Neuro Week 6 - Coordination and Balance

Coordination

The ability to execute smooth, accurate, controlled movement

Ataxia

Lack of coordination

Coordination involves __________, ______ and _______ of the activation of multiple muscle groups

Sequencing; timing; grading

Coordinated movement is characterized y appropriate _____, ________, _________, ______ and ________ __________

Speed

Distance

Direction

Timing

Muscular activation

What is the purpose of the coordination exam

-Safety, risk factors for falls

-Level of skill, efficiency of movement

-Initiation, control, termination of movement

-Contributing underlying pathology

-Timing, sequencing, accuracy of movement

-Effect of therapy or medication on motor function

-Synergistic action of muscles

What are the changes seen in coordination as age increases

Decreased strength

Slowed reaction time

Loss of flexibility

Faulty posture

Impaired balance

Elements for assessing coordination

Strength

ROM

Sensation

Muscular imbalance (weakness, abnormal muscle tone, shortening)

What should be tested prior to coordination testing (3)

Strength

ROM

Sensation

how to tell the difference between cerebellar and somatosensory ataxia

MMT and limb ataxia testing

Sensation testing

Romberg with eyes open and eyes closed

Tremor

Involuntary, oscillatory movement of opposing muscle groups

Intention (kinetic) tremor

Happens with voluntary movement

As you get closer to target, tremor increases

Postural (static) tremor

Tremor of head, trunk in sitting, standing, walking, tremor of extremities when trying to maintain a position.

Titubation

Rhythmic oscillations of the head; axial involvement of the trunk

Nonequilibrium coordination tests

Finger-to-nose

Finger -to-therapist's finger

Finger-to-finger

Alternate finger-to-nose

Finger opposition

Mass grasp

Pronation/supination

Rebound test

Tapping (hand or foot)

Pointing and past pointing

Alternate heel-to-knee; heel-to-toe

Toe to examiner's finger

Heel on shin

Draing a circle

Fixation or position holding

Standardized coordination tests

Bruininks-Oseretsky Test of Motor Proficiency (BOT2)

9 hole peg test (OT)

Bocks and Blocks (OT)

Minnesota Manual Dexterity Test (OT)

Tests for dysdiadochokinesia

Finger-to-nose

Alternate finger-to-nose

Proation/supination

Knee flexion/extension

Walking, alter speed or direction

Tests for dysmetria

Pointing and past-pointing

Drawing a circle or figure-8

Heel on shin

Placing festoon floor markers; sitting or standing

Tests for dyssynergia

Finger-to-nose

Finger-to-therapist's finger

Alternate heel-to-knee

Toe-to-examiner's finger

Hypotonia tests

Passive movement

DTRs

Asthenia

weakness

Tests for asthenia

Fixation or position holding (UE/LE)

Application of manual resistance to determine ability to hold

Rigidity tests

Passive movement

Observation

Bradykinesia tests

Waking, observation of arm swing and trunk motions

Walking, alter speed and direction

Request that a movement or gait activity be stopped abruptly

Observation of functional activities

Tests for disturbances of posture

Fixation or position holding

Displace balance unexpectedly in sitting or standing

Standing, alter BoS

Tests for disturbances of gait

Walk along a straight line

Walk sideways, backwards

March in place

Alter speed and direction of ambulatory activities

Walk in a circle

Documentation for coordination testing

Tests multiple sites

Measure time to complete tasks

Video recording

Intervention strategies for coordination impairments (4)

-Address impairments if possible

-Use sensorimotor systems to enhance motor performance when possible

-Train motor coordination -accuracy and speed

-Compensate when possible with other systems or equipment

Examples of compensation equipment for coordination impairments

Weighted vest

Weighted writing instruments and utensils

Orthotics (AFOs/wrist splints)

Intervention focus for cerebellar disorders

Core stability/proximal stability

Limiting overshooting of limbs/increase distal control

increase body awareness

Train VOR

What lobe of the cerebellum controls the VOR

Flocculonodular lobe

Method to increase proximal stability

Develop stability in WB positions

-POE

-Quadruped

-Sitting

-Kneeling

-Modified plantigrade

-Standing

Treatment activities: prone and quadruped

-POE

-Active reaching or PNF diagonals

-Quadruped

-Holding

-Weight shifts

-Limb movements

-Resisted transitions

Treatment activities in sitting

-Various positions (long sitting, short sitting, side sitting, work on holding)

-Balancing against manual perturbations or on Swiss ball

-STS agonist reversals

-Resisted transitions

Treatment activities in kneeling

-Holding

-Resisted transitions - heel sitting and side sitting

-Kneeling to half kneeling (w or w/out UE support)

Treatment activities in modified plantigrade

-Holding

-Slow reversals with stepping movements

Treatment activities in standing

-Holding

-Resisted gait

-Increase gait speed, foot placement, step ht.

-Side stepping

-Braiding

Stair climbing and drills

-Squat thrusts

-Lunges

-Jumping jacks, jump rope, hopscotch

Increasing distal control: unweighting

-Pool

-Gait trainer

Increasing distal control: after strengthening proximally

-Gait (increasing gait speed)

-Fine motor

-Higher level coordination

Methods to increase body awareness: tactile

Tactile input

Hinged AFOs manual contact

Different textures

Pool therapy

Methods to increase body awareness: proprioception

Approximation techniques - manually or through weighted vests/belts

Methods to increase body awareness: vision

Use mirrors

Frankel's exercises for ataxic conditions

Initially developed got DCML pathway loss in the LEs but can be applied to ataxia

Frenkel's exercises yes what sense as the primary source of feedback

Vision

Frenkel's exercises start in ______ postures and progress to _________ positions

Stable; unstable

Chorea

sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face

Athetosis

slow, writhing involuntary movements

Dystonia

a condition of abnormal muscle tone that causes the impairment of voluntary muscle movement

Treatment for patients with chorea/athetosis/dystonia

Improve proximal stability and distal control

Therapeutic activities for chorea/athetosis/dystonia

Similar to ataxia, however most of these patients will have most success when the UE and LE are weight bearing to control the involuntary movements

Restorative activities for basal ganglia and cerebellar impairments (4)

Aerobic activity

Core

Balance

Gait

General compensatory activities for basal ganglia and cerebellar pathologies (4)

Bracing (decrease DoF)

ADs

Taping/weighting/compression

Adaptive equipment

What is balance

Ability to maintain stability in an upright posture against gravity

In order to maintain balance, it's required to maintain ______ __ ____ over the ____ __ _______

COM; BOS

What are the 2 types of postural control

Anticipatory

Reactive

Limits of stability (LOS)

Max distance of intentional displacement of COM in each direction without LoB

Static balance

balance maintained while being still

Dynamic balance

Balance maintained while moving

Disequilibrium

Feeling off balance

Components of the postal control system (4)

Biomechanical

Sensory

Motor

Central processing

Biomechanical component of balance

Considers the forces applied and the mechanical factors that contribute to the body and joint/segment stability

-Center of pressure/COG

-LOS

Sensory component of balance

All coming info used to monitor equilibrium status and adjust to upright posture

What are the primary sensory systems involved in balance

Vision

Somatosensation

Vestibular

Motor component of balance

All parts of the NMS that help carry out postural adjustments and equilibrium reactions

What are the types of reflexive postural reactions

Righting reaction

Protective reactions

Equilibrium/balance reactions

What are the 3 types of balance strategies used to prevent falling

Ankle

Hip

Stepping

Role of central processing in balnce

Takes place in the CNS

Receives sensory info, processes the info and implements a response

Why is balance important

Independence

Risk of injury

Exam for balance

History and postural alignment

What information do you want to obtain in the history portion of the balance exam

Falls

-Both intrinsic and extrinsic

-Have you fallen in the last year?

In what positions should postural alignment be assessed in

Sitting

Standing

What systems should also be assessed in the balance exam

Sensation

Motor function

Cognition

Safety is the top priority for the balance exam. What methods/equipment should be used to maintain safety

Gait belt

Guarding

The balance exam often begins in _______ and progresses to ________

Sitting; standing

Common self-reported measures for balance ability

Falls efficacy scale

Activities specific balance confidence

Performance based measures for balance

TUG

FRT

POMA

Berg

DGI

BESTest (or mini)

Gait velocity

Balance and dual task measures

Balance grading scales

Ordinal scales

Normal balance

Patient able to maintain steady balance without handhold support (static)

Patient accepts max challenge and can shift weight easily within full range of LOS in all directions (dynamic)

Good balance

Patient able to maintain balance without handhold support, limited postural sway (static)

Patient accepts moderate challenge; able to maintain balance while picking up object off floor (dynamic)

Fair balance

Patient able to maintain bale without handhold support may require occasional minimal assistance (static)

Patent accepts minimal challenge able to maintain balance when turning head/trunk (dynamic)

Poor balance

patient requires handhold support and moderate to maximal assistance to maintain position (static)

Patient unable to accept challenge or move without loss of balance (dynamic)

Absent balance

Patient unable to maintain balance

Elements of exam of balance in functional context

-Steady-state postural control

-Anticipatory postural control

-Reactive postural control

Steady-state postural control exam

Observe: alignment, sway, BOS

Romberg/sharpened Romberg (EO/EC)

Vision system and balance

Info about the environment

Dynamic movement

Somatosensation system and balance

Cutaneous touch and pressure

Proprioception

Vestibular system and balance

Head in relation to gravity/space

VOR

Standardized test for assessing sensory systems and balance

CTSIB

How long is each position held for the CTSIB

30 seconds

Impact of sensory disorders on balance

Affect the ability to adapt sensory inputs to changes in task and environmental demands

Prevents development of accurate internal models of the body for postural control

The effect of loss of one sense for balance depends on (3)

-Availability of other senses to detect position in space

-Ability to use orientation cues in the environment

-Ability to correctly interpret and select sensory information for orientation

Therapy objectives for balance training

-Educate pt

-Maximally remediate/correct impairments

-Teach compensatory strategies when remediation is unsuccessful

-Improve pt confidence

-Return pt to PLOF

Age related changes in balance

Progressive decline in balance

Increase in falls and injury from falls

Specific changes to visual/vestib/MSK systems

Interventions for blank eat the impairment level

Correct impairments that can be corrected

-Strength

-ROM

-Alignment

Prevent secondary impairments

Classifications for activities to improve strategies for postural control (3)

movement strategies

sensory strategies

cognitive strategies

Alignment/position interventions for balance

get pt in a symmetrically vertical posture/midline

-align self to tape on wall

movement strategies for balance

Retraining reactive and anticipatory balance control

Sensory strategies for balance

Challenge the impaired system

Disadvantage/eliminate the intact systems

Additional considerations for balance training

Cardiopulmonary conditioning

Mental practice (low level patients)

Gradually withdraw assistance or support (tends to be trial and error)

Balance interventions: functional activities

Static/dynamic balance

Vary support surface

Vary BOS

Weight shifting

Profess level of support form UEs

Environmental predictability

Blocked vs random practice