Perturbation-Based Balance Training

Introduction[edit | edit source]

Balancing.jpeg

Perturbation-based balance training (PBT) is a form of reactive balance training aimed at improving reactive balance control after unexpected external perturbations. These perturbations elicit rapid postural responses, training reactive postural control[1]. PBT reduces fall risk, improves postural control and gait in many clinical populations, such as healthy elderly people, poststroke patients and people with Parkinson's disease [2]. PBT potentially stimulates the sensorimotor control system, causing quicker muscle response to unpredictable perturbations and hence better balance reactions[3].

  • In a safe and controlled environment, participants are repeatedly exposed to destabilizing perturbations during various activities of daily living. Many different training setups can be utilized, from fairly simple lean-and-release perturbations requiring only a safety harness, to advanced systems that can provide a wide variety of perturbation types and intensities during various tasks.
  • Balance boards are often incorporated in perturbation based balance training.
  • Besides improving balance and reducing falls incidence, PBT can significantly reduce the fear of falling. Fear of falling can have a major impact on older adults.[4]

Clinical Justification[edit | edit source]

Adaptations may occur faster with PBT than with conventional balance training, offering the potential of achieving equal or better results with fewer training sessions.[4]

Falling.jpeg

PBT has shown significant reductions in falls in older adults and in those with specific disorders eg Parkinson’s disease or stroke compared to various control groups). PBT also reduced fall risk in stroke, which traditional balance training (focused on static and dynamic balance) did not achieve[5].

  • A recent systematic review found that this form of training helped to reduce risk of falling in elderly adults and those with Parkinsons disease.[6]
  • Perturbation/balance exercises help Osteoarthritis (OA) knee clients via improving function, and balance and reducing pain.[7] PBT has the added positive effects of improving kinesthesia and increasing functional capacity.[8]
  • Ankle instability. Once pain-free range of motion and weight bearing have been established, balance-training exercises should be incorporated in ankle instability/acute sprain to normalise neuromuscular control.[9] A 2018 systematic review on bracing and balance training on rate of ankle sprains concluded that there is moderate quality evidence for balance training to decrease the incidence and risk of ankle sprains in competitive athletes.[10]
  • PBT reduced the multistep reaction and foot collision frequency[11], as well as reaction time to auditory stimuli[12]. A study found a significant lowering in the frequency of extra steps for balance reactions for the PBT group, indicating that PBT improves control of step reactions[13].

Clinical Application[edit | edit source]

Treadmill-based methods and perturbations applied by therapists are the most feasible forms of PBT[4]. Treadmill-based PBT constructs a safe environment with a harness and handrails, and is highly task-specific for fall prevention (eg, provoking slips or trips through unexpected accelerations)[14]. Most studies on PBT used a frequency of 2-3 training sessions a week[15].

Examples[edit | edit source]

Some examples of these techniques are shown in video below

[16]

Other examples are outlined below

  1. Double-Leg Foam Balance Activity: Subject stands on a soft foam surface with both feet on the ground. Therapist attempts to perturb patient balance in random fashion. Exercise dosage/progression: The duration of the activity is approximately 30 seconds. The difficulty is progressed as the subject improves by progressing to ball catching with therapist perturbing subject’s balance while standing on foam and progressing to single-leg support if tolerated without knee pain, swelling, or buckling.
  2. Tilt board Balance Training: The subject stands on a tilt board or balance board with both feet on the board. The therapist perturbs the tilt board in forward and backward and side-to-side directions for approximately 30 seconds each. Exercise dosage/progression: The difficulty of the activity is progressed by adding ball catching during the perturbations and progressing to single-limb support perturbations if the subject tolerates single-limb weight bearing without knee pain, swelling, or buckling.
  3. Roller board and Platform Perturbations: The subject stands with one limb on a stationary platform and the other limb on a roller board. Therapist perturbs roller board in multiple directions, at random, and the subject attempts to resist the perturbations. The activity lasts approximately 30 seconds. The activity is repeated by changing the limbs on the platform and the roller board. Exercise dosage/progression: The activity may begin with subject in the semi-seated position, with hips resting on plinth if the subject has difficulty doing the activity in full standing. The activity is progressed to the full standing position when the subject is able to tolerate this position without pain.

The video below shows use of perturbation activities for ankle instability

[17]

Outcome Measures[edit | edit source]

Studies that reflected balance improvement used outcome measures such as Berg Balance Scale, ABC, miniBESTest, and force plate center of pressure[1].

The goal for participants is to achieve improved control of reactive stepping (eg, faster reaction time). One method of assessing reactive balance is called the Lean-and-Release test, which simulates a forward fall in a safe environment.[18]

Push and Release test: Assesses postural instability and may assist in identifying patients with balance impairments before they experience a fall.

References[edit | edit source]

  1. 1.0 1.1 Coelho DB, de Oliveira CEN, Guimarães MVC, Ribeiro de Souza C, dos Santos ML, de Lima-Pardini AC. A systematic review on the effectiveness of perturbation-based balance training in postural control and gait in Parkinson’s disease. Physiotherapy. 2022;116:58–71.
  2. McCrum C, Gerards MHG, Karamanidis K, Zijlstra W, Meijer K. A systematic review of gait perturbation paradigms for improving reactive stepping responses and falls risk among healthy older adults. European review of aging and physical activity. 2017;14(1):3–3.
  3. Klamroth S, Steib S, Devan S, Pfeifer K. Effects of Exercise Therapy on Postural Instability in Parkinson Disease: A Meta-analysis. Journal of neurologic physical therapy. 2016;40(1):3–14.  
  4. 4.0 4.1 4.2 Gerards MH, Marcellis RG, Poeze M, Lenssen AF, Meijer K, de Bie RA. Perturbation-based balance training to improve balance control and reduce falls in older adults–study protocol for a randomized controlled trial. BMC geriatrics. 2021 Dec;21(1):1-2.https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-01944-7 (accessed 14.4.2021)
  5. Denissen S, Staring W, Kunkel D, Pickering RM, Lennon S, Geurts AC, et al. Interventions for preventing falls in people after stroke. Cochrane database of systematic reviews. 2019;2019(10):CD008728–CD008728.  
  6. Avril Mansfield, Jennifer S. Wong, Jessica Bryce, Svetlana Knorr, Kara K. Patterson, Does Perturbation-Based Balance Training Prevent Falls? Systematic Review and Meta-Analysis of Preliminary Randomized Controlled Trials, Physical Therapy, Volume 95, Issue 5, 1 May 2015, Pages 700–709, Available from: https://academic.oup.com/ptj/article/95/5/700/2686424 (last accessed 29.4.2019)
  7. Rhon D, Deyle G, Gill N, Rendeiro D. Manual physical therapy and perturbation exercises in knee osteoarthritis. Journal of Manual & Manipulative Therapy. 2013 Nov 1;21(4):220-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822322/ (last accessed 1.5.2019)
  8. Diracoglu D, Aydin R, Baskent A, Celik A. Effects of kinesthesia and balance exercises in knee osteoarthritis. JCR: Journal of Clinical Rheumatology. 2005 Dec 1;11(6):303-10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16371799 (last accessed 1.5.2019)
  9. Mattacola CG, Dwyer MK. Rehabilitation of the ankle after acute sprain or chronic instability. Journal of athletic training. 2002 Oct;37(4):413. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164373/ (last accessed 1.5.2019)
  10. Bellows R, Wong CK. THE EFFECT OF BRACING AND BALANCE TRAINING ON ANKLE SPRAIN INCIDENCE AMONG ATHLETES: A SYSTEMATIC REVIEW WITH META-ANALYSIS. International journal of sports physical therapy. 2018 Jun;13(3):379. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164373/ (last accessed 1.5.2019)
  11. Mansfield A, Peters AL, Liu BA, Maki BE. Effect of a Perturbation-Based Balance Training Program on Compensatory Stepping and Grasping Reactions in Older Adults: A Randomized Controlled Trial. Physical therapy. 2010;90(4):476–91.  
  12. Shimada H, Obuchi S, Furuna T, Suzuki T. New intervention program for preventing falls among frail elderly people: the effects of perturbed walking exercise using a bilateral separated treadmill. American journal of physical medicine & rehabilitation. 2004;83(7):493–9.  
  13. Schinkel-Ivy A, Huntley AH, Aqui A, Mansfield A. Does Perturbation-Based Balance Training Improve Control of Reactive Stepping in Individuals with Chronic Stroke? Journal of stroke and cerebrovascular diseases. 2019;28(4):935–43.  
  14. Klamroth S, Gaßner H, Winkler J, Eskofier B, Klucken J, Pfeifer K, et al. Interindividual Balance Adaptations in Response to Perturbation Treadmill Training in Persons With Parkinson Disease. Journal of Neurologic Physical Therapy. 2019;43(4):224–32.
  15. Coelho DB, de Oliveira CEN, Guimarães MVC, Ribeiro de Souza C, dos Santos ML, de Lima-Pardini AC. A systematic review on the effectiveness of perturbation-based balance training in postural control and gait in Parkinson’s disease. Physiotherapy. 2022;116:58–71.  
  16. Jo La Kasa del Noh. Balance and pertubations. Available from: https://www.youtube.com/watch?v=zX9o7CfusqM (last accessed 29.4.2019)
  17. Union phyiotherapy. Ankle stability. Available from: https://www.youtube.com/watch?v=JhQnWHmaXpg (last accessed 1.5.2019)
  18. Unger J, Chan K, Scovil CY, Craven BC, Mansfield A, Masani K, Musselman KE. Intensive balance training for adults with incomplete spinal cord injuries: protocol for an assessor-blinded randomized clinical trial. Physical therapy. 2019 Apr 1;99(4):420-7.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6438350/(accessed 14.4.2021)