ESP Unit 6: Balance and aquatic therapy

what is balance (postural stability)

the dynamic process by which a body maintains its position in equilibrium or in motion

what is postural orientation

the capability to maintain appropriate alignment of body segments relative to each other and to the environment, suitable for a given task (staying upright)

what is postural control

the regulation of the bodies position in space for orientation and stability

what does postural control maintain

balance

what is center of mass

a fixed point representing the average location of all the mass in the body and shifts with changes in body position

what is center of gravity

gravity acts on an object aligning with the COM in a consistent gravitational field

does COM move

yes with positional change

what is base of support

the area of contact between the body and its support surface

what is limits of stability

the sway boundaries within which a person can maintain balance without altering the BOS

what is center of pressure

the point on the ground at which the total sum of pressure forces is exerted by the body

how does the visual sensory system contribute to balance

the eyes help to detect orientation and movement to provide info about position and motion of body

how does the somatosensory system contribute to balance

receptors provide information about touch, pressure, proprioception, and kinesthesia to help perceive position of body in space and forces acting upon it

how does the vestibular system contribute to balance

inner ear detects head movements and orientation relative to gravity to provide information on balance and spatial orientation

how does the nervous system contribute to balance control

there is sensory processing from the visual, vestibular, and proprioceptive systems sending info to the brain which used the info to create a motor response to maintain balance through motor strategies

how does the MSK system contribute to balance control

adequate joint ROM ensures proper movement to support balance

adequate muscle performance allows execution of actions to control actions

uses sensations to aid in awareness and proprioception

what contextual factors can contribute to balance control

speed of perturbation

support surface

COM displacement magnitude

task complexity

awareness of disturbance

posture

prior experience

what is static balance control

maintain balance in stable antigravity position at fixed place

what is dynamic balance control

maintaining an upright position to stabilize the body when the support system is moving

COM moves outside BOS

what are automatic postural reactions

involuntary movements made by the body to maintain balance in response to unexpected external perturbations

what is steady state balance control

balance control in a predictable unchanging environment

what is anticipatory (proactive) balance control

utilizes feedforward mechanisms to prepare body for balance control

what is reactive balance control

utilizing feedback mechanisms to make adjustments during a task

what is the first response to external perturbations

automatic postural reactions

what are fixed support strategies for balance control

maintain the same BOS and keep COM within stability limited

what are change in support strategies for balance control

BOS is changed in order to establish new stability limit to recover balance

what is the ankle strategy

slight forward and back movement at ankle

when is ankle strategy used

small anterior-posterior perturbations on firm surface

what is the weight shift strategy

shifting body weight laterally from one leg to the other done by the hips mostly and some ankles

when is weight shift strategy used

used to control mediolateral perturbations

what is hip strategy

rapid bending and or extending the hips to adjust COM and regain balance

when is hip strategy used

with larger or faster perturbations or when support is narrow or unstable

what is stepping strategy

a step or series of steps to widen BOS and stabilize body

when is stepping strategy used

used when disturbance is too great for postural control to be maintained by ankle or hip strategy

what is suspension strategy

involves lowering the COM through bending knees and hips

when is suspension strategy used

used in dynamic environments or when moving surfaces

what factors can influence balance strategy selection

speed and intensity of displacing force

support surface

COM displacement magnitude

awareness of disturbance

posture at time of disturbance

prior experiences

what maintains balance during stance

ankle strategy

autonomic and selective activated

tonic postural muscles active to maintain posture

what regulates balance with perturbed standing

internally anticipatory and proactive reactions

externally reactive reactions

what should be considered in regards to balance during whole body lifting

the load with impact the COM position

at what age are falls common

above 65

how does medication effect balance

there is increased fall risk if individual is taking more than 4 meds

why is balance impaired in older adults

functional declines in sensory system

on more meds

longer muscle onset latencies

greater hip strategy and stepping strategy use

increased difficulty with dual task

what subjective information should be obtaining in a balance assessment

history of falls

detailed history of variables and situations with prior falls

environment assessment of home/fall location

outcome measures to assess fear of falling

what should be assessed in the objective assessment of balance

assess MSK

assess biomechanics

sensory input and processing

gait

function

balance assessments

what are examples of static balance assessments

observation

Romberg test

sharpened Romberg

SL stance test;stork stand test

what interventions can be done for static balance

vary postures

vary support surface

incorporate external loads

what are dynamic balance tests and measures

observe on unstable surface

observe performing transfers and functional activities

5x STS

what are interventions that can be done for dynamic balance

moving support surfaces

move head, trunk, arms, legs

transitional and locomotor activities

what tests and measures can be done for anticipatory balance assessment

observe catching ball, opening doors, lifting objects

functional reach test

multidirectional reach test

star excursion balance test

Y balance test

what are interventions that can be done for anticipatory balance

reaching

catching

kicking

lifting

obstacle course

what tests and measures can be done for reactive balance

observation of pushes

pull test

push and release test

postural stress test

what interventions can be done for reactive balance

standing sway

ankle strategy

hip strategy

stepping strategy

perturbations

what tests and measures can be done to test sensory organization for balance

clinical test of sensory integration on balance test (CTSIB)

what interventions can be done for sensory organization for balance

reduce visual input

reduce somatosensory cues

what tests and measures can be done to assess balance during functional activities

tinetti

TUG

Berg balance scale

four square step test

dynamic gait index

functional gait assessment

community balance and mobility scale

high level mobility assessment

dizziness handicap inventory

what interventions can be done for balance during functional activities

functional activities

dual or multitask activities

what tests and measures can be done to assess safety during gait, locomotion, or balance

observations

home assessment

activities specific balance confidence scale

fall efficacy scale

what interventions can be done for safety during balance, gait, or locomotion

balance within stability limits

environment modifications

assistive devices

what does the cognitive stage require

extreme processing

lots of external feedback

what does the associative stage require

some processing

external reminders on occasion but the individual uses intrinsic feedback also

what does the autonomous stage require

mostly subconscious activity with little processing

intrinsically corrects errors without need for external feedback

where does the sensory information for balance get sent for integration

the cerebellum, basal ganglia, and supplementary motor area

what information is processes the fastest for balance

somatosensory

what does improving sensory organization allow

the ability to adaptively shift sensory reliance

when is the somatosensory system dominant for balance

when maintaining balance on stable surfaces

when is somatosensory used the least for balance

an uneven surface

what part of the vestibular system responds to rapid head movements

semicircular canals

what part of the vestibular system responds to slower movements and head position

otoliths

does the vestibular system provide info about body position below the hed

not without additional sensory input from mechanoreceptors like in the neck

what does standing on a bosu ball do for the sensory components of balance

decreased use of somatosensory

increased visual and vestibular input

what does blindfolding a pt do for the sensory components of balance

increases somatosensory and vestibular input

decrease visual input

how can the vestibular systems function be affected

by a violent head shake after a crash or traumatic event

what is the modified clinical test of sensory integration on balance test (mCTSIB)

a test that measures balance ability by changing visual, somatosensory, and vestibular inputs allowing for assessment of balance under different conditions

what are the steps of the mCTSIB

stand on firm surface eyes open

stands on firm surface eyes closed

stand on foam eyes open

stand on foam eyes closed

what is the balance error scoring system (BESS)

test of postural stability that utilizes different stance positions and surfaces

what is the procedure of the BESS

pt does 20 sec trials of each stance position on firm surface then on foam for 6 trials total

the three stances are double leg, single leg, an tandem

tester notes any errors

how does proprioception work

the proprioceptors send info to the CNS through afferent pathways, the info is processed and integrated and then there is a coordinated reflexive and cognitive motor response to maintain balance, coordinate movement, and perform motor tasks

what is tactile sensation

detects mechanical stimuli like pressure, vibration, and texture

what is kinesthesia

the sense of movement and the dynamics of motion

nociception

senses potentially damaging stimuli indicating injury or threat

what is vibration sensation

perceives oscillatory motion through the skin and deeper tissues

what is pressure sensation

the perception of mechanical force against skin

what pts can benefit from somatosensory focused training

pts with functional joint instability

chronic functionally unstable ankles

athletes requiring precise movement control

tasks needing hand eye or foot eye coordination

individuals who have improved balance and injury through proprioception training

when is proprioception the most effective

in slow/moderate closed loop movement control

how does proprioception training affect the CNS

adaptations through diverse motor skills, goals, and sensory expereinces

how can CNS limitations be challenged with proprioceptive training

using multiple task demands to manage dual task interference and enhance real world application

would novices benefit from dual task or single task more

single task

what is balance training

multisystem approach to address patient specific underlying deficits contributing to fall or near falls

why is external focus of attention more effective for motor learning than internal focus

it facilitates the use of unconscious, fast, reflexive control processes which speeds up motor learning

what is an external focus on attention

cueing the patient to focus on something that they an see and react to

ex: keep the wobble board horizontal

what is an internal focus of attention

cueing the patient to focus on something they can internally feel

ex: put even pressure through the feet

how can you improve the safety of balance exercises

use gait belt

stand behind and to the side of pt

do exercises near railing or bars

have two PTs with high fall risk

gaurd pt when getting on/off equipment

clear floor

what is perturbation based balanc

a reactive balance training type that uses repeated perturbations to allow pts to learn to adjust their postural responses more effectively

what do most studies say is a good duration and frequency for balance training

20-30 min sessions 2-3x/wk

when should balance training be performed in a session

Perform first to get better results due to no fatigue which results in higher neuromuscular efficiency

what can occur if balance intensity is too high

pt frustration or fear

what can occur if balance intensity is too low

no improvement, time and resources wasted

what is the Balance intensity score (BIS)

a scale that measures the intensity of balance for older adults

BIS-T for therapist

BIS-E for exerciser

what is included on the BIS-T

Hesitation

Movement quality

reaction speed

fear

accuracy

what is included on the BIS-E

the perceived balance effort