Evaluation of Posture Control and Balance Flashcards
What are the necessary components of balance
- Static balance
- Dynamic Balance: anticipatory and reactive balance
When does balance begin?
infancy
Why is balance dysfunction a problem with children? (general)
– 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
Why is balance dysfunction a problem with children? (infants)
Difficulty sitting up, making eye contact with caregivers, playing with toys, eating, vocalizing, maintaining an open airway, etc
Why is balance disfunction a problem with children? (toddlers)
Difficulty learning to walk independently, exploring environment, playing, developing self care skills, etc
Why is balance dysfunction a problem with children? (preschoolers)
Difficulty playing with other kids (outside/inside/playground), dressing themselves, tying shoes, etc
Why is balance dysfunction a problem with children? (school age children)
Can impact self-confidence, peer relationships, learning, community mobility, participation in organized sports, etc
Activities to include in balance examination - Infant or toddler
Development of motor skills/milestones
Ability to perform antigravity movement
Postural reactions
Activities to include in balance examination - preschooler
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)
When does balance start looking like an adults?
15 years old
Activity and participation considerations for children/adolescents
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
how does PDMS, BOT2, and GMFM reflect balance?
- 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
Balance/Postural Control Across Developmental Positions
- Supine
- Pone
- Sitting
- 4 Point
- Standing
see dynamic equilibrium model
Which systems dominate at which ages?
Vision – birth to 3 years
Proprioception – 4-6 years of age
Vestibular – 7 years of age and older
Never occlude vision in a child less than…
3 years old
When are vestibular reflexes fully mature?
11-15 years of age
Ability to integrate info from systems and use to adapt balance continues to be refined to…
12-15 years old
Sensory factors contributing to balance dysfunction in children
Vision
Somatosensory
Vestibular
(impairment)
Motor system factors contributing to balance dysfunction in children
Anticipatory balance adjustments
Reactive balance
(impairment)
Biomechanical factors contributing to balance dysfunction in children
Soft tissue restrictions
Bony torsional deformity
Impaired strength
(impairment)
Take home message of the research
provide the child with good alignment so they can improve and make gains
How to test sensory impairments
Tilt Board (Reactive balance, proprioception)
Eyes-open vs Eyes-closed conditions
Surface compliance (stable vs compliant)
Age appropriate examples for testing sensory impairments
Infant: milestones
Toddler: standing, walking (I)
Preschooler: playground, run, hop, jump, skip
Grade school/Adolescent: sports-specific
Take a look at sensory organization test
PCTSIB grading
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
How to test motor impairments
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)
How to assess biomechanical impairments
- Strength
- ROM
- Static postural alignment
Considerations to improve reliability of balance/postural control exam in children
Use quiet, non-distractible setting
Simple, easy to follow directions – age appropriate
Do not excite the child, help them focus on balance
Important Characteristics of Pediatric Balance Scales
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
Standard Functional Reach Test
Measure of dynamic balance
Reliable in typically developing children and
children with a disability
Normative values for children from 6-12 y/o
Pediatric Reach Test
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
Pediatric modifications for FRT
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
TUG
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
TUG modifications from adult version
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
How young can you use the TUG
3 years old
is TUG good for children with CP?
yep
What is the TUG useful for?
- screening and outcome measure
What does TUG allow you to differentiate children by?
- 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
Four Square Step Test
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)
Pediatric Balance Scale (Berg) differentiates children among…
GMFCS II and III
- May not be sensitive enough to effectively identify issues with children with mild motor impairment
Pediatric Balance scale is for what ages
5 - 15 years old
Pediatric Balance Scale may be more appropriate for children:
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
Segmental Assessment of Trunk Control (SATCo)
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
Who is SATCo good for?
Children with CP and SCI
5x STS
- Measures lower extremity strength and balance
- Good with children with CP
- Moderate concurrent validity with TUG and BBS
Timed up and down stairs
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
SWOC
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
