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Chapter Objectives

Upon completion of this chapter, the learner should be able to:

  1. Recognize and describe the pathophysiology of balance impairment including the influence of aging.

  2. Design a balance intervention plan that is customized for a specific patient and his stage of disease or recovery.

  3. Design a balance intervention plan that addresses identified underlying impairments of body structure/body function.

  4. Implement a balance intervention plan including intentional progressive demand through advancing functional activities.


Fawn, age 17 years, was very athletic and active in her school before the accident. She now has a medical diagnosis of traumatic brain injury. She was the passenger in a motor vehicle accident and was not wearing her seat belt when her friend, the driver of the car, ran a stop sign. Her side of the car was hit by a city bus going 45 miles per hour. She was thrown from the car, sustained a closed head injury, and was unconscious for 3 days with an initial Glasgow Coma Scale (GCS) score of 7. Computed tomography scans revealed a subdural hematoma in the left parietal area, with cerebral contusions and scattered subarachnoid hemorrhages over the posterior aspects of the frontal lobe and the anterior aspects of the parietal lobe on the left, and focal hemorrhagic lesions of the deep cerebral white matter (corona radiata and internal capsule) on the left and the anterior surface of the brainstem on the left, particularly the cerebral peduncle, pons, and pyramids. With this damage, motor impairments are certain, with expected decreases in Fawn’s balance.

Balance, as described in more detail in Chapter 9, is the ability to maintain physical equilibrium or stability in an upright posture; it is pervasive across higher human physical functioning. Postural control, a related term, is defined by Horak (1987, p.1881) as “the ability to maintain equilibrium in a gravitational environment.” Upright balance can also be described using terms from the field of physics: A stable object is physically in equilibrium, with balanced interactions between all parts and the environment. With the upright human body, balance occurs by avoiding leaning too far forward, too far back, or too far to either side, with balanced use of lower extremity muscles to maintain the body over the points of support. Balance or postural control is an essential part of every upright skill we perform. We depend on balance to keep the body upright during a wide variety of functional tasks, ranging from simple, quiet standing to standing against extreme external disturbances. Whether sitting or standing, balance can be observed in every social setting. The postural adjustments used to maintain balance range from the nearly imperceptible to the extremely obvious.

The term balance can describe a process/action or a state or outcome. The concept of balance is sometimes described using other terms. Postural balance and postural control are more ...

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