Phinoj. K. Abraham
IInd MOTh Student
All India Institute of Physical Medicine & Rehabilitation,
General Concepts &
in the Elderly: Special Concerns
• Age Related Changes
• Intervention Strategies
• Balance is defined as a “complex process
involving the reception and integration of
sensory inputs, planning and execution of
movements, to achieve a goal requiring upright
posture.” (Nashner L, 1994)
• It is the ability to control the COG over the BOS
in a given sensory environment. (Nashner L,
• The term posture is often used to describe both
Biomechanical alignment of the body as well as
Orientation of the body to environment
impairment may resulting from,
• Neurological conditions
• Musculoskeletal conditions
• Psycological conditions.
• Based on neurophysiologic principles.
• Focused on Reflexive & Reactive equilibrium
• Incorporated other relevant systems
In a Systems model or system approach to
is the result of
interactions between the
individual, task and
Within the PERSON…
Sensory inputs & processing system. (b/w E & P)
Motor planning & execution system. (b/w P & T)
Influence of other systems.
CENTRAL NERVOUS SYSTEM
Peripheral sensory reception.
Dysfunction leads to impaired rendering of sensory
information's to brain.
Central sensory perception.
Multi Sensory reweighting - “Upweightage”
&“Downweightage” of sensory information(s).
Dysfunction result in to “sensory conflict”
motor planning & control
• Depends on
Attention, Intention & Motivation
motor execution- through bilateral
Joints & muscles.
• Factors influencing are,
Musculoskeletal evaluation is significant here.
- cutaneous receptors in soles of the feet
- muscle spindle & Golgi tendon organ information
- ankle joint receptors
- proprioreceptors located at other body segments
• - located in the inner ear
• - static information about orientation
• - linear accelerations, rotations in the space
• - the slowest system for corrections (200 ms)
Vestibulo-occular Reflex (VOR)
Allows the coordination of eye & head movements.
Vestibulospinal Reflex (VSR)
It helps to control movement & stabilize the body. (via.
Righting like labyrinthine, optical, body on head righting)
The VSR permits stability of the body when the head
moves and is important for the co ordination over the
trunk over the extremities in upright posture.
B. Automatic postural responses
Stepping & reaching strategy
• When the COG is outside of the BOS, a strategy is
required (shift, step or stumble) is required to
prevent a fall. (INHERENT FALL PREVENTION)
• Strategies are automatic
• Occur 85 to 90 msec after the perception of
instability is realized
when perturbation is:
• Low amplitude
surface firm, wide
and longer than foot
Muscles recruited distal - to
Head movements in-phase
when perturbation is:
• large amplitude
is unstable or
shorter than feet
Muscles recruited proximalto distal
Head movement out-of
phase with hips
bend of trunk with
progress to a Squatting
to prevent a fall
• Large amplitude
• Or when other strategies fail
• Base of Stability (BOS)
to “catch up”
C. Anticipatory postural adjustments
Aim: to counteract the destabilizing
consequences of a Voluntary movement.
Failure to produce this adjustment –
increases the risk of falling
D. Volitional Postural Movements
Self initiated disturbance of the COG to
accomplish a goal.
Basic Principles of Postural Control - Summery
The Sensory System
• Vision may decrease in acuity, contrast
sensitivity, and depth perception.
• The vestibular system may undergo agerelated changes, resulting in dizziness and
• There may be a decrease in proprioception
The Central Processing System
Aging may result in:
Slowing of sensory information
Slowing of nerve conduction velocity
Increased postural sway
Increased incidence of co-contractions
• High level Sensory Adaptation
Decreased ability to shift from the use of one sensory
input to other for poster control
Increased attention required for the Postural Control
Poorer performance in Dual Tasks (in Cognitive &
may result in:
Decreased muscle strength
Decreased ROM and flexibility
Increased “stiffness” of connective tissue
Aging may result in cardiovascular changes
- 30% fear falling1
35%-40% of people 65+ fall each year 2
Those who fall are 2-3 times more likely to fall
10%-20% of falls cause serious injuries4
• Incidence of fall is 14% (History of a
single fall in the last 6 months)
• M:F = 68%:32%
1. Vellas BJ, Age & Aging, 1997; Friedman SM, JAGS, 2002
2. Hornbrook, Gerontologist, 1994; Hausdorff, Arch Phys Med & Rehab, 2001
3. Tinetti, New Eng J Med, 1988; Teno, JAGS,1990
4. Sterling, J Trauma-Inj Infection & Critical Care, 2001
is “an appraisal or evaluation of a
patient’s condition, based on clinical &
laboratory data, medical history, and the
patient’s account of symptoms”
Taber’s cyclopedic medical dictionary., 18th ed. p 16
The system approach is a useful approach for the
assessment of balance in elderly
• A comprehensive assessment of balance function from
the system perspective would include examining the
older adult performing a range of balance tasks under a
variety of contexts.
Underlying Components of balance control to be assessed
• Motor &
Balance tasks to be assessed includes
• Self Report Measures
• Quiet standing (static)
• Active standing (dynamic)
• Sensory manipulation
• Functional scales
• Dual task & Multiple Task
The Activities-specific Balance
Confidence (ABC) Scale
• Description of the Instrument
The Activities-specific Balance Confidence (ABC)
Scale is a 16-item scale; each item is rated from 0%
(no confidence) to 100% (complete confidence).
• Form of instrument:
• Reliability Validity = Good
to test in which the client is standing
and the movement goal is to hold still. (i.e.
Perturbations may or may not be applied.
Double Limb Standing
Single Limb Stance (SLC)/ Unilateral standing
Sharpened / tandem Romberg
One legged stance tests (OLSTs)
• Both legs must be alternatively tested
• Difference b/w sides are noted
The client stands on both feet and crosses the arms
over the chest, then picks up one leg and hold it in
neutral and the knee flexed to 900.
The lifted leg may not be pressed in to the stance leg.
Five 30 sec trials are performed for each leg
Max. score is 150 for each leg
• Normal young subject are able to stand for 30 sec
• Gehlsen and Whaley found that a one-legged stance
test distinguished elderly fallers from non-fallers.
to test in which the client is standing and
the movement goal involves voluntary weight
• Functional reach test
• Multidirectional reach
• Sit-to-stand, Sit down
• Reaching movement
• Different walking tasks (turning, head rotation, on
beam, stop and start etc)
• Limits of stability : it is the farthest distance in any
direction a person can lean (away from the mid line)
with out altering the original BOS by stepping,
reaching, or falling
was developed for use with older adults to
determine risk for falls.
• The client stands near a wall with feet
A yard stick is attached to the walls in
shoulder (acromion) height
The client is asked to make a fist & raise the arm
nearest the wall (without touching) to 90° of shoulder
The examiner notes the fist (3ird MC head) on the
The client is then asked to lean forward as far as
possible, & the examiner notes the end point.
• Beginning position is subtracted from end position of
the fist on the yardstick.
Interpretation: Score is available
Simple single task test, easy to administer, Quick screen
High degree of agreement rates (reliability inter .98 intra
FR is affected by age and height (i.e. anthropometric
Studies shown that this test is useful for fall prediction
Limitation: it measures sway in only 0ne direction.
Less sensitive to illustrate the clinical improvement.
test measures how far an individual
can reach in the forward, backward, and
• For backward reach, the test position is the same
• For lateral reach, the client faces away from the
wall and reaches to sides (to right and left side)
• 1 practical trial is allowed before the start of 3 trial
Uses altered surface & visual conditions to
determine how well the CNS is using and
reweighting sensory input from postural control.
• Sensory organization test
• Clinical Test of Sensory Interaction on Balance
SOT uses a computerized, movable force
plate and movable visual surround to alter the
surface and visual environment systematically.
It is used to determine the effectiveness of an
individual to utilize different sensory inputs.
It examines body sway during three 20-second
trials under each of six sensory conditions are
• Moving platform (sliding or tilting)
• A moving visual surround screen
Test conditions are,
• C1: Eyes Open, Stable Surface (EOSS)
• C2: Eyes Closed, Stable Surface (ECSS)
• C3: Visual Conflict with Moving Surround, Stable
C4: Eyes Open, Moving Surface (EOSS)
C5: Eyes Closed, Moving Surface (ECSS)
C6: Visual Conflict with Moving Surround, Moving
Test condition 1 provides accurate somatosensory,
visual, and vestibular information & is the baseline
Each of the other 5 conditions increasing the level of
sensory conflict & postural difficulty.
• Posturography equipment provides a printed
• Ratio comparison provide information regarding
reliance on one system over another
• EMG – to know about muscle activity &
• SOT is reliable and valid scale
• Normative data is available.
is a clinical version of the SOT that does not
use computerized force plate.
The concept of 6 condition is remain intact.
A thick foam pad substitutes for moving force
• By using a stop watch
• Visual gradations.
SCORE 1 : Minimal sway
SCORE 2 : Mild sway
SCORE 3 : Moderate sway
SCORE 4 : Fall
These tests use various
• Visual acuity
body & head positions,
eye movement, or
stepping to stimulate or
restrict visual, vestibular
or somatosensory inputs.
• Oculomotor tests
• Vertigous positions
• Fukuda Stepping Test
• Hallpike-Dix Maneuver
• Dizziness Handicap
is a vertiginous position test
to stimulate the post
• Moving the patient from a sitting
position with the head turned so
that the affected ear is 30-45°
below the horizontal stimulate
post. Canal and may produce
nystagmus & vertigo
• A +ve result leads to a diagnosis
of Benign positional vertigo (BPV)
balance, mobility, and gait
scales involve the performance of wholebody movement task.
• Berg Balance Scale
• Tinetti performance oriented assessment of gait.
• Timed Up and Go Test
• Gait Assessment Rating Scale (GARS)
• Dynamic Gait Index
• Functional Gait Assessment
is a multi task test of 14 balance task (6 static &
• Maintanance of position
• Postural adjustment to volountry movement
Reliability (inter=.98 intra=.99)
: 5 point ordinal scale with specefic task criteria
• Simple, easy to administer
• Client should able to stand
• Provide baseline & outcome data; score of 45 or below
are predictive of falls in the elderly
It is a multi task test: have 2 parts
• Balance sub test: 9 items (4 static & 5 dyanamic)
• Gait sub test : 8 test
• Maintenance of position
• Postural response to perturbation
• Gait mobility
• Chair, walk way; patient can use usuan walking
• Some items graded can/cannot perform; some 3 point
scale with specific criteria
Reliability : inter=.85
Requirements: able to stand & walk independently
• Simple, easy to administer
• Provide baseline data; predictive of falls in elderly
> 24 low risk
19-24 mod risk
18> high risk
• Limitation: some scoring criteria vague; difficult to
detect small changes
is a single task test: stand up, walk 3 meter,
turn around and return to chair
Focuses on = Functional mobility
• Timed test uses 1 practice/3 trials for average score
: inter=.99, intra = .98
Requirements : able to stand & walk
• Simple, easy to administer
• Provides baseline & outcome data: predictive of falls in
are developed to examine the
concurrent activities (i.e. cognitive & postural
control demands)and divided attention on
balance and mobility performance.
• Stops Walking When Talks (SWWT) & Walking While
• Multiple Tasks Tests (MTT)
these tests, clinician asks the client 1 or
more questions and observe if the client must
stop walking to answer the question(s).
If so the test is positive. i.e. patient have to
stop walking to reallocate attention to the
is a more formalize test
It include 8 items involving gait plus other
cognitive and motor tasks such as carrying
a try and avoid obstacle.
Comments for Dual task tests
• Reliability & validity are not well established
• Disagreement in the literature exist regarding their
• In clinical use, these are helpful to detect clients
with major problems (Sensitivity ?).
topic will be discuss under the
• Preventive Exercises
• Recent Advanced techniques used for balance
intervention in elderly from Literatures.
Fall Prevention Recommendations
Home safety evaluation
Downloaded from www.circ.ahajournals.org by on May 16, 2010
Individual risk assessment
Regular strength & balance exercise
Gait & assistive device training
Medication review & management
Management of chronic conditions
Home safety improvements
WA State Dept. of Health, Falls Among Older Adults: Strategies for Prevention (2002)
Centers for Disease Control
The intervention strategies that were evaluated for their
effectiveness in preventing falls were classified as single or
multifactorial strategies and as generic or individually
designed. JAGS 49:664–672 MAY 2001–VOL. 49, NO. 5
Among community-dwelling older persons (i.e.,
those living in their own homes), multifactorial
interventions should include:
• Gait training and advice on the appropriate use of
assistive devices (B);
• Review and modification of medication, especially
psychotropic medication (B);
• Exercise programs, with balance training as one of
the components (B);
• Treatment of postural hypotension (B);
• Modification of environmental hazards (C); and
• Treatment of cardiovascular disorders, including
cardiac arrhythmias (D).
long-term care and assisted living settings
multifactorial interventions should include:
• Staff educationprograms (B);
• Gait training and advice on the appropriateuse of
assistive devices (B); and review and
• Modification of medications, especially
evidence is insufficient to make
recommendations for or against multifactorial
interventions in acute hospital settings
Although exercise has many proven benefits,
the optimal type, duration and intensity of
exercise for falls prevention remain unclear (B).
Older people who have had recurrent falls
should be offered long-term exercise and
balance training (B).
Tai Chi C’uan is a promising type of balance
exercise,although it requires further evaluation
before it can be recommended as the preferred
balance training (C)
• When older patients at increased risk of falls are
discharged from the hospital, a facilitated
environmental home assessment should be
• In a subgroup of older patients, a facilitated home
modification program after hospital discharge was
effective in reducing falls (Class I).
• Otherwise, modification of home environment
without other components of multifactorial
intervention was not beneficial (Class I).
Patients who have fallen should have their
medications reviewed and altered or stopped as
appropriate in light of their risk of future falls.
Particular attention to medication reduction should
be given to older persons taking four or more
medications and to those taking psychotropic
• Studies of multifactorial interventions that have
included assistive devices (including bed alarms,
canes, walkers (Zimmer frames), and hip protectors)
have demonstrated benefit. However, there is no direct
evidence that the use of assistive devices alone will
prevent falls. Therefore, while assistive devices may be
effective elements of a multifactorial intervention
program, their isolated use without attention to other
risk factors cannot be recommended (C).
• Among hospitalized patients there is insufficient
evidence for or against the use of bed alarms (Class I).
and Educational Programs
Although studies of multifactorial interventions that have
included behavioral and educational program have
demonstrated benefit, when used as an isolate
intervention, health or behavioral education does not
reduce falls and should not be done in isolation (B)
A structured group educational program among
community- dwelling older people did not reduce the
number of falls but did achieve short-term benefits in
attitudes and self-efficacy (Class I).
Practice guidelines in the emergency department did not
alter documentation of falls risk factors, causes of falls,
consequences of falls, or the implementation of practice
guidelines (Class I).
Bone Strengthening Medications
• It reduce fracture rates. But not reduce the rates of falls.
• Fall-related hip fractures were higher in patients with
• For Women: Static and dynamic balance were better in
low-heeled rather than high-heeled shoes or than the
patient’s own footwear.
• For men: foot position awareness and stability were
best with high midsole hardness and low mid-sole
thickness. Static balancewas best in hard-soled (low
Sensory-Specific Balance Training in Older Adults:
Effect on Position, Movement, and Velocity Sense at
• Results suggest that short-term improvements in velocity
sense, but not movement and position sense, may be
achieved following a balance exercise intervention
PHYS THER Vol. 87, No. DOI: 5, May 2007,Vol. 87, No. 5, May 2007, pp. 560-568
of ballates, step aerobics, and walking on
balance in women aged 50-75 years
• All three training programs improved dynamic balance,
however, step aerobics be better improvements in
postural stability or static balance when compared to the
of High-Intensity Strength Training on
Multiple Risk Factors for Osteoporotic Fractures A
Randomized Controlled Trial
• High-intensity strength training exercises are an effective
and feasible means to preserve bone density while
improving muscle mass, strength, and balance in
JAMA. 1994;272(24):1909-1914. Vol. 272 No. 24, December 28, 1994
Objective Approach for Assessment of Balance
Disorders and Role of Visual Biofeedback Training
in the Treatment of Balance Disorders : A
• Study suggests that visual biofeedback training
facilitates appropriate balance strategies and enables in
achieving improved postural control.
IJPMR 12, April 2001; 25-30
effect of proprioceptive physical
activities on balance control in elderly human
• Proprioceptive exercise therefore appears to have the
best impact on balance control.
Neuroscience Letters Volume 273, Issue 2, 1 October 1999, Pages 81-84
group exercise improves
balance and reduces falls in at-risk older people: a
randomised controlled trial
• participation in a weekly group exercise programme with
ancillary home exercises can improve balance and
reduce the rate of falling in at-risk community dwelling
Age and Ageing 2003; 32: 407-414
controlled trial of a general practice
programme of home based exercise to prevent falls
in elderly women
• An individual programme of strength and balance retraining
exercises improved physical function and was effective in
reducing falls and injuries in women 80 years and older
BMJ 1997;315:1065-1069 (25 October)
Effect of Multidimensional Exercises on Balance,
Mobility, and Fall Risk in Community-Dwelling Older
can improve balance and mobility function and
reduce the likelihood for falls among community-dwelling
older adults with a history of falling. The amount of exercise
needed to achieve these results, however, could not be
determined from this study.
PHYS THER Vol. 77, No. 1, January 1997, pp. 46-57
Training Elderly People in Martial Arts Could
Cut Their Risk of Injuries from Falls
• Training older people in martial arts could cut their
chances of suffering broken bones or fractures when
they fall, according to experts.
Health & Fitness, Science & Technology News April 22nd, 2010 at 10:10 am
of a Gentle Iyengar Yoga Program on Gait
in the Elderly: An Exploratory Study
• …. yoga programs tailored to elderly adults may offer a
cost-effective means of preventing or reducing agerelated changes in these indices of gait function.
Arch Phys med Rehabil Volume 86, Issue 9, Pages 1830-1837 (September 2005)
And remember, falls
can be prevented,
falling in love.