Therapeutic exercises for balance, coordination, and functional mobility. Basic principles, methods, and clinical applications

01How balance and coordination work

Think of a person as a tall pole standing on a small plate. As long as the pole's centre of weight stays above the plate, it stands; when it drifts beyond the edge, it falls unless a foot steps out to make a new plate. Balance (postural control) is the brain keeping that centre of mass over the base of support, standing still, moving, or when something pushes.

The brain needs to know where the body is. It takes three reports and compares them:

Healthy people lean mostly on the feet and joints on a firm floor. When one report is lost, the others can stand in for it, which is why a person without position sense stands well with eyes open but falls when the eyes close. That is the logic of the Romberg test.

The answer comes as movement strategies, chosen by how big the push is:

1. 1

   Ankle strategy

   A small sway is corrected by the calf and shin muscles, moving the body like a stiff pole around the ankles. Needs a firm, wide floor.
2. 2

   Hip strategy

   A bigger or faster sway, or a narrow or soft surface, is corrected by bending at the hips, moving the trunk against the legs.
3. 3

   Stepping strategy

   When the centre of mass passes the edge of the feet, a quick step makes a new base. Slow stepping is one of the main reasons older people fall.

Balance also works ahead of time: before you lift your arm fast, your legs and trunk tighten first (anticipatory control). After a trip, the reaction comes afterwards (reactive control). Training needs both.

Coordination is movement that hits its target smoothly: the right muscles fire in the right order, with the right force and timing, while the opposite muscles let go. The cerebellum compares the plan with what happens and corrects it; position sense tells it what happened. Poor coordination is ataxia, and its cause shapes treatment:

• Cerebellar ataxia: wide, staggering gait, overshoot (dysmetria), tremor near the target, clumsy fast alternating movements; it is as bad with eyes open as closed.
• Sensory ataxia: stamping gait watching the floor, much worse in the dark, Romberg positive.
• Vestibular ataxia: veering to one side, dizziness, worse with head turns.

02Assessing balance, coordination and mobility

Training starts with a baseline, so the change can be measured later.

The professor's school adds dynamic somatoscopy of walking and stepping patterns, and instrumented gait analysis with force plates, motion capture and surface electromyography where it is available. These are covered in functional assessment.

03Basic principles of training

Balance and coordination are skills, so they are learned the way any skill is learned: by practice that is specific, repeated, gradually harder and safe.

• Individual: train what is broken for this patient, at the level where they just manage.
• Task-specific: practise the real thing. Standing up from a chair trains standing up; a cerebellar patient learns to walk by walking, not only by lying exercises.
• Progression: just hard enough that the patient wobbles but does not fall. When it becomes easy, change one thing to make it harder.
• Variety: different surfaces, speeds, directions and senses, so the skill carries over to the street and the bathroom.
• Feedback: mirror, the therapist's words, a video, or a force platform, then less of it over time so the patient relies on their own senses.
• Repetition: a skill needs hundreds of practice tries, spread over many days.
• Safety: a non-slip floor, a rail or a parallel bar within reach, a therapist close by, a gait belt for high-risk patients.

04Methods: balance exercises

Every balance exercise sits somewhere on a few ladders. Moving one rung up on one ladder makes it harder; this is how the exercise is dosed.

Static balance means holding a position with less base or support; dynamic balance means moving while keeping control (weight shifts, reaching, stepping in all directions, walking on a line, turning). Programmes that work combine both, and in older people add strength training for the legs, because weak hip and ankle muscles cannot carry out the strategies.

Examples of established programmes:

• The Otago exercise programme: leg strengthening and balance exercises at home, with a walking plan, made for older people.
• Tai chi: slow, continuous weight shifting on bent knees; it reduces falls in older people living at home.
• Vestibular rehabilitation: for inner ear loss. Gaze stabilisation exercises (keeping the eyes on a target while turning the head) drive the brain to recalibrate; habituation exercises repeat the movements that provoke mild dizziness until it fades; substitution teaches use of vision and the feet. The older Cawthorne-Cooksey programme follows the same idea.
• Exergaming and balance platforms: a screen gives feedback on weight shift. They motivate, but are not better than good conventional training.

05Methods: coordination exercises

Coordination exercises repeat a precise movement many times, slowly at first, then faster, with less help from the eyes, and in more complex combinations.

Frenkel's exercises were designed for sensory ataxia (originally tabes dorsalis). The patient lies, then sits, then stands, and moves a limb slowly and precisely to targets (heel to knee, heel along the shin, foot into marked squares on the floor), watching the movement. Vision replaces the missing position sense. They need concentration and many repetitions, are done in short sessions because they tire the patient, and are made harder by speeding up, changing rhythm, and finally closing the eyes.

For cerebellar ataxia, the aim is control of the trunk and steady, rhythmic movement:

• trunk stability work in four-point kneeling, kneeling and sitting on a ball;
• slow, rhythmic movements to a beat (counting, a metronome), targets on a wall, stacking blocks;
• walking practice on a line, with turns, and with starts and stops;
• light weights on the wrists or ankles and heavier walking aids are sometimes used to damp the tremor; they help some patients for the time they are worn and do not retrain the cerebellum.

In the hand and arm, coordination training is mostly task practice: picking up small objects, writing, buttoning, pouring. Occupational therapy brings these into daily life.

06Functional mobility: from the bed to the street

Functional mobility is the ladder a patient climbs back to independence. Each step needs balance, strength and coordination, and each is practised as a whole task.

1. 1

   Bed mobility

   Rolling to each side, bridging (lifting the hips), moving up the bed, coming to sitting over the edge.
2. 2

   Sitting balance

   Sitting unsupported, then reaching outside the base of support. Good sitting balance early after a stroke predicts walking later.
3. 3

   Transfers

   Sit to stand (feet back, lean forward, nose over toes), bed to chair, onto a toilet, into a car.
4. 4

   Standing and walking

   Standing in parallel bars, then walking with a frame, crutches or a stick, then without.
5. 5

   Stairs, slopes and outdoors

   Stairs, kerbs, ramps, uneven ground, crowds, crossing a road in time.

Gait training

Gait training retrains the walking cycle: stance (60 per cent of the cycle, from heel strike to toe off) and swing (40 per cent). Practice includes walking between parallel bars, with a mirror, over markers that set step length, over and around obstacles, on a treadmill (with body-weight support through a harness for patients who cannot yet carry their weight), backwards and sideways, and with a second task. Speed is the simplest single number to follow: below about 0.8 m/s a person usually walks only indoors or locally.

Walking aids

A walking aid widens the base of support and takes load off a leg. More support means more stability but a slower, less natural gait, so the patient is given the least support that keeps them safe.

The rules for fitting and use follow from the levers:

• A stick goes in the hand opposite the painful or weak leg. The farther the stick is from the bad hip, the longer its lever, so a small push on it unloads the leg a lot. It moves forward together with the bad leg, as the arms swing naturally.
• The handle is at the level of the wrist crease (or the greater trochanter) with the arms hanging, so the elbow bends about 20 to 30 degrees when holding it.
• An axillary crutch top stays about 3 finger widths (about 5 cm) below the armpit, and the weight goes through the hands. Leaning on the armpit compresses the radial nerve and brachial plexus (crutch palsy).
• Stairs: up with the good leg first, down with the bad leg first ("the good go up to heaven, the bad go down"), the stick or crutches moving with the bad leg, and a rail used whenever there is one.

Crutch gait patterns follow how much weight the leg may take: a three-point gait (both crutches and the injured leg forward together, then the good leg) for non-weight-bearing or partial weight-bearing; a four-point or two-point gait (opposite crutch and leg together) when both legs bear some weight; swing-to and swing-through gaits for paraplegia with braces.

Terrain treatment

Terrain treatment is walking on marked outdoor routes chosen for their length and slope, a method from spa medicine (Oertel's "Terrainkur"). It trains endurance, balance and adaptation to uneven ground together. The dose is set by the length of the route, its slope, the walking speed, and the number and length of rests. The professor's slides give sessions of 10 to 45 minutes, 2 to 5 times a week, starting on level, firm paths and moving on to slopes, soft ground (sand, grass, snow) and obstacles. Nordic walking with poles is a modern form.

07Dosage and progression

or more of challenging balance and strength exercise in the programmes with the biggest effect on falls

3hours a weekor more of challenging balance and strength exercise in the programmes with the biggest effect on falls

of a falls-prevention programme, then kept up

12weeks at leastof a falls-prevention programme, then kept up

fewer falls with exercise in older people living at home

23per centfewer falls with exercise in older people living at home

fewer falls when balance and strength training are combined

34per centfewer falls when balance and strength training are combined

The professor's slides suggest balance and locomotion exercises at low to moderate intensity in short bouts, 5 minutes, several times (up to 5) a day. Short, frequent bouts suit a patient on a ward who tires quickly, and frequent practice helps learning. For preventing falls in older people the trials point to a larger total dose: about 3 hours a week of exercise that really challenges balance in standing, at least 3 times a week, progressive, for 12 weeks or more and then continued.

08Clinical applications

Evidence: in older people living at home, exercise that challenges balance reduces the rate of falls by about a quarter (high-certainty evidence), and more when combined with strength training. After stroke, task-specific practice of standing, walking and transfers improves those tasks. Vestibular rehabilitation has good evidence in one-sided vestibular loss.

09Safety and contraindications

There are almost no absolute contraindications to balance training, only to doing it unsafely. The risk is the fall, so the setting is matched to the patient:

• A high-risk patient never trains alone: the therapist stands on the weak side, a gait belt is used, and the exercise is done beside a rail or in parallel bars.
• Non-slip floor, good light, proper shoes, no rugs or cables.
• Stop and check if there is chest pain, breathlessness, new dizziness or palpitations, or a sudden drop in blood pressure on standing (measure lying and standing in people with fainting or Parkinson's disease).
• Postpone in acute illness, uncontrolled heart disease, an acute attack of vertigo with vomiting, or unhealed fractures that may not bear weight.
• Watch for fatigue: coordination and balance get worse when tired, so a short session that ends while the patient still performs well is better than a long one that ends in a stumble.