Balance

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Introduction

Balance refers to an individuals ability to maintain their line of gravity within their Base of support (BOS). Balance can be both static and dynamic, both of which will be discussed here.

Balance systems

The following systems all provide feedback in some form or another to contribute to a persons sense of balance:

1. Vestibulocochlear
2. Proprioceptive
3. Visual

Assessing balance

Several outcome measures for assessing balance exist, the Berg balance scale being one of the more commonly used tools. It allows a therapist to progressively score a patients ability to balance throughout a series of tasks.

Management

a. Parkinson’s disease

Parkinson’s disease (PD) is a progressive neurodegenerative disease. It’s often characterized by tremor, bradykinesia, postural instability and rigidity. Most frequently, patients have gait impairments, difficulty in linking movements together smoothly and episodes of freezing. The sum of these problems, together with balance disturbances lead to an increased incidence of falls. (1)

The physiotherapist is a member of the multidisciplinary team, with the purpose of maximising functional ability and minimising secondary complications. Physiotherapy for Parkinson’s disease focuses on: transfers, posture, upper limb function, balance, gait, and physical capacity. The therapist uses cueing strategies, cognitive movement strategies and exercise to maintain or increase independence, safety, and quality of life. Sensory cueing strategies such as auditory, tactile, and visual cues have often been used to help walking in PD. (2) (3)

Cognitive movement strategies

Cognitive movement strategies are used to improve transfers. Complex and automatic activities are divided into separate elements consisting of relatively simple movement components. By doing this, the person has to think consciously about his movements. Try to avoid dual tasking during complex automatic ADL. Furthermore, the movement or activity will be practiced and rehearsed in the mind. It is important that movements are not performed automatically; performance has to be consciously controlled (4)
Example: (5)

Cueing strategies

The performance of automatic and repetitive movements of patients with PD is disturbed as a result of fundamental problems of internal control. That’s why cues are used to complete or replace this reduced internal control.
Cues can be generated internally or externally. Rhythmical recurring cues are given as a continuous rhythmical stimulus, which can serve as a control mechanism for walking. (4) (6)

The physical therapeutic intervention goals apply to the phase addressed: (6)

• Early phase
Patients have no or little limitations. Goals of the therapeutic intervention are:
1. prevention of inactivity
2. prevention of fear to move/to fall
3. preserving/ improving physical capacity

• Mid phase

More severe symptoms; performance of activities become restricted, problems with balance and an increased risk of falls
Problems:
1. transfers
2. bodyposture
3. reaching and grasping
4. balance
5. gait

• late phase
Patients are confined to a wheelchair or bed. The treatment goal in this phase is to preserve vital functions and to prevent complications, such as pressure sores and contractures.

b. Elderly

Balance training can also be used in the elderly. Falls of elderly, due to poor balance, have important clinical and economical costs and intervention. For this reason it is interesting to search for possibilities to reduce these costs, such as the use of balance training.(7)

In 2011 weak evidence has been found for the effectiveness of several exercises in improving clinical balance outcomes in elderly:

• Gait
• balance
• co-ordination and functional tasks
• strengthening exercise
• But evidence for the effect of computerized balance programs or vibration plates is insufficient.(8)

To keep the therapy adherence up it is best to look for an approach with a ‘fun factor’. Some examples:

• music-based multitask exercise program
Basic exercises consisted of walking in time to the music and responding to changes in the music’s rhythmic patterns. Exercises involved a wide range of movements and challenged the balance control system mainly by requiring multidirectional weight shifting, walk-and-turn sequences, and exaggerated upper body movements when walking and standing.(9)

• balance training using a virtual-reality system
In contrast to the review of 2011, in 2013 it was found an effective method to train the balance in older fallers. This method is intended to complete, not replace, other fall prevention programs. (10)

• Tai chi
Tai chi has been proven to be an economic and effective way for training balance in older people. (11)
To ameliorate balance in elderly it isn’t enough to just follow a conventional exercise intervention (including muscle strengthening, stretching and aerobic exercises, and health education). Besides this it is better to also include static and dynamic balance exercises.

Examples of static balance exercises: squats, two-leg stance and one leg stance.

Examples of dynamic exercises: jogging end to end, sideways walking or running with crossovers, forward walking or running in a zigzag line, backward walking or running in zigzag line. (12)

Nevertheless to improve balance core strength training is an important element. The benefit is this therapy can be both given in a group setting or in individual fall preventive interventions

References

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