Balance and Falls
Nancy V. Karp, Ed.D., P.T.
[email protected]
Normal Postural Control
Postural control involves controlling the
body’s position in space for:
Stability
 Orientation

Falls

Falls in the elderly are a major cause of:
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morbidity
Mortality
The underlying causes of falls is a complex
interaction of:
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Biomedical factors
Physiological factors
Psychosocial factors
Environmental factors
Incidence and Cost of Falls in the Elderly
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Falls of people 65+
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One third of people 65+ fall each year.
Elders > 75 account for 60% of fall-related deaths.
25% of elders who fracture their hip in a fall will
die within a year.
Costs

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Falls account for 70% of all injury-related costs for
the elderly,
The average cost for a fall injury is $20,000.
Falls in the Elderly
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Most falls result in minor or no injury.
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Repeat fallers tend to fall in the same manner
as they did in the previous fall.
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A single fall results in:
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Fear of falling and loss of confidence
Restriction in activities
Social isolation
Dependence on others
Identification of Fall Risk Factors

Risk factors for falls are divided into two categories:

Intrinsic Risk Factors
Dizziness, weakness, gait abnormalities, poor balance,
confusion, poor coordination, ROM, cognitive impairment
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Extrinsic Risk Factors
Floor surface, poor lighting, cluttered furniture, obstacles,
non-level surface, poor shoes
Falls are a result of loss of
postural control.
Normal Postural Control (Balance)
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Balance requires keeping the “Center of
Mass” (COM) over the “Base of Support”
(BOS) during static and dynamic situations.
Neural components of postural control:

Sensory processes
visual, vestibular, somatosensory

Central processing
a higher-level integrative process
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Effector component
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sometimes referred to as the neuromuscular component
postural alignment, ROM, muscle force, power &
endurance
Normal Postural Control
Adaptive postural control requires
modifying sensory and motor systems
to changing tasks and environmental
demands.
Postural Control During Quiet
Stance

Body aligned to minimize the effect of
gravitational forces.

Muscle tone

Postural tone
Quiet Stance
Limits of Stability (LOS)

The maximum angle (from vertical) that
can be tolerated.
How far you can shit from front to back and
side to side without loosing balance? This
is often called your “Cone of Stability.”

“Postural Sway” refers to small postural
shifts from front to back and side to
side, during quiet stance.
Limits of Stability
Cone of
Stability
Cone of
Stability with
Assistive
Device
Postural Sway

The larger the sway path, the greater
the postural unsteadiness.

Romberg Test- Closing eyes will
decrease visual input. “Standing
Postural Sway” may increase,
decreasing balance.
Postural Control During
Perturbed Balance

The recovery of stability requires
movement strategies that control the
COM over the BOS.

“Limits of Stability” is defined as the
distance a person can move, without
losing balance or taking a step.
Perturbed Balance
Movement Strategies
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The “ankle strategy” occurs
with minimal perturbance of
balance.
Control is distal- to-proximal
Perturbed Balance
Movement Strategies
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Moderate instability leads to
the “hip strategy”.
Control is proximal-to-distal
Perturbed Balance
Movement Strategies
The “stepping strategy” is
used with greater
perturbance.
Perturbed Balance
Central Nervous System

The response can either be protective
or corrective.

“Anticipatory Postural Control” refers to
postural adjustments that are made
before voluntary movements to
minimize disturbances in balance (feed
forward).
Perturbed Balance
Central Nervous System
“Reactive control” is the response to a
disturbance in balance (feedback).

Corrective Strategy, such as the “ ankle strategy”
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Protective Strategy, such as covering your head
when you fall
This does not correct the fall, but controls the effects of
the fall.
Perturbed Balance
Movement Strategies

The CNS activates muscle synergies in
related joints.
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Force in one part of the body does not cause
instability in another part of the body.
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Leaning over in a chair to pick up a pen, you do not fall
out of the chair.
Neck extension during the “hip strategy” prevents the
body from falling forward.
Central Processing Tests
Manual Test of Postural Perturbance
Therapist pulls patient, at waist level,
several times with varying degrees of
force.
 See Guccione, p. 287
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Normal Postural Control
Sensory System

During perturbance of balance:
Adults rely on somatosensory inputs.
 Children rely more on visual input.
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The interaction of the senses allows the
modification needed to maintain stability
in a variety of environments.
Normal Postural Control
Sensory System

The three different parts of the sensory
system provide different sources of
information about the body’s position
and movement in space.

Each sense provides a different frame
of reference for postural control.
Normal Postural Control
Sensory System
The “Postural Dyscontrol” Test will be
performed in class.
“Foam and Dome Test”
O’Sullivan, p. 193
Normal Postural Control
Sensory System
Vision provides information about the position
and motion of the head in the environment.

Acuity- detects subtle differences in shapes
Snellen Eye Chart (min 20/200)
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Depth perception
Finger Test, Guccione p. 286
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Peripheral vision
Finger Test, Guccione p. 286
Normal Postural Control
Sensory System

The somatosensory system
provides information about the
body with reference to supporting
surfaces.

The somatosensory system
receives information from muscle
spindles, joint receptors, tendon
organs, and mechanoreceptors.
The Somatosensory system
Gross Tests of Proprioception
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Detecting the subtle movement of the big
toe (< 5mm).

Vibration- Placing a tuning fork at the first
metatarsal head.
Normal Postural Control
Sensory System
The Vestibular System
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Provides information about the position and
movement of the head, in reference to gravity and
inertial forces.
Information is received from the vestibule
responsible for position and linear acceleration.
Information is received from the semi-circular
canal responsible for rotational movement.
The Vestibular System
Gross Functional Tests
Guccione, p. 286
Looking at a object while turning head
 Reading a book while walking
 Marching in place with eyes closed
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Postural Control
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Controlling the body’s position in space
is an essential part of functional skills.
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Postural control requires all three:
Sensory system
 Central processing
 Effector components

Postural Control
The three systems in postural control
are complex and multifaceted. A
problem or impairment in one area may
affect several other areas, resulting in a
greater affect than the loss of the single
impairment.
The Effect of Aging on
Postural Control
The Sensory System
With aging, vision may decrease in acuity,
contrast sensitivity, and depth perception
 With aging, the vestibular system may
undergo age-related changes, resulting in
dizziness and unsteadiness.
 With aging, there may be a decrease in
proprioception and vibration.
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Aging Effects on Postural
Control
The Central Processing System
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Aging may result in a slowing of sensory
information.
Aging may result in a slowing of nerve conduction
velocity.
Aging may result in increased postural sway.
Aging may result in an increased incidence of cocontractions
Aging may result in an increased use of proximalto-distal control for balance.
Aging Effects on Postural
Control
The Effector System
Aging may result in decreased muscle
strength.
 Aging may result in decreased ROM and
flexibility.
 Aging may result in increased “stiffness” of
connective tissue
 Aging may result in cardiovascular
changes

Functional Tests
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Progressive Mobility Skills Assessment Task
Guccione, p. 288

Berg Balance Scale (note that the “Functional
Reach Test” is part of this test)
O’Sullivan, p. 208
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Performance-Oriented Assessment of
Mobility I (Tinetti)
O’Sullivan, p. 210
Other Assessments
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Environmental Assessments
Chapter 12, O’Sullivan
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Psychosocial Assessment
Cognitive assessments
 Social work assessments
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Interventions
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Interventions should be based on assessment
results.
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The ultimate goal will is to maximize independence in
mobility and function.

The therapist needs to identify and treat modifiable
deficits.

The therapist needs to identify and help the patient
compensate for deficits that cannot be modified.
Some balance exercises for
older people.
Exercises - National Institute on Agingl
Tandem
Walking
Fall Prevention
The purpose of assessment and
intervention is to prevent the next fall.
Balance and Falls
The End