1
Q
Why is it important to assess balance?
A
- 30% of individuals over 65 experience 1 or more falls per year
- Falls are the leading cause of TBI and death in individuals over 65
- Falls decrease balance confidence and cause fear
- Falls account for 40% of hospital visits in individuals over 65
2
Q
What are intrinsic factors that predicts falls?
A
- Decreased balance
- Mobility
- Functional skills
- Gait speed
- LE weakness
- Decreased vibration sense in feet
- Medications
- Orthostatic hypotension
- Impaired cognitive function
3
Q
What is postural control?
A
The ability to control the body’s position in space with respect to gravity, support surfaces, visual surround, and internal surfaces
4
Q
What is stability?
A
The ability to control the COM in relation to the BOS under static and dynamic conditions
5
Q
What is orientation?
A
The relationship between the body’s segments, the body, and the environment
6
Q
What are the 6 main factors that influence postural control?
A
- Biomechanical restraints
- Stability limits/verticality
- Anticipatory postural adjustments
- Postural responses
- Sensory orientation
- Stability in gait
7
Q
Which tasks should you use to observe movement patterns to identify balance deficits?
A
- Sit
- Sit to stand
- Walk and turn
- Step up/down
- Reach/grasp manipulate
8
Q
How can you identify balance deficits in patients?
A
- Observe movement patterns
- Include task progressions and regressions during assessment
- Include balance outcome measures
9
Q
What types of balance do we assess?
A
- Steady state postural control
- Anticipatory postural control
- Reactive postural control
10
Q
What is a deficit in postural movement strategies?
A
- Deficits related to abnormal postural movement strategies
- Can be observed in steady state, anticipatory, or reactive balance
11
Q
What is a deficit in sensory processing?
A
- Deficit related to abnormal sensory processing
- Can be observed in steady state, anticipatory, or reactive balance
12
Q
What is a deficit in balance confidence?
A
- Deficit related to fear of fall/reduced self-efficacy
- Can be observed in steady state and anticipatory balance
13
Q
What is a deficit in verticality?
A
- Deficit related to impaired orientation with respect to gravity
- Can be observed in steady state balance
14
Q
What is a deficit in executive function/multitask ability?
A
- Deficit is related to impair dual task ability
- Can be observed anticipatory balance
15
Q
What is “limits of stability” in terms of steady state balance?
A
How far an individual can weight shift outside their BOS without taking a step or losing their balance (dependent on individual characteristics such as height, foot length, etc.)
16
Q
What is “narrowing BOS” in terms of steady state balance?
A
Stances such as romberg (feet together), sharpened romberg (tandem), and single leg stance
17
Q
What is static sitting/standing balance?
A
The ability to achieve and maintain neutral alignment even when supported on a higher compliance surface or eyes are closed
18
Q
What is anticipatory postural control?
A
- Postural muscle activity anticipates the voluntary movement, ensuring stability of the body during performance of a task (feedforward mechanism)
- The ability to move from and return to neutral alignment while performing a functional task (reaching, head turns, crossing leg)
19
Q
What is reactive postural control?
A
- Ability to respond to sensory input that signals a need for a response to maintain postural control
- Response is unanticipated (feedback mechanism)
20
Q
What are some strategies individuals use in reactive postural control in standing?
A
- Ankle strategy
- Hip strategy
- Stepping strategy
21
Q
What is the ankle strategy?
A
- Response to small, slow perturbations
- Ankle muscles activate to keep COM within BOS
- Tib anterior will activate if perturbation comes from anterior (pushed backwards)
- Plantar flexors will activate if perturbation comes from posterior (pushed forwards)
22
Q
What is the hip strategy?
A
- Response to larger, faster perturbation
- Quadriceps (hip flexors) will activate if perturbation comes from posterior (pushed forward)
- Hamstrings (hip extensors) will activate if perturbation comes from anterior (pushed backwards)
23
Q
What is the stepping strategy?
A
Stepping response to very large, very fast perturbation that can not be corrected through the ankle or hip strategy
24
Q
How do you test a patient’s stepping strategy?
A
- Patient leans into PT hands until COM is outside of BOS, remove hands and observe response
- Normal: recovers independently, single large step
- Impaired: more than one step
- Absent: no step or would fall without assistance
25
What are some strategies individuals use in reactive postural control in sitting?
- Righting reaction: elongation on weight-bearing side, shortening on non-weight-bearing side, head aligns with gravity
- Protective extension: reaching limbs in response to perturbation to catch self
26
What body function/structure impairments can cause balance limitations?
- Musculoskeletal system
- Neuromuscular system
- Cognitive/mental function
- Behavioral factors
27
What are some determinants of balance in the musculoskeletal system?
- ROM at joints
- Flexibility, extensibility of muscles
- Muscle strength, power, and endurance
- Posture
28
What are some determinants of balance in the neuromuscular system?
- Postural movement strategies
- Coordination
- Sensory integrity and processing
- Perceptual function (verticality)
29
What are some determinants of balance in terms of cognition/mental function?
- Arousal
- Attention
- Executive function
- Multi-task ability
30
What are some determinants of balance in terms of behavioral factors?
- Past experiences
- Fear of falling
- Self-efficacy
- Balance confidence
31
What are postural movement strategies in terms of determinants of balance?
- Movement of the muscles and joints in a coordinated manner to maintain posture and balance during voluntary movement and when perturbed
- Biomechanical constraints, anticipatory postural adjustments, corrective responses, protective responses
- The CNS quickly moves between patterns depending on the demands of the task and environment
32
What is sensory processing in terms of determinants of balance?
- How well the body's sensory systems (vision, vestibular, somatosensation) work together
- Organization, selection, and integration of sensory information to maintain postural control as the task or environment change
33
What is perceptual function/verticality in terms of determinants of balance?
The ability to orient the body in relation to the line of gravity
34
What is executive function/multitask ability in terms of determinants of balance?
Executive Function
- Complex cognitive skills including insight, judgement, memory, problem-solving, and attention
- Skills necessary for planning, initiation, sequencing, and monitoring of goal directed behavior
- May have difficulty processing info and planning
Multitask Capacity
- Able to successfully participate in more than one task
35
What is balance confidence in terms of determinants of balance?
- Confidence in being able to maintain balance while performing activities
- Perception about their abilities to deal with a fall (fall self-efficacy)
- Worry or concern regardless of history of falls (fear of falling)
- Limiting an activity, despite capability, that can result in an increased risk of falls and decrease QOL (activity avoidance)
36
What are the outcome measures that can be used to measure balance?
- Clinical Test of Sensory Interaction and Balance (CTSIB)
- Function in Sitting Test (FIST)
- Activities Specific Balance Confidence Scale (ABCS)
- Berg Balance Scale (BBS)
- Fullerton Advanced Balance Scale
- Mini BESTest
- Timed Up and Go (TUG)
37
What is considered a grade 4 (normal) in the Functional Balance Scales?
Static: maintain steady balance without hand support
Dynamic: accepts maximal challenge and can shift weight easily within full-range in all directions
38
What is considered a grade 3 (good) in the Functional Balance Scales?
Static: able to maintain balance without handheld support with limited postural sway
Dynamic: accepts moderate challenge
39
What is considered a grade 2 (fair) in the Functional Balance Scales?
Static: maintains balance with handheld support, may require minimal assistance
Dynamic: able to accept minimal challenge, maintains balance while turning head/trunk
40
What is considered a grade 1 (poor) in the Functional Balance Scales?
Static: requires handheld support and moderate to maximal assistance to maintain the position
Dynamic: unable to accept challenge or move without loss of balance
41
What is considered a grade 0 (absent) in the Functional Balance Scales?
Unable to maintain balance at all
42
How does the Sensory Organization Test (SOT) and Clinical Test of Sensory Interaction and Balance (CTSIB) evaluate balance?
6 sensory conditions are examined to determine the somatosensory, visual, and vestibular contribution to postural control
43
What are the 6 conditions of the SOT/CTSIB?
Condition 1: eyes open on firm surface
Condition 2: eyes closed on firm surface
Condition 3: eyes open with sway referenced visual surround or dome
Condition 4: eyes open on sway referenced surface or foam
Condition 5: eyes closed on sway referenced surface or foam
Condition 6: eyes open on sway referenced surface and visual surround or dome
44
How does each condition of the SOT/CTSIB influence sensory input?
Condition 1: all sensations intact
Condition 2: vision absent, somatosensory unaltered, vestibular intact
Condition 3: vision altered, somatosensory unaltered, vestibular intact
Condition 4: vision unaltered, somatosensory altered, vestibular intact
Condition 5: vision absent, somatosensory altered, vestibular intact
Condition 6: vision altered, somatosensory altered, vestibular intact
45
During the CTSIB, the patient falls during conditions 2,3,5, and 6. What are they dependent on for balance?
Patient dependent on vision for balance
46
During the CTSIB, the patient falls during conditions 4,5, and 6. What are they dependent on for balance?
Patient dependent on somatosensation for balance
47
During the CTSIB, the patient falls during conditions 5 and 6. What does this indicate?
Patient has vestibular loss, show deficits in these conditions because they are unable to rely on vision or somatosensation
48
During the CTSIB, the patient falls during conditions 3, 4, 5, and 6. What does this indicate?
Patient has a sensory selection problem (multiple systems are involved)
49
What does the Function in Sitting Test evaluate?
- Examines sensory, motor, anticipatory, reactive, and steady state balance
- Sitting with optimal alignment, feet on floor, hands in lap
- Looks at perturbations, static 30 secs with EO and EC, head movements, picking up objects on floor, reaching, scooting
- Score 0-4 (0 = complete assistance, 4 = independence)
- MCD = 5.63
- MCID = > 6.5
50
What does the Activities Specific Confidence Scale (ABCS) evaluate?
- Examines the patient's confidence in their balance
- 16 item self report survey that ask the patient to rate their balance confidence in various activities from 0% (no confidence) to 100% (complete confidence)
- Activities include picking up objects from the floor and above their head, in and out of car, walking in open spaces or crowded space, stepping on escalator, walking on slippery surface
- <67% indicates increased risk of falls
- >80% high level of physical functioning in older adults
- 50%-80% moderate level of physical functioning in older adults
- <50% low level of physical functioning in older adults
- MDC for parkinson's = 13%
- MDC for acute or chronic stroke = 14%
51
What does the Berg Balance Scale evaluate?
- Examines static and dynamic balance which is rated out of 56 points
- 14 separate items rated on a scale of 0 (unable to perform) to 4 ( independent)
- Items include sit-to-stand and transfers, standing with EO, romberg, tandem, SLS, reaching, picking up an object from the floor, turning 360 degrees, alternating taps on a step
- Tests anticipatory and steady state balance
52
The ABCS is not recommended for which population and why?
Not recommended for brain injury/paralysis/cognitive deficits because they may misinterpret their confidence
53
What are the psychometric properties of the Berg Balance Scale?
- Older adults at an increased risk of falls with scores <45
- Scores <40 indicate almost 100% risk for falls
- 1 point drop can increase risk of falls by approx. 3%-8%
- Limited utility in mid-stage parkinson's because does not assess reactive balance
- MDC acute stroke = 6.9
- MDC chronic stroke = 4.13
- MDC nursing home patients = 10.4
- MDC parkinson's = 5
54
What does the Fullerton Advanced Balance Scale evaluate?
- Examines advanced balance for higher functioning patients
- 10 items scored on a scale of 0-4 (40 points total)
- Items include stepping on and over 6-inch bench, tandem walk, SLS, stand on foam, two-footed jump, walk with head turns, reactive postural control
- <25 indicates high risk for falls for older adults
- Tests reactive, anticipatory, and steady state balance
55
What does the Mini BESTest evaluate?
- Tests reactive, anticipatory, and steady state balance
- 14 items rated on a scale of 0 (severe impairment) to 2 (no impairment), 30 points total
- Items include sit-to-stand, rise on toes, SLS, reactive control (forward, backward, lateral), standing , standing on foam, standing on incline with eyes closed, walk with head turns, dual-task TUG, pivot turns, obstacles, changes in gait speed
- <24 indicates increased risk for falls
- MDC for older adults = 4
56
What does the Timed "Up and Go" (TUG) test evaluate?
- Tests anticipatory balance
- A timed test that examines how a patient stands up from the chair, walks 3 meters, turns, walks back to the chair and sits
- Timing begins once therapist says go and ends when patient sits back down
- Patient can use AD
- High risk for community dwelling older patients >13.5 seconds
- High risk for CVA patients >14 seconds
- Parkinson's risk for 11.5 seconds
- MDC CVA = 2.9 seconds
- MDC Parkinson's = 4.85 seconds
57
What changes are made in the TUG test: dual task?
- Tug manual: pick up glass of water, walk without spilling, place back down before sitting
- Tug cognitive: walk while counting backwards by 3's or reciting every other letter of the alphabet
- Increased risk of falls for older adults >15 seconds
- Parkinson's fall risk: >10% difference in speed between regular tug and cognitive tug
- Parkinson's fall risk: >4.5% difference in speed between regular tug and manual tug
Motor Control and Learning
flashcards
Decks in class (9)
# Cards
