This document discusses balance, fall prevention, and balance assessment and training. It defines balance as control of the center of mass over the base of support. Age-related changes and diseases that impact balance components are reviewed. Valid tools to measure balance include the Berg Balance Scale, Timed Up and Go test, and Functional Reach test. Balance training exercises discussed include calf stretches, heel/toe raises, soft surface stance, and exercises using movable surfaces like Swiss balls and tilt boards. Both hard and soft surfaces are used to challenge static and dynamic balance.

1. Balance and Fall Prevention
By,
Sankari Nedunsaliyan
Physiotherapist
Dip In PT (MAL), Bsc Hons Applied Rehab (UK)

2. Balance Defined
• Balance: Control of center of mass over
base of support (Shumway – Cook, 2001)14
• Center of mass: Center point of each body
segment combined
• Center of gravity: Vertical projection of
center of mass
• Base of support: Area of object that is in
contact with the ground

3. Base of Support

4. Center of Mass
Balance: Control of center of mass
over base of support

5. Balance: control of center of mass
over base of support

6. Vicious Cycle
Fall
↗ ↘
Imbalance ← Inactive

7. Indications/Needs
 Gait and balance difficulties regardless of the
underlying neurologic or orthopedic cause
 Medical conditions that can cause mobility
difficulties include Parkinson’s disease, multiple
sclerosis, stroke, neuropathies, and head trauma
 Vestibular disorders that cause dizziness
 Patients with osteoporosis or elderly can
benefit from specific balance training to prevent
falls and decrease risk of fractures.

8. Precautions
 High Fall Risk
 Co morbidities
 Recent Surgery
 Injuries

9. Types of Balance
• Steady state (static) balance
• Reactive balance (Dynamic Balance)
• Proactive (anticipatory) balance

10. Steady state (static) balance:
 Maintain stable position in standing or
sitting
 This happens when the objects centre of
gravity is on the axis of rotation.

11. Reactive balance:
 Recovering from an unexpected perturbation.
 Reactive balance is defined as automatic
movement patterns, or strategies, that occur
when balance is disturbed.
 They are faster responses than movements
under voluntary control. If the response is
appropriate no loss of balance will occur.

12. Proactive (anticipatory) balance
 To develop a device which provides safe,
controlled, simple, and inexpensive.
reactive balance training for adults
 Anticipatory - Body recognize that
something is going to happen that will
disturb its balance and make the
adjustments before it happens

13. A Systems Model of Balance1
1Courtesy of Sandra Rader, PT, Clinical Specialist

14. Stability & Balance
 Result of interaction of many variables (see
model)
 Limits of Stability - distance in any direction
a subject can lean away from mid-line
without altering the BOS
 Determinants:
◦ Firmness of BOS
◦ Strength and speed of muscular responses
◦ Range: 80 anteriorly; 40 posteriorly

15. Limits of Stability

16. Model Components
Musculoskeletal System
 ROM of joints
 Strength/power
 Sensation
◦ Pain
◦ Reflexive inhibition
 Abnormal muscle
tone
◦ Hypertonia (spasticity)
◦ Hypotonia

17. Model Components
Goal/Task Orientation
 What is the nature of
the activity or task?
 What are the goals or
objectives?

18. Model Components
Central Set
 Past experience may
have created “motor
programs”
 CNS may select a
motor program to
fine-tune a motor
experience

19. Model Components
Environmental Organization
 Nature of contact
surface
◦ Texture
◦ Moving or stationary?
 Nature of the
“surrounds”
◦ Regulatory features of
the environment
(Gentile)

20. Model Components
Motor Coordination
 Movement strategies
◦ Based on repertoire of
existing motor
programs
 Feedback &
feedforward control
 Adjustment/tuning of
strategies

21. Strategies to Maintain/Restore
Balance
 Ankle
 Hip
 Stepping
 Suspensory
 Strategies are automatic and occur 85 to
90 msec after the perception of instability
is realized

22. Ankle Strategy
 Used when
perturbation is
◦ Slow
◦ Low amplitude
 Contact surface firm,
wide and longer than
foot
 Muscles recruited
distal-to-proximal
 Head movements in-
phase with hips

23. Ankle Strategy

24. Hip Strategy
 Used when
perturbation is fast or
large amplitude
 Surface is unstable or
shorter than feet
 Muscles recruited
proximal-to-distal
 Head movement out-
of-phase with hips

25. Hip Strategy

26. Stepping Strategy
 Used to prevent a fall
 Used when
perturbations are fast
or large amplitude -
or- when other
strategies fail
 BOS moves to “catch
up with” BOS

27. Suspensory Strategy
 Forward bend of
trunk with hip/knee
flexion - may progress
to a squatting position
 COG lowered

28. Model Components
Sensory Organization
 Balance/postural
control via three
systems:
◦ Somatosensory
◦ Visual
◦ Vestibular

29. Somatosensory System
 Dominant sensory
system
 Provides fast input
 Reports information
◦ Self-to-(supporting)
surface
◦ Relation of one
limb/segment to
another
 Components
◦ Muscle spindle
 Muscle length
 Rate of change
◦ GTOs (NTOs)
 Monitor tension
◦ Joint receptors
 Mechanoreceptors
◦ Cutaneous receptors

30. Visual System
 Reports information
◦ Self-to-(supporting)
surface
◦ Head position
 Keep visual gaze parallel
with horizon
 Subject to distortion
 Components
◦ Eye and visual tracts
◦ Thalamic nuclei
◦ Visual cortex
 Projections to parietal
and temporal lobes

31. Vestibular System
 Not under conscious
control
 Assesses movements
of head and body
relative to gravity and
the horizon (with
visual system)
 Resolves inter-sensory
system conflicts
 Gaze stablization
 Components
◦ Cerebellum
◦ Projections to:
 Brain stem
 Ear

32. Sensory-Motor Integration
Somatosensory
Vestibular
Visual
Eye Movements
Postural Movements
10 Processor
20 Processor
Cerebellum
Motoneurons
Sensory Input Processing Motor Response

33. Body response to sensory input
Normal body response to perturbation(deviation)
(pushing patient forward and back)
A) Mild perturbation: Ankle response (push patient
forward, the calf muscles engage)
B) Moderate perturbation: Hip response (push patient
forward, patient leans back)
C) Large perturbation: Stepping response (patient
steps forward to avoid falling)

34. BALANCE COMPONENTS
VS
AGE

35. Age related changes to motor
components of balance
 Decreased magnitude of muscle response
 Increased reliance of arms

36. Age related changes to sensory
components of balance
 Decreased visual, vestibular,
somatosensory (body awareness), and
auditory (hearing) function
 Decreased ability to adapt responses (e.g.
using your inner ear and your feet

37. Age related changes to cognitive
components of balance
 Decreased overall attention capacity
 Decreased ability to multitask (e.g.
carrying a cup of water while walking)

38. BALANCE COMPONENTS
VS
DISEASE

39. Abnormal balance
 As the balance system declines, so does
the ability of the system to respond
correctly
 Individuals with an increased fall rate did
not use an ankle strategy

40. Abnormal balance
Cerebrovascular accident (CVA)—Stroke
 A) Synergistic pattern: Groups of muscles
work together in a “stuck” pattern
 B) Increased muscle tone
 C) Cognition (e.g. impulsive behavior)
 D) Impaired body awareness

41. Abnormal balance
Parkinson’s Disease
 A) Dynamic balance problem
 B) Difficulty initiating gait
 C) Moments of freezing during movement
 D) Altered gait cycle

42. Abnormal balance
Benign Paroxysmal PositionalVertigo (BPPV)
 A) Calcium crystals stuck in the semicircular
canals in the inner ear.
 B) Dependent on head position.
 C)Vertigo –sensation that the room is
spinning.

43. Abnormal balance
Orthopedic cases: (Hip or knee replacement)
 A) Impaired joint range of motion (alters
center of mass during gait and stance)
 B) Altered body awareness (new body part)

44. HOW TO TESTYOUR
BALANCE

45. Valid tools to measure balance
 Berg’s Balance scale
 Timed up and go test
 Functional reach test
 Nudge test
 Other tests: Hallpixe – Dix Test

46. Balance Tests – Berg Balance Scale
14 item scale for possible 56 points total
• Decrease in Berg score = increased fall risk14
• Score of 56-54, 1 point drop = 3-4% inc. fall risk
• Each point drop from 54-46, = 6-8% increase
• Below 36, fall risk = 100%
• Limitations: does not test reactive balance;
ceiling effect

47. Balance Tests
Timed up and go test12
• Get up from seated position, walk 3 meters,
turn around, walk back to chair
• Adults who took > 30 sec were dependent
in activities of daily living
Functional reach test
• Standing reaching forward with hand
• Highly predictive of falls among older adults3

48. Balance Tests
Nudge test:
• Moving patient forward, back, sideways
• Ankle vs hip, vs stepping strategy
• Test under different conditions: soft surface,
eyes closed, with head movements
Other tests:
• Hallpike - Dix (testing for vertigo),
observational gait analysis, dynamic gait index

49. Treatment of balance
Exercise examples
 A) Calf stretch
 B) Heel / toe raises
 D) Soft surface stance in corner
 E) Sitting to standing

50. Resources
 Active Life PhysicalTherapy Port Ludlow:
www.activelifetherapy.com
 Home Instead Senior Care
www.homeinstead.com/650/Pages/HomeInsteadSeniorCare.aspx
 Olympic Area Agency on Aging: www.o3a.org/
 ECHHO: http://echhojc.org/
 Boeing Bluebills Olympic Peninsula:
www.bluebills.org/olympic.html
 Centers for Disease Control and Prevention www.cdc.gov/
 National Osteoporosis Foundation » http://www.nof.org/
 American Physical Therapy Association: www.apta.org
 WA State Dept. Of Health www.doh.wa.gov/
 Washington State Falls Prevention web site
www.fallsfreewashington.org

51. References
 1.American Geriatric Society, British Geriatric Society,American Academy of Orthopedic
Surgeons Panel on Falls Prevention.Guidelines for the Prevention of Falls in Older Persons. JAGS
49: 664-672, 2001.
 2. Centers for Disease Control and Prevention,National Center for Injury Prevention and Control.
Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed
November 30, 2010.

 3. Duncan P, Studenski S, Chandler J, Prescott B. Functional Reach: a new clinical measure of
balance. J Gerontol 1990; 45M192-M197.

 4. Englander F, HodsonTJ,Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of
Forensic Science 1996;41(5):733–46.trial.The Gerontologist 1994;34(1):16–23.

 5. Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–living older adults:
a 1–year prospective study.Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.
 6. Hornbrook MC, StevensVJ,Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls
among community–dwelling older persons: results from a randomized trial.The Gerontologist
1994:34(1):16–23
 7. Issue Brief (Public Policy Inst (Am Assoc Retired Pers) 2002 Mar;(IB56):1-14.
 8. Kochera A. Public Policy Institute,American Association of Retired Persons,Washington, DC,
USA. Falls among older persons and the role of the home: an analysis of cost, incidence, and
potential savings from home modification. 2002.

52. References
 9. Morrison, C. Northwest Orthopaedic Institute. Proven Best Practices:Assessment and
Treatment of Patients Who are at Risk for Falls. Gentiva Seminar.Attended October 20,
2006.

 10. National Hospital Discharge Survey (NHDS), National Center for Health Statistics.
Available at: www.cdc.gov/nchs/hdi.htm. Assessed September 14, 2011.

 11. National Fire Safety Council, Inc., Michiagan Center, MI 49254-0378. Falls Prevention:
Protecting Your Active Lifestyle.
 12. Podsiadlo D, Richardson S.The timed “Up and Go” test: a test of basic functional
mobility for frail elderly persons. J Am Geriatr Soc 1991; 39:142-148.
 13. Roudsari BS, Ebel BE, Corso PS, Molinari, NM, Koepsell TD.The acute medical care costs
of fall-related injuries among the U.S. older adults. Injury, Int J Care Injured 2005;36:1316-22.
 14. Shumway-Cook A,Woollacott M. Motor Control Theory and Practical Applications, 2nd
Ed. Lippincott Williams & Wilkins. Baltimore, MD 2001.
 15.Tinetti ME. Clinical Practice. Prevention Falls in Elderly Persons. N Eng J Med 2003;
348:42-49

53. References
 16.Washington State Department of Health: Senior Falls Prevention Study 2006
 17.York, S. Northwest Orthopaedic Institute. Proven Best Practices:Assessment and
Treatment of Patients Who are at Risk for Falls. Gentiva Seminar.Attended October 20,
2006.

55.  Static balance control
◦ Maintaining sitting.
◦ Half-kneeling,
◦ Tall kneeling,
◦ Standing postures on a firm surface,
Balance Training
◦ Tandem, Single-leg stance.
◦ Working on soft surfaces (e.g., foam, sand, grass),
◦ Narrowing the BOS, moving the arms, or closing the eyes.

56.  Dynamic Balance Exercises Using
Movable Surfaces:
1. Swiss Ball
1. Tilt Boards
Balance Training

57.  Hard surfaces.
 Maintain static balance.
 Move some part (s) of body and try to maintain his
balance.
 Open then closed eyes.
 External challenge from therapist.
 Throw and catch exercises with ball.
 Soft surfaces.
 Maintain static balance.
 Move some part (s) of body and try to maintain his
balance.
 Open then closed eyes.
 External challenge from therapist.
 Throw and catch exercises with ball.