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Balance

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Title: Balance


1
Balance Its Functional Role in Rehabilitation
Gait
  • Sally Paulson Ph.D., ATC, CSCS
  • Shippensburg University

2
Objectives
  • Review balance what might affect balance
  • Present literature related to the role of balance
    in rehabilitation gait
  • Provide examples of static and dynamic exercises
    assessments

3
What is balance?
  • Balance is the means in which individuals
    maintain their body position while stationary or
    mobile in relationship to the environment
  • Balance requires input from
  • Visual system
  • Vestibular system
  • Proprioception
  • Muscular strength, endurance flexibility
  • CNS control balance through motor commands

Arnheim Sinclair, 1985 Auxter et al., 2005
Clark, 2004 Anderson Behm, 2004 Arnheim
Sinclair, 1985 Dieterich, 2004 Houglum, 2005
4
Balance is affected by
  • Muscular strength
  • Fatigue of the LE muscles occurs earlier due to
    inadequate strength
  • This can result in diminished coordination
  • With age strength decreases, which results in a
    decline in balance (Martin Morgan, 1992 Syed
    Davis, 2000)
  • CNS
  • Injury to the brain or spinal cord might
    interrupt communication between the body
    part/system the CNS
  • Medications
  • Blackburn et al., 2000 Carter et al., 2001
    Clark, 2004 Hamilton Luttgens, 2002 Houglum,
    2005 Nitz et al., 2003

5
Balance is affected by
  • Pathological /or age-related changes to
    vestibular visual systems
  • Tai Chi was found to balance improvement via the
    vestibular component of the sensory organization
    test in healthy, elderly subjects (Tsang
    Hui-Chan, 2004)
  • Someone with vestibular defect/injury might
    present with
  • Gait alterations decreased static balance
  • Limited control of the COG within the base of
    support (Krebs et al., 2002)
  • Age
  • Nitz et al. 2003 concluded that medial-lateral
    balance declines with age in women, especially
    between the ages of 40 60
  • Size of the base of support (BOS)
  • Smaller BOS requires finer body adjustments to
    maintain balance (Anderson Behm, 2004)

6
Balance is affected by
  • Injuries to the LE
  • Normal alignment stability of the supporting LE
    decreases friction which contributes to the
    smoothness of gait (Sailbene Minetti, 2003)
  • May result in inefficient energy expenditure
    during walking or running (Sailbene Minetti,
    2003)
  • May lead to the COG to fall outside of the BOS
    increase risk of falling (Blackburn et al., 2000
    Clark, 2004)
  • Balance impairments have been related to risk of
    injury /or risk of re-injury
  • May damage joint proprioceptors which contribute
    to maintaining balance
  • Restoring proprioception following injury
    increases the bodys awareness of joint position
    increase stability orientation during static
    or dynamic movement (Laskowski, et al. 1997)
  • Tropp et al. (1984) reported soccer players who
    presented with gt 2 SD above normal on postural
    sway measures had a significantly higher risk of
    injury to the LE
  • Hamilton Luttgens, 2002 Hills et al., 2001,
    2002 Houglum, 2005 Martin Morgan, 1992
    Spyropoulos et al., 1991

7
Balance is affected by
  • Obesity
  • McGraw et al. (2000) reported obese boys spent
    significantly greater time in the double support
    phase may have less dynamic static balance
  • Thigh mass of obese individuals may be
    disproportional to the rest of the body
  • Results in an increase in leg mass affects the
    internal work of the muscles (Martin Morgan,
    1992 Sailbene Minetti, 2003)
  • Increase in step width (Hills et al., 2001, 2002)
  • Additional mass can alter the position of the
    COG which can lead to falls (Clark, 2004)
  • Has been linked to gait changes, pathologies to
    the LE, loss of mobility increases in energy
    expenditure
  • Blackburn et al., 2000 Hamilton Luttgens,
    2002 Houglum, 2005 Spyropoulos et al., 1991

8
On the Contrary
  • McHugh et al. (2006) examined risk factors for
    noncontact ankle sprains in high school athletes
  • Measured balance via a tilt board hip strength
  • Found balance hip strength were not risk
    factors for noncontact ankle sprains
  • However, previous ankle injuries being
    overweight (especially in males) were found to be
    significant risk factors

9
Balance Rehabilitation
  • Blackburn et al. (2000) found dynamic
    semi-dynamic balance improved in all subjects
    that completed an ankle rehabilitation program
    vs. subjects that did not (control group)
  • Rehab programs were (a) strength training, (b)
    proprioception training, (c) strength
    proprioception training

10
Balance Prevention
  • Myer et al. (2006) compared plyometric training
    to balance training on LE biomechanics
  • Plyometric group
  • Exercises included jumps, hops, box drops
    cutting
  • Maximal effort
  • Balance group
  • Addressed dynamic stabilization core
    strengthening
  • Focus was on challenging the COG through
    single-leg movements or adding external weight
  • Pre/posttest 3D force plate measurements were
    taken while performing (2) tests
  • Drop vertical jump (31 cm in height)
  • Single-legged medial drop landing task
  • Results suggested the both groups demonstrated
    improvements in LE valgus motion
  • Drop vertical jump Significant decreases were
    noted in both groups at the hip ankle
  • Single-legged medial drop Significant decreases
    at the knee for both groups
  • Authors concluded both training programs can
    decrease LE valgus motion however, the
    improvements found were training and task specific

11
Balance Gait
  • Maintaining balance while walking is a challenge
    for the CNS
  • Internal external forces acting on the body
    which the CNS must process (Harris Wertsch,
    1994)
  • The body continually moves from a stable body
    position (double support) to an unstable position
    (single support)
  • Placement of the swing limb during double support
    is crucial for the CNS to make adjustments to
    maintain balance
  • Winter (1991) reported three measures related to
    balance when walking
  • (a) toe clearance, (b) the velocity of the heel
    at contact, (c) hip knee moment force
  • Gait analysis has been used a tool to measure
    balance (Lee Pollo, 2001)

12
Balance Gait
  • Effects of Balance Exercises on the Analysis of
    Selected Kinetic and Kinematic Variables of Gait
    in Developmentally Disabled (DD) Obese Adults
  • Additional body mass, decreases in strength
    place obese adults at risk for falls especially
    during unstable period during gait
  • 10-week balance program did not yield significant
    changes in the selected gait variables
  • However, interesting changes within the TX group
    were noted
  • TX group decreased knee angle at heelstrike by
    7.57 (medium effect size)
  • Cadence of the TX group increased by 7.22 steps
    per minute
  • Six out of the nine subjects in the TX group
    increased cadence

13
Subject Two Treatment Group Pre Gait Video
  • PRE Gait.avi

14
Subject Two Treatment Group Post Gait Video
  • Post Gait.avi

15
Individual Changes in Gait
16
Balance Exercises
  • Should be simple progressively become more
    challenging
  • They can be designed to address any of the
    systems that affect balance

17
Static Balance Exercises
  • Double to single leg standing
  • Alter the width of BOS
  • Semi-tandem to tandem
  • Add external equipment to stress the visual or
    vestibular systems
  • Playing catch
  • Unstable surface
  • Foam
  • BOSU
  • Eyes open to eyes closed
  • Table position
  • alternate hands knees while in table position
  • Swiss balls
  • Alternate arm/leg
  • Marching
  • UE or LE exercises

18
Dynamic Balance Exercises
  • Trampoline
  • Closed-chain kinetic exercises
  • Walking
  • Forward heel-to-toe
  • Sideways, on toes, on heels or backward between
    double lines that progressively get narrower
  • Squats
  • Step-ups
  • Mini hops
  • Jumping rope
  • Swiss balls
  • BOSU
  • Circle activities vestibular exercises
  • Sport-specific activities
  • Obstacle course
  • Games
  • Freeze tag
  • Statues
  • Hopscotch
  • Twister
  • Follow the leader
  • Scooter boards
  • Pull/push self with hands or feet sitting or
    lying prone
  • Sitting or lying prone spin self in one
    direction, stop change directions (vestibular)
  • Push/pull self through obstacle course or rope
  • Relay races

19
Assessing balance
  • Static balance tests include
  • (a) parallel stance with feet together or
    shoulder width apart
  • (b) semi-tandem stance
  • (c) tandem stance
  • (d) Romberg Test
  • (e) one legged stance
  • Measure postural sway via a force plate under any
    of these conditions to detect the oscillations of
    the center of pressure
  • These are timed a score of 30 s without using
    hand support is generally considered good
  • The visual vestibular systems can be tested in
    these positions with eyes open closed
    (Dieterich, 2004)
  • Sensory Organization Test
  • This test provides an outcome variable called an
    equilibrium score, which is based on the visual,
    proprioceptive, vestibular systems to maintain
    standing balance (Chaudhry et al., 2004)
  • Anemaet Moffa-Trotter, 1999 Clark, 2004
    Houglum, 2005

20
Assessing balance
  • Dynamical balance measurements include
  • Walking heel-to-toe for 10 feet (Clark, 2004)
  • Performing this task without looking at ones
    feet is a method to assess vestibular visual
    balance (Auxter et al., 2005)
  • Timed get-up-and-go test (Carmeli et al., 2002)
  • Berg Functional Balance Scale includes static
    dynamic assessment (designed for elderly)
  • Tinetti Balance Test shorter than Berg,
    addresses static dynamic

21
Assessing Functional Strength Proprioception in
LE
  • Line jumping
  • Forward backward
  • Side-to-side
  • Single leg
  • Score of gt 20 s is good
  • Four squares
  • Make a square
  • Person jumps clockwise around the square single
    legged
  • Repeated on opposite leg counterclockwise
  • Count the number of foot contacts in 20 s
  • Vertical jumping
  • Single leg jumping
  • Count the number of jumps completed in 20 s
  • Bounding
  • Single leg long jump
  • Bound forward land bound forward again
  • Take the average length of (2) jumps
  • With these tests one can compare bilaterally both
    in time number of jumps

McCrady Amato, 2004
22
Conclusion
  • The inclusion of balance exercises
  • May decrease the risk of injury or reinjury
  • Can be incorporated as a preventative measure
  • Should be included in exercise programs for
  • Obese individuals, elderly, people with a DD, LE
    injury rehab, or for someone with a balance
    deficiency

23
References
  • If you would like a complete list of references
    please contact me via email I will send you an
    electronic copy
  • Sally Paulson Ph.D., ATC, CSCS
  • Shippensburg University
  • Dept. of Exercise Science
  • sapaul_at_ship.edu
  • 717 477 1274

24
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