Balance and postural control

what are the three functional components of balance

Hold a posture = postural control

2. Postural adjustments in anticipation of & during self-initiated movements

3. Postural adjustments made inresponse to an external disturbance

what is the BESTest and its components

Balance Evaluation Systems Test

Base of Support (BOS)• CoM alignment• Ankle strength and PROM• Hip/trunk lateral strength• Sit on floor → stand up

What are the 6 systems assessed by the BESTest?

Biomechanical constraints, Stability limits/verticality, Anticipatory postural adjustments, Postural responses (motor), Sensory orientation, Stability in gait.

Why was the BESTest developed?

To identify which balance system is causing the deficit, helping guide appropriate treatment.

What are examples of biomechanical constraints affecting balance?

Ankle/hip mobility, postural alignment, and LE/trunk strength.

What are stability limits? and its components

How far the body's COM can move over its BOS without losing balance.

Sitting verticality (L & R)• Sitting lateral lean (L & R)• Standing Forward FunctionalReach• Standing Lateral FunctionalReach

What is an anticipatory postural adjustment (APA)? and its components

A "readiness" or stabilization response before a voluntary movement or balance disruption.

Sit to stand• Rise to toes• Single limb stance• Alternate stair touching• Standing arm raise

What is the ankle strategy?

Restores COM stability through movement centered around the ankle joints. Muscle activity progresses distal → proximal.

When is the ankle strategy primarily used?

For small, slow perturbations on a stable support surface.

What is the hip strategy?

Uses large, rapid hip movements with antiphase ankle rotation to control COM.

When is the hip strategy used?

With larger/faster perturbations, a compliant surface, or a small BOS.

What is the stepping strategy?

Used when in-place strategies aren't enough; the person steps to bring the BOS back underneath the COM.

Easy way to remember the motor strategies?

Small → Ankle | Big → Hip | Too big → Step

What 3 sensory systems contribute to balance?

Somatosensory, visual, and vestibular.

What does the somatosensory system tell the CNS?

Position/motion of the body relative to the supporting surface and the relationship between body segments.

When is somatosensation most important?

When the supporting surface is stable.

What does vision provide for balance?

Information about the position and movement of the head relative to surrounding objects and helps with verticality.

What does the vestibular system provide?

Information about head position and movement relative to gravity and helps distinguish object motion from self-motion.

During perturbed stance, which sensory response is fastest?

Somatosensory.

During perturbed stance, which sensory system is most accurate?

Vestibular.

Why does the CNS need sensory integration?

No single sensory system provides accurate information in every situation, so the nervous system adapts which sensory information it relies on.

What does the CTSIB assess?

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

What 3 factors are manipulated during the CTSIB?

Surface, vision, and vestibular challenge.

CTSIB Conditions 1-3 vs. 4-6?

1-3 = firm surface, 4-6 = foam surface

CTSIB Conditions 1 & 4?

Eyes open

CTSIB Conditions 2 & 5?

Eyes closed

CTSIB Conditions 3 & 6?

Dome/distorted vision.

What does failure on Condition 2 suggest?

Impaired somatosensory/proprioceptive input.

What does failure on Condition 3 suggest?

Visual dependence / impaired ability to use accurate somatosensory information.

What does failure on Condition 5 suggest?

Vestibular system impairment.

What does failure on Condition 6 suggest?

Vestibular impairment + visual dependence.

What does the BESTest Stability in Gait section assess?

Dynamic balance during gait.

What are examples of Stability in Gait tests?

Changing gait speed, horizontal head turns, pivot turns, stepping over obstacles, TUG, and TUG with dual task.

if you want to look at static balance what outcome tests do you do? what about for dynamic? what about sensory manipulation? and what about functional measurement?

static Balance• Romberg, SharpenedRomberg, 4-stage balance•

Dynamic Balance• Functional reach, 30s STS

• Sensory Manipulation• CTSIB, Modified CTSIB,Modified Romberg (compliant surface)

• Functional Measures• Tinetti, Berg, TUG, DGI

What does the Functional Reach Test assess?

Limits of stability in the forward direction.

What does the TUG assess?

Basic mobility: rise from chair → walk → return → sit.

What does the Tinetti Balance test assess?

Position changes and gait maneuvers used during normal daily activities.

How is the Tinetti scored?

3-point ordinal scale on 9 test items; 16 points total, with a higher score indicating less disability.

How is the Berg Balance Scale scored?

14 items, each scored 0-4, for a maximum of 56 points. Higher score = less disability.

What is the FIST?

Function in Sitting Test—assesses sitting balance, especially for patients who cannot tolerate standing balance tests.

How is the FIST scored?

14 items, using a 0-4 scale: 0 = dependent → 4 = independent.

•16 points total with high score = less disability

components of FIST

Rising from & sitting in achair• Standing with eyes open& closed• Withstanding a nudge onthe sternum• Turning the neck• Turning in place• Back extension3 - point ordinal scale0 = unable1 = requires assistance2 = independent

components of BERG

components:• Sit to stand• Unsupported standing• Unsupported sitting• Stand to sit• Transfer - chair• Standing EC• Standing feet together• Forward reach• Object retrieval off floor• Turn to look behind• Turn 360 degrees• Alternate foot → stool• Tandem stand• SLS

Patient loses balance with a small, slow perturbation on a firm surface. Which strategy should normally be used?

Ankle strategy.

Patient experiences a large, fast perturbation. Which strategy?

Hip strategy.

Patient cannot recover with ankle or hip strategies. What should occur?

Stepping strategy.

Patient loses balance primarily when standing on foam with eyes closed. What system should you suspect?

Vestibular system.

Patient has difficulty maintaining balance when proprioceptive information is removed/altered. What system is likely impaired?

Somatosensory/proprioceptive system.

You want to determine which sensory system a patient relies on for standing balance. What test?

CTSIB.

You want to identify the specific balance system contributing to a patient's deficit. What test?

BESTest.