Evaluation of Posture Control and Balance

Question 1

What are the necessary components of balance

Answer 1

• Static balance
• Dynamic Balance: anticipatory and reactive balance

Question 2

When does balance begin?

Answer 2

infancy

Question 3

Why is balance dysfunction a problem with children? (general)

Answer 3

– Balance dysfunction can potentially limit further development of movement and exploration and can affect their ability to produce coordinated and efficient functional movements
– Children with balance dysfunction may be fearful of movement if they start out unsteady

Question 4

Why is balance dysfunction a problem with children? (infants)

Answer 4

Difficulty sitting up, making eye contact with caregivers, playing with toys, eating, vocalizing, maintaining an open airway, etc

Question 5

Why is balance disfunction a problem with children? (toddlers)

Answer 5

Difficulty learning to walk independently, exploring environment, playing, developing self care skills, etc

Question 6

Why is balance dysfunction a problem with children? (preschoolers)

Answer 6

Difficulty playing with other kids (outside/inside/playground), dressing themselves, tying shoes, etc

Question 7

Why is balance dysfunction a problem with children? (school age children)

Answer 7

Can impact self-confidence, peer relationships, learning, community mobility, participation in organized sports, etc

Question 8

Activities to include in balance examination - Infant or toddler

Answer 8

 Development of motor skills/milestones
 Ability to perform antigravity movement
 Postural reactions

Question 9

Activities to include in balance examination - preschooler

Answer 9

 Play skills (ball throwing, jumping)
 Performance of ADL/self-care activities
 Higher level motor skills requiring balance (stand on one foot, walk on a balance beam)

Question 10

When does balance start looking like an adults?

Answer 10

15 years old

Question 11

Activity and participation considerations for children/adolescents

Answer 11

Children/adolescents with balance impairments may have difficulty keeping up with their friends; may not be able to participate in organized sports; may have difficulty with P.E. class

Question 12

how does PDMS, BOT2, and GMFM reflect balance?

Answer 12

• These tests include items related to complex balance and coordination, so the PT can focus on specific items within the subscales and use them as discriminative tests to document general problems with postural stability or coordination
• Can use standardized tests as evaluative measurements to document movement outcomes

Question 13

Balance/Postural Control Across Developmental Positions

Answer 13

• Supine
• Pone
• Sitting
• 4 Point
• Standing

Question 14

see dynamic equilibrium model

Question 15

Which systems dominate at which ages?

Answer 15

 Vision – birth to 3 years
 Proprioception – 4-6 years of age
 Vestibular – 7 years of age and older

Question 16

Never occlude vision in a child less than…

Answer 16

3 years old

Question 17

When are vestibular reflexes fully mature?

Answer 17

11-15 years of age

Question 18

Ability to integrate info from systems and use to adapt balance continues to be refined to…

Answer 18

12-15 years old

Question 19

Sensory factors contributing to balance dysfunction in children

Answer 19

 Vision
 Somatosensory
 Vestibular
(impairment)

Question 20

Motor system factors contributing to balance dysfunction in children

Answer 20

 Anticipatory balance adjustments
 Reactive balance
(impairment)

Question 21

Biomechanical factors contributing to balance dysfunction in children

Answer 21

 Soft tissue restrictions
 Bony torsional deformity
 Impaired strength
(impairment)

Question 22

Take home message of the research

Answer 22

provide the child with good alignment so they can improve and make gains

Question 23

How to test sensory impairments

Answer 23

 Tilt Board (Reactive balance, proprioception)
 Eyes-open vs Eyes-closed conditions
 Surface compliance (stable vs compliant)

Question 24

Age appropriate examples for testing sensory impairments

Answer 24

Infant: milestones
Toddler: standing, walking (I)
Preschooler: playground, run, hop, jump, skip
Grade school/Adolescent: sports-specific

Question 25

Take a look at sensory organization test

Question 26

PCTSIB grading

Answer 26

0 = can’t assume position
1 = can maintain stance 3 seconds or less
2 = can maintain stance 4-10 seconds
3 = can maintain stance 11-20 seconds, >15 degrees of sway
4 = maintains 30 seconds, 6-15 degrees of sway
5 = maintains 30 seconds, <6 degrees of sway

Question 27

How to test motor impairments

Answer 27

 Observe movement strategies during PCTSIB (hip, ankle, stepping) (*specifically balance)
 Functional Reach Test (specifically balance)
 Timed Up-&-Go (not just balance)
 Standardized tests (AIMS, PDMS-2, BOT-2, GMFM)

Question 28

How to assess biomechanical impairments

Answer 28

• Strength
• ROM
• Static postural alignment

Question 29

Considerations to improve reliability of balance/postural control exam in children

Answer 29

 Use quiet, non-distractible setting
 Simple, easy to follow directions – age appropriate
 Do not excite the child, help them focus on balance

Question 30

Important Characteristics of Pediatric Balance Scales

Answer 30

 Need to measure balance in a wide variety of positions to be useful for all pediatric patients
 Should measure the response to internal perturbation (self-initiated movement)
 Standardized tests such as the Berg Balance Scale may be most appropriate for use in children with mild to moderate balance impairments (i.e. children who are ambulatory; children who score at level II or III of the GMFCS)
 Vision should NOT be occluded for children from birth to 3

Question 31

Standard Functional Reach Test

Answer 31

 Measure of dynamic balance
 Reliable in typically developing children and
children with a disability
 Normative values for children from 6-12 y/o

Question 32

Pediatric Reach Test

Answer 32

 Includes both sitting and standing position
 Includes side reaching items
 Developed with children from 2.6 years – 14 years of age
 6 Items
 Not as reliable as other measures, but easy to do in any setting with tape measure

Question 33

Pediatric modifications for FRT

Answer 33

 Use taped line (stand with toes behind) instead of paper
 Toe to finger test (at start and at end position) – stable starting position
 Raise both arms (bilateral test) to decrease trunk twisting
 Do 3 trials (1 practice, 2 recorded)
 Modified position (preferred side to wall and back to wall

Question 34

TUG

Answer 34

Measure of functional mobility/dynamic balance
 Stand up from chair without arms
 Walk 3 meters – touch target
 Turn and return to chair and sit down

Question 35

TUG modifications from adult version

Answer 35

 Start/stop timing when child’s bottom leaves and
returns to seat (Not on command “GO”)
 Have child walk to touch a target (star, red circle)  Encourage natural walk pattern – may have to cue them that it’s not a race, hopping/jumping not allowed, etc.
 Chair should be correct height to allow 90-degree knee flexion with feet flat on floor

Question 36

How young can you use the TUG

Answer 36

3 years old

Question 37

is TUG good for children with CP?

Answer 37

yep

Question 38

What is the TUG useful for?

Answer 38

• screening and outcome measure

Question 39

What does TUG allow you to differentiate children by?

Answer 39

• age or disability level
   Age probably influenced by increase body size, strength
   Children with hemiplegia and spastic diplegia slower than typically developing children
   Children with quadriplegia – 6 times slower than typically developing peers
   Differentiates between children at different GMFCS levels

Question 40

Four Square Step Test

Answer 40

 Involves balancing over a moving base of support and making rapid changes in direction
 Includes moving sideways/backwards, stepping over an object
 Useful in children with CP and DS (children with DS slower than children with CP)

Question 41

Pediatric Balance Scale (Berg) differentiates children among…

Answer 41

GMFCS II and III
- May not be sensitive enough to effectively identify issues with children with mild motor impairment

Question 42

Pediatric Balance scale is for what ages

Answer 42

5 - 15 years old

Question 43

Pediatric Balance Scale may be more appropriate for children:

Answer 43

 Items reordered by functional sequence
 Decrease time required to maintain static position to make more age appropriate
 Clarify the instructions so that they are understood by children

Question 44

Segmental Assessment of Trunk Control (SATCo)

Answer 44

 Reliable and valid outcome for sitting balance in children with neuromotor disability
 Determines top-most segment at which control of upright posture is poor – cephalocaudal direction
 Static, active, and reactive control
 Video or live assessment

Question 45

Who is SATCo good for?

Answer 45

Children with CP and SCI

Question 46

5x STS

Answer 46

• Measures lower extremity strength and balance
• Good with children with CP
• Moderate concurrent validity with TUG and BBS

Question 47

Timed up and down stairs

Answer 47

 Child walks up and down 1 f light of steps
 Use stopwatch to measure time from standing at bottom of steps to when both feet return to landing
 Can wear shoes, but do not recommend using
orthotics in standardized format
 Good for children 8-14 yo; CP
 Good current validity with TUG, FR

Question 48

SWOC

Answer 48

 The purpose of the SWOC is to determine ambulation capacity by measuring stability and speed during gait under different circumstances in a safe, reproducible, and efficient way.
 Time, number of steps, and observations of stability (number of stumbles or number of steps off path)
 Could easily be used in any setting for any child who can follow the directions and walk without an assistive device