Balance Flashcards
What is postural control?
Involves controlling body’s position in space
Postural stability: balance
Postural orientation: ability to maintain appropriate relationship between body segments and between body and the environment
What is part of posture examination?
Alignment in sitting and standing using plumb line/grid: vertical, symmetrical?
Foot position/BOS
Use weight scales under each foot to check for even weight distribution
Use of force plates
Is initial position appropriate for functional tasks?
Is initial position efficient?
Is initial position stable?
What are the 5 types of balance scales?
Quiet standing: Romberg, sharpened Romberg, one legged stance test (OLST), postural sway
Active standing: functional reach, multi directional reach
Sensory manipulation: sensory organization test (SOT), clinical test of sensory interaction and balance (CTSIB)
Functional scales: berg, TUG, tinetti, dynamic gait, functional gait
Dual task: stops walking when talking, multiple task tests
What do the 5 balance scales look at?
Dual task: cognitive demands while trying to maintain posture
Functional: performance of whole body movement
Sensory manipulation: alter surface or visual condition to see how CNS can use inputs for postural control
Active: goal is to voluntary weight shift
Quiet standing: goal is to stand still
What were disadvantages and advantages to the KUSB balance scale study?
more detailed than fair, poor, good; doesn’t require equipment
Disadvantage: ceiling effect (no stepping over objects, dual tasks, etc)
What is description of patient performance for KUSBS scores?
0: performs 25% or less of standing activity (max assist)
1: supports self with upper extremities but requires therapist assistance, performs 25-50% of effort (mod assist)
1+: patient performs more than 50% of effort (min assist)
2: independently supports self with both UEs
2+: independently support self with one UE
3: independently stands without UE support for up to 30 sec
3+: independently stands w/o UE support for 30 sec or greater
4: independently moves and returns center of gravity 1-2 inches in one plane
4+: independently moves and returns center of gravity 1-2 inches in multiple planes
5: independently moves and return center of gravity in all planes greater than 2 inches
What determines which balance test is appropriate?
Purpose and population you are testing
Reliability, validity and ease of use
Modifications
Are normative data available for comparison
Combination of postural orientation, anticipatory, reactive task components
What are characteristics of the one leg stance test?
Steady state
Fold arms across chest, picks one leg and holds in hip neutral and knee flexed to 90 degrees, test both sides
Normal subjects can stand for 30 seconds
Clinical significance: single stance during gait
Good inter rater reliability
What are characteristics of the Romberg?
Steady state
Feet together, assess sway eyes open vs. eyes closed
Abnormal if excessive sway, loss of balance or stepping
Modification is the sharpened Romberg: more challenging, feet in heel toe position, eyes closed for 60 seconds
What are characteristics of functional reach test?
Functional performance measure: active standing balance Single item test Less than 10 inches is a high fall risk High reliability and variability Modifications: sitting, other directions
What are the functional reach norms?
20-40: 16.7 for men and 14.6 for women
41-69: 14.9 for men and 13.8 for women
80-87: 13.2 for men, 10.5 for women
What is the multi directional reach test?
Examine limits of stability in forward and backward but also medial-lateral direction
What are characteristics of the berg balance scale
Measures balance by assessing the performance of functional tasks
14 item scale, 5 point scale ranging from 0-4
0 indicates lowest level of function
Interpretation: 41-56 is low fall risk, 21-40 is medium fall risk, 0-20 is high fall risk
Has sitting component
Ceiling effect
What is relationship between the berg and falls?
Berg is single best predictor of fall status.
Relationship is nonlinear
In range of 56-54 each 1 point drop score is associated with a 3-4% increase in fall risk.
In range of 54-46 a 1 point change in the scores led to a 6-8% increase in fall risk
What is the Tinetti performance oriented mobility assessment? Scores?
Gait and balance sub scores: 3 point scale
25-28 is low fall risk, 19-24 is moderate fall risk, less than 19 is a high fall risk
Reliability/validity: TUG, one leg stance, functional reach, POMA- POMA has best test reliability and predictive abilities for fall risk in people aged 65 years and older
What are the different balance things the Tinetti looks at?
Steady state balance: sitting and standing balance
Proactive balance: arising, attempts to arise, sit down
Reactive balance: nudge
Sensory component: eyes closed
What are self reports of balance?
Perception/fear of falling is important risk factors
Activity-specific balance confidence (ABC) test
Falls efficacy scale
Dizziness handicap inventory
What were findings of stroke edge task force?
4 rating: berg (3 for acute care), functional reach, postural assessment scale
3 rating: ABC test, STREAM mobility scale, trunk impairment scale
2 rating: BEST test, brunnel balance test, falls efficacy scale, Hi mat, tinetti/POMA
1 rating: trunk control test
What are parts of balance master assessment?
Steady state balance
Center of gravity location
Amount of sway
Functional performance
What are ways to assess sensory integration?
Sensory organization test (SOT): use movable force plate and movable visual surroundings to alter environement, 3 20 second trials under each sensory condition
Equitest
CTSIB: clinical version of SOT
What are the different conditions for the SOT?
Determines relative reliance on visual, vestibular, somatosensory input for postural control.
1: accurate senses
2: eyes closed
3: inaccurate visual cue
4: inaccurate somatosensory
5: no vision, inaccurate somatosensory
6: inaccurate vision and perception
How would we determine how the visual system is working?
Compare position 1 (all three senses accurate) to position 4 (support surface is sway referenced/somatosensory cues are inaccurate)
How would we determine how vestibular system is working?
Compare position 1 (accurate systems) to position 5 (no vision, inaccurate somatosensory)
What positions would we look at to determine how well the CNS and client can reorganize and suppress inaccurate visual input when they conflict with somatosensory and vestibular cues?
Compare position 3 (inaccurate vision) and 6 (inaccurate vision and perception) to positions 2 (eyes closed) and 5 (no visual cue and inaccurate somatosensory)
What is the CTSIB?
Clinical version of SOT
Doesn’t use force plate: uses thick foam substitute and modified Japanese lantern substitute for moving visual surroundings
3-5 trials of 30 sec each
Normally a subject can stand for 30 sec w/o loss of balance/condition
what are conditions for CTSIB?
1: eyes open and firm surface (all 3 systems available)
2: eyes closed and firm surface (somatosensory and vestibular available)
3: eyes open, visual conflict, firm surface (all three available but conflict between eyes and vestibular)
4: eyes open and unstable surface (vision and vestibular available)
5: eyes closed and unstable surface (vestibular available)
6: eyes open, visual conflict, unstable surface (available)
When will patients dependent on vision, somatosensory, or vestibular be unstable?
Vision: unstable in conditions where we close eyes or have conflict between vision and vestibular system (2, 3, 5, 6)
Somatosensory: unstable in conditions where we are standing on foam (4, 5, 6)
Vestibular: unstable in conditions where they can’t rely on vision or surface (5 & 6)
What are other objective tests for balance in vestibular/mobility?
TUG: assess fall risk, young adults can do this in 5-7 sec
Dynamic gait index: postural control during gait, gait level surface, change in gait speed, gait with horizontal head turns, gait with vertical head turns
What are goals for treatment of balance?
Use objective assessment to set goals and design treatment plan
Treat impairments that contribute to poor balance
Effective sensory and motor strategies to maintain postural control
Consider steady state, reactive, anticipatory control in functional environments
What is a model to treat balance impairments, and treatment strategy?
Systems model: identify what body system is contributing to balance disorder and treat appropriately
Strategy: postural alignment, motor strategies, sensory strategies
What are posture strategies?
Augmented feedback on symmetric/vertical posture: verbal cues, manual cues, visual cues, force plate
Practice eyes open/eyes closed
Effect of assistive device
What are motor strategies?
Ankle, hip, stepping strategy training: add functional meaning, perturbations at hip and shoulder
What are ways to work on controlling center of gravity?
COG involves ability to establish stable BOS and transfer weight over it
Sitting balance: posture, removing UE support, making seating surface less stable, tasks (upper body tasks, reaching/passing objects, multi directional weight shifts)
Sit to stand transfer balance: progress by transferring surfaces of different height and firmness
Standing balance: stable surface with slow weight shifts, adding UE activities, narrowing base of support, training on less stable surface, one leg standing
How can you progress center of gravity training?
Involved training to establish, maintain, and reduce BOS to produce automatic, anticipatory postural responses to restrict or produce weight shifts
What are ways to work on gait training with balance problems?
Forward and then backwards and sideways
Starting, stopping, turning, bending, varying speed, stepping over obstacles
Increasing frequency and unpredictability of these types of tasks
Compensatory strategies: hazardous environments, vestibular disorder (whole foot at once, increase step width)
What are sensory strategies for training balance?
Goal: help patient learn to coordinate and select appropriate sensory info for postural control
Start with full sensory, then manipulate vision or vestibular
If increased reliance on vision- take away visual cues
If increased reliance on surface- carpet or compliant foam
To enhance vestibular info: standing on compliant surface with eyes close
with balance cases how do you treat functional tasks?
Requires ability to adapt sensory and motor strategies to changing task and environmental demands.
Motor learning concepts: individual/task/environment, skill acquisition (errors, continuous feedback), skill refinement (less errors, intermittent feedback)
Consider amount of practice
Home program/safety
What are examples of dual task training?
Trying to replicate every day function Auditory discrimination Name things Count/spell/recite alphabet backwards Imaging directions Memorize Tell a story
What are strategies to address physical problems for fall prevention in elderly?
Muscles needed for maintaining balance Demands/challenges/functional Hearing loss Vision deficits AD: more or less restrictive? Activity levels/lifestyle changes
What are lifestyle changes for elderly fall prevention?
Tai chi
Wellness programs
Community outreach: health fairs, balance screenings, exercise program
What is documentation of initial balance examination?
Exam: history, system review, tests and measures
Diagnosis: identify discrepancies that exist between the level of functioning that is desired by the patient and the capacity of the patient to achieve that level
Prognosis
POC: overall goal in functional objective terms, duration, and frequency of services required, anticipated discharge plan
Goals: able to stand on right leg for 30 seconds 3/3 trials, able to stand on right leg for 10 seconds so that the stairs can be ascended/descended
What should documentation of a visit look like?
Include changes in: progression of specific interventions (frequency, intensity, time, duration, level of assist provided), plans for next visit, patient’s response
What does home health cover for visits?
Audit with focus on claims with 10-12 home visits (10 visit rule)
Claims denied for reasons of medical necessity: poor rehab potential, final visit not covered following treatment by PTA, no skilled service provided, goals met prior to last visit
What is medicare criteria for medical necessity of services?
Treatment must be consistent with patient’s medical needs; specific, safe, effective; gauged to provide improvement or maintenance of patient’s condition; reasonable frequency, amount, duration
What is specific criteria for insurance coverage for ROM, ther ex, maintenance?
Ther ex: skilled PT if needed to ensure safety or effectiveness, due to type of exercise or patient condition
FOM: skilled PT if part of active treatment for loss of function due to decreased ROM
Maintenance: if involves complex and sophisticated procedures, judgement and skill of PT
