Reactive Balance Training

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (31/03/2021)

Original Editor -

Top Contributors - Pierre Roscher, Jonathan Wong, Tarina van der Stockt, Kim Jackson, Lucinda hampton, Jorge Rodríguez Palomino, Ewa Jaraczewska and Stacy Schiurring  

Description

Reactive balance training(RBT) is a type of exercise. RBT improves the control of certain reactions that are involved when someone loses their balance, and they want to prevent themselves from falling. 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 of a person.

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 maesure to use. Many patients may benefit from RBT, such as stroke patients , parkinsons patients and anyone who is at risk of falling.

How does RBT work?

A therapists will intentionally expose a patients to a challenging experience, progressively increasing the challenge over time. A force is applied to the patient. Forces may be internal or external force, and these affects 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 involves 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.

Next we will discuss four important aspects of RBT.

1. Internal and External Perturbations

Internal perturbations from my perspective occur while the patient is performing an anticipated activity and is not controlling the center of mass adequately. It’s the patient’s own lack of control or poor coordination or lack of center of mass awareness or lack of adequate motor response that leads to the center of mass approaching or falling outside of their pillars. 

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.

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 feedforward mechanisms and reactive strategies. Successful postural control relies on a variety of components: somatosensory system, vestibular system, visual system, and neuromuscular system. My brain immediately thinks of circus acts or gymnastics or figure skating when I think of activities that require individuals to have highly functioning postural control.  

Read more about Postural Control.

3. Balance Control

From a purely biomechanical perspective, balance control is simply the body’s ability to keep the center of mass within its base of support. When a person’s center of mass falls outside the base of support, if there is no reactive strategy, the person falls. Biomechanists refer to this situation as the center of mass being perturbed. The center of mass is no longer in a stable location with regard to the base of support. When I educate patients, I tell them that their legs and feet are their pillars. They have to keep their center inside their pillars.  

Read more about Centre of Gravity.

Similar Approaches that are NOT considered RBT

The Otago Exercise Program:

The Otago Exercise Program is not reactive balance training. 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 each of 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 helps retrain balance, this exercise is predominantly anticipatory in nature. If the patient is not able to perform the movements smoothly and has internal perturbations with enough of an 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:

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. 

Conclusion

Reactive balance training includes unexpected situations within the provision of care. The patient is not able to anticipate the condition or situation to pre-plan the response. A qualifying condition includes the center of gravity moving toward the outside limits of stability requiring a stepping strategy to prevent a fall. 

Resources

add appropriate resources here, including text links or content demonstrating the intervention or technique