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Examination of Coordination, Balance & Function PowerPoint
Terms in this set (76)
What does Postural Control involve?
maintained orientation of the relative positions of body parts with respect to each other and gravity
What is Balance
condition in which all the forces acting on the body are balanced such that the center of mass (COM) is within the stability limits, the boundaries of the base of support (BOS).
How does Reactive Postural Control occur
in response to external forces acting on the body (e.g., perturbations) displacing the COM
moving the BOS (e.g., moveable platform, therapy ball).
How does Proactive psotural control occur?
in anticipation of internally generated, destabilizing forces imposed on the body's own movements (e.g., catching a weighted ball).
aka Anticipatory Postural Control
What does adaptive postural control do?
allows the individual to modify postural responses to changing task and environmental demands.
What does Balance emerge from
A complex interaction of
(1) sensory systems responsible for the detection of body position and motion
(2) motor systems responsible for organization and execution of motor synergies
(3) higher-level CNS processes responsible for integration and action plans
An examination of " " requires all 3
What makes up the sensory systems
Vision, Somatosensory, and Vestibular
important source of information for the ability to perceive movements and detect the relative orientation of body segments and orientation of the body in space
include the cutaneous and pressure sensations from the body segments in contact with the support surface (e.g., the feet in standing, the buttocks, thighs, and feet in sitting) and muscle and joint proprioception throughout the body.
An important source of information for postural control and balance. The semicircular canals (SCCs) detect angular acceleration and deceleration forces acting on the head, whereas the otolith organs detect linear acceleration and orientation of the head with reference to gravity
standing with a stable support surface and surroundings
standing during a brief displacement of the support surface (moving surface) or displacement of the COM over BOS (perturbation).
When does the CNS place a greater weight on the somatosensory inputs?
During the Quiet Stance
When are somatosensory inputs activated quicker and provide much of the early restabilizing control?
During an unexpected perturbation
What contributes to later components of the postural restabilizing response?
vision and vestibular inputs with slower processing speeds
What is the Romberg Test?
is one of the oldest tests to assess sensorimotor control and was developed to diagnose TABES DORSALIS
the patient is instructed to stand with feet together (touching each other), eyes open (EO), unaided for 20 to 30 seconds. If the patient demonstrates significant sway or instability with EO, the test is over. The patient is then asked to stand with eyes closed (EC). The test is negative if the patient is stable and well balanced with either EO or EC. The test is positive if the patient is able to stand with EO but demonstrates significant instability (significant postural sway or loss of balance) with EC. During testing, it is important to tell the patient you are prepared to catch him or her in the event of a fall. The patient should not be given any clues to help orient and stabilize posture.
What is the Sharpened Romberg Test
the feet are placed in tandem (heel-to-toe position) and the EO to EC conditions imposed.
Individuals who are older or obese may have increased difficulty with the sharpened Romberg test
What is the Sensory Organization Test (SOT)?
based on the work of Nashner and is used to assess the sensory contributions to postural control and balance
It examines BODY SWAY during quiet standing under six different sensory test conditions (Fig. 6.9). Dynamic posturography equipment is used to provide a moving platform that introduces mechanical perturbations (sliding or tilting movements). A moving visual surround screen is sway referenced and introduces visual conflict.
The patient is asked to maintain each position for 20 seconds; three trials are used for each condition.
What is the Clinical Test of Sensory Interaction and Balance (CTSIB) or "Foam & Dome:
The cheaper SOT Test
low-tech version of the SOT developed by Shumway-Cook and Horak. It utilizes medium-density foam to substitute for a moving platform and a visual conflict dome affixed to the subject's head to substitute for a moving visual surrounding. Six sensory conditions are tested, similar to the SOT
What are the 6 conditions of the SOT
1)Normal vision, fixed support
2)Absent vision, fixed support
3)Sway-referenced vision, fixed support
4)Normal vision, sway-referenced support
5)Absent vision, sway-referenced support
6)Sway-referenced vision and support
SOT Condition 1: Eyes Open, Stable Surface (EOSS)
All Sensory systems available, unaltered (baseline condition)
SOT Condition 2: Eyes Closed, Stable Surface (ECSS)
SOT Condition 3: Visual Conflict, Stable Surface (VCSS)
SOT Condition 4: Eyes Open, Moving Surface (EOMS)
SOT Condition 5 Eyes Closed, Moving Surface (ECMS)
SOT Condition 6 Visual Conflict, Moving Surface (VCMS) Sensory Input?
What type of patients will demonstrate instability in conditions 2, 3, 5, and 6 (EC or visual conflict)
Patients who are Visually Dependent
What type of patients will demonstrate instability in conditions 4, 5, and 6 (standing on a moving platform [SOT] or foam [CTSIB])?
Patients who are surface/somatosensory dependent
What type of patients will demonstrate instability in conditions 5 and 6 (inability to rely on vision or somatosensory inputs)?
Patients with vestibular dysfunction
What type of patient will have abnormal findings in condition 3 through 6
Patients who demonstrate sensory selection problems
What are the fixed support strategies
to those movement strategies used to control the COM over a fixed BOS (in-place strategies)
The ankle strategy
The hip strategy
What is the ankle strategy
In standing, involves shifting the COM forward and back by moving the body (legs and trunk) as a relatively fixed pendulum about the ankle joints (Fig. 6.10). Muscles are activated in a distal-to-proximal sequence.
What is the hip strategy
involves shifts in the COM by flexing or extending at the hips. It has a proximal pattern of muscle activation before distal activation.
What are the change-in-support strategies
defined as movements of the lower or upper limbs to make a new contact with the support surface
Reach or grasp/reaching movements
What is the stepping strategy
realigns the BOS under the COM by using rapid steps or hops in the direction of the displacing force; for example, forward or backward steps
What is the reach-or-grasp strategy
Change-in-support movements of the upper limbs, can also assist in stabilizing the COM over the BOS and serve as a protective function in absorbing impact and protecting the head in a fall event
What assists in extending the BOS and stabilizing posture?
Where is the BOS in sitting
comprised of the thighs and buttocks and the feet if in contact with the support surface
What does postural strategies in sitting to maintain balance include?
Movement of the trunk about the hips
What was the Berg Balance Scale initially developed for
Used for a SPECIFIC population
For the use with patients with stroke
What was the Tinetti Performance Oriented Mobility Assessment (POMA) developed for
A more GENERALIZED purpose
developed to examine the frail elderly, especially nursing home residents, with a propensity to fall
What is the Berg Balance Scale
objective measure of static and dynamic balance abilities in sitting, sit-to-stand, and standing. There are six static balance items and eight dynamic balance items, with the first six items considered a measure of basic balance ability
What is the Tinetti Performance-Oriented Mobility Assessment
provides a measure of both static and dynamic balance. It was developed for use with the frail elderly, especially nursing home residents with a propensity to fall. Items are organized into two subtests of BALANCE and GAIT.
What is the Functional Reach Test (FRT)
A single-item test. provide a quick screen of balance problems in older adults. It has been shown a marker of physical frailty.
What is Functional Reach
the maximal distance one can reach forward beyond arm's length while maintaining a fixed BOS in the standing position.
What is the Multidirectional Reach Test (MDFRT)
evolved from the earlier FRT and measures how far an individual can reach in the forward, backward, and lateral directions
What is the Timed Up and Go Test (TUG)
To improve objectivity and reliability
Timing with a stopwatch begins when the patient is instructed with "go" and ends when the patient returns to the start position seated in the chair (walks up to 10ft/3m).
How long does it take healthy adults to complete a TUG?
Less than 10 seconds
What is the average score of older adults (Ages 60 to 80) for the TUG
Average score of less than 10 (mean of 8)
What is the scores considered typical for frail elderly or individuals with a mild disability performing a TUG?
What score for a TUG is indicative of impaired mobility and high fall risk?
Scores over 30 seconds
What is the Balance Evaluation System Test (BESTest)
comprehensive assessment of postural control and balance. It includes 36 items that examine six subsystem categories of postural control: biomechanical constraints (5 items), stability limits/verticality (3 items), transitions/anticipatory postural responses (5 items), reactive postural responses (5 items), sensory orientation (2 items), and stability in gait (7 items).
What is The Dynamic Gait Index (DGI)
examines a patient's ability to perform steady state walking and variations on command. Items include changing speed, walk with head turns (look right or left, look up or down), walk and pivot turn, walk while stepping over or around obstacles, and stair climbing (up and down).
What is the walking while talking test
dual-task measure that can be used to determine the effects of divided attention by introducing a secondary task, talking while walking
The patient walks at a self-selected comfortable speed for a distance of 20 ft (6 m), turns, and returns (total distance of 40 ft [12 m]). Cognitive tasks are superimposed on the motor activity. The patient is asked to recite the alphabet (WWT-simple) or recite every other letter (WWT-complex). The time required to complete the test is recorded.
What is the Function in Sitting Test (FIST)
a 14-item test that examines a person's ability to maintain sitting balance during static sitting (hands in lap) with eyes open and eyes closed, as well as during dynamic challenges to balance. Reactive challenges include nudges (anterior, posterior, and lateral). Anticipatory challenges include moving the head side to side, lifting the foot, turning and picking an object up from behind, performing a forward and lateral reach, picking up an object from the floor, and scooting (anterior, posterior, and lateral).
What are the Performance Based Measures
Berg Balance Scale
Tinetti Performance-Oriented Mobility Assessment
Functional Reach Test
Timed Up and Go Test
Balance Evaluation Systems Test
Dynamic Gait Index
Walking While Talking Test
Function in Sitting
What are the Self-Report Measures?
Activities-Specific Balance Confidence Scale
Tinetti Falls Efficacy Scale
What is the Tinetti Falls Efficacy Scale
self-report measure that examines how confident an individual feels to perform 10 activities of daily living (ADL) without falling
What is the Activities-Specific Balance Confidence Scale
16-item self-report measure that asks individuals to rate their overall level of self-confidence in performing both household and community activities.
What is the ultimate objective of any rehabilitation program?
return the individual to a lifestyle that is as close to their previous level of function as possible or, alternatively, to maximize the current potential for function and maintain it.
WHat is functional testing/assessment used for?
Used to measure how a person does certain tasks or fulfills certain roles in the various dimensions described by the ICF (International Classification of Functioning, Disability, and Health) model
What are the types of instruments used to examine function
What are the response formats
Visual analog scales attempt to represent measurement quantities in terms of a straight line placed horizontally or vertically on paper
A few tests use descriptive scales that describe a range of performance or the degree to which a person can perform the task. Most commonly, the scales are ordinal or rank-order scales; for example, "no difficulty," "some difficulty," or "unable to do"; or "always," "sometimes," "rarely," or "never."
One of the simplest formats in functional tests uses a nominal level of measurement by presenting a checklist of various functional tasks on which the patient is simply scored as able to do/not able to do, independent/dependent, completed/incomplete, or the like.
What is used the determine the quality of instruments?
Reliability, Validity, and Responsiveness
What is reliability
measures a phenomenon dependably, time after time, accurately, predictably, and without variation. If a functional test is not " ", the patient's initial baseline status or the true effect of treatment can be concealed. An instrument with acceptable test-retest " " is stable and will not indicate change when none has occurred. Should have both intrarater and interrater " "
What is intrarater reliability
Tests performed by the same therapist of the same performance should be highly correlated
What is interrater reliability
agreement among multiple observers of the same event.
What is validity
Attempts to determine (1) whether an instrument designed to measure function truly does just that, (2) what the appropriate applications of the instrument are, and (3) how the data should be interpreted
What is sensitivity?
proportion of individuals with a limitation in function (as identified by the gold standard or existing instrument) who are correctly classified.
indication of how well a test identifies persons who should have a positive finding on the test
proportion of individuals who do not have a limitation in function who are correctly classified
What is Responsiveness
A meaningful change in a patient's status.
The change should exceed the minimal detectable change (MDC) of the instrument and a minimal clinical important difference (MCID).
What is Minimal Detectable Change (MDC)?
smallest amount of change in a measurement that exceeds the measurement error of the instrument
What is important to remember for the consideration in selection of instruments?
No instrument can measure all the items potentially relevant to a particular individual and provide the perfect composite picture
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