Coordination and Balance Flashcards
Coordination - definition
ability to perform smooth accurate movements
Hypermetria deficit
Inability to grade forces appropriately for the distance and speed of a task
Hypermetria deficit is usually associated with what
cerebellar dysfunction
Coordination deficit
inability to coordinate an intersegmental task due to deficit in timing and sequencing of one segment to another
Requirements for coordination
Intact motor cortex, BG, Cbm and proprioception
REquires biomechanical and neuromuscular systems
Cerebellar coordination deficit - can lead to what
Ataxia Dysmetria Dysdiadochokinesia Intention tremor Dysarthria
Dorsal column medial lamniscus coordination deficit can lead to what
decreased proprioception
dysmetria
Basal ganglia coordination deficit can lead to what
Athetosis Chorea Dystonia Hemiballismus Resting tremor Rigidity Akinesia/bradykinesia
Athetosis -
slow, involuntary, worm-like movement
Chorea -
involuntary, rapid, irregular, jerky mvmnt
Dystonia -
sustained voluntary contractions (spasmodic torticollis)
Dysarthria -
speech articulation, melodic element lost
Components of coordination
Sequencing
Timing
Scaling/Grading Forces
What is involved in sequencing (components of coordination)
Synergies
Co-activation
What is involved in timing (components of coordination)
Initiation - force generation, ROM, motivation, postural control
Execution - prox stability with distal mob
Termination - difficulty with stopping or changing direction
What is involved in scaling/grading forces (components of coordination)
Hypermetria - overshooting
Dysmetria - judging force and distance
Documentation of coordination exam
Can do a scale - they were accurate 0 out of 5 times, or can be a percent
Narrative needs to be included
Goals of interventions with coordination dysfuncition
Improve prox stability
Improve eye-hand coord for funct tasks
Improve coord of reciprocal mvmnts
Control mvmnts against gracity
What to be cautious of with adding weights
Rebound effect - can lead to ataxia being worse when take weights off
Frenkels exercises
progression of exercises for coordination
no evidence to support it - but can give good exercises for HEP
Interventions for those with mvmnt deficit associated with accuracy (timing and direction) or speed problem
1 Timing/speed
2 Sensory
If timing.speed - add music or metronome
If sensory deficit - add vibration, approximation, visual cues/targets
Interventions for those with mvmnt deficit associated with adaptability problem (sensing change, obstacles)
Empty cup vs full cup - can incorporate strength too
Set up obstacle to improve problem solving - can offer endurance component too
Maybe take away visual so they dont know if it is heavy or light
Interventions for those with mvmnt deficit associated with strength problem
Stability
Postural control -
interaction of neural and musculoskeletal systems
Control of body positiions in space for purpose of stability, orientation
Postural stability
balance
System changes - vestibular
1 Can be peripheral or central
2 Info from peripheral system transmitted to vesibular nucleus and cbm
- dec hair cells
- degeneration of vest system
System changes - sensory
Tactile - dec prop and cutaneous receptors, inc thresholf for firing
Visual - dec pupil reactivty and lends elasticity
Pathologies that can lead to vestibular changes
BPPV
Menieres
Bilateral vestibular dysfunction
Pathologies that can lead to sensory changes
Cataracts (cloudy)
Glaucoma (loss of peripheral vision)
Macular degeneration (loss of central vision)
System changes - musculoskeletal
Dec in bone density Dec in ROM/flexibility Mm dec in size type 1, dec in type 2 mm atrophy inc in mm fat and CT
System changes - neuromuscular
Dec in nerve cells
Dec in cog processing
Dec in speed of impulses
Dec sensitivity of baroreceptors - ortho hypo
Central sesnory processing of input - sensory reweighting
postural control based on vision, vestib, somatosens
They all come in together - but when one is not function we need to adjust the contributions to make up for the difference
Recurrent fallers -
2 or more falls in either a 6 or 12 months time span
Types of falls
Accidental or non
Syncopal or non
Intrinsic vs. extrinsic
with or without injury
False assumpations with falls
due to carelessness
normal with aging
they just hapen
cant be predicted or anticipated
MS - what percent fall risk
more then 50%
PD - what percent fall risk
60% one fall a year
39% recurrent falls
CVA - what percent falls
double fall risk
most happen with ambulation
Alzheimers - what percent fall risk
double the fall risk
Intellectual/Developmental disability - fall risk screening
limited fall risk screenings for this populaion
Mvmnt system diagnosis - Sensory detection deficit
inability to execute intersegmental mvmnt due to lack of joint position sense of multisensory failure (joint position sense, vision, vestibular)
Mvmnt system diagnosis - sesnsory selection and weighting deficit
inability to screen for and attent to appropriate sensory inputs
pts likely complain of dizziness or visual motion sensitivity
Measurement tools for screening fall risk
STEADI
Stay independent questionnaire
TUG
FRAST
PT exam - history
function in diff environments fall hx and fear of falling adaptive equipment meds medical testing family, social, work hx
PT exam - vestibular
Dizzy - have them define it Details of their sx Exam - 1 smooth pursuit 2 VOR cancellation 3 VOR 4 Saccades 5 Hallpike 6 Determine if periph or centr vertigo
PT exam - static balance tests
Romberg Single leg stance Postural stress test Perturbations Functional reach LOS on force plate
PT exam - dynamic balance tests
Fukuda
FSST
Mini BEST
Fregly Gabriel Quantitative Ataxia Test Battery
Mini BESTest addresses what 4 systems
Anticipatory postural adjustments
Postural responses
Sensory orientation
Gait stability
What other 2 does the long BESTest add
Biomechanical
Stability limits/verticality
Berg - what is inc fall risk
less than 45 out of 56
TUG - what is abnormal
more than 30 seconds
Tinetti POMA - what is increased fall risk
Less than 23 out of 28
Five times sit to stand - what is abnormal
scores greater than 15 sec
measures strength
LImitations of Funtional balance measures
might not predict balance in complex environemtns
most dont measure all 3 aspects of postural control (steady state, reactive, anticipatory)
No measure of the quality of mvmnt
Sensory manupualtion tests
clinical test for sensory integration and balance (foam)
equi-test = surround on movable force plate
vestibular tests
Participation exam tools
(all questionnaires)
Fall efficacy scale
Activities specific balance confidence scale
UIC fear of falling scale
Comprehensive fall risk assessment - if in community
multidisciplinary with medical review, medications, physical exam, gait/balance exam, home assessment
Comprehensive fall risk assessment - if in hospital
mental status, medications, toileting, other dx, footwear
Goals for interventions
pt ed improve balance reduce motion provoked sx improve coordination dec disability, improve function dec falls - be careful with this one
Interventions - need to consider if
restorative or compensatory
Interventions - CVA
aerobic is beneficial
Interventions - PD
need to use block practice and lots of repititions
Intervetnions - Guillain Barre, polio, ALS, MS
Risk of fatigue or overworking the motor units
six dimensions of mvmvnt
flexibility strength accuracy speed adaptability endurance
What mode of balance exercise is effective
should be done in stance
progressive program that has strength and abalnce is best
Not effective in balance exercise
strength, stretching, walking as single interventions are not effective
inconclusive on perturbation and compensatory stepping training
Factors to manipulate for Rx
Surface Speed of mvmnt Cognitive demands Sensory input Task - objects to manipulate Time to complete tasks
Dosage (this is all balance)
1 to 3 times a week
Min of 50 hours over 3 to 6 months (best if over 10 week time frame)
PT supervision vs. Can they stay at home
Monitor safety, vitals, fatigue
Progressions - do they need assistance or can they do them
Cognition
Upside to home - a lot more to practice that we can’t simulate in clinic
Evidence based exercise programs for balance
Otago
Stepping On
Tai Chi
Otago
Home based
17 exercises to be done for a year with levels of progression
Highly effective for those over 80
35% fall and injury reduction
Stepping on
7 sessions for 2 hours over 2 months
Focuses on adoption of safety strategies
31% fall reduction in community adults
Tai Chi
reduce fall risk by 47.5%
Intervention for older adults
hip protector pads Vit D vibrating insoles grab bars, assistive devices exercise program for balance, gait, strength