BALANCE AND COORDINATION and PROPIOCEPTION.pptx

BALANCE AND COORDINATION

1. BALANCE, COORDINATION AND PROPRIOCEPTION Presented by DEEPA DANGWAL, PT

2. BALANCE Balance refers to an individuals ability to maintain their line of gravity within their base of support(BOS) or it is the state in which the body is in equilibrium and resultant of force acting is zero. Balance is the ability to maintain a controlled body position during task performance, whether it is sitting at a table, walking the balance beam or stepping up onto a kerb. To function effectively across environments and tasks, we need the ability to maintain controlled positions during both static (still) and dynamic (moving) activities.

3. FACTORS ON WHICH BALANCE DEPENDS 1.VISUAL SYSTEM - Correct sensory information from your eyes . Your vision helps you see where your head and body are in relationship to the world around you and to sense motion between you and your environment. 2. PROPIOCEPTIVE INPUT - muscles, tendons, and joints . Special sensors sensitive to stretch or pressure in your muscles, tendons, and joints help your brain to know how your feet and legs are positioned compared to the ground and how your head is positioned compared to your chest and shoulders.

4. 3. VESTIBULAR SYSEM- balance organs in the inner ear . Balance organs in the inner ear tell the brain about the movements and position of your head. There is a set of three tubes (semi-circular canals) in each ear, and these sense when you move your head around and help keep your vision clear. There are also two structures in each ear called otoliths (the utricle and saccule ). They tell the brain when the head is moving in a straight line (like when you are riding in a car or going up or down in an elevator) and sense the position of the head even when it is still (if it is upright or tilted).

5. BRAIN STEM - Putting it all together--the brain stem: Information from your vision, muscles, tendons, joints, and balance organs in your inner ear are all sent to the brain stem. The brain stem also gets information from other parts of the brain called the cerebellum and cerebral cortex, mostly about previous experiences that have affected your sense of balance. Your brain can control balance by using the information that is most important for a particular situation. For example, in the dark, when the information from your eyes is reduced or might not be accurate, your brain will use more information from your legs and your inner ear.

6. MOTOR OUTPUT : Once your brain stem sorts out all of this information, it sends messages to the eyes and other parts of your body to move in a way that will help you keep your balance and have clear vision while you are moving.

7. STATIC AND DYNAMIC BALANCE Static balance is the ability to hold a stationary position with control (e.g. “Freeze” or “statue” games ). Dynamic balance is the ability to remain balanced while engaged in movement (e.g. running or bike riding).

8. Problems occurs with balance and coordination difficulties! Motor (muscle) planning  Spatial awareness Low Endurance Pre-writing skill development Pencil grasp Pencil control Left right discrimination Hand dominance Articulation Self care Sensory processing

9. How to improve balance and coordination ? Improve attention to task and alertness Strengthen the ‘core’   Simplify tasks   Improve muscle strength   Improve muscular endurance   Improve sensory processing Social motivators

10. SPECIAL TEST Timed up and go test Tinetti test Berg balance scale Nudge test Functional reach test Y balance test Dix – Hallpike test

11. Timed “Up and Go” Directions: The timed “Up and Go” test measures, in seconds, the time taken by an individual to stand up from a standard arm chair (approximate seat height of 46 cm, arm height 65 cm), walk a distance of 3 meters (approximately 10 feet), turn, walk back to the chair, and sit down. The subject wears their regular footwear and uses their customary walking aid (none, cane, walker). No physical assistance is given. They start with their back against the chair, their arms resting on the armrests, and their walking aid at hand. They are instructed that, on the word “go” they are to get up and walk at a comfortable and safe pace to a line on the floor 3 meters away, turn, return to the chair and sit down again. The subject walks through the test once before being timed in order to become familiar with the test. Either a stopwatch or a wristwatch with a second hand can be used to time the trial.

12. Instructions to the patient : “When I say ‘go’ I want you to stand up and walk to the line, turn and then walk back to the chair and sit down again. Walk at your normal pace.” Variations: You may have the patient walk at a fast pace to see how quickly they can ambulate. Also you could have them turn to the left and to the right to test any differences.

13. Tinetti Performance Oriented Mobility Assessment Description: The Tinetti assessment tool is an easily administered task-oriented test that measures an older adult’s gait and balance abilities. Equipment needed: Hard armless chair Stopwatch or wristwatch 15 ft walkway Completion Time: 10-15 minutes Scoring: A three-point ordinal scale, ranging from 0-2. “0” indicates the highest level of impairment and “2” the individuals independence. Total Balance Score = 16 Total Gait Score = 12 Total Test Score = 28 Interpretation: 25-28 = low fall risk 19-24 = medium fall risk < 19 = high fall risk

14. Tinetti Performance Oriented Mobility Assessment Initial instructions: Subject is seated in hard, armless chair. The following maneuvers are tested. 1. Sitting Balance Leans or slides in chair =0 Steady, safe =1 2. Arises Unable without help =0 Able, uses arms to help =1 Able without using arms =2 3. Attempts to Arise Unable without help =0 Able, requires > 1 attempt =1 Able to rise, 1 attempt =2

15. 4. Immediate Standing Balance (first 5 seconds) Unsteady (swaggers, moves feet, trunk sway) =0 Steady but uses walker or other support =1 Steady without walker or other support =2 5. Standing Balance Unsteady =0 Steady but wide stance( medial heals > 4 inches apart) and uses cane or other support =1 Narrow stance without support =2 6. Nudged (subject at maximum position with feet as close together as possible, examiner pushes lightly on subject’s sternum with palm of hand 3 times)

16. Begins to fall =0 Staggers, grabs, catches self =1 Steady =2 7. Eyes Closed (at maximum position of item 6) Unsteady =0 Steady =1 8. Turing 360 Degrees Discontinuous steps =0 Continuous steps =1 Unsteady (grabs, staggers) =0 Steady =1 9. Sitting Down Unsafe (misjudged distance, falls into chair) =0 Uses arms or not a smooth motion =1 Safe, smooth motion =2 BALANCE SCORE: _____/16

17. Initial Instructions: Subject stands with examiner, walks down hallway or across room, first at “usual” pace, then back at “rapid, but safe” pace (using usual walking aids) 10. Initiation of Gait (immediately after told to “go”) Any hesitancy or multiple attempts to start =0 No hesitancy =1 11. Step Length and Height a. Right swing foot Does not pass left stance foot with step =0 Passes left stance foot =1 Right foot does not clear floor completely With step =0 Right foot completely clears floor =1 b. Left swing foot Does not pass right stance foot with step =0 Passes right stance foot =1 Left foot does not clear floor completely With step =0 Left foot completely clears floor =1

18. 12. Step Symmetry Right and left step length not equal (estimate) =0 Right and left step length appear equal =1 13. Step Continuity Stopping or discontinuity between steps =0 Steps appear continuous =1 14. Path (estimated in relation to floor tiles, 12-inch diameter; observe excursion of 1 foot over about 10 ft. of the course) Marked deviation =0 Mild/moderate deviation or uses walking aid =1 Straight without walking aid =2 15. Trunk Marked sway or uses walking aid =0 No sway but flexion of knees or back or Spreads arms out while walking =1 No sway, no flexion, no use of arms, and no Use of walking aid =2

19. 16. Walking Stance Heels apart =0 Heels almost touching while walking =1 GAIT SCORE = _____/12 BALANCE SCORE = _____/16 TOTAL SCORE (Gait + Balance ) = ____/28 {> 19 high fall risk, 19-24 medium fall risk, 25-28 low fall risk}

20. Berg Balance Scale Description: 14-item scale designed to measure balance of the older adult in a clinical setting. Equipment needed: Ruler 2 standard chairs (one with arm rests, one without) Footstool or step Stopwatch or wristwatch 15 ft walkway Completion Time: 15-20 minutes Scoring: A five-point ordinal scale, ranging from 0-4. “0” indicates the lowest level of function and “4” the highest level of function. Total Score = 28

21. Interpretation: 41-56 = low fall risk 21-40 = medium fall risk 0 –20 = high fall risk < 36 fall risk close to 100%

22. Berg Balance Scale Name: _____ Date: ______ Location: _____ Rater : _____ ITEM DESCRIPTION SCORE (0-4) Sitting to standing ________ Standing unsupported ________ Sitting unsupported ________ Standing to sitting ________ Transfers ________ Standing with eyes closed ________ Standing with feet together ________ Reaching forward with outstretched arm ________ Retrieving object from floor ________ Turning to look behind ________ Turning 360 degrees ________ Placing alternate foot on stool ________ Standing with one foot in front ________ Standing on one foot ________ Total ________

23. DIX – HALLPIKE TEST This figure illustrates the Dix- Hallpike test for  BPPV . A person is brought from sitting to a supine position, with the head turned 45 degrees to one side and extended about 20 degrees backward. Once supine, the eyes are typically observed for about 30 seconds. If no nystagmus ensues, the person is brought back to sitting. There is a delay of about 30 seconds again, and then the other side is tested. When doing the Dix- Hallpike on a flat table, it is often helpful to place a flat "boat" cushion under the persons back, to obtain head extension. One of these is illustrated below (in the mat-table illustration).

24. Dix – Hallpike Test

25. If the person has arthritis in their neck, the maneuver may be performed in side-lying position. A positive Dix- Hallpike tests consists of a burst of nystagmus (jumping of the eyes).

26. COORDINATION

27. COORDINATION The ability to use different parts of the body together smoothly and efficiently. Harmonious combination or interaction, as of functions or parts . Coordination tests can be further subdivided into  nonequilibrium   and  equilibrium  tests.   Nonequilibrium tests  address both static and mobile components of movements when the patient is in a sitting position. These tests involve both gross and fine motor activities.   Equilibrium tests  consider both static and dynamic components of posture when patient is in an upright standing position. They involve primarily gross motor activities and require observation of the body in both static (stationary) and dynamic (body in motion) postures.

28. NONEQUILIBRIUM TESTS 1.   Finger-to-Nose  – The shoulder is abducted to 90 degrees with elbow extended. The patient is asked to bring the tip of the index finger to the tip of his or her nose. 2.  Finger-to-Therapist’s finger   – The patient and therapist sit opposite each other. The therapist’s index finger is held in front of the patient. The patient is asked to touch the tip of his or her index finger to the therapist’s index finger. 3.  Finger-to-Finger  – both shoulders are abducted to 90 degrees with the elbows extended. The patient is asked to bring both hands toward the midline and approximate the index fingers from opposing hands. 4.   Alternate nose-to-finger  – the patient alternately touches the tip of his or her nose and the tip of the therapist’s finger with the index finger. 5.  Finger Opposition  – the patient touches the tip of the thumb to the tip of each finger in sequence. 6.  Mass Grasp  – an alteration is made between opening and closing fist (from finger flexion to full extension).

29. 7.   Pronation / Supination  – with elbows flexed to 90 degrees and held close to the body, the patient alternately turns the palms up and down. This test is also performed with shoulders flexed to 90 degrees and elbows extended. 8.  Rebound test  – the patient is positioned with the elbow flexed. The therapist applies sufficient manual resistance to produce and isometric contraction of the biceps. Resistance is suddenly released. Normally, the opposite muscle group (triceps) will contract and “check” movement of the limb. 9.  Tapping (hand)  – with the elbow flexed and the forearm pronated , the patient is asked to “tap” the hand of the knee. 10.   Tapping (foot)   – the patient is asked to “tap” the ball of one foot on the floor without raising the knee; heel maintains contact with floor.

30. 11.  Pointing and past pointing  – the patient and the therapist sit opposite to each other. Both patient and therapist bring shoulders to a horizontal position of 90 degrees flexion with elbow extended. Index fingers are touching or the patient’s finger may rest lightly on the therapist’s. the patient is asked to fully flex the shoulder and then return to the horizontal position such that index fingers will again approximate. A normal response consists of an accurate return to the starting position. In an abnormal response, there is typically a “past pointing”, or movement beyond the target. 12.   Alternate heel-to-knee; heel-to-toe  – from a supine position, the patient is asked to touch the knee and big toe alternately with the heel of the opposite extremity. 13.  Toe to examiner’s finger  – from a supine position, the patient is instructed to touch the great toe to the examiner’s finger.

31. 14.  Heel on shin  – from a supine position, the heel of one foot is slid up and down the shin of the opposite lower extremity. 15.   Drawing a circle   – the patient draws an imaginary circle in the air with either upper or lower extremity. This also may be done using a figure-eight pattern. 16.  Fixation or position holding  – UE: the patient holds arms horizontally in front (sitting or standing)…LE: the patient is asked to hold the knee in an extended position (sitting).

32. EQUILIBRIUM TESTS Standing, comfortable posture with normal base of support (BOS). Standing, feet together (narrow BOS). Standing in tandem position, with one foot directly in front of the other (toe of one foot touching heel of opposite foot) Standing on one foot. Arm position may be altered in each of the above postures (i.e., arms at side, over head, hands on waist, and so forth). Perturbations: displace balance unexpectedly Standing, functional reach: forward trunk flexion with upper extremity reach. Standing, laterally flex trunk to each side

33. Standing: eyes open (EO) to eyes closed (EC); inability to maintain an upright posture without visual input is referred to as a positive Romberg sign. Standing in tandem position eyes open (EO) to eyes closed (EC) (Sharpened Romberg). Tandem walking, placing the heel of one foot directly in front of the toe of the opposite foot. Walking along a straight line drawn or taped to the floor, or place feet on floor markers while walking. Walk sideways, backward, or cross-stepping. March in place. Alter speed of ambulatory activities; observe patient walking at normal speed, as fast as possible, and as slow as possible.

34. Stop and start abruptly on command while walking. Walk and pivot on command (turn 90, 180 or 360 degrees) Walk in a circle, alternate directions. Walk on heels or toes. Walk with horizontal and vertical head turns on command. Step over or around obstacles Stairclimbing with and without using handrail; one step at a time, step over step. Jumping jacks. Sitting on therapy ball: alternate flexing and extending the knees (coordinated movement with upright balance).

35. PROPIOCEPTION Proprioception , also called kinesthesia , is the body’s ability to sense its location, movements, and actions. It’s the reason we’re able to move freely without consciously thinking about our environment.

36. SUB - MODALITIES Proprioception itself can be understood as including various sub-modalities: Proprioception (Joint Position Sense):   Proprioception is our sense of joint / limb positioning. It is often measured through joint position sense - active joint position sense (AJPS) and passive joint position sense (PJPS). Joint position sense determines the ability of a person to perceive a presented joint angle and then, after the limb has been moved, to actively or passively reproduces the same joint angle (Clinically measured as a joint matching task). Kinaesthesia:  Kinaesthesia ( kinaesthesis ) is the awareness of motion of the human body (motion sense). Sense of movement refers to the ability to appreciate joint movement, including the duration, direction, amplitude, speed, acceleration and timing of movements.

37. Sense of Force:  Sense of Force ( SoF ) is also known as sense of effort / heaviness / tension or the force matching sense. It is the ability to reproduce (or match) a desired level of force one or more times. Sense of force is thought to stem from the afferent feedback of the Golgi Tendon Organs (GTOs) embedded within our tendons, the muscle spindles within our muscles and proprioceptions within our skin. Sense of Change in Velocity ( SoV ):   SoV is our ability to detect vibration, derived from oscillating objects placed against the skin. [6]  It is believed to travel through the same type of large afferent nerve fibers ( Aαβ ) as proprioception .

38. Causes of Proprioception Impairment Proprioception can be affected by the following factors: Temporary impairment from a compromised state (for example the consumption of  alcohol ). Age-related changes also affect proprioception . The risk of proprioception loss increases as we age due to a combination of natural age-related changes to the nerves, joints, and muscles. Injuries or medical conditions that affect the neuromuscular system (muscles, nerves, and the  cerebellum , CNS) which can cause long-term or permanent proprioception impairment.

39. Proprioception impairments have been noted among the following neurological conditions: Brain injuries; multiple sclerosis ( MS ); stroke;  Parkinson’s  disease;  Huntington’s  disease;  ALS  (amyotrophic lateral sclerosis) Also health conditions: herniated  disc ;  arthritis ; autism spectrum disorder (ASD);  diabetes ;  peripheral neuropathy . Post-surgery: joint replacement surgery, such as  hip replacement  or  knee replacement MSK conditions: ankle sprains, ACL injuries, shoulder dislocations and tendinopathies , whiplash associated disorders (among others).

40. Special test for Proprioception Romberg test.  This is the most  commonlyTrusted Source  used diagnostic test for proprioceptive abnormalities. To do the test, you stand unsupported for 30 seconds with your heels together and your eyes closed. If you lose your balance during that time, it’s considered a positive result. Field sobriety test.  This may involve one or a series of tests often used by police officers to evaluate suspected drunk drivers. One such test involves closing your eyes and touching your nose with each of your index fingers. The standardized field sobriety test (SFST) is a battery of three tests. It includes the horizontal gaze nystagmus (HGN) test, which involves following a slowly moving pen or other object with your eyes; the walk-and-turn (WAT) test, in which you walk a few steps in a straight line with one foot in front of the other; and the one leg stand (OLS) test, which is simply standing with one foot raised off the floor.

41. Thumb finding test.  For this test, the tester will place one of your hands in a certain position. Then, you’ll be asked to touch the placed thumb with your other thumb and forefinger while your eyes are shut. Sequential finger touching.  This test is often used on children and adults. To perform the test, touch each of your fingers to your thumb, starting with your forefinger. Distal proprioception test.  The tester will hold the sides of your big toe and perform up and down movements while you watch. You then have to repeat the same movement with your eyes closed.