Sitting Postural Control - Balance Assessment and Interventions Flashcards
What is Postural Control?
-Orientation of body position in space relative to gravity
- The way we hold our bodies while standing, sitting, or lying down
What is Balance?
- 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
What is Reactive Postural Control?
Responds to external forces acting on the body
What is Anticipatory Postural Control?
Internally generated destabilizing forces imposed on the body’s own movements (ex. catching a weighted ball)
What are you observing when doing as assessment of Sitting Postural Control and Balance?
-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
How do you test Static (EO and EC)?
- Posture
- Time spent sitting without loss of balance
- Perturbations: (nudge-push) and motor strategy for recovery
How do you test Dynamic (EO and EC)?
- Head movement: looking over shoulder 180 deg
- Reaching to determine LOS
- Reaching outside BOS: reach to the floor
What is “Normal” on the Postural Control/Balance General Grading Scale?
- 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
What is “Good” on the Postural Control/Balance General Grading Scale?
- 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
What is “Fair” on the Postural Control/Balance General Grading Scale?
- 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
What is “Poor” on the Postural Control/Balance General Grading Scale?
- 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
What is “Absent” on the Postural Control/Balance General Grading Scale?
Patient unable to maintain balance
What are aspect of “Normal” Sitting?
- 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
What are some key elements a therapist should include in their documentation from what they observed?
- 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
What are some stroke considerations?
- 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
What are the balance and fall risks with stroke survivors?
- 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
How would you document your findings for a “Fall Risk/Safety” patient?
- Can be left alone during functional tasks/ADLs (dressing, eating)
- Nursing, SLP need to know
How would you document your findings for a patient who requires additional “Support Needed”?
Does a caregiver need to be present for cueing
How would you document your findings for a “Limits of Stability” patient?
Keeping items within reach or is the patient able to safely reach outside BOS
How would you document your findings when it comes to preparing for a patient “DC Planning”?
Safety with sitting up independently, do they need a hospital style bed at home
What are some examples of Postural Control/Balance Goals?
- 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 _____
What are some interventions that can be used to help a patient find “midline”?
- 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
What is “Inattention”?
Patients suffering from acute neurological disorder often have a misalignment of their midline orientation
What is Dynamic Balance?
Static sitting posture + volitional patient movement
What is needed for functional mobility?
Transfers, weight shifting
What is needed for moving the limbs?
Reaching and lifting
What is needed for functional ADLs?
Putting on shoes, Lower Body pressing
What deficits can observed in assessment that can lead to interventions?
- 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
What are some Intervention Strategies for Weight Bearing (internal cues)?
- Increased proprioceptive awareness through approximation of joint
- 70% of balance is somatosensory input
What are some Intervention Strategies for Visual Feedback (internal cues)?
- Promotes awareness of posture or limb
- 20% of balance is visual input
What are some Intervention Strategies for Salience?
- The training experience must be sufficiently salient to induce plasticity
- Intervention must be meaning and related to the patient’s goal
What are some other Intervention Strategies?
- Self Efficacy
- Modeling/ Guided Movements/ Facilitation
- Recall other practice/Feedback strategies through stages of learning
What are some PT consideration when it comes to thinking about interventions?
- 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
What are some other considerations a PT should make?
- 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
What are some strategies a PT should make?
- Guided movements: tactile cueing
- Verbal cueing: “Chest up tall”
- Visual feedback: Mirroring
- Manual Contacts: Facilitation
What are some UE weight bearing protocols for assisted stabilization?
Patient performs WBing through the affected extremity with assisted stabilization and positioning from therapists and performs weight shifting
Why is full extension of the elbow important?
Avoids elbow flexors contractures due to flexor spasticity
What are some UE weigh bearing interventions protocols?
- 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
What is Mirror Therapy?
Sitting directly in front of a mirror a plumb line can be used to orient to vertical position
What are some Modeling Strategies Interventions?
- Therapist demonstrates how movement is to be done
- Helps patient develop an internal cognitive map
- Helps patient learn sensation of the movement
What are some Guided Movements Interventions?
- 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
What are some interventions for Static Posture Control?
- 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
What are some interventions for Dynamic Posture Control?
- 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
What are some interventions for dynamic balance and postural control with active weight shifts?
- 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
What are some interventions for varying UE and LE support?
- 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
