Transcript Therapeutic techniques to improve balance in neurological

University of the Philippines Manila
College of Allied Medical Professions
PT 154: Therapeutic Exercise III
Ms. Mary Grace M. Jordan, PTRP
December 8, 2009
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one of the most common problems treated
by physical therapists.
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are thought to be common after stroke, and
they have been implicated in the poor
recovery of activities of daily living (ADL) and
mobility and an increased risk of falls.
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Define balance
Define terminologies
Discuss the theoretical underpinnings of
balance
Discuss the guidelines for training balance in
neurologic and developmental conditions
Identify techniques that can address
impairments of balance in patients with
neurologic and developmental conditions
“…the ability to maintain the body’s center of
gravity over its base of support with minimal
sway or maximal steadiness.”
(Emery et.al, 2005)
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a complex process involving the reception
and organization of sensory inputs and the
planning & execution of movement to
achieve a goal requiring upright posture
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is the set of functions which maintains man’s
upright during stance and locomotion by
detecting and correcting displacement of the
line of gravity beyond the BOS.
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Postural control – involves controlling the
body’s position in space for the dual purposes
of stability and orientation.
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Postural orientation –The control of relative
positions of the body parts by skeletal
muscles with respect to gravity and each
other.
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Postural stability - The condition in which
all the forces acting on the body are balanced
such that the center of mass (COM)is with in
the stability limits or boundaries of BOS
Normal anterior/posterior sway – 12 degrees from
most posterior-anterior position.
Lateral sway - 16 degrees from side to side.
If sway exceeds boundaries, compensation is
employed to regain balance.
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Static balance - the base of support (BOS)
remains stationary and only the body center
of mass (COM) moves. The balance task in
this case is to maintain the COM within the
BOS or the limit of stability (the maximal
estimated sway angle of the COM).
Maintaining a stable antigravity position
while at rest such as when standing and
sitting
Automatic postural reactions - maintaining
balance in response to unexpected external
perturbations, such as standing on a bus that
suddenly accelerates forward.
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Dynamic balance - Maintaining balance
when a person is moving from point A to
point B, where both the BOS and COM are
moving, and the COM is never kept within the
BOS.
is stabilizing the body when the support
surface is moving or when the body is moving
on a stable surface such as sit-to-stand
transfers or walking
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Reactive control - in response to external
forces (perturbation).
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Proactive control – in anticipation of internal
forces imposed on the body’s own
movements.
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Balance control is very complex and involves
many different underlying systems.
Postural control results from a set of
interacting systems that work cooperatively
to control both orientation and stability of
the body.
Neuromuscular
Synergies
Musculoskeletal
Components
Body
Schema
BALANCE
Sensory
Systems
Proactive
Mechanisms
(external)
Reactive
Mechanisms
Anticipatory
Mechanisms
(internal)
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Joint range of motion
Spinal flexibility
Muscle properties
Biomechanical relationships among linked
body segments
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Motor processes (neuromuscular response
synergies)
Sensory processes ( visual, vestibular, and
somatosensory systems)
Higher-level integrative processes
• Mapping sensation to action
• Ensuring anticipatory and adaptive aspects of postural
control
ADAPTIVE POSTURAL
CONTROL
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Involves modifying sensory
and motor systems in
response to changing task
and environmental
demands
ANTICIPATORY POSTURAL
CONTROL
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Involves preparing the
sensory and motor systems
for postural demands
based on previous
experience and learning
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Body alignment
Muscle tone
Postural tone
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Minimize the effect of gravitational forces,
which tend to pull us off center
The ideal alignment in stance allows the body
to be maintained in equilibrium with the least
expenditure of internal energy.
STANDING ALIGNMENT
SITTING ALIGNMENT
Head balanced on level
shoulders
 Upper body erect,
shoulders over hips
 Hips in front of ankles
 Feet a few cm (10 cm)
apart
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Head balanced on level
shoulders
Upper body erect
Shoulders over hips
Feet and knees a few cm
apart
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The force with which a muscle resists being
lengthened (Basmajian and De Luca, 1985)
Keeps the body from collapsing in response
to the pull of gravity
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Increased level of activity in antigravity
muscles
Activation of antigravity muscles during quiet
stance.
Muscles that are tonically active during quiet
stance: gastrocsoleus, tibialis anterior,
gluteus medius, TFL, iliopsoas, and erector
spinae
Ankle strategy
Hip strategy
Stepping strategy
 Used when displacements are small.
 Displaces COG by rotation about the ankle joint.
 Posterior displacement of COG – Dorsiflexion at
ankle, contraction of anterior tibialis, quadriceps,
abdominals.
 Anterior COG displacement – Plantar flexion at
ankle, contraction of gastrocnemius, hamstring,
trunk extensors.
 Employed
when ankle motion is limited,
displacement is greater, when standing on
unstable surface that disallows ankle strategy.
 Preferred when perturbation is rapid and near
limits of stability.
 Post. Displacement COG – Backward sway,
activation of hamstring and paraspinals.
 Ant Displacement COG – Forward sway,
activation of abdominal and quadricep muscles.
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If displacement is large enough, a forward
or backward step is used to regain
postural control
The maintenance of balance is based on an
intrinsic cooperation between the
 Vestibular system
 Proprioceptive
 Vision
 Postural control does not only depends on
the integrity of the systems but also on
the sensory integration with in the CNS,
visual and spatial perception, effective
muscle strength and joint flexibility
Provides information regarding:
(1) The position of the head relative to the environment;
(2) The orientation of the head to maintain level gaze;
(3) The direction and speed of head movements because
as your head moves, surrounding objects move in the
opposite direction.
 Provide a reference for verticality
 Visual stimuli can be used to improve a person’s
stability when proprioceptive or vestibular inputs are
unreliable by fixating the gaze on an object.
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Since most individuals can keep their balance
when vision is occluded
In addition, visual inputs are not always an
accurate source of orientation information
about self-motion.
Visual system has difficulty distinguishing
between object motion, referred to as
exocentric motion, and self-motion, referred
to as egocentric motion.
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Provides the CNS with position and motion
information about the body with reference to
supporting surfaces
Report information about the relationship of
body segments to one another
Receptors: muscle spindles, Golgi tendon
organs, joint receptors, and cutaneous
mechanoreceptors
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A powerful source of information for postural
control
Provides the CNS with information about the
position and movement of the head with
respect to gravity and inertial forces,
providing a gravitoinertial frame of reference.
Distinguish exocentric and egocentric
motions
SEMICIRCULAR CANAL
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Sense angular acceleration
of the head
Sensitive to fast head
movements ( those that
occur during gait or
imbalance such as slips,
trips, and stumbles)
OTOLITH ORGANS
Signal linear position and
acceleration
 Source of information
about head position with
respect to gravity
 Respond to slow head
movements (those that
occur during postural sway)
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Vestibular, visual, and somatosensory inputs
are normally combined seamlessly to
produce our sense of orientation and
movement.
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Incoming sensory information is integrated
and processed in the cerebellum, basal
ganglia, and supplementary motor area.
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Somatosensory information has the fastest
processing time for rapid responses, followed
by visual and vestibular inputs
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When sensory inputs from one system are
inaccurate the CNS must suppress the
inaccurate input and select and combine the
appropriate sensory inputs from the other
two systems.
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Injury to or diseases of the structures (e.g. eyes,
inner ear, peripheral receptors, spinal cord,
cerebellum, basal ganglia, cerebrum)
Damage to Proprioceptors
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Injury to or pathology of hip, knee, ankle, and
back have been associated with increases
postural sway and decreased balance
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Lesions produced by tumor , CVA, or other
insults that often produced visual field losses
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Patients with muscle weakness and poor control
lack effective anticipatory, ongoing, and
reactive postural adjustments and therefore
experience difficulty in:
 Supporting the body mass over the paretic lower
limb
 Voluntarily moving the body mass from one lower
limb to another
 Responding rapidly to predicted and unpredicted
threats to balance
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Changing the base of support
Restricting movement of body mass
Using hands for support
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Wide BOS
Shuffling feet with inappropriate stepping
Shifting on the stronger leg
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Stiffening the body with altered segmental alignment
Moving slowly
Changing segmental alignment to avoid large shifts in COG
 standing reaching forward - flexing at hips instead of
dorsiflexing ankles
 standing reaching sideways - flexing trunk sideways
instead of moving body laterally at hips and feet
 sitting reaching sideways - flexing forward instead of to
the side
 in standing - not taking a step when necessary.
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holding on to support
grabbing
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Balance cannot be trained in isolation from
the actions which must be relearned.
▪ In training walking, standing up and sitting
down, reaching and manipulation… postural
adjustments are also trained, since acquiring
skill involves in large part the fine tuning of
postural and balance control.
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Postural adjustments are specific to each
action and the conditions under which it
occurs.
 It cannot be assumed that practice of one action
will transfer automatically into improved
performance in another.
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Progressive complexity is added by
increasing the difficulty under which goals
must be achieved, keeping in mind the
various complex situations in which the
patients will find themselves in the
environment in which they live, both inside
and outside their homes, and the precarious
nature of balance.
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As control over balance and confidence
improves, tasks are introduced which require
a stepping response, and responses to
external constraints such as catching a
thrown object and standing on a moving
support surface
Use a gait belt any time the patient practices
exercises or activities that challenge or destabilize
balance.
 Stand slightly behind and to the side of the patient
with one arm holding or near the gait belt and the
other arm on or near the top of the shoulder (on the
trunk, not the arm).
 Perform exercises near a railing or in parallel bars to
allow patient to grab when necessary.
 Do not perform exercises near sharp edges of
equipment or objects.
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Have one person in front and one behind when
working with patients at high risk of falling or during
activities that pose a high risk of injury.
 Check equipment to ensure that it is operating
correctly.
 Guard patient when getting on and off equipment
(such as treadmills and stationary bikes).
 Ensure that the floor is clean and free of debris.
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A variety of mode can be used to treat balance
impairment
 Begin with weight shifts on a stable
surface
Gradually increase sway
Increase surface challenges (mini-tramp,
etc.)
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Rehabilitation balls ,foam rollers ,foam
surfaces are often used to
• Provide uneven or unstable surface for
exercise
• Sitting balance ,trunk stability, and weight
distribution can be trained on a chair, table,
or therapeutic ball
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Pool is an ideal palace for training balance
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Awareness of posture and the position of the
body in space is fundamental to balance training
 Begin
in supine or seated position
 Over sessions, use a variety of arm positions,
 unstable surfaces, single leg stances, etc.
 Training both Static posture & Dynamic
posture
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Mirrors can provide postural feedback –Visual
feedback
 Adding
movement patterns to acquired stable
static postures increases balance challenge.
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Add ant./post. sway to increase stability limits
 Trunk
rotations and altered head positions alter
vestibular input.
 Stepping
back/forward assists in re-stabilization
exercises.
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From simple to complex involves
• BOS – Advance from wide to narrow base
• Posture – Stable to unstable posture (sway)
• Visual – Closing of the eyes
• COG – Greater disruption to elicit hip or stepping
strategy
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Progress to more dynamic activities, unstable surfaces,
and complex movement patterns
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Frequency,intensity,and duration
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Normal postural activity forms necessary
background for normal movement and for
functional skills
Flaccid stage – balance exercises in sitting
Stage of spasticity – practice symmetrical
weight bearing in standing, weight shifting,
bending of knees and hips
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For stability
Combination of isotonics
Stabilizing reversals
Rhythmic stabilization
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Analysis of task
• Individual
• Task
• Environment
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Practice of missing components
• Strategy training
• Impairment and strategy level
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Practice of whole task
• Functional level
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Transference of learning
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Vary postures
Vary support surface
Incorporate external loads
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Moving support surfaces
Move head, trunk, arms, legs
Transitional and locomotor activities
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Reaching
Catching
Kicking
Lifting
Obstacle course
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Standing sway
Ankle strategy
Hip strategy
Stepping strategy
Perturbations
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Reduce visual inputs
Reduce somatosensory cues
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acute stage post-stroke
Head and trunk movements
Reaching actions
To progress:
 Increasing distance to be reached
 Varying speed
 Reducing thigh support
 Increasing object weight and size to involve both upper limbs
 Adding an external timing constraint such as catching or
bouncing a ball
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Head and body movements
Reaching actions
Single limb support
Sideways walking
Picking up objects
The following main aspects should be developed:
 Antigravity support or weight bearing on the feet
 Postural fixation of the head on the trunk and on the
pelvis in the vertical
 Counterposing
 Control of anteroposterior weight shift of the child’s
COG
 Control of lateral sway from one foot to the other.
 Tilt reactions in standing
 Saving from falling (strategies)
Training should check:
 Equal distribution of weight on each foot
 Correction of abnormal postures
 Building up of the child’s stability by decreasing
support
 Delay training in standing and walking if the child is
not ready
 Weight shift leading to stepping
 Training lateral sway
 Training on different surfaces
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Define balance
Define terminologies
Discuss the theoretical underpinnings of
balance
Discuss the guidelines for training balance in
neurologic and developmental conditions
Identify techniques that can address
impairments of balance in patients with
neurologic and developmental conditions
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Read Kisner’s Chapter on Techniques to
improve balance.
Read Shumway-cook’s Chapter on
interventions for postural control
impairments
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Carr JH & Shepherd RB (2003). Stroke rehabilitation: Guidelines for exercise and
training to optimize motor skill. Edinburgh, Butterworth-Heinemann.
Davies PM (1985). Steps to follow: A guide to the treatment of adult hemiplegia.
Berlin, Springer-Verlag.
Kisner C & Colby LA (2007). Therapeutic exercise: Foundations and techniques (5th
ed). Philadelphia, F. A. Davis Company.
Levitt S (2004). Treatment of cerebral palsy and motor delay (4th ed). Singapore,
McGraw-Hill Inc.
Sawner K & LaVigne J (1992). Brunnstrom’s Movement Therapy in hemiplegia: A
Neurophysiological Approach (2nd ed). Philadelphia, J.B. Lippincott Company.
Shumway-Cook, A & Woollacott, M. (2001). Motor control: Theory and practical
applications (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.