Week 10 : Falls / Balance

Question 1

Define balance

Answer 1

a state whereby the projection of the centre of mass (COM) falls within the stability limits of the base of support (BOS)
• Stability limit is the point at which balance is lost and corrective action is required
• Core component of functional activities
• Incorporates the concepts of posture and movement

Question 2

define postural control

Answer 2

control of posture and movement in attaining a state of balance
• Motor action that occurs following integration of sensory, perceptual, cognitive and motor processes
• Aims of postural control:
– Postural equilibrium/ stability (maintain upright position and maintain COM within stability limits of BOS during internally and externally initiated movement)
– Postural orientation (gravity, vertical, internal references, the environment)

Question 3

Sensory input and balance - input

Answer 3

Visual Input
– Reference for upright vertical
– Predicting forthcoming threats to balance
• Somatosensory System (Proprioception)
– Reference for body position relative to the supporting surface and other body parts
• Vestibular System
– Reference for head position and movement of head in relation to gravity

Question 4

sensory input and balance - main functions

Answer 4

• Sensory Feed Forward
– Allows preparation for movement
– Requires input from internal and external environment – Strongly linked to previous experience
• Sensory Feedback
– Allows ongoing regulation and appropriate muscle adjustments during movement

Question 5

integration

Answer 5

Minimal cognitive processing by the cortex for postural control
– Contribution dependent on task complexity and the capability of the individual’s postural control system
• CNS intervenes if a sensory conflict exists when it must weight the sources and reject the potential source of error

Question 6

Motor output and balance

Answer 6

refers to displacement of COM in relation to the BOS during movement

motor response by which balance recovers determines whether the displacement of COM causes a fall

motor adjustments are flexible and varied dependent on the task, the environmental context and the individual

as appropriate motor response requires

• muscle strength, endurance, ROM
• fine grading of agonists, antagonists, synergists
• appropriate co-contraction
• high level of reciprocal innervation

Question 7

movement strategies

Answer 7

ankle strategies
hip strategies
step strategy
outstretched arm

Question 8

balance reactions - equilibrium reactions

Answer 8

postural sway

subtle changes in muscle tone required to maintain equilibrium

Question 9

balance reactions - righting reactions

Answer 9

response to displacement of the COM beyond the stability limits in an attempt to regain equilibrium
-may involve movement of the head, the trunk or limbs

Question 10

balance reactions - saving/protective

Answer 10

step or extended upper limb

- establish a new BOS and restore equilibrium

Question 11

Common impairments in neurological patients
motor dysfunction
MSK

Answer 11

decreased muscle strength, trunk stability, decreased ROM, altered muscle tone

Question 12

common impairments in neurological patients
motor dysfunction
biomechanics

Answer 12

decreased stability limits, decreased balance responses (magnitude and velocity), altered movement strategies

Question 13

common impairments in neurological patients
sensory dysfunction
altered sensation

Answer 13

decreased ankle proprioception, vestibular system damage, dizziness, visual deficits

Question 14

common impairments in neurological patients
sensory dysfunction
altered sensory integration

Answer 14

difficulty dividing attention between tasks, impaired ability to use sensory weighting, delayed or inadequate anticipatory response, altered perceived stability limits, abnormal perception of vertical via somatosensory systems

Question 15

balance assessment : functional observation

- set an appropriate balance task

Answer 15

create a safe situation (environment, assistance)
incorporate various environmental contexts and tasks
challenge their behaviour (decreased BOS, raise COM, displace COM towards stability limits, unstable surface, alter visual input)

Assess all aspects of balance responses (posture and movement, balance strategies/reactions, planes of movement

Question 16

balance assessment : functional observation

observe the patient performing the balance task

Answer 16

can they balance in a specific posture
can they balance during movement
if they can balance, what strategies do they use to achieve balance
does the patient use compensatory strategies to maintain balance
are these compensations effective
is the goal completed successfully
do they interact with their BOS during their movement
what happens to the balance if sensory input is reduced?

Question 17

Balance assessment : outcome measures

Answer 17

Tinetti Balance 
Berg Balance scale
BOOMER
Rhomberg's test/sharpened Romberg's
CTSIB 
Functional reach test 
Functional activities
Sitting; supported sitting, sitting arm raise, sitting forward reach 
Standing: supported standing, standing arm raise, standing forward reach, static tandem standing, weight shift
Walking : timed 5m walk, tap and step

Question 18

Balance training

Answer 18

trained simultaneously as part of functional motor actions

• sitting, standing, mobility and transfers
• control and stability of the COM is specific to each task and the conditions in which it is carried out

increasing evidence that challenging balance in standing, with the aim of reducing the BOS and practising controlled movements of the COM is the optimal way to improve balance during performance of everyday actions

Mobility requires accurate sense of balance, sufficient lower limb strength, and sufficient soft tissue extensibility and joint flexibility

training programmes should include exercises that require a fast build up of force and propulsive muscle activity (power)

Question 19

continued balance training

Answer 19

strength relates directly to functional motor control and both can be improved by intensive and functional based training that is challenging for the individual

• progress to extend capabilities of patient
• functional tasks strengthen muscles concentrically and eccentrically
• increase intensity by increasing reps, increasing step height, lowering chair height, reducing hand support

maximise skill through progressively challenging the tasks according to destablishing effects (complex environment, unpredictable demands)

Question 20

define a fall

Answer 20

an event which results in a person coming to rest inadvertently on the ground or other lower level
• Do not include an intentional change in position
• Do include when a person inadvertently comes to rest on furniture, against a wall or other object or person

Question 21

falls may result from

Answer 21

loss of balance
tripping
slipping
legs giving way

Question 22

fear of falling

Answer 22

post fall anxiety syndrome
negative consequence of falls
resultant self imposed activity restrictions and loss of confidence in the ability to ambulate safely can lead to further functional decline, depression, feelings of helplessness and social isolation, which in turn places an individual at a higher risk of another fall

Question 23

risk factors for falling

Answer 23

limitations in activity for daily living or mobility
impaired balance
impaired gait

reduced vestibular function 
visual impairments 
reduced peripheral sensation
reduced muscle strength 
poor reaction time

Question 24

falls assessment : screening

Answer 24

screening recommended for

• all patients who present with/report a fall
• all neurological patients
• all vestibular patients
• all patients >65 years
• all patients with known risk factors for falling

questions

• any falls within the past year?
• frequency, context and characteristics

Question 25

post screening - does not warrant full multifactorial assessment

Answer 25

discuss with the patient offering education and advice related to falls and any potential risk factors is still recommended

Question 26

falls risk assessment gold standard

Answer 26

multifactorial MDT approach

Question 27

fall assessment : risk assessment

Answer 27

identification of fall hx
gait, balance and mobility, and muscle strength 
osteoporosis risk 
perceived functional ability and fear relating to falling 
visual impairment 
cognitive impairment 
neurological examination 
urinary incontinence 
home hazards
CV examination 
meds review

Question 28

Falls assessment : outcome measures

Answer 28

TUG
Tinetti scale 
functional reach 
DGI- dynamic gait 
BOOMER
BERG balance scle 
ABC 
FES - fall efficacy scale

Question 29

falls prevention

Answer 29

most falls among older individuals are associated with identifiable and modifiable risk factors for which preventive efforts are more effective

current evidence supports multi-strategy , multifactorial falls prevention intervention

Question 30

Falls prevention strategied

Answer 30

exercise programs 
environmental hazard modifications 
education programs 
cognitive behavioural program 
assistive devices 
technological aids
footwear and foot problems 
hip protectors 
lifestyle interventions 

medication review 
vision assessment 
CV interventions 
bone strenghtening meds/supplements 
nutrition

Question 31

exercise programs

Answer 31

challenging and progressive balance exercises performed in weight bearing positions that minimise the use of upper limbs for support
targeted to patient’s deficits/risk factors/impairments and lifestyle

Question 32

summary

Answer 32

balance 
=postural control 
=sensory input and balance, integration and motor output and balance 
balance assessment 
balance training 

falls 
-falls and fear of falling 
epidemiology
-risk factors 
-falls assessment 
-falls prevention