Balance is the ability to control body position to maintain upright posture. It involves integration of sensory inputs and motor outputs. Balance training progresses from simple to complex tasks in positions like lying, sitting, kneeling, and standing static and dynamic exercises before walking, stairs, and community tasks. Assessment evaluates vision, sensation, vestibular function, range of motion, strength, and limits of stability. Treatment addresses sensory, strategy, musculoskeletal, and environmental factors through exercises, modifications, and assistive devices.

1. BALANCE TRAININGBALANCE TRAINING

2. DefinitionDefinition
Balance is defined as the ability toBalance is defined as the ability to
control the body mass or center ofcontrol the body mass or center of
gravity to the base of support ingravity to the base of support in
order to maintain a upright postureorder to maintain a upright posture
or a functional equilibrium inor a functional equilibrium in
dynamic activitiesdynamic activities

3. Normal Balance MaintenanceNormal Balance Maintenance
 Human balance is a complex process whichHuman balance is a complex process which
involves the integration of sensory informationinvolves the integration of sensory information
from peripheral end organs to detect bodyfrom peripheral end organs to detect body
position in relation to environment.position in relation to environment.
 Integration of this information by CNS toIntegration of this information by CNS to
produce adequate and proper motor output inproduce adequate and proper motor output in
the form of automatic postural responsesthe form of automatic postural responses..

4. The Sensory factorsThe Sensory factors
 Somato Sensory InputsSomato Sensory Inputs
(Proprioceptors)(Proprioceptors)
 Visual InputsVisual Inputs
 Vestibular InputsVestibular Inputs

5. 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 motion andPerception of verticality, object motion and
motion of self in relation to environment.motion of self in relation to environment.
Vestibular InputsVestibular Inputs::
Position of head in relation to gravity andPosition of head in relation to gravity and
linear and angular acceleration of headlinear and angular acceleration of head
during movement.during movement.

7. StrategiesStrategies
 Ankle strategyAnkle strategy
Describes postural sway control from ankleDescribes postural sway control from ankle
musculature level. This strategy act when themusculature level. This strategy act when the
sway is small, slow and near midline.sway is small, slow and near midline.
 Hip StrategyHip Strategy
It is the postural sway from pelvis and trunk. It isIt is the postural sway from pelvis and trunk. It is
seen when the sway is large, fast and nearingseen when the sway is large, fast and nearing
the limits of stability.the limits of stability.

8.  Suspensary strategySuspensary strategy
It describes lowering of COG by flexing both theIt describes lowering of COG by flexing both the
knees. Commonly seen in windsurfing.knees. Commonly seen in windsurfing.
 Stepping strategyStepping strategy
It describes steps with feet or reaches with armsIt describes steps with feet or reaches with arms
in an attempt to re-establish a new base ofin an attempt to re-establish a new base of
support when COG has exceeded the originalsupport when COG has exceeded the original
base of support.base of support.

9. What is a balance disorder?What is a balance disorder?
A balance disorder is aA balance disorder is a
disturbance that causes andisturbance that causes an
individual to feel unsteady, giddy,individual to feel unsteady, giddy,
or have a sensation of movement,or have a sensation of movement,
spinning, or floating.spinning, or floating.

10. Causes of balance disordersCauses of balance disorders
Sensory system disordersSensory system disorders
 Sensory ataxia (dorsal column degeneration)Sensory ataxia (dorsal column degeneration)
 Vestibular neuronitisVestibular neuronitis
 Benign paroxysmal positional vertigoBenign paroxysmal positional vertigo
 Neuropathic jointsNeuropathic joints

11. 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

12. Biomechanical ProblemsBiomechanical Problems
 WeaknessWeakness
 Limitation of joint rangeLimitation of joint range
Environmental risk factorsEnvironmental risk factors
 General risk factors like Furniture, Bathroom,General risk factors like Furniture, Bathroom,
Toilet, Stairs, Outdoor curbsToilet, Stairs, Outdoor curbs
Falls in the ElderlyFalls in the Elderly

13. Symptoms of balance disordersSymptoms of balance disorders
 When balance is impaired, an individual hasWhen balance is impaired, an individual has
difficulty maintaining orientationdifficulty maintaining orientation
 An individual may experience the "roomAn individual may experience the "room
spinning" and may not be able to walk withoutspinning" and may not be able to walk without
staggeringstaggering
 May not even be able to ariseMay not even be able to arise
 A sensation of dizzinessA sensation of dizziness
 Falling or a feeling of fallingFalling or a feeling of falling
 LightheadednessLightheadedness
 Visual blurringVisual blurring
 DisorientationDisorientation

14. ASSESSMENTASSESSMENT
1.1. Visual system:Visual system:
Check visual acuity, depth perception, visualCheck visual acuity, depth perception, visual
field defects.field defects.
2.2. Somatosensory:Somatosensory:
Check proprioception, cutaneous sensationCheck proprioception, cutaneous sensation
(touch, pressure), lower extremities and trunk,(touch, pressure), lower extremities and trunk,
especially feet and ankle.especially feet and ankle.

15. 3. Vestibular:3. Vestibular:
Check motor responses to positional andCheck motor responses to positional and
movement testingmovement testing
 Righting reactions: Move or position the body, observe automatic adjustmentsRighting reactions: Move or position the body, observe automatic adjustments
that restore normal alignment of the head position (face vertical, mouththat restore normal alignment of the head position (face vertical, mouth
horizontal).horizontal).
 Equilibrium reactions: Alter the body’s center of mass or base of support,Equilibrium reactions: Alter the body’s center of mass or base of support,
observe automatic postural adjustments that serve to maintain balance (keepobserve automatic postural adjustments that serve to maintain balance (keep
centre of mass within the BOS).centre of mass within the BOS).
 Protective reactions: Alter the body’s centre of mass outside of the BOS,Protective reactions: Alter the body’s centre of mass outside of the BOS,
observe the automatic adjustments of the arms or legs to extend and supportobserve the automatic adjustments of the arms or legs to extend and support
the body weight in anticipation of a fall.the body weight in anticipation of a fall.
Testing considerations: Can use a displacing manualTesting considerations: Can use a displacing manual
force against the Centre Of Mass (a perturbation orforce against the Centre Of Mass (a perturbation or
push) or displace the BOS using a moveable surfacepush) or displace the BOS using a moveable surface
(platform, gymnastic ball, equilibrium board).(platform, gymnastic ball, equilibrium board).

16. 4. Assessment of Musculoskeletal4. Assessment of Musculoskeletal
ElementsElements
Determine musculoskeletal strengthDetermine musculoskeletal strength
and ROM especially in the lowerand ROM especially in the lower
extremities and trunkextremities and trunk
Tightness, contracturesTightness, contractures
SpasticitySpasticity
Determine limits of stability: maximumDetermine limits of stability: maximum
sway in any direction.sway in any direction.

17. 5. CHECK STATIC BALANCE5. CHECK STATIC BALANCE
A. Standing tests:A. Standing tests:
 Double limb supportDouble limb support
 Single limb supportSingle limb support

20. 6.Dynamic Balance:6.Dynamic Balance:
 Standing upStanding up
 SteppingStepping
 StoopingStooping
7. Scoring:7. Scoring:
A. Three point scale: absent, impaired,A. Three point scale: absent, impaired,
presentpresent
B. Functional balance grades: 0, poor,B. Functional balance grades: 0, poor,
fair, good, normal (with descriptivefair, good, normal (with descriptive
criteria for each)criteria for each)

21.  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 hands2 – Able to maintain balance with hands
offoff
3 – Able to maintain balance with hands3 – Able to maintain balance with hands
off, accepts minimal challengesoff, accepts minimal challenges
4 – Able to maintain support with hands4 – Able to maintain support with hands
off, accepts maximal challengesoff, accepts maximal challenges

25.  Romberg test:Romberg test:
Standing with feet in normal stanceStanding with feet in normal stance
position, first with eyes open, then withposition, first with eyes open, then with
eyes closed: used to detect posterioreyes closed: used to detect posterior
column ataxiacolumn ataxia
 Sharpened or Tandem Romberg:Sharpened or Tandem Romberg:
Have patient stand in a tandem heel toHave patient stand in a tandem heel to
toe position, first with eyes open, thentoe position, first with eyes open, then
eyes closed; increases sensitivity ofeyes closed; increases sensitivity of
Romberg testRomberg test

27. TREATMENT SUGGESTIONS FORTREATMENT SUGGESTIONS FOR
BALANCE DISORDERSBALANCE DISORDERS
 Cognitive impairment treatmentCognitive impairment treatment
suggestionssuggestions
 Reduce confusionReduce confusion
 Improve motivationImprove motivation
 Improve attentionImprove attention
 Encourage consistencyEncourage consistency
 Start with simple task increase the complexityStart with simple task increase the complexity
graduallygradually

28.  Managing sensory problemsManaging sensory problems
(Vestibular, Proprioceptive, Visual)(Vestibular, Proprioceptive, Visual)
Facilitating demand system, encourageFacilitating demand system, encourage
remaining systemremaining system
 Managing strategy selection problemsManaging strategy selection problems
(Parkinson’s disease)(Parkinson’s disease)
Appropriate sensory demandsAppropriate sensory demands
(Pertubations)(Pertubations)
Hip strategy – Stand on foam surface,Hip strategy – Stand on foam surface,
narrow surface, Treadmillnarrow surface, Treadmill

29.  Managing preparatory problemsManaging preparatory problems
(Bradykinesia)(Bradykinesia)
Strategy trainingStrategy training
 Managing sequencing and timingManaging sequencing and timing
problemsproblems
(CP, Hemiplegia)(CP, Hemiplegia)
Facilitate normal sequential muscleFacilitate normal sequential muscle
contraction from distal to proximal incontraction from distal to proximal in
response to pertubation (EMGresponse to pertubation (EMG
Biofeedback, Balance master)Biofeedback, Balance master)

30.  Managing scaling problemManaging scaling problem
(Cerebellar dysfunctions)(Cerebellar dysfunctions)
Correct faulty amplitude of contractionCorrect faulty amplitude of contraction
(Visual Biofeedback, Balance master,(Visual Biofeedback, Balance master,
Wobble board, weighted cuffs)Wobble board, weighted cuffs)
 Managing musculoskeletal problemsManaging musculoskeletal problems
(Muscle weakness, ROM restriction,(Muscle weakness, ROM restriction,
Spasticity)Spasticity)
Muscle strengthening exercises, ElectricalMuscle strengthening exercises, Electrical
stimulation, Stretchingstimulation, Stretching

31. Functional Sequence inFunctional Sequence in
Balance TrainingBalance Training
Balance activities starts from lying,Balance activities starts from lying,
kneeling, sitting, then progressed to statickneeling, sitting, then progressed to static
and dynamic standing and walking.and dynamic standing and walking.
NOT NECESSARY TO FOLLOWNOT NECESSARY TO FOLLOW
THE STEP LADDER PATTERNTHE STEP LADDER PATTERN

32.  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 armHigh 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

33.  KneelingKneeling
4 point kneeling4 point kneeling
Kneel sittingKneel sitting
2 point kneeling2 point kneeling
Half kneelingHalf kneeling
(with and without support, challenges)(with and without support, challenges)

34.  Sit to StandSit to Stand
 StandingStanding
# Static# Static
Double limb stanceDouble limb stance
Single leg stanceSingle leg stance
Tandem positionTandem position
## DynamicDynamic
Static marchingStatic marching
Wobbling boardWobbling board

35.  WalkingWalking
ForwardForward
BackwardBackward
SidewaysSideways
TandemTandem
BraidingBraiding
TreadmillTreadmill

36.  StepsSteps
 RampsRamps
 Rough terrainRough terrain
 CurbsCurbs
 ObstaclesObstacles
 Community ambulationCommunity ambulation

37. TasksTasks
 Looking up at the ceilingLooking up at the ceiling
 Turning to look behind without moving theTurning to look behind without moving the
feetfeet
 Reaching forward to take an objectReaching forward to take an object
 Reaching sidewaysReaching sideways
 Reaching backwardsReaching backwards
 Reaching down to stool and floorReaching down to stool and floor
 Ball catching and throwingBall catching and throwing

38.  Environmental modificationsEnvironmental modifications
 Low chairs, low beds - leg modificationsLow chairs, low beds - leg modifications
 Unstable furniture - repair immediatelyUnstable furniture - repair immediately
 Ladders and step ladders - avoid themLadders and step ladders - avoid them
 Lack of grab rails - installation of grabLack of grab rails - installation of grab
railsrails

39.  Hand rails not present or inadequate –Hand rails not present or inadequate –
installation of appropriate handrailsinstallation of appropriate handrails
 Stairs too steep, tread too narrowStairs too steep, tread too narrow
-modification of stairs-modification of stairs
 Foot wear - thin, flat, broad, made up ofFoot wear - thin, flat, broad, made up of
firm material, textured sole, anklefirm material, textured sole, ankle
supportsupport
 Avoid – high heeled shoes, shoes withAvoid – high heeled shoes, shoes with
soft and slippery soles.soft and slippery soles.

40. THANK YOUTHANK YOU