12 Assessing Balance and Designing Balance Programs chapter chapter 12 Author name here for Edited books

Objectives Differentiate between static and dynamic balance Identify factors influencing balance Understand general guidelines for balance testing Identify exercises to improve balance Understand guidelines for designing balance programs

Principles of Balance Balance is gaining recognition as a key component of functional fitness. Balance training is emerging as one of the top 10 exercise trends. For seniors, balance is extremely important to maintenance of independent living status and successful completion of ADLs. Balance training helps prevent falls.

Definitions and Nature of Balance Balance is the ability to keep the body’s center of gravity (COG) within the base of support when maintaining a static position, performing voluntary movements, or reacting to external disturbances. Static Dynamic Functional

Static, Dynamic, and Functional Balance Static balance is the ability to maintain COG within the supporting base while standing or sitting. Dynamic balance is maintaining an upright position while COG and base of support are moving and the COG is moving outside of the supporting base. Functional balance is the ability to perform daily movement tasks requiring balance.

Factors Affecting Balance and Risk of Falling The further the COG from the base of support, the lower the stability. The broader the base of support, the higher the stability. Resistance training and stretching programs may be useful for maintaining and improving balance. Exercising on unstable surfaces can challenge balance response and provide variety. (continued)

Factors Affecting Balance and Risk of Falling (continued) Balance, resistance, and flexibility training programs are more effective than endurance training for reducing risk of falling. No optimal fall prevention program has been identified yet.

Assessment of Balance Most balance test batteries are comprehensive and include multiple test items to assess both static and dynamic balance. Direct measures of balance may be obtained using computerized force plate devices.

Assessing Static Balance Using Indirect Measures Romberg tests: measure static balance while standing with eyes open and eyes closed Looking for any kind of sway. the subject stands with feet together, eyes open and hands by the sides. the subject closes the eyes while the examiner observes for a full minute. a positive sign is noted when a swaying, sometimes irregular swaying and even toppling over occurs The essential feature is that the patient becomes more unsteady with eyes closed. Romberg's test is positive if the patient sways or falls while the patient's eyes are closed

Assessing Static Balance Using Indirect Measures Unipedal stance test: timed one-leg stance test that provides simple measure of static balance; two conditions: eyes open, eyes closed

Test Prodedures for Unipedal Stance Test Determine clients’ dominant leg by having them kick a ball Prior to raising one leg off the floor, clients fold their arms across the chest Client stands barefooted on dominant leg and raises other near but not touching ankle of stance limb. Start stopwatch as soon as client lifts the foot off the floor.

Test Procedures for Unipedal Stance Test (cont.) For the eyes open test, client focuses on a spot on the wall at eye level Terminate test when client does any of the following: Uncrosses or uses arms to maintain balance Moves raised foot away from standing limb or touches floor Moves weight-bearing foot to maintain balance Exceeds maximum duration of 45 seconds Opens eyes during eyes closed test Administer 3 trials and use best score

Assessing Static Balance Using Indirect Measures Clinical test of sensory integration of balance: evaluates the contributions of the visual, proprioception, and vestibular sensory systems to balance Standard Romberg test with eyes open Modified Romberg tests standing on a foam pad with eyes open and closed

Assessing Dynamic Balance With Indirect Measures Functional reach tests: measure maximum distance one can reach beyond an arm’s length without losing balance or moving the feet Yardstick is attached to wall, parallel to floor at the height of the client’s acromion process Client stands with lateral aspect of the shoulder parallel to the wall, makes a fist and extends elbow until fist is at ht. of stick Initial measure is point along measuring stick of 3rd metacarpal Client reaches forward as far as possible without falling or taking a step Farthest distance reached along the stick is recorded Functional reach score is difference between 2 recorded distances

Figure 12.1

Assessing Dynamic Balance With Indirect Measures Timed up and go tests: assess dynamic balance and agility of older adults Begin test with client sitting correctly in a chair with arms Place a piece of tape or other marker on the floor 3 meters away On the word “Go” stand up, walk to the line mark on the floor, turn around and walk back to chair and sit Start timing on word “Go” and stop timing when client is seated correctly in the chair Subject wears regular footware

Assessing Dynamic Balance With Indirect Measures Timed Up and Go Test Scoring < 10 seconds = normal < 20 seconds = good mobility, can go out alone, mobile without a gait aid < 30 seconds = problems, cannot go outside alone, requires a gait aid A score of more than 14 seconds or more has been shown to indicate high risk of falls

Figure 12.2

Assessing Dynamic Balance With Indirect Measures Star excursion balance test: provides a significant challenge to athletes and physically active individuals Must maintain a base o support on one leg while maximally reaching in different directions in a star pattern with the opposite leg Useful for screening deficits in dynamic postural control due to musculoskeletal injuries and during rehab of orthopedic injuries in otherwise healthy, physically active adults

Assessing Dynamic Balance With Indirect Measures Star Excursion Test Client stands in middle of grid formed by 8 lines extending from the center at 45o Clients begin by reaching in anterior direction and progress clockwise around the grid. 3 trials in the eight directions for each limb Client reaches to farthest point possible on the line (tester marks this point on grid line) Test both dominant and non-dominant leg

Figure 12.3a

Figure 12.3b

Assessing Dynamic Balance Using Test Batteries Tinetti performance-oriented assessment of mobility test (POMA): assesses balance and gait of older adults; contains 14 performance-based items Berg balance scale: evaluates balance performance of nursing home and community-dwelling older adults; contains 14 functional mobility items Dynamic gait index: composite measure of ability to adapt gait during movement-related tasks

Assessing Static and Dynamic Balance With Direct Measures Uses expensive, computerized force plate with at least three force transducers that quantify vertical pressures applied to the support platform. System derives coordinates of center of pressure. Computerized systems provide data about postural sway and steadiness. Force platform balance tests provide valid information about postural control that can be used to predict risk of falling among older clients. (continued)

Assessing Static and Dynamic Balance With Direct Measures (continued) Computerized dynamic posturography assesses the individual and composite functioning of sensory, motor, and biomechanical components of balance. Can examine ability to maintain an upright posture when visual and proprioceptive sensory information is modified mechanically. Can be used to assess functional tasks such as walking, turning, and changing posture. (continued)

Assessing Static and Dynamic Balance With Direct Measures (continued) Limits of stability test measures maximum excursion of COG and assesses degree to which one is able to lean in several directions while maintaining balance over a fixed supporting base. Limits of stability test provides reliable scores and is predictive of risk of falling. Biodex Stability System can evaluate and train neuromuscular control by quantifying ability to maintain dynamic postural stability on both stable and unstable surfaces.

Designing Balance Training Programs 2008 Physical Activity Guidelines for Americans suggests balance training at least 3 days a week for inactive and active older adults (≥65 years). ACSM stated that balance, agility, and proprioceptive training is effective for preventing falls. Balance training exercises are effective for reducing the risk of ankle sprains and recurrent sprains in athletes. (continued)

Designing Balance Training Programs (continued) General guidelines: Engage in balance activities 2 or 3 days a week. Progressively increase difficulty of the balance exercises by using a narrower base of support. Include dynamic movements that challenge the COG. Use exercises that stress postural muscles.

Balance Training Exercise Prescription Resistance training, stretching programs, and numerous other forms of exercise may help maintain and improve balance. Uneven surfaces and computerized balance training systems may add variety and challenge to balance training programs. (continued)

Balance Training Exercise Prescription (continued) Exercises specifically designed to improve functional ability of lower extremities may help improve balance and prevent falls in older adults. They complement flexibility and resistance training routines. Square-stepping exercise is better than regular walking in reducing risk factors associated with falling. (continued)

Balance Training Exercise Prescription (continued) Resistance training as an isolated intervention is not shown to consistently improve balance of older adults. Therefore, strength alone is not the major underlying mechanism for poor balance. Muscle power (force x velocity) may be a limiting factor in balance control. High-intensity strength training targeting key lower-extremity muscle groups can improve postural control in balance-impaired older adults. (continued)

Balance Training Exercise Prescription (continued) Research on balance training is scarce. Therefore, there are no existing guidelines for balance program design other than to individualize the program. Tai chi is a popular method of exercise with numerous benefits; it has received substantial amount of research interest. Yoga is not as well researched in terms of balance programming.

Balance Training Exercise Prescription Feet Position – Progression Feet in hip width stance Staggered or step position Feet together Split position Heel to toe Single leg

Balance Training Exercise Prescription Variables (progression) – Do 10 reps each Hands over head Drop one arm out to side Lean to side Lean to front Lean backward Rotate around

Balance Training Exercise Prescription Variables (make sure tight in core and glutes) Finger 10 inches in front of face Finger drift upward – follow with eyes Finger move around – follow with eyes Finger move around – follow with whole head (works on balance center in ears) Repeat movements with eyes closed

Balance Training Exercise Prescription One-legged exercises Mimic walking Swing leg forward and back let arm naturally swing Reach down toward floor Add reaching back up in the air Move in Frontal Plane Foot out then across body (arm opposite) As leg goes out drop into a squat Move in 3rd Plane (transverse) Across front of body then back (rotate)

Working Balance Into Regular Workouts Change Your Base of Support Bring your legs closer together while you do standing bicep curls, shoulder raises, squats or other upper body moves Be sure to keep your abs pulled tight Make sure there is no backward lean as the exercises are performed Can do this while performing exercises on stability ball as well

Working Balance Into Regular Resistance Workouts Try It on One Leg Start by just lifting one heel (keeping heel on the floor) Then lift one foot Play around with position of leg (back, forward, etc.) Can also move the leg around while performing lifts Alternate legs to keep strength and muscle tone balanced

Working Balance Into Regular Resistance Workouts Close your eyes Make sure subject is in a controlled environment Do with body planted Over time combine with narrow base and one leg exercises