Postural Control (Exam 2) Flashcards
What is postural control (balance)?
Ability to control the body’s position in space with respect to gravity, support surfaces, visual surround and internal references
What is stability?
Ability to control the COM in relation to BOS under static and dynamic conditions
What is orientation?
Relationship between body’s segments, the body and the environment
What are the constructs that affect balance?
- Biomechanical Contraints
- Stability limits/ verticality
- Anticipatory Postural Adjustment
- Postural responses
- Sensory Orientation
- Stability in Gait
What are some other factors to consider for balance?
- Task Complexity
- Environmental Demands
- Cognition
- Perception/ Pusher’s Syndrome
- Confidence/ Balance Self- efficacy
How do we identify balance deficits?
- Observe movement patterns
- Include task progressions or regressions to detect balance deficits
- Include balance outcomes
What are 3 types of balance dysfunction?
- Steady State Postural Control
- Anticipatory Postural Control
- Reactive Postural Control
In the core task of sitting how can you see a deficit in:
Steady State
Anticipatory
Reactive
- This task can test it with no changes
- Add a task or change the environment
- Spontaneous LOB or perturbed
In the core task of sit to stand how can you see a deficit in:
Steady State
Anticipatory
Reactive
- Can’t test
- This alone will test it
- Spontaneous LOB or perturbed
In the core task of standing how can you see a deficit in:
Steady State
Anticipatory
Reactive
- Will test it with no changes
- Task or environmental change
- Spontaneous LOB
In the core task of walk & turn how can you see a deficit in:
Steady State
Anticipatory
Reactive
- Can’t test it
- This will test it
- Spontaneous LOB or perturbed
In the core task of step up & down how can you see a deficit in:
Steady State
Anticipatory
Reactive
- Can’t test
- this will test it with no changes
- Spontaneous LOB
In the core task of reach, grasp, & manipulate how can you see a deficit in:
Steady State
Anticipatory
Reactive
- Can’t test
- this will test it with no changes
- Spontaneous LOB
In regards to Steady State Postural Control what are the determinants and describe what each determinant is?
- Postural Movement Strategies: (related to abnormal postural movement strategies)
- Sensory processing: (Related to abnormal sensory integrity/processing)
- Balance Confidence: (Related to fear of falling/ reduced self efficacy)
- Verticality: (Related to impaired orientation with respect to gravity)
In regards to Anticipatory Postural Control what are the determinants and briefly describe them
- Postural Movement Strategies: (related to abnormal postural movement strategies)
- Sensory processing: (Related to abnormal sensory integrity/processing)
- Balance Confidence: (Related to fear of falling/ reduced self efficacy)
- Executive Function/Multitask Ability: (primarily related to impaired dual task ability)
In regards to Reactive postural control what are the determinants and briefly describe them
- Postural Movement Strategies: (related to abnormal postural movement strategies)
- Sensory processing: (Related to abnormal sensory integrity/processing)
What is the definition of Steady State Postural Control?
Ability to control the body’s COM within BOS under predictable, stable condition
What are two general ways you can test steady state postural control?
- Limits of Stability (how far someone can weight shift outside BOS w/o invoking a strategy)
- Narrow BOS (Romberg)
What is static sitting balance?
Ability to achieve and maintain neural alignment (eyes closed & on foam)
What is Anticipatory Postural Control?
Postural muscle activity anticipates the voluntary movement, ensuring stability of the body during the performance of this task
- Unconscious muscle activity to counterbalance a movement
- Feedforward mechanism
Describe anticipatory postural control in sitting?
- Dynamic Sitting Balance
- Ability to move from & return to a neutral alignment while performing a functional task
- (Ie reaching forward, head turns & actively crossing a leg)
What is Reactive Postural Control?
- Ability to respond to sensory input that signals a need for a response to maintain postural control
- Response is unanticipated (response may be generated internally or externally)
What are the 3 feedback mechanism that may be invoked during Reactive Postural Control?
Ankle Strategy
Hip Strategy
Stepping Strategy
What is an ankle strategy? And when is it invoked?
- Ankle muscle respond to keep COM within the BOS
- Invoked during small, slow perturbance
What is a hip strategy? And when is it invoked?
- Hip muscles respond to keep the COM within BOS
- Invoked during larger, faster perturbation
When is stepping strategy invoked?
When COM falls outside the BOS
A forward ankle strategy would be invoked when and what is the order of muscle activation?
- A push from behind or platform is ripped behind you
- Gastrocs –> Hamstrings –> Paraspinals
A backward ankle strategy would be invoked when and what is the order of muscle activation?
- Push from in front or if platform is ripped infront of you
- Anterior Tib–> Quads –> Abs
A forward hip strategy would be invoked when and what is the order of muscle activation?
- Push from behind or platform ripped from behind you
- Abdominal –> Quads
A backward hip strategy would be invoked when and what is the order of muscle activation?
- Pushed from front or platform ripped from in front of you
- Paraspinals –> Hamstrings
What muscles are activated during a lateral sway?
Hip abductors
Describe the grading of Stepping Strategy
Normals
Impaired
Absent
Normal: recover independently, single large step
Impaired: more than one step
Absent: No step or would fall without assistance
In sitting postural control reactive balance when is a righting reaction invoked?
Slow perturbation
In regards to a righting reaction what happens when reaching above shoulder level on same side?
- Trunk elongates (lengthens/extends) on WB side
- Trunk shortens (flexes) on NWB side
- Head aligns with gravity
When is protective extension invoked in sitting postural control reactive balance? And what is it?
- Fast perturbation
- Results in a reach, abduction of limbs toward downward side
What body function or structures can cause limitation of balance?
- Musculoskeletal
- Neuromuscular
- Cognitive/Mental Function
- Behavioral
In regards to the musculoskeletal system what are some determinants of balance?
- ROM
- Flexibility
- Muscle performance
- Alignment/Posture
In regards to neuromuscular system what are some determinants of balance?
- Postural Movement
- Coordination
- Sensory Integrity & Processing
- Perceptual Function: Verticality
In regards to cognitive/ mental function what are some determinants of balance?
- arousal
- attention
- executive function
- multitask ability
In regards to behavioral factors what are some determinate of balance?
- past experience
- Fear of falling
- Self efficacy
- Balance confidence
Within steady state what determinants of balance can be affected?
- postural movement strategy
- Sensory processing
- Balance confidence
- Verticality
Within Anticipatory what determinants of balance can be affected?
- Postural movement strategy
- Sensory procession
- Balance confidence
- Executive function/multitask ability
Within reactive what determinants of balance can be affected?
- Postural movement strategy
- Sensory processing
In general describe Postural movement strategies?
- movement of muscles & joints in coordinated manner to maintain posture & balance during voluntary movement when perturbed
- CNS quickly moves between patterns depending on demands of the activity or environment
What are some of the components of sensory processing?
- Vision
- Vestibular
- Somatosensation
What are 2 tests that test the sensory systems and determine the accuracy of the sense for orientation ?
- Sensory Organization Test (SOT)
- Clinical Test of Sensory Interaction & Balance (CTSIB)
What is perceptual Function/ verticality?
Ability to orient the body in relation to the line of gravity
What is executive function?
- Complex cognitive skills including insight, judgement, memory, problem-solving & attention
- These skills are necessary for planning, initiation, sequencing, and monitoring of goal - directed behavior
What is multitask capacity?
Able to successfully participate in more than one task (dual task or multitask)
What can affect balance confidence?
- Falls self efficacy
- Fear of falling
- Activity Avoidance
Describe Condition 1, 2 & 3 of the Clinical Test of Sensory Interaction and Balance
- Eyes open on firm surface
- Eyes closed on firm surface
- Eyes open with sway referenced visual surround or dome
Describe Condition 4, 5 & 6 of the Clinical Test of Sensory Interaction and Balance
- Eyes open on sway referenced support surface or foam
- Eyes closed on sway referenced support surface or foam
- Eyes open on sway referenced support surface and visual surround or dome
What does it mean if a person has increased sway or falls on condition 2,3,4,5&6?
Dependent upon their vision for balance
What does it mean if a person has increased sway or falls on condition 4,5,6?
They are dependent upon surface/somatosensory system for balance
What does it mean if a person has an increased sway or falls on condition 5 & 6?
They have vestibular loss (inability to rely on vision or somatosensory)
What does it mean if a person has sway or falls on condition 3-6?
Sensory selection problem
What does Function in Sitting Test (FIST) examine?
Sensory, motor, proactive, reactive & steady state balance
For the FIST how is the patient set up and what do they do?
- Patient sits at edge of bed with feet flat on floor & hands on lap
- They perform 14 items: nudging, timed sit for 30sec with eyes open and closed, moving head from side to side, picking up an object behind them and on the floor, reaching, scooting
How is FIST scored, what is the MCD & MDIC?
- Scored 0-4
- MCD = 5.63 acute stroke & adults with balance dysfunction
- MDIC = >6.5
What does the Activities Specific Balance Confidence Scale (ABC) examine?
Patient confidence in their balance
Describe the ABC scale and how it is scored?
16 item self report survey where patient rates their confidence on different activities from 0-100% (0 being none and 100 complete)
What are the items rated in the ABC scale?
- Picking something from floor & above their head
- Getting in & out of car
- Walking across large parking lot or in a small crowded mall
- Stepping on or off an escalator
- Walking on icy or slippery sidewalks
According to the ABC, what is the cut off score for older adults being at risk of falls?
less than 67%
Describe the % needed on the ABC scale for older adults to have:
- High level of physical functioning
- Moderate level of physical functioning
- Low level of physical functioning
High: > 80%
Moderate: 50-80%
Low: < 50%
According to the ABC what is the MDC for Parkinson disease and acute & chronic stroke?
Parkinson Disease = 13%
Acute & Chronic stroke = 14%
Why is the ABC not reccommended for those in brain injury or spinal cord injury?
They are not able to do the activities asked about
What does the Berg Balance Scale (BBS) examine?
Static & dynamic balance
What are the items included on the Berg Balance Scale?
- Sit to stand & transfers
- Standing w/ eyes open
- Standing in Romberg
- Tandem & one legged stance
- Reaching forward
- Picking up an object from floor
- Turning 360 degrees
- Alternating foot taps on step
What control strategies for balance does the BBS measure?
Steady state & anticipatory
According to the BBS what is the cut off score for being at a greater risk for falling for older adults?
<45
If a patient scores under 40 in the BBS what are they at risk for?
almost 100% at risk for falls
What is the score for Parkinson Disease according to the BBS?
less than or equal to 52
Why is there limited utility of the BBS in the middle stage of Parkinson Disease?
basal ganglia helps respond to reactive postural control so since this test doesn’t test this not seeing the full extent of deficits
From the BBS what is the MDC for:
- Patients with acute stroke
- Patients with chronic stroke
- Older adults living in nursing home
- Patients with Parkinson disease
Acute: 6.9
Chronic: 4.13
Older: 10.4
PD: 5
What does the Fullerton Advanced Balance Scale examine?
Advanced balance for higher functioning patients
What are the items included on the Fullerton Advanced Balance Scale (FAB)?
- Stepping on & over 6 in bench
- Tandem walking
- One legged stance
- Stand on foam
- Two footed jump
- Walk w/ heads turns
- Reactive Postural control (posterior)
What is the cut off to be at high risk for fall according to the Fullerton Advanced Balance Scale?
< 25
What control strategies for balance does the FAB measure?
All aspects of balance
What is the Mini BESTest based on ?
Balance Evaluation Systems Test (BESTest)
What items are included on the Mini BESTest?
- Anticipatory (sit to stand, rise on toes, one legged stance)
- Reactive Postural Control (forward, backward, lateral)
- Sensory orientation (Standing, standing on foam & incline with eyes closed)
- Dynamic Gait (Walk w/ heads turns, TUG w/ dual task, pivot turns, obstacles, change in gait speed)
According to the Mini BESTest what is the cut off score for falls?
24 points
What is the MDC for older adults according to the mini BESTest
4
In the Mini BESTest what control strategies for balance does this test?
all aspects of balance
What does the Timed “up & Go” (TUG) examine?
How a patient stands up from a chair, walks 3 metes, turns, walks back to chair and sits
According to the TUG what is the cut off score indicating high risk for falls in:
- Community Dwelling adults
- CVA
- PD
Community: >13.5 sec
CVA: >14 sec
PD: 11.5 sec
In regards to the TUG what is the MDC for CVA & PD?
2.9 (CVA)
4.85 (PD)
how is the TUG manual performed?
Addition of holding a glass of water
How is TUG cognitive performed?
Addition of having patient count backwards by 3s from a number between 20-100
OR
repeat every other letter of the alphabet
What are the cut off scores in regards to the TUG dual tasks for:
Older adults
PD (cog)
PD (man)
Older adults: > 15 seconds
PD (cog): > 10% difference in speed between typical
PD (man): >4.5 sec difference between typical
