Part

15
BalanceTraining Activities
BENEFITS OF BALANCE TRAINING
Balance training activities can be- used Lo:
Improve trunk stability, biomechanical alignment, and symmetrical weight distribution
Improve awareness and control of center of mass (COM) and limits of stability (LOS)
Improve musculoskeletal responses necessary for balance including functional range of
motion (ROM) and strength
Promote use of normal balance strategies and synergies during static and dynamic activities
Improve utilization of sensory (somatoscnsory, visual, vestibular, systems for balance and
challenge CNS sensory integration mechanisms
Teach safety awareness and compensation
Motor control goals. Skill level, static and dynamic balance control. Functional outcomes
" The patient demonstrates appropriate functional balance during standing and walking.
The patient performs activity-of-daily-living skills (ADLs) safely during standing and
walking without loss of balance or falls.

TREATMENT STRATEGIES AND CONSIDERATIONS

Repetition and practice are important to assist the CNS in modification and compensation of
balance dysfunction. Effective practice schedules can improve responsiveness of postural
muscles and
overall balance performance.
o Repetition and practice provide appropriate feedback about sensory information, muscle
recruitment, coordination, and postural patterns.
Some activities may cause the patient distress initially. The patient will feel threatened
when placed in situations where he or she is in jeopardy of losing balance.
The therapist should give a clear explanation of what is going to be done, and explain what
is expected of the patient in terms that are easy to understand.
o The therapist should ensure patient confidence and patient safety.
o The patient should practice under close supervision at first, then progress to independent
practice (a home exercise program).
The patient needs to develop and maintain adequate lower extremity ROM and strength to
withstand challenges to balance. Activities should include: o Standing, heel-cord stretches
(wall push-ups)for the Achilles tendon ROM Standing, heel-risesfor the
gastrocnerm'us-soleus muscles Standing, toe offsfor the anterior tibial muscles
Standing, partial.wall squats and chair risesfor the quadriceps and hip extensors Side
kicks, single-leg stance, or single-leg stance with the dynamic leg pushing into
the wallfor the hip abductors

o Back kicksfor the hip extensors

o Marching in placefor the hip and knee flexors
The therapist should focus on obtaining the responses necessary to maintain static balance in
a symmetrical stance: c The therapist should help the patient improve sway in the direction of
an instability (for
example, the patient recovering from stroke typically needs to shift weight from the
sound side toward the affected side).
The therapist should focus on obtaining the correct postural synergies in response to
disturbances of the COM:
Small shifts in COM alignment or slow sway movements should result in activation of an
ankle strategy.
Larger shifts in COM alignment or faster sway movements should result in activation of a
hip strategy.
Even larger shifts in which the COM exceeds the LOS should result in activation of stepping
strategies; the patient should practice stepping in all directions.
Extraneous movements should be eliminated.
Balance skills are highly task and context specific. o Balance control should be practiced
using a variety of different functional tasks
and environments. Training on balance machines (for example, center of pressure
biofeedback devices)
should not be expected to transfer to functional balance tasks such as
sit-to-stand transfers, walking, or stair climbing.
A variety of training activities should hr; provided:
Training should progress with the patient holding in a posture (static balance) to moving in a
posture (dynamic balance).
o Training should progress with the patient standing on a stationary surface to a compliant
surface (foam) or moveable surface (equilibrium or wobble board).
Training should progress from self-initiated voluntary challenges to posture (feed-forward
and feedback-driven) tn therapist-initiated (feedback-driven) challenges.
A variety of environments should be provided: o Training should progress from a closed
(fixed) environment to an open (variable or
changing) environment.
Training should progress from simulated home, community, and work environments to reallife environments.
The therapist should help the patient improve response latencies: Slowed response times
may result in inadequate postural responses or falls. Sensory stimulation techniques (for
example, quick stretch or tapping) can be used
oosturril muscles.
".o :_r. cruise resoonsivenfiss
restorisiveness of postural rriUH'.l':i.

BALANCE TRAINING ACTIVITIES

The therapist appropriately varies challenges to balance, combining some activities that are
relatively easy for the patient with some that arc more difficult. Progression is
not dependent upon successful attainment of all the activities listed at nny given
level. An effective motor learning strategy ensures that the patient experiences
success Ihus, the therapist alternates easier activities with more difficult ones

and begins and ends each treatment session with activities the patient can
complete successfully.

Beginning-level Balance Activities

il These activities are appropriate for initial balance training for the pi tient with instability
and significant disturbances in balance control.

Standing Activities
^ The patient is positioned in a bilateral stance on a level surface wilh normal or widened
stance, eyes open (EO). Light touch-down support of both hands or one hand is achieved
I by having the patient stand near a support surface (treatment table, parallel bars, or a
wall). Activities that can be practiced include:
(Weight shifts in all directionsto foster re-education of the limits of stability (LOS), centered LOS.
Look-aroundshead and trunk rotation. Head tiltsup and down, side to side. I Heel-rises
active plantarflexion.
Toe offsactive dorsifiexion. Toe of'fs are generally more difficult thnn heel offs because
the COM is shifted posteriorly, whore there is no effective BOS. Single-leg stands(Fig. 151). f Hip circlesbody clock.

Gait Activities

The patient begins with assisted walking, using parallel bars or walking near a wall for

light touch-down support; the base of support (BOS) is normal and the eyes are open
lEO). ' Assistive devices (for example, a straight or slant cane) can be used to assist
balance. A . swimming pool provides an ideal supportive environment for initial walking
for the patient vith balance dysfunction (for example, the patient with ataxia).
(

Intermediate-Level Balance Activities

These activities arc appropriate for the patient who is able to withstand moderate chal-'
lenges to balance.

Movement Transitions
Sit-to-stand transfers (chair rises) can be varied by changing the height of the seat from high
to low, the speed of the transitions, or the UE supportfrom using a chair with armrests to no
armrests.

Standing Activities
Activities that can be practiced at this level include:
Exaggerated arm swings
Functional reach activities
Reduced BOSfeet together
Eyes open (EO) to eyes closed (EC) Romherg position
Heel offs, toe offs, or single-leg standsholding on with light touch-down support
of one hand, progressing to no hands Marching in place (high stepping)holding on with
light touch-down support,
progressing from both hands to one hand Partial squats Partial lungesone foot advanced
with the trunk upright and the hips in neutral
position, with the knee flexed on the advanced limb (Fig. 15-2)

Gait Activities
Activities at the intermediate level include:
Gait with narrowed BOS Gait with wide turns to right and left
Side-steppingholding on with light touch-down support, progressing from both hands to
one hand