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Intro to Practice 3 Neuro > Balance > Flashcards

Balance Flashcards

1
Q

Define balance

A

The static or dynamic equilibrium of the body, relative to the support base:
Balance is maintained as long as the COG remains over the BoS

Balance is not based on a fixed set of equilibrium reflexes but on a flexible, functional motor skill that can adapt with training and experience

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2
Q

What is needed for balance

A

Sensory input:

  1. Proprioception
  2. Vestibular
  3. Visual

Central Processing:

  1. Sensory input into sensory cortex
  2. Motor initiation (basal ganglia) to motor output (motor cortex)
  3. Cerebellar co-ordination

Motor output:

  1. Muscle length, strength, power, endurance, tone
  2. Joint ROM

Balance reactions:

Saving and protective reactions:

  1. Visual fixing
  2. Lowering COG (requires muscle control)
  3. Stepping reactions
  • Ankle and hip strategies*
  • Head and trunk RR*

Feedforward mechanisms:

  • Storage of learnt movement patterns in basal ganglia
  • Anticipatory movement

Feedback mechanisms:

  • Continuous sensory feedback
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3
Q

Where does sensory input comes from

A
  1. Vestibular system
  2. Vision
  3. Proprioception
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4
Q

What needs to remain intact for balance to be maintained

A
  1. Intact sensory receptors
  2. Intact PNS and CNS to transmit, receive and process sensory information
  3. Intact CNS and PNS to initiate, transmit and produce motor output
  4. Intact musculoskeletal system to produce movement
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5
Q

State type and function of the sensory receptors

A

Exteroceptive:

External environment: pain, touch, temp, vision (cones, rods in eyes)

  1. Free nerve endings - pain, touch, temp
  2. Merkel discs - touch
  3. Krause end bulb (in skin) - touch
  4. Root hair plexus - touch
  5. Meisner corpuscles (close to epidermis) - light touch
  6. Pacinian corpuscles (deeper in skin) - pressure, deep touch
  7. Ruffini endings (deep in skin) - pressure, deep touch

Proprioceptive:

Body position: from muscle, tendon, joint capsule

Muscle spindle, golgi tendons, joint receptors picking up info from stretching in muscles, muscle tension, joint movement & position

Interoceptive:

internal pain, unconscious sensation, from deep structures, vestibular

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6
Q

What is needed for sensory information to be transmittedted, received and processed

A

Intact sensory pathways:

  1. Dorsal columns – gracilis and cuneatus – touch, position and vibration
  2. Spinothalamic – pain and temp
  3. Spinocerebellar - proprioception

Intact sensory central processing:

  1. Sensory information to sensory cortex in Parietal lobe
  2. Sensory cortex perceives different parts of the body in different place – sensory homunculus
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7
Q

What is needed to initiate, transmit and produce motor output

A

Intact motor central processing:

  1. Motor cortex in the back of the frontal lobe links with the basal ganglia to produce movement
  2. Different areas of the cortex will stimulate different areas in the body - motor homunculus

Intact motor pathways:

  1. Corticospinal - Lateral – motor info for limbs, anterior – motor info for axial muscles
  2. Vestibulospinal - Integration of head and neck and trunk with extremities
  3. Reticulospinal - Lateral – facilitates flexion and inhibits extension. Medial – opposite
  4. Rubrospinal - Control of fine movement
  5. Tectospinal - Controls muscles in response to visual stimuli
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8
Q

The cyclical process of balance is co-ordinated mainly in which part of the brain

A

Cerebellum

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9
Q

What is needed to produce movement

A

Intact peripheral motor systems:

  1. Alpha motor neurone
  2. Muscle strength/length/power/endurance/tone
  3. Joint range
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10
Q

What is the structure & function of the vestibular system

A

Structure:

  1. Located in the inner ear; deeper than hearing mechanisms
  2. Made up of three semi-circular canals and otoliths
  3. Semi-circular canals pick up rotation, nodding, side flexion
  4. Fluid in semi-circular canals move and stimulate hairs that send info along vestibular nerves into brain

Function:

  1. Vestibular pathways - Vestibular afferents synapse on the vestibular nuclei in medulla and pons (brainstem) and send info to cerebellum
  2. Provides information to brain about movement and position of head
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11
Q

Name the automatic balance reactions you may see?

A

Ankle strategy

Move somebody challenge their balance

Looking for DF to pull pt forwards when pushed back

Looking for PF to pull backwards when pushed forwards

Hip strategy

Same as ankle but larger movements

Looking for hip reaction to keep CoG over BoS

Head and trunk righting reactions

Learned as a child and it becomes automatic with aging;

Lost in brain damage thus re-education required

Protective and saving reactions

Visual fixing on something

Lowering COG (requires muscle control)

Stepping reactions

Step done when CoG moves out of BoS

No reactions

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12
Q

State balance mechanisms

A
  1. Reactive - feedback return to stability after perturbation and in response to displacement; compensatory
  2. Proactive - feedforward and anticipatory learned response in response to expected displacement
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13
Q

How to assess for sensory input impairments

A
  1. Vestibular - Rapid movement tests
  2. Vision - Visual field
  3. Proprioception - Mirroring/joint position sense
  4. Somatosensory - Light and deep touch, sharp and blunt
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14
Q

How to assess for central processing impairments

A

Tone (high or low):

  1. AROM & PROM
  2. Damage to either alpha-motor neurone, descending pathways, motor cortex

Initiation of movement:

  1. AROM & function
  2. Damage to basal ganglia

Coordination:

  1. FTN/HTS and function
  2. Damage to cerebellum

Smooth movement:

  1. FTN/HTS and function
  2. Damage to cerebellum, descending pathways

Reactive:

  1. Function
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15
Q

How to assess for motor output impairments

A
  • Tone - PROM/reflexes
  • Muscle strength - Isometric or isotonic or AROM
  • Joint ROM - AROM/PROM
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16
Q

What can you do in clinical practice to challenge balance?

A
  1. Reduce BoS – narrow stance, step stance, tandem stance, one foot
  2. Increase CoG – lying, sitting, perched sitting, standing
  3. Take away senses
  4. Encourage automatic reactions – balloon tapping, rolling, throwing & catching
  5. Add reactive or proactive elements
  6. Add dual tasking – functional activities, cognitive tasks
17
Q

Standing balance treatment ideas

A

Individual - Step stand

Task - Standing/standing and throwing ball/heel lifts/onto toes/kick a ball, trap a ball/standing with a push

Environment - Standing on stable/unstable surface

Individual - Feet together forwards, backwards, sideways

Task - Standing with one foot on step

Environment - Use of parallel bars

Individual - Feet apart

Task - Sit to stand/stand to sit/squats/picking object up off the floor

Environment - High plinth, low plinth or perched sitting– sit to stand

Individual - Tandem stand

Task - Stepping with unaffected leg – forwards, backwards, sideways, step

Environment - Use gym ball, step - Sit to stand

Individual - Eyes open/closed

Task - Stepping with affected leg – forwards, backwards, sideways, step

Environment - Use of step, rollerskate, cloth

Individual - Talking

Task - Sliding foot with cloth/rollerskate

Environment - Use of table – front/side

Individual - Use of arms

Task - Standing and reaching – forwards/sideways/back

Environment - Use of ball, balloon, cones, functional objects

18
Q

Outcome Measures for balance

A
  1. TUSS (Time unsupported steady standing/sitting) < 1 min at risk of fall
  2. Rombergs Test
  3. FR (Functional reach) <6” at risk of falls
  4. 180 turn <7 secs or >5 steps at risk of fall
  5. POMA (Performance Oriented Mobility Assessment or Tinetti) < 19 at risk of fall
  6. BBS (Berg Balance Scale) <45 = risk of fall
  7. GUAG (Get Up And Go)
  8. Four square step test
  9. Five times Sit to stand
  10. Alternate step test
  11. Star Excursion test (outpatient)
  12. Y balance test (outpatient)
19
Q

Balance Rehab ideas in lying

A
  1. Holding crook lying; controlled knee rolling and return to midline
  2. Bridging, asymmetrical bridging, one legged bridging
20
Q

Balance Rehab ideas for trunk alignment

A

Trunk alignment:

  1. Sitting behind patient to increase BOS
  2. Hands on either side of trunk – move from side to side, alternate elongation of either side
  3. Progress into flexion (focus on lat dorsi stretch (flexion / rotation)
  4. Once patient is symmetrical, facilitate sitting up straight / dropping back.
  5. Progress to touch my hand (with good hand - and affected hand on lap)
  6. Show tapping beach ball balloon to keep ‘fixing arm’ active

Weight-bearing in sitting:

  1. Touch my hand
  2. Sitting up straight, crossing good leg over bad leg
21
Q

Aims of standing

A
  1. Increase proximal stability
  2. Increase extensor activity (in general and on affected side)
  3. Stimulation of balance reactions
22
Q

Methods to facilitate standing

A
  1. Symmetrically sitting on edge of high plinth. Gradually bring patient into standing, blocking their affected knee and encouraging equal weight bearing.
  2. As above but with unaffected foot 1-2” in front of affected foot to increase weight bearing on affected limb
23
Q

Standing balance progression rehab ideas

A
  1. Facilitate balance reactions (perturb – realign) include tapping & ‘don’t let me move you’.
  2. Perched sitting – stand (handling to facilitate affected side) – symmetrical and asymmetrical (to hemi side)
  3. Progress to lower sitting – stand (in midline and to affected side)
  4. Transfer weight onto affected limb (handling: facilitation not forcing)
  5. Stimulation of balance reactions (facilitation of extension / abduction of weight bearing hip)
  6. Standing to perched sitting
  7. Perched sitting to standing
  8. Standing to sitting to one side
  9. Standing, turn and lower one side of bottom to plinth
  10. Perched sitting, to standing over affected leg
  11. Symmetrical standing: gentle flex / ext good knee (stops fixing)
  12. Heel lifts (good leg)
  13. Progress to side step with good leg
  14. Progress to fwd / back steps
  15. Stepping on / off block
  16. Unaffected leg on cloth (polishing floor)
  17. Unaffected foot on roller skate
  18. Unaffected foot on block: slow, controlled squats with affected leg
  19. Simultaneous activities in upper limb to promote proximal stability

Intro to Practice 3 Neuro (13 decks)

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