1st law: Standing balance begins when the hands let go. If patient unable to stand without hand support, do not introduce balance challenges. Instead, focus on exercises to help patient reduce and eliminate need for hand support. Wait until patient is able to stand and let go, before adding balance challenges.
2nd law: Add movement or stance challenges before introducing unstable or uneven surfaces. For static balance exercises, surfaces challenges (foam, rocker board, hip stick, etc.) create larger balance disruptions than most movements (head turns, reaching up, weight shifting, etc.) or stances (feet together, split stance, heel-toe stance, etc.). As such, when introducing balance challenges, start by adding new movements or stances, and then progress to unstable surfaces when bigger challenges are needed.
3rd law: Training should address static, dynamic, and reactionary balance. Not all balance exercises work in the same manner and, furthermore, there is little carryover among the three types of balance. Knowing this, balance training should incorporate static, dynamic, and reactionary balance exercises as appropriate.
4th law: In order to bias balance challenges in one plane of motion, you can add movement, narrow the base of support, and/or limit the surface support in that same plane. For example, a patient that loses their balance backward (sagittal plane), will benefit from balance challenges that are biased to the sagittal plane. Movements in the sagittal plane include head tilts, weight shifting forward-back, reaching overhead, hip swivels, etc. Standing with feet together is an example of narrowing the base of support in the sagittal plane. Conversely, standing with a split stance (one foot forward and the other back) is an example of widening the base of support in the sagittal plane, which would make balancing easier. Examples of limiting support in the sagittal plane include standing on foam, hip stick, rocker (with AP rock), inflatable surface, etc.
5th law: Balance training intensity ratio is 20% steadiness: 20% unsteadiness. Patients should be steady at least 20% of the exercise time AND unsteady at least 20% of the exercise time. Unlike speed on a treadmill or weights on a bar, steadiness is not a constant when performing balance exercises. Patients will fluctuate in and out of steadiness while training balance. The goal is provide a balance intensity that allows the patient to experience both steadiness and unsteadiness while exercising.
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