Balance

Original Editor - The Open Physio project.

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Introduction

Balance refers to an individuals ability to maintain their line of gravity within their Base of support (BOS) or the ability to maintain equilibrium, where equilibrium can be defined as any condition in which all acting forces are cancelled by eachother resulting in a stable balanced system.  Balance can be both STATIC AND DYNAMIC BALANCE.

Variation in Terminologies

In literature the balance term has been used synonymously with

• Postural Control
• Postural Stability
• Equilibrium

Balance systems

The following systems provides input regarding the body's equilibrium and thus maintains balance.

1. Somatosensory / Proprioceptive System
2. Vestibular System
   
3. Visual System

The Central Nervous System receives feedback about the body orientation from these three main sensory systems and integrates this sensory feedback and subsequently generates a corrective, stabilizing torque by selectively activating muscles.

Somatosensory System

Proprioceptive information from spino-cerebellar pathways, processed unconsciously in the cerebellum, are required to control postural balance.  

Vestibular System

The vestibular system generates compensatory responses to head motion via

1. Postural responses (Vestibulo Spinal Reflex)
2. Ocular-motor responses (Vestibulo Ocular Reflex)
3. Visceral responses (Vestibulo Colic Reflex)

To achieve this the vestibular system measures

• Head rotation
• Head acceleration 
  
  

Visual System

Friedrich et al. (2007)  observed that adults with visual disorders were able to adapt peripheral, vestibular, somatosensoric perception and cerebellar processing to compensate their visual information deficit and to provide good postural control. In addition, Peterka (2002), found that adults with bilateral vestibular deficits can enhance their visual and proprioceptive information even more than healthy adults in order to reach an effective postural stability. The influence of moving visual fields on postural stability depends on the characteristics of the visual environment, and of the support surface, including the size of the base of support, its rigidity or compliance.

Management

a. Parkinson’s disease

Parkinson’s disease (PD) is a progressive neurodegenerative disease. It’s often characterized by tremor, bradykinesia, postural instability and rigidity. Most frequently, patients have gait impairments, difficulty in linking movements together smoothly and episodes of freezing. The sum of these problems, together with balance disturbances lead to an increased incidence of falls. 

The physiotherapist is a member of the multidisciplinary team, with the purpose of maximising functional ability and minimising secondary complications. Physiotherapy for Parkinson’s disease focuses on: transfers, posture, upper limb function, balance, gait, and physical capacity. The therapist uses cueing strategies, cognitive movement strategies and exercise to maintain or increase independence, safety, and quality of life. Sensory cueing strategies such as auditory, tactile, and visual cues have often been used to help walking in PD.  

Cognitive movement strategies

Cognitive movement strategies are used to improve transfers. Complex and automatic activities are divided into separate elements consisting of relatively simple movement components. By doing this, the person has to think consciously about his movements. Try to avoid dual tasking during complex automatic ADL. Furthermore, the movement or activity will be practiced and rehearsed in the mind. It is important that movements are not performed automatically; performance has to be consciously controlled 
Example: Sit to stand 

1.Hands on chair
2.Place feet correctly
3.Move forward
4.Flex trunk
5.Rise up from chair

Cueing strategies

The performance of automatic and repetitive movements of patients with PD is disturbed as a result of fundamental problems of internal control. That’s why cues are used to complete or replace this reduced internal control.
Cues can be generated internally or externally. Rhythmical recurring cues are given as a continuous rhythmical stimulus, which can serve as a control mechanism for walking.  

• Auditory (moves on music/ walkman, singing, counting,...)
• Visual (p follows another person, walks over stripes on the floor or over stripes he projects to himself with a laserpen,...)
• Tactile(p taps his hip or leg)

The physical therapeutic intervention goals apply to the phase addressed: 

• Early phase
Patients have no or little limitations. Goals of the therapeutic intervention are:
1. prevention of inactivity
2. prevention of fear to move/to fall
3. preserving/ improving physical capacity

• Mid phase

More severe symptoms; performance of activities become restricted, problems with balance and an increased risk of falls
Problems:
1. transfers
2. bodyposture
3. reaching and grasping
4. balance
5. gait

• Late phase
Patients are confined to a wheelchair or bed. The treatment goal in this phase is to preserve vital functions and to prevent complications, such as pressure sores and contractures.

b. Elderly

Balance training can also be used in the elderly. Falls of elderly, due to poor balance, have important clinical and economical costs and intervention. For this reason it is interesting to search for possibilities to reduce these costs, such as the use of balance training.

In 2011 weak evidence has been found for the effectiveness of several exercises in improving clinical balance outcomes in elderly:

• Gait
• balance
• co-ordination and functional tasks
• strengthening exercise
• But evidence for the effect of computerized balance programs or vibration plates is insufficient.

To keep the therapy adherence up it is best to look for an approach with a ‘fun factor’. Some examples:

• music-based multitask exercise program
Basic exercises consisted of walking in time to the music and responding to changes in the music’s rhythmic patterns. Exercises involved a wide range of movements and challenged the balance control system mainly by requiring multidirectional weight shifting, walk-and-turn sequences, and exaggerated upper body movements when walking and standing. 

• balance training using a virtual-reality system
In contrast to the review of 2011, in 2013 it was found an effective method to train the balance in older fallers. This method is intended to complete, not replace, other fall prevention programs. 

• Tai chi
Tai chi has been proven to be an economic and effective way for training balance in older people. 
To ameliorate balance in elderly it isn’t enough to just follow a conventional exercise intervention (including muscle strengthening, stretching and aerobic exercises, and health education). Besides this it is better to also include static and dynamic balance exercises.

Examples of static balance exercises: squats, two-leg stance and one leg stance.

Examples of dynamic exercises: jogging end to end, sideways walking or running with crossovers, forward walking or running in a zigzag line, backward walking or running in zigzag line. 

Nevertheless to improve balance core strength training is an important element. The benefit is this therapy can be both given in a group setting or in individual fall preventive interventions