Balance and Motor Control

What are some factors that can impair balance and motor control

Sensory input
Sensorimotor integration
Biomechanical/Motor output deficits

What are the components of sensory input

Visual
Somatosensory
Vestibular

What throws off sensory input

MSK injury
Throws off proprioception of the affected area

What is sensorimotor integration

Appropriate integration of each system

What needs to happen when an individual heavily relies on one system vs the others

The individual needs challenge of each system individually to identify a weakness

What are the types of biomechanical and motor output deficits

MSK limitations
Pain
Posture
Inability to actively contract required musculature

What are the two MSK limitations that impact biomechanical and motor output deficits

ROM
Reduced muscular endurance

Effect of aging on the efficiency of visual, somatosensory, vestibular systems, and sensory organization

Reduces the efficiency

Effect of aging on response to perturbations

Slowers response

With aging there is MORE/REDUCED frequency use of hip strategies

More

True or False:
There is less impaired anticipatory postural adjustments

False

With aging is there INCREASED/DECREASED fear of falling

Increased

How does CVA impact balance and motor control

Visual/sensory/vestibular input involvement is impaired
Sensory integration difficulty
Biomechanical output dysfunction
Selective muscle contraction

How does MS impact balance and motor control

Visual/sensory/vestibular input involvement is impaired
Sensory integration difficulty
Biomechanical output dysfunction
Selective muscle contraction

How does Parkinson’s impact balance and motor control

Visual/sensory/vestibular input involvement is impaired
Sensory integration difficulty
Biomechanical output dysfunction

How does a SCI impact balance and motor input

Selective muscle contraction
Biomechanical output dysfunction

How would you assess visual system

Removing visual input

How would you improve visual system

Allowing eyes open during activates while challenging other systems

How would you assess sensorimotor system

Removing ability to use sensorimotor feedback

How would you improve sensorimotor system

Allowing use of sensorimotor at first and then progressing difficulty

How would you assess vestibular system

Changing head position during task

How would you improve vestibular system

Habituating to different head positions during tasks

If there is an input issue, how would you treat the patient

You would treat as if there is an integration issue

What does integration requrire

Different challenges during individual treatment sessions

What are the four areas that should be assessed if balance and motor control is affected due to biomechanical/motor output

ROM
Muscle activation
Strength
Endurance

What does MSK pain do to motor control

It reduces muscle activation and impairs integration

What does a MSK injury do to motor control

It impairs activation and integration

If there is an inability to perform movement, what should be targeted first

ROM

What reasons are there for an impaired ability to perform a movement

Impaired innervation to the muscle group
Impaired sensation to the area
Impaired muscle activation
Impaired coordination of muscle activation

How would you identify if there is impaired innervation

Knowledge of injury/pathology
Myotome screen
MMT
Volitional contraction

How would you identify if there is a sensation deficit

Knowledge of injury/pathology
Patient report
Dermatome screen
Sensation testing

How would you identify if there is a muscle activation deficit

Knowledge of injury/pathology
Myotome screen
Volitional contraction
Palpation during tasks

What are you looking for while palpating a muscle during a task

Muscle to increase in firmness

How would you identify if there is impaired coordination

Knowledge of injury/pathology
Visual inspection of movements
Palpation during movement

What are the components of the visual inspection of movements

Asymmetrical movements
Movement “faults”

What is the treatment for impaired innervation

Electrical stimulation: FES or Russian
Biofeedback
Manual facilitation techniques: tapping or rubbing

What is the treatment for impaired sensation

Teach use of other symptoms to compensate
Coach on overall health (if sensation deficit is related to modifiable disease)

What is the treatment for impaired muscle activation

Electrical stimulation
Biofeedback
Manual facilitation
Eccentric load
Cross training
Closed chain activities

Why use eccentric loading for impaired muscle activation treatment

It can override internal inhibition

Why use cross training for impaired muscle activation treatment

High intensity contralateral training can have overflow of neural stimulus to ipsilateral side

Why use closed chain activities for impaired muscle activation treatment

It can increase muscle cocontraction

What is the treatment for impaired coordination

Task breakdown
Electrical stimulation
Biofeedback
Manual facilitation

Palpation for activation

Place hand on muscle group that is expected to activate to perform the motion
Ask patient to perform the task

When palpating for activation, what should you feel for

Increased firmness of the muscle

What are the types of manual facilitation used for muscle activation

Tapping
Rubbing
Pressure
Rhythmic stabilization

What is rhythmic stabilization

Alternating isometric contractions of agonist and antagonist musculature

What are the types of manual facilitation used for coordination

Tapping
Rubbing
Pressure
Support through the motion

What are the guidelines for rhythmic stabilization

Place joint in a desired position
Instruct the patient to hold the position an resist manually applied forces
Force then is applied in various directions
Can be progressed/regressed

How can rhythmic stabilization be progressed or regressed

By changing the lever arm, the pattern of predictability, timing, and the force application to an area with little to no sensation

What are the guidelines for manual support

Take patient through ROM passively
Ensure patient understands the motion
Have patient begin to perform motion with “guarding” as needed to ensure motion is occurring properly
Remove support as able

What do cues direct a patient to do

Where to focus when trying to perform a movement

Internal attention

Concentration on the movement of the body

What do internal attention cues promote

Proper motion

External attention

Concentration on the intended effect of the body

What do external attention cues promote

Completion of a task

Is external or internal attention more historically used

Internal

Does external or internal attention appear to lead to higher levels of muscle activation

Internal

Is external or internal attention hypothesized to produce more efficient movement

External

Does external or internal attention appear to be more effective in learning

External

Why does external attention allow for more effective learning

It’s associated with higher motor performance, higher attention, and possibly higher skill transference

Does external or internal cues provide stronger environments for motor learning

External

Does external or internal cues allow for higher levels of muscle activation

Internal

True or False:

Some individuals may only respond to one type of cues

True

When going through movement analysis, what areas should you assess as causes of the faulty movement

Mobility
Motor control
Strength
Endurance

What is the treatment for vestibular causes for difficulties with balance and motor control

Challenge the vestibular system

How do you challenge the vestibular system

Head movements

How can you progress vestibular habituation

Static → Dynamic
Increase speed of head turns
Eyes open → Eyes closed
Firm surface → Compliant/uneven surface