KINESIOLOGY 484 - Exam 2

The Components of Balance

1. Vestibular System

2. Vision

3. Somatosensory

Vestibular System

Semicircular Canals

3 Planes of Movement

• Detects change in motion

• Acceleration

• Deceleration

Vision

Orientation to horizon

Somatosensory

1. Proprioception…

   • Joint mechanoreceptors (ligaments, jt. capsule)

   • Musculotendinous: Muscles spindles, GTOs

2. Kinesthesia…

   • Tactile/touch perception of skin mechanoreceptors

     • Pressure, vibration, stretch

Balance

A complex feedback loop to create the ability to adapt to the ever-changing enviornment

Common Measurements of Balance

1. Postural Sway

   • Horizontal movement of the center of gravity when a person is standing still

2. Functional Movement Tests

3. Dual task challenges: adding cognitive

Prognosis with Vision Impairment

• Lower level of self-efficacy

• Lower level of social connection

• Less overall physical activity

Vision Impairment

Even mild vision impairment increases mortality risk in adults 40+ years old

Vision loss causes…

Apprehension (scared) of Environment

Vision Maladaptations…

• Poor static & dynamic balance

• Forward head posture

• Slower gait, wider stance

Results of Vision from Exercise

• Improves balance skills, spatial orientation, and gait efficiency

  • Decreases chronic disease

  • Improved socialization abilities

  • Improvement in independence, confidence & self-image

Almost all individuals with visual impairment have…

Residual vision

Legal Blindness

Vision of 20/200 or less with the best correction

Blind by visual field

Less than 10 ft. of central vision or having tunnel vision

Visual field disturbances…

• Halos

• Ghosting

• Glare

• Visual Snow

Visual Impairment Effective Program Design

GOAL: Create a program that will strengthen self-efficacy, as well as physiological adaptations

SAFETY

Plan for Cues is Essential: Give environmental, verbal, and exercise instruction cues

Visual Impairment Special Considerations

1. Have safety precautions for balance

2. Environmental cues: Use good contrasting colors with equipment

3. Pair with a partner of similar skill level for higher demand activities (ex. special soccer team where all individuals have a sort of vision impairment)

4. ACSM rules for bodily safety: Extra clearance is needed for high-impact activities

5. Create a predictable facility environment: Give a tour of the facility then keep the facility layout consistent every time

6. Wandering happens and is a safety risk: use a constant sound source so they can always have an understanding of where they are

7. Verbal Cues and Exercise Directions: Consistent, simple, direct verbal cues established prior to exercise (do not correct every movement or self-efficacy will weaken)

8. Manual Guidance: Describe where and how you intend to touch individual, be gentle

Braille-Me Method (Vision Impairment)

Demonstrate an action first, while the participant feels your movements

Hands-on Method (Visual Impairment)

Guide the participant through an action by grasping the most beneficial body areas (wrists, shoulder, etc.) then moving them through the desired movements

Hearing Loss…

Umbrella term that applies to people who are hard of hearing or deaf

Hard of Hearing…

Mild to severe level of loss

• Some range of useful hearing and intentional use for the purpose of communication

  • Usually has assistance of auditory device

Deaf…

Severe to profound level of hearing loss

• Unable to use residual hearing for processing information or communication

• May or may not use sign language as a primary mode of communication

• Not viewed as a disability/limitation

• Distinct cultural community

Sensorineural Hearing also commonly has…

Commonly also have vestibular disorder (issues with semicircular canals)

Most common risk factor for hearing loss

Aging and excessive noise

4 Types of hearing loss

1. Conductive

2. Sensorineural

3. Mixed

4. Central

Conductive Hearing Loss…

Sound cannot effectively pass through the outer or middle ear

• Preventing proper transfer of vibration

Sensorineural Hearing Loss…

The inner ear structures and associated nerves have deteriorated

• MOST COMMON type of hearing loss

• Region where sensory receptors (stereocilia) convert sound vibration waves to neural signals transmitted to brain for interpretation

Mixed Hearing Loss…

Combined conductive and sensorineural

• Common with aging

Central Hearing Loss…

Central nervous system damage

• NOT COMMON

Hearing aids do not…

Correct or restore hearing

• They provide amplification so the person can make most of their abilities

Sound Amplifiers, Auditory Cue Converters

• Can help combat background noise, echos

• Visual light alarms

• Tactile clocks

Cochlear Implants

• Directly stimulates auditory nerve

• Could possibly restore some useable hearing

Special Considerations for Hearing Loss…

• Be aware of balance and spatial awareness with sensorineural hearing loss

1. Content of message must be recieved

2. Make sure there is not misinterpretation

3. Concise, Consistent Cues

How to train with someone with hearing loss?

• Plan together on what communication strategies work best for them

• Generally no altered responses to exercise

How to communicate effectively with an individual with hearing loss?

1. USE: Preferred method of communication AND prepare before an exercise session

2. FACE: Square up to the person to utilize as much non-verbal AND visual communication as possible, avoid focusing on the interpreter

3. LIP READING: Nothing should hinder the view of your mouth

4. VOLUME: Do not try to talk louder, it makes it harder to read lips

2. Make sure there is no misinterpretation (SC Hearing Loss)

• Individuals with hearing loss are often visual learners

  • Demonstrations are essential

• Be careful of sarcasm and non-verbal communication

• If the individuals speech is hard to understand, ask for clarification

3. Concise, Consistent Cues (SC Hearing Loss)

• Facial, body language, gestures

• Have them choose how to get their attention in the gym during activity

  • Correctional cues: Make together based upon their communication preference

What to avoid with hearing loss individuals?

• Avoid loud, constant, background noise

  • Always use sound for a purpose (ex. sound vibration)

• Avoid “visual noise”

  • AKA a busy environment, they will focus on what is moving around them

  • Make sure they remove their assisted hearing device if they are doing contact sports

Tympanic Membrane Tubes

Prevent water entry into the ear canal with ear plugs

Communication in a busy gym… How do you keep them focused on you?

Have them face a wall if possible so that the visual noise is behind them and they can focus on you if you need to communicate something quickly

Nevermind rule

Never say “nevermind” to your patient because it lowers their self-efficacy

Multiple Sclerosis is…

Inflammatory neuromuscular disease that damages the myelin sheath of the Central Nervous System

• “Immune-Mediated”

MS Facts…

• Average age of diagnosis is 30 years

• 2/3 more common in women than men

• Severity and progression is unpredictable from very aggressive to mild

Risk Factors for MS…

• Genetics (not considered a hereditary disease)

• Environmental Factors (more common in those living farther from the equator)

• Lifestyle (smoking, high BMI)

• Infectious Disease (linked with mono)

MS Physiology is a…

Disease of communication leak

What is Insulation? (MS)

Insulation is the material that resists electrical signal flowing through itself

What is the function of insulation? (MS)

It enhances the ability of the electrical signal to stay within the conductive wires and efficiently travel down the wire path

• It keeps signals separate within individual wires that are close to each other

What do nerves send electrical signals for?…

Communication

Myelin is…

An insulating sheath surrounding the nerve axon

• Increases both the velocity and strength of electrical signal traveling down the length of the axon

Velocity is…

The speed of electrical impulse (MORE communication sent)

• How MUCH message is sent to the muscles

• Repeating message = more force

Strength is…

Amplitude of message (EFFECTIVE message sent)

Complex Movement is…

The precise ability to immeasurable vary these two properties of communication

Slower Signals =

Less strength in communication of message

Oligodendrocytes

Cells that create and maintain myelin the the CNS only!

What are the 2 structures attacked and destroyed by inflammation in MS?

Oligodendrocytes and myelin

What are the 2 unique symptoms found in MS?

1. Uhthoff’s phenomenon

2. Lhermitte’s sign

Uhthoffs Phenomenon is…

An increase in neurological symptoms with elevated body temperatures

Healthy Electrical Signals…

The electrical signal travels down the axon and myelin insulates the axon to keep the electrical signal travelling down the axon path

MS Electrical Signals…

Myelin has been damaged, but often some are still present. In some places, thin myelin will be enough to insulate an electrical signal at normal body temperature

MS Electrical Signals (at elevated core temperature)…

Electricity travels faster/easier at higher temperatures, therefore it needs more insulation, but the damaged myelin insulation is insufficient to keep electrical signals going down the axon

• Therefore less signal reaches dendrites to send the impulse to the next neuron = A weaker, slower, signal and more symptoms like weakness, fatigue, and less coordination (Uhthoffs phenomenon)

Why is it called Multiple Sclerosis?

-       More than one area that has the scaring of myelin

-       Random per person

-       Multiple different symptoms due to many different areas affected

What qualifies individuals for MS?

• Having more than one legion within the entire CNS

  • Have to have a full body MRI every 6 months to see if you have more legions

• 2 incidences of attacks that occurred at least 1 month apart

• Spinal fluid may have antibodies specific to attacking oligodendrocytes and by-products of myelin breakdown

• Symptom history that matches MS

Synonyms for “attack” (MS)

Flares and/or Relapses

Areas of Symptomology (MS)

• VERY individualized, which leads to the difficult nature of the diagnosis

  • People with the diagnosis can present with very different symptoms

Why are there so many different ways that MS can manifest as symptoms for an individual?

Because MS can happen at multiple different locations in the CNS, therefore it depends on the location to determine symptoms. It also depends on the severity of the condition, ranging from mild to severe, some individuals may not experience symptoms and some may be very affected by them.

(Broad) Signs and Symptoms of MS

• The most commonly reported symptom is FATIGUE

• Pain/Perception…

  • Neuropathy

  • Visual changes

  • Heat/cold insensitivity

  • Bladder and bowel difficulties

• Movement

  • Muscle weakness

  • SPASTICITY: Increased excitability in muscles due to CNS damage

  • ATAXIA: Lack of muscle control during voluntary movements

  • Balance issues, vertigo/dizziness

• Intellectual

  • Cognitive impairment

    • Emotional imbalances

Why does MS happen?

Starts with a dysfunction of the inflammatory/immune system

Lhermitte’s Sign is…

Electrical sensation down the back or limbs when bending the neck

• Commonly located right on the brainstem

• Only an issue with neck flexion

• Lesions are hyperexcitable, stretching them triggers an electrical impulse

How to avoid Lhermittes Sign? (MS)

Avoid having individuals do exercises resulting in neck flexion

How to resolve Lhermitte’s if it occurs

You do not have to completely cease exercise, try a different position where they do not have to do neck flexion

How is MS diagnosed?

Through the process of elimination

• Rule out everything else that might be the cause, the evaluate if symptoms match the checklist

The most common type of MS is…

Relapsing-Remitting: Unpredictable flares which may or may not leave permanent deficits followed by periods of remission. Decline is not constant

What are the other types of MS?

• Progressive Relapsing

• Primary Progressive

• Secondary Progressive

All of these conditions continue to get worse no matter the treatment

What to do during Flares? (MS)

• Do not exercise

  • Use steroid-anti inflammatories to completely eliminate inflammatory response

The older the age of initial onset…

The faster the rate of decline

• The older you are when you get diagnosed, the faster the rate of decline (ages 50+)

MS is considered a….

Chronic disease that affects daily life

• 75% of individuals are still capable of walking 15 years after diagnosis

  • Not a mortality disease, individuals often die of another chronic disease rather than MS

Effects of Exercise on MS

Exercise has no direct influence on prognosis or progression of the disease

• There is no proof that exercise can change the course of MS

• However, exercise significantly increases quality of life and improves aspects of fitness/functional movement

Expected Body Response to Exercise (MS)

80-90% age-predicted peak VO2 during exercise

• Caused by lower extremity weakness and ANS dysfunction

  • Fatigue will hit quickly and when it does, they should stop!!

Common Maladaptations that influence gait (MS)

• Balance challenges

• Gait Ataxia = Lack of coordination with gait movement

• Spasticity = Changes ability for ROM and ability to fire muscles in smooth manner

• Muscle weakness causing foot drop (anterior tibialis very weak)

Maladaptations Result in… (MS)

• Slower gait speeds

• Imbalanced movements that lack efficiency

• Shorter stride length

• Wide base of support

  • Arms outstretched “tight roping”

What kind of exercises would you do to help improve MS?

• Single-leg star excursion

• Reverse and forward lunges

• Single leg balance

Parkinson’s Disease is…

A chronic, progressive neurological disorder involving the division of the nervous system that primarily regulates coordinated muscle action

Epidemiology of Parkinson’s…

• Men are about twice as likely to develop the disease than women

• 2nd most common neurodegenerative disease

  • Usually in individuals over 60 years

Etiology (causes) of Parkinson’s

It is idiopathic

• Genetics (15-25%link)

• Head trauma

• Autoimmune

• Environmental toxins (pesticides)

• Higher rates with certain professions

Substantia Nigra…

Coordinates the motor control messages between the brain and spinal cord

Substantia Nigra is a….

Relay center

• Afferent and Efferent messages pass through

Parkinson’s is also known as….

Disease of the regulator of the brain

Dopamine!

Neurotransmitter of the brain responsible for coordination and focus

What is the primary neurotransmitter used in substantia nigra? (PD)

DOPAMINE

• You lose dopamine losing the ability to send messages= communication problem

Once diagnosed with Parkinson’s what is the first change the doctor perscribes?

A change in diet, a Mediterranean diet is best

Diagnosis of Parkinson’s….

• Process of elimination

  • Must include all three categories

What are the three categories in diagnosis? (PD)

1. Bradykinesia = Slow movement(s)

2. ONE or MORE of the following…

   • Muscular rigidity

   • Resting tremor (unilateral)

   • Postural instability

3. Decrease in symptoms on dopamine medication

Primary signs and symptoms of Parkinson’s….

1. Bradykinesia

2. Muscle Rigidity

3. Tremor

4. Postural Instability

Bradykinesia is….

• Reduced ability to initiate/coordinate movements

  • Freezing/start hesitation

  • Slowness

    • Incomplete motions/Decreased perception of motion

Muscle Rigidity is….

On the same side as the tremor

• Stiffness can add to decreased joint ROM and cause pain

• Stiffness can contribute to a lack of balance

Tremor is described as…

1. Pill Rolling (hand movement)

2. Resting tremor (tremor is not bad with movements, but resting there is a tremor)

Postural Instability (PD)

• Occurs later in disease progression

• Cant catch themselves when imbalance occurs

• Retropulsion difficulties (when an individual starts falling backwards they cannot catch themselves)

What exercises can you do to strengthen postural instability? (PD)

• Have the individual perform medicine ball throws

Signs and symptoms begin with… (PD)

60-80% of cell death - This is typically when diagnosis occurs, this is because the body survives for as long as possible until it cant anymore causing symptoms

Pathophysiology of Cell Damage (PD)

1. Chronic inflammation/oxidative stress causes progressive cell death of neurons in substantia nigra that produce DOPAMINE, and the dopamine RECEPTORS

2. Damage to Norepinephrine producing neurons (need to be ready for ANS dysfunction)