Lecture 5-Power Point PDF Balance Rehabilitation

VI. MANAGEMENT OF COMMON FUNCTIONAL DEFICITS To direct and establish priorities for treatment, clinicians must review the problem list and ask themselves the following questions: Which impairments are temporary and can be remediated? How much improvement can be expected? How soon will it o...

VI. MANAGEMENT OF COMMON FUNCTIONAL DEFICITS To direct and establish priorities for treatment, clinicians must review the problem list and ask themselves the following questions: Which impairments are temporary and can be remediated? How much improvement can be expected? How soon will it occur? Which impairments are permanent or progressive and must be compensated for? What other body systems can be counted on to substitute? What external compensations may be needed? For some clients with neurological impairments, knowing whether a problem is permanent or temporary is not possible, as in recovery from a stroke or head injury. Which impairments are temporary and can be remediated? How much improvement can be expected? How soon will it occur? Which impairments are permanent or progressive and must be compensated for? What other body systems can be counted on to substitute? What external compensations may be needed? A clinical decision-making tree to illustrate the treatment-planning process in balance rehabilitation MANAGEMENT OF BALANCE PROBLEMS 1. CLINICAL ASSESSMENT OF BALANCE  No single, simple test for balance is possible because balance is such a complex sensorimotor process.  Many relatively simple balance tests exist, but not all tests are appropriate for all clients.  Different tests may be needed to answer specific questions. For example, several good tests have been developed to determine the risk of falls in elderly people.  Therapist should understand the advantages and limitations of different balance tests to be able to select appropriate evaluative tools. Because so many balance tests are available, several questions must be asked to determine whether a test is appropriate for use: – For what purpose and population was the test designed? – Can that test be used legitimately for a different purpose or with a different population? Is it valid? – Is it repeatable by different examiners or by the same examiner multiple times? – Are results reliable? In what populations are they reliable? – What is the threshold for this test—that is, how large must performance changes be before this test can detect them? – Are normative data available for comparison?  Types of balance test Functional Quiet Active Sensory balance, Combination Dual-task standing standing manipulation mobility, and tests tests (static) (dynamic) gait scales TYPE TESTS Quiet standing Romberg Postural sway (Figure 2 and Figure 3) (with or without perturbation) Sharpened Romberg or tandem Romberg Nudge or push One-legged stance test (OLST) Postural Stress Test Timed stance battery Motor Control Test (Figure 4) Active standing Functional Reach Test Multi-Directional Reach Test Limits of stability (Figure 5) Sensory manipulation Sensory Organization Test (SOT) (Figure 7) Clinical Test of Sensory Interaction and Balance (CTSIB) (Figure 6) Vestibular Vertiginous positions Visual acuity Hallpike-Dix maneuver Oculomotor tests Nystagmus Fukuda Stepping Test Semicircular canal function Dizziness Handicap Inventory Visual-vestibular interaction Functional scales Timed Up-and-Go Test Dynamic Gait Index Tinetti Performance-Oriented Assessment of Balance Functional Gait Assessment Tinetti Performance-Oriented Assessment of Gait Gait Assessment Rating Scale (GARS) Combination test Fregly-Graybiel Ataxia Test Battery Batteries Fugl-Meyer Sensorimotor Assessment of Balance Performance Mini-BESTest Dual task Stops walking when talking Multiple Tasks Test Fig. 3. Graphic and numerical postural sway Fig. 2. A, A wearable accelerometer for motion measures using a computerized force plate detection that can be used to measure postural system. Top left, Normal subject, eyes open. Top sway and other physical motions. B, the right, Healthy subject, eyes closed. Bottom left, accelerometer worn in a belt at the L5-S1 level. C, Client with Parkinson disease, eyes open. Bottom right, Client with Parkinson disease, Postural sway data recorded by the accelerometer. eyes closed. Fig 5. Graphic postural sway measures from the limits of stability test using a computerized force plate system (numerical measures not shown). Clients are asked to move away from and return to midline. A, Subject with normal postural sway. B, Hemiplegic client on initial evaluation. C, Fig. 4. Surface perturbations during Hemiplegic client on discharge evaluation. (A) the adaptation test and (B) the motor control test using computerized dynamic posturography. Force plate measures include latency and amount of response and adaptation of the response to repeated Fig. 7. The Clinical Test of Sensory Fig. 6. The six Sensory Organization Test conditions. The Interactions on Balance uses foam and a Sensory Organization Test determines the relative reliance Japanese lantern to replicate the six sensory on visual, vestibular, and somatosensory inputs for conditions. A stopwatch is used to time trials. postural control using computerized dynamic posturography. balance and mobility scale items Gait scale items. A combination of tasks (Romberg test, one-legged stance test [OLST], walking) and environments (eyes open, eyes closed, rail) are included in the Fregly-Graybiel Ataxia Test Battery. The Fugl-Meyer Sensorimotor Assessment of Balance Performance includes both low-level and high-level tasks. 2. BALANCE TRAINING  Balance Motor learning Individual TrainingTRAINING BALANCE concepts TECHNIQUES Task Techniques Environment Intervention Sensory systems Multisensory and motor control dysfunction Control of COG Other considerations Treatment tools Safety education and environmental education Home program Concurrent tasks Fall prevention 1.Motor learning concepts What is motor learning? Motor learning is a set of internal processes associated with practice or experience leading to relatively permanent changes in the capability for skilled behavior. In other words, motor learning is when complex processes in the brain occur in response to practice or experience of a certain skill resulting in changes in the central nervous system that allow for production of a new motor skill.  Stages of motor learning Associative Autonomous Cognitive Stage Stage Stage The therapisr must remember that successful treatments address the interaction of the individual, the task, and the environment. a. Individual Therapists should know their clients’ impairments: sensory and motor, peripheral, and central. Which impairments can be rehabilitated, and which require compensation or substitution. Optimal learning of skilled movement requires that the client have: (1) knowledge of self (abilities and limitations), (2) knowledge of the environment (opportunities and risks), (3) knowledge of the task (critical components), (4) the ability to use those knowledge sets to solve motor problems, and (5) the ability to modify and adapt movements as the task and environment change. b. Task Functional rating scales performed as a part of the evaluation yield information about what tasks, or functional activities, are limited by the postural control impairments. Repeating the problematic tasks over and over is one approach; however, analyzing the problematic tasks to determine what postural control demands are placed on the client when undertaking those tasks is far more productive for the therapist. By using task analysis, the therapist may consciously select or design tasks to place specific demands on the client such that the postural control systems that need improvement will be challenged to respond. c. Environment Environmental conditions also must be included in the design of the therapy plan to stimulate the necessary systems. Gravity cannot be manipulated by the therapist, but the client needs to learn to counteract it at different speeds and from different positions. The therapist can vary the surface conditions. They may be stable, even, and predictable, unstable, uneven, or compliant. Visual conditions also may be manipulated. Visual cues may be available and accurate, unavailable, unstable, used for purposes other than balance, or dependent on head movements. II. Intervention Successful intervention for the individual with a balance disorder depends on the ability of the therapist to identify the components of the problem. The therapist must create a program that addresses several components at a time, not just for efficiency, but because these systems should be able to function together to perform functional activities in real world environments. The intervention must be matched to the level and combination of body system impairments.  Progression of the program follows the changes seen from one intervention to the next to promote carryover and retention of learning. The exercise progression integrates activities that reflect those changes. This usually involves more complex movement skills in a greater range of gradually more challenging environments. (1) Sensory system (2) Multisensory and motor control dysfunction (3) Control of COG: – Sitting balance – Sitting to standing and transfer balance – Standing balance – Gait training  Effective control of the COG depends on accurate awareness of body position and motion in space and the relation between body parts (perception) as well as biomechanical and musculoskeletal systems (execution). Trunk and head control abilities are primary. Early treatment progression for COG control may include “neurodevelopmental sequence activities”, and the purposes are: ✓ To balance with progressively less surface contact ✓ greater control, coordination, and generation of power of the neck, trunk, and axial muscles. ✓ useful for simultaneously addressing impairments such as lower- extremity extensor tone, trunk weakness and asymmetries, and head and neck extensor weakness. ✓ Functionally, bed mobility and floor-to- stand transfers are related to these progressive position exercises and should be practiced concurrently. III. Other considerations (1) Treatment tools A, Biodex Balance System SD measures the motion on the surface, B, Proprio Reactive Balance System uses motion sensors on the body placed at the level of the COG. A, SMART Balance Master is a system with a 3-sided booth with unidirection motion combined with a unidirectional movable forceplate. B, Stimulopt Optokinetic Ball. A, Biodex FreeStep SAS uses overhead harness system to challenge balance during gait. B, GAITRite Portable Walkway System challenges gait during overground walking. C, Biodex Gait Trainer 3 with Unweighting System is another example of how to challenge balance during gait training. (2) Safety education and environmental modifications When permanent deficits exist, the client and the family should be taught in what environments the client is at risk (e.g., a client with vestibular loss on a gravel driveway at night), what tasks are unsafe (e.g., ladder climbing, changing ceiling light bulbs), how the client can compensate (e.g., use a cane at night or in crowds), and what changes in the home or workplace are needed. (3) Home program Strengthening, stretching, posture, and endurance exercises can all be performed safely at home so that time in the clinic can be spent on balance-challenge exercises requiring supervision. Improvements in strength, ROM, posture, and endurance support improvements in balance. Many balance exercises can and should be performed at home if safety and adherence can be ensured; however, unstable clients should always be supervised. (4) Concurrent tasks Normal balance is largely subconscious. One objective in balance retraining is to force the nervous system to solve postural control problems at the automatic, subconscious level. A great deal of practice and dual-task training are necessary to accomplish this; the conscious brain is focused on accomplishing some other goal(s) and thus balance control must be achieved at a less conscious level. (5) Fall prevention For any client with balance deficits the risk of falls is increased and must be addressed in every clinical management program. Fall prevention is a critical primary objective for clinicians serving clients with neurological conditions who have impaired balance and gait. Fall risk factors are categorized as intrinsic, relating to the individual, and extrinsic, relating to the environment.