Balance lecture

1
Balance lecture Postural Equilibrium
Dr.Afaf A.M Shaheenlecture 11RHS 322
2

• Factors affecting balance
• Muscular weakness
• Proprioceptive deficits
• ROM deficits

3
Terminology

• Balance - Process of maintaining bodys CoG
  (Center of Gravity) within base of support
• Ability to align body segments against gravity to
  maintain or move the body within the available
  base of support without falling .
• Bodys CoG rests slightly above the pelvis
• Strength is emphasized before proprioception in
  rehab because strength influences balance
• Postural equilibrium - broader term that
  incorporates alignment of joint segments
• Maintaining CoG within the limits of stability
  (LOS)

4
Terminology

• Proprioception bodys ability to transmit
  position sense, interpret information respond
  consciously/unconsciously to stimulation
• Coordination smooth pattern of activity is
  produced through a combo of muscles acting
  together with appropriate intensity timing
• Agility ability to control the direction of a
  body or segment during rapid movement

5
Postural Control System

• 3 Components of the system
• Sensory detection of body motions
• Visual
• Vestibular
• Somatosensory inputs
• Integration of sensorimotor information within
  the CNS
• Execution of musculoskeletal responses
• Balance is both a static dynamic process

6
Control of Balance

• Tall body vs. Small base of support
• Balance relies on network of neural connections
• Postural control relies on feedback
• CNS involvement
• Sensory organization
• Determines timing, direction amplitude of
  correction based on input
• System relies on one sense at a time for
  orientation
• Muscle coordination
• Collection of processes that determine temporal
  sequencing distribution of contractile activity

7

• Sensory Input
• Vision
• Measures orientation of eyes head in relation
  to surrounding objects
• Helps maintain balance
• Vestibular
• Provides information dealing with gravitational,
  linear angular accelerations of the head with
  respect to inertial space
• Somatosensory
• Provides information concerning relative position
  of body parts to support surface each other

8

• Somatosensation Proprioceptive system
• Specialized variation of the sensory modality of
  touch, encompassing joint sense (kinesthesia)
  position
• Process
• Input from mechanoreceptors
• Stretch reflex triggers activation of muscles
• Results in muscle response to compensate for
  imbalance and postural sway
• Muscle spindles sense stretch in agonist, relay
  information afferently to spinal cord
• Information is sent back to fire muscle to
  maintain postural control

9

• Body position in relation to gravity is detected
  by sensory input
• Balance movements involve a number of joints
• Ankle
• Knee
• Hip
• Coordinated movement along kinetic chain

10
Prentice, 2004, 4th ed.
11

• Postural sway
• Deviation from Center of Pressure, Balance
  Vertical Force (CoP, CoB, or CoF)
• Determined using mean displacement, length of
  sway path, length of sway area, amplitude,
  frequency and direction relative to CoP
• Symmetry - Ability to distribute weight evenly
  between 2 feet in upright stance

12
Balance Disruption

• Balance Deficiencies - Inappropriate interaction
  among 3 sensory inputs
• 2 Factors that Disrupt Balance
• Position of CoG relative to base of support is
  not accurately sensed
• Automatic movements required to maintain the CoG
  are not timely/effective
• In the event of contact, the body must be able to
  determine what to do in order to control CoG
• Joint mechanoreceptors initiate automatic
  postural response

13
Selecting Movement Strategies during Balance
Disruption

• Joints (Ankle, Knee Hip) involved allow for a
  wide variety of postures that can be assumed in
  order to maintain CoG

14

• Instance of musculoskeletal abnormality
• Damaged tissue result in reduced joint ROM
  causing a decrease in the LOS placing
  individual at a greater risk for fall
• Research indicates that sensory proprioceptive
  function is affected when athletes are injured

15
Assessment of Balance

• Subjective Assessment
• Romberg Test traditional assessment
• Balance Error Scoring System (BESS)

Prentice, 2004, 4th ed.
Google Images
16

• Semi-dynamic dynamic tests
• functional reach tests
• timed agility tests
• carioca
• hop test
• Timed T-band kicks
• Timed balance beam walks (eyes open closed)

17

• Objective Assessment
• Balance systems
• Provide for quantitative assessment training
  static dynamic balance
• Easy, practical cost-effective
• Utilize to assess
• Possible abnormalities due to injury
• Isolate various systems that are affected
• Develop recovery curves based on quantitative
  measures in order to determine readiness to
  return
• Train injured athlete
• Computer interfaced force-plate technology
• Vertical position of CoG is calculated
• Vertical position of CoG movement indirect
  measure of postural sway

18
Prentice, 2004, 4th ed.

• Force plate measures
• Allows for static dynamic postural assessment
• Single or double leg stance, eyes opened or closed

19

• Dynamic stability - Ability to transfer vertical
  projection of CoG around a stationary supporting
  base
• Perception of safe limit of stability
• Athlete should maintain their CoP near A-P and
  M-L midlines

20
Injury Balance

• Stretched/damaged ligaments fail to provide
  adequate neural feedback, contributing to
  decreased balance proprioception
• May result in excessive joint loading
• Could interfere with transmission of afferent
  impulses
• Alters afferent neural code conveyed to CNS
• Decreased reflex excitation
• Caused via a decrease in proprioceptive CNS input
• May be the result of increased activation of
  inhibitory interneurons within the spinal cord
• All of these factors may lead to progressive
  degeneration of joint continued deficits in
  joint dynamics, balance coordination

21

• Ankles
• Joint receptors believed to be damaged during
  injury to lateral ligaments
• Knee Injuries
• Ligamentous injury has been shown to alter joint
  position detection
• Head Injury

22
Balance Training

• Vital for successful return to competition from
  lower leg injury
• Possibility of compensatory weight shifts and
  gait changes resulting in balance deficits
• Functional rehabilitation should occur in the
  closed kinetic chain nature of sport
• Adequate AND safe function in the open chain is
  critical first step in rehabilitation

23
Rules of Balance Training

• Exercise must be safe challenging
• Stress multiple planes of motion
• Incorporate a multisensory approach
• Begin with static, bilateral stable surfaces
  progress to dynamic, unilateral unstable
  surfaces
• Progress towards sports specific exercises
• Utilize open areas
• Assistive devices should be in arms reach early
  on
• Sets and repetitions
• 2-3 sets, 15 ? 30 repetitions or
• 10 of the exercise for 15 ? 30 seconds later on
  in the program

24
Classification of Balance Exercises

• Static -
• CoG is maintained over a fixed base of support,
  on a stable surface
• Semi-dynamic
• Person maintains CoG over a fixed base of support
  while on a moving surface
• Person transfers CoG over a fixed base of support
  to selected ranges and or directions within the
  LOS, while on a stable surface
• Dynamic
• Maintenance of CoG within LOS over a moving base
  of support while on a stable surface
• Functional
• Same as dynamic with inclusion of sports specific
  task

25
Prentice, 2004, 4th ed.

• Phase I
• Non-ballistic types of drills
• Static balance training
• Bilateral to unilateral on both involved
  uninvolved sides
• Utilize multiple surfaces to safely challenge
  athlete maintaining motivation
• With without arms/counterbalance
• Eyes open closed
• Alterations in various sensory information
• Incorporation of multiaxial devices
• Train reflex stabilization postural orientation

26

• Phase II
• Transition from static to dynamic
• Running, jumping and cutting activities that
  require the athlete to repetitively lose and gain
  balance in order to perform activity
• Incorporate when sufficient healing has occurred
• Semi-dynamic exercised should be introduced in
  the transition
• Involve displacement or perturbation of CoG
• Bilateral, unilateral stances or weight transfers
  involved
• Sit-stand exercises, focus on postural

27
Bilateral Stance Exercises
Prentice, 2004, 4th ed.
28
Prentice, 2004, 4th ed.

• Unilateral Semi-dynamic exercises
• Emphasize controlled hip flexion, smooth
  controlled motion
• Single leg squats, step ups (sagittal or
  transverse plane)
• Step-Up-And-Over activities
• Introduction to Theraband kicks
• Balance Beam
• Balance Shoes

29

• Phase III
• Dynamic functional types of exercise
• Slow to fast, low to high force, controlled to
  uncontrolled
• Dependent on sport athlete is involved in
• Start with bilateral jumping drills straight
  plane jumping patterns
• Advance to diagonal jumping patterns
• Increase length and sequences of patterns
• Progress to unilateral drills
• Pain fatigue should not be much of a factor
• Can also add a vertical component to the drills
• Addition of implements
• Tubing, foam roll
• Final step functional activity with
  subconscious dynamic control/balance

30
Phase III Exercises
Prentice, 2004, 4th ed.
31

• The dynamic proprioceptive re-education consists
  of seven stages-
• Slow exercises followed by quicker movement
• Exercise with limited effort followed by
  exercises requiring greater strength
• Exercises requiring volition, followed by
  exercises done freely
• Progress from walking to jogging
• Running and sprinting
• Jumping and changes of direction
• Twirling and twisting around the injured or
  operated knee

32

• Balance and control proprioceptive exercises
• Stand on one leg.
• Stand on one leg with eyes closed.
• Stand on one leg throw and catch a ball.
• Stand on one leg bend and straighten knee    

33

1. Stand on one leg- pick up item from floor.
2. Hold knee dip throw and catch a ball.
3. Stand on one leg move other leg to side, front
   and back.
4. Push up onto toes (2 legs) and hold.  
5. Push up onto toes with eyes closed.
6. Push back onto heels, balance and hold.
7. Push up on toes on one leg.     

34

• Walking proprioceptive exercises
• Walk forward along a straight line. 
• Walk on tip toes along straight line. 
• Walk backwards along straight line.
• Side step along straight line.  
• Walk sideways crossing one foot over other
  (Cariocas).  
• Walk fast in one direction, quickly changing
  direction at intervals.

35

• Running proprioceptive exercises
• Run fast in one direction.
• Run backwards and do sidesteps.
• Fast crossovers (Cariocas).
• Run in figure of eight make it smaller and
  smaller.    

36

1. Hopping on spot
2. Hop forwards and backwards stop between hops.
3. Hop in zigzags.
4. Hop on and off step
5. Do triple jump - run, hop, jump and land.

37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40

• Balance and strength exercises are combined by
  incorporating light external forces and
  increasing the level of difficulty for balancing
  while strengthening the muscles required for
  dynamic stabilization

41

The Fitter is useful for
weight shifting
42
(No Transcript)
43

• Plyometrics begin with low-impact hopping,
  progressing to double-leg bounding, and finally
  single-leg hopping.

44
References

• Prentice, W.E. (2004). Rehabilitation Techniques
  for Sports Medicine and Athletic Training, 4th
  ed., McGraw-Hill
• Houglum, P.A. (2005). Therapeutic Exercise for
  Musculoskeletal Injuries, 2nd ed., Human
  Kinetics.
• Kisner, C. Colby, L. (2002). Therapeutic
  Exercise Foundations Techniques, 4th ed., F.A.
  Davis.
• http//www.google.com - Images