Balance

1
Balance Its Functional Role in Rehabilitation
Gait

• Sally Paulson Ph.D., ATC, CSCS
• Shippensburg University

2
Objectives

• Review balance what might affect balance
• Present literature related to the role of balance
  in rehabilitation gait
• Provide examples of static and dynamic exercises
  assessments

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What is balance?

• Balance is the means in which individuals
  maintain their body position while stationary or
  mobile in relationship to the environment
• Balance requires input from
• Visual system
• Vestibular system
• Proprioception
• Muscular strength, endurance flexibility
• CNS control balance through motor commands

Arnheim Sinclair, 1985 Auxter et al., 2005
Clark, 2004 Anderson Behm, 2004 Arnheim
Sinclair, 1985 Dieterich, 2004 Houglum, 2005
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Balance is affected by

• Muscular strength
• Fatigue of the LE muscles occurs earlier due to
  inadequate strength
• This can result in diminished coordination
• With age strength decreases, which results in a
  decline in balance (Martin Morgan, 1992 Syed
  Davis, 2000)
• CNS
• Injury to the brain or spinal cord might
  interrupt communication between the body
  part/system the CNS
• Medications
• Blackburn et al., 2000 Carter et al., 2001
  Clark, 2004 Hamilton Luttgens, 2002 Houglum,
  2005 Nitz et al., 2003

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Balance is affected by

• Pathological /or age-related changes to
  vestibular visual systems
• Tai Chi was found to balance improvement via the
  vestibular component of the sensory organization
  test in healthy, elderly subjects (Tsang
  Hui-Chan, 2004)
• Someone with vestibular defect/injury might
  present with
• Gait alterations decreased static balance
• Limited control of the COG within the base of
  support (Krebs et al., 2002)
• Age
• Nitz et al. 2003 concluded that medial-lateral
  balance declines with age in women, especially
  between the ages of 40 60
• Size of the base of support (BOS)
• Smaller BOS requires finer body adjustments to
  maintain balance (Anderson Behm, 2004)

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Balance is affected by

• Injuries to the LE
• Normal alignment stability of the supporting LE
  decreases friction which contributes to the
  smoothness of gait (Sailbene Minetti, 2003)
• May result in inefficient energy expenditure
  during walking or running (Sailbene Minetti,
  2003)
• May lead to the COG to fall outside of the BOS
  increase risk of falling (Blackburn et al., 2000
  Clark, 2004)
• Balance impairments have been related to risk of
  injury /or risk of re-injury
• May damage joint proprioceptors which contribute
  to maintaining balance
• Restoring proprioception following injury
  increases the bodys awareness of joint position
  increase stability orientation during static
  or dynamic movement (Laskowski, et al. 1997)
• Tropp et al. (1984) reported soccer players who
  presented with gt 2 SD above normal on postural
  sway measures had a significantly higher risk of
  injury to the LE
• Hamilton Luttgens, 2002 Hills et al., 2001,
  2002 Houglum, 2005 Martin Morgan, 1992
  Spyropoulos et al., 1991

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Balance is affected by

• Obesity
• McGraw et al. (2000) reported obese boys spent
  significantly greater time in the double support
  phase may have less dynamic static balance
• Thigh mass of obese individuals may be
  disproportional to the rest of the body
• Results in an increase in leg mass affects the
  internal work of the muscles (Martin Morgan,
  1992 Sailbene Minetti, 2003)
• Increase in step width (Hills et al., 2001, 2002)
• Additional mass can alter the position of the
  COG which can lead to falls (Clark, 2004)
• Has been linked to gait changes, pathologies to
  the LE, loss of mobility increases in energy
  expenditure
• Blackburn et al., 2000 Hamilton Luttgens,
  2002 Houglum, 2005 Spyropoulos et al., 1991

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On the Contrary

• McHugh et al. (2006) examined risk factors for
  noncontact ankle sprains in high school athletes
• Measured balance via a tilt board hip strength
• Found balance hip strength were not risk
  factors for noncontact ankle sprains
• However, previous ankle injuries being
  overweight (especially in males) were found to be
  significant risk factors

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Balance Rehabilitation

• Blackburn et al. (2000) found dynamic
  semi-dynamic balance improved in all subjects
  that completed an ankle rehabilitation program
  vs. subjects that did not (control group)
• Rehab programs were (a) strength training, (b)
  proprioception training, (c) strength
  proprioception training

10
Balance Prevention

• Myer et al. (2006) compared plyometric training
  to balance training on LE biomechanics
• Plyometric group
• Exercises included jumps, hops, box drops
  cutting
• Maximal effort
• Balance group
• Addressed dynamic stabilization core
  strengthening
• Focus was on challenging the COG through
  single-leg movements or adding external weight
• Pre/posttest 3D force plate measurements were
  taken while performing (2) tests
• Drop vertical jump (31 cm in height)
• Single-legged medial drop landing task
• Results suggested the both groups demonstrated
  improvements in LE valgus motion
• Drop vertical jump Significant decreases were
  noted in both groups at the hip ankle
• Single-legged medial drop Significant decreases
  at the knee for both groups
• Authors concluded both training programs can
  decrease LE valgus motion however, the
  improvements found were training and task specific

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Balance Gait

• Maintaining balance while walking is a challenge
  for the CNS
• Internal external forces acting on the body
  which the CNS must process (Harris Wertsch,
  1994)
• The body continually moves from a stable body
  position (double support) to an unstable position
  (single support)
• Placement of the swing limb during double support
  is crucial for the CNS to make adjustments to
  maintain balance
• Winter (1991) reported three measures related to
  balance when walking
• (a) toe clearance, (b) the velocity of the heel
  at contact, (c) hip knee moment force
• Gait analysis has been used a tool to measure
  balance (Lee Pollo, 2001)

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Balance Gait

• Effects of Balance Exercises on the Analysis of
  Selected Kinetic and Kinematic Variables of Gait
  in Developmentally Disabled (DD) Obese Adults
• Additional body mass, decreases in strength
  place obese adults at risk for falls especially
  during unstable period during gait
• 10-week balance program did not yield significant
  changes in the selected gait variables
• However, interesting changes within the TX group
  were noted
• TX group decreased knee angle at heelstrike by
  7.57 (medium effect size)
• Cadence of the TX group increased by 7.22 steps
  per minute
• Six out of the nine subjects in the TX group
  increased cadence

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Subject Two Treatment Group Pre Gait Video

• PRE Gait.avi

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Subject Two Treatment Group Post Gait Video

• Post Gait.avi

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Individual Changes in Gait
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Balance Exercises

• Should be simple progressively become more
  challenging
• They can be designed to address any of the
  systems that affect balance

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Static Balance Exercises

• Double to single leg standing
• Alter the width of BOS
• Semi-tandem to tandem
• Add external equipment to stress the visual or
  vestibular systems
• Playing catch
• Unstable surface
• Foam
• BOSU
• Eyes open to eyes closed

• Table position
• alternate hands knees while in table position
• Swiss balls
• Alternate arm/leg
• Marching
• UE or LE exercises

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Dynamic Balance Exercises

• Trampoline
• Closed-chain kinetic exercises
• Walking
• Forward heel-to-toe
• Sideways, on toes, on heels or backward between
  double lines that progressively get narrower
• Squats
• Step-ups
• Mini hops
• Jumping rope
• Swiss balls
• BOSU
• Circle activities vestibular exercises
• Sport-specific activities
• Obstacle course

• Games
• Freeze tag
• Statues
• Hopscotch
• Twister
• Follow the leader
• Scooter boards
• Pull/push self with hands or feet sitting or
  lying prone
• Sitting or lying prone spin self in one
  direction, stop change directions (vestibular)
• Push/pull self through obstacle course or rope
• Relay races

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Assessing balance

• Static balance tests include
• (a) parallel stance with feet together or
  shoulder width apart
• (b) semi-tandem stance
• (c) tandem stance
• (d) Romberg Test
• (e) one legged stance
• Measure postural sway via a force plate under any
  of these conditions to detect the oscillations of
  the center of pressure
• These are timed a score of 30 s without using
  hand support is generally considered good
• The visual vestibular systems can be tested in
  these positions with eyes open closed
  (Dieterich, 2004)
• Sensory Organization Test
• This test provides an outcome variable called an
  equilibrium score, which is based on the visual,
  proprioceptive, vestibular systems to maintain
  standing balance (Chaudhry et al., 2004)
• Anemaet Moffa-Trotter, 1999 Clark, 2004
  Houglum, 2005

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Assessing balance

• Dynamical balance measurements include
• Walking heel-to-toe for 10 feet (Clark, 2004)
• Performing this task without looking at ones
  feet is a method to assess vestibular visual
  balance (Auxter et al., 2005)
• Timed get-up-and-go test (Carmeli et al., 2002)
• Berg Functional Balance Scale includes static
  dynamic assessment (designed for elderly)
• Tinetti Balance Test shorter than Berg,
  addresses static dynamic

21
Assessing Functional Strength Proprioception in
LE

• Line jumping
• Forward backward
• Side-to-side
• Single leg
• Score of gt 20 s is good
• Four squares
• Make a square
• Person jumps clockwise around the square single
  legged
• Repeated on opposite leg counterclockwise
• Count the number of foot contacts in 20 s

• Vertical jumping
• Single leg jumping
• Count the number of jumps completed in 20 s
• Bounding
• Single leg long jump
• Bound forward land bound forward again
• Take the average length of (2) jumps
• With these tests one can compare bilaterally both
  in time number of jumps

McCrady Amato, 2004
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Conclusion

• The inclusion of balance exercises
• May decrease the risk of injury or reinjury
• Can be incorporated as a preventative measure
• Should be included in exercise programs for
• Obese individuals, elderly, people with a DD, LE
  injury rehab, or for someone with a balance
  deficiency

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References

• If you would like a complete list of references
  please contact me via email I will send you an
  electronic copy
• Sally Paulson Ph.D., ATC, CSCS
• Shippensburg University
• Dept. of Exercise Science
• sapaul_at_ship.edu
• 717 477 1274

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Questions