MUSCULOSKELETAL EXAMINATON: POSTURAL BALANCE AND GAIT

In our field, balance is often used in association with terms such as ____________ and __________control

stability and postural control

The evaluation of balance is pertinent in the assessment of patients with which deficits?

• Neurological Deficits

• Orthopedic deficits

• Vestibular disorders

True or False:

An object or person is balanced when the forces acting upon them all summate to 0 (equilibrium)

True

Which law was related to the previous flashcard?

Newton's First Law: Law of Inertia

COG of an adult can be located where?

COG of an infant is located where?

2 inches anterior to S2

Xiphoid process

A multidimensional concept, referring to the ability of a person to not fall

Human Balance

The point at which the vector of the total body weight passes

COG (Center of Gravity)

Vertical line running through the COG

Line of gravity

The area of single contact between body and the support surface or, if there is more than one contact with the support surface, the area enclosing all the contacts with the support surface

Base of support

The inherent ability of an object to remain in or return to a specific state of balance

Stability

The inherent ability of an object to remain in or return to a specific state of balance and not fall, or, the inherent ability referring to the motor and sensory systems and to the physical properties of the person

Human stability

True or False:

If the COG of an object is within the BOS we can say that the object is balanced.

True

State if this increases or decreases stability:

• Larger BOS

• Smaller BOS

• Lower COG

• Higher COG

• COG at center of BOS

• COG at edge of BOS

State if this increases or decreases stability:

• Larger BOS = increases

• Smaller BOS = decreases

• Lower COG = increases

• Higher COG = decreases

• COG at center of BOS = increases

• COG at edge of BOS= decreases

If an object becomes unbalanced where would the COG move in relation to the mass?

COG moves to the side with more mass

That feeling when you find a golden scar

dekubopdomnem dekubopdomnem
I, was d knight in shoining armour in ur mooviee

True or False:

During an upright stance, the human body has a relatively low COG and wide BOS.

False

During an upright stance, the human body has a relatively high COG and small BOS.

The act of maintaining, achieving or restoring a state of balance during any posture or activity

Postural control

True or False:
Postural control is one of the prerequisites to the maintenance oa a myriad of postures and activities

True

Postural control is used in the following EXCEPT:

• The maintenance of a specified posture such as sitting or standing

• Voluntary movement, such as the movement between postures

• The reaction to an internal disturbance such as a trip slip or push

• None of the above
  

Postural control is used in the following EXCEPT:

• The reaction to an internal disturbance such as a trip slip or push

EXTERNAL disturbance not internal

Postural control strategies may be ___________ (compensatory) or ____________ (anticipatory), or a combination of both

Postural control strategies may be reactive (compensatory) or predictive (anticipatory), or a combination of both

This postural control strategy involves a voluntary movement or increase in muscle activity, in ancticipation of a disturbance

Predictive postural control

This control strategy involves a movement or muscular response following an unpredicted disturbance

Reactive postural control

What were postural control strategies traditionally considered as?

reflex-like responses elicited automatically by a sensory stimulus.

True or False:

Postural responses are now understood to rely on the assessment and control of many variables by the PNS

False:

Postural responses are now understood to rely on the assessment and control of many variables by the CNS

True or False:

Strategies of postural control vary depending on an individual’s goals and environmental context. This implies that balance control is a fundamental motor skill learned by the CNS.

True

Balance emerges from the interaction of the individual, the task, and the environment; Functional tasks require three types of balance control: (Enumerate)

• steady-state

• reactive

• proactive.

Environmental constraints that affect balance control:

• support surface

• sensory cues

• cognitive demands/load

Individual variations that affect balance control:

• motor

• sensory

• cognitive abilities

the ability to control our balance in fairly predictable and nonchanging conditions.

Steady-state balance

is the ability to activate muscles in the legs and trunk for balance control in advance of potentially destabilizing voluntary movements.

Proactive or anticipatory balance

is the ability to recover a stable position following an unexpected perturbation.

Reactive balance control

Reactive balance control relies on __________ mechanisms; on the other hand, proactive balance utilizes __________ mechanisms.

Reactive balance control relies on feedback mechanisms; on the other hand, proactive balance utilizes feedforward mechanisms.

Identify which balance control is needed for this task:

• reaching for a heavy object while standing; for maintaining a stable position before reaching for the object

• balance control to prevent loss of stability during the reach and lift

• balance control if the object is heavier than expected, and lifting it causes us to lose balance

• the completion of the task

Identify which balance control is needed for this task:

• reaching for a heavy object while standing; for maintaining a stable position before reaching for the object = Steady State balance

• balance control to prevent loss of stability during the reach and lift = Anticipatory Balance Control

• balance control if the object is heavier than expected, and lifting it causes us to lose balance = Reactive balance control

• the completion of the task = Steady state balance

Stability required for tasks like sitting or standing is called:

Static Balance

True or False:

Steady state balance, when controlling postural sway, is quite static.

FALSE:

Steady state balance, when controlling postural sway, is quite dynamic.

True or False:

The berg balance test is useful for young athletic patients.

False:

The berg balance test is useful for geriatric patients.

True or False:

Movement patterns used to recover stability following perturbations are selected by the central nervous system based on several factors such as characteristics of perturbation.

True

In reactive balance control, these strategies are used to maintain balance in a fixed BOS

Anke and Hip Strategy

These strategies are used to maintain balance when the BOS changes

Stepping and Reach to Grasp strategy

Congrats you won a 5 min break

In this balance control, the CNS uses the sensory information gathered and the information from previous experiences to predict forces and control needed for the task ahead with also the ability to change and adapt to new information if the task turned out to be different than expected.

Proactive Balance control

kaya ung mga bata di alam paano mag react to stairs at first

The gold standard for investigating sensory information and organization for balance

Sensory Organization Test

Memorize this Table

SOT test condition 1:

• Eyes:

• Surroundings:

• Platform:

• Sensory System used:

• Disadvantaged sensory system:

SOT test condition 1:

• Eyes: Open

• Surroundings: Fixed

• Platform: Fixed

• Sensory System used: Somatosensory

• Disadvantaged sensory system: N/A

SOT test condition 2:

• Eyes:

• Surroundings:

• Platform:

• Sensory System used:

• Disadvantaged sensory system:

SOT test condition 2:

• Eyes: Closed

• Surroundings: N/A

• Platform: Fixed

• Sensory System used: Somatosensory

• Disadvantaged sensory system: Visual

SOT test condition 3:

• Eyes:

• Surroundings:

• Platform:

• Sensory System used:

• Disadvantaged sensory system:

SOT test condition 3:

• Eyes: Open

• Surroundings: Sway referenced

• Platform: Fixed

• Sensory System used: Somatosensory

• Disadvantaged sensory system: Visual

SOT test condition 4:

• Eyes:

• Surroundings:

• Platform:

• Sensory System used:

• Disadvantaged sensory system:

SOT test condition 4:

• Eyes: Open

• Surroundings: Fixed

• Platform: Sway referenced

• Sensory System used: Visual

• Disadvantaged sensory system: Somatosensory

SOT test condition 5:

• Eyes:

• Surroundings:

• Platform:

• Sensory System used:

• Disadvantaged sensory system:

SOT test condition 5:

• Eyes: Closed

• Surroundings: N/A

• Platform: Sway referenced

• Sensory System used: Vestibular

• Disadvantaged sensory system: Somatosensory/Visual

SOT test condition 6:

• Eyes:

• Surroundings:

• Platform:

• Sensory System used:

• Disadvantaged sensory system:

SOT test condition 6:

• Eyes: Open

• Surroundings: Sway referenced

• Platform: Sway referenced

• Sensory System used: Vestibular

• Disadvantaged sensory system: Somatosensory/Visual

Normal Values in Relation to Gait

• Pelvic Rotation ?

• Pelvic Tilt ?

• Vertical Displacement ?

• Lateral Displacement ?

• Cadence ?

Normal Values in Relation to Gait

• Pelvic Rotation 8 deg

• Pelvic Tilt 5 deg

• Vertical Displacement 5 cm

• Lateral Displacement 5 cm

• Cadence 90-120 steps/min

Percentage Distribution

• Stance Phase ?

• Swing Phase ?

• Double Support ?

• Acceleration ?

• Midswing ?

• Deceleration ?

Percentage Distribution

• Stance Phase 60% of gait cycle

• Swing Phase 40% of gait cycle

• Double Support 20% of gait cycle

• Acceleration 10% of swing phase

• Midswing 80% of swing phase

• Deceleration 10% of swing phase

Inman’s Six Determinants (Braddom):

• Pelvic rotation

• Pelvic tilt

• Knee flexion in stance phase

• Ankle flex/ext mechanism

• Lateral motion of the pelvis

4 Determinants of Gait (De Lisa & Hoppenfeld)

• Pelvic Rotation

• Pelvic Obliquity

• Lat. Displacement in the coronal plane

• Interchange between knee, ankle, foot

Muscle activity during Gait:

• Hip flexors- peak activity during?

• Hamstrings- peak activity during?

• Quadriceps- peak activity during?

• Hip abductors- peak activity during?

• Ankle DF- peak activity during ?

• Ankle PF- peak activity during?

Muscle activity during Gait:

• Hip flexors- peak activity during EARLY SWING

• Hamstrings- peak activity during TERMINAL SWING

• Quadriceps- peak activity during HS to FOOT FLAT

• Hip abductors- peak activity during MIDSTANCE

• Ankle DF- peak activity during HEEL STRIKE

• Ankle PF- peak activity during PUSH- OFF

force which produces the external moments occurring about the hip, knee and ankle during quiet standing and gait.

Ground Reaction Force

Ground reaction force location (HIP):

• Loading Response

• Midstance

• Terminal Stance

Ground reaction force location (HIP):

• Loading Response - Anterior

• Midstance - Through

• Terminal Stance - Posterior

Ground reaction force location (Knee):

• Loading Response

• Midstance

• Terminal Stance

Ground reaction force location (Knee):

• Loading Response - Posterior

• Midstance - Through

• Terminal Stance - Anterior

Ground reaction force location (Ankle):

• Loading Response

• Midstance

• Terminal Stance

Ground reaction force location (Ankle):

• Loading Response - Posterior

• Midstance - Anterior

• Terminal Stance - Anterior

Clinical Test to Assess Contracture of Two-joint muscles in UMN Pathology:

• differentiate a rectus femoris from iliopsoas contracture

• differentiate a soleus from gastrocnemius contracture

• differentiate a contracture of gracilis from short adductors

Clinical Test to Assess Contracture of Two-joint muscles in UMN Pathology:

• DUNCAN-ELY TEST

• SILVERSKIOLD TEST

• PHELPHS

Braddom (Pathologic Gait)

• Abnormal Base of Support

  • Equinus foot or ankle

  • Equinovalgus foot

  • Flexion deformity of the Toes

  • Hitchhiker’s Great toe

• Joint Stability

  • Drop-Off Gait

  • Knee Instability

  • Hip Instability

  • Trunk Instability

• Limb Clearance

  • Stiff knee Gait

  • Excessive Pelvic Obliquity

  • Inadequate Hip flexion

  • Drop Foot

De Lisa/ Magee (Pathologic gait)

• Antalgic (Painful) Gait

• Steppage Gait/ Drop foot Gait

• Festinating Gait

• Shuffling Gait

• Ataxic Gait

• Arthrogenic (Stiff Hip or knee) Gait

• Spastic Paretic Stiffed-legged Gait

• Dynamic Knee Recurvatum

• Diplegic Crouch Gait

• Equinus Gait

• Gluteus Maximus Gait

• Trendelenberg /Gluteus Medius Gait

• Psoatic Limp

• Hemiplegic Gait

• Short Leg Gait

Cause of antalgic gait?

Pain on weight bearing

Characteristics of antalgic gait:

• _______ steps with overall __________ of gait; decreased ________ time on the affected leg

Characteristics of antalgic gait:

• Short steps with overall slowness of gait; decreased stance time on the affected leg

Cause of steppage gait?

“functionally long” lower leg (example, plantarflexion contracture)

Characteristics of steppage gait:

• Excessive hip and knee ___________

Characteristics of steppage gait:

• Excessive hip and knee flexion

Cause of festinating gait?

Parkinson’s

Characteristic of festinating gait?

• ________ , ________ steps

Characteristic of festinating gait?

• Short, quick accelerating steps

Cause of Ataxic gait?

Poor balance / Cerebellar lesion

Characteristic of Ataxic Gait?

• Wide ______ and variable motion from stride to stride

Characteristic of Ataxic Gait?

• Wide BOS and variable motion from stride to stride

Cause of Spastic Paretic Stifflegged gait/ Circumducting gait?

Weak hip flexors, weak hams, spastic plantarflexors

Characteristics of Spastic Paretic Stifflegged gait/ Circumducting gait:

• Decreased knee _______; compensatory ______ and excessive _______ motion

Characteristics of Spastic Paretic Stifflegged gait/ Circumducting gait:

• Decreased knee flexion; compensatory vaulting and excessive pelvic motion

Cause of Dynamic Knee Recurvatum:

Weakness of quads, plantarflexor weakness or spasticity/ contracture, weak dorsiflexors

Characteristics of Dynamic Knee Recurvatum:

• ____________ of knee during _________

Characteristics of Dynamic Knee Recurvatum:

• Hyperextension of knee during stance

Cause of Diplegic Crouched gait:

Tight hip flexors, plantarflexor weakness, heelcord contracture

Characteristics of Diplegic Crouched gait:

• Excessive knee _______ in stance with _______ and _______ of the hips, _______ and forefoot _______during stance, reduced knee _______ in swing

Characteristics of Diplegic Crouched gait:

• Excessive knee flexion in stance with adduction and IR of the hips, equines and forefoot abduction during stance, reduced knee flexion in swing

Cause of Equinus gait

Heelcord contracture, dorsiflexor weakness, inappropriate plantarflexor activity

Characteristics of Equinus Gait:

• Excessive ___________ in ___________ or ___________

Characteristics of Equinus Gait:

• Excessive plantar flexion in stance or swing

Cause of Trendelenburg gait?

Weakness of hip abductors

Characteristics of Trendelenburg gait?

• Uncompensated: _____________

• Compensated: _____________

Characteristics of Trendelenburg gait?

• Uncompensated: excessive pelvic drop

• Compensated: excessive lateral lean towards affected extremity

“Never let the future disturb you. You will meet it, if you have to, with the same weapons of reason which today arm you against the present”

Marcus Aurelius