CF1 Exam 3 study guide (2).docx

CF 1 Fall 2023 Exam #3 Study Guide Week 10: Balance Assessment and Equipment Balance definition Condition where all forces acting on the body are balanced. Center of mass is within limits of stability (ie boundaries of base of support) Balance strategies (ankle, hip, stepping) Ankle strategy S...

CF 1 Fall 2023 Exam #3 Study Guide Week 10: Balance Assessment and Equipment Balance definition Condition where all forces acting on the body are balanced. Center of mass is within limits of stability (ie boundaries of base of support) Balance strategies (ankle, hip, stepping) Ankle strategy Shifts COG forward & back by moving body as a relatively fixed pendulum about the ankle joints Muscles activated distal to proximal Plantar flexors contract as weight shifts forward Dorsiflexors contract as weight shifts backward Commonly used: disturbances small & well within LOS Hip strategy Shifts COG by flexing or extending hips Recruited with faster & larger muscles What muscles are used? Abdominals, then quads, paraspinals, then hamstrings Change in support Upper or lower limbs make new contact with surface Occur with large & rapid disturbances Stepping or hopping grasping Three Systems involved in balance Sensory Detection of body position, motion, & external forces Visual proprioception Focal vision (cognitive/explicit vision): Localize features in environment & our conscious reaction to visual events Requires visual acuity Ambient vision Uses entire visual field Provides information about environment & guide movements using mostly unconscious awareness Requires adequate peripheral vision Clinical application: Visual agnosia= unable to recognize common object, but can use ambient visual system to reach & grab object Agnosia is the ability to recognize familiar objects or stimuli Optic ataxia= can recognize object (focal vision) but cannot use information to accurately guide hand to the object (impaired ambient vision) Ataxia is the inability to coordinate voluntary muscular movements that is symptomatic of some central nervous system disorders and injuries and not due to muscle weakness. Benign paroxysmal positional vertigo (BPPV) Otoconia displaced into semicircular canals- diagnose with positional testing Otoconia is crystalline particles of calcium carbonate adhering to gelatinous membrane of utricle & saccule Dysequilibrium Feel off balance Produced by acute & chronic vestibular lesions Non-vestibular etiology: weakness in BLE or decreased somatosensation Somatosensory inputs Gives info on body in contact with surface via cutaneous & pressure sensation, muscle & joint proprioceptors Standing: feet Sitting: posterior thighs & buttocks Muscle & joint proprioception Ankles & hips are very important- for upright balances Info on relative orientation & movement of body in relation to support surface Vestibular system Semicircular canals (SCC): detects angular acceleration & deceleration forces acting on head (i.e change of movement) Responds to fast movements of head (endolymph) Otolith organs: responds to linear acceleration & orientation of head with reference to gravity Respond to slow head movements & position Function is to stabilize gaze during head movements & regulates postural tone and postural muscle activation Central nervous system Integration of sensory information is flexible. CNS weighs various inputs depending on circumstances Somatosensory (SS) inputs= key when platform perturbations are introduced If somatosensory inputs are impaired, vision will play a greater role. If somatosensory and vision are affected, vestibular system plays a greater role & resolves any conflict If more than one system is affected then balance problem are likely. Patients with deficits in cognition or attention also pose a fall risk. Dynamic posturography Attempts to isolate different sensory systems and increase the level of sensory conflict and postural difficulty It involves expensive equipment -neurocom’s balance master Poor man’s dynamic posturography Foam-and-dome test Musculoskeletal Execution of motor responses Postural adjustments are highly varied As simple as stretch reflexes to complex synergistic patterns of movement Terminology: Limits of Stability Maximum distance individual is able or willing to lean in any direction without loss of balance or changing BOS (circular shape). Postural Sway Normal amount of postural shifts in standing; cycling intermittently from side to side & heel to toe Large sway path= unsteady Center of Mass The point where the mass of the body is concentrated Base of Support The area beneath an object or person that includes every point of contact that the object or person makes with the supporting surface Center of gravity Where the force of gravity acts on the body Balance testing tools/techniques Balance tests of function focus on: Maintenance of posture (static balance) balance during weight shift or voluntary movements (dynamic balance) Balance responses to manual perturbations Functional mobility (gait) Static balance tasks: Double limb stance Single limb stance Tandem stance (heel-toe position) Romberg test Dynamic balance tests : Sit to stand Reaching (functional reach test & multidirectional reach test) Functional reach= measures max distance can reach forward beyond arm’s length while maintaining a fixed BOS in standing. Timed walk tests Timed up and go (TUG) Patient gets up from chair, walks 3 meters (10 ft). turns, returns to chair & sits back down. > 10 s to complete= limited physical mobility & high risk for falls > 20 s= high risk & limitation (may be considered normal for frail & disabled. Turning Step ups Combination balance tests Berg balance scale Performance based test, used to measure balance and function in older adults (> 60), post CVA, s/p hip fracture 14 common movement tasks (6 static & 8 dynamic) Score of <45 patient is at high risk for falls Score <50 patient needs fall prevention program Tinetti Predictor of falls in elderly Score 19-24 increased/moderate risk for falls Score <19 high/severe risk for falls no single balance test can adequately measure all 3 components of balance (vestibular, somatosensory, visual) Types of Postural Control Static: ability to maintain stability & orientation with COG over BOS with body at rest Dynamic: ability to maintain stability & orientation with COG over BOS while part of body are in motion Reactive postural control: moving COG or BOS in response to external forces acting on the body (perturbations) Requires sensory feedback Proactive postural control: occurs in anticipation of internally-generated destabilizing forcing on body’s own movements Requires: prior experiences; feed forward mechanisms. Adaptive postural control: appropriately modify sensory & motor systems in response to changing tasks and environmental demands Balance training Sensory-CNS integration mechanisms Take one system away & work others: Eyes closed, blindfold, distortions (Visual) Eyes closed & standing on foam (Vestibular) Foam, tilt board, ramps, carpet (Somatosensory) Motor Self initiated sways, perturbations (ankle) Tandem stance, single leg stance (SLS) (hip) Give large perturbations (stepping strategy) Postural Alignment Midline activities, weight shift, push LOS, plumb line, back against wall with yard stick, mirrors, tactile & verbal cues Function- incorporate bed mobility, transfers different surfaces Indicator for use of assistive device Amputation, injury, disease, or structural deformity Result: inability to weight bear on LE Muscular weakness and/or paralysis of BLE or trunk Poor balance Benefits of using ambulatory devices on balance Increases BOS Additional support during ambulation Large BOS- more area to shift without loss of balance Improves balance control= redistributing weight during ambulation 11: Mobility Assessment Wheelchair Fitting/measuring Proper fitting Decrease sensory awareness Limited ability to change position Decreased soft tissue (bony prominences) Impaired periphery; circulation in BLE Abnormal skin integrity Extended use of wheelchair Types of wheelchairs Standard adult Heavy-duty adult Intermediate or junior Growing Child or youth Indoor Hemiplegic Amputee One-hand drive Externally powered Sports reclining Components/parts Includes: seat, seat back, foot supports & other devices needed to maintain postural alignment including head support, lateral support for trunk, hips, and knees, medial support for the knees, foot supports, & UE support surfaces Selection for patient needs Considerations for wheelchair type & components Impairments & functional ability Patients age, size, stature & weight Expected use (indoors, outdoors, recreation, transfer needs, ability to transport chair) Temporary (ST) vs permanent (LT) use Potential for change in patients condition, especially affecting mobility Mental & physical condition or capacity of patient Portability Cosmetic features Options available cost Seating strategies and problems Goals of a seating system Postural support Optimal soft tissue loading by pressure redistribution Optimal comfort Facilitate distal extremity function by providing a stable base Permit optimal access to mobility components Optimize interface and function with environment for maximal independence Teaching patient to propel and manage obstacles Persons in w/c must learn: Operate locking mechanism Remove / replace arm rests Swing away, remove & replace front rigging Raise & lower footplates Need to practice & do return demonstration Learn maneuvering Elevators Up curbs facing forward facing backward Down curbs facing backward: better control Steep ramps safer to come down backward, go up forward Advanced skills Wheelies Open/close doors (away and toward) Uneven surfaces (gravel, dirt roads, etc.) In and out of car High carpet Week 12: Gait and Assistive Devices Types of assistive devices (specific crutches, canes walkers etc) Selecting for patient needs (such as weigh bearing status, balance etc) More severe patients 4-point gait patterns Bilateral ambulation aids Choosing devices based on mobility vs. stability Use of AD is based on PT assessment Weight bearing status Diagnosis Mental & physical abilities Expected ambulation Key factors in the PT assessment: Muscle strength ROM Balance & coordination Endurance Least stable to most stable ADs Single tip cane, quad cane, forearm (lofstrand) crutches, axillary crutches, walker, parallel bars, wheelchair Least coordination to most coordination Wheelchair, parallel bars, walker, cane, crutches Guarding techniques for different devices and surfaces Safety precautions before walking the patient: Check equipment Lock wheelchair Check safety belt Shoes Remove leg rests Clear obstacles Assess physiologic condition Sit to stand with crutches When using crutches, pt places both crutches on involved side and pushes up from the chair & the hand grip surface of crutches, the patient places one crutch under the noninvolved side, then the involved side Sit to stand with Walkers guard pt from side with gait belt and other hand on ipsilateral, anterior shoulder. Pt pushes from arm rests to stand maintaining WB status at all times. Then grasps AD. If pt insists on pushing with ONE hand on the walker and the other from arm rest, make certain they are pushing DOWN onto the walker in the center bar and not on the side (would tilt it over) PT’s position guarding during ambulation w/AD Depends on patient’s balance & skill with AD (SBA, CGA, Mod A) PT’s positioning guarding on level surfaces PT stands in stride w/ pt, slightly off to one side, grasp gait belt in supination, other hand over pt’s shoulder (not arm) in close guarding at first & later contact guarding so that one hand is only on gait belt in back How to react if a patient begins to fall? 1. maintaining patient in upright & pulling patient into the patients BOS 2. permitting controlled lowering to floor to prevent injury What side should the PT stand on? Initially guard on the uninvolved side pts push away from involved side to protect it & if LOB occurs, PT can pull pt into PT’s BOS onto Uninvolved side to protect limited WB side; however either side acceptable Ascending stairs up with the good noninvolved LE first, involved and AD follow Descending stairs Down with the bad AD down first, followed by involved LE, then noninvolved LE Where should the PT stand when guarding a patient on stairs? Therapist stands on the down side of training, patient rarely falls up Gait belt Use the gait belt with snug fit Hold the gait belt with forearm supination= stronger grip One hand on gait belt, other on patients shoulder (on side therapist is standing) Holding patients clothing is not safe & does not provide enough support during guarding. Pre-ambulation functional activities Goal: independent & safe performance of functional activities Requirements vary= depend on goals, needs, etc Functional Activities to prepare a patient for: Stairs, curbs, inclines, ramps, doors Transfers off/on various surfaces Gait over all surfaces Fall & get up from ground Using public facilities Precautions for pre-ambulation functional activities Check w/c parts for loose fit, wear or damage Assure spring adjustment buttons securely positioned Wet surfaces – cause slips & slides Loose objects Waxed floors Sidewalks cracked or iced Pre-ambulation exercise To strengthen specific muscles used in ambulation, often crutches What are the major UE muscles used during gait with an AD? support body weight and propel body: Scapular stabilizers Shld depressors, flexors & extensors Elbow flexors & extensors Finger flexors What are the major LE muscles to support the LE during stance? help to support body weight: Hip extensors & abductors Knee flexors & extensors Ankle plantar flexors What are the major LE muscles to elevate the leg and provide momentum? Hip flexors Knee flexors Ankle dorsiflexors Weight bearing status (abbreviations) and when each may apply WB: weight bearing Amount of weight that can be borne on LE during standing or ambulation Status depends on pathology, impairment, & medical management. NWB: non-weight bearing Involved LE does NOT bear any weight & usually does not touch ground TTWB: Toe touch weight bearing Patient can rest foot of involved LE but NOT put weight (i.e. touch ground with toe only) PWB: partial weight bearing Pt can put limited amount of weight (about 5 lbs) on involved LE; If specific amount not specified, put only minimal until told otherwise. WBAT: weight bearing as tolerated Patient determines amount of weight he/she can bear on involved lower extremity Can vary from minimal to full FWB: full weight bearing Patient can put full weight on involved LE Can still use AD for balance Parameters/components of the gait cycle Gait cycle is a complex interaction and coordination of major joints of body, particularly the lower extremities. Normal gait cycle begins When heel of one leg contacts the supporting surface & ends when the heel of same LE contacts ground again If the heel is not the part to first hit the ground? The cycle is considered to begin when some other portion of the lower extremity contacts (initial contact) the ground, and ends when the same portion hits the ground again. What are the phases of gait? Stance and swing Stance phase= the lower extremity is in contact with the ground, is about 60% of gait cycle Swing phase= foot is not touching the ground, is about 40% of the gait cycle Double support phase 2 intervals of gait- both feet in contact with the floor Stride= 2 steps ( R& L) comprise a stride Stride is a gait cycle Step length Distance from heel strike to one of LE to heel strike of opposite LE Gait pattern A selected sequence of movements for BLE & ambulatory device(s) 2-point 3-point 4-point Step-to (swing to) Step-through (swing through) Choice of gait pattern depends on: Medical condition Strength ROM Balance Weight bearing status Coordination Energy level Biomechanics of gait Types of assistive devices: Wheelchair Fitting/measuring Advantages/disadvantages for each device Walker Fitting/measuring Pt stands upright with shoulders relaxed within walker with crossbar in front. With arms relaxed at side =hand grips of walker should be at level of ulnar styloid processes When pt grasps handgrips, elbow should be ~20 º -30º flexed Handgrip of walker – at level of ulnar styloid process Advantages/disadvantages for each device Disadvantages Difficult to store/transport Difficult on stairs Decreased speed of ambulation May be difficult to perform normal ambulation gait patterns Difficult in crowded or narrow rooms or areas Axillary crutches Fitting/measuring Patient erect; shoulders relaxed Crutch tip 6” up & 45º angle out from small toe Elbow 20-25º flexion holding handgrip Hand piece at level of ulnar styloid process 2-3 fingers space between top of crutch & axilla With patient in crutches, wrist should be in a neutral position during grip. Advantages/disadvantages for each device Disadvantages: Potential for injury to axillary vessels & nerves Less stable than walker Require good standing balance Elderly patients may feel insecure With some gait patterns the patient needs functional strength of both upper extremities and trunk Advantage: Provide greater selection of gait patterns & ambulation speeds Forearm (Lofstrand ) crutches Fitting/measuring Patient erect; shoulders relaxed Crutch tip 6” up and 45º angle out from small toe Elbow 20-25º flexion holding handgrip Hand piece - level ulnar styloid process Cuff height - adjusted to as high as possible on forearm without interfering with elbow flexion Cuff width - tight enough to stay on arm, but loose enough to not bind Advantages/disadvantages for each device Advantages: Adjustable tops & bottoms More durable Good for a long term user Forearm cuff Frees hands for movement ( like opening a door) Allows for use of hands without loss of crutch More mobile in tight spaces Disadvantages Expensive Require more stability & trunk support Cuff makes it more difficult to remove crutch Used: When hand or forearm impaired (ie fracture or rheumatoid arthritis) Platform crutches Combines platform (for forearms) & standard axillary crutch Used When hand or forearm impaired (ie fracture or rheumatoid arthritis) Patients with inability to bear weight through hands & wrists Below- elbow amputation Unable to extend one or both elbows Can be attached to walker, axillary, or forearm crutch Disadvantages: Loss of triceps (elevate body during swing phase) May need assistance to don/doff More difficult on stairs Quad cane Fitting/measuring Pt stands - shoulders relaxed Handgrip at level of ulnar styloid process Cane positioned upright with tip alongside small toe Top of cane should be at level of ulnar styloid process When properly fitted, elbow should be flexed ~20º-30º (force of cane should be directed straight downward) Advantages/disadvantages for each device Advantages Stable base Does not fall over when let go Disadvantages Troublesome if patient cannot maintain full base contact Single Tip cane Fitting/measuring Pt stands - shoulders relaxed Handgrip at level of ulnar styloid process Cane positioned upright with tip alongside small toe Top of cane should be at level of ulnar styloid process When properly fitted, elbow should be flexed ~20º-30º (force of cane should be directed straight downward) Advantages/disadvantages for each device Advantages More functional with stairs and confined areas Use with: Minor balance problems & if need only minimal support Different Gait Patterns 2-point gait pattern Used with 2 assistive devices (A.D.) Use: 2 crutches, 2 canes Simultaneous, reciprocal forward placement of aid & patient’s lower extremity. R crutch & L foot then L crutch and R foot Each combination of AD & LE= 1 point. A complete cycle is 2-points Stable pattern> rapid & less stable than 4- point pattern Low energy & similar to normal gait pattern Use this pattern with Patients with impairments including muscle weakness, pain or poor balance. Requires coordination. 2-point modified gait pattern Using 1 AD (cane or crutch) Aid held by UE opposite the involved side Advance cane and involved LE together & then the uninvolved LE When to use modified 2-point gait pattern? Patient with only 1 functional UE 3-point gait pattern Used for: Patients with impairments of one LE, such as a fracture, muscle weakness, pain or injury/surgery requiring less weight bearing Pattern uses: 2 crutches, 2 canes or a walker With walker= walker is moved forward as a unit, equivalent to moving 2 crutches or 2 canes. With crutches= both crutches move forward simultaneously, placed on floor, then involved LE moves forward up to crutch tips, uninvolved LE moves forward past crutches. Cycle of 3 points can be progressed to a 2-point pattern 3-point NWB gait pattern Cannot use bilateral canes Requires= good strength with both UE, trunk and one lower extremity. High energy expenditure Emphasize step through rather than swing through 3-point PWB gait pattern This pattern uses: bilateral aids or walker. Full weight bearing on one LE & PWB on other LE Sequence: Aid/walker advances simultaneously with affected LE- then FWB LE moves Benefit of this pattern: More stable than 3-point NWB but slower Requires less energy & less strength than 3-point NWB 4-point gait pattern Used for more severe impairments Use bilateral ambulation aids: 2 crutches, 2 canes, reciprocal walker Ex: R crutch, L foot, L crutch, R foot Stable pattern Low energy expenditure Best in crowded areas; slow Step-to gait pattern Requires use of 2 crutches or walker Used for: Patients with LE impairments (muscle weakness, paresis, paralysis, or decreased WB on one LE) When using crutches, advance 2 crutches simultaneously= place on floor= BLE move forward together up to crutch tips= then start over 2 part cycle: BLE swing through Step-through gait pattern Gait Cycle ??