PT Activity Examination: Balance and Trunk Control Flashcards
base of support (BOS)
boundary created by body parts in contact w supporting surface
center of mass (COM)
mean/avg location of total mass in the body
center of pressure (COP)
theoretical position under BOS through which all forces act on the body
- weighted avg (net force) of all forces acting on supports
ie imaginary point where all pressure is located (right vs left, toes vs heels)
center of gravity (COG)
mean location of moments and forces acting on a body
- imaginary point about which sum of forces and moments equal ZERO
limits of stability (LOS)
COG approaches BOS; further distance a person can WTS without LOB or altering the original BOS
- influenced by a person’s height, foot length, confidence
what are two ways to define balance
ability to control COG relative to BOS
ability to achieve and maintain postural orientation and stability for function
what does adaptive postural control require
sensory and motor modifications as task and environment changes
balance is an ACTIVITY that emerges from the complex interaction of:
- sensory systems responsible for detection of body position and motion
- CNS integration processes
- motor systems responsible for execution of motor responses
how does the incidence falls related to age
inc as you get older
- 30 at >65yo
- 42-49 at >75yo
- 83 at >85yo
how is neurological dysfunction related to the incidence of falls
5x more likely
why is the inc incidence of falls w age so significant
falls account for 50% of injury related deaths in older adults d/t
- severe disability
- wounds/infections
- ability to mobilize
- people might not know they fell
what is the impact on the healthcare system from inc incidence of falls w age
costly public health crisis
- surgery, hospital stay, rehab/SNF
what are 6 anatomical and physiological functions/processes contribute to balance
sensory orientation
motor function
biomechanical constraints
stability limits
anticipatory postural adjustments
- proactive balance
postural responses
- reactive balance
what is anticipatory or proactive balance
anticipation of a destabilizing force
- ms activation prior to expected COG disturbance by an internal perturbation
what drives proactive balance
feedforward mechanisms drive response based on past experiences and established motor programs
how is proactive balance seen in infants and young children
presence of righting and equilibrium reactions
what is reactive postural response
displacement of COG requiring motor response and/or changes in BOS
what drives reactive postural responses
sensory inputs drive corrective response (feedback)
what are displacement forces that trigger reactive postural responses
external forces or perturbations
- train stops, someone bumps into you
internal forces - LOB
what are perturbations
something that is destabilizing
what are reactive balance responses (3)
ankle strategy
hip strategy
stepping strategy
describe ankle strategy
small shifts of COG within LOS
- feet maintained on ground
body rotates as a rigid mass about the ankle joints
how does ankle strategy often manifest itself
anterior/posterior sway
when is ankle strategy used
ALLLLLL THE TIME
- smaller forces
when is hip strategy used
elicited w faster, larger amplitudes of COG displacement
when is hip strategy most effective
when COG is near BOS or when support surface is small, variable
when is hip strategy required
lateral displacement in COG via hip ABD/ADD
- due to nature of movement at hip
when is stepping strategy used
when COG displaced beyond BOS and outside LOS
how does stepping strategy work
establish new BOS in which COG is maintained
- take a step or steps to prevent a fall
- in sitting may have UE ext also
when is stepping strategy elicited
by larger and/or fast amplitude and external perturbation
how is BOS changed by someone sitting down
BOS includes all body parts in contact w a support surface
describe postural responses in sitting
trunk moves on hips
-if feet on supporting surfaces, gastroc and soleus may be activated
describe postural responses in sitting to posterior excursion of COG
ie leaning back
- hip flexors fire first
- then abs
- then neck flexors
extensors fire for anterior displacement of COG
what postural responses in sitting do you see to large, quick excursions in COG
protective extension
step responses
trying to establish larger, more stable BOS
what is required for sensorimotor integration in balance
complex interactions of musculoskeletal and neural systems required
what provides sensory input for balance
joint and muscle proprioceptors
cutaneous and pressure receptors
what information are your sensory receptors providing in terms of balance
relationship of body to supporting surface
what sensory input is provided by visual proprioception (3)
- perceive movement of objects
- recognition of environmental factors
- perception of verticality or orientation of self to the environment
sensory input from the vestibular system: otoliths vs semicircular canals
OTOLITHS - position of head in relation to gravity and linear acceleration
SEMICIRCULAR CANALS - info on angular/rotary motions of the head
what are the two otolith organs? how does their function differ?
saccule - vertical info
utricle - horizontal info
what is the role of CNS integration in balance
CNS “weight” of different sensory input varies w task and sensory environment, health conditions
how does CNS weigh sensory input when on a firm surface
70% somatosensory
20% vestibular
10% vision
how does CNS weigh sensory input when on an unstable surface
10% somatosensory
60% vestibular
30% vision
why does the CNS weigh somatosensory input less on unstable surfaces
giving you inaccurate info
3 vestibular reflexes
VOR
VSR
VCR
what does the VOR do
stabilize gaze during head movements
what does the VSR do
helps detect head movement/position
postural tone adjustment
what does the VCR do
adjusts firing of the neck muscles to stabilize the head
what does CNS integration do after receiving sensory inputs from task & environment
sensory organization to compare, select, and combine senses
- determine body position & movement
- select & adjust muscle activation
how is motor execution achieved after CNS integration
ankle, hip, trunk, and neck muscles were selected and adjusted for muscle activation
generate body movement via reflexes, automatic & anticipatory postural responses & voluntary movements
what is CNS integration doing when comparing and selecting inputs
deciding which source is more reliable and has been more reliable
what is a screening tool
not a standardized test and outcome measure
what is a static control clinical exam
ability to maintain a posture or position statically - either standing or sitting
what is dynamic control
anticipatory
- head turns
- reaching within and outside BOS
- WTS
reactive
- external perturbations in A/P and lateral directions
how are clinical balance exams usually described
screening tools
what should you use to select outcome measures
sound clinical reasoning based on pt pop
- rationale?
psychometric properties
level of functioning and abilities
practice setting
what are two dynamic sitting balance tests
Trunk Impairment Scale (TIS)
Function in Sitting Test (FIST)
what are subscales of the trunk impairment scale (TIS)
static sitting balance
dynamic balance
trunk coordination
what pt population was the trunk impairment scale (TIS) initially developed for? what populations are tested by it now?
CVA
CP MS, PD
what are 3 static standing tests
romberg test
single leg stance test
mCTSIB
what is a positive Romberg? what does
this indicate of the patient
loss of balance w eyes closed
visually dependent
what is a Romberg test mostly testing for
proprioception
- relying on orientation in space and joints telling you where you are in space, and info from the surface
firm surface - vestib not as high
how is a sharpened Romberg different from a regular Romberg
standing in a tandom stance vs standing w feet together
what is included in a full CTSIB but not in. a mCTSIB
visual conflict - on firm and on foam
- able to open eyes but giving you inaccurate input
what is the CTSIB really testing about balance
Clinical Test for Sensory Interaction in Balance (CTSIB)
is the person relying on one sensory input more than others
- eliminate vision w eyes closed
- inaccurate somatosensation w foam
- can’t get rid of vestib
what is the ABC scale
self report measure of confidence in maintaining balance
from an assessor’s POV what do you look at in someone’s ABC scale
see if they are aware of their own deficits
- look at their judgment level
the ABC scale has benchmarks established for what pt population
hx of CVA, PD
why is the BERG highly used
functional motions
what is an important consideration when determining if a patient is an appropriate candidate for a BERG
can’t require an AD, or have had an AD
if person never had an AD and considering it now, do this test
what is the goal of a BERG
not to need AD
what is the TUG related to
fall risk and functional mobility
what is the TUG responsive to
change in acute stroke rehab
what is an advantage to the TUG vs the BERG
can use an AD
what is a dual task TUG
add a cognitive or manual task to complete while doing the TUG
- count back from 7
- hold a cup of water
what patient population would you do a dual task TUG with
if cognitive impairment
- ex: Parkinsons
what are you looking to see during a dual task TUG
if can multitask
- see what they are will to sacrifice if can’t multitask (motor over cog or cog over motor)
what does a FTSST look at
lower limb strength (gluts, quads, power)
assess risk for falls
what are the 6 categories the Bestest looks at
- biomechanical constraints
- stability limits/verticality
- anticipatory postural adjustments
- postural responses
- sensory orientation
- stability in gait
mini BESTest vs BESTest
mini addresses 4 of the 6 original areas
1. anticipatory postural adjustments
2. reactive postural control
3. sensory orientation
4. dynamic gait
what are the bony structures associated w the trunk
vertebral columns
ribs and sternum
pectoral girdle (clavicle, scapula)
pelvic girdle (SI joint, ilia)
what is the function of the vertebral column
designed for stability and motion
what is the function of the ribs and sternum
stability, protection, and motion required for respiration
what is the function of the pectoral girdle (clavicle and scapula)
connects UE to axial skeleton
- via SC joint
scapula is highly mobile and moves glenoid fossa
what is the function of the pelvic girdle (SI joint, ilia)
connects trunk to LE
designed for stability and shock absorption
muscle, fascia attachments for lower trunk and LEs
what are the core trunk muscles
extensors
flexors
rotators
lateral flexors
what are other (not core) trunk muscles
pecs
traps
lats
serratus
rhomboids
quad lumborum
iliopsoas
what are 5 functions that contribute to trunk function of stability and postural control
COG contained w/i trunk
vital organs housed in trunk
required for AG postures
stable base for efficient limb movements
shock absorption and wt distribution
what are 5 functions that contribute to trunk function of mobility
- minimal motor activity in supine, static sitting/standing
- transitional movements (supine to sit)
- change in orientation of head, face, and limbs
- extend functional range of limbs
- movement of our COG
how is wt shifting initiated in upper vs lower trunk
upper - shoulder girdle
lower - pelvis
what is trunk wt shifting
movements that result in changes of wt distribution, posture, and moves COG
what are 4 possible directions of weight shifting
anterior
posterior
lateral
diagonal
normal trunk movements (5)
flex/ext
lateral flex
rotation
upper and lower trunk dissociation
tilts
process of trunk wt shifts exam
test in sitting
expose trunk
examine alignment, ms bulk
visualization of ms responses
assess for compensatory strategies
demonstrate - reaching/scooting for desired wt shift or passively move first
what is the significance of a hands on technique when assessing trunk wt shifts
by putting hands on, can trigger activation that wasn’t before
what population is a trunk control test (TCT) usually utilized in
CVA, geri pop w acute illness
what are the 4 functional items included in a TCT
rolling to weak side
rolling to strong side
sitting balance
sit up from lying down
what are some PT interventions w trunk control (6)
- PNF
- upper and lower trunk rotation, counter rotation
- bridging, rolling, scooting, transfers, amb, obstacle course
- WTS in sitting, standing
- external perturbations
- reaching activities
what are some pedi PT interventions for trunk control
wheelbarrow
tug of war
ball toss
what are 4 PNF techniques for trunk control
stabilizing reversals (alternating isometrics) – more intuitive
rhythmic stabilization
combined isotonics
lift and chop
