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Objectives

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After completion of this chapter, the physical therapist should be able to do the following:

  • Define and explain the roles of the 3 sensory modalities responsible for maintaining balance.

  • Explain how movement strategies along the closed kinetic chain help maintain the center of gravity in a safe and stable area.

  • Differentiate between subjective and objective balance assessment.

  • Differentiate between static and dynamic balance assessment.

  • Evaluate the effect that injury to the ankle, knee, and head has on balance and postural equilibrium.

  • Identify the goals of each phase of balance training, and how to progress the patient through each phase.

  • State the differences among static, semidynamic, and dynamic balance-training exercises.

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Although maintaining balance while standing may appear to be a rather simple motor skill for able-bodied athletes, this feat cannot be taken for granted in a patient with musculoskeletal dysfunction. Muscular weakness, proprioceptive deficits, and range of motion (ROM) deficits may challenge a person’s ability to maintain their center of gravity (COG) within the body’s base of support, or, in other words, cause them to lose their balance. Balance is the single most important element dictating movement strategies within the closed kinetic chain. Acquisition of effective strategies for maintaining balance is therefore essential for athletic performance. Although balance is often thought of as a static process, it’s actually a highly integrative dynamic process involving multiple neurologic pathways. Although balance is the more commonly used term, postural equilibrium is a broader term that involves the alignment of joint segments in an effort to maintain the COG within an optimal range of the maximum limits of stability (LOS).

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Despite often being classified at the end of the continuum of goals associated with therapeutic exercise,45 maintenance of balance is a vital component in the rehabilitation of joint injuries that should not be overlooked. Traditionally, orthopedic rehabilitation has placed the emphasis on isolated joint mechanics, such as improving ROM and flexibility, and increasing muscle strength and endurance, rather than on afferent information obtained by the joint(s) to be processed by the postural control system. However, research in the area of proprioception and kinesthesia has emphasized the need to train the joint’s neural system.46-50 Joint position sense, proprioception, and kinesthesia are vital to all athletic performance requiring balance. Current rehabilitation protocols should therefore focus on a combination of open- and closed-kinetic-chain exercises. The necessity for a combination of open- and closed-kinetic-chain exercises can be seen during gait (walking or running), as the foot and ankle prepare for heel strike (open chain) and prepare to control the body’s COG during midstance and toe off (closed chain). This chapter focuses on the postural control system, various balance training techniques, and technologic advancements that are enabling therapists to assess and treat balance deficits in physically active people.

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Postural Control System

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The therapist must first have an understanding of the postural control system and its ...

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