Coordination and Balance Exam Flashcards
1
Q
Motor systems involved in coordination/balance
A
- Peripheral systems: muscles and joints
- Central systems: 3 levels (flexible hierarchy), Strategy level = decides the goal of movement, represented by association motor areas, basal ganglia, & cerebellum; Tactics level = decides sequence of muscle contraction in space & time, represented by primary motor cortex & cerebellum; Execution level = stimulate motor neurons to activate muscles appropriately for movements/postural control, & feedback (cerebellum)
2
Q
Coordination impairments associated with cerebellum
A
- Ataxia: most common problem, results in ‘ataxic gait’ (poor trunk control, wide BOS, arms high guard position, irregular stepping)
- Dysdiadochokinesia: impaired ability to perform RAM (rapid alternating movements)
- Dysmetria: inability to judge the distance, over-/under- shooting
- Dyssynergia: inability to perform smooth movements using synergistic muscle
- Nystagmus: mostly vertical nystagmus
- Tremor: intention tremor, during movements, tends to increase with speed
- Dysarthria: scanning speech, hanging onto syllables for too long/pronounced
3
Q
Coordination impairments associated with basal ganglia
A
- Bradykinesia: slow movements, decreased arm movements, shuffling, & destination during gait (Parkinson’s gait)
- Akinesia: progression to inability to initiate movements (freezing gait)
- Athetosis: involuntary writhing/’worm-like’ movements (clinical sign of athetoid cerebral palsy)
- Chorea: involuntary irregular jerky movements, cannot be inhibited, mostly seen in UE (clinical sign of Huntington’s disease)
- Dystonia: sustained involuntary contractions of agonist/antagonist muscle, abnormal posturing, torsion spasms
- Rigidity: lead-pipe & cog-wheel types
- Tremor: resting tremor (pill-rolling in fingers in Parkinson’s disease)
- Hemiballismus: large amplitude movements, sometimes violent, one side of body, arm or leg
4
Q
Sensory impairments involved in coordination/balance
A
- appropriate sensory input is also critical for coordination & balance
- responsible for joint position sense, kinesthesia, discriminative touch
- Romberg’s sign tests for imbalance/incoordination due to proprioceptive loss, also sharpened Romberg
5
Q
Coordination tests
A
- Gross vs Fine motor tests
- Gross motor tests: involve large muscle groups to test ability to crawl, kneel, stand, walk w/o abnormal postures w/o loss of balance, called equilibrium tests
- Fine motor tests: involve small distal muscle groups, test fine motor activities like finger dexterity tasks, non-equilibrium tests
6
Q
Fine motor/non-equilibrium tests
A
- finger to nose
- finger to examiner’s finger
- finger opposition
- rapid alternating pronation/supination (diadochokinesis)
- rebound test
- tapping hand/foot following rhythm
- pronator drift test with eyes closed: either contralateral pyramidal lesion or ipsilateral cerebellar or DC/ML lesion, also tests proprioceptive loss
- alternate heel to knee, heel to toe
- heel on shin
- drawing circle/figure of 8: both UE and LE
- use some kind of rating scale: time to completion, error rates
7
Q
Standardized instruments for UE coordination
A
- mostly measure time for completion & accuracy
- 9 hole peg test
- Jebsen Taylor hand function test: writing, card turning, stacking
- Minnesota Manual Dexterity test: used to select personnel for work requiring coordinated hand/finger movements
- O’connor Tweezer test
- Computerized instruments for assessment: ARMEO
8
Q
What is the dynamic systems theory
A
- postural control movements are also guided by the task at hand, our individual capabilities, & the environmental constraints
9
Q
Define balance/postural control
A
- condition in which all forces acting on body are balanced such that the center of mass (COM) is within base of support (BOS)
- also called postural control
10
Q
Define COM
A
- center point of the whole body mass
- same as center of gravity (COG)
- occurs at 2nd sacral vertebra in anatomical standing
11
Q
Define line of gravity (LOG)
A
- vertical line from COM to floor
- expected to fall anterior to ankle and knee, posterior to hip joints, anterior to thoracic vertebrae, just anterior to shoulder joint, but can change with dynamic
12
Q
Define limits of stability (LOS)
A
- max distance one can lean/reach w/o taking step w/o loss of balance (LOB)
- also called the cone of stability
13
Q
Define postural alignment
A
- perfect alignment when line of gravity (LOG) passes through structures as expected
- minimal muscle activity required
14
Q
Define steadiness/postural sway
A
- ability to maintain COM/LOG at place with minimal movements
- can be measured by COP (center of pressure) movements on force plates
- normally exhibit small postural sway during standing
- sway envelope: path of excursion of the COP during quite standing
15
Q
Reactive balance strategies
A
- ankle
- hip
- suspension
- stepping
- reaching strategies
16
Q
Define fixed support strategies
A
- used to control COM over fixed BOS, COM remains within limits of stability so BOS does not change
17
Q
Describe ankle strategy
A
- move COM of body as a block about ankle joints
- used when sways are small/slow
- muscles are activated distal-to-proximal
- during forward sway, gastrocnemius -> hamstrings -> paraspinals
- during backward sway, tib ant -> quads -> abdominals
- used on firm support surface
18
Q
Describe hip strategy
A
- moves COM by flexing/extending/abd/adducting hips
- used with larger/faster sways
- muscles are activated proximal to distal
- forward sway, abdominals -> quads
- backward sway, paraspinals -> hamstrings
- used when support surface is small/narrow/complaint
19
Q
Describe suspension strategy
A
- moves COM down by flexing hips/knees & flexing trunk
- may progress to squatting
20
Q
Define change in support strategies
A
- used to control COM over moving BOS, such that the COM moves out of LOS
21
Q
Describe stepping strategy
A
- brings COM back within LOS by taking a rapid step in the direction of the destabilizing force
- recruited in response to fast large perturbations when ankle/hip strategies are not adequate to recover postural control
- should not viewed as strategy of last resort, they are recruited quickly ahead of ankle/hip strategies if CNS perceives a big perturbation
22
Q
Describe reaching/grasping strategies
A
- bring COM within LOS (limits of stability) by extending BOS by reaching/grasping using UE
23
Q
Describe protective reactions for reactive balance (and anticipatory balance) control in sitting
A
- use of trunk, head, arm, & leg responses during reactive or anticipatory balance control with increasing COG displacements
24
Q
Sensory systems involved in balance
A
- visual
- somatosensory
- vestibular
- provide important info about body’s own actions & surrounding environment
- the CNS then has to process/interpret those inputs & decide on goal-directed conscious response or unconscious adjustments to posture
25
Q
Describe the visual system
A
- has roles in both feedforward & feedback balance mechanisms
- Feedforward balance: focal vision (central vision), to see obstacle ahead of you & react beforehand, needed for proactive/anticipatory postural control
- Feedbackward balance: ambient vision (mostly peripheral vision), to regain postural control after perturbations, needed for reactive postural control
26
Q
Describe the somatosensory system
A
- provides cutaneous & pressure sensations form body segments in contact with support surface
- also proprioceptive sensations from muscles, tendons, & joints
- provide info about orientation & movement of body in relation to support surface
27
Q
Describe the vestibular system
A
- provide CNS with info about position/movement of head with respect to gravity/inertial forces: provides ‘gravitoinertial frame of reference’
- info about angular/linear acceleration
- functions to stabilize gaze during head movements using VOR also functions to regulate tone in postural/antigravity muscle for postural control using VSR
- it alone cannot provide true picture of body movements in space
28
Q
How does the CNS integrate all 3 sensory inputs for ‘best’ balance performance
A
- it re-weighs sensory inputs, depending on the sensory environment & accuracy of the sensory info, shown by SOT (sensory organization test)
29
Q
What are the 6 levels of balance tests for the sensory organization test
A
1) stable ground
2) stable ground with blind fold
3) stable ground with altered vision/visual environment
4) unstable ground
5) unstable ground with blind fold
6) unstable ground with altered vision/visual environment
30
Q
Describe the modified clinical test for sensory integration of balance (mCTSIB)
A
1) stable ground
2) stable ground with blind fold
3) unstable ground
4) unstable ground with blind fold
31
Q
Describe steady state balance
A
- quite sitting/standing
- ability to control the location of the body’s center of mass within the area defined by the base of support under predictable quasi-static conditions
32
Q
Describe proactive/anticipatory balance
A
- ability to generate postural adjustments prior to the onset of & during voluntary movement for the purpose of either countering an upcoming postural disturbance due to voluntary movement or realigning the body’s COM prior to changing the BAS
33
Q
Describe reactive balance
A
- ability to respond to sensory input that signals a need for a response to ensure successful maintain of postural control
- the need for a response is unanticipated but may be generated externally or secondarily to an internally generated movement
34
Q
10 balance dysfunction diagnoses
A
- Postural moment strategies: primarily related to abnormal postural movement strategies (steady state postural control/SSPC, anticipatory postural control/APC, & reactive postural control/RPC)
- Sensory processing: primarily related to abnormal sensory integrity/processing (SSPC, APC, and RPC)
- Balance confidence: primarily related to fear of falling/reduced self-efficacy (SSPC and APC)
- Verticality: primarily related to impaired orientation with respect to gravity (SSPC)
- Executive function/multitask ability: primarily related to impaired dual-task ability (APC)
35
Q
Examples of steady state balance tests
A
- single limb stance time test
- Romberg test
- CTSIB (mCTSIB)
36
Q
Examples of anticipatory balance tests
A
- Functional Reach Test
- Multi-Directional Reach Test
- Star Excursion Balance Test/YBT (Y-Balance Test): test of LE reach that challenges an individual’s limits of stability
37
Q
Examples of reactive balance tests
A
- Retropulsive Pull Test
- Push and Release Test: better test, 0 = recovers w/1 step; 1 = 2-3 small steps, independently recovers; 2 = ≥4 steps, independent recovery; 3 = multiple steps, needs assistance to prevent fall; 4 = falls w/o attempting steps
38
Q
Tests for seated balance
A
- FIST (function in sitting test): tests mostly anticipatory balance
- SATCo (segmental assessment of trunk control)
39
Q
Tests for standing balance
A
- FRT (functional reach test)/MDRT (multi-directional reach test): MS (cut off for normal <7 inches)
- Romberg (NBOS)/Sharpened Romberg (tandem stance)
- SLST
- 4-stage balance test
- DGI: MS
- FGA (functional gait assessment): core measure, PD
- Four square step test: MS
- BESS: steady state, mTBI/concussion
- Community mobility and balance scale: TBI (dramatic brain injury)
40
Q
Combined sitting and standing tests
A
- TUG: SCI (spinal cord injury), cut off for normal is about 13 secs
- TUG cog, TUG man: MS, PD (Parkinson’s disease)
- PASS: steady state vs dynamic, stroke
- BBS (cut off for normal <45): core measure, MS, SCI (spinal cord injury)
- (mini)BESTest: reactive vs anticipatory, stroke, PD (Parkinson’s disease)
- 5-times sit-to-stand (can also be considered as a balance assessment): core measure for all neuro conditions, can also use 30-sec-chair-stand-test
41
Q
Describe the cut offs for fall risk for the BESTest and the miniBESTest
A
- BESTest: <69% for general population or for Parkinson’s disease
- MiniBESTest: <23/28 for fall risk
42
Q
Describe the FGA standing balance test
A
- gait level surface
- change in gait speed
- gait with horizontal head turns
- gait with vertical head turned
- gait and pivot turn
- step over obstacle
- gait with narrow base of support
- gait with eyes closed
- ambulating backwards
- steps
43
Q
Example interventions based on steady state postural control (SSPC) diagnoses
A
- Postural Movement Strategies: mirror with line for vertical & sitting or standing with visual, verbal, and/or manual cues
- Sensory Processing: standing feet together with eyes closed and tandem stance on foam
- Verticality: standing with back and heels against wall
- Balance Confidence: systematically reducing UE support or altering LE base of support in sitting/standing for longer periods of time
44
Q
Example interventions based on anticipatory postural control (APC)
A
- Postural Movement Strategies: add UE & LE movement to functional tasks and stepping over obstacles
- Sensory Processing: marching with eyes closed and reaching with varying speed, direction, & amplitude
- Balance Confidence: systematically reducing UE support or increasing postural control challenge to allow successful task performance while incorporating self-efficacy strategies
- Executive Function/Multi-task Ability: increase challenge of balance task and increase difficulty of secondary task
45
Q
Example interventions based on reactive postural control (RPC)
A
- Postural Movement Strategies: external perturbations and treadmill slip training
- Sensory Processing: marching with eyes closed and tandem standing with head turns
