Introduction

Balance refers to an individuals ability to maintain their line of gravity within their Base of
support (BOS). It can also be described as the ability to maintain equilibrium, where equilibrium
can be defined as any condition in which all acting forces are cancelled by eachother resulting in
a stable balanced system.

Variation in Terminologies
In literature the balance term has been used synonymously with [1]

Postural Control

Postural Stability

Equilibrium

Balance systems
The following systems provides input regarding the body's equilibrium and thus maintains
balance.
1. Somatosensory / Proprioceptive System
2. Vestibular System
3. Visual System

The Central Nervous System receives feedback about the body orientation from these three main
sensory systems and integrates this sensory feedback and subsequently generates a corrective,
stabilizing torque by selectively activating muscles.[2] In normal condition, healthy subjects rely
70% on somatosensory information and 20% Vestibular & 10% on Vision on firm surface but
change to 60% vestibular information, 30% Vision & 10% somatosensory on unstable surface.

Somatosensory System
Proprioceptive information from spino-cerebellar pathways, processed unconsciously in the
cerebellum, are required to control postural balance. [3] Proprioceptive information has the
shortest time delays, with monosynaptic pathways that can process information as quickly as 40
50 ms[4] and hence the major contributor for postural control in normal conditions.

Vestibular System
The vestibular system generates compensatory responses to head motion via:
1. Postural responses (Vestibulo Spinal Reflex) - keep the body upright and prevent falls
when the body is unexpectedly knocked off balance.
2. Ocular-motor responses (Vestibulo Ocular Reflex) - allows the eyes to remain steadily
focused while the head is in motion.
3. Visceral responses (Vestibulo Colic Reflex) - help keep the head and neck centred, steady,
and upright on the shoulders.
To achieve this the vestibular system measures head rotation and head acceleration through
semicircular canals and otolith organs (utricule and sacule)
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Visual System
For non impaired individuals under nornal conditions the contribution of visual system to
postural control is partially redundant as the visual information has the longer time delays as
long as 150-200 ms.[4] Friedrich et al. (2007) [5] observed that adults with visual disorders were
able to adapt peripheral, vestibular, somatosensoric perception and cerebellar processing to
compensate their visual information deficit and to provide good postural control. In addition,
Peterka (2002), found that adults with bilateral vestibular deficits can enhance their visual and
proprioceptive information even more than healthy adults in order to reach an effective postural
stability. The influence of moving visual fields on postural stability depends on the
characteristics of the visual environment, and of the support surface, including the size of the
base of support, its rigidity or compliance.[6]

Static and Dynamic Balance

Balance can be classified in to :

1. Static Balance: it is the ability to maintain the body in some fixed posture. [7] Static
balance is the ability to maintain postural stability and orientation with centre of mass
over the base of support and body at rest.[1]
2. Dynamic Balance: Defining dynamic postural stability is more challenging, Dynamic
balance is the ability to transfer the vertical projection of the centre of gravity around the
supporting base of support. [8] Dynamic balance is the ability to maintain postural
stability and orientation with centre of mass over the base of support while the body parts
are in motion.[1]
[9]

Mechanisms
The mechanisms involved in static balance were best summarized by Bannister [7]. He noted that
normal standing required:
1. Sufficient power in the muscles of the lower limbs and trunk to maintain the body erect.
2. Normal postural sensibility to convey information concerning position.
3. Normal impulses from the vestibular labyrinth concerning position.
4. A central coordinating mechanism, the chief part of which is the vermis of the
cerebellum.
5. The activity of higher centers concerned in the willed maintenance of posture.
With this mechanisms the dynamic balance requirements can be inferred as:
1. Sufficient power in the muscles of the body to maintain movement and stability.
2. Normal postural sensibility to convey information regarding movement.
3. Normal impulses from the vestibular system and visual system concering movement and
environment.
4. Central co ordinating mechanism including cerebellum and basal ganglia
5. The activity of higher centers concerned in the willed/ involuntary maintenance of
movement and stability.

Correlation between Static and Dynamic Balance

A study by Sell TC (2012) examined the relationship and differences between static and dynamic
postural stability in healthy, physically active adults.[10] Static postural stability was measured by
a single-leg standing task and dynamic postural stability was measured by a single-leg landing
task using the Dynamic Postural Stability Index.The author concludes that there was a lack of a
correlation between static and dynamic measures. However, the increase in difficulty during
dynamic measures indicates differences in the type and magnitude of challenge imposed by the
different postural stability tasks.
The lack of correlation between the two different conditions is likely due to the challenge
imposed on the systems necessary for maintenance of postural stability. Maintenance of postural
stability during both dynamic and static conditions involves establishing an equilibrium between
destabilizing and stabilizing forces and requires sensory information derived from vision, the
vestibular systems, and somatosensory feedback.

Management of balance in specific conditions

Parkinsons disease
Parkinsons disease (PD) is a progressive neurodegenerative disease. Its 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. [11]
The physiotherapist is a member of the multidisciplinary team, with the purpose of maximising
functional ability and minimising secondary complications. Physiotherapy for Parkinsons
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. [12] [13]
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 [14]
Example: Sit to stand [15]
1. Hands on chair
2. Place feet correctly
3. Move forward

4. Flex trunk
5. Rise up from chair
Cueing strategies
The performance of automatic and repetitive movements of patients with PD is disturbed as a
result of fundamental problems of internal control. Thats 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. [14] [16]

Auditory (moves on music/ walkman, singing, counting,...)

Visual (p follows another person, walks over stripes on the floor or over stripes he
projects to himself with a laserpen,...)

Tactile(p taps his hip or leg)

The physical therapeutic intervention goals apply to the phase addressed: [16]
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.

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.[17]
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.[18]

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 musics 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.

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.

Tai chi - tai chi has been proven to be an economic and effective way for training balance
in older people. [19]
To ameliorate balance in elderly it isnt 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. [20]

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