Therex Exam 3 (Ch 8 Balance, & Biofeedback)

• Muscle Spindles

• Golgi Tendon Organs

• Cutaneous Receptors

The Proprioceptors

Balances comes from where?

• Vestibular System + Eyesight

What are the 3 Parts of the Ear?

• Outer Ear

• Middle Ear

• Inner

• External Auditory Canal

Outer Ear

• Malleus

• Incus

• Stapes

Middle Ear

• Semicircular Canals

• Cochlea

• Vestibule

• Eustachian (Auditory) Tube

Inner Ear

1. Sensory info detected (proprioceptors)

2. Integration of info (eyes + proprioceptors + vestibulocochlear)

3. Assessment of static position/motion

Process of Balance

• Coordination (in charge of)

• If damaged = Ataxia

• Cerebellum

• Point at which the body is at perfect equilibrium

Center of Mass (COM)

• Vertical projection of COM to the ground

Center of Gravity (COG)

• Max x Velocity

• Linear & Angular

Momentum

• Perimeter of contact area between the body & its support surface

Base of Support (BOS)

• Sway boundaries in which one can maintain equilibrium without changing BOS

Limits of Stability (LOS)

• Defined by Newton’s Law of Reaction

Ground Reaction Force (GRF)

• Location of vertical projection of GRF

Center of Pressure (COP)

What is involved in Balance Control?

• Detection of Sensory Information

• Integration of Information

• Assessment of Position & Motion

• Cutaneous Receptors

• Golgi Tendon Organs

• Muscle Spindles

• Joint Receptors

Detection of Sensory Information

What Systems are involved in the Integration of Information?

• Visual

• Somatosensory (Proprioceptors)

• Vestibular

Assessment of Position is what Type of Equilibrium?

Static Equilibrium

Assessment of Motion is what Type of Equilibrium?

Dynamic Equilibrium

What are the Types of Balance Control?

• Static

• Dynamic

• Automatic Postural Reactions

• Maintain stable antigravity position at rest

  • Sitting or standing

Static

• Stabilize body in motion or when support surface is moving

Dynamic

• Maintain balance in response to unexpected external perturbations

Automatic Postural Reactions

Balance Control is controlled by what Types of Control?

• Feedforward (Open Loop)

• Anticipatory

• Closed Loop

• Reactive responses for fast stimuli

Feedforward (Open Loop)

• Planned control in anticipation of movement

  • Postural muscles

Anticipatory

• Precision movements requiring sensory feedback

  • Sitting on a physioball

Closed Loop

• Body is always trying to keep COM over BOS

  • Ankle

  • Hip

  • Stepping

  • Weight Shift Strategy

  • Suspension Strategy

Movement Strategies

• Occurs with relatively small perturbations

Ankle

• Occurs with large external perturbations

Hip

• Large forces displaces COM

Stepping

• Lateral plane

Weight Shift Strategy

• Quickly lowering COM

Suspension Strategy

What can disrupt the patients ability utilize Movement Strategies and what can it create?

• Muscle weakness

• Loss of vision

• Decreased sensation

• Creating a fall risk

• Sensory

• Sensorimotor Integration

• Musculoskeletal (Motor Output)

• Age

• Medications

Impairments Leading to Impaired Balance

• Proprioceptors, Somatosensations, Vision, Vestibular Damage

  • DM

  • Polyneuropathy

  • Macular Degeneration

  • TBI

  • Stroke

  • Meniere’s Disease

Sensory

• Damage to structures that process incoming sensory information

  • Neuro Pathologies, Trauma

  • Basal Ganglia, Cerebellum, Supplementary Motor Area

Sensorimotor Integration

• Posture, Weakness, ROM loss, Malalignment

  • Orthopedic Pathologies & Surgeries

Musculoskeletal (Motor Output)

• Multiple risk factors

• Multi risk decline

Age

• Certain medication side effects

  • Hypnotics, Sedatives, Tranquilizers, Anti-Depressants, Antihypertensives, Narcotics

Medications

1. Romberg

2. Sharpened (Tandem) Romberg

3. Single Leg Balance Stance Test

4. Stork Stand Test

Common Static Balance Tests (Special Tests)

• Outcome Measures for Fall Risk Assessment

• Dynamic Balance Tests

• Anticipatory Postural Control Tests

• Sensory Organization Tests

Common Dynamic Balance & Anticipatory Postural Control Tests

• Berg Balance Scale

• Tinetti

• Timed Up & Go (TUG)

• Four Square Step Test (4SST)

• Dynamic Gait Index (DGI)

Outcome Measures for Fall Risk Assessment

• Five Times Sit to Stand Test (5xSTS)

Dynamic Balance Tests

• Functional Reach Test

• Star Excursion Balance Test

Anticipatory Postural Control Tests

• Benign Positional Paroxysmal Vertigo (BPPV)

• Parkinson’s Disease

• Cerebellar Lesion

• Meniere’s Disease

• Cerebral Vascular Accident (CVA)

• Traumatic Brain Injury (TBI)

• Sensation Impairing Pathologies

• Visual Pathologies

Pathologies Related to Impaired Balance

• Sensation of room spinning around you

• Involves the sensation of movement

• Caused by inner ear dysfunction &/or vision problems

• May also include nauseas & vomiting

Vertigo

• Described as “light headed”, “woozy”

• Caused by a number of things:

  • Medications

  • BP

  • Blood Glucose

  • Certain Pathologies

  • Sinus Problems

  • Headaches

Dizziness

• Most common cause of vertigo

• Risk of falls

• Usually brief & resolves on its own

• Treated by medication & PT

Benign Positional Paroxysmal Vertigo (BPPV)

• Chronic, progressive disease of the CNS

• Characterized (S&S) by:

  • TRAP

• Visual perception changes

Parkinson’s Disease

• Difficulty w/coordination of movements

• Caused by:

  • CVA, TBI, Chronic Alcoholism

• S&S:

  • Ataxic Gait

Cerebellar Lessions

• Usually affects patients between ages 40 & 60, & affects the inner ear with symptoms including:

  • Tinnitus

  • Hearing loss

  • “Fullness” in the ear

  • Vertigo

• It may be related to family history, immune disorders, migraines, infections, head trauma, & pre menstrual edema

Meniere’s Disease

• One sided weakness, paralysis, or paresthesia

  • Motor &/or Sensory Impairment

• Impaired cognition

  • Left CVA = slow, cautions, hesitant

  • Right CVA = impulsive, poor judgment, decreased safety

• Coordination deficits

• Proprioceptive deficits

• Blurred vision; visual deficits

Cerebral Vascular Accident (CVA)

• Trauma to the brain, neck, & spinal cord

  • Contact forces

  • Rotational acceleration forces

• Complex injuries w/many symptoms & disabilities

Traumatic Brain Injury (TBI)

• Diabetic neuropathy

• Multiple sclerosis (MS)

• Chronic alcoholism

• Hanson’s disease

Sensation Impairing Pathologies

• Motor & sensory losses

• Diabetic Neuropathy

• Multiple Sclerosis (MS)

• Sensory losses

• Chronic Alcoholism

• Hansen’s Disease “Lepersy”

• Diabetic Retinopathy

• Multiple Sclerosis (MS)

• Macular Degeneration

• Cataracts

• Glaucoma

Visual Pathologies

• Global loss of vision, common in diabetics after 8-10 years

Diabetic Retinopathy

• Diplopia & blurred vision

Multiple Sclerosis (MS)

• Loss of central vision

Macular Degeneration

• Loss of visual acuity

Cataracts

• Loss of peripheral vision

Glaucoma

• **Challenge patient’s limits of stability

  • This means that patients require increased assist & guarding to ensure that they do not fall during your treatment

• Exercises:

  • Weight shifts

  • Decreasing base of support (BOS)

  • Single leg stance (SLS) activities

  • Changing surfaces from most stable to least stable

  • Eyes closed balance activities

  • Trunk rotation

Balance Training (Retraining)

• Motor Command (CNC)

• Effector Organs (Muscles)

• Functional Outcomes

• Assessment of Outcome

Biofeedback Loop

• Increase strength

• Increase relaxation

• Muscle re-education

• Decrease anxiety

• Improve pelvis floor muscle control

• Treatment of incontinence-

  • Bowel & Bladder

• Decrease muscle spasm & guarding

  • Decreases muscle pain & headaches

• Increase postural control

• Biomechanics, motion analysis, & ergonomics

Indications for Biofeedback

• Any musculoskeletal condition in which muscular contraction might exacerbate that condition

• Pacemaker

• Avoid placing electrodes aligned w/axis of heart to reduce EKG artifacts. Place electrodes on same side of body

Contraindications for Biofeedback

• Uses scalp sensors to monitor the brain’s electrical activity using an electrocenephalograph (EEG)

• Neurofeedback (also called EEG biofeedback) is used to treat ADHD, alcoholism/substance abuse, epilepsy, headache, & TBI & use to teach optimal performance.

Brainwave Biofeedback

• Used bands places around the abdomen & chest to monitor breathing pattern & respiration rate.

• Is used to treat anxiety, asthma, COPD, & high BP, & to teach optimal performance.

Breathing (Respiratory) Biofeedback

• Uses finger or earlobe sensors w/a photoplethysmograph or sensors placed on the chest & lower torso (or on the wrist) using an electrocardiograph to measure both heat rate & heart rate variability.

• HRV biofeedback is used to treat asthma, depression, high BP, & unexplained abdominal pain, & to teach optimal performance.

Heart Rate Biofeedback

• Uses sensors placed over skeletal muscle w/an Electromyography (EMG) to monitor the electro activity that causes skeletal muscle contraction.

• EMG is used to treat anxiety, headache, high BP, asthma, cerebral palsy, fecal &urinary incontinence, pain involving the lower back, pelvis muscles, & temporomandibular joint, & paralysis, & muscle weakness due to peripheral nerve injury & stroke, & to teach optimal performance.

Muscle Biofeedback

• Uses sensors placed around the fingers on the palm & wrist w/ an electrodermograph (EDG) to monitor changes in skin moisture produced by sweating.

• Used to treat excessive sweating & high BP, & to teach optimal performance.

Sweat Gland Biofeedback

• Uses sensors placed on the hands or feet w/ a feedback thermometer to measure blood flow to the skin.

• Used to treat headache, high BP, Raynaud’s disease, & swelling, & to teach optimal performance.

Temperature Biofeedback