Week 4 Cue Cards

safety and environment in postural control assessment

• Do not rush into postural control assessment; first set up a safe environment.

• For standing assessments, use supports as needed (e.g., parallel bars or a physio/assistant nearby). The assessor remains in charge of safety and task demands.

• Use a team approach for safety: practitioner in control, one or more helpers ready to assist if the patient lurches or begins to fall.

• Consider environmental factors (space, surfaces, obstacles) and adapt tasks accordingly.

• Document base of support and environmental setup as safety and task difficulty vary (e.g., two bars, proximity of assistants, etc.).

hierarchy of postural control

• Static posture control: standing or seated, with minimal movement; common starting point.

• Anticipatory postural control: planning and execution of movement that shifts the base of support (e.g., reaching for an object outside the base of support).

• Reactive postural control: response to unexpected perturbations; examiner applies a disturbance (nudge or push) to test response strategies.

• Adaptive postural control: adaptation to different environments and sensory cons; typically practised in different real-world settings (e.g., busy spaces, uneven surfaces).

• In practice, start with static seated and/or standing, then progress to anticipatory, then reactive, with adaptive tasks introduced later in the therapy course.

• Rationale for sequencing: avoid fatigue and excessive transfers between seated/standing; minimise risk while maximising informative assessment progression.

practical approach to static postural control assessment

• Safety first: ensure support if needed; consider having multiple people around the patient.

• Quantitative and qualitative aspects:

• Quantity: how long can the person maintain a static upright position (e.g., >20,s is a common benchmark for standing without movement).

• Quality: alignment of head, trunk, pelvis, knees, ankles, and toes; weight distribution; presence of sway.

• Head-to-toe assessment strategy (recommended): start at the head and work down to the feet to avoid missing proximal contributors that affect distal segments.

• Cervical alignment (forward head posture?), shoulder position (pro-/retraction), thoracic and lumbar alignment, hip position (extension vs flexion), pelvic tilt (anterior/posterior), knee and ankle positions, and toe posture.

• Rationale: pelvic tilt changes lumbar lordosis and can mask trunk findings if you go straight to the pelvis.

• Common observation points and notes:

• Document base of support (feet shoulder-width apart, heels together, tandem stance, or one-leg stance).

• Note sway pattern and likely strategies (ankle-dominant vs hip-dominant).

• Recognise that even in static standing there is sway; ankle strategy often dominates static upright posture.

• Example considerations for documentation:

• If feet are shoulder-width apart, longer static time may be feasible; if feet are together, static time is typically shorter.

• Tandem stance is useful for functional tasks like walking, more challenging than feet apart/together.

• Practical note: consistency in approach matters; choose head-to-toe or toe-to-head and apply it consistently.

anticipatory postural control assessment details

• Con: seated or standing; task involves reaching or moving outside the base of support while maintaining upright posture.

• Observed strategies: head turns toward target, upper limb movement (shoulder flexion, arm positioning), trunk adjustments (lumbar/thoracic extension or flexion), and balance control via counterbalancing (one arm extending forward while the other sits behind or to the opposite side).

• Base of support considerations: stepping or weight shift may occur to counterbalance; observe changes in hip extension, knee extension, ankle plantarflexion, and toe engagement.

• Surface considerations: surface type can affect strategy and stability (carpet, hard floor, foam, outdoor surfaces).

• Key learning: anticipate limits and plan to shift base of support or adjust body alignment to maintain balance during reaching tasks.

reactive postural control assessment details

• Purpose: test response to perturbations when the person cannot anticipate the force, or when anticipation is insufficient.

• Safety emphasis: high priority for safety; use a safety plan with multiple present personnel.

• Testing approach: provide nudges or perturbations in multiple directions (anterior, posterior, lateral) and observe response strategies.

• Typical observed responses:

• Step forward to widen base of support when perturbation is anterior.

• Step backward when perturbation is posterior (older adults may fall backwards more commonly).

• Lateral steps to reestablish stability.

• Case example: a patient with stroke and paretic limb, where perturbations were used to trigger stepping with the paretic leg to improve confidence and motor control; demonstration of how reactive assessment informs targeted treatment (e.g., retraining paretic limb to step forward).

• Practical takeaway: reactive testing provides insight into real-world fall risks and helps tailor perturbation-based training.

adaptive postural control assessment details

• Concept: moving beyond the clinic to real-world environments and tasks with varied sensory inputs and surfaces.

• Examples of adaptive cons:

• Busy shopping centres, corridors with crowds, uneven outdoor surfaces (grass, gravel, sand), wooden bridges, or transition spaces between hospital wards and gyms.

• Outdoor and community environments to mimic home and work cons.

• Practical tools: use safe, controlled environments that still reflect real-life challenges; consider long-term planning for progressive challenges.

• Testing approach: may not be part of a single-day assessment; often integrated over multiple sessions as the patient progresses.

• Sensory and environmental manipulation: use varied surfaces, lighting (eyes open vs eyes closed), and different sensory cues to train adaptation (e.g., reducing reliance on vision, enhancing somatosensory and vestibular inputs).

assessment sequencing and clinical reasoning

• Inpatient rehab vs community settings:

• Inpatient: notes may indicate prior mobility and the ability to transfer to a toilet or walk short distances; prioritise standing and anticipatory control as starting points.

• Community: observe the patient in waiting areas (static/seated) and during transfer to a gait aid; use this to infer static and anticipatory control before moving to standing tasks.

• Reasoning for starting with seated postures in some cases: some patients may benefit from immediate standing evaluation, others may have safer or more efficient assessments starting seated and progressing to standing.

• Practical implication: tailor assessment progression to patient goals and safety, and justify the sequencing to clinical educators.

formal assessment tools

• Berg Balance Scale (BBS):

  • 56-point scale; reliability and validity discussed; higher scores indicate better balance.

  • Predictive value for falls risk; reliable across evaluators and time points depending on training.

• Timed Up and Go (TUG):

  • Sequence: sit to stand, walk 3,metres, turn around, return, and sit down.

  • Time-based; normative data exist; commonly used as a quick screen for fall risk.

  • Strength: functional snapshot of mobility and balance during a simple task sequence.

• Functional Reach Test:

  • Stand with arm forward and reach as far as possible without stepping; measure distance reached in centimetres.

  • Normative data available by age, gender, and height.

  • Pros: simple distance measure; Cons: does not capture movement quality or underlying impairments.

• Important limitations of these tests:

  • They largely address static and anticipatory aspects; reactive postural control is not directly quantified by these tests.

  • They do not reveal specific impairments (e.g., strength, tone, sensory deficits).

  • They do not directly assess coordination or task-specific adaptability.

impairments and management considerations

• Common impairment domains to consider:

  • Muscle strength (e.g., quadriceps weakness affecting knee extension and standing control).

  • Tone abnormalities (spasticity or hypertonia) affecting range of motion and control.

  • Sensory impairments (proprioception, somatosensorial, vestibular input).

  • Coordination and sequencing of muscle activation (co-activation, timing of hip/ankle strategies).

  • Movement strategy selection (ankle, hip, stepping) and optimisation of postural responses.

• Management ideas by impairment:

  • Strength deficits: targeted strengthening programs.

  • Tone/intermittent hypertonia: active stretching to increase range of motion and reduce resistance; may provide a window for improved mobility.

  • Prevent secondary impairments: address risk of contractures through stretching and position changes.

  • Permanent impairments (e.g., amputation): devise alternative strategies and prosthetic considerations.

functional vs impairment focused strategies

• Alignment-focused rehab to improve body schema and postural alignment (mirror feedback, wall alignment cues).

• Movement strategy retraining: focus on ankle, hip, and stepping strategies; address maladaptive patterns (e.g., over-reliance on one strategy or avoidance of a paretic limb).

• Sensory strategy retraining: adjust visual input, somatosensory feedback, or vestibular cues to improve balance in different cons.

• Task-specific practice: part-whole practice, block vs random practice, and ensuring practice is challenging but safe to promote motor learning.

• Practical examples and clinician reflections:

• A stroke patient with paretic limb issues benefited from reactive perturbation training to promote stepping with the paretic leg.

• Observations of co-activation at the hip suggested that testing with EMG could help determine if there is excessive co-contraction limiting appropriate hip strategy usage.

practical tips for conducting postural control assessments

• Always begin with safety planning: consider who is available to assist and how to position the environment for safety.

• Use a consistent assessment approach (head-to-toe or toe-to-head) to avoid missing critical information.

• Document both quantity and quality, as well as base of support and surface characteristics.

• When observing, look for the underlying strategies (ankle vs hip) and consider how proximal trunk control contributes to distal limb movements.

• Use mirrors for real-time feedback and alignment corrections; consider weight distribution measurements (if equipment allows).

• Consider real-world relevance early in assessment by noting patient goals (e.g., fall during kitchen tasks) and prioritising tasks that reflect those goals.

• Plan practice progression using motor learning principles: start where the patient can achieve success but consistently challenge them to push the limit safely; adapt task difficulty using part-whole practice, block vs random practice, and progressive surface challenges.

• Be mindful of psychosocial factors: the patient’s confidence, fear of falling, and daily task goals influence engagement and adherence to therapy.

3 sensory systems for postural control

Somatosensory – cutaneous touch and pressure sensations Proprioceptive and kinaesthetic info from muscle and joint receptors

Visual – feedback of where we are and where our body is in space. Nearby objects Visual cues regarding the orientation of the environment relative to the individual

Vestibular – equilibrium, balance, hearing – position relative to gravity Position of the head relative to gravity

Modified Clinical test for Sensory Interaction in Balance (mCTSIB)

A physiotherapist can test how well sensory inputs are being integrated by the CNS to maintain a client’s standing balance.

o   Subject should be able to maintain each condition for 30 seconds.

o   They can have 3 attempts. If they achieve the full 30 seconds on the second attempt, they were successful.

o   If they took 3 attempts, record the average time across the 3 attempts.