Therapeutic Exercise Exam 3

Lectures 16, 17, 18, 19, 20

what is balance?

a complex motor control task; boundaries of the limits of stability (cone of stability)

optimal balance requires the interaction of

NS, MSK system, contextual effects

NS and balance

sensory system assesses position and motion of body in space

MSK system and balance

executes appropriate MSK responses to control body position

contextual effects and balance

provides input about the environment and the task

static balance

“holding” position, stable position at rest; maintain balance within cone of stability

dynamic balance

stable body while in motion; transition between positions

automatic postural reactions

(anticipating) maintain balance in response to unexpected perturbations

development of balance

* combination of reflexes, righting, and equilibrium reactions
* activities change our balance (requires practice everyday)

at what age does balance develop?

7-10 years old

what does the balance system involve?

1. sensory inputs
2. integration of input
3. execution of neuromuscular response

sensory inputs include

visual, vestibular, somatosensory

visual inputs

position and movement of head relative to environment

vestibular input

position and movement of head relative to gravity; semicircular canals (in inner ear) and otoliths (crystalline structures on semicircular canals)

somatosensory input

position and movement of body parts relative to each other; from muscle and joint proprioceptors

sensorimotor integration of input

interpret information and what to do about it (within CNS- cerebellum and cerebrum); dependent on environment (open or closed; support surface), experience, and level of arousal (any meds?)

execution of neuromuscular response

body’s attempt to maintain balance or response to balance disruption (reflexive and volitional responses); automatic, anticipatory, volitional

3 strategies of motor responses to maintain/recover balance

ankle, hip, and steppage

strategy to maintain/recover balance depends on:

* speed, magnitude of displacing force
* support system
* posture at time of perturbation
* prior experience

ankle strategy

most common when perturbation is small; muscle activation is distal to proximal; needs ankle strength and mobility

hip strategy

used with larger/rapid displacements, unstable surface, presence of ankle impairment, muscle activation is proximal to distal; need good hip strength and ROM

steppage strategy

larger displacements beyond limits of stability; step forward or backward to increase BOS; BOS moves to “catch up”; used when other strategies fail

combined strategies

* most healthy individuals use combinations of strategies to maintain balance depending on the demands
* balance control requirements and movement response patterns vary depending on the task and the environment
* when treating balance impairments and disorders, it’s important to VARY both the task and the environment (so pt will develop movement strategies for different situations)

3 stages of information processing

1. sensory
2. sensorimotor integration
3. neuromuscular response

sensory processing with impaired balance

1. proprioceptive deficit (ligament injury)
2. somatosensory deficit (neuropathy)
3. decreased visual acuity (with aging)

sensorimotor integration with impaired balance

where CNS isn’t integrating input appropriately, properly, or with enough clarity


1. Parkinson Disease (PD)
2. Spinal stenosis

neuromuscular response with impaired balance

1. poor posture
2. impaired ROM or strength
3. pain
4. reaction time

impaired balance and aging

* decrease in all sensory systems and all stages of information processing
* multiple medications
* lots of evidence-based interventions

falls

major source of morbidity/mortality and nursing home placements

adults have an increased risk of falling if:

they take 4+ medications and if certain medications are antihypertensive, anti-depressants, sedatives

assessment of balance

thorough history:

* include comprehensive history of falls
* environmental conditions and activities at time of fall
* medications
* fear of falling?

environmental assessments to determine fall risk hazards in a person’s home

MSK and neuro exam assessment of balance include

* sensory input: proprioception, visual, vestibular input
* sensory processing: sensorimotor integration, anticipatory and reactive balance control
* biomechanical and motor: postural alignment, muscle strength, and endurance, joint ROM, flexibility, coordination, pain

static balance tests

single leg stance, Rhomberg/Sharpened Rhomberg, observations

Interventions to consider if deficits present

* vary postures
* vary support surface
* incorporate external loads
* observe pt maintaining different postures

dynamic balance tests

5xSTS, observations

interventions to consider if deficits present

* move head, trunk, arms, legs
* moving support surfaces
* transitional and locomotor activities
* observations of pt standing or sitting on unstable surface, performing functional activities, and/or performing postural transitions (STS, supine to sitting)

anticipatory postural control tests

functional reach test, star excursion test, observations

interventions to consider if deficits present

* reaching
* lifting
* catching, kicking
* obstacle course
* observations of pt opening doors, lifting objects of different weights, catching a ball

reactive balance tests

pull test, push and release test, observations

functional tests

berg balance scale, mini-BES test, TUG

goals of balance training interventions

* correct temporary impairment
* prevent secondary impairment
* change impairment
* teach compensatory strategies for permanent impairment
* prevent falls

safety during balance training

* use a gait belt
* stand slightly behind and to the side of the pt
* perform exercises near railing or in parallel bars
* ensure safe environment
* ensure the floors in the area of activity/exercise is clean and free of debris
* for pts at high risk of falling: have one person in front and one behind

reinforce safety for home exercises too

improving static balance control

have pt maintain sitting, half kneeling, tall kneeling, and standing postures on a firm surface

progressing static balance control

* have pt hold bar in outstretched hand and instruct them to maintain bar in horizontal position
* practice holding standing postures in 1/2 tandem, tandem positions
* SLS, lunge, squat positions- held and repeated
* narrow BOS, EO/EC, move UEs
* work on soft/less firm surface
* clinic: foam, yoga mat, floor mat
* outside: grass, gravel, sand
* provide resistance (handheld weights, TheraBand)
* add a secondary task (catch a ball, tap a target, cognitive challenge)

improving dynamic balance control

have patient practice balance control while on an unstable surface

* sitting on stability ball
* standing on foam square, wobble board, air disc
* bouncing/standing on mini trampoline

progressing dynamic balance control

progress balance control activities by superimposing other movements while maintaining dynamic balance

* shifting body weight
* rotating trunk
* moving head, UEs

example wobble board progession

1. stand on wobble board
2. maintain board in a level position
3. while maintaining the board in a level position, turn your head right and left OR alternately reach arm above head

activities for improving dynamic balance control

* practice stepping exercises: begin small, progress to large; move forward and backward
* progress exercise program to include hopping, skipping, jump roping
* have pt practice maintaining balance after: stepping down from foam square, hopping down from foam square, small stool
* have pt perform arm and leg exercises while standing: normal stance, half tandem, tandem stance, single leg

activities for anticipatory balance control

* reach in all directions to touch or grasp objects, catch/kick a ball
* use different postures for variation (sitting, standing, or kneeling)
* maneuver through an obstacle course

activities for reactive balance control

* to emphasize training of ankle strategy (activities standing on one leg)
* emphasize training of hip strategy (walk on lines on floor, balance beam; perform tandem stance or SLS with trunk bending)
* emphasize training of steppage strategy (grapevine or carioca)

fear of falling

individuals (especially the elderly) who have had one or more falls may develop a fear of falling; leads to loss of confidence to perform routine tasks

if fear of falling is unaddressed it can progress to:

* restricted activity
* social isolation
* depression
* functional decline
* decreased QOL

how to screen for fear of falling

ABC scale and FAQ

evidence for reducing risk of falling

* 2 hours/week devoted to exercises and activities to improve balance
* incorporate multiple types of exercises (balance training, strength/resistance training, constant repetitive movements through all 3 planes
* tai chi (depends on duration of program and target population- more evidence to support improvements in static balance than dynamic balance)
* time devoted to a walking program should be in addition to time spent in balance training program, rather than a substitute for it

fitness

the ability to perform whole-body activities for extended periods of time without undue fatigue; requires cardio-respiratory function, muscle strength and endurance, and muscle/joint mobility

endurance

measure of fitness; energy expenditure (VO2 max)

endurance training

(aerobic/CV training) goal is to increase energy utilization of muscles; used to train healthy clients for wellness + prevention and pts with impaired endurance

impaired CV status due to deconditioning/chronic illness

* decreased VO2 max
* decreased blood volume/flow
* decreased lean body mass
* decreased muscle strength
* increased Ca2+ excretion

ATP-PC

fuel source: phosphocreatine

max capacity: small

power output: larger

energy use: short, quick bouts

time of ex: first 30s

anaerobic glycolytic

fuel source: glycogen

max capacity: intermediate

power output: intermediate

energy use: mod intensity, short duration

time of ex: 30-90s

aerobic

fuel source: glycogen, fats, proteins

max capacity: large

power output: small

energy use: long duration

time of ex: after 2 min

acute response to aerobic training

necessary to maintain homeostasis:

* meet O2 demand
* remove waste products
* regulate temp

cardiac, respiratory, and circulatory system acute response aerobic training

* increased HR, increased systolic BP, increased CO
* increased respiratory frequency, increased tidal volume, increased gas exchange across alveoli (capillary membrane)
* increased blood flow to muscles involved
* increased excretion of O2 from blood

metabolic adaptations for long-term aerobic training

increase in:

* size and number of mitochondria
* aerobic enzymes
* rate of O2 transport
* lipid metabolism
* muscle fiber size- Type I

CV adaptations for long-term aerobic training

increase in:

* heart size
* stroke volume
* cardiac output
* oxygen extraction

decrease in:

* heart rate
* BP

other adaptations for long-term aerobic training

* body comp changes- decreased body fat
* improved cholesterol
* increased bone/ligament strength
* psychological benefits
* fibromyalgia (most benefit from it)

intensity

must overload above threshold; determined by GXT (graded exercise test), METS (metabolic equivalents), formulas (% max HR), RPE

metabolic equivalents (METS)

amount of O2 used per minute; 1 MET= 3.5 O2/kg/min

target heart rate

THR= % max HR (max HR= 220-age)

target HR for healthy + sedentary

healthy: THR > or = 70% max HR

sedentary: THR= 40-50% max HR

karvonen’s formula

(more accurate)

THR= RHR + %HR reserve

HR reserve

max HR- RHR

borg RPE scale

* RPE: 11-13= 49-70% VO2 max
* RPE: 13-15= 70-80% VO2 max
* can use this scale as an approximation of HR by adding a 0 to the number (RPE of 11= HR 110bpm)

optimal duration

* depends on total work performed, exercise intensity and frequency, and fitness level
* primarily depends on intensity (higher intensity for shorter time vs moderate intensity for longer time)
* usually 20-30 mins, minimum of 10 minute bouts

frequency for endurance training

* 3-5x/week
* AHA recommends: 30 min, mod intensity, daily
* ACSM recommends: 20-60mins, 65-90% max HR, 3-5 days/week
* may take 10-12 weeks to get adaptations

type of endurance training

any rhythmic activity that uses larger muscle groups

endurance training warm-up

10 mins, increases muscle temp, vascular dilation, increases venous return, increases O2 uptake

aerobic exercise period

overload to achieve adaptations but not evoke abnormal sx

endurance training cool down

5-10 mins; prevent pooling, assist venous return, prevent fainting, enhances recovery period

reversibility principle

detraining can occur after 1-2 weeks; need to maintain intensity but can back off with frequency or duration

abnormal responses to endurance training

* failure of HR to rise in proportion to intensity
* failure of SBP to rise >240
* decrease in SBP > 20mm/Hg during ex
* increased DBP > 15mm/Hg during ex
* labored breathing
* know meds!

signs/sx of intolerance (ACSM guidelines)

* angina
* unusual SOB
* abnormal diaphoresis
* pallor, cyanosis, cold, clammy skin
* vertigo, ataxia, confusion (CNS sx)
* leg cramps
* severe fatigue

aerobic training in children

appropriate as long as safe and enjoyable; children > 6 y.o. (30 min/day); susceptible to overuse injuries; need to balance with strengthening/flexibility

aerobic training in elderly

* 30 mins mod intensity, 7 days/week
* implement slowly for at-risk populations: lower intensity, longer duration or break up into bouts

primary aging

universal, developmental process due to passage of time

secondary aging

result of disease, disuse, environment, nutrition, injury and other factors (ex: an older adult with T2D who develops cardiac disease and peripheral neuropathies)

normal neuromuscular and MSK changes with aging

* muscle mass loss beginning in fourth decade that escalates with advancing age
* over 40: mm mass loss/year = .5%/year
* over 50: mm mass loss/year increases to 1-2%/year
* over 60: 3%/year

rate of decrease in strength and power are

greater in sedentary older adults compared to those who are physically active (combined with a decrease in the quality of the muscle tissue)

muscle weakness in older adults

* affects gait and related activities:
* ascending, descending stairs
* ADLs
* mobility around home
* overall efficiency of movement, can lead to abnormal gait

normal MSK system changes

associated with aging (osteoporosis, osteopenia, OA, etc.) are often accompanied by stiffness, pain and deformity (affects balance and can lead to greater number of falls)

normal MSK system changes + neuromuscular changes + sensory changes =

* decreased mobility
* decreased independence
* decreased socialization
* increased isolation
* decreased QOL

benefits of physical activity for older adults

* slowing physiological changes associated with aging
* supporting psychological and cognitive health
* optimizing body composition
* managing chronic disease
* decreasing risk of developing chronic disease
* minimizing risk of physical disability
* increasing lifespan

strong evidence that physical activity reduces the risk of premature death

risk of premature death declines with greater time and frequency (mins/week) of physical activity; lowers risk of stroke, HTN, T2DM, colon cancer, breast cancer, etc. (also decline in bone density can be lessened)

PREs in older adults

can increase muscle mass, strength, power, functional mobility, and performance of ADLs

high intensity or power training in older adults

greater strength adaptations compared to low or moderate intensity training; power training improves functional tasks like STS and climbing stairs

increasing skeletal mm mass in older adults (via strengthening)

skeletal mm have secondary roles of metabolism, glycogen storage, body temp regulation

exercise prescription for older adults

multidimensional program that includes:

* aerobic exercise
* resistance training
* balance training/exercises
* flexibility exercises

MSK prenatal/post-partum changes with pregnancy

* increased lumbar lordosis due to anterior shift of COG (stress on ST can lead to LBP)
* rounded shoulders due to increased breast size
* genu recurvatum and pes planus due to ligamentus laxity
* wider BOS with gait

metabolic prenatal/post-partum changes with pregnancy

* increased fluid/ retention of fluid
* CTS
* ankle swelling/edema
* weight gain
* 25-40 lbs recommended (but always changing)
* \~1 lb/week last 2 trimesters

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CV prenatal/post-partum changes with pregnancy

increased HR, dyspnea

genitourinary prenatal/post-partum changes with pregnancy

urinary frequency/incontinence due to pressure of fetus on bladder and shifting of abdominal organs as fetus grows

benefits of exercise (during/after uncomplicated pregnancy)

* improved CV and digestive function
* manage wt gain
* decreased co-morbidities: gestational DM, HTN, pre-eclampsia
* decrease in generalized discomfort: LBP, leg cramps, urinary incontinence
* can assist in managing labor pain
* increased strength/fitness: can facilitate quicker recovery post-partum
* improved mental well-being (decreased depression)

exercise during uncomplicated pregnancy

* engage in > or = 150 mins of mod intensity activoty over 3 or more days/week
* level of activity reduces the odds of developing preg complications w/out increasing odds of miscarriage, early delivery, or a small baby
* reduces odds of developing depression by 67% and reduces severity of depression sx
* increasing the amount of weekly ex concomitantly reduces odds of developing pregnancy-related complications