Clinical Management of Functional Deficits

Management of Common Functional Deficits

• Clinicians must prioritize treatment by reviewing problem lists and asking questions about impairments.
• Temporary impairments can be remediated. Clinicians should consider how much improvement is expected and how soon it will occur.
• Permanent or progressive impairments require compensation strategies. Clinicians must assess the ability of other body systems to substitute and if external compensations are needed.
• For neurological impairments, predicting whether a problem is temporary or permanent might be difficult, as demonstrated in stroke or head injury recovery.

Clinical Assessment of Balance

• A single, simple balance test is not possible due to the complex sensorimotor process.
• Several relatively simple balance tests exist, but not all are appropriate for all clients.
• Specific tests are needed to answer questions about risk factors—like falls in elderly people.
• Therapists need to understand the benefits and limitations of different balance tests to choose the right tool.
• Considering the purpose and population for a test, validity, repeatability by different examiners, reliability in different populations, performance change detection thresholds, and normative data is essential for test selection.

Types of Balance Tests

• Quiet standing (static): Quiet standing tests are categorized as static.
• Active standing (dynamic): Active standing tests are categorized as dynamic.
• Sensory manipulation: Sensory manipulation tests evaluate the client's ability in response to changing sensory environments.
• Functional balance: Functional balance is a category of balance tests. Mobility, gait, and balance scales are examples of assessments within this category.
• Combination tests: Combination tests combine elements of different types of balance tests.
• Dual-task tests: These examine balance while performing another task.

Stages of Motor Learning

• Motor learning is a complex set of internal processes for skilled behaviors that change due to practice and experience.
• Motor learning stages:
  • Cognitive: The initial phase of learning, which focuses on figuring out how to perform a skill.
  • Associative: The middle stage, where connections between movements are stronger and there is less variation.
  • Autonomous: The final stage, when the skill becomes automatic and subconscious.

Treatment Tools

• Biodex Balance System SD: Measures motion on the surface.
• Proprio Reactive Balance System: Uses motion sensors on the body at the level of the center of gravity (COG).
• SMART Balance Master: System with a 3-sided booth with unidirectional motion combined with a unidirectional movable force plate.
• Stimulopt Optokinetic Ball—is a device used to simulate movement and challenge balance.
• Biodex FreeStep SAS: Uses an overhead harness system to challenge balance during gait.
• GAITRite Portable Walkway System: Challenges gait during overground walking.
• Biodex Gait Trainer 3 with Unweighting System: Challenges balance during gait training by reducing the support.

Safety Education and Environmental Modifications

• Teach clients and families about the environments in which the client is at risk, e.g., gravel driveway at night, and unfamiliar environments.
• Teach unsafe tasks like ladder climbing or changing ceiling light bulbs and how to compensate, like using a cane or making home/workplace adjustments.

Home Program

• Strengthening, stretching, posture, and endurance exercises can be performed safely at home.
• Balance exercises can be practiced at home if safety can be ensured, however, unstable clients should always be supervised.

Concurrent Tasks

• Balance is normally subconscious.
• Practice and dual-tasking are necessary to make balance control subconscious.
• The conscious brain is focused on another task while balance is controlled subconsciously.

Fall Prevention

• The risk of falls in clients with balance deficits is often higher and should be considered in every clinical management program.
• Fall prevention is key for clients with neurological conditions and impaired balance and gait.
• The factors for falls are categorized into intrinsic and extrinsic. Intrinsic is related to the individual, and extrinsic is related to the environment.