Exam 2 Flashcards
What are the components of the balance assessment subjective history?
Ask questions about how many falls have occurred
Inquire about how the patient is managing in the home (and what strategies they are using)
What their perception of the risk of falls is
What are the 4 components of a balance assessment?
Subjective History
Ongoing Movement Analysis
Objective balance examination
Patient Self-Reporting Questionnaires
Steady State Balance Tests
Static timed tests
Single leg balance
Dynamic Balance Tests
Any test involving movement
Sensory Organization Tests
CTSIB
BESS Test
Reactive Balance Tests
Push, Pull, or Release Tests
Anticipatory Balance Tests
Functional Reach
Star Excursion Balance
Functional Balance Tests
Include a variety of components and incorporate functional tasks (Walking While Talking)
Components of selecting appropriate balance tests
Evidence support
What you hope to learn (screening, falls risk, comparison to norms, etc.)
Clinical limitations (time, equipment, stairs/environment)
Romberg/Sharpened Romberg Test
Romberg: Feet together, eyes open and eyes closed for up to 30 seconds
Sharpened: tandem stance, arms crossed, eyes closed up to 30 seconds
+ Test: opening eyes, taking a step, or LOB
Romberg Benefits and Challenges
Benefits:
quick screen
Limited Equipment
Challenges
Not specific
Not used in isolation => need to perform other tests
Modified Functional Reach
Measurement: 1 practice, average 2 next trials in each direction
Cut Off Scores: Not established in the modified version
Stroke Norms:
Forward: 31.7; 37.6
Paretic: 13.8; 17.7
Non-Paretic: 15.5; 18.1
Modified Functional Reach Pros and Cons
Pros
Easy
Limited equipment
Patients who can’t stand
Cons
Cognition may limit ability to follow instructions
Need to sit without much assistance
TUG Dual Task
Community Dwelling: 15 seconds
PD: TUG manual = 4.5 different than TUG
TUG Pros and Cons
Pros
Quantify cognitive impairments
May use Assistive Device
Highly recommended for PD and MS
Cons
Need more research for meaningful changes
Walking While Talking Test
Walk 20 feet, turn around, and walk back naming letters out loud
Cut off scores: 20 seconds (simple) 33 seconds (complex) <70 cm/s = increased risk of frailty and disability
Walking While Talking Pros and Cons
Pros
Functional testing for people with cognitive impairments
Adds cognitive component
Cons
Standardization
Limited Evidence
Clinical Test of Sensory Integration and Balance
Test balance in 6 conditions (4 on modified: no conflict dome); 3 trials in each condition with max of 30 seconds in each trial
Cut off scores
Community Dwelling: less than 260 of 540 possible seconds (summing all 6 trials) or 48%
CTSIB Pros and Cons
Pros
Identify sensory strategies
Limited equipment
Adults and Peds
Cons
Little evidence in cut offs or MDC
Not useful in tracking changes (ceiling/floor effect)
Conflict dome not always available
BESS Test
Number of errors during 20 second time frame for 6 conditions on firm and foam surface
Feet together
Single leg stance
Tandem stance
BESS Statistics
Max Score: 60 points
Performance worsens after 50 years old
No established cut off for increased fall risk
BESS Pros and Cons
Pros Recommended for concussion Evidence for use in younger population Easy to perform Identify vestibular processing impairments
Cons
Less evidence across populations
Not useful in lower level or older adults
Dynamic Gait Index
Focus on activity level on ICF model
8 items testing vestibular input on 0-3 points scale
DGI Statistics
Max Score: 24 points MDC: 3 points (community dwelling, vestibular, and PD) Cut offs 19: older adults, vestibular, and PD 12: MS
DGI Pros and Cons
Pros Short amount of time Dynamic balance focus Moderate level of equipment With or without AD
Cons
Need 20 ft space
Subjective rating
Not super sensitive
Functional Gait Assessment
7 from DGI and 3 additional (Narrow BOS walking, backwards, eyes closed walk)
FGA Statistics
Max Score: 30 points
Cut offs:
22/30: older adults
15:30: PD
FGA Pros and Cons
Pros
Short test
Focus on dynamic balance with integration of systems involvement
More objective than DGI
Highly recommended for PD and Vestibular EDGE groups
With or without AD
Cons
20 foot space
Not appropriate for lower level (higher balance level)
Mini Best
14 items
Foam, ramp, chair w/ and w/o arms, shoe box
Mini Best Statistics
Max Score: 28 points MCID: 4 points (balance disorders) Cut off scores: 20: PD 17: Chronic stroke
Mini Best Pros and Cons
Pros Different systems Functionally based Highly recommended for PD More time efficient than BEST
Cons
More equipment
Can take longer if patients are slower
HiMAT
13 items for 54 points
HiMAT Statistics
Max score: 54 points
Norms: 50-54 (males); 44-54 (females)
Cut offs: none established
HiMAT Pros and Cons
Pros
Good objective test for higher level balance deficits
Integrates functional tasks for younger populations
Highly recommended for TBI/concussion
Cons
Must be independent with ambulation
Consider contraindications
Limited research in other populations
Activity Balance Confidence Scale
16 item self-report measure rating patient’s confidence in various tasks
0 = no confidence
100 = very confident
Score is average of all items
ABC Scale Statistics
Max Score: 100% Cut offs: Older adults: 67% PD: 69% Stroke: 81% indicates multiple faller
ABC Pros and Cons
Pros
Identify self-perception of balance
Objective measure of fear of falling
MS, PD, and acute vestibular
Cons
Confusing for cognitively impaired
Time intensive
Requires reading skills
Falls Efficacy Scale
16 items self-reported measure rating patient’s confidence in various tasks
10 = very confident
100 = not confident
Score based on sum of all items
Falls Efficacy Statistics
Cut offs:
80: increased risk of fall
70: increased fear of fall
Falls Efficacy Pros and cons
Pros
Identify patient’s perception of balance
Objective measure of fear of falling
Cons
Confusing for cognitively impaired
Requires reading skills
Less researched than ABC
Tests for identifying fall risk
Berg Balance DGI FGA Tinetti (POMA) 10 meter walk ABC Scale TUG
Tests for Dual Tasks
Walking While Talking
TUG Dual
DGI
FGA
Tests for younger patients after concussion
HiMAT
Mini BEST
TUG
Tests for older community dwelling adult with history of falls
Mini Best CTSIB Berg DGI FGA ABC Scale TUG
Tests for complaints of dizziness
DGI
FGA
Mini Best
10 Meter Walk Test
Average 3 trials
Can use AD
Space to accelerate/decelerate
10 Meter Walk Statistics
MCID: 0.05 m/s (geriatrics)
Walking speed Table
0-0.6 m/s: Dependent and likely to be hospitalized
0-0.9 m/s: need intervention to reduce fall risk
0-0.1 m/s: Discharge to SNF
0.1+ m/s: discharge home more likely
1.0 m/s: independent in ADLs, less chance of hospitalization, less likely for adverse event
Household Walker: 0-0.4 m/s
Limited Community Ambulation: 0.4-0.8 m/s
Community Ambulator: 0.8-1.2 m/s
Cross street and normal walking speed: 1.2+ m/s
Berg Balance
14 items testing static and dynamic activities (non-vestibular)
Berg Balance Statistics
Max Score: 56 points MDC: 6 points (older adults) Cut offs: 45: elderly population and stroke increased risk 40: 100% risk of falls in elderly
Pediatric Balance Scale
Peds version of Berg
Scored as best of 3 trials
Ages 4-15
Berg Pros and Cons
Pros
Highly recommended for incomplete SCI, MS, stroke, PD, TBI
Good evidence use for mild-moderately impaired patients
Cons
Not useful in those requiring AD
Not recommended for low level patients not anticipated to ambulate (floor effect)
Tinetti (POMA)
16 items (9 balance, 7 gait)
Tinetti Statistics
Max Score: 28 points
Cut offs: 19 (older adults)
Tinetti Pros and Cons
Pros
Recommended for PD (not for other edge groups)
Can use AD
Strong evidence older adult population that has been hospitalized
Gait analysis component
Cons
Less generalizable for younger or healthy older adults
Can’t track changes in higher functioning (Ceiling effect)
Postural Control
Controlling the body’s position in space which includes STABILITY and ORIENTATION
Environment factor of balance
Layout of home
Task factor of balance
Tasks performed (walking: dynamic; standing: static)
Individual factor of balance
PMH
Center of Mass
Center of total body mass (point)
Assumed
Center of Gravity
VERTICAL projection of the COM
Base of Support
Area of the body in contact with the support surface
Postural Orientation
Maintain an appropriate relationship between body segments and between the body and the environment
Postural Stability
Ability to control the COM within the BOS
Posture vs Postural Systems
Posture: Task, individual, and environment
Postural Systems: Musculoskeletal, cognition, muscle synergies, sensory systems, sensory organization
Task Constraints of postural control
Balance control: steady-state, reactive, proactive balance
Feedback control: occurs in response to sensory feedback from external perturbation
Feedforward control: anticipatory postural adjustments made in anticipation of voluntary movement
Environmental Constraints of postural control
Changes in support surfaces
Differences in visual and surface conditions
Multiple tasks
Steady-State Balance
Body Alignment can minimize effect of gravitational forces
Muscle tone keeps body from collapsing in response to the pull of gravity (intrinsic stiffness, background muscle tone, postural tone)
Stability Limits
Point at which a person will change configuration of his/her BOS to achieve stability
Change based on task, individual’s biomechanics, and environment
Not fixed boundaries
Not set
Depend on the tasks you are performing
Factors affecting Movement Strategy
Stability limit
Perceptual and cognitive factors
Reactive Balance Control
Motor Patterns: ankle, hip, step, reach-to-grasp
Fixed-support vs. change-in-support
Synergy: functional coupling of muscle groups to act as a unit
Fixed-support vs Change-in-support
Ankle: slowed perturbation
Hip: Faster perturbation or narrow BOS
Stepping: Fastest perturbation or very narrow BOS
Reach-and-Grasp: reach and grasp while stepping after perturbation
Ankle Strategy
Distal to proximal activation
Useful with small balance disturbances, on a firm surface, intact ankle ROM and strength
Hip Strategy
Proximal to Distal activation
Longer length of time to regain balance
Useful with larger and faster disturbances, small support surface, and compliant support surface
Refining and Tuning Muscle Synergies
Postural synergies are not fixed, stereotypical reactions
Synergies are refined and tuned in response to changing demands in task and environment
Adaptation: movements in response to demands
Proactive Postural Control
Preselect muscles required to complete the task prior to the movement
Based on previous experiences
Benefits: prevent disturbances to the system
Sensory Inputs for steady-state balance
Visual inputs
Somatosensory Contributions
Vestibular Contributions
Components of visual inputs
Position and motion of head with respect to surrounding objects
Reference for verticality
Somatosensory contributions
Provides CNS with position and motion information about body with reference to supporting surfaces
Report information about relationship of body segments to one another
Vestibular Contributions
Provides CNS info about position and movement of head with respect to gravity and inertial forces
Sensory integration of balance
Tend to rely on visual input when learning a new task
Transition to reliance on somatosensory system once in associative phases of learning
Increased tactile feedback changes postural muscle activation
Utilize sensory info to prevent loss of balance in different ways
Moving room example
Neurocom Results
Nothing: Vestibular, Vision, and Somato Blindfold: Vestibular and Somato Head Box: Vestibular and Somato Foam Surface: Vestibular and Vision Blindfold and Foam: Vestibular Foam and Head Box: vestibular
CTSIB Results
Vision: 2, 3, 5, and 6
Somatosensory: 4-6
Vestibular: 5-6
Sensory Selection: 3-6
Strategies for Steady State Stability
Passive skeletal alignment and muscle tone
Postural tone
Hip and Ankle strategies
Strategies for Perturbation Stability
Ankle, hip, and stepping strategies
Attentional Resources
Info processing resources required to complete a task
Dual-Task Interference
Two tasks performed simultaneously
Attentional resources may decrease in performance on one or more tasks (motor and cognitive)
Cognitive Systems in Postural Control
Attentional demands vary as function of sensory context
Performance of secondary task not always detrimental effect on postural control
Important to assess balance under single and dual-task conditions
