Therapeutic Exercise for Impaired Balance PDF

Therapeutic Exercise for Impaired Balance https://giphy.com/explore/balance  Learning Objectives Review important terminology and concepts related to balance Identify key physiologic and sensory systems that contribute to postural control Describe the movem...

Therapeutic Exercise for Impaired Balance https://giphy.com/explore/balance  Learning Objectives Review important terminology and concepts related to balance Identify key physiologic and sensory systems that contribute to postural control Describe the movement strategies required to maintain postural control Differentiate between the type of postural control Identify common causes for balance impairment  Review of Key Terminology Center of Mass Vertical projection of the center of mass to the ground; in anatomical position, slightly anterior to S2 vertebra Center of Gravity Perimeter of the contact area between the body and its support surface Point that corresponds to the center Base of Support of the total body mass and is the point of which the body is in perfect equilibrium  Postural Control (Balance) Postural Control: Control of body’s position in space for purposes of maintaining orientation and stability – Orientation: Ability to maintain alignment in relation to the environment – Stability: Ability to maintain body’s position in equilibrium either at rest (static) or in Maintaining Orientation Maintaining Stability motion (dynamic) Figure 7.2 Shumway-Cook A, Woollacott MH. Motor Control : Translating Research into Clinical Practice. Fifth edition. Wolters Kluwer; 2017.  Balance, It’s Complex! Balance is a complex process that emerges from the interactions between: T 1. Personal factors – Physiologic systems – Cognition P E – Psychological factors 2. Environmental factors 3. Task demands Figure 7.4 Shumway-Cook A, Woollacott MH. Motor Control : Translating Research into Clinical Practice. Fifth edition. Wolters Kluwer; 2017.  Primary Physiologic Systems Neurologic – Takes input from different sensory systems, interprets it, and creates a motor strategy Musculoskeletal – Posture, range of motion, muscle performance Cardiovascular – Sends blood to the brain Figure 8.2. Kisner C, Borstad J, Colby LA. Therapeutic Exercise : Foundations and Techniques. Eighth edition. F.A. Davis Company; 2023. Sensory Contributions to Balance Visual Somatosensory Vestibular Sensory Organization/Integration Visual The ability to integrate and Vestib -ular process various sensory Soma inputs to produce the sense tosen of orientation and sory movement Sense of Orientation & Movement  Motor Strategies for Balance Fixed: keep the same BOS Change-in-support: – Ankle change the BOS – Hip – Stepping – Weight shift (lateral) – Reaching – Suspension Combined strategies  Fixed Support Strategies Ankle Hip Weight Shift (Lateral) Suspension Shumway-Cook A, Woollacott MH. Motor Control : Translating Research into Clinical Practice. Fifth edition. Wolters Kluwer; 2017. Change-in-Support Strategies Stepping Reaching Shumway-Cook A, Woollacott MH. Motor Control : Translating Research into Clinical Practice. Fifth edition. Wolters Kluwer; 2017.  Types of Postural Control 1. Steady State: – Ability to control COM relative to BOS in predictable and non-changing conditions Stable body, stable surface (static) Static Stable body, moving surface (dynamic) Moving body, stable surface (dynamic) – Examples: Dynamic Sitting on a bench (static) Dynamic Sitting on a therapy ball (dynamic) Walking on firm, flat surface  Types of Postural Control 2. Reactive: 3. Anticipatory: – Ability to recover a stable – Ability to activate muscles in position after an unexpected the legs and trunk for balance perturbation before a potentially – Examples: destabilizing voluntary Tripping on an object movements Standing on the metro – Examples: (accelerates/decelerates Kicking or passing a ball quickly) Reaching for objects on high shelves Picking object off the floor  Knowledge Check: Types of Postural Control Stance on Wobble Boards Unexpected Single Leg Stance Reaching For Object Perturbations (nudges) Kisner C, Borstad J, Colby LA. Therapeutic Exercise : Foundations and Techniques. Eighth edition. F.A. Davis Company; 2023.  Environmental Considerations Environment Lighting – Closed: Predictable with no – Day vs. Night distractions – Vision loss – Open: Unpredictable with Footwear distractions – Supportive (sneakers) vs. – Hazards: Stairs without Unsupportive (high heels, loose handrails, throw rugs, objects slippers, socks without grip) on ground Support surface – Stable vs. Unstable – Firm vs. Compliant – Narrow vs. Wide  Causes of Balance Impairment Sensory input Biomechanical and motor – Vision: changes in acuity, contrast, output peripheral field, depth perception – Poor posture – Somatosensation: peripheral – Joint range of motion restrictions neuropathies, aging, ligamentous – Muscle performance deficits injuries (e.g. ACL, ankle sprain) (e.g. weakness, poor – Vestibular: viral infections, TBI, coordination) – Pain aging Medications Sensorimotor integration – Polypharmacy: taking >4 – Reliance on medications vision/somatosensation – Side effects: hypnotics, – Damage to central nervous sedatives, tranquilizers, system antihypertensives, diuretics  Selecting Balance Interventions Treatment is very individualized and will be based on the patient’s goals and impairments Consider the following:  Type of balance task: steady state, anticipatory, reactive, sensory organization  Determine level of difficulty Challenging, but doable Think of potential ways to progress/regress  Dosage: repetitions or time  Always maintain safety Modifications to Balance Interventions Identify an appropriate Progressions and Regressions: challenge: – Base of support – If patient is always – Use of hands/upper successful, it’s too easy extremities – If patient is never – Type of surface successful, it’s too hard – Use of vision See Lab Handout  Maintaining Safety Always use a gait belt Guard where your patient is most likely to fall Setup your environment – Stable surface nearby – Away from sharp edges/object – Level of distraction Check for safe footwear – Supportive sneakers, grippy socks Applies to clinic and home exercise program interventions  Summary Postural control (balance) involves complex interactions between the person, task, and environment There are several physiologic systems that contribute to balance, including the nervous, musculoskeletal, and cardiovascular systems There are several types of fixed and change-in-support motor strategies utilized to maintain balance There are three types of postural control - steady-state, anticipatory, and reactive – used to maintain stability while accomplishing various tasks Determining an appropriate balance intervention depends on the patient's goals, the type of postural control affected, level of difficulty, dosage, and the PT’s ability to maintain safety  Reference and Reading Overview Kisner, Carolyn, et al. Therapeutic Exercise: Foundations and Techniques, 8e. Available from: FADavis, (8th Edition). F. A. Davis Company, 2022. – Chapter 8: Exercise for Impaired Balance (pgs. 271-288)  Knowledge Check: Types of Postural Control Stance on Wobble Boards Unexpected Single Leg Stance Reaching For Object Perturbations Steady-State (nudges) Steady-State Reactive Anticipatory (dynamic) (static) Kisner C, Borstad J, Colby LA. Therapeutic Exercise : Foundations and Techniques. Eighth edition. F.A. Davis Company; 2023.