Balance Evaluation and Treatment Flashcards
what is postural control and how do we achieve postural control?
Postural control is controlling body position in space to maintain dynamic Stability (COM within BOS) and orientation (relationship between segments and between body and
environment)
We achieve these goals by:
- using and integrating sensory info
- generating forces to control the body’s position.
what is COM?
center of the total body’s mass (weighted average of each segment)
what is BOS?
area of object in contact with the supporting surface
what is COG?
vertical projection of the COM
What is balance?
ability to maintain projected COM within the limits
of BOS
what systems are involved in postural control?
musculoskeletal system
eye-head coordination
adaptive mechanisms
anticipatory mechanisms
sensory strategies
sensory systems
neuromuscular synergies
what is needed for balance?
- ROM - especially at the
ankles. - Tone/strength in muscles
- Postural tone- antigravity
muscles - Postural Alignment - allows
the body to be in equilibrium
with the least amount of
what are neuromuscular ankle strategies? when do we use them?
-ankle strategies mainly with smaller perturbations
- for normal stance on flat or slightly uneven surfaces
-Backward motion of the surface induces
forward sway and muscle response
Gastrosoleus –> Hamstrings –> Paraspinals
- Forward motion of the surface induces
backward sway and muscle response
Tib Anterior –> Quadriceps –> Abdominals
what are neuromuscular hip strategies?
when do we use them?
- for narrow/ small/ very unstable/moving surfaces, inclines
- for larger backward pertubations –> response: Paraspinals –> Hamstrings
- Brings hips forward to counteract change in COG
- Larger Induced Forward sway–> response: Abdominals–> Quadriceps
- Brings hips backward to counteract change in COG
what are other neuromuscular strategies besides ankle and hip?
- Stepping Strategy occurs when the COM moves outside the BOS with very strong perturbation
- Mediolateral control occurs in the hip and in the trunk primarily (adduction of one leg and abduction of the other). Main muscles include gluteus Med and TFL.
what are adaptive mechanisms with regard to balance strategies?
- The boundaries of the strategies
are dynamic; boundaries can shrink following
habituation.
what is nystagmus
Eyes move in a slow phase to the side with a
rapid return to midline with a regular beat.
what is an abnormal saccade
inability of the eyes to maintain focus
with the head moving
what is diplopia
Double vision
what is the visual sensory system?
Info about position of the head and motion,
verticality.
Problems arise when an individual can not distinguish between self-motion and environment motion
what is the somatosensory system?
Info about the body position /movement in space with reference to the supporting surface.
Includes spindles, golgi tendon organs, joint
receptors, cutaneous receptors
what is the vestibular system?
Provides the CNS with information about the position and movement of the head with
respect to gravity.
describe anticipatory control
- The patient’s ability to prepare for anticipated
displacements based on prior experience, anticipation, practice, and knowledge of physical constraints. - Postural “preparation ” @ 30 msec before actual
movement occurs. - They also reoccur after the movement takes place to make adjustments.
what should be included in a balance assessment?
- A standardized functional measure of skills requiring postural control. (ex. Tinetti, Berg, Get up and Go, etc…)
- Assessment of sensory inputs. (ex.Foam and Dome, Balance Master, Equitest)
- Assessment of balance strategies through observation
- Tests for underlying impairments of sensory, motor, and cognitive systems.(ex. ROM measurements, strength testing, sensory testing, cognitive testing etc…)
what is the functional reach test?
The functional reach test is a quick screening tool for balance problems in older adults. It assesses the area within the BOS that a person can confidently and safely move his/her COM.
The test requires the patient to
* Stand with feet shoulder width apart, arms raised to 90° flexion, without moving feet, subject reaches forward as far as s/he can without losing balance. Distance of the middle fingertip measured with a yard stick mounted on the wall.
what do scores on the Functional Reach test mean?
Predictive validity (men):
- 15.2cm-25.4cm 2x as likely to fall
- <15.2 4 x more likely to fall
- Cannot reach at all: 8x more likely to fall (Duncan et al, 1992)
FR scores do not differentiate between healthy vs. vestibular hypofunction. FR scores not related to Antero-posterior postural measures
what is the performance- oriented mobility assessment POMA (Tinneti)? How is it performed?
- Screen for balance and mobility skills used in
normal daily activities in older adults. Used to determine likelihood of falls. - Two-part test with nine balance items (Rated at
normal, adaptive, or abnormal) and seven gait items (graded as normal or abnormal) or (numerical score 0-2) depending on version. - Assistive devices ok (but graded down for)
what is the scoring of POMA (tinneti)?
- Max score on both tests= 28 points
- Moderate fall risk 19-24 of total
- High Falls risk < 19 of total
- < 14 on balance scale indicates patient would benefit from PT for balance.
- Sensitivity better than Timed Up and Go and Functional Reach test
what is the Berg Balance Screen?
- Screen individuals who would benefit from PT referral and to predict multiple falls.
- Task: Fourteen items assessing ability to maintain position during decreasing base of support, transitional movement and center of mass transference (rated 0-4, worst to best).
- Do not use assistive device
what do the scores on the BBS mean?
- Score of < 48= benefit from PT referral
- Score of < 45 = risk of recurrent falls and predictive of a future fall.
- Score of < 36 = 100% risk for falls
what is the significance of the BBS?
- Currently best single predictor of falls in the community dwelling elderly (Shumway-Cook et. al 1997)
- Parkinson’s disease- Berg has been shown to be
valid for Parkinson’s - Acute Stroke- Higher Berg score related to lower
Length of stay - Chronic Stroke-Berg not able to differentiate
between fallers and non-fallers
what is the TUG test?
Quick performance based screening tool to
measure functional mobility in community dwelling older adults.
Task: Ability of an individual to rise from a chair, ambulate 3 meters (10 ft), turn 180 degrees and ambulate back to the chair then return to sitting.
- Assistive devices ok
- 3 trials; 1 practice; 2 timed trials with time averaged between the 2
what is the significance of the TUG test?
- has high Intra-rater and Inter-rater reliability
- has high Correlation with Berg Balance
- < 10-12 seconds = normal
- > 14 seconds indicative of faller
- > 20 seconds indicative of frail for functional
independence - > 30 indicates dependence
- TUG is not as highly correlated to the Parkinsonian scale as the Berg
- Tinetti Balance subtest and TUG predict ADL decline and Falls in elderly (Tinetti better than TUG)
what are the different types of TUG test?
- TUG manual: Carry a cup of water
- TUG cognitive: Count backward by 3’s
- Measure of dual task conditions –>Currently no norms & no further sensitivity to falls in community elderly
what is the CTSIB?
- Purpose: To test effect of sensory interactions on
postural stability - Task: Six static standing positions with altered visual, vestibular and somatosensory conditions.
- Reliability/Validity: Subjects should be able to
maintain all conditions for 30 seconds x 3.
what are indications for balance training?
- Vestibular inner ear disorders
- Neurological problems
- Orthopedic injuries and procedures
- Decreased strength and flexibility
- Medications
- Self-confidence
what are possible treatments for balance issues?
- Tasks involving higher degrees of freedom or
decreasing base of support - Training alignment (biofeedback systems)
- Train movement strategies
- Facilitate activity of muscles- icing, vibration, FES,
biofeedback - Improving sensory strategies- decrease visual
dependence, decrease somatosensory dependence, strengthen vestibular system
