balance tests + prescription of exercises

How ageing affects balance + why 

Deterioration of individual sensory/ cognitive/ motor control affects steady state/ anticipatory/ reactive control 

Effects of age on postural stability: 

1. Time to overbalance ↓ in tandem + single leg stance in older adult 

2. Balance deteriorates in the 60s when EO foam/ EO SLS

3. Balance deteriorates in 40s when EC foam/ EC SLS 

Why: 

1. COP + COM motion increases with age ( area + distance + velocity of movement increases but frequency decreases ) 

2. Motion in AP > ML 

3. Balance more visually dependent in old age

Effect of age related somatosensory pathology on balance + training 

Effect on quiet stance	Functional mvt	Effect on reactive balance	Pathology
Increased postural sway/ COP excursion esp on foam/ EC	More errors	Slower/ less accurate/ overshoot more	LL osteoarthritis → decrease joint position sense  → increase COP excursion  Cervical spine pathology → neck pain/ whiplash → ↓ quiet stance time

Training: 

• Training: quiet stance in compliant surfaces w/ EC 

• Wear firm soled shoes

Effect of age related vision deterioration on balance + training

Effect on quiet stance	Effect on functional mvt	Effect on reactive balance
Increased sway → greater reliance on somatosensors	More cautious + erroneous + falls	/

Training: → raise awareness about fall risks 

→ practise at-risk situations 

→ train somatosensory challenges safely 

Effect of age related vestibular deterioration on balance 

Effect on quiet stance	Effect on functional mvt	Effect on reactive balance
Increased sway → w/ sensory conflicts	Overbalance during gait w/ head turns → dizziness	Slowed detection of head movement

Effect of age related deterioration of  cognitive function on balance 

Effect on quiet stance	Effect on functional mvt	Effect on reactive balance
Reduced ability to multi-task when one is a postural task  Worse w/ more challenging balance + age  Restricted mvt due to fear of falling		Slower to react to postural perturbations → slower choice reaction time

Effect of age related deterioration of motor function on balance

Effect on quiet stance	Effect on functional mvt	Effect on reactive balance
/	Slower mvt w/ less power	Slower responses w/ smaller amplitude bc muscle activation timing delayed + amplitude reduced

Definitions + physiological deficits affecting steady state/ anticipatory / reactive control

	Definition	Physiological deficits
Steady state	Ongoing control of body balance	Detection + processing of sensory info  Determination of COM position
Anticipatory control	Postural adjustments made in advance of voluntary movement to stabilize body	Basal ganglia  → timing/ scaling/ co-ordination of muscle activity
Reactive control	Rapid stereotypical patterns of body segment motion in response to external perturbation to reduce degrees of freedom	Timing/ co-ordination/ scaling of activity  → diff strategies for AP vs ML motion

Strategies of postural recovery for ML 

1. Most optimal: outward right step 

2. Combination step 

3. Crossover in front 

4. Crossover behind 

5. Leg lift 

→ older adults often choose strategies placing them at risk of falling + take longer time to complete the strategy 

Components + outcome measure of tests for steady state

Components	Outcome measure
Ability tested: holding position for 30s  Progressions:  Foot position:  Comfortable stance  Feet tgt  Step stance  Tandem  Single  Sensory conditions:  EO EC  Firm Foam	Amount of time w/o overbalancing  Sway direction + amount  Describe movement

Quiet stance test

Components + outcome measure of tests for anticipatory control 1 ( timed up + go )

Components	Outcome measure
Timed up + go test  Comfortable: Time how long it takes to  Stand from chair  Walk 3m  Turn + return  Sit  → comfy pace/ as quickly as safely can  → 1-3 reps → take best time  → Aids can be used but X physical assistance  Hands on lap default  If armrests used → record  → usual footwear	Speed during functionally relevant tasks that threatens balance

Components + outcome measure of tests for anticipatory control 1 ( reach test ) 

Components	Outcome measure
Functional reach / lateral reach Ruler at acromial height on wall  Start line marked on floor Feet comfy position facing parallel to wall  Close to wall but X touch it + raise arm closest to wall + hold at ruler height  Reach as far forwards w/o taking a step/ overbalancing/ rising on toes  Mark the point reached by 3rd finger tip  Return to starting position	Distance reached beyond arm’s length

Lateral reach: for ppl w/ difficulty WB to one side 

Components + outcome measure of tests for anticipatory control 1 ( step test )

Components	Outcome measure
→ tests ability to weight shift at speed —> hip issues	Number of steps w/ 1 leg on 7.5/ 15cm block in 15s

Components + outcome measure of tests for reactive control ( marsden pull 

Components	Outcome measure
→ pull to shoulders: AP  → pull at pelvis from behind : ML —> hands X touch body part before pulling	0: normal → upright w/o stepping 1: normal: 1 steps + regains own balance   2: normal: > 1 steps + regain own balance  3: abnormal: takes > 1 step + needs to be caught  4: abnormal: falls w/o stepping

Components + outcome measure of tests for reactive control ( hold + release test ) 

Components	Outcome measure
→ patient leans back into hands until CoM is outside BoS → release	Rate ability to recover balance after a perturbation/ disturbance  → same score as Marsden

Components + outcome measure of tests for sensory system manipulation

Components	Outcome measure
Sensory organisation test/ clinical test for sensory integration of balance  Diagnostic test for which sensory system most reliant on  → 6 stance conditions: 30s max  → change visual/ support condition	Conditions w/ greatest sway  → ability to resolve sensory conflict  → X sway until condition 5 if normal  Interpretation:  2: visual dependent ( X somatosensation )  3: difficulty resolving visual conflict  4: somatosensory dependent / poor use of vision  5: vestibular problems  6: difficulty resolving conflicting info

Components + outcome measure of tests for cognitive demands

Components	Outcome measure
Dual task timed up + go test  → do TUG test as quickly as safely can + repeat w/ added motor/ cognitive task  → Manual: TUG fast + hold mug of water  → Cognitive: TUG fast + count backwards x 3  Observation/ subjective findings: stop walking while talking	Dual task TUG: measure gait + added tasks ( accuracy )

Pros + cons of quiet stance test

Pros:  Quick  Easy  Able to progress  Cons:  30s ceiling  Subjective observation of sway Instrumented:  Pros”  Quantification of sway  → COP  → COM  → Segment motion Accurate + sensitive to small changes  Cons:  X consensus on ideal outcome measure  Expensive  Takes time + expertise  Inertia measurement units

Pros + cons of timed up + go test

Pros: 

1. Well-used + researched 

2. Global indicator 

3. Quick 

4. Predictive 

Cons: 

1. Limited evaluative capacity 

Can be instrumented → gait speed + turning speed + stride length detected → related to disease severity

Pros of reach test + lateral test

In general: Pros:  Excellent test-retest reliability  For frail elderly < 18.5 cm → falls risk

Lateral reach test: 

Pros: 

1. Good reliability 

2. Valid compared w/ BBS + one leg stance time 

3. Quick 

4. Lateral measure 

Cons: 

1. Repeatable foot position

Pros + cans of step test

Pros: 

1. Ax of rapid weight shift 

2. Quick 

Cons: 

1. Dependent on strength + speed

Pros of hold + release test

More reliable therapist pressure + response > Marsden

Pros + cons of dural TUG

Pros:  commonly used + reliable  Quick ‘ Predictive  Cons:  X do manual w/ bilateral aid  Need to be able to do cognitive task alone

Training for steady state

Challenge at level of Ax 

Progressions: 

1. Holding for longer 

2. Reduce size of base of support 

3. Internal perturbations ( feet tgt/ step stance/ stride ) 

4. Increase proprioceptive demand

Training for anticipatory control

TUG test: 

If slow → determine which aspect is contributing to slowing 

Analyze movement

 → are all sit to stand components done → feet back + lean forwards + slow stand 

→ weak quads → strengthen 

Slow gait: steps to turn, stand-sit 

Functional reach is short: 

Why: 

1. Ability to move COM 

2. Strength 

3. Confidence/ fear 

4. Pain 

5. Flexibility 

Ax + address issues 

→ education + low resistance training 

→ agility + strength training

Training for reactive control

Voluntary stepping 

1. All directions 

2. Concentrate on single large step 

3. Increase speed, less predictable 

→ add perturbation for best results 

Add small perturbation( pull )  or via treadmill ( stop + start ) 

→ reactive control improved

Training for cognitive demands

Start w/ single task training 

Add easiest type of tasks

Switch attention bwt tasks ( keep walking quickly, unfold paper ) 

Progress w/ added task + gait 

• Gait tasks ( increasing difficulty) 

1) Transitions ( sit - stand/ stop/ start ) 

2) Speed 

3) Environmental demands 

• Cognitive task increasing difficulty 

1. Listening 

2. Monologue 

3. Conversation 

4. Generating lists 

5. Calculation 

6. Visuospatial planning tasks 

→ include functional tasks