- Provides CNS with info about position and movement of head with relation to gravity - CNS: Cerebellum - PNS: Labyrinth of inner ear - Semicircular canals: Respond to movement of fluid with acceleration and deceleration of head - Otolith: measures acceleration and orientation of head with reference to gravity - Stabilizes gaze during head movement (VOR) and regulates postural tone/control via VSR

- Applications of external force acting on the body to displace COM - Used to assess vestibular

- Proprioceptive and tactile info - Receptors provide proprioceptive info about length, tension, pressure, pain, joint position - Receptors located in joints, muscles, ligaments, skin

- Change surface area (standing or sitting) to test balance - Stationary surface vs moving surface, solid vs foam - Used to assess somatosensory

Receptors provide perceptual acuity info about - vertical - motion of objects - motion of self - environmental orientation - postural sway - movements of the head and neck

Affects sense of movement and rotation - Of self - Of environment

- Nonvolitional, rhythmic oscillation of eyes - Abnormal eye movements - Normal end range

05-06: Balance Flashcards by Ken Panganiban

Definition of balance

A state of physical equilibrium
Maintenance and control of COG within BOS
Achieving and maintaining upright posture

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Systems that contribute to balance (3)

Vestibular
Somatosensory
Visual

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Vestibular Input

Provides CNS with info about position and movement of head with relation to gravity
CNS: Cerebellum
PNS: Labyrinth of inner ear
Semicircular canals: Respond to movement of fluid with acceleration and deceleration of head
Otolith: measures acceleration and orientation of head with reference to gravity
Stabilizes gaze during head movement (VOR) and regulates postural tone/control via VSR

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Perturbations

Applications of external force acting on the body to displace COM
Used to assess vestibular

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Somatosensory Input

Proprioceptive and tactile info
Receptors provide proprioceptive info about length, tension, pressure, pain, joint position
Receptors located in joints, muscles, ligaments, skin

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Challenges

Change surface area (standing or sitting) to test balance
Stationary surface vs moving surface, solid vs foam
Used to assess somatosensory

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Visual Input

Receptors provide perceptual acuity info about

vertical
motion of objects
motion of self
environmental orientation
postural sway
movements of the head and neck

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Assessing visual input

Eyes open
Eyes closed
Dim lighting
Dark

If visual input is taken away and balance gets worse, visual system is compensating for impairment elsewhere

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Vestibuloocular reflex (VOR)

Allows for head-eye movement coordination
Supports gaze stabilization: Eyes can move while head is fixed, Visual tracking can occur when both eyes and head are moving

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Vestibulospinal reflex (VSR)

Stabilizes the body and controls movement
Stability of trunk while head is moving
Coordination of trunk during upright postures

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Automatic postural strategies (4)

Maintain COG over BOS
Ankle: Elicited by small range and slow velocity force, challenge or perturbation when feet on ground; muscles contract distal to proximal
Hip: Elicited by greater force, challenge or perturbation through pelvis and hips; hips move in opposite direction of head; muscles contract proximal to distal
Suspensory: Lowering COG during standing and ambulation in order to control COG; Used when both stability and mobility required (surfing)
Stepping: LE or UE reaches out when challenge/perturbation moves COG outside BOS; UE = sitting balance, LE = standing balance

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Vertigo

Affects sense of movement and rotation

Of self
Of environment

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Nystagmus

Nonvolitional, rhythmic oscillation of eyes
Abnormal eye movements
Normal end range

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Vestibular rehabilitation

Addresses central or peripheral balance disorders
Exercises address: compensation, adaptation, plasticity
Intervention goals: Increase brain sensitivity, restore symmetry, improve VOR control, increase motor control and movement

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Static Standing Tests

Romberg Test
One legged stance (cross arms, stand on one leg)
Timed standing test
Clinical Test for Sensory Interaction on Balance (CTSIB): Foam and Dome Test
SOT: Computerized posturography of CTSIB

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Active Standing Tests

Functional Reach
Sensory Organization Test (SOT)
Gait observation

Dynamic Balance Tests

Tinetti Performance Oriented Mobility Assessment (POMA)
Berg Balance Scale
Timed Up and Go Test (TUG)

Nystagmus Tests

Head-shaking test
Head-thrust test
Hallpike-Dix test
Electrooculography
Saccadic Test
Gaze Test

Functional Balance Grades

4 = Normal: Pt able to maintain balance without handheld support (static); pt accepts max challenge and can shift weight easily within full range in all directions (dynamic)
3 = Good: Pt able to maintain balance without handheld support, limited postural sway (static); pt accepts mod challenges; able to maintain balance while picking object off floor (dynamic)
2 = Fair: Pt able to maintain balance with handheld support, may require min assistance (static); pt accepts min challenge, able to maintain balance while turning head/trunk (dynamic)
1 = Poor: Pt requires handheld support and mod to max assistance to maintain position (static); pt unable to accept challenge or move without loss of balance (dynamic)
0 = Absent: Pt unable to maintain balance

Berg Balance Scale

Assesses fall risk
Categories: static, transitional, dynamic activities in sitting/standing
14 tasks on an 0-4 ordinal scale, Max 56
Less than 45 = higher risk of fall

BBS Scoring (Risk of fall)

> 45 = normal
41-45 = mild
34-41 = moderate
< 35 = severe

Functional Reach Test

Assesses standing balance, risk of falling
Yard stick measures reach without moving feet
Average of 3 trials assessed in standing or sitting

Function Reach Standards

20-40 yo: men 16.7” (+1.9); women 14.6 (+2.2)
41-69 yo: men 14.9” (+2.2); women 13.8 (+2.2)
70-87 yo: men 13.2” (+1.6); women 10.5 (+3.5)

TUG Test

Assesses level of mobility and balance
Scores based on: amount of postural sway, excessive movements, reaching for support, side stepping, other signs of LOB
Requiring more than 20 seconds indicates increase in falls

TUG Scoring

Normal: < 10 sec Mild Impairment: 11-15 sec Mod Impairment: 15-20 sec Severe: > 20 sec

Romberg Test

- Assesses proprioceptive contribution - Unsupported standing > Feet together > UE folded > EO > EC - Normal = able to maintain position for 30 sec

Romberg Scoring

- Negative: No LOB when standing with feet together, arms crossed (EO or EC) - Positive: LOB when standing with feet together, arms crossed (EO or EC)

Tinetti (POMA) Test

- Assesses risk of falling during gait | - Two tests: Balance, Gait

Tinetti Scoring

- Max score: 28 - Normal: > 24 - Mild: 21-24 - Mod: 17-20 - Severe: < 17

CTSIB Test

- Determines effectiveness of different balance input system - 1st: determines baseline (all 3 systems) - 2nd: Visual is removed - 3rd: Visual reference is removed by use of dome (tests vestibular) - 4-6: Perform on foam for unstable somatosensory input - Monitor sway for 30 seconds on each position

Activity Balance Confidence Scale

- Self-report (16 point scale) - 0% = no confidence - 100% = completely confident

Falls Efficacy Scale

- Self-report - Low score = Less fear of falling - 70 = Fear of Falling