Balance: Exam 1 Flashcards
Balance is controlling ______ OVER ________ in ANY GIVEN SENSORY ENVIRONMENT
COG over BOS
Motor plans are ___________
Goal driven!!!
“where do I want to be?”
“What do I want to do?”
NORMAL execution req’s these things
- ROM
- strength/endurance
- feet
- ankles
- hips
- trunk
- neck
- eyes
Balance is common among MANY dx’s
Is knowing the dx important?
ex’s
- MS
- progressive
- TBI
- one time thing
- cerebellar strokes vs. peripheral vestib dysf.
- these can be similar dysf’s
Balance and the ICF model
- body structure/function
- balance contributes to a LARGER scale!!!
Terms involved w/ Balance
COG
BOS
Limits of Stability—how far can they go w/out feeling unstable?
COG
*where avg mass is loc’d*
pt @ which ALL wt of object can be considered concentrated
normal or avg loc?
see pics
When COG is IN BOS====>
Stability
BOS
*think surface
Surface that experiences pressure as the result of weight and gravity, and the area contained therein
Limit of Stability or
LOS
farthest dist a person can what?
- Farthest dist. in any direction a person can lean (away from midline) w/out altering original BOS by stepping, reaching or falling
Pt @ which you cannot catch balance w/out moving feet or re-positioning
What direction is usually the furthest LOS?
FRONT
3 VARIABLES that affect balance
- surface cond’s
- visual envir’s
- Intentions/task choice
Demands of the system
NOTE: fluctuate continuously, producing CHANGING DEMANDS on the systems that control balance
- Loc. of COG, BOS, LOS
- surf cond’s
- visual envir’s
- intentions/task choices
Sensory Systems:
Peripheral (3 components)
- Somatosensory
- Visual
- Vestibular
Sensory Systems
Central (3 components)
- compares sides body + diff sensory modalities
-
integrates sensory info
- compares 3 sensory comps
-
resolution of sensory conflict
- NOTE: motion sickness is an INABILITY to resolve this conflict
Somatosensation is made up of….
proprio
kinesthesia
Somatosensation comes from your what?
joints
ligs
mm’s
skin
Somatosensation provides info about mm _________ and joint__________
mm length, stretch,
joint pos. and pressure
2 roles of vision:
Central (focal)
Peripheral (ambient) or perception of mvmt
2 components of Central vision (Focal)
- environment orientation and perception of verticality
- obstacle motion and avoidance
Peripheral vision of ambient
PERCEPTION OF MVMT
detects what?
- detects motion of SELF in relation to the environment
Vestibular
provides info regarding what and during what?
- regarding:
- head pos. in relation to gravity
- during:
- linear and rotary mvmt
This type of perception compares input w/ 3 systems:
*NOTE: brain performs BEST w/ input from ALL systems
Central Sensory perception
Central Sensory perception
Conflict
- brain recognizes these “discrepancies” and selects the BEST input
Central Sensory Perception
Unresolved sensory conflict
impaired balance
dizziness
nausea
vomiting
Remember the Systems Model !!!
see pics
Balance===result of interactions b/w individual, task, environment that you perform the task in
The Systems model
what is the cycle driven by?
- purposeful choices of the indiv. and demands placed ON the indiv. by the environment
Systems Model for Balance
*remember the basics—–>
Plan—-> Execution
see pics
Motor Planning and Execution
Consists of Reflexes and 3 diff. types of postural responses
- Automatic
- Anticipatory
- Volitional
*ALL dependent on task/goal
VOR and VSR contribute to orientation of:
eyes
head
body
VOR
what does it do and what is the input vs. output
INPUT: vestibular
OUTPUT: ocular
aligns head in pos. while the eyes are moving
***remember hockey game ex. Dr. Najeeb
VSR
what does it do and what is the input vs. output
INPUT: vestibular
OUTPUT: spinal
maintains posture (spinal) in resp. to same input (vestibular)
AUTOMATIC Postural Resp’s
- Righting rxns
- postural/balance strats.
“Righting” Rxns aka
straightening things out
Righting rxns
*remember…..this is like when someone is talking to you so you turn your head to see them and the body stays facing one way….but then eventually we turn our whole body that way as a righting rxn
Orientation of the head and trunk
fixing our body to match where our gaze is going!!!
3 types of Righting
- Optical and Labyrinthine righting
- labyrinthine==inner ear
- Body-on-head righting
- head/body alignment
- Body-on-body righting
- upper/lower body alignment
**ALL keep head/neck UPRIGHT relative to ground
Optical & Labyrinthine Righting
- Vestib tells us which way gravity pulling
-
VIS + VESTIB===checks body tilt, keeps eyes in line w/ horizon
- so if we are tilted or leaning over, it keeps our eyes in line w/ horizon
Auto. Postural Responses are NOT
quick reflexes
Automatic postural resp’s are NOT under________
volitional control
they are Reactive
Operate to keep the COG over BOS
auto. postural resp’s
Auto. Postural Resp’s
used w/ perturbations
how?
functionally organized to match amplitude and direction of stimulus
Four diff. types of “Strategies”
- Ankle
- Hip
- Suspensory
- Stepping
Ankle strategy —->
where is the motion?
body moves as a unit over FEET
motion @ ankle
W/ the ankle strategy
how do the mm’s contract? from where to where?
Distally to Proximally
Ankle strategy used when?
sway is small, slow, near midline
When the ankle strategy fails….
Hip Strategy!!!
Proximal response !!!
hip strategy controlled from…
pelvis and trunk
W/ the Hip strategy….
the head and hips move in________
OPPOSITE directions
mm contract. direction Hip Strategy….
from where to where
Prox. to dist.
WHEN is hip strategy used?
Sway is lg, fast, nearing LOS
Suspensory strategy ex.
surfing
*short-squat or lowering COG*
Suspensory Strategy
lowering COG
lowering COG TOWARDS BOS via B/L LE flex or “short-squatting”
Suspensory strategy
Shortening the dist. b/w COG and BOS allows what?
easier control of COG
Suspensory Strategy is most often used during a combo of what and what?
Combo of stability and mobility
ex. surfing, snowboarding
ALLOWS FOR MOBILITY
SUSPENSORY STRATEGY
SEE PICS
remember lowering COG toward BOS
stability + mobility
Stepping Strategy
*reestablishing NEW BOS
reestablish BOS when COG moves OUTSIDE orig. BOS
stepping to catch yourself
Anticipatory postural responses
exactly what it sounds like
- occurs BEFORE disturbance
- disturbance is PREDICTED
- develop a “postural set”
- you get “set” before disturbance
Volitional means….
under conscious control
Volitional postural responses
under conscious control
ex. wt. shifting during reaching
Volitional postural mvmts are under _________ control
conscious
Volitional postural mvmts are ____________ to accomplish a goal
self-initiated
volitional postural mvmts range from ____to _____
simple to complex
W/ Volitional postural mvmts….
the more familiar the task…… the ________
shorter the response time!!!
well rehearsed====easier to react
Objective Testing of Balance:
- Purpose?
- Choosing a test…
- functional?
- valid/reliable?
- time to admin?
- static or dynamic balance?
- Interpret results:
- consider ALL systems!
Quiet Standing:
Romberg Test
client stands w/ feet parallel and together
THEN close eyes 20-30s
Sharpened Romberg
Tandem 60s
NOTE: documenting Romberg tests==> how long they hold, any marked postural sway
Quiet Standing
One Legged Standing
can be SOLEO, SOLEC
hip==neutral
knee==flex 90
Five 30s trials/leg
Quiet Standing
Postural Sway
use of force plate or other measuring device
Quiet Standing:
Nude-Push
*can vary b/w testers
*NOT reliable
*qualitative
- automatic resp. to unpredictable perturbations
- Backwards @ sternum/pelvis
- forwads b/w shoulder blades/pelvis
“don’t let me push you” ======> judging of anticipatory postural control
Quiet Standing:
Motor Control Response Test
- perturbs client thru surf. displacement
- client stands on movable footplate, surface rotates toes up or down, translates forward or backward
Quiet Standing
Postural Stress Test
*basically a Quantifiable, repeatable nudge/push test*
- waist belt attached to pulleys w/ wts
- wts are dropped from standard hts
CTSIB or
Clinical Test of Sensory Integration and Balance
CTIS aka
Fome and Dome
CTSIB
Tests balance under a number of cond’s
- firm vs. soft surface
- eyes open vs. eyes closed vs. conflicting vis. info (remember the lined paper)
- 5 reps 30s for ea. cond.
CTSIB can help determine which sensory system is responsible for balance dysfunction how?
- reducing impact of sensory systems
CTSIB ex’s
see pics
CTSIB
The conditions
The conditions and results explained
CTSIB
CTSIB
The conditions
The results/Cond’s explained
CTSIB
Easy chart
Sensory Organization Test
*similar to CTSIB
computerized moveable force plate + movable vis. surrounds alter surf/vis environ.
Sensory Integration Test
Three 20s trials under 6 cond’s
Cond’s 1,2,3—FIXED surf.
Cond’s 4, 5, 6—SWAY REF’D 1:1 (moves when you sway)
Balance Error Scoring System
BESS
*the one where we count the # of errors you make
- closed, single, tandem stance
- firm or soft surf
- EYES CLOSED FOR ALL TESTS
- count errors during 20s test pd
- hands lifted off illiac C.
- opening eyes
- step, stumble, fall
- moving hip into >30deg ABD
- lifting forefoot/heal
- remaining out of test pos. >5s
Functional Scales for Balance Tests include….
Functional Reach
TUG
Berg
Dynamic Gait Index
Tinetti
BESTest/Mini-BESTest
Functional reach test
- Functional perform. measure
- <10” ====high risk falls
-
reliable/valid
- no ceiling
-
mods?
- sitting
- multi-directional
TUG test
PT times pt up from chair, walk 10’ turn sit
4x—-avg them out
<13.5s===elevated fall risk
TUG-cognitive===serial 7’s
TUG-manual====hold cup w/ water (dual tasking)
reliable/valid==no ceiling
Berg Balance Test
- 14 items
- 56=normal
- <42===very high fall risk
- reliable/valid
- ceiling effect
*NOTE: score of = 49/56 w/ + hx falls was found to be MOST SENSITIVE measure of falls prediction in community-dwelling older adults
Mini-BESTest
SHORT version Balance Equilibrium Systems Test (BEST)
14 items (0-2) that examine anticipatory and reactive postural control, sensory orientation and dynamic gait
Self Report Scales: Balance
Activities-specific Balance Confidence Scale (ABC)
- questionnaire about confidence in performing variety of typ. acs—-scored out of 100
- total/16 for # out of 0 to 100
Clinical Decision Making w/ Balance Examination
ID problems
set GOALS —-objective assess.
Tx Planning—-balance practice
use Motor Learning concepts—–indiv, task, environment
Tx for balance
based off of everything we talked about!!!
- sitting balance
- static
- dynamic
- sit-stand transfers
- transitional balance
- standing
- static
- dynamic
- strategy training
- ankle, hip, standing, suspensory
-
gait training
- CLOSE prox. w/ balance training
Considerations w/ Balance training
- Tx tools
- safety edu./environ. mods
- rails in shower
- lighting
- railing
- preventing wall walking—-EXACTLY WHAT IT SOUNDS LIKE
- throw rugs
- HEP
Interventions for Balance
manip envir.
task specific
adjust to stage of learning
manip amt of sensory info
work for control of COG in all planes
train specific strategies
Interventions for Balance
High tech:
force plates, balance master, EMG biofeedback, video, TM
Interventions: Balance
Low Tech
rocker board, swiss ball, trampoline, foam, wedges, foarm rollers
Interventions for balance training
PUSH THEM TO LIMITS OF ABILITY!!!
This is the ONLY WAY TO IMPROVE!!!
YOU NEED TO REMEMBER THIS TOO!!!
YOU FUCKING GOT THIS!!!!
