Title: Balance
1Balance Its Functional Role in Rehabilitation
Gait
- Sally Paulson Ph.D., ATC, CSCS
- Shippensburg University
2Objectives
- 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
3What 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
5Balance 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)
6Balance 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
7Balance 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
8On 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
9Balance 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
10Balance 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
11Balance 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)
12Balance 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
13Subject Two Treatment Group Pre Gait Video
14Subject Two Treatment Group Post Gait Video
15Individual Changes in Gait
16Balance Exercises
- Should be simple progressively become more
challenging - They can be designed to address any of the
systems that affect balance
17Static 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
18Dynamic 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
19Assessing 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
20Assessing 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
21Assessing 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
22Conclusion
- 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
23References
- 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
24Questions