The document discusses postural control, which involves maintaining stability and orientation of the body in space, through various types of balance control: steady-state, reactive, and anticipatory. It outlines strategies for retraining balance, including functional electrical stimulation, strength training, and task-oriented balance rehabilitation, emphasizing the importance of adapting tasks to the individual's needs. Additionally, it highlights the role of practice and exposure to perturbations in improving balance control and reducing the risk of falls.

1. Postural control
from theory to
practice

2. HELLO!
I am Heba el saeid
PT. MSc. Neurological rehabilitation specialist at the
Department of Neurology, Kasr al Ainy Medical
School. Cofounder of Nervology educational platform
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3. Postural Control
▰ Postural control is the ability to maintain our body in space
achieving both goals of stability and orientation.
▰ Postural orientation is the ability to maintain an appropriate
relationship between body segments, and between the body
and the environment for a certain task.
▰ Postural stability - also referred to as balance - is the ability to
control the center of mass (COM) within the base of support
(Bos).
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5. Three types of control
▰ Steady-state balance is the ability to control our balance in
fairly predictable and nonchanging conditions.
▰ Reactive balance control is the ability to recover a stable
position following an unexpected perturbation.
▰ Proactive or anticipatory balance is the ability to activate
muscles in the legs and trunk for balance control in advance
of potentially destabilizing voluntary movements.
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7. Steady State Balance
▰ Alignment of the body can minimize the effect of gravitational
forces that tend to pull us off-center.
▰ Postural tone to counteract the force of gravity the activity of
the antigravity muscles increases during upright standing.
▰ Movement strategies (Ankle, Hip)
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8. Reactive Balance Control
1. Fixed support strategies: ankle and hip strategy.
2. Change in support strategies: the step strategy and
the reach-to-grasp strategy.
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9. Fixed
support
strategies
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10. Ankle strategy
▰ Used most commonly in situations in which the perturbation
to equilibrium is small and the support surface is firm.
▰ Activation of the gastrocnemius produces a plantarflexion
torque that slows and then reverses, the body's forward
motion.
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11. Hip strategy
▰ This strategy controls motion by producing large and
rapid motion at the hip joints, the hip strategy is used
to restore equilibrium in response to larger, faster
perturbations or when the support surface is smaller
than the feet.
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12. Change in
support
strategies
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▰ Step Strategy: A step strategy realigns the base of
support under the falling center of mass by placing the
feet in the direction of the perturbation
▰ Grasp Strategy: relies on extending the BOS by using
the arms to grasp an external object for stability.

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▰ Research has demonstrated that during recovery of stability,
we continuously change and add multiple synergies,
depending on the context of the task at hand. This suggests
that when retraining balance, it will be important not to limit
training to the activation of a single strategy (e.g., ankle vs. hip
vs. step vs. reach) but to create conditions in which strategies
are continuously modulated.

15. Anticipatory Balance Control
1. Fixed support strategies: ankle and hip strategy.
2. Change in support strategies: the step strategy and
the reach-to-grasp strategy.
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16. TASK-
ORIENTED
BALANCE
REHABILITATI
ON 16

17. Goals
▰ Modify (or prevent) impairments in body structure and
function impacting postural control.
▰ Improve the ability to meet the demands of balance
(motor, sensory, and cognitive) during the performance of
functional activities.
▰ Improved participation which can be demonstrated by
increased frequency of participation or increased
independence and safety (reduced falls and near falls)
when performing ADLs.
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18. Treating Underlying Motor
Impairments
▰ Effect of strength training on balance: Among older
adults, many studies have shown that resistance strength
training is effective in increasing strength;
however, while in some studies, this was associated with
improved balance, in others, it was not.
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19. Treating Underlying Motor
Impairments
▰ Functional Electrical Stimulation: FES to the lower
extremity, particularly the ankle dorsiflexors, is used
to improve performance in functional tasks such as
standing and walking. But it was found that the
position at which the stimulus is delivered matters.
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20. Functional Balance Training: Improving
Motor Strategies
Training balance within the context of function
includes:
(1) Improving underlying movement strategies used for
steady-state, reactive, and anticipatory balance
control.
(2) Adapting functional tasks to changing environmental
conditions.
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21. Steady-State Balance Control
focuses on retraining orientation and alignment to help the
patient develop an initial position that:
(1) Is appropriate for the task.
(2) Is efficient with respect to vertical alignment.
(3) Maximizes stability, that is, places the vertical line of gravity well
within the patient's stability limits.
Many tasks use a symmetrical vertical position, but this
may not be a realistic goal for all patients. 21

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23. Steady-State Balance Control
HOW ABOUT ASSISTIVE
DEVICES?
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24. Retraining Reactive Balance
Control
▰ The goal when retraining reactive balance control is to help the
patient develop coordinated multijoint movements, including
both in-place and change-in-support strategies‫ز‬
▰ Training involves exposing the patient to external perturbations
that vary in direction, speed, and amplitude.
▰ Small perturbations can facilitate the use of in-place strategies
for balance control, while larger and faster perturbations
encourage the use of a step or a reach.
▰ Large perturbations in the standing position are combined with
instructions to reach (or step) as quickly as possible.
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25. Retraining Anticipatory Balance
Control
▰ Movement strategies to control the COM can also be practiced
during voluntary sway in all directions. With practice, patients
learn to control COM movements over increasingly larger areas
while varying speed.
▰ Patients who are very unsteady or extremely fearful of falling can
practice movements while in the parallel bars or when standing
close to a wall or in a corner with a chair or table in front of them.
▰ When training anticipatory postural control, patients can be
asked to carry out a variety of manipulation tasks, such as
reaching, lifting, and throwing
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26. Retraining Anticipatory Balance
Control
▰ The magnitude of anticipatory postural activity is directly related
to the potential for instability inherent in a task. Potential
instability relates to speed, effort, degree of external support, and
task complexity.
▰ Research provided evidence that anticipatory postural control
training changes the timing at which lower limb muscles are
activated before arm movements.
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THANKS!