Neuro - Balance

What are the six systems involved with balance?

Biomechanical constraints

Stability limits/verticality

Anticipatory postural adjustments

Postural responses (motor)

Sensory orientation

Stability in gait

What is the purpose of the BESTest?

To differentiate balance deficits by identifying which systems contributing to balance are problematic

What impairments can affect biomechanical constraints?

Ankle or hip mobility/ROM

Postural alignment

Lower-extremity/trunk strength

What does the BESTest examine under biomechanical constraints?

Base of support, center of mass alignment, ankle strength/PROM, hip/trunk lateral strength, and sit-to-floor/stand-up ability

What is the cone of stability/limits of stability?

How far the body's center of mass can be moved over its base of support

The ability to perceive and maintain appropriate postural alignment against gravity

Sense of verticality

What does the BESTest assess for stability limits/verticality?

Sitting verticality, sitting lateral lean, standing forward functional reach, standing lateral functional reach, and weight shifts toward stability limits

What are anticipatory postural adjustments (APAs)?

"Readiness" or stabilization occurring before distal voluntary movement and/or balance disruption

Are APAs feedforward or feedback?

Primarily feedforward, although feedback mechanisms also contribute

What BESTest tasks assess anticipatory postural adjustments?

Sit-to-stand, rise to toes, single-limb stance, alternate stair touching, and standing arm raise

What is the motor system responsible for during balance?

Generating and coordinating forces that effectively control the body's position in space

What types of stance require motor control?

Quiet stance, perturbed stance, and active stance

What influences stability during quiet stance?

Body alignment, postural muscle tone, and limits of stability

What are the three major motor strategies for recovering balance?

Ankle strategy, hip strategy, and stepping strategy

In what direction does muscle activity occur during the ankle strategy?

Distal → proximal

When is the ankle strategy typically used?

For smaller, slower perturbations while standing on a stable support surface

When is the hip strategy used?

With larger/faster perturbations or when the support surface is compliant or smaller than the feet

What direction is the hip strategy especially important for?

Mediolateral (ML) stability

What are the three major sensory systems involved in balance?

Somatosensory, visual, and vestibular systems

What structures provide somatosensory information?

Joints, muscles, ligaments, connective tissue, and skin

What are the two types of visual information?

Focal and ambient vision

What structures make up the vestibular system?

Semicircular canals and otolith organs—the utricle and saccule

What CNS structures are involved in sensory integration?

Brainstem, cerebellum, and cortex

During perturbed stance, which sensory response is fastest?

Somatosensory

During perturbed stance, which sensory response is most accurate?

Vestibular

What does the Clinical Test for Sensory Interaction in Balance assess?

Which sensory system a person relies on to maintain static standing balance

What are the six CTSIB conditions?

Condition 1 - Firm surface eyes open

2 - Firm eyes closed

3 - Firm dome/distorted

4 - Foam eyes open

5 - Foam eyes closed

6 - Foam dome/distorted

What does failure on condition 1 suggest?

Possible impairment across balance systems

What does failure on condition 2 suggest?

Somatosensory/proprioceptive impairment

What does failure on condition 3 suggest?

Somatosensory impairment or visual dependence

What does failure on condition 4 suggest?

Visual impairment

What does failure on condition 5 suggest?

Vestibular system impairment

What does failure on condition 6 suggest?

Vestibular impairment and/or visual dependence

What sensory tests are included in the BESTest sensory orientation section?

Modified CTSIB and stance on an incline

What conditions are used in the Modified CTSIB?

Firm surface with eyes open/closed, foam surface with eyes open/closed, and incline with eyes open/closed

What gait activities are included in the BESTest?

Level walking, changing gait speed, walking with horizontal head turns, pivot turns, and stepping over obstacles

What are examples of static balance tests?

Romberg, Sharpened Romberg, and 4-Stage Balance Test

What are examples of dynamic balance tests?

Functional Reach and 30-second Sit-to-Stand

What is a normal Romberg response according to the presentation?

Maintaining the position without increased sway for 30 seconds

What does increased sway with eyes open suggest?

Possible vestibular lesion

What does increased sway with eyes closed suggest?

Possible somatosensory lesion

What is the Sharpened Romberg?

Tandem stance with eyes closed

What is the Modified Romberg?

Romberg performed on a foam/compliant surface

What are the listed norms for functional reach test for adults aged 70-87?

Men: 13.16 inches

Women: 10.47 inches

What population is TUG particularly associated with?

Frail older adults with a wide variety of physical conditions

What time range is listed in the presentation for TUG?

10-30 seconds

How is Tinetti scored?

3-point ordinal scoring on 9 test items

What does a higher Tinetti score indicate?

Less disability

What are components of the Tinetti?

Rising/sitting in a chair, standing with eyes open/closed, resisting a sternum nudge, turning the neck, turning in place, and back extension

What are the three Tinetti scoring levels?

0 = unable; 1 = requires assistance; 2 = independent

What is the maximum Berg score?

56

What does a higher Berg score indicate?

Less disability

Who is FIST especially useful for?

Lower-level patients unable to tolerate other balance tests or unable to stand/ambulate without excessive assistance

How many functional activities are included?

14

What are the FIST scoring levels?

0 = dependent

1 = needs assistance

2 = UE support

3 = verbal cues/increased time

4 = independent

How many random nudges are included?

3

Where are the FIST nudges applied?

Anterior at sternum, posterior between the scapulae, and lateral at the acromion