BALANCE

Balance basics
Balance def.+ ability to maintain ones COM within the BOS in a given sensory environment. Systems involved: MS, NM Somatosensory,visual,and vestibular

Stabilizing postural responses

Postural control is maintained in a cooperative manner

Faulty balance
Pathology in any system Disruption between the potential biomechanical and neurophysiologic constraints

Performing A Comprehensive Balance Exam

Interview Pt.

PMH Social Hx Fall hx Meds Mental Status Observation

Biomechanical Factors Sensation Coordination Vision Cone of Stability Motor Coordination Sensory Organization

Components of Postural Control

Limits of Stability: maximum angle from vertical that is tolerated without the loss of balance. Base of support: proportional with LOS Height of COM is inversely proportional to LOS Sway

Sensory organization
Afferents provide information about body position from 3 sources:
Somatosensory Visual Vestibular

Somatosensory
Peripheral receptors and Joint receptors of the foot and ankle Detects motion of the body with respect to the supporting surface Detects motion of the body segments with respect to each other In impairment delayed responses of 20-30 msec Role in scaling motor response to perturb.

Vision
Provides info about body position relative to environment and moving environment itself Most sensitive to low frequency stimulation When moving more information is processed

Vestibular
Two Functions:
Stabilizes the eyes during head movement to assure steady gaze Maintains upright vertical body alignment during head movement Slowest of the three afferent systems With conflicting info, vestibular system acts as a reference to ensure appropriate motor responses

Central processing
Compares information from the three systems Intact processes result in the right motor output Conflict: Sitting in a car and the car next to you moves
visual identifies movement of environment somatosensory perceives no change in position

Motor Coordination
Motor synergies maintain upright posture

Response depends on:

Latency of response Task dependence Invariance of motor output

Automatic postural reactions

Def: Synergistic patterns of activation of LE muscle in response to perturbation Occur to maintain the COM within the BOS Three synergistic motor responses are:
Ankle strategy Hip strategy Stepping strategy

Ankle Strategy
Used during quiet stance or secondary to small perturbations on a normal support surface M activity initiates distally at the ankle and the radiates to the thigh and abdominal m, producing torque at the ankle

Hip Strategy
Occurs in response to moderate perturbation and or when the support surface is narrow relative to the base of support, or when there is a direct perturbation to the pelvis. I.E. Standing on a curb and being pushed. If this didnt occur, you would have to step off the curb Muscle are activated in prox to distal

Stepping Strategy
Occurs when the LE and trunk cannot maintain the COM with the BOS. A step will Increase the BOS or realign it

Evaluating Automatic Postural Reactions

Selection of the appropriate synergy Latency of response Amplitude of response or evidence of cocontraction Visually assess the pts. motor response when perturbated I.D. the deficit so your intervention will be optimal

Balance strategies
Selected in response also to sensory input
expectation prior experience practice

Adaptation and Flexibility

Assess motor synergies and determine whether they are appropriate Change the testing conditions by:
Changing the support surface Varying the magnitude of the perturbation Pts. should be able to utilize a variety of strategies

Cognition
Attention is not required to maintain balance However we monitor the environment Inattention to the environment may result in being at risk for falls

Increased risk for falls: MS impairment

Biomechanical limitations:
ROM M weakness

Neuromuscular impairment
Loss of m mass, dec. force production, and decreased isokinetic jt. Mvt., impaired motor learning, slower simple and complex voluntary reaction times

Function of afferent system

Redundancy allows pts. with impairments to maintain upright postural alignment

Somatosensory impairments
Elderly have 30-50% dec. vibration sense at the ankle Jt. Position sense is dec. Peripheral Nerve conduction slows with age

Visual impairments
Dec. visual acuity, reduced visual fields, increased susceptibility to glare, poor depth perception, and reduction in peripheral fields are seen in the elderly Dec. sensitivity to low spatial frequencies results in the requirement for greater contrast to detect spatial differences successfully

Vestibular impairments
Loss of the vestibular system results in appropriate use of the ankle strategy, but he hip strategy is not used in the maintenance of upright control Declines in auditory and vestibular function are widely documented in the elderly

Sensory organization testing

Also referred to as CTSIB. 6 conditions the pt is viewed for degree of sway and maintenance of position. Enables the examiner to select and weigh conflicting sensory references Misleading visual information is more problematic than absent vision

Balance Assessment Tools

Should have the following characteristics:
Reliable Valid Sensitive Specific Ability to detect change over time

Assessment Tools
Measures of Standing Balance
Romberg: Assess the integrity of the neural systems for individuals with neurosyphyllis. Selective loss of the posterior columns. Pt stands, both feet together with narrow BOS arms folded across chest. Assess the amt. Of postural sway observed with eyes open and then closed for 30 sec. How long the pt. can maintain the position is timed.

One leg stance time

Document length of time pt. maintains position Important predictor of falls in the elderly

Functional Reach
DEF: Max distance a person can reach forward while maintaining a fixed base of support. Margin of stability can be determined. Reach is the mean difference of initial and final positions over three test trials Impaired reach has been found predictive of falls

Computerized assessment of postural control

Utilizes computerized measurement of postural sway using a force platform Effectively captures age associated changes inc. postural sway during static and controlled leaning conditions. Relationship to pt. functional performance is not clearly established

Eval of Sensory Organization

Roles of various sensory inputs on the maintenance of postural control. Computerized versions measure on stable and moving support surfaces CTSIB

Functional Performance Measures

Evaluate functional performance of selected tasks with performance criteria established for scoring purposes Rely on factors such as strength, flexibility, motor control, and endurance to complete the activities. Therefore they require more than balance Ex: TUG, Berg, Tinetti

Timed Up and Go
Measures the time required to rise from a std. Chair, walk 3 meters, turn around, return, and sit down. I ADLs scored task<10sec <20 sec =cutoff functional ability. >30 sec. Had impaired mobility and inc risk for falls

BERG functional balance scale

14 tasks ranging in difficulty. Each item is scored 0-4 based on specific criteria. Scale allows grading to reflect improvement. < 45/56 increased risk for falls Best single predictor of falls Scores < or = to 40 present with almost 100% risk of fall

Tinnetti (POMA)
2 sections balance and gait Highest possible score 28 Scores <19 indicate high risk for falls 19-24 at risk, but not high risk Attempts to quantify quality of gait performance, captures higher level of function. Pt may use an assistive device

Treatment approaches
Any underlying impairment potentially modifiable should be addressed If not modifiable, compensation techniques and pt. education should be the initial focus. Practice reactions to improve reaction time Comprehensive tx plans include: inc. pts. ability to maintain postures, control movements of the COM, respond to disturbances of the COM

Treatment of Balance Dysfunction

1. Weakness: Progress from staticdynamic 2. Challenge on different surfaces, use visual distortion, modify perturbations 3. Vestibular emphasize appropriate strategy to decrease symptoms. 4. Somatosensory change the external environment add stimulus to inc. awareness ofextremities