Reactive Balance Training

Original Editor - Pierre Roscher based on the course by Selena Horner
Top Contributors - Pierre Roscher, Jonathan Wong, Tarina van der Stockt, Kim Jackson, Lucinda hampton, Jorge Rodríguez Palomino, Ewa Jaraczewska and Stacy Schiurring

Introduction

Gait and balance problems are considered high risk factors for falls. The World Health Organization (WHO) reported that fall frequency increases with age. According to WHO, one-third of population over 65 experience at least one fall each year. Reactive balance (RB) is defined as the ability to control balance in response to mechanical disturbances. It allows to counter react external forces that compromise individual's postural stability.

This article describes reactive balance training and helps to differentiate it from other similar balance training approaches.

Description

Reactive balance training (RBT) is a type of exercise aimed at improving the control of fall-prevention reactions when one loses balance. RBT involves whole-body movements, and these movements have similar benefits to other exercises such as walking, and may over time also improve strength and conditioning . RBT has the potential to improve multiple aspects of physical health simultaneously.

Many balance programs have traditionally targeted only the static and dynamic components of balance, without thought for the reactive component. However, the dominating factor for falls is a slip or trip while walking. Appropriate and timely balance reactions are essential for stability following balance loss. Balance reactions such as reactive stepping, are crucial for fall prevention.

Systematic reviews suggest reactive balance training may reduce fall rates by 46%–48%.

Indication

The indication for using RBT as a treatment technique is largely (but not exclusively) based on an indication that a patient has an issue with their balance. As a physiotherapist, there are many ways to assess balance, but the Berg Balance Scale is a useful outcome measure to use, and can predict the risk of falling in older adults. It is also important to ensure that a patient receives the appropriate exercise for their current condition. The Balance Intensity Scale (BIS) is a clinical measure of the intensity of balance exercises in older adults. The BIS has a component that is rated by clinicians and a component that is rated by the exerciser. Many patients may benefit from RBT, such as stroke patients , parkinsons patients and anyone who is at risk of falling.

Here is an example of RBT:

How Does RBT Work?

Therapists will intentionally expose a patient to a challenging experience, progressively increasing the challenge over time. A force is applied to the patient. Forces may be an internal or external force, and these affect the patient’s centre of mass. The goal of the exercise is to create instability at a level of intensity that requires the patient to execute a strategy to maintain the centre of mass within the base of support to prevent a fall. 

The exercises may often involve repeatedly introducing the same unexpected dynamic activity that requires a physical response to prevent a fall until the patient is able to consistently respond in a way that ensures adequate control of their centre of mass.

Four Important Aspects of RBT

1. Internal and external perturbations

Reactive balance training incorporates perturbations in interventions .

Internal perturbations occur while the patient is performing an anticipated activity, and is not controlling their center of mass adequately. It’s the patient’s own i) lack of control, ii) poor coordination, iii) lack of centre of mass awareness or iv) lack of adequate motor response that leads to the centre of mass approaching or falling outside of their base of support.  

External perturbations are different from internal perturbations. An external perturbation requires something in the environment outside of the person that causes a force, that acts upon the center of mass, causing the center of mass to move and reach or exceed the limits of stability. 

Read more about perturbations techniques.

Have a look at the following video of RBT using a rolling platform, and see if you can identify the different types of perturbations.

2. Postural control

Postural control is the body’s way of maintaining equilibrium in any situation. It requires a flexible, automatic system to adequately respond to anticipated and unanticipated events. It includes both feedforward mechanisms and reactive strategies. Successful postural control relies on a variety of systems such as the: somatosensory system, vestibular system, visual system, and neuromuscular system.   

Read more about Postural Control.

3. Balance control

Balance control is simply the body’s ability to keep the centre of mass within its base of support. A fall occurs when a person’s centre of mass falls outside the base of support, and they no reactive strategy. One can also refer to the event of falling biomechanically as the centre of mass being perturbed. The centre of mass is no longer in a stable location with regards to the base of support.   

Read more about Centre of Gravity.

Approaches That are RBT and Those That are NOT Considered RBT

Perturbation based balance training

Perturbation based balance training is the main form of reactive balance training, used widely in the literature. A perturbation is applied externally to the patient, forcing them to react to the external force and maintain postural stability so as not to fall. Examples include therapists applying forwards, backwards, and sideway forces through pulling at the hips or shoulders.

The Otago Exercise Program

The Otago Exercise Program is not reactive balance training, but it is a very effective approach to improving balance and reducing falls in older adults. Although the program includes activities to help retrain balance, the activities are anticipatory in nature. Anticipatory adjustments that challenge a person to maintain balance are not necessarily reactive balance training. When a person is aware of a task to perform, the person has the time to think about the task and to determine how to perform the activity. The person is able to anticipate what needs to be done. Examples include clinic activities like the grapevine, Clock Yourself App, tandem walking, braiding, walking backwards, or reaching activities. In these examples, the person knows the activity to perform because the person was provided with a command and can anticipate the activity to perform.

Tai-Chi

Tai Chi is not necessarily reactive balance training. Although Tai Chi includes slow, controlled movements and those movements help to retrain balance, this exercise is predominantly anticipatory in nature. If someone is not able to perform the movements smoothly and that creates internal perturbations with enough of intensity to generate a response to prevent a fall, then the activity will fall into the realm of reactive balance training. Read more about Tai-Chi and the older person.

Wii Balance

Video game systems are a cost-effective alternative to custom-designed rehabilitation equipment for individuals who require physical rehabilitation. They can use body movements as a game controller like the Nintendo's Wii Fit, where the patient must change the centre of pressure on the board to control the movement of the game's virtual character. The Wii balance activities are typically not reactive balance training. The balance activities are more anticipatory in nature. Again, the patient’s performance determines if the activity is reactive or anticipatory.    

Virtual reality balance training 

Virtual reality technology is based on human-computer interaction technology, which utilises visual, tactile, and kinesthetic stimuli through rich virtual scenes, providing a sense of immersion and offering real-time feedback on physical actions. The content of these virtual environments can be created for specific purposes, such as exercise or balance training. Virtual reality balance training has the potential to be considered reactive balance training. The application would need to provide a situation of the patient feeling as though unstable and needing to respond to the feeling of instability via a motor response.    

Designing Your Own RBT Training  

There are many examples of RBT. Situations can be set up and applied to clinical interventions. It is important to remember a few things when you incorporate RBT into practice.   

1. The activity has to be at a level of intensity that challenges your patient to react to prevent a fall.   
2. The activities will include internal or external perturbations.   
3. Activities need to be progressively challenging.   
4. Your patient needs to be presented with the activity over and over again until your patient is able to adequately respond.   

Conclusion

RBT includes unexpected situations within the provision of care. The patient should not able to anticipate the condition or situation to pre-plan the response. A qualifying condition includes the centre of gravity moving toward the outside limits of stability, requiring a stepping strategy to prevent a fall. RBT is an effective strategy for preventing falls for patients over a varied lifespan. 

Additional Resources

Balance Intensity Scale

Perturbations on a Treadmill:

Reactive Balance/React Board:

Shuttle Board

Proprio Reactive Balance System: