MOTOR CONTROL LECTURE 11: CLINICAL MANAGEMENT OF POSTURAL CONTROL (EXAM II)

Goals for ____ ____:

- to educate the patient regarding safety and fall prevention

- to maximally remediate or correct identified impairments through skilled intervention

- to help the patient gain and learn compensatory strategies if remediation cannot be complete

- to improve the patients confidence in his/her balance abilities

- to return the patient to ADLs and recreational activities which were impaired by his/her balance dysfunction

Balance interventions

_____ is expected

Instability

Proper _____ techniques should be utilized at all times

Guarding (hair belt/harness)

Environment should be clear of _____

Hazards

The ____ should wear sensible, flat, nonslip shoes and have a wide BOS

Therapist

You should have the patient perform a safe ____ of UE support

Decrease (fingertips, one hand at a time)

_____ ____ stability (postural movement strategies):

- unable to maintain position/falls

- maintains position only with UE support, with atypical BOS, or with atypical postural sway

Steady state

_____ ____ alignment (postural movement strategies):

- impaired orientation of axial body segments

- UE held close to side of body

- high guard, reaching, counter balancing with UE

Steady state

____ ____ body structure function (postural movement strategies):

- decreased strength in LE/trunk

- abnormal muscle tone

- impaired ability to isolate body segment or limb movements through available ROM

- decreased coordination

Steady state

____ ___ activity (postural movement strategies):

- impaired or atypical performance on the Berg Balance Scale & Mini-BESTest

Steady state

____ ____ focus of intervention (postural movement strategies):

- develop initial conditions appropriate for task & increase efficiency for organization and timing of motor responses generated to allow for sitting & standing under various tasks and environmental conditions

Steady state

Steady state (postural movement strategies):

- practice aligning the body during various tasks while using ____ _____ feedback to assist in finding a vertical posture that maintains LOG within individuals stability limits

Augmented sensory (visual, manual, verbal, auditory, vibrotactile)

Steady state (postural movement strategies):

- practice maintaining alignment and stability in sitting & standing during various ____ conditions

BOS (feet together, semi tandem, tandem)

_____ _____ stability (sensory processing):

- maintains position with atypical posture sway

Steady state

____ ____ alignment (sensory processing):

- impaired orientation of axial body segments with respect to plumb line or each other

Steady state

____ ____ & _____ activity (sensory processing):

- impaired or atypical performance on the Mini-BESTest

Steady state & reactive

_____ ____ body structure function (sensory processing):

- impaired performance on Modified Clinical Test for Sensory Interaction in Balance (inability to maintain each position for 30 seconds)

- impaired sensory integrity (light touch, vibration or proprioception in LE)

- impaired visual acuity

- impaired gaze stability (Head Impulse Test, Dynamic Visual Acuity)

Steady state

___ ____ focus of intervention (sensory processing):

- improve organization and selection of appropriate sensory information for postural control under various task & environmental conditions

Steady state

Steady state (sensory processing):

- practice maintaining sitting or standing under ____ & _____ sensory & BOS conditions while systematically varying availability and accuracy of 1 or more senses for orientation (vestibular, visual, somatosensation)

Unpredictable & predictable

To decrease reliance on ____:

- perform activities with eyes closed of with a blindfold

- perform activities in dim lighting

Vision

To increase reliance on ____:

- stand on compliant surfaces (foam)

Vision

Before decreasing reliance on ____, explain what you are going to do to the patient so they are not scared

Vision

To decrease reliance on _____:

- change the support surface

Somatosensory

To increase reliance on ____:

- standing with vision occluded or reduced lighting

Somatosensory

To increase reliance on ____:

- stand on foam with eyes closed

- stand on foam while wearing goggles that distort vision

- perform activities with reduced input from the vision and somatosensory system

Vestibular

______ (executive function/multitask ability):

- variability of task performance with regards to timing, sequencing, smoothness, speed, and stability

Anticipatory

_____ (executive function/multitask ability):

- difficulty maintaining attention during task performance with need for verbal or tactile cueing to complete task

Anticipatory

_____ body structure function (executive function/multitask ability):

- impaired cognitive/mental function as noted by performance on the Saint Louis Mental Status

Anticipatory

______ activity (executive function/multitask ability):

- impaired to atypical performance on the TUG (cognitive & manual)

Anticipatory

_____ focus of intervention (executive function/multitask ability):

- build skill in ability to maintain balance during various tasks and environmental conditions under dual task conditions (while performing a secondary cognitive or manual task)

Anticipatory

Anticipatory (executive function/multitask ability):

- practice single condition balance challenging tasks followed by performance of same task under ____ ____ conditions

Dual task

The goal of ____ ____ _____ is to have the patient perform a motor task without degrading with increased attentional demands or consistent performance whatever the attentional demands

Dual task training

Increase the challenge of the ____ task before increasing the difficulty of the ____ task

Balance; secondary

_____ stability (balance confidence):

- grasping for/clutching external supports

- completes task only with wide BOS

Anticipatory

______ symptom provocation with any task (balance confidence):

- performance may vary based on availability of nearby support surfaces

- attempts to complete task evoke symptoms such as pain, anxiety, fatigue, fear, lightheadedness, dizziness

Anticipatory

_____ body structure function (balance confidence):

- vital signs (increase in RR, HR & BP

Anticipatory

_____ activity (balance confidence):

- scores on the Activities Balance Confidence Scale are lower than expected as compared to patients actual performance on the core tasks & performance based outcome measures

Anticipatory

Availability of nearby _____ ____ may increase performance and decrease anxiety/fear on the following:

- Functional Gait Assessment

- Berg Balance Scale

- Mini-BESTest

- Timed Up & Go Test

- Functional Reach Test

Support surfaces

_____ focus of intervention (balance confidence):

- improve balance confidence and self efficacy so patients perceived balance abilities more closely align with actual balance abilities under various task and environmental conditions

Anticipatory

Anticipatory (balance confidence):

- practice ___ ____ destabilizing tasks that do not necessitate use of balance recovery strategies, focus on ___ ____ coaching and incrementally increasing postural control challenge

Self initiated; self efficacy

_____ balance control:

- weight shifts

- limb movements

- stepping

- reaching & stepping

- stepping up and down

Anticipatory

____ ____:

- A/P

- M/L

- diagonal

Weight shifts

What order to do ___ ____:

1. M/L

2. A/P

3. Diagonal (mimics walking)

Weight shifts

____ ____:

- reaching

- LE activities

Limb movements

You can vary the ____ of limb movements to make it more difficult

Speed

_____ stability (postural movement strategies):

- LOB with ineffective, atypical, or absent trunk and/or extremity response to stabilize or prevent a fall

- ineffective responses may be delayed, slow, and/or to small to prevent a fall

Reactive

______ body structure function (postural movement strategies):

- impaired ability to isolate body segment or limb movements through available ROM

- presence of dysmetria, slowed movement, or dysdiadokokinesia during non-equilibrium tests of coordination

Reactive

_____ activity (postural movement strategies):

- impaired or atypical performance on the Mini-BESTest

Reactive

____ focus of intervention (postural movement strategies):

- improve organization and timing of multi joint motor responses (including both in place and change in support strategies) effective in recovering stability after an unexpected loss of balance under various task and environmental conditions

Reactive

Reactive (postural movement strategies):

- practice tasks requiring recovery of balance after ____ ____

Unexpected perturbations

______ stability (sensory processing):

- LOB with ineffective, atypical, or absent trunk and/or extremity response to stabilize or prevent a fall

- ineffective responses may be delayed, slow, and/or too small to prevent a fall

Reactive

_____ body structure function (sensory processing)

- impaired sensory integrity in UE/LE including touch, pressure, proprioception, protective sensation, contrast sensitivity, depth perception, or visual acuity

- impaired cranial/peripheral nerve integrity

- impaired performance on Modified Clinical Test for Sensory Interaction in Balance

Reactive

_____ focus of intervention (sensory processing)

- improve organization and selection of appropriate sensory information for recovering stability after an unexpected loss of balance under various task and environmental conditions

Reactive

Reactive (sensory processing):

- practice tasks requiring balance recovery after unexpected perturbations while systematically varying ____ & ____ or 1 or more sense for orientation

Availability & accuracy

____ ____ muscles:

- gastroc

- anterior Tibialis

Ankle strategy

_____/_____ muscles:

- peroneals

- posterior Tibialis

- glute med

M/L

____ ____ muscles:

- glute max

- quads

- hamstrings

- hip flexors

Hip strategies

____ ____ muscle:

- abdominals

Core stability

____ ___ balance (sitting):

- head control (tilted wheelchair, angled back support)

- trunk control (use of manual cues of assistance)

Steady state

____ balance (sitting):

- weight shifts

- reaching/limb movements (increasing LOS)

Anticipatory

____ balance (sitting)

- perturbations (forward, backward, sideways, diagonal)

Reactive

Sitting balance sensory systems: ___

- eyes closed

Vision

Sitting balance sensory systems: ___

- seated on ball

- cross legs

Somatosensory

Sitting balance sensory systems: ____

- sit on ball and close eyes

Vestibular