Exercise for Impaired

Balance
 OLEH :
• ARIS WIDYANTARA 14121001004
• RATNASARI DIKA SUMANTRI 14121001016
• MITA ARDIASARI 14121001019
• NUGRAHA 14121001023
 Balance: Key Terms and Definitions
Balance, or postural stability, is a generic term used to
describe the dynamic process by which the body’s position is
maintained in equilibrium.
Equilibrium means that the body is either at rest (static
equilibrium) or in steady-state motion (dynamic equilibrium).
Balance is greatest when the body’s center of mass (COM) or
center of gravity (COG) is maintained over its base of support
(BOS).
 Balance Control

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.
Thus, balance control requires the interaction of the
nervous and musculoskeletal systems and contextual effects.
 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 (proprioceptive, joint, and cutaneous
receptors), and vestibular systems.
Types of Balance Control
Functional tasks require different types of balance control,
including :
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 postural reactions to maintain balance in response to
unexpected external perturbations, such as standing on a bus that
suddenly accelerates forward.
Types of Balance Control
• Feedforward (open loop motor control) is utilized for movements that
occur too fast to rely on sensory feedback (e.g., reactive responses) or
for anticipatory aspects of postural control.
• Anticipatory control involves activation of postural muscles in advance
of performing skilled movements, such as activation of posterior leg
and back extensor muscles prior to a person pulling on a handle when
standing30 or planning how to navigate to avoid obstacles in the
environment.
• Closed loop control is utilized for precision movements that require
sensory feedback (e.g., maintaining balance while sitting on a ball or
standing on a balance beam).
 Motor Strategies for Balance Control
To maintain balance, the body must continually adjust its position in
space to keep the COM of an individual over the BOS or to bring the
COM back to that position after a perturbation. To maintain balance,
the body must continually adjust its position.
Horak and Nashner61 described three primary movement strategies
used by healthy adults to recover balance in response to sudden
perturbations of the supporting surface (i.e., brief anterior or posterior
platform displacements) called ankle, hip, and stepping strategies.
• Ankle Strategy (Anteroposterior Plane)
In quiet stance and during small perturbations (i.e., slowspeed
perturbations usually occurring on a large, firm surface), movements at the
ankle act to restore a person’s COM to a stable position.
• 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.
• Suspension Strategy
The suspension strategy is observed during balance tasks when a person
quickly lowers his or her body COM by flexing the knees, causing associated
flexion of the ankles and hips. The suspension strategy can be combined
with the ankle or the weight-shift strategy to enhance the effectiveness of a
balance movement.
• Hip Strategy
For rapid and/or large external perturbations or for movements executed
with the COG near the limits of stability, a hip strategy is employed.106 The
hip strategy uses rapid hip flexion or extension to move the COM within the
BOS.
• 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. The
uncoordinated step that follows a stumble on uneven ground is an example
of a stepping strategy.
• Combined Strategies
Research has shown that movement response patterns to postural
perturbations are more complex and variable than originally described by
Nashner.75 Most healthy individuals use combinations of strategies to
maintain balance depending on the control demands.
 Balance Control Under Varying
Conditions
• Balance During Stance
In quiet stance, the body sways like an inverted pendulum about the ankle
joint.162 The balance goal is to keep the body’s COM safely within the BOS.
To accomplish this goal, an ankle strategy is utilized in which ankle muscles
(i.e., ankle plantarflexors/ dorsiflexors, invertors/evertors) are automatically
and selectively activated to counteract body sway in different directions.
• Balance with Perturbed Standing
Perturbations to balance in standing can be either internal (i.e., voluntary
movement of the body) or external (i.e., forces applied to the body).
• Balance During Whole-Body Lifting
One of the most common ways that balance is challenged during
everyday life is when lifting boxes or other large objects that are resting
on the floor or at a level that is low relative to the person’s COM (Fig.
8.4). Loss of balance during lifting may result in a fall, slip, or back injury.
- COM shift
- Anticipated weight and momentum (fig.8.5)
- Loss of balance
- Lifting style (Fig.8.6)
- Lifting instructions (Figs.8.7 and 8.8)
- Lifting styles
 Impared Balance
Impaired balance can be caused by injury or disease to any
structures involved in the three stages of information processing—
sensory input, sensorimotor integration, and motor output generation.
• Sensory Input Impairments
Proprioceptive deficits have been implicated as contributing injuries or
pathologies. Decreased joint position sense has been reported in individuals
with recurrent ankle sprains, knee ligamentous injuries, degenerative joint
disease, and low back pain.to balance impairments following lower extremity
and trunk.
• Sensorimotor Integration Impairments
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 and in
disruption of anticipatory and reactive postural adjustments.
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, whereas patients with
cerebellar lesions typically demonstrate larger response amplitudes.
• Biomechanical and Motor Output Impairments
Deficits in the motor components of balance control can be caused
by musculoskeletal (i.e., poor posture, joint ROM limitations, decreased
muscle performance) and/or neuromuscular system (i.e., impaired
motor coordination, pain) impairments. 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.
• Deficits with Aging
Falls are common and are a major cause of morbidity, mortality,
reduced functioning, and premature nursing home admissions in
persons over age . The most common risk factors associated with falls
in the elderly are listed in Box 8.2.
Deficits with Aging
• Deficits from Medications
There is an increased risk of falling among older individuals who
take four or more medications and among those taking certain
medications (i.e., hypnotics, sedatives, tricyclic antidepressants,
tranquilizers, antihypertensive drugs) due to dizziness or other side
effects.4,25 Individuals who have fallen should have their medications
reviewed and altered or stopped as appropriate to prevent future falls.
Management of Impaired Balance
• Examination and Evaluation of Impaired Balance
The key elements of a comprehensive evaluation of individuals with
balance problems include the following.
• A thorough history of falls (whether onset of falls is sudden versus gradual; the frequency
and direction of falls; the environmental conditions, activities, and presence of dizziness,
vertigo, or lightheadedness at time of the fall; current and past medications; presence of
fear of falling)
• Assessments to identify sensory input (proprioceptive, visual, vestibular), sensory
processing (sensorimotor integration, anticipatory and reactive balance control), and
biomechanical and motor (postural alignment, muscle strength and endurance, joint ROM
and flexibility, motor coordination, pain) impairments contributing to balance deficits
• Tests and observations to determine the impact of balance control system deficits on
functional performance
• Environmental assessments to determine fall risk hazards in a person’s home.
• Balance Training
There are many factors to
consider when developing an
intervention program for
balance impairments. Most
balance intervention programs
require a multisystem
approach.
Static Balance Control
Dynamic balance control
Anticipatory balance control
• Reative balance control
• Sensory organization
• Balance during functional aktivities
(fig.8.19)
• Safety during gait, locomotion, or
balance
 Health and environmental factors
• Low vision
To address low vision issues, encourage regular eye examinations
with adjustments to lens prescriptions and cataract surgery, if
necessary. Wearing a hat and sunglasses in bright sunlight, taking extra
precautions when it is dark, and making sure lights are on when
walking about the house at night are other recommendations.
• Medications
Patients should be educated about the influence of certain
medications, such as sedatives and antidepressants, on their risk of
falling.
Evidence-Based Balance Exercise Programs for
Fall Prevention in the Elderly
• Home Exercise Program for Reducing Risk of Falls for People at High
Risk
• Otego home
exercise program
• Supervised Group Program Incorporating Strengthening, Walking, and
Functional Activities
A recent systematic review of the literature concluded that multimodal
exercise programs incorporating muscle strengthening, gait, balance,
coordination and functional exercises led to greater beneficial effects on
balance than usual exercise programs, at least in the short-term.
• Multisystem Group Exercise Program Incorporating a Circuit of
Activities to Address Balance Impairments and Function
Nitz and Choy112 investigated the efficacy of a balance training
program that integrated individual and group exercises targeting strength,
coordination, sensory systems (vision, perception, vestibular), cognition,
reaction time, and static and dynamic stability.
• Tai Chi for Balance Training (fig8.24)
Tai Chi has become a popular form of
exercise for balance training. Tai Chi is a
traditional Chinese exercise program consisting
of a sequence of whole-body movements that
are performed in a slow, relaxed manner with
an emphasis on awareness of posture
alignment and synchronized breathing. The
four styles of Tai Chi are Yang, Sun, Chen, and
Wu, and they differ in terms of principles,
forms, and function. Yang style Tai Chi is the
most popular and widely practiced style today
and consists of 24 forms (postures and
movements).
 Evidence-Based Balance Exercise Programs
for Specific Musculoskeletal Conditions
• Ankle sprains (fig.8.25)
Several systematic reviews have concluded that balance training
programs can improve static and dynamic balance and reduce the risk
of ankle sprains in individuals with a history of ankle sprains.Successful
programs utilized wobble or unstable balance platforms, single-leg
stance progressions, and resisted kicks of the uninvolved leg against an
elastic band or tubing.
• Anterior Cruciate Ligament Injuries
Proprioceptive and balance training programs either alone or in combination
with neuromuscular training that includes lower extremity plyometrics, trunk
stabilization, strengthening, and sport-specific functional training have been
shown to reduce risk factors and the incidence of first-time noncontact anterior
cruciate ligament (ACL) injuries in athletes. These proprioceptive and balance
training programs frequently consisted of double and single leg balance
exercises progressing from firm to unstable surfaces, such as ankle disks, tilt
boards, or foam, with variations, such as squatting or catching a ball.
• Low Back Pain
Research indicates that proprioceptive or balance training may improve
postural control in individuals with low back pain. Specific spinal stabilization
exercises consisting of voluntary contractions of deep abdominal muscles
reduced pain and disability and produced immediate and long-term
improvements in feedforward postural adjustments in people with chronic
nonspecific low back pain.
Coordination
Coordination

• Coordination refers to the body’s ability to execute smooth, fluid,

accurate, and controlled movements. Simple movement, such as
combing hair, involves a complex muscular interaction using the
appropriate speed, distance, direction, rhythm, and muscle tension to
execute the task.
• Coordination may be divided into two categories:
o gross motor movements involving large muscle groups
o fine motor movements using small groups
• Gross motor movements involve activities such as standing, walking,
skipping, and running.
• Fine motor movements are seen in precise actions, particularly with
fingers, such as picking up a coin off a table, clutching anopponent’s
jersey, or picking up a ground ball with a glove.
Field Strategy 8.5 lists several lower extremity exercises used to improve coordination and balance.