This document discusses the concept of balance, detailing the systems involved in maintaining equilibrium, such as the somatosensory, vestibular, and visual systems. It highlights the differences between static and dynamic balance, the importance of balance training for improving stability and preventing falls, especially in the elderly and those with Parkinson's disease, and presents various exercises and management strategies for enhancing balance. Additionally, it notes the significance of tailored interventions and outcome measures for assessing balance in different populations.

1. BALANCE
Dr. SUMAIYA BANU. I
MPT (Cardio)

2. BALANCE
Balance refers to an individuals ability to maintain their
line of gravity within their Base of support (BOS). It can also
be described as the ability to maintain equilibrium, where
equilibrium can be defined as any condition in which all acting
forces are cancelled by each other resulting in a stable
balanced system.

3. BALANCE SYSTEMS
The following systems provides input regarding the body's
equilibrium and thus maintains balance.
• Somatosensory / Proprioceptive System
• Vestibular System
• Visual System
The Central Nervous System receives feedback about the body
orientation from these three main sensory systems and integrates this
sensory feedback and subsequently generates a corrective, stabilizing
torque by selectively activating muscles. In normal condition, healthy
subjects rely 70% on somatosensory information and 20% Vestibular &
10% on Vision on firm surface but change to 60% vestibular
information, 30% Vision & 10% somatosensory on unstable surface.

4. SOMATOSENSORY SYSTEM
Proprioceptive information from spino-cerebellar pathways,
processed unconsciously in the cerebellum, are required to control
postural balance. Proprioceptive information has the shortest time
delays, with monosynaptic pathways that can process information as
quickly as 40–50 ms and hence the major contributor for postural
control in normal conditions.

5. VESTIBULAR SYSTEM
The vestibular system generates compensatory responses to
head motion via:
• Postural responses (Vestibulo-Spinal Reflex) - keep the body upright
and prevent falls when the body is unexpectedly knocked off
balance.
• Ocular-motor responses (Vestibulo-Ocular Reflex) - allows the eyes
to remain steadily focused while the head is in motion.
• Visceral responses (Vestibulo-Colic Reflex) - help keep the head and
neck centred, steady, and upright on the shoulders.

6. VISUAL SYSTEM
• For non-impaired individuals, under normal conditions the contribution
of visual system to postural control is partially redundant as the visual
information has longer time delays as long as 150-200 ms.
• Friedrich et al. observed that adults with visual disorders were able to
adapt peripheral, vestibular, somatosensory perception and cerebellar
processing to compensate for their visual information deficit and to
provide good postural control.
• In addition, Peterka found that adults with bilateral vestibular deficits
can enhance their visual and proprioceptive information even more
than healthy adults in order to reach effective postural stability.
• The influence of moving visual fields on postural stability depends on
the characteristics of the visual environment, and of the support
surface, including the size of the base of support, its rigidity or
compliance.

7. TYPES OF BALANCE
Balance can be classified in to :
• Static Balance: It is the ability to maintain the body in some fixed
posture. Static balance is the ability to maintain postural stability and
orientation with centre of mass over the base of support and body at
rest.
• Dynamic Balance: Defining dynamic postural stability is more
challenging, Dynamic balance is the ability to transfer the vertical
projection of the centre of gravity around the supporting base of
support. Dynamic balance is the ability to maintain postural stability
and orientation with centre of mass over the base of support while
the body parts are in motion.

8. THE MECHANISMS INVOLVED IN STATIC BALANCE
1. Sufficient power in the muscles of the lower limbs and trunk to
maintain the body erect.
2. Normal postural sensibility to convey information concerning
position.
3. Normal impulses from the vestibular labyrinth concerning
position.
4. A central coordinating mechanism, the chief part of which is
the vermis of the cerebellum.
5. The activity of higher centers concerned in the willed
maintenance of posture.

9. THE MECHANISMS INVOLVED IN DYNAMIC BALANCE
1. Sufficient power in the muscles of the body to maintain movement
and stability.
2. Normal postural sensibility to convey information regarding
movement.
3. Normal impulses from the vestibular system and visual system
concerning movement and environment.
4. Central coordinating mechanism including cerebellum and basal
ganglia
5. The activity of higher centers concerned in the willed/ involuntary
maintenance of movement and stability.

10. CORRELATION BETWEEN STATIC AND DYNAMIC
BALANCE
• Maintenance of postural stability during both dynamic and
static conditions involves establishing an equilibrium
between destabilizing and stabilizing forces and requires
sensory information derived from vision, the vestibular
systems, and somatosensory feedback.

11. BALANCE TRAINING

12. Balance training involves doing exercises that strengthen the muscles
that help keep upright, including muscles of legs and core. These kinds
of exercises can improve stability and help prevent falls.
Balance training programs aim to:
• Strengthen balance control in everyday activities leading to improved
fall-related self-efficacy, reduced fear of falling and increased walking
speed
• Improve physical function
• Improve quality of life

13. Examples of balance exercises include:
• Standing with weight on one leg and raising the other leg to the side
or behind,
• Putting heel right in front of your toe, like tandem walking,
• Standing up and sitting down from a chair without using hands,
• Walking while alternating knee lifts with each step,
• Doing tai chi or yoga,
• Using equipment, like a Bosu, which has an inflatable dome on top of
a circular platform, which challenges your balance.

14. Over time, the balance training can improve balance with these exercises by:
• Holding the position for a longer amount of time
• Adding movement to a pose
• Closing eyes
• Letting go of chair or other support
Balance exercises can be done as often as we like, even every day. Adding in
two days a week of strength training, which also helps improve balance by
working the muscles that keep stable.

15. AREAS IT TARGETS
• Core: Yes. We need strong core muscles for good balance. Many
stability exercises will work with abs and other core muscles.
• Arms: No. Most balance exercises are about balancing on feet. So
unless we are doing moves that involve our arms, or holding weights,
we don’t work for arms.
• Legs: Yes. Exercises in which we balance on one leg and then squat or
bend forward also work the leg muscles.
• Glutes: Yes. The same balance exercises that work the legs also tone
the glutes.
• Back: Yes. Our core muscles include some of our back muscles.

16. TYPE
• Flexibility: No. Balance training is more about strengthening muscles and
improving stability than gaining flexibility.
• Aerobic: It can be, but often is not. It depends on how intense the activity
is. If it involves moving fast, then it may be aerobic. Slower balance
exercises do not make breathe faster or make heart pump harder.
• Strength: Yes. Many of these exercises will work on the muscles, especially
the muscles of legs and core. Some moves may also use chest
and shoulder muscles, like the plank position.

17. MANAGEMENT OF BALANCE IN SPECIFIC
CONDITIONS
Parkinson’s disease:
Physiotherapy for Parkinson’s disease focuses on: transfers,
posture, upper limb function, balance, gait, and physical capacity. The
therapist uses cueing strategies, cognitive movement strategies and
exercise to maintain or increase independence, safety, and quality of
life. Sensory cueing strategies such as auditory, tactile, and visual cues
have often been used to help walking in PD.

18. COGNITIVE MOVEMENT STRATEGIES
• Cognitive movement strategies are used to improve transfers. Complex and
automatic activities are divided into separate elements consisting of
relatively simple movement components.
• By doing this, the person has to think consciously about his movements.
Try to avoid dual tasking during complex automatic ADL. Furthermore, the
movement or activity will be practiced and rehearsed in the mind.
• It is important that movements are not performed automatically;
performance has to be consciously controlled.

19. EXAMPLE: Sit to stand
• Hands on chair
• Place feet correctly
• Move forward
• Flex trunk
• Rise up from chair

20. Cueing strategies
• The performance of automatic and repetitive movements of is
disturbed in some patients as a result of fundamental problems of
internal control. That’s why cues are used to complete or replace
this reduced internal control. Cues can be generated internally or
externally. Rhythmical recurring cues are given as a continuous
rhythmical stimulus, which can serve as a control mechanism for
walking.
• Auditory (moves on music, singing, counting,...)
• Visual (patient follows another person, walks over stripes on
the floor, he projects himself with a laser pen,...)
• Tactile(patient taps his hip or leg)

21. THE PHYSICAL THERAPEUTIC INTERVENTION
GOALS APPLY TO THE PHASE ADDRESSED:
Early phase - patients have no or little limitations. Goals of the
therapeutic intervention are:
• Prevention of inactivity
• Prevention of fear to move/to fall
• Preserving/ improving physical capacity

22. Mid phase - more severe symptoms; performance of activities
become restricted, problems with balance and an increased
risk of falls.
Problems:
• Body Transfers
• posture
• Reaching and grasping
• Balance
• Gait

23. • Late phase - patients are confined to a wheelchair or bed.
The treatment goal in this phase is to preserve vital functions
and to prevent complications, such as pressure sores and
contractures.

24. BALANCE TRAINING IN ELDERLY
Balance training can also be used in the elderly. Risk of Falls in elderly,
is very common due to poor balance. For this reason, the use of balance
training might be very helpful to them.
The training includes:
• Gait pattern
• Balance control
• Co-ordination and functional tasks
• Strengthening exercise
• Computerized balance programs or vibration plates.

25. To keep the therapy adherence up it is best to look for an approach
with a ‘fun factor’. Some examples:
• Music-based multitask exercise program - basic exercises consisted of
walking in time to the music and responding to changes in the music’s
rhythmic patterns. Exercises involved a wide range of movements and
challenged the balance control system mainly by requiring
multidirectional weight shifting, walk-and-turn sequences, and
exaggerated upper body movements when walking and standing.
• Tai chi has been proven to be an economic and effective way for
training balance in older people.

26. • To ameliorate balance in the elderly it isn’t enough to just follow a conventional
exercise intervention (including muscle strengthening, stretching and aerobic
exercises, and health education). It is better to also include static, and dynamic
balance exercises.
• Static balance exercises: squats, two-leg stance and one-leg stance.
• Dynamic exercises: jogging end to end, sideways walking or running with
crossovers, forward walking or running in a zigzag line, backward walking, or
running in zigzag line.
• Use of Balance Boards.
• Core strength training: Nevertheless to improve balance core strength training is
an important element. The benefit is this therapy can be both given in a group
setting or in individual fall preventive interventions

27. OUTCOME MEASURES
Many exists some commonly used test are:
• 4 Stage Balance Test
• Berg Balance Scale to evaluate static and dynamic balance, the
• Falls risk assessment tool
• Timed Up and Go Test to assess a patient's mobility
• The Balance Outcome Measure for Elder Rehabilitation
• Functional Reach

28. THANK YOU…