Clinical Management of Postural Control Disorders

What type of approach should be taken in regard to postural control?

systems approach

What is the first concern with postural control during an exam? How should this concern be addressed.

safety; wear gait belt / closely guarded at all times

How should the effect of the pt's balance on their participation be examined?

-ask subjectively to give information

-ask the pt and family or caregiver about

--># of recent fall / near falls

--> perceptions of balance during activities

--> impact on ADLs

What are self report scales that can be utilized to assess a pt's balance?

-ABC scale

-Falls efficacy scale

What is the definition of a fall?

unintentionally moving to a lower surface

What is the definition of a near fall?

losing balance, but ability to self correct

-pt becomes briefly unsteady

What are extrinsic risk factors for falls?

all environmental factors

-throw rugs

-stairs

-poor lighting

-pets

-slippery surfaces

-medications

What are intrinsic risk factors for falls?

all personal factors

-poor balance

-poor vision

-poor strength

-poor flexibility

-increased age

-depression / anxiety

-comorbidities

T or F: Medication side effects are a type of extrinsic risk factor for a fall

True

T or F: Medication side effects are a type of intrinsic risk factor for a fall

False -- it is extrinsic

What are the types of systems/strategies for postural control?

motor system / strategy

sensory system / strategy

cognitive system / strategy

What are the 3 types of postural control demands/ tasks?

-steady state

-anticipatory / proactive

-reactive

If a pt is having instability when leaning over to pick something up, is there a problem with steady state, anticipatory, or reactive balance?

anticipatory

If a pt is having loss of balance when washing hair in the shower, is there a problem with steady state, anticipatory, or reactive balance?

anticipatory and maybe reactive

If a pt is reporting balance loss and dizziness while carrying a tray across a crowded room, is there a problem with steady state, anticipatory, or reactive balance?

anticipatory balance, possibly reactive too

Which aspect of postural control is being examined in the BBS? Is sensory, cognitive, or motor aspect being manipulated for?

proactive balance

-manipulates the motor aspect

Which aspect of postural control is being examined in the Functional reach test? Is sensory, cognitive, or motor aspect being manipulated for?

proactive

-manipulates motor aspect

Which aspect of postural control is being examined in the multi-directional reach test? Is sensory, cognitive, or motor aspect being manipulated for?

proactive balance

-motor aspect

Which aspect of postural control is being examined in the Tinetti? Is sensory, cognitive, or motor aspect being manipulated for?

steady state, proactive, and reactive

-motor aspect, sensory aspect (EC, diff surfaces) cognitive aspect (walk with head turns)

Which aspect of postural control is being examined in the FAB (Fullerton advanced balance scale)?

steady state, anticipatory, reactive

Which aspect of postural control is being examined in the BESTest? Is sensory, cognitive, or motor aspect being manipulated for?

steady state, proactive, and reactive

-motor aspect, sensory (diff surface, EC), and cognitive (cognitive TUG, obstacles, head turns)

Which aspect of postural control is being examined in the Mini-BESTest? Is sensory, cognitive, or motor aspect being manipulated for?

steady state, anticipatory and reactive

motor, sensory, and cognitive aspects manipulated

Which aspect of postural control is being examined in the AM-PAC? Is sensory, cognitive, or motor aspect being manipulated for?

anticipatory

motor

Which aspect of postural control is being examined in the PASS? Is sensory, cognitive, or motor aspect being manipulated for?

steady state and anticipatory

motor

Which aspect of postural control is being examined in the SATCo?

steady state, anticipatory, and reactive

Which aspect of postural control is being examined in the Sitting balance scale?

steady state and anticipatory

Which tests examine all 3 aspects of postural control?

Tinetti, BESTest (and the mini BEStest), FAB, and SATCo

What are limitations of using outcome measures to evaluate functional level activity with balance?

-test are done under a limited set of conditions

-few tests examine all 3 aspects of postural control

-provide little insight into sensory, motor, and cognitive strategies

What encompasses motor strategies with postural control?

-alignment

-change of support movement strategies (hip, ankle, stepping)

-weight shifting

-adapting to change of BOS with narrow base, tandem stance, SLS, etc

What encompasses sensory strategies with postural control?

-evaluating whether someone uses the vision, vestibular, or somatosensory systems more

-use the CTSIB or SOT to evaluate

What encompasses cognitive strategies with postural control?

-dual task may affect ability to maintain balance

-divided attention is required with dual tasks

Balance impairments during dual tasks can be documented through which validated clinical tests?

TUG cog

BBS

The effect of an additional task on motor performance can be measured with what?

the dual-task cost equation

DTC = (DT motor - ST moto) / ST motor x 100

Describe how alignment can be evaluated for motor strategy

-observe steady state alignment in sitting, standing

-look at verticality, symmetry, BOS

-utilize a plumb line or force plates

T or F: Motor strategies can be evaluated when there are changes in environmental demands, like decreased BOS or moving surfaces

True

What are examples of impairments the most directly affect postural control?

-LE strength (ankles)

-ankle ROM

-core strength, neck strength

-vertebral or chest deformities

-vision

-sensation integrity in feet and ankles

If a pt is having difficulty standing in a narrow BOS with their eyes open, what diagnostic label can be given?

deficit in steady state postural control

If a pt is having difficulty picking up an object from the floor due to LOB, what diagnostic label can be given?

deficit in anticipatory postural control

If a pt is having difficulty navigating a crowded room due to getting bumped by other people, what diagnostic label can be given?

deficit in reactive postural control

During treatment of postural control, what should be treated for motor impairments? How?

target impairments that have the greatest impact on postural control

-strength training

-task specific training

-ROM

T or F: Strength training alone can improve balance

False

How can motor strategies be improved within steady state balance?

improved alignment and verticality

How can motor strategies be improved within reactive balance control?

practice and improve movement strategies via perturbation training

How can motor strategies be improved within anticipatory balance control?

train and improve self initiation of movement strategies prior to movement

What are treatment ideas to help improve steady state balance control?

-practice with EC and EO

-use mirrors

-use verbal and manual cues

-use kinetic / force feedback (like force plates)

-use flashlight attached to waist to wt shift over lights / targets on walls

What is the goal of retraining reactive balance control?

help the pt develop coordinated multi joint movements both in-place and change in support strategies

How can developing in-place strategies for reactive balance control be trained?

-improve ROM and strength in ankles

-practice self initiated sway in various directions

-use of perturbation training

How can perturbation training be incorporated into treatment?

-pulls and pushes applied at hips/shoulders

-use of moving surfaces like rocker boards, treadmills, and cable release systems

-small pertubations facilitate in plate strategies

-large perturbations encourage use of a step / reach for change in support

...eventually progress to changing the sensory conditions and adding in cognitive conditions

How should reactive balance be trained in regard to using a stepping strategy?

just straight up practice STEPPING to avoid a fall

can manually facilitate stepping by shifting pt's wt to one side and bring COM toward unweighted le

How can retraining anticipatory balance occur?

-perform manipulation tasks

-progressively reduce assistance

-progressively increase distance to reach targets

What is the goal of training balance in sitting?

help pts with mod to severe disabilities gradually improve control over increased # of trunk segments while maintaining upright sitting posture

How is training balance in sitting progressed?

moving support. lower and changing support surfaces

How can underlying sensory impairments be treated and what is the goal?

-goal = use of sensory stimulation to facilitate activation of motor system

-EX) icing, vibrating, tapping, TENS

always used in. conjunction with functional task practice

How should a pt be trained if they have increased visual dependence?

perform tasks with EC or dimmed lights or inaccurate cues (glasses with vaseline)

How should a pt be trained if they have increased visual motion sensitivity?

exposure to optokinetic stimulate such as curtains with stripes, moving large posters with vertical lines, moving rooms

How should a pt be trained if they have increased somatosensory dependence?

perform tasks on different surfaces like carpet, foam, tilt board

How should you train the vestibular system to improve its ability to use informatin?

perform tasks while both visual and somatosensory inputs are simultaneously reduced

What are examples of augmented sensory inputs to improve balance control?

-touch, auditory, vibratory

EX) touching index finger to a support surface

EX) real time visual feedback about sway

EX) shoes or inserts that provide tactile and proprioceptive stimulation

EX) auditory feedback or vibration on trunk

How should a pt be trained to improve performance during dual task conditions?

-do dual task training!!!

-utilize cognitive tasks

A successful fall prevention exercise trials should have a total dosage of what?

more than 50 hours of training that are highly challenging activities

For movement system diagnoses, what observable movement constructs can be observed / then included within the diagnostic labels?

-alignment

-verticality

-stability

-symmetry

-speed

-amplitude

-smoothness

-sequencing

-timing

-accuracy

-sx provocation