Balance Training
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Transcript of Balance Training
BALANCE TRAININGBALANCE TRAINING
DefinitionDefinition
Balance is defined as the ability Balance is defined as the ability to control the body mass or to control the body mass or
center of gravity to the base of center of gravity to the base of support in order to maintain a support in order to maintain a upright posture or a functional upright posture or a functional
equilibrium in dynamic activitiesequilibrium in dynamic activities
Normal Balance MaintenanceNormal Balance Maintenance
Human balance is a complex process which Human balance is a complex process which involves the integration of sensory information involves the integration of sensory information from peripheral end organs to detect body from peripheral end organs to detect body position in relation to environment.position in relation to environment.
Integration of this information by CNS to Integration of this information by CNS to produce adequate and proper motor output in produce adequate and proper motor output in the form of automatic postural responsesthe form of automatic postural responses. .
The Sensory factorsThe Sensory factors
Somato Sensory Inputs Somato Sensory Inputs (Proprioceptors) (Proprioceptors)
Visual Inputs Visual Inputs
Vestibular InputsVestibular Inputs
Somato sensory receptors:Somato sensory receptors:Proprioceptors located in Muscles , Proprioceptors located in Muscles , Ligaments and Joints.Ligaments and Joints.
Visual Inputs:Visual Inputs:Perception of verticality, object Perception of verticality, object motion and motion of self in relation motion and motion of self in relation to environment.to environment.
Vestibular InputsVestibular Inputs::Position of head in relation to gravity Position of head in relation to gravity and linear and angular acceleration and linear and angular acceleration of head during movement. of head during movement.
StrategiesStrategies
Ankle strategyAnkle strategy
Describes postural sway control from ankle Describes postural sway control from ankle musculature level. This strategy act when musculature level. This strategy act when the sway is small, slow and near midline.the sway is small, slow and near midline.
Hip StrategyHip Strategy
It is the postural sway from pelvis and It is the postural sway from pelvis and trunk. It is seen when the sway is large, trunk. It is seen when the sway is large, fast and nearing the limits of stability.fast and nearing the limits of stability.
Suspensary strategySuspensary strategy
It describes lowering of COG by flexing both It describes lowering of COG by flexing both the knees. Commonly seen in windsurfing.the knees. Commonly seen in windsurfing.
Stepping strategyStepping strategy
It describes steps with feet or reaches with It describes steps with feet or reaches with arms in an attempt to re-establish a new arms in an attempt to re-establish a new base of support when COG has exceeded base of support when COG has exceeded the original base of support.the original base of support.
What is a balance disorder?What is a balance disorder?
A balance disorder is a A balance disorder is a disturbance that causes an disturbance that causes an individual to feel unsteady, individual to feel unsteady, giddy, or have a sensation of giddy, or have a sensation of movement, spinning, or floating.movement, spinning, or floating.
Causes of balance disordersCauses of balance disorders
Sensory system disordersSensory system disorders
Sensory ataxia (dorsal column Sensory ataxia (dorsal column degeneration)degeneration)
Vestibular neuronitisVestibular neuronitis Benign paroxysmal positional vertigoBenign paroxysmal positional vertigo Neuropathic jointsNeuropathic joints
CNS disordersCNS disorders
Cerebro vascular accidentsCerebro vascular accidents Parkinson’s diseaseParkinson’s disease Cerebellar dysfunctionCerebellar dysfunction Vertibro basilar insufficiencyVertibro basilar insufficiency Brain injuryBrain injury
Motor disordersMotor disorders
Gross poliomyelitis involving both lower limbsGross poliomyelitis involving both lower limbs Motor neuron diseaseMotor neuron disease
Biomechanical ProblemsBiomechanical Problems
WeaknessWeakness Limitation of joint rangeLimitation of joint range
Environmental risk factorsEnvironmental risk factors
General risk factors like Furniture, General risk factors like Furniture, Bathroom, Toilet, Stairs, Outdoor curbsBathroom, Toilet, Stairs, Outdoor curbs
Falls in the ElderlyFalls in the Elderly
Symptoms of balance disordersSymptoms of balance disorders
When balance is impaired, an individual When balance is impaired, an individual has difficulty maintaining orientationhas difficulty maintaining orientation
An individual may experience the "room An individual may experience the "room spinning" and may not be able to walk spinning" and may not be able to walk without staggeringwithout staggering
May not even be able to arise May not even be able to arise A sensation of dizziness A sensation of dizziness Falling or a feeling of falling Falling or a feeling of falling LightheadednessLightheadedness Visual blurring Visual blurring Disorientation Disorientation
ASSESSMENTASSESSMENT
1. 1. Visual system:Visual system:Check visual acuity, depth perception, Check visual acuity, depth perception, visual field defects.visual field defects.
2. 2. Somatosensory:Somatosensory:Check proprioception, cutaneous sensation Check proprioception, cutaneous sensation (touch, pressure), lower extremities and (touch, pressure), lower extremities and trunk, especially feet and ankle.trunk, especially feet and ankle.
3. Vestibular:3. Vestibular:
Check motor responses to positional and Check motor responses to positional and movement testingmovement testing
Righting reactions: Move or position the body, observe automatic Righting reactions: Move or position the body, observe automatic adjustments that restore normal alignment of the head position (face adjustments that restore normal alignment of the head position (face vertical, mouth horizontal).vertical, mouth horizontal).
Equilibrium reactions: Alter the body’s center of mass or base of Equilibrium reactions: Alter the body’s center of mass or base of support, observe automatic postural adjustments that serve to support, observe automatic postural adjustments that serve to maintain balance (keep centre of mass within the BOS).maintain balance (keep centre of mass within the BOS).
Protective reactions: Alter the body’s centre of mass outside of the Protective reactions: Alter the body’s centre of mass outside of the BOS, observe the automatic adjustments of the arms or legs to BOS, observe the automatic adjustments of the arms or legs to extend and support the body weight in anticipation of a fall.extend and support the body weight in anticipation of a fall.
Testing considerations: Can use a displacing Testing considerations: Can use a displacing manual force against the Centre Of Mass (a manual force against the Centre Of Mass (a perturbation or push) or displace the BOS using perturbation or push) or displace the BOS using a moveable surface (platform, gymnastic ball, a moveable surface (platform, gymnastic ball, equilibrium board). equilibrium board).
4. Assessment of Musculoskeletal 4. Assessment of Musculoskeletal ElementsElements
Determine musculoskeletal Determine musculoskeletal strength strength
and ROM especially in the lower and ROM especially in the lower
extremities and trunkextremities and trunkTightness, contracturesTightness, contracturesSpasticitySpasticityDetermine limits of stability: Determine limits of stability: maximum maximum
sway in any direction.sway in any direction.
5. CHECK STATIC BALANCE5. CHECK STATIC BALANCE
A. Standing tests:A. Standing tests:
Double limb supportDouble limb support
Single limb supportSingle limb support
6.Dynamic Balance:6.Dynamic Balance: Standing upStanding up SteppingStepping StoopingStooping
7. Scoring: 7. Scoring:
A. Three point scale: absent, A. Three point scale: absent, impaired, impaired, presentpresent
B. Functional balance grades: 0, B. Functional balance grades: 0, poor, poor, fair, good, normal (with fair, good, normal (with descriptive criteria for each)descriptive criteria for each)
Berg’s Balance ScaleBerg’s Balance Scale
0 – No Balance0 – No Balance 1 – Able to maintain balance with support1 – Able to maintain balance with support 2 – Able to maintain balance with hands 2 – Able to maintain balance with hands offoff 3 – Able to maintain balance with hands 3 – Able to maintain balance with hands off, accepts minimal challengesoff, accepts minimal challenges 4 – Able to maintain support with hands 4 – Able to maintain support with hands off, accepts maximal challengesoff, accepts maximal challenges
Romberg test: Romberg test: Standing with feet in normal Standing with feet in normal
stance position, first with eyes open, stance position, first with eyes open, then with eyes closed: used to detect then with eyes closed: used to detect posterior column ataxiaposterior column ataxia
Sharpened or Tandem Romberg:Sharpened or Tandem Romberg: Have patient stand in a tandem Have patient stand in a tandem heel to toe position, first with eyes heel to toe position, first with eyes open, then eyes closed; increases open, then eyes closed; increases sensitivity of Romberg testsensitivity of Romberg test
TREATMENT SUGGESTIONS FOR TREATMENT SUGGESTIONS FOR BALANCE DISORDERSBALANCE DISORDERS
Cognitive impairment treatment Cognitive impairment treatment suggestionssuggestions Reduce confusionReduce confusion Improve motivationImprove motivation Improve attentionImprove attention Encourage consistencyEncourage consistency Start with simple task increase the Start with simple task increase the
complexity graduallycomplexity gradually
Managing sensory problemsManaging sensory problems(Vestibular, Proprioceptive, Visual)(Vestibular, Proprioceptive, Visual)
Facilitating demand system, Facilitating demand system, encourage remaining system encourage remaining system
Managing strategy selection Managing strategy selection problemsproblems
(Parkinson’s disease)(Parkinson’s disease) Appropriate sensory demands Appropriate sensory demands
(Pertubations)(Pertubations) Hip strategy – Stand on foam Hip strategy – Stand on foam
surface, narrow surface, Treadmillsurface, narrow surface, Treadmill
Managing preparatory problemsManaging preparatory problems (Bradykinesia)(Bradykinesia) Strategy trainingStrategy training
Managing sequencing and timing Managing sequencing and timing problemsproblems
(CP, Hemiplegia)(CP, Hemiplegia) Facilitate normal sequential muscle Facilitate normal sequential muscle
contraction from distal to proximal in contraction from distal to proximal in response to pertubation (EMG response to pertubation (EMG Biofeedback, Balance master)Biofeedback, Balance master)
Managing scaling problemManaging scaling problem (Cerebellar dysfunctions)(Cerebellar dysfunctions) Correct faulty amplitude of contraction Correct faulty amplitude of contraction
(Visual Biofeedback, Balance master, (Visual Biofeedback, Balance master, Wobble board, weighted cuffs)Wobble board, weighted cuffs)
Managing musculoskeletal Managing musculoskeletal problemsproblems
(Muscle weakness, ROM restriction, (Muscle weakness, ROM restriction, Spasticity)Spasticity)
Muscle strengthening exercises, Muscle strengthening exercises, Electrical stimulation, StretchingElectrical stimulation, Stretching
Functional Sequence in Balance Functional Sequence in Balance TrainingTraining
Balance activities starts from lying, Balance activities starts from lying, kneeling, sitting, then progressed to kneeling, sitting, then progressed to static and dynamic standing and static and dynamic standing and walking.walking.
NOT NECESSARY TO FOLLOW NOT NECESSARY TO FOLLOW THE STEP LADDER PATTERNTHE STEP LADDER PATTERN
LyingLying Prone lying – Neck ExtensionProne lying – Neck Extension Prone on elbowsProne on elbows Prone on handsProne on hands
SittingSitting High sitting with foot on ground, with arm High sitting with foot on ground, with arm
support on the sidessupport on the sides Weight shiftsWeight shifts Without arm supportWithout arm support Without feet touching the groundWithout feet touching the ground Sit walkingSit walking Long sittingLong sitting
KneelingKneeling
4 point kneeling4 point kneeling
Kneel sittingKneel sitting
2 point kneeling2 point kneeling
Half kneelingHalf kneeling
(with and without support, (with and without support, challenges)challenges)
Sit to StandSit to Stand
StandingStanding
# Static# StaticDouble limb stanceDouble limb stance
Single leg stanceSingle leg stance
Tandem positionTandem position
# # DynamicDynamic
Static marchingStatic marchingWobbling boardWobbling board
WalkingWalkingForwardForwardBackwardBackwardSidewaysSidewaysTandemTandemBraidingBraidingTreadmillTreadmill
Steps Steps
RampsRamps
Rough terrainRough terrain
CurbsCurbs
ObstaclesObstacles
Community ambulationCommunity ambulation
TasksTasks
Looking up at the ceilingLooking up at the ceiling Turning to look behind without Turning to look behind without
moving the feetmoving the feet Reaching forward to take an objectReaching forward to take an object Reaching sidewaysReaching sideways Reaching backwards Reaching backwards Reaching down to stool and floorReaching down to stool and floor Ball catching and throwingBall catching and throwing
Environmental modificationsEnvironmental modifications
Low chairs, low beds - leg Low chairs, low beds - leg modificationsmodifications
Unstable furniture - repair Unstable furniture - repair immediatelyimmediately
Ladders and step ladders - avoid Ladders and step ladders - avoid themthem
Lack of grab rails - installation of Lack of grab rails - installation of grab railsgrab rails
Hand rails not present or inadequate Hand rails not present or inadequate – installation of appropriate handrails– installation of appropriate handrails
Stairs too steep, tread too narrow -Stairs too steep, tread too narrow -modification of stairsmodification of stairs
Foot wear - thin, flat, broad, made Foot wear - thin, flat, broad, made up of firm material, textured sole, up of firm material, textured sole, ankle supportankle support
Avoid – high heeled shoes, shoes Avoid – high heeled shoes, shoes with soft and slippery soles. with soft and slippery soles.
THANK YOUTHANK YOU