their balance.

(3)Berg Balance Scale

1. Sit to Stand

( ) 0: Needs moderate or maximal assistance to stand

( ) 1: Needs minimal assistance to stand or to stabilize

( ) 2: Able to stand using hands after several tries

( ) 3: Able to stand independently using hands

( ) 4: Able to stand with no hands and stabilize independently

2. Standing unsupported

( ) 0: Unable to stand 30 seconds unassisted

( ) 1: Needs several tries to stand 30 seconds unsupported


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( ) 2: Able to stand 30 seconds unsupported

( ) 3: Able to stand 2 minutes without supervision

( ) 4: Able to stand safely for 2 minutes

If person is able to stand 2 minutes safely, score full points for sitting unsupported (item 3).

Proceed to item 4.

3. Sitting with back unsupported with feet on floor or on a stool

( ) 0: Unable to sit without support for 10 seconds

( ) 1: Able to sit for 10 seconds

( ) 2: Able to sit for 30 seconds

( ) 3: Able to sit for 2 minutes under supervision

( ) 4: Able to sit safely and securely for 2 minutes

4. Stand to sit

( ) 0: Needs assistance to sit

( ) 1: Sits independently but had uncontrolled descent

( ) 2: Uses back of legs against chair to control descent

( ) 3: Controls descent by using hands

( ) 4: Sits safely with minimal use of hands

5. Transfers

lease move from chair to chair and back again (Person moves one way toward

a seat with armrests and one way toward a seat without armrests) Arrange chairs for pivot

transfer


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( ) 0: Needs two people to assist or supervise to be safe

( ) 1: Needs one person to assist

( ) 2: Able to transfer with verbal cueing and/or supervision

( ) 3: Able to transfer safely with definite use of hands

( ) 4: Able to transfer safely with minor use of hands

6. *Standing unsupported with eyes closed

( ) 0: Needs help to keep from falling

( ) 1: Unable to keep eyes closed for 3 seconds but remains steady

( ) 2: Able to stand for 3 seconds

( ) 3: Able to stand for 10 seconds without supervision

( ) 4: Able to stand for 10 seconds safely

7. *Stand unsupported with feet together

( ) 0: Needs help to attain position and unable to hold for 15 seconds

( ) 1: Needs help to attain position but able to stand for 15 seconds with feet together

( ) 2: Able to place feet together independently but unable to hold for 30 seconds

( ) 3: Able to place feet together independently and stand for 1 minute without supervision

( ) 4: Able to place feet together independently and stand for 1 minute safely

The following items are to be performed while standing unsupported

8. *Reaching forward with outstretched arm

touch


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the ruler while reaching forward. The recorded measure is the distance toward that the fingers

reach while the person is in the most forward lean position.)

( ) 0: Needs help to keep from falling

( ) 1: Reaches forward but needs supervision

( ) 2: Can reach forward more than 2 inches safely

( ) 3: Can reach forward more than 5 inches safely

( ) 4: Can reach forward confidently more than 10 inches

9. *Pick up object from the floor from a standing position

( ) 0: Unable to try/needs assistance to keep from losing balance or falling

( ) 1: Unable to pick up shoe and needs supervision while trying

( ) 2: Unable to pick up shoe but comes within 1-2 inches and maintains balance independently

( ) 3: Able to pick up show but needs supervision

( ) 4: Able to pick up show safely and easily

10. *Turn to look behind over left and right shoulders while standing

look over you right shoulder

( ) 0: Needs assistance to keep from falling

( ) 1: Needs supervision when turning

( ) 2: Turns sideways only but maintains balance

( ) 3: Looks behind one side only; other side shows less weight shift

( ) 4: Looks behind from both sides and weight shifts well


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completely in a full circle. Pause, then turn in a full circle in the other

direction

( ) 0: Needs assistance while turning

( ) 1: Needs close supervision or verbal cueing

safely but slowly

12. *Place alternate foot on bench or stool while standing unsupported

lternately on the bench (or stool). Continue until each foot hastouched the bench (or stool) four times. (Recommended use of 6-inch-high-bench.)

( ) 0: Needs assistance to keep from falling/unable to try

( ) 1: Able to complete fewer than two steps; needs minimal assistance

( ) 2: Able to complete four steps without assistance but with supervision

( ) 3: Able to stand independently and complete eight steps in more than 20 seconds

( ) 4: Able to stand independently and safely and complete eight steps in less than 20 seconds

13. *Stand unsupported with one foot in front

foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of

the toes of the other foot (Demonstrate this test item)

( ) 0: Loses balance while stepping or standing

( ) 1: Needs help to step but can hold for 15 seconds

( ) 2: Able to take small step independently and hold for 30 seconds

( ) 3: Able to place one foot ahead of the other independently and hold for 30 seconds

( ) 4: Able to place feet in tandem position independently and hold for 30 seconds


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14. *Standing on one leg

( ) 0: Unable to try or needs assistance to prevent fall

( ) 1: Tries to lift leg, unable to hold 3 seconds but remains standing independently

( ) 2: Able to lift leg independently and hold up to 3 seconds

( ) 3: Able to lift leg independently and holds for 5 to 10 seconds

( ) 4: Able to lift leg independently and hold more than 10 seconds

Total Score /56

Note: Perform only items 6 thorough 14 (*) in the modified version of the scale. Maximum score

for modified version is 36 points.

Interpretation of Individual Test Item Results on the Berg Balance Scale (BBS)(14)


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(4)BALANCE AND MOBILITY SCALE Mary Tinetti, a physician researcher at Yale

University, has published a test to screen for balance and mobility skills in older adults and to

determine the likelihood for falls.

(5)FUNCTIONAL BALANCE SCALE:

The functional balance scale was developed by Kathy berg, a CanadianPhysiotherapist.

This test uses 14 different items, which are rated 0 to 4. The test is reported to have good test-

retest and inter-rater reliability.(11)


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Limitations of functional assessment:

Inability to:

a- assess a patient performance of tasks under changing environmental contexts.

b- Determine the quality of movement used

c- Identify specific neuronal or musculoskeletal systems responsible for a decline of

performance.

b-Strategy Assessment:

The next level of assessment examines the motor and sensory strategies used to control the

body's position in space under a variety of conditions.

1- MOTOR

1- MOTOR STRATEGIE

Alignment in Sitting and Standing:

The patient's alignment in sitting and standing is observed. Is the patient vertical? Is weight

symmetrically distributed right to left, and forward and backward? A plumb line in conjunction

with a grid can be used to quantify changes in alignment at the head, shoulders, trunk, pelvis,

hips, knees, and ankles. In addition, the width of the patient's base of support upon standing can

be measured and recorded using a tape to measure the distance between the medial malleoli (or

alternatively, the metatarsal heads).

Alternative ways to quantify placement of the center of mass in the standing position include the

use of static force plates to measure placement of the center of pressure (Fig 10.2), or the use of

two standard scales to determine if there is weight discrepancy between the two sides


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The use of a static forceplate can be helpful when quantifying static

alignment changes in standing.

Movement Strategies

Movement strategies are examined under three different task conditions: self-initiated sway, in

response to externally induced sway,and anticipatory to a potentially destabilizing upper

extremity movement .


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Controlling self-initiated trunk movements in sitting. A, Small movements produce adjustmentsat the head and trunk. B, Larger movements require counterbalancing with the arms and legs. C,

When the line of gravity for the head and trunk exceeds

the base of support, the arm reaches out to prevent a fall.

two types of movement strategies being used to control

self-initiated sway in standing. Two patients have been

asked to sway forward as far as they can without taking a

step. Patient A is swaying forward primarily about theankles, using what has been referred to as an ankle

strategy to control center of mass motion. In contrast,

Patient B is moving primarily the trunk and hips (a hip

strategy), which minimizes forward motion of the center

of mass.

Controlling self-initiated sway in stance. Shown are two

types of movement strategies being used to controlself-initiated sway in standing.A, the ankle,and B, the hip.


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Movement strategies used to recover from a perturbation are also assessed:

Holding the patient about the hips, the therapist displaces the patient forward, backward, right,

and then left. Figure 10.6A illustrates the use of an ankle strategy used to recover from a small

backwarddisplacement.A larger displacement by the therapist usually results in a greater

amount of hip and trunk motion, that is, a hip strategy, as the subject continues to try to keep the

center of mass within the base of support and not take a step . Finally, if the therapist displaces

the subject far enough, and the center of body mass moves outside the base of support, the

subject will take a step to avoid a fall (Fig. 6C) .

Movement strategies used to recover from an external perturbation to balance. A, An ankle

strategy is

used to recover from a small displacement at the hips. B, A larger displacement produces a hip

strategy. C, Movement of

the COM outside the base of support requires a step to recovery stability.

SENSORY STRATEGIES

The Clinical Test for Sensory Interaction in Balance (CTSIB) is one method that has been

proposed for clinically assessing the influence ofsensory interaction on postural stability in the

standing position (14).


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The method is based on concepts developed by Nashner (5), and requires the subject to maintain

standing balance for 30 seconds under six different sensory conditions that either eliminate input

or produce inaccurate visual and surface orientation inputs.

A modified lapanese lantern is used to change the accuracy of visual input for postural

orientation.

Patients are tested in the feet together position, with hands placed on the hips. Using condition 1

as a baseline reference, the therapist observes the patient for changes in the amount and direction

of sway over the subsequent five conditions. If the patient is unable to stand for 30 seconds, a

second trial is given (5).Neurologically intact young adults arc able to maintain balance for 30

seconds on all six conditions with minimal amounts of body sway. In conditions 5 and 6, normal

adults sway on the average 40% more than in condition .(14).

Systems Assessment: Identifying Impairments

The next step in a task-oriented assessment involves evaluating the sensory, motor (neural and

musculoskeletal), and cognitive subsystems that underlie task-based performance.

Mental Status:

Mental status can be determined informally by determining the patient's orientation to person,

place, and time. Other aspects of cognitive function that are subjectively evaluated include:

attention,communication, and motivation.


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MUSCULOSKELETAL SYSTEM:

Assessment of the musculoskeletal system includes evaluation of range of motion and flexibility.

Neuromuscular System:

Assessment of neuromuscular impairments includes measurement of strength, muscle tone, and

nonequilibrium forms of coordination in addition to assessment of the sensory system.

Other computerized equipements used for assessment of balance:

1- COMPUTERIZED DYNAMIC POSTUROGRAPHY:1- The Sensory Organization Test (SOT) : objectively identifies

problems with postural control by assessing the patient's ability to

make effective use of (or suppress inappropriate) visual, vestibular,

and proprioceptive information.The SOT protocol is comprised of the following six sensory

conditions:

a. Eyes open, fixed surface and visual surround.

b. Eyes closed, fixed surface.

c. Eyes open, fixed surface, sway referenced visual surround.


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d. Eyes open, sway referenced surface, fixed visual surround.

e. Eyes closed, sway referenced surface.

f. Eyes open, sway referenced surface and visual surround. (5,6) .

2- The Motor Control Test (MCT)assesses the patient's ability to quickly and automatically

recover from unexpected external provocations. Sequences of small, medium or large (scaled to

the patient's height) platform translations in forward and backward directions elicit automatic

postural responses. Measurements includeonset timing, strength and lateral symmetry of

responses.(20).

3- The Adaptation Test (ADT)assesses the patient's ability to modify motor reactions and

minimize sway when the support moves unpredictably in the toes-up or toes-down direction. For

each platform rotation, a sway energy score quantifies the magnitude of the force response

required to overcome induced postural instability. This adaptive test simulates daily life

conditions such as irregular support surfaces.(19).


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2- The Biodex Stability System

The static test requires the patient to look straight a head while standing as still as possible withhis eyes open, focusing on the display monitor using visual feed backto maintain the cursor

within a centrally positioned in the bulls eye through the time of the test (20 seconds for each

trial). The dynamic test requires the patient to shift his center of gravity through weight shifting

to eight targets positioned in a ellipse, the perimeter of which corresponded to 50% of the limits

of stability (LOS). The patient was asked to follow a cursor to each target as it was highlighted,

and to fix at that target for three seconds before returning to the central target (neutral). Targets

were highlighted in random order, however, each target was selected only once.(17).

(3)Balance master:

The Basic Balance Master provides objective assessment and retraining of the sensory and

voluntary motor control of balance with visual biofeedback.The interactive technology and

clinically proven protocols allow the clinician to objectively assess patients performing tasks

essential to daily living. The objective data aids the clinician in effective treatment planning

decisions.(18)

The Basic Balance Master includes the following standardized assessment protocols:


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Sensory DysfunctionVoluntary Motor

Impairments

Functional

Limitations

modified Clinical Test of Sensory Interaction on

Balance (mCTSIB)

Limits of Stability (LOS)

Rhythmic Weight Shift

(RWS)

Weight Bearing Squat

(WBS)

Unilateral Stance

(US)

Balance Master

INTERPRETATION OF ASSESSMENT :Following completion of theassessment, the clinician must interpret theassessment, identify the problems, both at the level of

function andimpairments, and establish the goals and plan of care.
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Treatment for balance disorders

a-Strategies to Improve StaticPostural Control

Patients who demonstrate impairments in static postuial control are

unable to maintain or hold a steady position for a

number of reasons. including decreased strength, tonal

imbalances (hypolonia. spasticih), impaired voluntary Control andhypermobility (ataxia. athetois). sensory hypersensitivty tactile

avoidance. reactions), or increased avoidance or

arousal (high sympathetic stak). Instability is associated

execessive postural sway. wide BOS, a high guard hand positionl or

handhold. anid loss of balance.46

The therapist can select any number of weight bearing (antigravity>postures to develop stability control

. postures are selected on basis of

1patient safety and level of control and I2) variety in terms of

functionaI tasks. It is important to remember that some

Activities may cause the patient distress initially .the

Patient will feel threatened when placed in situations

Where he or she is in jeopardy of losing balance .the therapist

Should ensure the patient confidence by providing a clearExplanation what is going to happen and what is expected of the

patient in terms that are easy to understand.support may be given

initially to reduce fear if using anew posture,but should be withdrawn

as soon as possible to


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alloW focus on active control. The therapist varies the level

of actiVties , selecting activities that both provide success

as well as appropriately challenge the patient.

In sitting or standing. the patient is instructed to hold

steady while sitting or standing tall and maintaining a

visual focus on a torward target. Progression is to holding

for longer and longer durations. Neuromuscular/sensory

stimulation techniques that can be used to enhance stabilizing

muscle contractions include quick stretch, tapping.

resistanCe. approximation, manual contacts. and verbal

cues tce Appendix C). For the patient unable to actively

stahihze the body. the therapist can begin with resisted iso

metric contractions of antagonist postural muscle groups46


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using the technique of Rhythmic Stabilization (RS)

For example. the patient with severe instahilitv following traumatic

brain injury who s unable to sit

independently may need to practice holding first in the side-

lying position during application of RS. The therapist can

then progress training through postures that demand increas

ing amounts of upright (antigravity) postural control


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prone-on-elbows to quadruped and finally sifting. In each

position the therapist carefully provides matching resist

ance using RS. If an imbalance exists, the stabilizing act ivity i can be

cont tolloed by a strengthening act ivitv for the weak

muscles)46

rhysmic stabilization


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As the trunk becomes more stable. the patient

is expected to assume active control in stabilizing in the

sture. For a patient with hyperkinetic disorders (e.g..ataxia, athetosisi. the PNF technique of Stabilizing

Reersals Slow Reversals is appropriate

Alternating isOtonic contractions are used, allowing only

very small range moements. Progression is toward

&crcasing range (decrements of range) until finally the


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patient is asked to stabilize and hold steady in the posture.46

Additional strategies to improve stability include the

Use of elastic resistance bands or weights to enhance proprioceptive loading and contraction of stabiIizin muscles. 46

The therapist can have the patient stabilize while sitting

On atherapy ball (also known as swiss or stability ball)

Gentle bouncing provide joint approximation through the

vertebral Joints, facilitating extensors and an upright postures

for patient requiring more assistance,sitting controlcan first he practiced on a compliant surface (foam, wobble board, or

dynastic) placed on a platform mat or sitting

(On a ballwith a ball holder underneath the therapy

ball. Task difficulty can be increased by reducing the bOS

(feet apart to feet together to single limb support).46


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Aquat ic therapy can also be used t0 enhance propriocepti ve

loading. The wa te r provides a degree of unwe ig hting and res istance

to movement. Thi s can be quite effective in reduc ing hype rkinet ic

movement s and enhanci ng postural sta bi lity. For exampl e. a

patient recovering from traumatic brain injury who demonstrates

significant ataxia may be able to sit or stand in the pool with

minimal ass istance whil e these same acivities outside the pool are

not possible. 46


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To improve standing cont rol, the pa ti ent is directed to

practi ce neuromuscular jixed-suppor t strategies that occur

at the ankle and hip jo int s. Feedback is provided to ass ist

the patient in rec ruiting the correc t pa ttern. To recruit ankle

strategies. the patient practi ces small -range. s low-velocity

shifts. Attention is direc ted to the action of ank le muscles

to move the body (COM) over the fixed feet (BaS).

Standing on a wobble board or foam rolle r with the flat

s ide down progress ing to fl at side up are effective ac tivit ies

to recrui t ankle strategies. The patient is a lso directed to

prac ti ce tasks that nomlally recruit hip strategies. 46

These are rec ruited wi lh large r shifts in the COM. that approach

the limits of stability (LOS). and/or faster body sway

motions and are charac te rized by earl y ac ti vation o f prox-

imal hip and trunk muscles. Hip flexion and extension

res pon~es are gene rated during ante rior- poste rio r (AP)

di splacement s and lateral hip motions are generated during

late ra l dis placements. Patient s can be instructed to move

their uppe r body forward and backward while standing on


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a foam rolle r. Tandem standing o r tandem standing on a

foam roJler can be used to recruit late ral hip strategies.46


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b-Strategies to Improve Dynamic Postural Control

Patients who demonstrate impairments in dynamic postural control are

un able to control postural and orienatation while moving body

segments . anumber of impairmentsmay be contributing factors,including tonal imbalance (hper\hypo tonia),ROMrestrictions,impaired

voluntary control and hyper mobility (ataxia, athetosis),impaired

reciprocal actions of the antagonists


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(cerebellar dysfunction0 . or impaired proximal stabilization. clinically.

the patient demonstrates difficulty weight

shifting from side-t-side. forwardbackward. or diagonally. difficulties

are also apparent in moving one or more

limbs while maintaining a posture (sometimes referred to

as static dynamic control. For example. one limb is freed

for movement (reaching or stepping while the patient

maintains the sitting or standing posture. Or from the

quadruped position the patient is asked to lift one arm or

leg or to lift the opposite arm and Ieg. These added move

ments increase the demand for stabilization control

because the overall BOS is reduced and the COM must

shift over the remaining support segments beforethe

dynamic limb movement can be successful.46

The therapist can select any of a number of weightbear

ing (antigravity). postures lo develop dynamic postural

control. Practice begins with movements emphasizing

smooth directional changes that engage antagonist actions

e.g.. weight shills). As control improves, the movements

arc gradually expanded through an increasing range

increments ot range). Dynamic movements can be facili

tated using quick stretch. tapping. light tracking resistance.

manual contacts. and dynamic verbal commands 46

. Although active movement is the goal. assis

tance may be required during initial movement attemptsfor both the dynamic movements as well as the stabilizing

body segments. Specific task-oriented training (e.g.. reach

ing. stepping) are more motivating, especially if the task s

important to the patient. 46


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Specific PNF tech

niques appropriate or assisting patients include Dynamic

Reversals (Slow Reversals), Repeated Contractions,Rhysmic initiation, and Combination of isotonics

(Agonist Reversals (see Appendix B). For example. in

bridging the patients movements are resisted in assuming

the bridge posture isoLonic comractions) and during

moVement from the bridge position to hooklying (eccentric

contractions) using the comhination of isotonic technique

this activity is an important leadup for other func

functional activitie that reqiire similar combinations including sit- lostand transitions, moving from kneeling to heel

sitting. amid ascending descending stairs 46

therapy ball activities are effective in deveIoping

dynamic stability control. For examble, the patient sits on a

ball and gently moves the ball side to side, forwardbackward

or in compination( pelvic clock motions). Or thepatients sits on ballwhile performing voluntary movements of the arm or legs (alternate leg

or arm raise) 46

TO improve standing control, the patient is direct ed to

practice neuromuscular stepping strategies. The traditional

view holds that stepping strategies occur when the COM

exceeds the LOS. Perturbation is used to provi de the

COM displacement. Stepping movements are accompanied

by early activation of hip abductors and ankle cocontraction


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for mediallateral stability during single-limb support.40-45


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c-postural Awareness TrainingFaulty postures such as forward head. kyphosis. lordosis.

excessive hip and knee flexion, or pelvic asymmetries can

result in decreased postural stability. inaccurate kines

thetic awareness of true vertical, and pain. Although mild

deficits may not affect balance control, deficits that sig


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nificantly alter the COM position can impair balance.39

Patients are typically unable to self-correct faulty pos

tures. Physical therapy interventions should focus first on

improvrng specific musculoskeletal impairments (e.g..

limited ROM. weakness). For example, active exercises to

improve standing balance can include standing heel-cord

stretches, heel-rises. toe-offs. partial wall squats. chair

rises. side-kicks. hack-kicks, and marching in place using

touch-down support of the hands as needed (sometimes

reterred to as the kitchen sink exercises). 39

Postural reeducation gins with demonstration of the correct posture.

verbal cues should focus on control of essential postural

elements, that is, stable (neutral) pelvis, axial extension

e.g.. sit or stand tall), and normal alignment (e.g., head

erect, shoulders back, weight evenly distributed under

both hips [sitting] or feet [standing]). 39

Patients can benefit

from tactile cues during initial practice (manual or sur

face-related. For example, patients can stand with the

back positioned against a wall or patients with a lateral

lean (e.g.. poststroke patients with pusher syndrome) can

sit with their side positioned against the seated therapist or

a wall. 39

Corner standing or standing tween two plinths

can effective for patients with significant COM distor

tion. Mirrors provide important visual cues regarding ver

tical position but are generally contraindicated for the


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patient with visuospatial perceptual deficits. Application

of correct postures to real-life functional situations is

important to ensure carryover and lasting change.39

Biodex system

d-Center-of-Mas Control TrainingThe therapist should focus on obtaining symmetrical, bal

anced weightbearing. Patients may present with specific

directional instabilities, such as weightbearing more on

one side than the other. For example, after a stroke the

patient typically keeps weight centered toward the sound

side Practice should focus on redirecting the patient into acentered position by moving toward the affected side, both

In Sitting and standing positions. Limits of sability (LOS)

should be explored. 30-39


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posturography Feed back

Balance training using augmented visual feedback has

become increasingly popular in treating the elderly and otherpatients at risk for falls. Research reports substantiate its

effectiveness in improving balance.10-16

Force-platform devices are used to measure forces and provide center

of pressure (COP) biofeedback or posturographv feedback.37,38

Posturography training can be used to shape sway

movements to enhance symmetry and steadiness. Thepatient can be instructed to increase or decrease sway

movements or move the COP cursor on the computer

screen to achieve a designated range or to match a desig

nated target. It is an effective training mode for patients

who demonstrate problems in force generation. For exam

ple, the patient with decreased force generation (hypome

tria) as typically demonstrated by individuals with

Parkinsons disease is directed toward achieving larger andfaster sway movements during posturography training. 37,38

Finally, a set of bathroom scales or limb load monitors can

provide a low tech, low cost form of biofeedback weight

information to assist patients in achieving symmetrical

weightbearing.28,29

e-Strategies to Improve SafetyPrevention of falls for the patient with balance deficiency is

an important goal of therapy. Lifestyle counseling is impor

tant to help recognize potentially dangerous situations and


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reduce the likelihood ot falls. For example, high-risk acti

ities likely to result in falls include turning, sit to stand

transfers, reaching and bending over, and stair climbing.27

f-Sensory TrainingSeveral general concepts are important to an Understanding

of the role of sensation in movement. Sensation allows one

to interact with the environment, guiding the selection of

movement responses. Sensory inputs are used to modify

movements and shape motor programs through feedback

for corrective actions. Variability and adaptability of move

ments to environmental change are made possible by the

information processing of sensory inputs. 23

Damage to the CNS can produce impairments in Sen

sory function. Alterations in tactile. proprioceptive. VISUaI.

or vestibular systems can affect a patients ability to move

and learn new activities. Deafferentation in animals and in

humans is associated with nonuse of a limb, although gross

movements are possible under forced situations. Learning

of new movements through corrective actions is impaired.

The therapist must focus on forced training of sensory

deficient limbs even though the patient may have little

Interest in moving the limb. 24

The movements obtained should not be expected lo be normal,

however, because significant deficits have been noted in fine motor

control indeaffrentated limbs. Following damage to the cNS. sensory

inputs may be reduced or distorted. Perceptions are


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therefore impaired. Sensory training strategies can be used

to sharpen and heighten perceptions and assist in reorganizing the

CNS.24

Training Strategies for Sensory LossSensorv stimulation refers to the structured presentation of

stimuli to improve (1) alertness, attention, and arousal:

(2)sensory discrimination: or

(3) initiation of muscle activity

and improvement of movement control. Effects are immediate and

specific to the current state of the nervous system.23

Behaviors are modified using techniques to increase or decrease

attention and arousal. Movements are elicited and modified through

the use of specific stimuli (e.g.. stretching. tapping). The effects do not

carry over to subsequent movement attempts.

Because the movements rely on augmented inputs, their

greatest use is to assist the patient with absent or severely

disordered voluntarv control (e.g.. a patient who sustained

a stroke and who s unable to consistently initiate muscle

contractions) . 24

Once a desired motor response is obtained.

focus should shill to active movements that utilize naturally occuring

intrinsic sensory information. Thus, sen

sory stimulation techniques may be an effective bridge to

assist early attempts at movement hut should be withdrawn

as soon as possible. Repeated use of sensory stimulation long

alter it IS necessary Can result iii movements that become

stimulus dependent, and can further limit the patients ability


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to regain voluntary control.25

Sensory integration training refers to the use of enhanced, controlled

sensory stimulation in the context of a meaningful,self directed activityin order to elicit adaptive behavior.

Varied sensory stimuli are presented(tactile,vestibular-

proprioceptive,and visual) in order to engage higher brain centers for

central processing of sensory information23

The overall goals are to

1- improve sensory discrimination :identification of specific stimuli( e.g.shapes,weights, textures, numbers written on skin),intensities , and

localization of stimuli

2- improve perception : selection,attention, and response to sensory

inputs with appropriate use of information to generate specific motor

responses . the key elements are multimodal presentation of various

different stmuli compined with functional task training. Focus is also on

postural training activities with progression to more difficult adaptive

motor responses.24

Sensory reeducation has been used successfully to

improve sensory function in patients with peripheral nerve

damage Patients with stroke-related impairments have

also shown benefits from specific sensory training pro

grams. Components of these programs consist of

having the patient practice sensory identification tasks(numbers, letters drawn on the hand or arm). discrimina

tion tasks (detecting size, weight and texture of objects

placed in the hand), and passive-assisted drawing using a

pencil.25


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The tasks are alternated between both affected and

unaffected hands. Each training session starts and ends

with a sensory task the patient could successfully master.

The training group showed a positive and significant

improvement in sensory function. An important feature

of this study was that the subjects were at least 2 years

post-stroke, providing strong evidence that the effects were

due to training and not recovery. 24

Sensory Training Strategies for BalanceAn important focus of balance training is uilization and

integration of appropriate sensory systems. Normally

three sources of inputs are utilized to maintain balance:

somatosensory inputs (proprioceptive and tactile inputs

from the feet and ankles), visual inputs, and vestibular

inpus.2 Careful camination can identity the patientsuse ot inputs to maintain balance (e.g., Clinical Tes for

sensory and Balance CTSIB. 22

. Training is directed lo using

practice balance tasks with

eyes open and eves closed, in reduced lighing. or in sItuations ol

Inaccurate vision (petroleum-coated lenses or prism glasses). Alteringthe visual inputs allows the patient to shih focus and reliance to other

sensory inputs.22

practice varying somatosensory inputs by standing and walking on

different surfaces, from flat surfaces


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(floor) to compliant surfaces (low to hiugh carbet pile), to dense foam.

Apatient who is bare foot or wearing thin-soled shoes is better able to

attend to sensation from the feet than if wearing thick soled shoes.22

Challenges to the vestibular system can be introduced by reducing both

visual and somatosensory inputs through sensory conflict situations. 22

For example. the patient practices standing on dense foam with the

eyes closed. Thepatient can also be directed to walk on foam with eyes

closed, a condition that requires maximum use of

vestibular inputs. Patients should also practice varying

environmental influences such as walking outside, pro

gressing (rom relatively smooth terrain (sidewalks) to

uneven terrain to moving surfaces (escalator, elevator).

Repetition and practice are important factors in assisting

CNS adaptation.21

Compensatory training with an assistive

device is indicated. Other patients must be encouraged to

ignore distorted information (e.g.. impaired propriocep

tion accompanying stroke) in favor of more accurate sen

sory information (e.g.. vision). Augmented feedback can

assist in training (e.g.. verbal commands, light-touch fin

ger contact, biofeedback cane with auditory signals, limb

load monitor).21


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Balance master

Smart balance master


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1)Shumway-Cook A, Horak F. Assessing the influence of sensoryinteraction on

balance.PhysTher 1986;66:1548-1550.

2)SusanOsullivan,Physical rehabilitation.

3)Lee.Dn.andLishman visual proprioceptive control of stance ,1975.

4)Nashner,l:Sensory,neuromuscular,and biomechanical contributions to human

balance.in balance American physical therapy association,1990.

5)Nashner,L and Mccollum,G:The organization of human postural

movements.Aformal basis and experimental synthesis,1985.

6)Nashner,L:Adaptive reflexes controlling human posture,1976.

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