Lower-level patients typically cannot stand without touching or holding onto something sturdy - walker, dresser, counter, chair, etc. If these patients where to let go, e.g., stand without touching/holding anything, they would likely sway, tip, or tilt and lose their balance. For this type of patient, balance exercise selection should focus on reducing their need for hand support. The 5-step exercise progression discussed below will help you better prepare patients to stand and balance without hand support, which, ultimately, helps better prepare them for ADLs.
Step 1: Two-hands horizontal. In standing, the Individual relies on a horizontal support/surface (parallel bars, ADL Balance Trainer, edge of table, etc.) for balance. While holding on, the patient begins by finding and maintaining their balance center. Their balance center is the point of equal weight distribution side-to-side (not too heavy on left or right foot) and forward-back (not too heavy through heels or toes). This entry-level exercise helps the patient begin to build postural awareness and establish a foundation on which to better balance can be built.
Step 2: Two-hands vertical. The patient progresses from a horizontal surface/support to touching or holding a vertical support (poles, ADL Balance Trainer, etc.). Because the hands are positioned higher, the use of vertical supports help foster a more upright posture. An upright posture is important for reducing weight bearing in the arms and hands, and continuing to shift more of the balance demand to the trunk and legs.
Step 3: Two-hands unstable surface. Progressing from stable supports, the patient is now asked to place their hands on unstable surfaces, such as balls or hiking poles. While unstable surfaces provide sensory feedback through the hands, they do not provide much support for balancing. Because the balls or poles are free to rock, tilt, and roll, the balance demands are increasingly shifted to the trunk and legs, further preparing the patient to let go and stand without support.
Step 4: One-handed standing. Using only one hand for support, the patient progresses through steps 1,2, and 3 (horizontal, vertical, and unstable surfaces). The use of one hand continues to increase the workload on the trunk and legs for balance. NOTE: Alternate hands to build balance equally on both sides of body.
Step 5: Two-handed tasks. The last progression in guiding patients to stand without hand support is to introduce simple 2-handed tasks. Examples include uncoupling a stack of cones, passing a ring from one hand to the other, or uncoupling clothespins, to name a few. Because these simple exercises require the use of both hands, the individual must let go in order to complete the task.
As the patient gains steadiness and confidence in standing without hand support, consider progressing exercises by reducing the proximity of your spotting position (stand next to patient instead of sitting in front), decreasing the level of facilitation (less touching or supporting), and minimizing the amount of cuing/feedback (fewer tips and instructions).
About the Author: Shane Haas is a Physical Therapist with 20+ years of experience in the area of balance rehabilitation. He currently serves as Director of Rehabilitation at New Braunfels Regional Rehabilitation Hospital in New Braunfels, TX. He is also President and co-founder of ADL 365 Inc. (www.ADLbalance.com), a company that invents, tests, and makes exercise products to help improve strength and balance. Shane can be reached at firstname.lastname@example.org.