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University of the Philippines Manila College of Allied Medical Professions PT 154: Therapeutic Exercise III Ms. Mary Grace M. Jordan, PTRP December 8, 2009. Therapeutic techniques to improve balance in neurological and developmental conditions. Balance deficits….

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therapeutic techniques to improve balance in neurological and developmental conditions

University of the Philippines Manila

College of Allied Medical Professions

PT 154: Therapeutic Exercise III

Ms. Mary Grace M. Jordan, PTRP

December 8, 2009

Therapeutic techniques to improve balance in neurological and developmental conditions

balance deficits
Balance deficits…
  • one of the most common problems treated by physical therapists.
  • are thought to be common after stroke, and they have been implicated in the poor recovery of activities of daily living (ADL) and mobility and an increased risk of falls.
learning objectives
Learning objectives…
  • Define balance
  • Define terminologies
  • Discuss the theoretical underpinnings of balance
  • Discuss the guidelines for training balance in neurologic and developmental conditions
  • Identify techniques that can address impairments of balance in patients with neurologic and developmental conditions

“…the ability to maintain the body’s center of gravity over its base of support with minimal sway or maximal steadiness.”

(Emery, 2005)

  • a complex process involving the reception and organization of sensory inputs and the planning & execution of movement to achieve a goal requiring upright posture
  • is the set of functions which maintains man’s upright during stance and locomotion by detecting and correcting displacement of the line of gravity beyond the BOS.
  • Postural control – involves controlling the body’s position in space for the dual purposes of stability and orientation.
  • Postural orientation –The control of relative positions of the body parts by skeletal muscles with respect to gravity and each other.
  • Postural stability- The condition in which all the forces acting on the body are balanced such that the center of mass (COM)is with in the stability limits or boundaries of BOS
      • Normal anterior/posterior sway – 12 degrees from most posterior-anterior position.
      • Lateral sway - 16 degrees from side to side.
      • If sway exceeds boundaries, compensation is employed to regain balance.
  • Static balance - the base of support (BOS) remains stationary and only the body center of mass (COM) moves. The balance task in this case is to maintain the COM within the BOS or the limit of stability (the maximal estimated sway angle of the COM).
  • Maintaining a stable antigravity position while at rest such as when standing and sitting
  • Automatic postural reactions - maintaining

balance in response to unexpected external perturbations, such as standing on a bus that suddenly accelerates forward.

  • Dynamic balance - Maintaining balance when a person is moving from point A to point B, where both the BOS and COM are moving, and the COM is never kept within the BOS.
  • is stabilizing 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
  • Reactive control - in response to external forces (perturbation).
  • Proactive control – in anticipation of internal forces imposed on the body’s own movements.
systems model
Systems Model…
  • Balance control is very complex and involves many different underlying systems.
  • Postural control results from a set of interacting systems that work cooperatively to control both orientation and stability of the body.

Musculo-skeletal Components

Neuro-muscular Synergies

Body Schema


Sensory Systems


Proactive Mechanisms(external)

Anticipatory Mechanisms(internal)

musculoskeletal components
Musculoskeletal components
  • Joint range of motion
  • Spinal flexibility
  • Muscle properties
  • Biomechanical relationships among linked body segments
neural components
Neural components
  • Motor processes (neuromuscular response synergies)
  • Sensory processes ( visual, vestibular, and somatosensory systems)
  • Higher-level integrative processes
      • Mapping sensation to action
      • Ensuring anticipatory and adaptive aspects of postural control
adaptive vs anticipatory
Adaptive vs. Anticipatory

Adaptive postural control

Anticipatory postural control

Involves preparing the sensory and motor systems for postural demands based on previous experience and learning

  • Involves modifying sensory and motor systems in response to changing task and environmental demands
factors that contribute to stability
Factors that contribute to stability…
  • Body alignment
  • Muscle tone
  • Postural tone
body alignment
Body alignment…
  • Minimize the effect of gravitational forces, which tend to pull us off center
  • The ideal alignment in stance allows the body to be maintained in equilibrium with the least expenditure of internal energy.
body alignment appropriate to quiet standing and sitting
Body alignment appropriate to quiet standing and sitting

Standing alignment

Sitting alignment

Head balanced on level shoulders

Upper body erect

Shoulders over hips

Feet and knees a few cm apart

  • Head balanced on level shoulders
  • Upper body erect, shoulders over hips
  • Hips in front of ankles
  • Feet a few cm (10 cm) apart
muscle tone
Muscle tone…
  • The force with which a muscle resists being lengthened (Basmajian and De Luca, 1985)
  • Keeps the body from collapsing in response to the pull of gravity
postural tone
Postural tone…
  • Increased level of activity in antigravity muscles
  • Activation of antigravity muscles during quiet stance.
  • Muscles that are tonically active during quiet stance: gastrocsoleus, tibialis anterior, gluteus medius, TFL, iliopsoas, and erector spinae
ankle strategy
Ankle strategy…
  • Used when displacements are small.
  • Displaces COG by rotation about the ankle joint.
  • Posterior displacement of COG – Dorsiflexion at ankle, contraction of anterior tibialis, quadriceps, abdominals.
  • Anterior COG displacement – Plantar flexion at ankle, contraction of gastrocnemius, hamstring, trunk extensors.
hip strategy
Hip strategy…
  • Employed when ankle motion is limited, displacement is greater, when standing on unstable surface that disallows ankle strategy.
  • Preferred when perturbation is rapid and near limits of stability.
  • Post. Displacement COG – Backward sway, activation of hamstring and paraspinals.
  • Ant Displacement COG – Forward sway, activation of abdominal and quadricep muscles.
stepping strategy
Stepping strategy…
  • If displacement is large enough, a forward or backward step is used to regain postural control
sensory processes
Sensory processes…

The maintenance of balance is based on an intrinsic cooperation between the

    • Vestibular system
    • Proprioceptive
    • Vision
  • Postural control does not only depends on the integrity of the systems but also on the sensory integration with in the CNS, visual and spatial perception, effective muscle strength and joint flexibility
visual inputs
Visual inputs…
  • 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 because as your head moves, surrounding objects move in the opposite direction.

  • Provide a reference for verticality
  • 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.

Visual inputs are important source of information for postural control, but are they absolutely necessary?

  • Since most individuals can keep their balance when vision is occluded
  • In addition, visual inputs are not always an accurate source of orientation information about self-motion.
  • Visual system has difficulty distinguishing between object motion, referred to as exocentric motion, and self-motion, referred to as egocentric motion.
somatosensory inputs
Somatosensory inputs…
  • Provides the CNS with position and motion information about the body with reference to supporting surfaces
  • Report information about the relationship of body segments to one another
  • Receptors: muscle spindles, Golgi tendon organs, joint receptors, and cutaneous mechanoreceptors
vestibular inputs
Vestibular inputs…
  • A powerful source of information for postural control
  • 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.
  • Distinguish exocentric and egocentric motions
vestibular receptors
Vestibular receptors

Semicircular canal

Otolith organs

Signal linear position and acceleration

Source of information about head position with respect to gravity

Respond to slow head movements (those that occur during postural sway)

  • Sense angular acceleration of the head
  • Sensitive to fast head movements ( those that occur during gait or imbalance such as slips, trips, and stumbles)
sensory organization
Sensory organization…
  • Vestibular, visual, and somatosensory inputs are normally combined seamlessly to produce our sense of orientation and movement.
  • Incoming sensory information is integrated

and processed in the cerebellum, basal ganglia, and supplementary motor area.

sensory organization39
Sensory organization…
  • Somatosensory information has the fastest processing time for rapid responses, followed by visual and vestibular inputs
  • When sensory inputs from one system are inaccurate the CNS must suppress the inaccurate input and select and combine the appropriate sensory inputs from the other two systems.
causes of balance impairments
Causes of balance impairments
  • Injury to or diseases of the structures (e.g. eyes, inner ear, peripheral receptors, spinal cord, cerebellum, basal ganglia, cerebrum)
  • Damage to Proprioceptors
  • Injury to or pathology of hip, knee, ankle, and back have been associated with increases postural sway and decreased balance
  • Lesions produced by tumor , CVA, or other insults that often produced visual field losses
following a stroke
Following a stroke…
  • Patients with muscle weakness and poor control lack effective anticipatory, ongoing, and reactive postural adjustments and therefore experience difficulty in:
    • Supporting the body mass over the paretic lower limb
    • Voluntarily moving the body mass from one lower limb to another
    • Responding rapidly to predicted and unpredicted threats to balance
spatiotemporal adaptations
Spatiotemporal adaptations
  • Changing the base of support
  • Restricting movement of body mass
  • Using hands for support
changing the base of support
Changing the base of support
  • Wide BOS
  • Shuffling feet with inappropriate stepping
  • Shifting on the stronger leg
restricting movement of body mass
Restricting movement of body mass
  • Stiffening the body with altered segmental alignment
  • Moving slowly
  • Changing segmental alignment to avoid large shifts in COG
    • standing reaching forward - flexing at hips instead of dorsiflexing ankles
    • standing reaching sideways - flexing trunk sideways instead of moving body laterally at hips and feet
    • sitting reaching sideways - flexing forward instead of to the side
    • in standing - not taking a step when necessary.
using the hands for support
Using the hands for support
  • holding on to support
  • grabbing
  • Balance cannot be trained in isolation from the actions which must be relearned.
      • In training walking, standing up and sitting down, reaching and manipulation… postural adjustments are also trained, since acquiring skill involves in large part the fine tuning of postural and balance control.
  • Postural adjustments are specific to each action and the conditions under which it occurs.
    • It cannot be assumed that practice of one action will transfer automatically into improved performance in another.
  • Progressive complexity is added by increasing the difficulty under which goals must be achieved, keeping in mind the various complex situations in which the patients will find themselves in the environment in which they live, both inside and outside their homes, and the precarious nature of balance.
  • As control over balance and confidence improves, tasks are introduced which require a stepping response, and responses to external constraints such as catching a thrown object and standing on a moving support surface
  • Use a gait belt any time the patient practices exercises or activities that challenge or destabilize balance.
  • 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).
  • Perform exercises near a railing or in parallel bars to allow patient to grab when necessary.
  • Do not perform exercises near sharp edges of equipment or objects.
  • 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.
  • Check equipment to ensure that it is operating correctly.
  • Guard patient when getting on and off equipment (such as treadmills and stationary bikes).
  • Ensure that the floor is clean and free of debris.
  • A variety of mode can be used to treat balance impairment
        • Begin with weight shifts on a stable surface
        • Gradually increase sway
        • Increase surface challenges (mini-tramp, etc.)
  • Rehabilitation balls ,foam rollers ,foam surfaces are often used to
      • Provide uneven or unstable surface for exercise
      • Sitting balance ,trunk stability, and weight distribution can be trained on a chair, table, or therapeutic ball
  • Pool is an ideal palace for training balance
postural training
Postural training
  • Awareness of posture and the position of the body in space is fundamental to balance training
    • Begin in supine or seated position
    • Over sessions, use a variety of arm positions,
    • unstable surfaces, single leg stances, etc.
    • Training both Static posture & Dynamic posture
  • Mirrors can provide postural feedback –Visual feedback
  • Adding movement patterns to acquired stable static postures increases balance challenge.
  • Add ant./post. sway to increase stability limits
  • Trunk rotations and altered head positions alter vestibular input.
  • Stepping back/forward assists in re-stabilization exercises.
  • From simple to complex involves
      • BOS – Advance from wide to narrow base
      • Posture – Stable to unstable posture (sway)
      • Visual – Closing of the eyes
      • COG – Greater disruption to elicit hip or stepping strategy
  • Progress to more dynamic activities, unstable surfaces, and complex movement patterns
  • Frequency,intensity,and duration
  • Normal postural activity forms necessary background for normal movement and for functional skills
  • Flaccid stage – balance exercises in sitting
  • Stage of spasticity – practice symmetrical weight bearing in standing, weight shifting, bending of knees and hips
pnf techniques
PNF techniques
  • For stability
  • Combination of isotonics
  • Stabilizing reversals
  • Rhythmic stabilization
motor relearning program
Motor Relearning Program
  • Analysis of task
      • Individual
      • Task
      • Environment
  • Practice of missing components
    • Strategy training
    • Impairment and strategy level
  • Practice of whole task
    • Functional level
  • Transference of learning
static balance
Static balance
  • Vary postures
  • Vary support surface
  • Incorporate external loads
dynamic balance
Dynamic balance
  • Moving support surfaces
  • Move head, trunk, arms, legs
  • Transitional and locomotor activities
anticipatory feedforward
Anticipatory (feedforward)
  • Reaching
  • Catching
  • Kicking
  • Lifting
  • Obstacle course
reactive feedback
Reactive (feedback)
  • Standing sway
  • Ankle strategy
  • Hip strategy
  • Stepping strategy
  • Perturbations
sensory organization71
Sensory organization
  • Reduce visual inputs
  • Reduce somatosensory cues
sitting balance
Sitting balance…
  • acute stage post-stroke
  • Head and trunk movements
  • Reaching actions

To progress:

  • Increasing distance to be reached
  • Varying speed
  • Reducing thigh support
  • Increasing object weight and size to involve both upper limbs
  • Adding an external timing constraint such as catching or bouncing a ball
standing balance
Standing balance…
  • Head and body movements
  • Reaching actions
  • Single limb support
  • Sideways walking
  • Picking up objects

The following main aspects should be developed:

  • Antigravity support or weight bearing on the feet
  • Postural fixation of the head on the trunk and on the pelvis in the vertical
  • Counterposing
  • Control of anteroposterior weight shift of the child’s COG
  • Control of lateral sway from one foot to the other.
  • Tilt reactions in standing
  • Saving from falling (strategies)

Training should check:

  • Equal distribution of weight on each foot
  • Correction of abnormal postures
  • Building up of the child’s stability by decreasing support
  • Delay training in standing and walking if the child is not ready
  • Weight shift leading to stepping
  • Training lateral sway
  • Training on different surfaces
learning objectives76
Learning objectives…
  • Define balance
  • Define terminologies
  • Discuss the theoretical underpinnings of balance
  • Discuss the guidelines for training balance in neurologic and developmental conditions
  • Identify techniques that can address impairments of balance in patients with neurologic and developmental conditions
  • Read Kisner’s Chapter on Techniques to improve balance.
  • Read Shumway-cook’s Chapter on interventions for postural control impairments

Adler SA, Beckers D, & Buck M (1993). PNF in practice. Berlin, Springer-Verlag.

Carr JH & Shepherd RB (2003). Stroke rehabilitation: Guidelines for exercise and training to optimize motor skill. Edinburgh, Butterworth-Heinemann.

Davies PM (1985). Steps to follow: A guide to the treatment of adult hemiplegia. Berlin, Springer-Verlag.

Kisner C & Colby LA (2007). Therapeutic exercise: Foundations and techniques (5th ed). Philadelphia, F. A. Davis Company.

Levitt S (2004). Treatment of cerebral palsy and motor delay (4th ed). Singapore, McGraw-Hill Inc.

Sawner K & LaVigne J (1992). Brunnstrom’s Movement Therapy in hemiplegia: A Neurophysiological Approach (2nd ed). Philadelphia, J.B. Lippincott Company.

Shumway-Cook, A & Woollacott, M. (2001). Motor control: Theory and practical applications (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.