Balance tests:
- Quiet Stance
- CTSIB
- TUG
- Marsdell Pull Test
- Step Test
- Lateral Reach
- Functional Reach
Quiet Stance
Barefoot, hands by side, commences each 30 second test period using a stop watch and the “starting now”, and stops each test after 30 seconds. If the patient overbalances or requires steadying before the 30 seconds is complete, they are allowed up to two further trials. The highest duration balanced, or 30 seconds is recorded for each test (whichever is the highest) The therapist notes the amount of sway – minimum, moderate, maximum
• If patient has UL impairment, not which foot is infront
The progression of test conditions is: start firm floor then progress to foam surface
Feet apart (comfortable width) – eyes open
Feet apart (comfortable width) – eyes closed
Feet together – eyes open
Feet together – eyes closed
Stride stance – eyes open
Stride stance – eyes closed
Tandem stance – eyes open
Tandem stance – eyes closed
One leg stance – eyes open
One leg stance – eyes closed
CLINICAL TEST OF SENSORY INTEGRATION OF BALANCE (CTSIB)
- determines what system person is most reliant on for sensory information
- determines ability to resolve sensory conflict
Need Stopwatch, high density foam, visual conflict dome
- determines ability to resolve sensory conflict
- Feet together or apart (10cm), no shoes, “steady as they can during the test procedures”, demonstrate, 30 seconds
If the patient overbalances or requires steadying before the 30 seconds is complete, they are allowed up to two further trials. The highest duration balanced, or 30 seconds is recorded for each test (whichever is the highest). The therapist notes the amount of sway – minimum, moderate, maximum
The six test conditions are:
1. Eyes open, firm support surface: All senses operating.
2. Eyes closed, firm support surface: Removes vision to determine an over-reliance on this system.
3. Visual conflict dome on firm support surface: Gives false information – as the patient sways, the dome moves with them. If patients can’t integrate this information, they lose balance/fall.
4. Eyes open, foam surface: Reduces the available proprioceptive input.
5. Eyes closed, foam surface: This is a test of the integrity of the vestibular system.
6. Visual conflict dome, foam surface: This condition has two systems giving false/altered information and tests the ability of the vestibular system to integrate information.
TUG
Seat height between 44-47cm, line 3m away on floor, normal footwear or mobility aid, back against chair, : “On the word “go”, I want you to walk at a comfortable and safe pace to the line on the floor, turn, walk back to the chair and sit down again.” Perform practice run.
- Can also be performed as a speed test “as quickly and as safely as possible”
- TUG Cognitive: Patient walks as quickly and as safely as possible, whilst counting backwards in threes from a randomly selected number between 20 and 100. Test can do numerical task first. Can also name household objects beginning with letter “S”
- TUG MOTOR: Patient walks as quickly and as safely as possible whilst carrying a full cup of water
Used to measure Transferability and mobility of a patient. As tests sit to stand ability + independent travel
Step Test
- assess dynamic single-leg balance, assess the patient’s ability to maintain balance whilst negotiating steps) – self perturbation
“On the word go I want you to lift your foot up onto this block and then place it back onto the floor as many times as you can in 15 seconds. Do not move the opposite (supporting) foot during the test.” One complete step involves placing the foot fully up onto the step, then returning it to the floor - Start with feet 10cm apart, block 5cm Infront of patient and height is 7.5cm for stroke, 11cm for normal, need stopwatch
- No hands on support unless patient loses balance, . If this occurs, counting stops at the number of completed steps, and the score of completed steps is recorded.
- REPEAT WITH OPPOSITE LEG
Lateral Reach
- assesses ability to transfer weight/change position/control movement of the centre of mass, when carrying out daily activities
same as above but back facing wall and feet 30˚ outwards, “Please reach as far as you can to the left / right without overbalancing, taking a step or touching the wall.” FEET MUST REMAIN ON THE GROUND AND MAXIMUM DISTANCE HELD OUT FOR 3 SECONDS BEFORE RETURNING TO START
Functional reach
- assesses ability to transfer weight/change position/control movement of the centre of mass, when carrying out daily activities
Feet 10cm apart, no shoes, The non-affected arm is raised to 90 degrees shoulder flexion and the therapist reads off the level of the knuckles (third metacarpal head) on the tape measure (not touching wall). instructed to lean forwards as far as possible, and the therapist notes the level of the knuckles at the point of furthest reach. Standardized instructions: “Keeping your arm out in front of you, I want you to reach as far forward as you can without losing your balance or moving your feet.”
DON’T TOUCH WALL, ALLOED TWO PRACTISES
Marsden Pull
- assess ability to withstand an external perturbation, assesses reactionary balance
Deliever a brief tug on shoulder in posterior direction (stand behind), anterior(in front) and lateral (behind and to the side) at the hips on both left and right sides.
Pateint’s eyes remain open, “try to resist the pull’
The patient’s response is rated according to the following:
0 = staying upright without taking a step
1 = staying upright, with one step required for stability
2 = two or more steps required for stability, but able to steady self
3 = several steps, but unable to steady self, requiring therapist to steady patient
4 = falling within attempting to step
Standardized instruction: “I am going to give you a brief tug from behind. I want you to resist the backward movement [alter the direction, as applicable]”
Exercise for Peripheral Neuropathy
- Balance with sensory changes
- Standing on foam block
a. Normal stance Eyes opened; eyes closed
b. Progress to narrow stance, eyes open and eyes closed
c. Step stance, eyes open, eyes closed
Head turning, normal stance, eyes open and eyes closed
- Standing on foam block
- Foot muscle strengthening
Scrunching paper towel under foot - Calf stretch on step
Exercise for Joint Range of Motion (Knee and Hip)
- Active-assisted knee flexion
- Using alternate limb, bring knee into flexion
- Feet on towel
- Active-assisted knee flexion (feet planted)
- Sitting on chair with feet on floor shuffle back and forth on - Partial sit to stand:
- Seated in chair with rails
- Feet planted lift out of chair
- Only go up until hands nearly off chair
- Progression: Full sit to stand without hands
- Forward lunge onto step:
- With no slip mat, lunge onto step
Full lunge and then feet back together off step = one rep
Exercise for Muscle Strength (Lower Limbs)
- Clams – side lying
- Pillow under head
- Palpate glutes to ensure proper activation
- Feet stay together
- Progression- add TheraBand - Hip flexion/extension in standing
- Progression – Add ankle weights - Hip abduction in standing
- Progression – add ankle weights - Partial squat
- Progression – remove upper limb support for stabilisation - Wall squats against wall with slight hold
- Crab walks
Progression – add TheraBand
Exercise to Stimulate Osteogenesis (Lower Limbs + Upper Limbs)
Exercise to Stimulate Osteogenesis (Lower Limbs)
1. Multidirectional stepping – Forward and backwards
- One direction onto the block and turn around
- Progression – up and over and turn around
- Multidirectional stepping – lateral
- Progression – lateral step onto the box with jump off the other side to 2-foot landing - Jumping – Forwards and backwards
- Standing on one side of line, jump 2 foot to the other side
- Progression- single leg hop forwards and backwards - Jumping – Lateral
- Standing on one side of line, jump 2 foot to the other side laterally
- Progression- single leg hop laterally
Exercise to Stimulate Osteogenesis (Upper Limbs)
1. Wall push ups
• Progression – Feet further from the wall or a clap
- Four-point kneeling with arm and leg raises
• Stabilise first on floor
• Add arm extension or leg extensions
• Progression 1: Alternate arm + leg at the same time
• Progression 2: stability ball + feet contacting ground. - Free weight wrist ext + flexion
- Free weight - Shoulder press
Exercise for Spinal Flexibility, Posture & Extensor Muscle Strength
- Supine lying arm raises (opening up chest/Tx region)
- Ensure deep breathing - Prone lying (resting on forearms) for spinal flexion
- Progression: active extension – superman - Shoulder retraction + deep breathing
- inhale as you take the arms back, opening the chest hold and exhale
- Progression 1: Adding free weights
- Progression 2: sitting on core stability ball
- Progression 3: sitting on core stability ball + free weights - Modified bent over row single arm
Exercise to Improve Balance Control
- Dynamic balance: Obstacle course
- Progression: Incorporating a visual challenge on a foam block - Reactive stepping to a verbal cue
Progression – stepping to a metronome
