Test 3: Standing Balance Assessment and Interventions Flashcards
3 types posture control
steady state- normal; unsupported
reactive - perturbations/sensory integration challenges
proactive- dynamic reaching/resisted limb/prepare for movement
balance grading scale
4 = normal
3= good; maintain without support; minimal sway; low fall risk
2= fair; maintain with handheld support; may require min A; moderate fall risk
1 = poor; requires hand support and mod to max A; high fall risk
0 = absent; unable to maintain
aspects of normal standing biomechanics
ASIS’s level
neutral pelvis
head in midline
active trunk muscles
feet flat on floor/weight even distributed
what is limit of stability
max excursion in any direction without losing balance
need to assess to inform eval and POC
components when testing postural stability with neuro pts and things to keep in mind
check standing unsupported - always have support on affected side and cue for hip/knee/trunk ext
if using assistive device highest grade is fair
weight shifting- start toward less affected side
trunk RT- reach across midline, look over shoulder
limb advancement - pregait stepping with sound limb
assessment techniques for dynamic posture stability
active weight shift
active weight shift against resistance
reaching outside of BOS
task oriented practice (i.e. folding clothes, reaching for tray, etc)
dual cognitive task
resisted limb movement
environmental changes
key observations to make when evaluating dynamic posture
BOS/COM
use of UE/LE
degree of stability maintained by WBing segments
range/degree of control of moving segments
level/type of assistance
environmental constraints that influenced performance
how to set up STS for assessment
initial conditions - feet on floor with hips/knees flexed to 90
WBing symmetry- arms should be in position to WB at first; if they have enough strength they can push up with both arms then use one to grab AD; dont want unilateral AD b/c it encourages learned nonuse
bedside table can be used as AD - Wbing through BUEs; can start lower and raise up later on
what is a push and release test/retropulsive pull test
quick assessment for reactive postural instability
high score = increased risk of fall
0 = independent recovery w/ 1 normal step
1 = 2-3 small steps bwd but recovers still
2 = 4+ steps bwd but recovers
3 = steps but needs to be assisted to prevent fall
4 = falls w/o attempting to step/unable to stand independently
examples of goals for postural stability
more automatic posture control (i.e. less static sway/better ankle or hip strategy)
timed goals (i.e. hold 10s or reach for 30s)
orientation goals (i.e. self correct midline)
decreased dependence (i.e. weight shift w/o assist, stand by assist, etc)
improved awareness of posture/limb
examples of important things to document with posture stability assessment
fall risk or safety/out of bed safety
support needed (physical assistance, cueing)
limits of stability (balance strategies, UE/LE body dressing while standing)
DC planning (safety with out of bed; need home assist?)
describe Postural Assessment Scale for Stroke Patients (PASS)
10 min to administer
total score from 0-36
each item scored 0-3 (i.e. from cant perform to perform w/o help)
higher score = higher function
high responsive to acute pts (14-30 days); high sensitivity
least responsive to chronic pts
describe Berg Balance Scale
14 items
measure of balance for geriatric pt or neuro pt to determine FALL RISK
15-20 min
score 0-4; 0 lowest functional level, 4 highest level
total score = 56
45-56 = independent
<45 = fall risk
ceiling effect possible
describe the Activiries Specific Balance Confidence (ABC) scale
confidence in performing various acivities w/o losing balance
self report measure
16 item questionnaire
subjective to pt
describe tinetti test
measures balance and gait function in elderly
16 items; 2 parts (balance and gait)
each item scores 0-2
28 possible points
higher score = more independent
<19 high fall risk
19-24 = medium fall risk
25-28 = low fall risk
stroke cutoff score <20 = fall risk
describe Mini BESTest: Balance Evaluation Systems Test
shortened version of original BESTest (14 vs 36)
research trying to add to core set of neuro rehab outcome measures
low level pts = floor effect
4 subcategroies
- anticipatory posture response
- reactive posture response
- sensory orientation
- stability in dynamic gait
total score = 28
higher score = higher function
each item: 0 severe impairment, 2 no impairment
pros of assistance devices
should improve pt stability by
- expanding BOS
- reduce WBing through LE
more stability
safety/fall prevention
cons of assistance devices
learned dependence
pt usually starts with max stability vs mobility
- if you max stability too much pt can become too reliant and develop compensatory strategies while missing restorative opportunities
- need to find a balance of supportive and robust vs challenging and allowing for symmetrical WBing
AD too robust gives false sense of stability
asymmetry in gait can develop
guidelines for AD fitting arm position
pt should be in 20-25 deg elbow flexion when standing upright
how to help a pt use a walker if they have poor grip strength
can use arm trough
therapist can facilitate grip with hand over hand
taping with ACE bandage
alternative ADs for gait and standing
weighted shopping cart
walking staff
hand rail
hand help assist (can feel hoe much weight they are putting into you but requires therapist presence)
goals of intervention
improve functional skills (ADLs, gait, mobility, etc)
need to be intense enough to promore behavioral change and neural reorganization (challenge pt outside of LOS)
final goal = adaptability of learned skill for independent function (transer tests and retention tests)
considerations for interventions involved with dynamic posture
consider multiple therapist for first attempt for safety
positon for safety and body mechanics
employ strategies based on stage of learning and level of assist
static stabilization lead up to functional movement
consider strengthening exercises in functional positions
challenge sensory integration and reactive postural control
functional strengthening intervention examples
standing partial wall squats/bedside squats
improve static strength or eccentric control
pt holds position for 2-3 sec and then slowly returns to standing
examples of interventions to improve sensory integration
challenge vision, somatosensory, and vestibular
EO vs EC
dual task
compliant surface
ankle strategies
small shifts in COM alignment
using DF/PF
intervention = manual perturbations/ankle rocker board
hip strategies
larger/faster shifts in COM alignment when ankle strategies are not sufficient
hip flexors/extensors
interventions = stronger manual perturbations, add eyes closed, tandem stance
stepping strategies
larger faster shifts in COM alignment which exceed the LOS causing a step to prevent fall
based on push/release assessment
intervention = push/release or push/pull
benifits/examples of resisted limb movements in standing
add resistanc eto limb strengthens and enhances control
proximal stabiity while creating distal strength/mobility
increases automaticity of trunk control and awareness
resistance options: weight cuffs, theraband, pulleys/machines, manual resistance
benefit of dual task control
ability to perform secondary task while standing
training enhances the patients postural control with cognitive/motor interference
secondary task increases cognitive load
stabilizing reversal example in standing
push against me fwd, pull against me bwd
dont let me push you bwd, now dont let me pull you fwd
rhythmic stabilization example in standing
hold dont let me move you
dont let me twist you, hold, now dont let me twist you the other way, hold
what is pregait training
initiated for lower level pts to emphasize stance phase stability
acute stage
emphasis on stance stability (60% of gait cycle)
good stance phase is key to successful swing
phases of overground gait training
pregait = acute; weight shift toward affected limbor wh to advance less affected
lead up to exercise = early in gait training; faciliate lead up to reciprocal stepping; position affected limb in hip ext
encourage larger step = faciliates load to paretic limb and an extended hip position is prep for swing; hip flexors in stretch position activates gait pattern generator which further assists in achieving reciprocal gait pattern
standing options for motor relearning of pts with moderate TBI
for more alert pts
standing frame
body weight shift support
sabina (sit to stand) lift
describe use of parallel bars for sit to stand
encourages pull up dependency instead of more functional push up
parallel bars technically not AD
good to use for standing tolerance and eventual transfers
technique 1 = caregiver to side of pt
technique 2 = more assistance; caregiver in front pf pt blocking knees
