Examination and Evaluation of Impaired Balance
The key elements of a comprehensive evaluation of individuals with balance problems include the following.
A thorough history of falls (whether onset of falls is sudden versus gradual; the frequency and direction of falls; the environmental conditions, activities, and presence of dizziness, vertigo, or lightheadedness at time of the fall; current and past medications; presence of fear of falling)
Assessments to identify sensory input (proprioceptive, visual, vestibular), sensory processing (sensorimotor integration, anticipatory and reactive balance control), and biomechanical and motor (postural alignment, muscle strength and endurance, joint ROM and flexibility, motor coordination, pain) impairments contributing to balance deficits
Tests and observations to determine the impact of balance control system deficits on functional performance
Environmental assessments to determine fall risk hazards in a person's home.25
Commonly used tests and measures for each of the three categories of balance assessment described in the Guide to Physical Therapist Practice5 are presented in Table 8.3. Clinicians should carefully select a variety of tests and measures that assess all of the various types of balance control.
TABLE 8.3Balance Assessments and Interventions ||Download (.pdf) TABLE 8.3 Balance Assessments and Interventions
|Category of Assessment ||Clinical Tests/Measures ||Interventions if Deficits Present |
|I. Balance* |
|Static ||Observations of patient maintaining different postures; Romberg Test110; sharpened (tandem) Romberg110; Single-Leg Stance Test154 Stork Stand Test 74 || |
Vary support surface
Incorporate external loads
|Dynamic ||Observations of patient standing or sitting on unstable surface or performing postural transitions and functional activities; Five-times-sit-to-stand Test (5 × STS)32 || |
Moving support surfaces
Move head, trunk, arms, legs
Transitional and locomotor activities
|Anticipatory (feedforward) ||Observations of patient catching ball, opening doors, lifting objects of different weights; Functional Reach Test37; Multidirectional Reach Test111; Star Excursion Balance Test114 || |
|Reactive (feedback) ||Observation of patient's responses to pushes (small or large, slow or rapid, anticipated and unanticipated); Pull Test101; Push and release Test (PRT)72; Postural Stress Test164 || |
|Sensory organization ||Clinical Test of Sensory Integration on Balance Test (CTSIB) also called the "Foam and Dome" Test135 || |
Reduce visual inputs
Reduce somatosensory cues
|II. Balance during functional activities* ||Tinetti Performance-Oriented Mobility Assessment (POMA)144; Timed Up and Go Test (TUG)118; Berg Balance Scale (BBS)10; Four Square Step Test (4SST)33; Dynamic Gait Index (DGI)137; Functional Gait Assessment (FGA)167; Community Balance and Mobility Scale65; High Level Mobility Assessment (HiMat)160; Dizziness Handicap Inventory (DHI)73 || |
Dual or multitask activities (e.g., walking with secondary cognitive or motor task)
|III. Safety during gait, locomotion, or balance* ||Observations; home assessments; Activities-Specific Balance Confidence (ABC) Scale120; Falls Efficacy Scale145 ||Balance within stability limits; environmental modifications; assistive devices; external support |
Static balance can be assessed by observing the patient's ability to maintain different postures.
The Romberg Test110 tests the patient's ability to stand with the feet parallel and together with the eyes open and then closed for 30 seconds..
The sharpened Romberg, also known as the tandem Romberg,110 requires the patient to stand with the feet in a heel-to-toe position with arms folded across the chest and eyes closed for one minute.
The Single-Leg Balance Stance Test154 (SLB) asks the patient to stand on one leg without shoes with arms placed across the chest without letting the legs touch each other. Five 30-second trials are performed for each leg, with a maximum possible score of 150 seconds per leg. The SLB is reliable and has been found to predict injurious falls in community-dwelling elderly154 and ankle sprains in athletes.148
The Stork Stand Test74 is performed by having the patient stand on both feet with hands on the hips, then lift one leg and place the toes of that foot against the knee of the other leg. On command from the tester, the patient then raises the heel to stand on the toes and tries to balance for as long as possible without letting either the heel touch the ground or the other foot move away from the knee. Normal adults should be able to balance for 20 to 30 seconds on each leg.
Dynamic balance control can be assessed by observations of how well the patient is able to stand or sit on unstable surfaces (e.g., foam or Swiss ball), transition from one position to another (e.g., supine-to-sit or sit-to-stand transfers), and perform activities such as walking, jumping, hopping, and skipping.
The Five-times-sit-to-stand test (5 × STS) can be used to evaluate balance control when moving between sitting and standing.32 The person is seated in a chair with the arms across the chest and then stands up and sits back down as quickly as possible five times consecutively while being timed. A score of >15 seconds on the 5 × STS was found to predict recurrent falls (sensitivity 55%, specificity 65%) in 2,735 community-dwelling elderly individuals.17
Anticipatory Postural Control Tests
Anticipatory postural control is evaluated by having the patient perform voluntary movements that require the development of a postural set to counteract a predicted postural disturbance. The patient's ability to catch balls, open doors, lift objects of different weights, and reach without losing balance is indicative of adequate anticipatory control.
The Functional Reach Test37 and the Multi-Directional Reach Test111 require the patient to reach in different directions as far as possible without changing the BOS. Normative data are available, and the tests are reliable and valid.111
The Star Excursion Balance Test is a test of lower extremity reach that challenges an individual's limits of stability.114 The patient is instructed to reach as far as possible with one leg in each of eight prescribed directions while maintaining balance on the contralateral leg. The test is reliable56,78 and can detect deficits in individuals with chronic ankle instability.57,114
Reactive Postural Control Tests
Automatic postural responses or reactive control can be assessed by the patient's response to external perturbations.
Pushes (small or large, slow or rapid, anticipated and unanticipated) applied in different directions to the sternum, posterior trunk, or pelvis are used widely, but they are not quantifiable or reliable. The clinician subjectively rates the responses as normal, good, fair, poor, or unable.
The Pull Test,101 Push and Release Test,72 and Postural Stress Test164 are more objective and reliable measures of reactive postural control.
Sensory Organization Tests
The Clinical Test of Sensory Integration on Balance Test (CTSIB), also called the "Foam and Dome" Test,135 measures the patient's ability to balance under six different sensory conditions.
Standing on a firm surface with the eyes open (visual, somatosensory, and vestibular information accurate);
Standing on a firm surface with the eyes closed (somatosensory and vestibular information accurate);
Standing on a firm surface wearing a dome made from a modified Japanese lantern (somatosensory and vestibular information accurate, visual information inaccurate);
Standing on a foam cushion with the eyes open (visual and vestibular information accurate, somatosensory inaccurate);
Standing on foam with the eyes closed (vestibular information accurate, somatosensory information inaccurate); and
Standing on foam wearing the dome (vestibular information accurate, somatosensory and visual information inaccurate).
The patient stands with feet parallel and arms at sides or hands on hips. A minimum of three 30-second trials of each condition are performed.
Individuals who rely heavily on visual inputs for balance (i.e., visual dependent) will become unstable or fall in conditions 2, 3, 5, and 6.
Those who rely heavily on somatosensory inputs (i.e., surface dependent) show deficits with conditions 4, 5, and 6.
With generalized adaptation problems, individuals are unstable in conditions 3, 4, 5, and 6.
Individuals with vestibular loss are very unstable in conditions 5 and 6.
NOTE: A computerized version of the CTSIB using a moveable force plate and visual surround is called the Sensory Organization Test (SOT).105
Functional tests are used to determine activity limitations and participation restrictions and to identify tasks that a patient needs to practice. Three mobility scales (i.e., Tinetti Performance-Oriented Mobility Assessment [POMA],144 Timed Up and Go Test [TUG],118 Berg Balance Scale,10 Four Square Step Test [4SST33]), and two gait scales (i.e., Dynamic Gait Index137 and Functional Gait Assessment167) can be easily used to assess balance performance during functional activities. Most of these tests were designed to assess fall risk in the elderly, with the exception of the Functional Gait Assessment, which was developed specifically for use with patients with vestibular disorders. The Community Balance and Mobility Scale65 and the High Level Mobility Assessment Tool (HiMAT)160 can be used to evaluate balance and mobility in people who are ambulatory and functioning at a high level, yet have some balance deficits. The 25-item Dizziness Handicap Scale is a questionnaire that can evaluate the self-perceived impact of dizziness and unsteadiness on functional activities in people with vestibular disorders.73
There are many factors to consider when developing an intervention program for balance impairments. Most balance intervention programs require a multisystem approach. For example, an individual who has experienced prolonged bed rest or inactivity following an illness may require a program that includes stretching the lower extremities and trunk to improve postural alignment and mobility; strengthening exercises to improve motor performance; and dynamic, functional balance activities to improve the ability to perform daily activities safely. The following elaborates on the interventions suggested previously (see Table 8.3), which are based on identified deficits in static, dynamic, anticipatory, and reactive control as well as problems involving sensory organization, function, and safety. For specific procedures to address musculoskeletal problems such as strength, joint mobility, flexibility, or posture, refer to the chapters addressing these interventions or to chapters focused on specific regions of the body.
Because balance training often involves activities that challenge the patient's limits of stability, it is important that the therapist takes steps to ensure the patient's safety. Box 8.3 lists safety measures that should be considered and utilized to prevent falls and injuries during therapy.
BOX 8.3 Safety During Balance Training
Use a gait belt any time the patient practices exercises or activities that challenge or destabilize balance.
Stand slightly behind and to the side of the patient with one arm holding or near the gait belt and the other arm on or near the top of the shoulder (on the trunk, not the arm).
Perform exercises near a railing or in parallel bars to allow patient to grab when necessary.
Do not perform exercises near sharp edges of equipment or objects.
Have one person in front and one behind when working with patients at high risk of falling or during activities that pose a high risk of injury.
Check equipment to ensure that it is operating correctly.
Guard patient when getting on and off equipment (such as treadmills and stationary bikes).
Ensure that the floor is clean and free of debris.
Cognitive deficits can considerably impact the success of balance training programs. If deficits are moderate to severe and a person is unable to follow directions, then performance of specific balance exercises may be unsafe and have limited success. In these cases, repetitive practice of common functional activities is advised.
Activities to promote static balance control include having the patient maintain sitting, half-kneeling, tall kneeling, and standing postures on a firm surface.
More challenging activities include practice in the tandem and single-leg stance (Fig. 8.10), lunge, and squat positions.
Progress these activities by working on soft surfaces (e.g., foam, sand, grass), narrowing the base of support, moving the arms, or closing the eyes.
Provide resistance via handheld weights or elastic resistance (Figs. 8.11 and 8.12).
Add a secondary task (i.e., catching a ball or mental calculations) to further increase the level of difficulty (Fig. 8.13).
Balance during single leg stance.
Balance while standing with resistance provided to the arms via elastic resistance.
Balance while standing with arm abducting and holding a weight.
Balance while standing and catching a ball.
To promote dynamic balance control, interventions may involve the following.
Have the patient maintain equal weight distribution and upright trunk postural alignment while on moving surfaces, such as sitting on a therapeutic ball, standing on wobble boards (Fig. 8.14), or bouncing on a mini-trampoline.
Progress the activities by superimposing movements such as shifting the body weight, rotating the trunk, moving the head or arms (Fig. 8.15).
Vary the position of the arms from out to the side to above the head (Fig. 8.16).
Practice stepping exercises starting with small steps, then mini-lunges to full lunges.
Progress the exercise program to include hopping, skipping, rope jumping, and hopping down from a small stool while maintaining balance.
Have the patient perform arm and leg exercises while standing with normal stance, tandem stance, and single-leg stance (Fig. 8.17).
Balance while standing on wobble boards.
Balance while standing on wobble boards with arm movements.
Balance while standing on wobble boards with arms above the head.
One-legged stance with resisted shoulder extension using elastic resistance.
Anticipatory Balance Control
Practice anticipatory balance control by performing the following.
Reach in all directions to touch or grasp objects, catching a ball, or kicking a ball.
Use different postures for variation (e.g., sitting, standing, kneeling) and throwing or rolling the ball at different speeds and heights (Fig. 8.18).
Use functional tasks that involve multiple parts of the body to increase the challenge to anticipatory postural control by having the patient lift objects of varying weight in different postures at varying speeds, open and close doors with different handles and heaviness, or maneuver through an obstacle course.
Balance when standing while reaching and catching the ball overhead.
Train reactive balance control by using the following activities.
Have the patient work to gradually increase the amount of sway when standing in different directions while on a firm stable surface.
To emphasize training of the ankle strategy, have the patient practice while standing on one leg with the trunk erect.
To emphasize training of the hip strategy, have the patient walk on balance beams or lines drawn on the floor; perform tandem stance and single-leg stance with trunk bending; or stand on a mini-trampoline, rocker balance, or sliding board.
To emphasize the stepping strategy, have the patient practice stepping up onto a stool or stepping with legs crossed in front or behind other leg (e.g., weaving or braiding).
To increase the challenge during these activities, add anticipated and unanticipated external forces. For example, have the patient lift boxes that are identical in appearance but of different weights; throw and catch balls of different weights and sizes; or while on a treadmill, suddenly stop/start the belt or increase/decrease the speed.
Many of the activities previously described can be utilized while varying the reliance on specific sensory systems.
To reduce or destabilize the visual inputs, have the patient close the eyes, wear prism glasses, or move the eyes and head together during the balance activity.
To decrease reliance on somatosensory cues, patients can narrow the BOS, stand on foam, or stand on an incline board.
Balance During Functional Activities
Focus on activities similar to the functional limitations identified in the evaluation. For example:
If reaching is limited, have the patient work on activities, such as reaching for a glass in a cupboard, reaching behind (as putting arm in a sleeve), or catching a ball off center.
Perform two or more tasks simultaneously to increase the level of task complexity.
Practice recreational activities the patient enjoys, such as golf, to increase motivation while challenging balance control (Fig. 8.19).
Functional balance during a golf swing.
Safety During Gait, Locomotion, or Balance
To emphasize safety, have the patient practice postural sway activities within the person's actual stability limits and progress dynamic activities with emphasis on promoting function. If balance deficits cannot be changed, environmental modifications, assistive devices, and increased family or external support may be required to ensure safety.
Assistive devices, such as rollator walkers, are often appropriately prescribed as a compensatory measure for people with a variety of balance impairments. However, clinicians should be aware that assistive devices that are incorrectly fitted or used by a patient can precipitate falls. Therefore, clinicians must properly adjust and provide instruction on proper use of assistive devices to prevent unnecessary falls.
Health and Environmental Factors
In addition to exercise and balance training activities, clinicians should address several other factors affecting balance to reduce the risk of falls.87
To address low vision issues, encourage regular eye examinations with adjustments to lens prescriptions and cataract surgery, if necessary. Wearing a hat and sunglasses in bright sunlight, taking extra precautions when it is dark, and making sure lights are on when walking about the house at night are other recommendations. Advise patients to avoid using bifocal glasses when walking, because single lens glasses are safest for improving depth perception and contrast sensitivity, especially on stairs.86
For individuals with sensory loss in the legs, caution them to take extra care when walking on soft carpet or uneven ground and use a cane or other device if necessary. Recommend that they wear firm rubber shoes with low heels. Regular medical examinations should be encouraged to ensure that a patient's blood glucose levels and other factors (i.e., cholesterol, lipids) are under control to minimize damage to sensory nerves from diseases such as diabetes and peripheral vascular disease. Advise patients to seek medical attention if they experience any symptoms of dizziness.
Patients should be educated about the influence of certain medications, such as sedatives and antidepressants, on their risk of falling. For example, if such medications are used at night as a sleep aid, an individual should take extra precautions when getting up to use the bathroom.
Evidence-Based Balance Exercise Programs for Fall Prevention in the Elderly
Mounting evidence from randomized clinical trials indicates that therapeutic exercise is an effective tool in the prevention of falls, especially if it is incorporated with a comprehensive strategy targeting health, environmental, and behavioral risk factors that contribute to falls.48,96 The selection of exercises and activities for balance training should be based on two major factors: the person's fall risk and the setting in which the training will take place. Economic and transportation factors also play a role in these decisions. Since people can fall while participating in balance training and exercise programs, it is critical that adequate protections are in place to prevent falls. Based on these issues, the following guidelines are proposed.
Elderly individuals who have no history of falls and do not have scores that are within the "at risk" category on standardized balance tests should participate in an individual or community-based group exercise program incorporating muscle strengthening, balance, and coordination exercises.
Individuals who are at risk of falls, based on standardized balance tests, but have not developed a history of falls should participate in individual or group exercise programs in which there are well-trained leaders and support staff who appropriately supervise and guard the person during the activities that challenge balance.
People who are at risk of falls and have a history of falls require an individually tailored, supervised, exercise program by a physical therapist or physical therapist assistant and, if appropriate, a caregiver who is trained to supervise and guard the person during the home exercise activities. This program may take place in a clinic- or home-based setting.
According to current best evidence, an exercise program to reduce risk of falls should include at least 50 hours devoted to exercises and activities to improve balance.131 This might be in the form of a 1-hour group exercise program twice a week for 26 weeks. A more intensive program may consist of 1-hour of balance training three times a week that is supplemented with a 30-minute daily home exercise program for 8 to 10 weeks. Although walking has many health benefits, the time devoted to a walking exercise program should be in addition to time spent in balance training and not a substitute for it.
Home Exercise Program for Reducing Risk of Falls for People at High Risk
The home setting may be the best option for an exercise-based falls prevention program for some people who are at high risk of falls. Reasons why the home may be the best location for such a programs include: 1) the person functions most often in this environment, therefore, the training takes place in the location where falls are most likely to occur; and 2) the person may participate more fully to his or her physical capacity without the stress and fatigue that may be associated with transportation issues.
Otego Home Exercise Program
The Otego Exercise Program21,44,125 is a cost-effective program for reducing falls for people aged 80 and over. This program consists of an individually tailored, 30-minute leg strengthening and balance training program that is performed at home at least three times per week and is complemented with a walking plan. The program is designed to be performed for 24 weeks under the supervision of physical therapists or health professionals trained by physical therapists.44
The patient receives a booklet with illustrations and instructions on each exercise.
Ankle weights are used to provide resistance during the leg strengthening exercises that target the muscles that extend and abduct the hip and flex and extend the knee.44
The amount of resistance should be based on the amount of weight that the person can lift for 8 to 10 repetitions of the exercise before fatiguing. Most people start with 1 or 2 kg (2.2 or 4.4 lb) cuff weights.
The goal is for the person to be able to do two sets of 10 repetitions before the amount of weight is increased.
The ankle dorsiflexor and plantarflexor muscles are strengthened using body weight as the resistance (Fig. 8.20 and Fig. 8.21).
Box 8.4 provides a list of the strengthening exercises in the Otego program.
The balance training component of the Otego Exercise Program is also tailored to the individual and emphasizes dynamic exercises that are closely related to functional activities (Fig 8.22).44 Depending on the ability of the individual, the balance exercises may be performed by holding on to a large, stable piece of furniture or a kitchen counter and progressed by performing the exercises without support (Fig 8.23). Balance training exercises are listed in Box 8.4.
A walking program is part of the Otego Exercise Program.44 People are told to walk for at least 30 minutes per day at their usual pace. The walking plan may be accomplished by taking walks of smaller intervals (e.g., 10 minutes) throughout the day.
Rising up on toes to strengthen plantarflexors.
Rocking back onto the heels while raising the toes to strengthen dorsiflexors.
Practicing the sit-to-stand transfer is an important functional activity to strengthen the legs and improve dynamic balance.
Tandem walking (A) performed with light touch on a firm surface for support; and (B) performed without external support. Note that the therapist closely guards the patient for safety.
BOX 8.4 The Otego Home Exercise Program44 Lower Extremity Strengthening
With person sitting in a hard, straight-back chair:
Perform 5 minutes of active, gentle warm-up exercises to minimize soreness*.
Add appropriate ankle cuff weight and have patient perform unilateral knee extension.
Repeat for the opposite leg.
With person in standing, use a counter or heavy furniture to support as needed.
Add appropriate ankle weight and have patient perform unilateral knee flexion. Repeat for the opposite leg.
Adjust cuff weight if necessary and have patient perform unilateral hip abduction. Repeat for the opposite leg.
Raise up on toes to strengthen ankle plantarflexors.
Rock back on heels for ankle dorsiflexors.
Knee bends—10 repetitions**
Backward walking—10 steps, 4 times
Walking and turning around—Make figure of "8," 2 times
Sideways walking—10 steps, 4 times
Tandem stance—10 seconds
Tandem walk—10 steps, 2 times
Heel walking—10 steps, 4 times
Toe walking—10 steps, 4 times
Sit to stand—5 stands with two hands, 5 stands with one hand or 10 stands with two hands, 10 stands with one hand, 10 stands with no support, 10 stands with no support repeated
Supervised Group Program Incorporating Strengthening, Walking, and Functional Activities
A recent systematic review of the literature concluded that multimodal exercise programs incorporating muscle strengthening, gait, balance, coordination and functional exercises led to greater beneficial effects on balance than usual exercise programs, at least in the short-term.66 There was limited evidence for long-term effectiveness. Most exercise programs lasted 3 months and met three times per week for 1 hour.
FOCUS ON EVIDENCE
One example of a supervised group program comes from a study by Means and colleagues96 that investigated the effects of a program designed to improve balance in community-residing elders with or without a history of falls. The program incorporated activities such as stretching, strengthening, coordination exercises, body mechanics, balance training, survival training maneuvers, and walking for endurance. The participants attended 90-minute exercise sessions three times per week in groups of six to eight. The exercises were performed under the direction of a physical therapist. Initially, participants were encouraged to exercise at a "fairly light" level (equal to 11 on the 6- to 20-point Borg perceived exertion scale12). After the first week, participants were encouraged to exercise at a level of intensity that was "somewhat hard" (equal to 13 on the Borg scale). The participants who attended this 6-week comprehensive exercise program showed a reduction in the time to complete an obstacle course (e.g., walking, climbing stairs, opening doors, getting up from a chair, stepping over objects) and in the number of fall and fall-related injuries for up to 6 months after participation.
Box 8.5 provides general guidelines for exercise repetitions, duration of endurance walking, and progression of a supervised group program.96
BOX 8.5 Balance Exercise Program Incorporating Strengthening, Walking, and Functional Activities96 Week 1
Flexibility exercises (5 repetitions, 15-second hold)
Gluteus maximus and hip flexor stretch
Gastrocnemius and soleus stretch
Strengthening exercises (baseline determination of preferred elastic-band strengths for lower limb exercises—1 repetition maximum)
Lower limb muscles (elastic band: 1 set of 8–10 repetitions for each leg)
Quadriceps (sitting and straight-leg raises)
Upper limb muscles (5–10 repetitions)
Abdominal muscles (5 repetitions)
Curl-ups with arms behind head Instruction in body mechanics for:
Arising from floor
Baseline walking evaluation (determine maximum comfortable distance) Week 2
Flexibility exercises (as above)
Strengthening exercises: lower limb muscles (elastic band: 1 set of 10 repetitions, each leg), upper limb muscles (10 repetitions), abdominal muscles (5–10 repetitions)
Postural exercises (10 repetitions, 10-second hold)
Head and neck
Trunk Coordination exercises
Reciprocal leg movements (10 repetitions, eyes closed)
Bridging (10 repetitions)
Sitting/standing (5 repetitions)
Braiding exercises (2 repetitions)
Reciprocal ankle motion (10 repetitions)
Rung ladder: forward stepping (2 repetitions) "Survival" maneuvers
Floor recovery exercises—"how to get up if you should fall"
Ascending and descending stairs safely (individual practice)
Endurance walking (begin at 75%–100% of baseline minutes walked; increase at comfortable pace) Week 3
Flexibility exercises (5 repetitions, 20-second hold)
Strengthening exercises: lower limb (2 sets of 10 repetitions), upper limb (push-ups, 10–15 repetitions), abdominals (curl-ups, 10–15 repetitions)
Postural exercises (15 repetitions, 10-second hold)
Coordination exercises (repetitions increased)
Survival maneuvers: practice (floor recovery/stairs)
Endurance walking (0–6 minutes, comfortable pace) Week 4
Flexibility exercises (5 repetitions, 25-second hold)
Strengthening exercises: lower limb (2–3 sets of 10 repetitions), upper limb (push-ups, 15 repetitions), abdominals (curl-ups, 15 repetitions)
Postural exercises (20 repetitions, 10-second hold)
Coordination exercises (repetitions increased)
Reciprocal legs (eyes closed)
Braiding (no holding, eyes open)
Rung ladder (forward, side, and backward stepping)
Survival maneuvers: practice (floor recovery/stairs)
Endurance walking (3–8 minutes, comfortable pace) Week 5
Flexibility exercises (5 repetitions, 30-second hold)
Strengthening exercises: lower limb (3 sets of 10 repetitions), upper limb (push-ups, 15–20 repetitions), abdominals (curl-ups, 15–20 repetitions)
Postural exercises (25 repetitions, 10-second hold)
Coordination exercises: as above with increased repetitions, plus: Braiding (no holding, eyes closed)
Reciprocal ankle dorsi/plantar flexion (25 repetitions)
Survival maneuvers: practice (floor recovery/stairs)
Endurance walking (6–10 minutes, comfortable pace) Week 6
Flexibility exercises (5 repetitions, 30-second hold)
Strengthening exercises: lower limb (3 sets of 10 repetitions), upper limb (push-ups, 20 repetitions), abdominals (curl-ups, 15–20 repetitions)
Postural exercises (25 repetitions, 10-second hold)
Coordination exercises (as above with increased repetitions)
Endurance walking (8–12 minutes, comfortable pace)
Survival maneuvers: practice (floor recovery/stairs)
Multisystem Group Exercise Program Incorporating a Circuit of Activities to Address Balance Impairments and Function
Nitz and Choy112 investigated the efficacy of a balance training program that integrated individual and group exercises targeting strength, coordination, sensory systems (vision, perception, vestibular), cognition, reaction time, and static and dynamic stability. Community-residing elderly individuals with a recent history of falls were randomly assigned to two groups. One group participated in the balance training program that addressed multisystem activities. The control group participated in a more traditional group exercise program. Participants in both groups received an educational booklet on how to prevent falls in the home and attended a 1-hour exercise session once a week for 10 weeks. The exercises were led by a physical therapist assisted by one or two students when small group activities (six participants per group) were performed.
After the intervention, both groups reported a reduction in the number of falls. The reduction in falls was greater in the group that performed the circuit training program; they also showed greater improvements in functional tests of the ability to perform activities of daily living. Although the circuit training program devised by Nitz and Choy112 clearly incorporates many important activities to address multiple systems affecting balance, the results should be interpreted with caution, because there was a small sample size and a high proportion of dropouts throughout the study.
Table 8.4 provides the details of the balance exercise program, consisting of circuit training and group activities, from the Nitz and Choy study.112
TABLE 8.4Circuit Training Program to Address Balance Impairments and Function112 ||Download (.pdf) TABLE 8.4 Circuit Training Program to Address Balance Impairments and Function112
|Activity ||Responses targeted ||Progression of Activity |
|Sit-to-stand-to-sit || |
Lower limb strength
Lower the height of the chair.
Add/remove upper limb assistance.
Hold an item in the hands, balance a cup with/without water on a saucer/tray.
Add a cognitive task to the manual task.
|Stepping in all directions (forward, side, and back) || |
Choice step reaction time
Lower limb strength and coordination
Increase speed of step.
Perform stepping on a soft surface.
|Reaching to limits of stability || |
Challenging limits of stability
Vestibular stimulation and integration
Upper and lower limb strengthening
Stick objects on a wall in the front by reaching to limits in all directions up and down while keeping feet in one position.
Lunge forward to pick up objects that are shifted to a high shelf to the side and behind, progress by reaching further and increasing the weight and size of objects.
|Step up and down || |
Lower limb strengthening and endurance
Step reaction time
|Step up forward, backward, and sideways over blocks of various heights; increase height, repetitions, and speed of stepping. |
|Ankle, hip, and upper limb balance strategy practice || |
Lower limb strengthening
Balance strategy training
|Stand in front of a wall with toe touching a line 0.5 meter from the wall. Lean back toward the wall, keeping balance and dorsiflexing the feet and using arm movement to balance while lowering toward the wall. |
|Sideways reach task || |
Mediolateral muscle strengthening in lower limbs
Vestibular stimulation and integration
Challenging limits of stability
Multiple tasks and confounded proprioceptive input
Stand between a high and a low table positioned on either side; pick up objects from one table and transfer to other table.
Move the tables farther apart and increase the weight and size of the objects to increase the challenge.
Perform task while standing on an exercise mat on the floor.
|Ball games || |
Ballistic upper and lower limb activity
Use inflated beach balls and progress to smaller or harder balls or two or three balls at once.
Add a cognitive task such as naming an animal that starts with a G, while throwing and catching or kicking the ball.
|Card treasure hunt/sort into suits || |
Coping strategies with visual conflict
Vestibular stimulation and challenge of limits of stability
Prior to the session, hide playing cards in the room such that to collect the cards the participants have to bend and look under furniture, reach up high, or detect the card from a visually confounding background. Red and black teams are possible and the team with the most cards returned to a collecting point inside 5 minutes is the winner.
Add the cognitive challenge of finding/sorting cards into order according to suit.
Tai Chi for Balance Training
Tai Chi has become a popular form of exercise for balance training. Tai Chi is a traditional Chinese exercise program consisting of a sequence of whole-body movements that are performed in a slow, relaxed manner with an emphasis on awareness of posture alignment and synchronized breathing. The four styles of Tai Chi are Yang, Sun, Chen, and Wu, and they differ in terms of principles, forms, and function. Yang style Tai Chi is the most popular and widely practiced style today and consists of 24 forms (postures and movements).88 Tai Chi programs for the elderly may adopt a short form of Tai Chi with only 6 to 12 forms.88 During Tai Chi training, participants learn to control the displacement of the body COM while standing and increase their lower extremity strength and flexibility during the regimens of physical movement.27
Some of the characteristics of Tai Chi exercise and the therapeutic rationale for why Tai Chi may affect posture and balance include the following.157
The slow, continuous, even rhythm of the movements facilitates sensorimotor integration and awareness of the external environment (see Fig. 8.2).
The emphasis on maintaining a vertical posture enhances postural alignment and perception of orientation.
The continuous weight shifting from one leg to the other facilitates anticipatory balance control, motor coordination, and lower-extremity strength.
Finally, the large dynamic, flowing, and circular movements of the extremities promote joint ROM and flexibility (Fig 8.24). These characteristics should be considered when recommending Tai Chi classes to patients to ensure that instructors are following these principles and that the patients are appropriate for these activities.
In this Tai Chi form, the participant shifts the body-weight toward one leg while moving the arms.
FOCUS ON EVIDENCE
The effectiveness of Tai Chi training depends on the duration of the program, which may range from 4 weeks to 1 year, and the targeted populations. Studies have shown that Tai Chi improves standing balance control through performing head, trunk, and arm movements simultaneously with weight shifting.7 Older people living in the community who participated in a Tai Chi group program report a reduced fear of falling compared to those who do not exercise, perhaps because the training leads to an increased self-awareness of balance.7,168 However, Tai Chi training is unlikely to improve dynamic balance during functions such as gait and turning.7,85 This may explain why there is conflicting evidence as to whether Tai Chi reduces falls or the risk of falls among people over the age of 50.85,88 For this reason, Tai Chi should be considered as only one part of a comprehensive fall prevention program rather than being advocated as the sole exercise intervention.
Evidence-Based Balance Exercise Programs for Specific Musculoskeletal Conditions
Evidence is growing that specific balance exercise programs can effectively prevent and/or treat balance control deficits associated with lower extremity and trunk injuries and pathologies.
Several systematic reviews have concluded that balance training programs can improve static and dynamic balance and reduce the risk of ankle sprains in individuals with a history of ankle sprains.58,69,94,158 Successful programs utilized wobble or unstable balance platforms, single-leg stance progressions, and resisted kicks of the uninvolved leg against an elastic band or tubing.38,52,93,99,126,155 Programs typically were conducted for at least three times per week throughout a competitive season for prevention or two to three times per week for approximately 6 to 8 weeks post injury.
FOCUS ON EVIDENCE
A balance program developed by McGuine and Keene93 reduced the risk of ankle sprains by 38% in male (n=112) and female (n=261) high school soccer and basketball players. Participants performed the single-leg stance (Fig. 8.25), progressing from standing on the floor to standing on a wobble board with and without eyes open. They performed the balance activities 5 days a week for the first 5 weeks and then 3 days a week for the rest of the season. Each exercise was performed for a duration of 30 seconds per leg, and legs were alternated during a rest period of 30 seconds between repetitions.
Balance program for reducing the incidence of ankle sprains in athletes using a wobble board: (A) single-leg squat (knee bent 30° to 45°), (B) single-leg stance while rotating the board; and (C) single-leg stance while performing functional activities (i.e., catching a ball).
Anterior Cruciate Ligament Injuries
Proprioceptive and balance training programs either alone or in combination with neuromuscular training that includes lower extremity plyometrics, trunk stabilization, strengthening (refer to Chapter 16), and sport-specific functional training (refer to Chapters 21 and 23) have been shown to reduce risk factors and the incidence of first-time noncontact anterior cruciate ligament (ACL) injuries in athletes.2,115,143 These proprioceptive and balance training programs frequently consisted of double and single leg balance exercises progressing from firm to unstable surfaces, such as ankle disks, tilt boards, or foam, with variations, such as squatting or catching a ball.22, 40, 46, 95 Balance exercises usually were done 10 to 15 minutes daily during preseason training and 3 times a week during the season for prevention.
A balance training program developed by Fitzgerald and colleagues41 that consisted of multidirectional perturbations manually applied by a therapist while a person stood with one or two legs on tilt or roller boards increased the likelihood by almost five times that a person with acute anterior cruciate ligament injury or ruptures of anterior ligament grafts would return to high-level physical activity compared to those that received a standard program. Treatment in this study was done two to three sessions per week for a total of 10 sessions.
Research indicates that proprioceptive or balance training may improve postural control in individuals with low back pain.20,39,92,149,150 Specific spinal stabilization exercises consisting of voluntary contractions of deep abdominal muscles reduced pain and disability92 and produced immediate and long-term improvements in feedforward postural adjustments in people with chronic nonspecific low back pain (refer to Chapters 15 and 16).149,150
Cacciatore and associates20 studied the effects of a 6-month, once a week course of 20 lessons in the Alexander Technique (AT), a technique that addresses anticipatory postural adjustments through conscious control of tonic muscular activity, on postural coordination and back pain in a 49-year-old woman with a 25-year history of left-sided, idiopathic low back pain. Before the AT lessons, the patient consistently had asymmetrical automatic postural responses to horizontal force platform movements and poor ability to balance on the left leg. Following the lessons, she had improved postural responses, better standing balance, and decreased low back pain.