Balance and Fall Prevention

By,
Sankari Nedunsaliyan
Physiotherapist
Dip In PT (MAL), Bsc Hons Applied Rehab (UK)
 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
Base of Support
 Center of Mass

Balance: Control of center of mass

over base of support
Balance: control of center of mass
over base of support
 Vicious Cycle

Fall

↗ ↘

Imbalance ← Inactive
 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.
 Precautions
 High Fall Risk

 Co morbidities

 Recent Surgery

 Injuries
 Types of Balance
• Steady state (static) balance

• Reactive balance (Dynamic Balance)

• Proactive (anticipatory) balance

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.
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.
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
A Systems Model of Balance1

1Courtesy of Sandra Rader, PT, Clinical Specialist

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
Limits of Stability
Model Components
Musculoskeletal System
 ROM of joints
 Strength/power
 Sensation
◦ Pain
◦ Reflexive inhibition
 Abnormal muscle
tone
◦ Hypertonia (spasticity)
◦ Hypotonia
Model Components
Goal/Task Orientation
 What is the nature of
the activity or task?
 What are the goals or
objectives?
Model Components
Central Set
 Past experience may
have created “motor
programs”
 CNS may select a
motor program to
fine-tune a motor
experience
Model Components
Environmental Organization
 Nature of contact
surface
◦ Texture
◦ Moving or stationary?
 Nature of the
“surrounds”
◦ Regulatory features of
the environment
(Gentile)
Model Components
Motor Coordination
 Movement strategies
◦ Based on repertoire of
existing motor
programs
 Feedback &
feedforward control
 Adjustment/tuning of
strategies
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
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
Ankle Strategy
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
Hip Strategy
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
Suspensory Strategy
 Forward bend of
trunk with hip/knee
flexion - may progress
to a squatting position
 COG lowered
Model Components
Sensory Organization
 Balance/postural
control via three
systems:
◦ Somatosensory
◦ Visual
◦ Vestibular
Somatosensory System
 Dominant sensory  Components
system ◦ Muscle spindle
 Provides fast input  Muscle length
 Rate of change
 Reports information
◦ GTOs (NTOs)
◦ Self-to-(supporting)  Monitor tension
surface
◦ Joint receptors
◦ Relation of one  Mechanoreceptors
limb/segment to
◦ Cutaneous receptors
another
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
Vestibular System

 Not under conscious  Components

control ◦ Cerebellum
 Assesses movements ◦ Projections to:
of head and body  Brain stem
 Ear
relative to gravity and
the horizon (with
visual system)
 Resolves inter-sensory
system conflicts
 Gaze stablization
 Sensory-Motor Integration
Sensory Input Processing Motor Response

Somatosensory 10 Processor
Vestibular Motoneurons

Visual

20 Processor
Cerebellum
Eye Movements

Postural Movements
 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)
BALANCE COMPONENTS
VS
AGE
 Age related changes to motor
components of balance
 Decreased magnitude of muscle response

 Increased reliance of arms

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
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)
BALANCE COMPONENTS
VS
DISEASE
 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
 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

 Abnormal balance
Parkinson’s Disease
 A) Dynamic balance problem

 B) Difficulty initiating gait

 C) Moments of freezing during movement

 D) Altered gait cycle

 Abnormal balance
Benign Paroxysmal Positional Vertigo (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.
 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)

HOW TO TEST YOUR
BALANCE
Valid tools to measure balance
 Berg’s Balance scale
 Timed up and go test
 Functional reach test
 Nudge test
 Other tests: Hallpixe – Dix Test
 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
 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
 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
Treatment of balance
Exercise examples
 A) Calf stretch

 B) Heel / toe raises

 D) Soft surface stance in corner

 E) Sitting to standing
 Resources
 Active Life Physical Therapy 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
 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, Hodson TJ, 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, Stevens VJ, 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.
 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
 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.
 Balance Training
 Static balance control
◦ Maintaining sitting.
◦ Half-kneeling,
◦ Tall kneeling,
◦ Standing postures on a firm surface,
◦ Tandem, Single-leg stance.
◦ Working on soft surfaces (e.g., foam, sand, grass),
◦ Narrowing the BOS, moving the arms, or closing the eyes.
 Balance Training
 Dynamic Balance Exercises Using
Movable Surfaces:
1. Swiss Ball

1. Tilt Boards
 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.