Standing Postural Control

Question 1

What common post stroke impairments can cause asymmetric weight bearing issues?

Answer 1

• reduced activation of gluteus medius
• poor orientation of the longitudinal axis of the body
• ankle clonus
• reduced cutaneous sensation of foot

Question 2

Roughly what percentage of pts. fall post-stroke?

Answer 2

35-67%

Question 3

How can you promote symmetry in patients who have reduced activation of glute med. post-stroke?

Answer 3

• Force use of the paretic limb (use a lift or a step under the non-impaired leg to immediately improve symmetry)
• Use center of pressure feedback ( can use force pad or wii-fit pad to promote glute med. activation)

Question 4

How can you promote symmetry in patients who have poor orientation to the longitudinal body axis post-stroke?

Answer 4

Using visual feedback (like with a mirror) with volitional weight shifts can help promote orientation, however this has shown to mainly only improve short term symmetry, it is unknown if this strategy can improve long term orientation

Question 5

How can you promote symmetry in patients who have gastrocnemius clonus post-stroke?

Answer 5

Using EMG biofeedback in quiet standing

weight bearing asymmetry was most pronounced in pts. w/ disturbed sensibility or ankle clonus

Question 6

How can you promote symmetry in patients who have reduced foot sensation post-stroke?

Answer 6

using sensory threshold stimulation to sole of foot

Question 7

True or False: Weight bearing asymmetry, was most pronounced in patients with reduced gluteus medius activation.

Answer 7

False, the asymmetry was most pronounced in patients with disturbed sensibility and ankle clonus

Question 8

What two main impairments can affect lower extremity alignment? How can you help promote alignment in each impairment?

Answer 8

• Reduced quadriceps femoris force production (strengthening the quads via sit-to-stand movements with mirror biofeedback to improve postural stability)
• Excessive activation of gastroc-soleus (use biofeedback via EMG to reduce activity in gastrocs while standing)

Question 9

What ways can you increase excitation of the system and increase a patients readiness to learn for decreasing postural sway?

Answer 9

• Have patient be in standing
• use E-stim to the foot and leg (eases sway with eyes open or closed)
• Motor imagery
• Aerobic exercise primes the system

Question 10

How can you promote quiet standing postural control in post-stroke patients who have reduced cutaneous sensation of the foot?

Answer 10

• Improving sensory discrimination program such as using tactile sensory input to improve stnading stability and decrease sway
• using mental imagery

Question 11

How can you promote quiet standing postural control in post-stroke patients who have reduced ankle proprioception?

Answer 11

-force use of the ankle w/ impaired proprioception (have pt. stand on level surface w/ blindfold or have patient stand on unstable surface and point their ankle in a certain angle)

Question 12

True or False: light touch significantly reduces sway and provides proprioception info. through the hand.

Answer 12

True

Question 13

How can you promote quiet standing postural control in post-stroke patients who have an inability to reweight their sensory systems?

Answer 13

Have patient test their sensory systems via increasing/decreasing their BOS, using a blindfold, standing on a foam pad, and using unstable surfaces

Question 14

How can you promote quiet standing postural control in post-stroke patients who have poor timing and sequencing of the G-S and TA?

Answer 14

biofeedback promotes reciprocal sequencing of gastroc and TA (EMG biofeedback to promote reciprocal activation of G-S and TA) can also use mirror feedback

Question 15

How can you promote quiet standing postural control in post-stroke patients who have perceptual deficit/hemineglect?

Answer 15

increase proprio awareness on involved side by increasing weight of cues/cognitive awareness of deficit

Question 16

How can you promote quiet standing postural control in post-stroke patients who have impaired vestibular spinal function?

Answer 16

Force the use of the vestibular system by having them stand and shift weight on a foam pad and using a blindfold

Question 17

What training dosage is recommended for patient in the acute stage?

Answer 17

2-3 sessions per week for 40-120 minutes per session
or
5 per week for 45-60 minutes
(intense programs lasting longer than 90 minutes or more for 5 times a week may be too excessive and lead to higher drop-out)

Question 18

What training dosage is recommended for a patient in the chronic stage?

Answer 18

intense programs demonstrate excellent adherence and remained partially effective after 3 months

Question 19

True or False: AFOs were only seen to improve sway in patients in the acute, sub-acute and chronic stages.

Answer 19

False, AFOs improved sway in patients with stroke in the acute and sub-acute stages but not chronic

Question 20

True or False: BWSTT interventions have been shown to improve both quiet standing and ankle proprioception.

Answer 20

False, BWSTT does not work for either

Question 21

True or False: To help patients rest their feet, working on sitting balance to work on lateral weight shifts is an effective intervention.

Answer 21

False, sitting balance to work on lateral weight shifts and weight bearing on involved side in lateral sitting weight shifts does not work

Question 22

True or False: non-specific fall prevention programs are not effective for post-stroke patients

Answer 22

True

Question 23

What are some common observation in the standing postural alignment of patients with hemiplegia?

Answer 23

• asymmetry between the limbs with excessively large inter-foot distance
• knee hyperextension w/ excessive ankle PF

Question 24

What are some common observation in the quiet standing of patients with hemiplegia?

Answer 24

• excessive amount of sway at the ankle where head and hips are moving in same direction
• excessive sway or requires increased base of support in dim lighting conditions
• falls or requires increased BOS on uneven or compliant surfaces

Question 25

What are some common observation in the anticipatory postural adjustments of patients with hemiplegia?

Answer 25

- reaches forward with a fast forward reach and steps forward or falls - stands on one foot and falls or pelvis drop

Question 26

What are some common observation in the reactive postural adjustments of patients with hemiplegia?

Answer 26

- small perturbation leads to sway at the hips where head and hips are moving in opposite direction - larger perturbation leads to fall

Question 27

True or False: Post stroke patients have preserved APA sequences but their timing is delayed

Answer 27

True

Question 28

True or False: Asymmetrical positions were associated with impaired APAs between trunk and LE

Answer 28

True

Question 29

True or False: For safety you must use slow movements to train APAs

Answer 29

False, APA must be practiced with rapid movements because slow movements can use feedback for correction of balance

Question 30

True or False: Avoid touching the patient while training APAs because it can negate the need for an APA

Answer 30

True

Question 31

How can you promote APAs if a patient has poor timing, sequencing, and activation of G-S and deltoid?

Answer 31

force the use of the gastroc before the deltoid by repeatedly catching and throwing a weighted ball, reaching as fast as possible or by moving as far as possible as fast as possible

Question 32

How can you promote APAs if a patient has poor timing, sequencing, and activation of Glute Med.?

Answer 32

- practice assuming single limb support - manual cues: tapping muscle belly - PNF techniques (you must fade manual contacts)

Question 33

What do you usually observe in patients who have ineffective RPAs post stroke?

Answer 33

- small perturbation leads to sway at the hips where head and hips are moving in opposite direction - larger perturbation leads to falls

Question 34

True or False: post stroke pts. use ankle strategies more than hip or stepping strategies

Answer 34

False, they usually don't use ankle strategies

Question 35

How are motor strategies impaired in post-stroke patients?

Answer 35

- stepping strategies are too short and move laterally, thus being ineffective - slowed rate of force production - delayed/absent responses for unexpected perturbations - delayed step response to perturbations

Question 36

How can you promote an ankle strategy RPA for patients who have reduced ankle proprioception?

Answer 36

force the use of ankle proprioception by having patient stand on unstable surface but make them achieve a particular target by changing the angle at the ankle

Question 37

How can you promote an ankle strategy RPA for patients who have poor sequencing of TA and G-S?

Answer 37

biofeedback helps promote reciprocal sequencing of gastroc and TA (use EMG biofeedback to promote the G-S and TA reciprocal activation)

Question 38

How can you promote an ankle strategy RPA for patients who have poor timing of distal muscles before proximal muscles?

Answer 38

- perturbation training promotes timing of distal muscles - massed practice (100 perturbations a day 5 days a week) - practice reaching to external perturbations, up to 1100 reps

Question 39

How can you promote an ankle strategy RPA for patients who have poor timing and activation of proximal muscles?

Answer 39

perturbation training (dynamic platform training improved the ability to recover from large perturbations and intensive perturbation training in children resulted in improved latency of response and decreased sway after the perturbation)