Introduction:

Balance: Control of center of mass over base of support (1) Center of mass: Center point of each body segment combined(1) Center of gravity: Vertical projection of center of mass(1) Base of support: Area of object that is in contact with the ground(1) Postural control:involves controlling the bodys position in space
for the dual purposes of stability and orientation.(1)

Postural orientation:
Is defined as the ability to maintain an appropriate relationship between the body and the environment for a task.(1) stability limits (during quit stance)are defined as: the area encompassed by the outer edges of the feet in contact with the ground. These are the boundaries in which the body can maintain its position without changing the base of support. Stability limits are not fixed boundaries but change according to the task, the individuals biomechanics, and various aspects of the environment.(2)

Prerequests for balance:

I)Musculoskeletal components: include such things as joint range of motion, spinal flexibility, muscle properties, and biomechanical relationship among linked body segment.

II)Neural components essential to postural control encompass: (a)motor processes, including neuromuscular response synergies; (b)sensory processes, including the visual, vestibular, and somatosensory systems; and (c) higher-level integrative processes essential for mapping sensation to action and ensuring anticipatory and adaptive aspects of postural control.(2)

strategies for postural control:

Postural motor strategies are the organization of movement appropriate for controlling the body's position in space.Sensory strategies organize sensory information from visual, somatosensory, and vestibular system for postural control. Finally,sensorimotor strategies reflect the rules for coordinating sensory and motor aspects of postural control.

I)Motor mechanisms for postural control:

A number of factor contribute to our stability in quit stance .First, body alignment can minimize the effect of gravitational forces, which tend to pull us off center. Second, muscle tone keeps the body from collapsing in response to the pull of gravity.Three main factor contribute to our background muscle tone during quiet stance: (a) the intrinsic stiffness of the muscles themselves, (b) the background muscle tone, which exists normally in all muscles because of neural contributions,and (c) postural tone, the activation of antigravity muscles during quiet stance.(5,6,7,8)

II)Sensory mechanisms related to postural control:

The CNS must organize information from sensory receptorsthroughout the body before It can determine the bodys position in space.Normally, peripheral inputs from visual, somatosensory (proprioceptive,cutaneous,and joint receptors), and vestibular systems are available todetect the body's position and movement in space with respect to gravityand the environment.

(A)Visual inputs:
Visual inputs report information regarding the position and motion of the head with respect to surrounding objects.visual inputs are not always an accurate source of orientation information about self-motion. Thus, visual information may be misinterpreted by the brain. The visualsystem has difficulty distinguishing between object motion, referred to as exocentric motion, and self-motion, referred to as egocentric motion.(3)

(B)Somatosensory inputs:
The somatosensory system provides the CNS with position and motion information about the body with reference to supporting surfaces. In addition, somatosensory inputs throughout the body report information about the relationship of body segments in one another. Somatosensory receptors include muscle spindles and Golgi tendon organs (sensitive tomuscle length and tension), joint receptors (sensitive to joint movement and stress), and cutaneous mechanoreceptors, including Pacinian corpuscles (sensitive to vibration), Meissner's corpuscles (sensitive to light touch and vibration), Merkel's discs (sensitive to local pressure) and Ruffini endings (sensitive to skin stretch).(2)

(C)Vestibular inputs:
Information from the vestibular system is also a powerful source of information for postural control. The vestibular system provides the CNS with information about the position and movement of the head with respect to gravity and inertial forces, providing a gravitoinertial frame of reference for postural control.(2, 4).

(III)Central processing systems for postural control: (A) Vestibular nuclear complex:
The vestibular nuclear complex in the medulla and pons is an important center for the integration of vestibular, somatosensory, andvisual information and plays a large part in the control of posturalorientation and equilibrium.(4).

(B) Basal ganglia:

The basal ganglia play an important role in postural alignment and control of stability.(4).

(C)Cerebellum:
The cerebellum plays several roles in the control of posture involving sensory-motor integration.The most profound deficits in dynamic postural control occur with damage to the anterior lobe of the cerebellum, which receives somatosensory inputs from throughout the body and projects to the spinal cord via the red nucleus and reticular formation.(4).

(D)Cerebral cortex:
Cerebral Cortex is most important in the anticipatory postural adjustments that accompany voluntary movement.(4)
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The role of postural reactions in maintenance of balance:

The postural reactions (righting, equilibrium, and protective reactions) have been identified as the underlying responses that are related, most functionally; to motor milestones. Postural reactions provide automatic support and stability to the head, trunk and extremities; and facilitate normal weight shifts and mobility.(5,6,7,8)

The different postural responses controlling balance:

(a) Automatic postural responses:There are three commonly identified automatic postural
responses, or strategies:

1) Ankle strategy:restores the center of mass (COM) to a position of stability through

bodymovement centered primarily about the ankle joints. Muscle activity begins after perturbation onset in the gastrocnemius, followed by activation of the hamstrings and finally by activation of the paraspinal muscles. The ankle movement strategyappears to be used commonly in situations in which the perturbation to equilibrium is small and the support surface is firm.(8,10)

2) Hip strategy:controls motion of the COM by producing large and rapid motion at the hip
joints with antiphase motions of the ankles. The hip strategy is used to restore equilibrium in response to larger, faster perturbations or when the support surface is smaller than the feet.(8,9)

3) Stepping and reaching strategies:describe steps with the feet or reaches with the arms in
an attempt to reestablish a new BOS with theactive limb(s) when the COG has exceeded the original BOS. Stepping strategy is used to bring the support base back into alignment under the COM when in-place strategies such as the ankle and hip strategies are insufficient to recover balance(8,9) .

(b) Antcipatory postural responses:These responses are similar to automatic postural

responses, but they occur before the actual disturbance. If a balance disturbance is predicted, the body will respond in advance by developing a "postural set" to counteract the coming forces.(8,9,10,16)

(c) Volitional postural responses:These responses are under conscious control. Volitional
postural movements can range from simple weightshifts to complex balance skills of skaters and gymnasts.(9,10,16).

The systems model of postural control(16). ASSESSMENT A task-oriented approach assesses postural control on three levels: (a) the functional skills requiring posture control, (b) the sensor and motor strategies used to maintain posture in various contexts and

tasks, and (c) the underlying sensory, motor, and cognitive impairments thatconstrain posture control.
Safety First Concern

During the course of evaluating postural control, patients will be asked to perform a number of tasks that will likely destabilize them. Safety is of paramount importance. All patients should wear an ambulation belt during testing, and be closely guarded at all times.

A-Functional Assessment
A task-oriented approach to evaluating postural control begins with afunctional assessment to determine how well a patient can perform avariety of skills that depend on postural control.

1-GET UP AND GO TEST

The Get Up and Go test (1) was developed as a quick screening tool for detecting balance problems in elderly patients. The test requires that subjects stand up from a chair, walk 3 meters, turn around, and return. Performance is scored according to the following scale: 1 normal; 2 very slightly abnormal; 3 mildly abnormal; 4 moderately abnormal; 5 severely abnormal. An increased risk for falls was found among older adults who scored 3 or higher on this test. The Get Up and Go test modifies the original test by adding a timing component to performance (2). Neurologically intact adults who are independent in balance and mobility skills are able to perform the test in less than 10 seconds.(13,15).

2-FUNCTIONAL REACH TEST

The Functional Reach Test is another single item test developed as a quick screen for balance problems in older adults. subjects stand with feet shoulder distance apart, and with the arm raised to 90 flexion. Without moving their feet, subjects reach as far forward as they can while still maintaining their balance (Fig. 1). The Functional Reach Test has established inter-rater reliability, and is shown to be highly predictive of falls among older adults (12).

Figure (1 ) The functional reach test. A, Subjects begin by standing with feet shoulder distance apart, arm raised to 90 flexion, and reach as far forward as they can while still maintaining their balance.

(3)Berg Balance Scale

1. Sit to Stand

( ) 0: Needs moderate or maximal assistance to stand ( ) 1: Needs minimal assistance to stand or to stabilize ( ) 2: Able to stand using hands after several tries ( ) 3: Able to stand independently using hands ( ) 4: Able to stand with no hands and stabilize independently 2. Standing unsupported

( ) 0: Unable to stand 30 seconds unassisted ( ) 1: Needs several tries to stand 30 seconds unsupported
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( ) 2: Able to stand 30 seconds unsupported ( ) 3: Able to stand 2 minutes without supervision ( ) 4: Able to stand safely for 2 minutes If person is able to stand 2 minutes safely, score full points for sitting unsupported (item 3). Proceed to item 4. 3. Sitting with back unsupported with feet on floor or on a stool

( ) 0: Unable to sit without support for 10 seconds ( ) 1: Able to sit for 10 seconds ( ) 2: Able to sit for 30 seconds ( ) 3: Able to sit for 2 minutes under supervision ( ) 4: Able to sit safely and securely for 2 minutes 4. Stand to sit

( ) 0: Needs assistance to sit ( ) 1: Sits independently but had uncontrolled descent ( ) 2: Uses back of legs against chair to control descent ( ) 3: Controls descent by using hands ( ) 4: Sits safely with minimal use of hands 5. Transfers lease move from chair to chair and back again (Person moves one way toward a seat with armrests and one way toward a seat without armrests) Arrange chairs for pivot transfer

( ) 0: Needs two people to assist or supervise to be safe ( ) 1: Needs one person to assist ( ) 2: Able to transfer with verbal cueing and/or supervision ( ) 3: Able to transfer safely with definite use of hands ( ) 4: Able to transfer safely with minor use of hands 6. *Standing unsupported with eyes closed

( ) 0: Needs help to keep from falling ( ) 1: Unable to keep eyes closed for 3 seconds but remains steady ( ) 2: Able to stand for 3 seconds ( ) 3: Able to stand for 10 seconds without supervision ( ) 4: Able to stand for 10 seconds safely 7. *Stand unsupported with feet together

( ) 0: Needs help to attain position and unable to hold for 15 seconds ( ) 1: Needs help to attain position but able to stand for 15 seconds with feet together ( ) 2: Able to place feet together independently but unable to hold for 30 seconds ( ) 3: Able to place feet together independently and stand for 1 minute without supervision ( ) 4: Able to place feet together independently and stand for 1 minute safely The following items are to be performed while standing unsupported 8. *Reaching forward with outstretched arm

touch

the ruler while reaching forward. The recorded measure is the distance toward that the fingers reach while the person is in the most forward lean position.)

( ) 0: Needs help to keep from falling ( ) 1: Reaches forward but needs supervision ( ) 2: Can reach forward more than 2 inches safely ( ) 3: Can reach forward more than 5 inches safely ( ) 4: Can reach forward confidently more than 10 inches 9. *Pick up object from the floor from a standing position

( ) 0: Unable to try/needs assistance to keep from losing balance or falling ( ) 1: Unable to pick up shoe and needs supervision while trying ( ) 2: Unable to pick up shoe but comes within 1-2 inches and maintains balance independently ( ) 3: Able to pick up show but needs supervision ( ) 4: Able to pick up show safely and easily 10. *Turn to look behind over left and right shoulders while standing look over you right shoulder

( ) 0: Needs assistance to keep from falling ( ) 1: Needs supervision when turning ( ) 2: Turns sideways only but maintains balance ( ) 3: Looks behind one side only; other side shows less weight shift ( ) 4: Looks behind from both sides and weight shifts well

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completely in a full circle. Pause, then turn in a full circle in the other direction

( ) 0: Needs assistance while turning ( ) 1: Needs close supervision or verbal cueing safely but slowly

12. *Place alternate foot on bench or stool while standing unsupported lternately on the bench (or stool). Continue until each foot has touched the bench (or stool) four times. (Recommended use of 6-inch-high-bench.)

( ) 0: Needs assistance to keep from falling/unable to try ( ) 1: Able to complete fewer than two steps; needs minimal assistance ( ) 2: Able to complete four steps without assistance but with supervision ( ) 3: Able to stand independently and complete eight steps in more than 20 seconds ( ) 4: Able to stand independently and safely and complete eight steps in less than 20 seconds 13. *Stand unsupported with one foot in front

foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot (Demonstrate this test item)

( ) 0: Loses balance while stepping or standing ( ) 1: Needs help to step but can hold for 15 seconds ( ) 2: Able to take small step independently and hold for 30 seconds ( ) 3: Able to place one foot ahead of the other independently and hold for 30 seconds ( ) 4: Able to place feet in tandem position independently and hold for 30 seconds
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14. *Standing on one leg

( ) 0: Unable to try or needs assistance to prevent fall ( ) 1: Tries to lift leg, unable to hold 3 seconds but remains standing independently ( ) 2: Able to lift leg independently and hold up to 3 seconds ( ) 3: Able to lift leg independently and holds for 5 to 10 seconds ( ) 4: Able to lift leg independently and hold more than 10 seconds Total Score /56 Note: Perform only items 6 thorough 14 (*) in the modified version of the scale. Maximum score for modified version is 36 points. Interpretation of Individual Test Item Results on the Berg Balance Scale (BBS)(14)

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(4)BALANCE AND MOBILITY SCALE Mary Tinetti, a physician researcher at Yale

University, has published a test to screen for balance and mobility skills in older adults and to determine the likelihood for falls.

(5)FUNCTIONAL BALANCE SCALE:

The functional balance scale was developed by Kathy berg, a CanadianPhysiotherapist. This test uses 14 different items, which are rated 0 to 4. The test is reported to have good testretest and inter-rater reliability.(11)

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Limitations of functional assessment: Inability to:

a- assess a patient performance of tasks under changing environmental contexts. b- Determine the quality of movement used c- Identify specific neuronal or musculoskeletal systems responsible for a decline of performance.

b-Strategy Assessment:
The next level of assessment examines the motor and sensory strategies used to control the body's position in space under a variety of conditions.

1- MOTOR 1- MOTOR STRATEGIE

Alignment in Sitting and Standing:

The patient's alignment in sitting and standing is observed. Is the patient vertical? Is weight symmetrically distributed right to left, and forward and backward? A plumb line in conjunction with a grid can be used to quantify changes in alignment at the head, shoulders, trunk, pelvis, hips, knees, and ankles. In addition, the width of the patient's base of support upon standing can be measured and recorded using a tape to measure the distance between the medial malleoli (or alternatively, the metatarsal heads). Alternative ways to quantify placement of the center of mass in the standing position include the use of static force plates to measure placement of the center of pressure (Fig 10.2), or the use of two standard scales to determine if there is weight discrepancy between the two sides

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The use of a static forceplate can be helpful when quantifying static alignment changes in standing.

Movement Strategies
Movement strategies are examined under three different task conditions: self-initiated sway, in response to externally induced sway,and anticipatory to a potentially destabilizing upper extremity movement .

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Controlling self-initiated trunk movements in sitting. A, Small movements produce adjustments at the head and trunk. B, Larger movements require counterbalancing with the arms and legs. C, When the line of gravity for the head and trunk exceeds the base of support, the arm reaches out to prevent a fall.

two types of movement strategies being used to control self-initiated sway in standing. Two patients have been asked to sway forward as far as they can without taking a step. Patient A is swaying forward primarily about the ankles, using what has been referred to as an ankle strategy to control center of mass motion. In contrast, Patient B is moving primarily the trunk and hips (a hip strategy), which minimizes forward motion of the center of mass.

Controlling self-initiated sway in stance. Shown are two types of movement strategies being used to controlself-initiated sway in standing.A, the ankle, and B, the hip.

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Movement strategies used to recover from a perturbation are also assessed:

Holding the patient about the hips, the therapist displaces the patient forward, backward, right, and then left. Figure 10.6A illustrates the use of an ankle strategy used to recover from a small backwarddisplacement.A larger displacement by the therapist usually results in a greater amount of hip and trunk motion, that is, a hip strategy, as the subject continues to try to keep the center of mass within the base of support and not take a step . Finally, if the therapist displaces the subject far enough, and the center of body mass moves outside the base of support, the subject will take a step to avoid a fall (Fig. 6C) .

Movement strategies used to recover from an external perturbation to balance. A, An ankle strategy is used to recover from a small displacement at the hips. B, A larger displacement produces a hip strategy. C, Movement of the COM outside the base of support requires a step to recovery stability.

SENSORY STRATEGIES
The Clinical Test for Sensory Interaction in Balance (CTSIB) is one method that has been proposed for clinically assessing the influence ofsensory interaction on postural stability in the standing position (14).
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The method is based on concepts developed by Nashner (5), and requires the subject to maintain standing balance for 30 seconds under six different sensory conditions that either eliminate input or produce inaccurate visual and surface orientation inputs.

A modified lapanese lantern is used to change the accuracy of visual input for postural orientation. Patients are tested in the feet together position, with hands placed on the hips. Using condition 1 as a baseline reference, the therapist observes the patient for changes in the amount and direction of sway over the subsequent five conditions. If the patient is unable to stand for 30 seconds, a second trial is given (5).Neurologically intact young adults arc able to maintain balance for 30 seconds on all six conditions with minimal amounts of body sway. In conditions 5 and 6, normal adults sway on the average 40% more than in condition .(14).

Systems Assessment: Identifying Impairments

The next step in a task-oriented assessment involves evaluating the sensory, motor (neural and musculoskeletal), and cognitive subsystems that underlie task-based performance.

Mental Status:
Mental status can be determined informally by determining the patient's orientation to person, place, and time. Other aspects of cognitive function that are subjectively evaluated include: attention,communication, and motivation.
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MUSCULOSKELETAL SYSTEM:
Assessment of the musculoskeletal system includes evaluation of range of motion and flexibility.

Neuromuscular System:
Assessment of neuromuscular impairments includes measurement of strength, muscle tone, and nonequilibrium forms of coordination in addition to assessment of the sensory system.

Other computerized equipements used for assessment of balance:

1- COMPUTERIZED DYNAMIC POSTUROGRAPHY:
1- The Sensory Organization Test (SOT) : objectively identifies problems with postural control by assessing the patient's ability to make effective use of (or suppress inappropriate) visual, vestibular, and proprioceptive information. The SOT protocol is comprised of the following six sensory conditions:

a. Eyes open, fixed surface and visual surround. b. Eyes closed, fixed surface. c. Eyes open, fixed surface, sway referenced visual surround.
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d. Eyes open, sway referenced surface, fixed visual surround. e. Eyes closed, sway referenced surface. f. Eyes open, sway referenced surface and visual surround. (5,6) .

2- The Motor Control Test (MCT)assesses the patient's ability to quickly and automatically
recover from unexpected external provocations. Sequences of small, medium or large (scaled to the patient's height) platform translations in forward and backward directions elicit automatic postural responses. Measurements includeonset timing, strength and lateral symmetry of responses.(20).

3- The Adaptation Test (ADT)assesses the patient's ability to modify motor reactions and
minimize sway when the support moves unpredictably in the toes-up or toes-down direction. For each platform rotation, a sway energy score quantifies the magnitude of the force response required to overcome induced postural instability. This adaptive test simulates daily life conditions such as irregular support surfaces.(19).

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2- The Biodex Stability System

The static test requires the patient to look straight a head while standing as still as possible with
his eyes open, focusing on the display monitor using visual feed backto maintain the cursor within a centrally positioned in the bulls eye through the time of the test (20 seconds for each trial). The dynamic test requires the patient to shift his center of gravity through weight shifting to eight targets positioned in a ellipse, the perimeter of which corresponded to 50% of the limits of stability (LOS). The patient was asked to follow a cursor to each target as it was highlighted, and to fix at that target for three seconds before returning to the central target (neutral). Targets were highlighted in random order, however, each target was selected only once.(17).

(3)Balance master:
The Basic Balance Master provides objective assessment and retraining of the sensory and voluntary motor control of balance with visual biofeedback.The interactive technology and clinically proven protocols allow the clinician to objectively assess patients performing tasks essential to daily living. The objective data aids the clinician in effective treatment planning decisions.(18) The Basic Balance Master includes the following standardized assessment protocols:
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Sensory Dysfunction modified Clinical Test of Sensory Interaction on Balance (mCTSIB)

Voluntary Motor Impairments

Functional Limitations

Limits of Stability (LOS) Unilateral Stance (US) Rhythmic Weight Shift (RWS) Weight Bearing Squat (WBS)

Balance Master INTERPRETATION OF ASSESSMENT :Following completion of the

assessment, the clinician must interpret theassessment, identify the problems, both at the level of function andimpairments, and establish the goals and plan of care.

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Treatment for balance disorders

a-Strategies to Improve StaticPostural Control Patients who demonstrate impairments in static postuial control are unable to maintain or hold a steady position for a number of reasons. including decreased strength, tonal imbalances (hypolonia. spasticih), impaired voluntary Control and hypermobility (ataxia. athetois). sensory hypersensitivty tactile avoidance. reactions), or increased avoidance or arousal (high sympathetic stak). Instability is associated execessive postural sway. wide BOS, a high guard hand positionl or handhold. anid loss of balance.46 The therapist can select any number of weight bearing (antigravity> postures to develop stability control . postures are selected on basis of 1patient safety and level of control and I2) variety in terms of functionaI tasks. It is important to remember that some Activities may cause the patient distress initially .the Patient will feel threatened when placed in situations Where he or she is in jeopardy of losing balance .the therapist Should ensure the patient confidence by providing a clear Explanation what is going to happen and what is expected of the patient in terms that are easy to understand.support may be given initially to reduce fear if using anew posture,but should be withdrawn as soon as possible to
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alloW focus on active control. The therapist varies the level of actiVties , selecting activities that both provide success as well as appropriately challenge the patient. In sitting or standing. the patient is instructed to hold steady while sitting or standing tall and maintaining a visual focus on a torward target. Progression is to holding for longer and longer durations. Neuromuscular/sensory stimulation techniques that can be used to enhance stabilizing muscle contractions include quick stretch, tapping. resistanCe. approximation, manual contacts. and verbal cues tce Appendix C). For the patient unable to actively stahihze the body. the therapist can begin with resisted iso metric contractions of antagonist postural muscle groups46

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using the technique of Rhythmic Stabilization (RS) For example. the patient with severe instahilitv following traumatic brain injury who s unable to sit independently may need to practice holding first in the sidelying position during application of RS. The therapist can then progress training through postures that demand increas ing amounts of upright (antigravity) postural control
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prone-on-elbows to quadruped and finally sifting. In each position the therapist carefully provides matching resist ance using RS. If an imbalance exists, the stabilizing act ivityi can be cont tolloed by a strengthening act ivitv for the weak muscles)46

rhysmic stabilization

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As the trunk becomes more stable. the patient is expected to assume active control in stabilizing in the sture. For a patient with hyperkinetic disorders (e.g.. ataxia, athetosisi. the PNF technique of Stabilizing Reersals Slow Reversals is appropriate Alternating isOtonic contractions are used, allowing only very small range moements. Progression is toward &crcasing range (decrements of range) until finally the
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patient is asked to stabilize and hold steady in the posture.46 Additional strategies to improve stability include the Use of elastic resistance bands or weights to enhance pro prioceptive loading and contraction of stabiIizin muscles. 46 The therapist can have the patient stabilize while sitting On atherapy ball (also known as swiss or stability ball) Gentle bouncing provide joint approximation through the vertebral Joints, facilitating extensors and an upright postures for patient requiring more assistance,sitting control can first he practiced on a compliant surface (foam, wobble board, or dynastic) placed on a platform mat or sitting (On a ballwith a ball holder underneath the therapy ball. Task difficulty can be increased by reducing the bOS (feet apart to feet together to single limb support).46

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Aquat ic therapy can also be used t0 enhance propriocepti ve loading. The wa te r provides a degree of unwe ig hting and res istance to movement. Thi s can be quite effective in reduc ing hype rkinet ic movement s and enhanci ng postural sta bi lity. For exampl e. a patient recovering from traumatic brain injury who demonstrates significant ataxia may be able to sit or stand in the pool with minimal ass istance whil e these same acivities outside the pool are not possible. 46
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To improve standing cont rol, the pa ti ent is directed to practi ce neuromuscular jixed-suppor t strategies that occur at the ankle and hip jo int s. Feedback is provided to ass ist the patient in rec ruiting the correc t pa ttern. To recruit ankle strategies. the patient practi ces small -range. s low-velocity shifts. Attention is direc ted to the action of ank le muscles to move the body (COM) over the fixed feet (BaS). Standing on a wobble board or foam rolle r with the flat s ide down progress ing to fl at side up are effective ac tivit ies to recrui t ankle strategies. The patient is a lso directed to prac ti ce tasks that nomlally recruit hip strategies. 46

These are rec ruited wi lh large r shifts in the COM. that approach the limits of stability (LOS). and/or faster body sway motions and are charac te rized by earl y ac ti vation o f proximal hip and trunk muscles. Hip flexion and extension res pon~es are gene rated during ante rior- poste rio r (AP) di splacement s and lateral hip motions are generated during late ra l dis placements. Patient s can be instructed to move their uppe r body forward and backward while standing on
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a foam rolle r. Tandem standing o r tandem standing on a foam roJler can be used to recruit late ral hip strategies.46

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b-Strategies to Improve Dynamic Postural Control Patients who demonstrate impairments in dynamic postural control are un able to control postural and orienatation while moving body segments . anumber of impairmentsmay be contributing factors ,including tonal imbalance (hper\hypo tonia),ROMrestrictions,impaired voluntary control and hyper mobility (ataxia, athetosis),impaired reciprocal actions of the antagonists

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(cerebellar dysfunction0 . or impaired proximal stabilization. clinically. the patient demonstrates difficulty weight shifting from side-t-side. forwardbackward. or diagonally. difficulties are also apparent in moving one or more limbs while maintaining a posture (sometimes referred to as static dynamic control. For example. one limb is freed for movement (reaching or stepping while the patient maintains the sitting or standing posture. Or from the quadruped position the patient is asked to lift one arm or leg or to lift the opposite arm and Ieg. These added move ments increase the demand for stabilization control because the overall BOS is reduced and the COM must shift over the remaining support segments beforethe dynamic limb movement can be successful.46 The therapist can select any of a number of weightbear ing (antigravity). postures lo develop dynamic postural control. Practice begins with movements emphasizing smooth directional changes that engage antagonist actions e.g.. weight shills). As control improves, the movements arc gradually expanded through an increasing range increments ot range). Dynamic movements can be facili tated using quick stretch. tapping. light tracking resistance. manual contacts. and dynamic verbal commands 46 . Although active movement is the goal. assis tance may be required during initial movement attempts for both the dynamic movements as well as the stabilizing body segments. Specific task-oriented training (e.g.. reach ing. stepping) are more motivating, especially if the task s important to the patient. 46
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Specific PNF tech niques appropriate or assisting patients include Dynamic Reversals (Slow Reversals), Repeated Contractions, Rhysmic initiation, and Combination of isotonics (Agonist Reversals (see Appendix B). For example. in bridging the patients movements are resisted in assuming the bridge posture isoLonic comractions) and during moVement from the bridge position to hooklying (eccentric contractions) using the comhination of isotonic technique this activity is an important leadup for other func functional activitie that reqiire similar combinations includ ing sit- lostand transitions, moving from kneeling to heel sitting. amid ascending descending stairs 46 therapy ball activities are effective in deveIoping dynamic stability control. For examble, the patient sits on a ball and gently moves the ball side to side, forward- backward or in compination( pelvic clock motions). Or thepatients sits on ball while performing voluntary movements of the arm or legs (alternate leg or arm raise) 46

TO improve standing control, the patient is direct ed to practice neuromuscular stepping strategies. The traditional view holds that stepping strategies occur when the COM exceeds the LOS. Perturbation is used to provi de the COM displacement. Stepping movements are accompanied by early activation of hip abductors and ankle cocontraction
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for mediallateral stability during single-limb support.40-45

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c-postural Awareness Training

Faulty postures such as forward head. kyphosis. lordosis. excessive hip and knee flexion, or pelvic asymmetries can result in decreased postural stability. inaccurate kines thetic awareness of true vertical, and pain. Although mild deficits may not affect balance control, deficits that sig
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nificantly alter the COM position can impair balance.39 Patients are typically unable to self-correct faulty pos tures. Physical therapy interventions should focus first on improvrng specific musculoskeletal impairments (e.g.. limited ROM. weakness). For example, active exercises to improve standing balance can include standing heel-cord stretches, heel-rises. toe-offs. partial wall squats. chair rises. side-kicks. hack-kicks, and marching in place using touch-down support of the hands as needed (sometimes reterred to as the kitchen sink exercises). 39 Postural reeducation gins with demonstration of the correct posture. verbal cues should focus on control of essential postural elements, that is, stable (neutral) pelvis, axial extension e.g.. sit or stand tall), and normal alignment (e.g., head erect, shoulders back, weight evenly distributed under both hips [sitting] or feet [standing]). 39 Patients can benefit from tactile cues during initial practice (manual or sur face-related. For example, patients can stand with the back positioned against a wall or patients with a lateral lean (e.g.. poststroke patients with pusher syndrome) can sit with their side positioned against the seated therapist or a wall. 39 Corner standing or standing tween two plinths can effective for patients with significant COM distor tion. Mirrors provide important visual cues regarding ver tical position but are generally contraindicated for the
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patient with visuospatial perceptual deficits. Application of correct postures to real-life functional situations is important to ensure carryover and lasting change.39

Biodex system

d-Center-of-Mas Control Training

The therapist should focus on obtaining symmetrical, bal anced weightbearing. Patients may present with specific directional instabilities, such as weightbearing more on one side than the other. For example, after a stroke the patient typically keeps weight centered toward the sound side Practice should focus on redirecting the patient into a centered position by moving toward the affected side, both In Sitting and standing positions. Limits of sability (LOS) should be explored. 30-39

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posturography Feed back Balance training using augmented visual feedback has become increasingly popular in treating the elderly and other patients at risk for falls. Research reports substantiate its effectiveness in improving balance.10-16 Force-platform devices are used to measure forces and provide center of pressure (COP) biofeedback or posturographv feedback.37,38 Posturography training can be used to shape sway movements to enhance symmetry and steadiness. The patient can be instructed to increase or decrease sway movements or move the COP cursor on the computer screen to achieve a designated range or to match a desig nated target. It is an effective training mode for patients who demonstrate problems in force generation. For exam ple, the patient with decreased force generation (hypome tria) as typically demonstrated by individuals with Parkinsons disease is directed toward achieving larger and faster sway movements during posturography training. 37,38 Finally, a set of bathroom scales or limb load monitors can provide a low tech, low cost form of biofeedback weight information to assist patients in achieving symmetrical weightbearing.28,29

e-Strategies to Improve Safety

Prevention of falls for the patient with balance deficiency is an important goal of therapy. Lifestyle counseling is impor tant to help recognize potentially dangerous situations and
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reduce the likelihood ot falls. For example, high-risk acti ities likely to result in falls include turning, sit to stand transfers, reaching and bending over, and stair climbing.27

f-Sensory Training
Several general concepts are important to an Understanding of the role of sensation in movement. Sensation allows one to interact with the environment, guiding the selection of movement responses. Sensory inputs are used to modify movements and shape motor programs through feedback for corrective actions. Variability and adaptability of move ments to environmental change are made possible by the information processing of sensory inputs. 23 Damage to the CNS can produce impairments in Sen sory function. Alterations in tactile. proprioceptive. VISUaI. or vestibular systems can affect a patients ability to move and learn new activities. Deafferentation in animals and in humans is associated with nonuse of a limb, although gross movements are possible under forced situations. Learning of new movements through corrective actions is impaired. The therapist must focus on forced training of sensory deficient limbs even though the patient may have little Interest in moving the limb. 24 The movements obtained should not be expected lo be normal, however, because significant deficits have been noted in fine motor control indeaffrentated limbs. Following damage to the cNS. sensory inputs may be reduced or distorted. Perceptions are
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therefore impaired. Sensory training strategies can be used to sharpen and heighten perceptions and assist in reorganizing the CNS.24

Training Strategies for Sensory Loss

Sensorv stimulation refers to the structured presentation of stimuli to improve (1) alertness, attention, and arousal: (2)sensory discrimination: or (3) initiation of muscle activity and improvement of movement control. Effects are immediate and specific to the current state of the nervous system.23 Behaviors are modified using techniques to increase or decrease attention and arousal. Movements are elicited and modified through the use of specific stimuli (e.g.. stretching. tapping). The effects do not carry over to subsequent movement attempts. Because the movements rely on augmented inputs, their greatest use is to assist the patient with absent or severely disordered voluntarv control (e.g.. a patient who sustained a stroke and who s unable to consistently initiate muscle contractions) . 24 Once a desired motor response is obtained. focus should shill to active movements that utilize naturally occuring intrinsic sensory information. Thus, sen sory stimulation techniques may be an effective bridge to assist early attempts at movement hut should be withdrawn as soon as possible. Repeated use of sensory stimulation long alter it IS necessary Can result iii movements that become stimulus dependent, and can further limit the patients ability
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to regain voluntary control.25 Sensory integration training refers to the use of enhanced, controlled sensory stimulation in the context of a meaningful,self directed activity in order to elicit adaptive behavior. Varied sensory stimuli are presented(tactile,vestibularproprioceptive,and visual) in order to engage higher brain centers for central processing of sensory information23 The overall goals are to 1- improve sensory discrimination :identification of specific stimuli( e.g. shapes,weights, textures, numbers written on skin),intensities , and localization of stimuli 2- improve perception : selection,attention, and response to sensory inputs with appropriate use of information to generate specific motor responses . the key elements are multimodal presentation of various different stmuli compined with functional task training. Focus is also on postural training activities with progression to more difficult adaptive motor responses.24 Sensory reeducation has been used successfully to improve sensory function in patients with peripheral nerve damage Patients with stroke-related impairments have also shown benefits from specific sensory training pro grams. Components of these programs consist of having the patient practice sensory identification tasks (numbers, letters drawn on the hand or arm). discrimina tion tasks (detecting size, weight and texture of objects placed in the hand), and passive-assisted drawing using a pencil.25
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The tasks are alternated between both affected and unaffected hands. Each training session starts and ends with a sensory task the patient could successfully master. The training group showed a positive and significant improvement in sensory function. An important feature of this study was that the subjects were at least 2 years post-stroke, providing strong evidence that the effects were due to training and not recovery. 24

Sensory Training Strategies for Balance

An important focus of balance training is uilization and integration of appropriate sensory systems. Normally three sources of inputs are utilized to maintain balance: somatosensory inputs (proprioceptive and tactile inputs from the feet and ankles), visual inputs, and vestibular inpus.2 Careful camination can identity the patients use ot inputs to maintain balance (e.g., Clinical Tes for sensory and Balance CTSIB. 22 . Training is directed lo using practice balance tasks with eyes open and eves closed, in reduced lighing. or in sItuations ol Inaccurate vision (petroleum-coated lenses or prism glasses). Altering the visual inputs allows the patient to shih focus and reliance to other sensory inputs.22 practice varying somatosensory inputs by standing and walking on different surfaces, from flat surfaces
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(floor) to compliant surfaces (low to hiugh carbet pile), to dense foam. Apatient who is bare foot or wearing thin-soled shoes is better able to attend to sensation from the feet than if wearing thick soled shoes.22 Challenges to the vestibular system can be introduced by reducing both visual and somatosensory inputs through sensory conflict situations. 22 For example. the patient practices standing on dense foam with the eyes closed. Thepatient can also be directed to walk on foam with eyes closed, a condition that requires maximum use of vestibular inputs. Patients should also practice varying environmental influences such as walking outside, pro gressing (rom relatively smooth terrain (sidewalks) to uneven terrain to moving surfaces (escalator, elevator). Repetition and practice are important factors in assisting CNS adaptation.21 Compensatory training with an assistive device is indicated. Other patients must be encouraged to ignore distorted information (e.g.. impaired propriocep tion accompanying stroke) in favor of more accurate sen sory information (e.g.. vision). Augmented feedback can assist in training (e.g.. verbal commands, light-touch fin ger contact, biofeedback cane with auditory signals, limb load monitor).21

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Balance master

Smart balance master

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References:
1)Shumway-Cook A, Horak F. Assessing the influence of sensoryinteraction on balance.PhysTher 1986;66:1548-1550. 2)SusanOsullivan,Physical rehabilitation. 3)Lee.Dn.andLishman visual proprioceptive control of stance ,1975. 4)Nashner,l:Sensory,neuromuscular,and biomechanical contributions to human balance.in balance American physical therapy association,1990. 5)Nashner,L and Mccollum,G:The organization of human postural movements.Aformal basis and experimental synthesis,1985. 6)Nashner,L:Adaptive reflexes controlling human posture,1976. 7)Horak,F,andNashner,L:Central programming of central movements:Adaptation to altered support surface configuration 55:1548,1986. 8)Nashner,L:Fixed patterns of rapid postural responses among leg muscles during stance 30.13,1977. 9)Maki,B and Mcllron ,w:The role of limb movement in maintaining upright stance :The change in base of support strategy 77:488,1977. 10)Dean,C, and Shephered, R:Task related training improves performance of seated reaching tasks following stroke:Arandomized controlled traial28:722,1997. 11)Lee,W,Etal:Quantitative and clinical measures of static standing balance in hemiparetic and normal subjects.64:1967.1984. 12)Newton,R:Balance screening of an inner city older adult population .1997. 13)Guralnick,J,etal:Lower extremity function over age of 70 years as apredictor of subsequent disability.1995.
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14)Berg,K, et al:Measuring balance in elderly .1992. 15)Mathias, S etalBalance in elderly patients ,1986. 16)Darcy,A, umphered Neurological rehabilitation fifth edition. 17)http://www.biodex.com/physical-medicine/products/balance/balance-system-sd. 18)http://resourcesonbalance.com/neurocom/products/BasicBalanceMaster.aspx. 19) resourcesonbalance.com/neurocom/protocols/motorImpairment/adt.aspx. 20) resourcesonbalance.com/neurocom/protocols/motorImpairment/mct.aspx. 21- Shumwav-Cook. A. and Woollacott. M: Motor Control Theory and Practical Applications. ed 2. Lippincolt Williams & Wilkins. Baltimore. 2001 22- Nashner. L: Sensory. neurormuscular. and biomechanical contributions to human balance. in Duncan. P {ed}: Balance. American Physical Therapy Association. Alexandria. VA. 1990. p 5. 23-Wynn Parry. C. and Salter, M: Sensory reeducation after median nerve lesions. The Hand 8:250. 1976. 24-Goldman, H: Improvement of double simultaneous stimulation perceptIon in hemiplegic patients. Arch Phys; Med Rehabil147:681. 1966. 25-Weinberg, S. et al ' Training sensory awareness and spatial organization in people .... with right brain damage. Arch Phys . Med Rehabil 60:'491.1979. 26-Yekatiel. M. and Guttman. E: A controlled trial of the retraining of the sensory function of the hand in stroke patients. J Neural Neurosurg Psychiatry 56:241. I993.

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27-Jeka. J : Light touch contact as a balance aid. Phys Ther 77:476. 1997. 28-Gapsis, J. el al: Limb IO;ld monitor: Evaluation of a sensory feed-back. device for controlling weight-bearing. Arch Phys Med Rehabil 63:38. 1982. 29-Gauthier-Gagnon. C. el al: Augmented sensory feedback in the early training of standing balance of below-knee amputees, Physiother Can 38: 137, 1986. 30- Wannstedt. F. and Herman, R: Use of augmemed sensory feedback to achieve symmetrical . sIanding. Phys Ther 58:553. 1978. 31- Hocherman. S. et al: Plalform training and postural stability in hemiplegia. Arch Phys Med Rehabil 65:588. 1984. 32- Shumway-Cook. A. Anson, D. and Haller. S: Postural sway biofeedbac k: It's effect on reestablishing stance stability in hemiplegic patients. Arch Phys Med Rehabil 69:395. 1988. 33- Hammon, R. et al: Training effects during repeated therapy sessions of balance training using visual feedback. Arch Phys Med Rehabil 73:738. 1992. 34- Moore. S. and Woollacolt. M: The use of biofeedback: devices to improve postural stability. Phys Ther Practice 2: I. 1993. 35- Nichols. D : Balance retraining after stroke using force platform biofeedback. Phys Ther 77:553.1997. 36- Kasser. S, Rosc. D. and Clark. S: Balance training for adults with multiple sclerosis: Multiple case studies. Neuro Report (now JNPT) 23:5. 1999.

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37- Nashner. L. and McCollum. G: The organization of human postural movements: A formal basis and experimental synthesis. Behav Brain Sci 8:135. 1985.

38- Benda, B. ct al: Biomechanical relationship between center of gravity and center of pressure during standing. IEEE Trans Rehab Eng 2:3. 1994. 39- Damis. C. el al: Relationship between standing posture and stability. Phys Ther 78:502. 1998, 40-Nashner. 1-: Fixed patterns ot rapid postural responses among leg muscles during stance. Exp Braini Res 30:13, 1977 41-Nashner. l.-. Adapttiig reexes controlling the human posture. Esp Bram Res 26:29. 1976 42- Horah. F. and Nashner L: Central programnting of postural movements: Adaptation to altered support surface: configurations j neurophysiology 55;1369. 1986 43- Mcllroy, W and Maki. B" adaptive: changes to compensatory stepping responses, Gait Posture, 3.:43. I995. 44- Maki,B,AND Mcrolly-l- B. W" The role of limb movements in maintaining upright stance: the change in support 77:488 1997 45- Horak f . et al: Postural perturbations: new insight for treatment of balance disorders phys ther77:517. 1997.

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46- O'Sulliivan. S. and Sclimitz. T: Physical rehabilitation 5th edition ,strategies to improve postural control ,2005

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