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Neuromuscular Exam and Rehab Exam 2 > Sitting Postural Control - Balance Assessment and Interventions > Flashcards

Sitting Postural Control - Balance Assessment and Interventions Flashcards

1
Q

What is Postural Control?

A

-Orientation of body position in space relative to gravity
- The way we hold our bodies while standing, sitting, or lying down

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2
Q

What is Balance?

A
  • Condition in which all forces acting on the body are balanced such that center of mass (COM) is within the base of support (BOS)
  • Ability to maintain stability and control in different position and movements
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3
Q

What is Reactive Postural Control?

A

Responds to external forces acting on the body

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4
Q

What is Anticipatory Postural Control?

A

Internally generated destabilizing forces imposed on the body’s own movements (ex. catching a weighted ball)

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5
Q

What are you observing when doing as assessment of Sitting Postural Control and Balance?

A

-Degree and direction of sway
-Endurance (how long can a patient hold unsupported sitting posture)
- Ability to accept perturbations and recover (note: movement strategies for recovery)
- Fixation or grasp strategies, using hands, or legs hooking to support
- Dynamic reach and limits of stability (LOS)- distance outside of BOS
-Sensory Integration: eyes open (EO), eyes closed (EC), fixed surface, unstable surface

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6
Q

How do you test Static (EO and EC)?

A
  • Posture
  • Time spent sitting without loss of balance
  • Perturbations: (nudge-push) and motor strategy for recovery
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7
Q

How do you test Dynamic (EO and EC)?

A
  • Head movement: looking over shoulder 180 deg
  • Reaching to determine LOS
  • Reaching outside BOS: reach to the floor
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8
Q

What is “Normal” on the Postural Control/Balance General Grading Scale?

A
  • Patient able to main steady balance without handhold support (static)
  • Patient accepts maximal challenge and can shift weight easily within full ranges of LOS in all direction (dynamic)
  • Fall risk no different than otherwise healthy age-related individual
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9
Q

What is “Good” on the Postural Control/Balance General Grading Scale?

A
  • Patient able to maintain balance without handhold support, limited postural sway (static)
  • Patient accepts moderate challenge; able to maintain balance while picking up object off floor (dynamic)
  • Fall risk low, considered independent but safety concerns outside of norm
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10
Q

What is “Fair” on the Postural Control/Balance General Grading Scale?

A
  • Patient able to maintain balance with handhold support; may require occasional minimal assistance (static)
  • Patient accepts minimal challenge; able to maintain balance while turning head/trunk (dynamic)
  • Moderate risk of falls which can be improved with an assistive device
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11
Q

What is “Poor” on the Postural Control/Balance General Grading Scale?

A
  • Patient requires handhold support and moderate to maximal assistance to maintain position (static)
  • Patient unable to accept challenge or move without loss of balance (dynamic)
  • High fall risk, uncorrectable balance even with assistive device requiring support from caregiver
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12
Q

What is “Absent” on the Postural Control/Balance General Grading Scale?

A

Patient unable to maintain balance

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13
Q

What are aspect of “Normal” Sitting?

A
  • ASIS is level or slightly lower than PSIS
  • Ischial tuberosities equal weight bearing
  • ASIS are level with each other
  • Head in midline with “chin- in”
  • Trunk muscles active maintaining upright posture: co-contraction of core stability, erector spinae and abdominal flexors
  • Feet flat on floor
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14
Q

What are some key elements a therapist should include in their documentation from what they observed?

A
  • BOS and the position and stability of the COM within the BOS
  • Degree of postural sway
  • Use of stabilization from UEs (grasp-strategies- holding on to the edge of the seat/mat) or LEs legs hooked around mat (forceful knee flexion)
  • The level and type of assistance required (manual cues, verbal cues, physical assistance)
  • Environmental constraints that influenced performance
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15
Q

What are some stroke considerations?

A
  • Disruptions of central sensorimotor systems may result in loss of sensation in trunk and impaired vertical alignment
  • Reactive and anticipatory postural control may be impaired or delayed in response
  • Uneven weight distribution through BOS generally less weight bearing on involved side
  • Ipsilateral pushing: pushing toward hemiparetic side
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16
Q

What are the balance and fall risks with stroke survivors?

A
  • Delayed, varied or absent balance responses
  • Deficits in latency, amplitude, and timing of muscle activity
  • Stroke survivors have low balance self-efficacy as compared to healthy older adults
  • Falls can lead to further morbidity and loss of confidence
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17
Q

How would you document your findings for a “Fall Risk/Safety” patient?

A
  • Can be left alone during functional tasks/ADLs (dressing, eating)
  • Nursing, SLP need to know
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18
Q

How would you document your findings for a patient who requires additional “Support Needed”?

A

Does a caregiver need to be present for cueing

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19
Q

How would you document your findings for a “Limits of Stability” patient?

A

Keeping items within reach or is the patient able to safely reach outside BOS

20
Q

How would you document your findings when it comes to preparing for a patient “DC Planning”?

A

Safety with sitting up independently, do they need a hospital style bed at home

21
Q

What are some examples of Postural Control/Balance Goals?

A
  • Holds static sitting position with increased independence
    -Timed goals: maintains upright midline-oriented posture for 10 seconds/30 seconds
  • Orientation: independently self corrects to midline without visual or verbal cues
  • Decreased Care Giver Dependence: weight shifting without physical assist/facilitation/verbal cues
  • Improved awareness of posture or limb: patient attends to left UE during seating activity of _____
22
Q

What are some interventions that can be used to help a patient find “midline”?

A
  • Utilize verbal cues and tactile curing to guide and recalibrate positioning
  • Utilize mirrors for visual feedback (EO) of vertical position and posture. Progress to EC “feel vertical” in the absence of visual cues
23
Q

What is “Inattention”?

A

Patients suffering from acute neurological disorder often have a misalignment of their midline orientation

24
Q

What is Dynamic Balance?

A

Static sitting posture + volitional patient movement

25
Q

What is needed for functional mobility?

A

Transfers, weight shifting

26
Q

What is needed for moving the limbs?

A

Reaching and lifting

27
Q

What is needed for functional ADLs?

A

Putting on shoes, Lower Body pressing

28
Q

What deficits can observed in assessment that can lead to interventions?

A
  • BOS and the position and stability of the COM within the BOS
  • Degree of postural sway
  • Use of stabilization from UEs (grasp-strategies- holding on to the edge of the seat/mat) or LEs legs hooked around mat (forceful knee flexion)
  • The level and type of assistance required (manual cues, verbal cues, physical assistance)
  • Environmental constraints that influenced performance
29
Q

What are some Intervention Strategies for Weight Bearing (internal cues)?

A
  • Increased proprioceptive awareness through approximation of joint
  • 70% of balance is somatosensory input
30
Q

What are some Intervention Strategies for Visual Feedback (internal cues)?

A
  • Promotes awareness of posture or limb
  • 20% of balance is visual input
31
Q

What are some Intervention Strategies for Salience?

A
  • The training experience must be sufficiently salient to induce plasticity
  • Intervention must be meaning and related to the patient’s goal
32
Q

What are some other Intervention Strategies?

A
  • Self Efficacy
  • Modeling/ Guided Movements/ Facilitation
  • Recall other practice/Feedback strategies through stages of learning
33
Q

What are some PT consideration when it comes to thinking about interventions?

A
  • Chose the best activity , be task specific and manipulate the environment accordingly (train specific strategies to complete a task)
  • Adjust to the stage of motor learning
  • Manipulate the amount of sensory information (sensory reweighing)
  • Challenge all systems involved in postural control including cognitive (dual- task intervention)
  • Use patient’s goals (salience)
  • Promote self efficacy (level of confidence in independent performance)
  • Patient safety (setup of hospital bed, feet on the floor with shoes on or non-skid socks, therapist positioning for guarding, use of 2nd person, bedside table
34
Q

What are some other considerations a PT should make?

A
  • First attempt consider having +2 therapist/tech for safety: patients who are unstable during sitting are likely to demonstrate increased anxiety and fear of falling
  • Position for safety and body mechanics
  • Which strategies to employ based on stage of learning and level of assist needed
  • Static stabilization exercises are “lead up” exercises for functional movements (transfers) and ADLs
35
Q

What are some strategies a PT should make?

A
  • Guided movements: tactile cueing
  • Verbal cueing: “Chest up tall”
  • Visual feedback: Mirroring
  • Manual Contacts: Facilitation
36
Q

What are some UE weight bearing protocols for assisted stabilization?

A

Patient performs WBing through the affected extremity with assisted stabilization and positioning from therapists and performs weight shifting

37
Q

Why is full extension of the elbow important?

A

Avoids elbow flexors contractures due to flexor spasticity

38
Q

What are some UE weigh bearing interventions protocols?

A
  • The hand is positioned in WBing to the patients side
  • Shoulder is extended, abducted and externally rotated with the elbow, wrist and fingers extended
  • Maintain position performing weight shifting loading for several minutes
39
Q

What is Mirror Therapy?

A

Sitting directly in front of a mirror a plumb line can be used to orient to vertical position

40
Q

What are some Modeling Strategies Interventions?

A
  • Therapist demonstrates how movement is to be done
  • Helps patient develop an internal cognitive map
  • Helps patient learn sensation of the movement
41
Q

What are some Guided Movements Interventions?

A
  • Therapist physically assists patient through the movement with use of hand contact. Therapist hands effectively substitutes for missing elements or facilitates poor performing elements
  • Facilitation
  • Stabilization of body part to reduce errors
  • Constrain unwanted movements
  • Guide toward correct motor performance
42
Q

What are some interventions for Static Posture Control?

A
  • Focus cues on stability of pelvis, posture extension, weight evenly distributed
  • Verbal Cues: “sit tall”, “shoulders back”, “find the middle”
  • Try to keep hands off the patient: let them find and feel their position and try to correct alignment
  • Hands are an external input that the patient may mistake for internal
  • If patient is unable to find appropriate midline oriented upright postural control then use facilitation is indicated
43
Q

What are some interventions for Dynamic Posture Control?

A
  • Weight shifts in all directions to LOS
  • Weight shifting practice is important for CNS to develop an accurate perceptual awareness of postural control anticipatory postural control
    -Lateral weight shift: associated with appropriate elongation/shortening of lateral trunk
    -Anterior/Posterior Weight Shift: associated with anterior/posterior pelvic movement and corresponding trunk ext/flx
  • Maintaining midline while performing dynamic task: focus on care stability, being able to return to midline while reaching outside BOS, dual task reaching in all directions to grab objects and return to midline adds interference
  • Introduce reactive postural control: add intermittent pulls/pushes and nudges while performing reaching tasks to retrain reactive control of posture
44
Q

What are some interventions for dynamic balance and postural control with active weight shifts?

A
  • Patient is encouraged to shift weight from side to side
  • Limit of stability (LOS): gradually increasing and reeducating their LOS
  • WBing through UE: can facilitate relaxation of spasticity for UE flexor postural synergies
  • A large ball can be used to facilitate: reduces anxiety, and provides UE support for affected extremity
45
Q

What are some interventions for varying UE and LE support?

A
  • Bil hand flat, hand over hand PT support
  • Unilateral UE support unaffected side
  • Unilateral UE support “weaker” side
  • No UE support
  • Both feet flat on flat surface, wide BOS
  • Both feet flat on flat surface, normal BOS
  • One foot crossed over other leg, no floor contact
  • Elevated seat with both feet off floor
46
Q
A

Neuromuscular Exam and Rehab Exam 2 (8 decks)

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