Balance and Falls

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Balance and Falls

• Nancy V. Karp, Ed.D., P.T.
• Nvkarp_at_gmail.com

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Normal Postural Control

• Postural control involves controlling the bodys
  position in space for
• Stability
• Orientation

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Falls

• Falls in the elderly are a major cause of
• morbidity
• Mortality
• The underlying causes of falls is a complex
  interaction of
• Biomedical factors
• Physiological factors
• Psychosocial factors
• Environmental factors

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Incidence and Cost of Falls in the Elderly

• Falls of people 65
• One third of people 65 fall each year.
• Elders gt 75 account for 60 of fall-related
  deaths.
• 25 of elders who fracture their hip in a fall
  will die within a year.
• Costs
• Falls account for 70 of all injury-related costs
  for the elderly,
• The average cost for a fall injury is 20,000.

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Falls in the Elderly

• Most falls result in minor or no injury.
• Repeat fallers tend to fall in the same manner as
  they did in the previous fall.
• A single fall results in
• Fear of falling and loss of confidence
• Restriction in activities
• Social isolation
• Dependence on others

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Identification of Fall Risk Factors

• Risk factors for falls are divided into two
  categories
• Intrinsic Risk Factors
• Dizziness, weakness, gait abnormalities, poor
  balance, confusion, poor coordination, ROM,
  cognitive impairment
• Extrinsic Risk Factors
• Floor surface, poor lighting, cluttered
  furniture, obstacles, non-level surface, poor
  shoes

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Falls are a result of loss of postural control.
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Normal Postural Control (Balance)

• Balance requires keeping the Center of Mass
  (COM) over the Base of Support (BOS) during
  static and dynamic situations.
• Neural components of postural control
• Sensory processes
• visual, vestibular, somatosensory
• Central processing
• a higher-level integrative process
• Effector component
• sometimes referred to as the neuromuscular
  component
• postural alignment, ROM, muscle force, power
  endurance

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Normal Postural Control

• Adaptive postural control requires modifying
  sensory and motor systems to changing tasks and
  environmental demands.

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Postural Control During Quiet Stance

• Body aligned to minimize the effect of
  gravitational forces.
• Muscle tone
• Postural tone

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Quiet Stance
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Limits of Stability (LOS)

• The maximum angle (from vertical) that can be
  tolerated.
• How far you can shit from front to back and side
  to side without loosing balance? This is often
  called your Cone of Stability.
• Postural Sway refers to small postural shifts
  from front to back and side to side, during quiet
  stance.

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Limits of Stability
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Cone of Stability
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Cone of Stability with Assistive Device
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Postural Sway

• The larger the sway path, the greater the
  postural unsteadiness.
• Romberg Test- Closing eyes will decrease visual
  input. Standing Postural Sway may increase,
  decreasing balance.

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Postural Control During Perturbed Balance

• The recovery of stability requires movement
  strategies that control the COM over the BOS.
• Limits of Stability is defined as the distance
  a person can move, without losing balance or
  taking a step.

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Perturbed BalanceMovement Strategies

• The ankle strategy occurs with minimal
  perturbance of balance.
• Control is distal- to-proximal

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Perturbed BalanceMovement Strategies

• Moderate instability leads to the hip strategy.
• Control is proximal-to-distal

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Perturbed BalanceMovement Strategies

• The stepping strategy is used with greater
  perturbance.

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Perturbed Balance Central Nervous System

• The response can either be protective or
  corrective.
• Anticipatory Postural Control refers to
  postural adjustments that are made before
  voluntary movements to minimize disturbances in
  balance (feed forward).

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Perturbed Balance Central Nervous System

• Reactive control is the response to a
  disturbance in balance (feedback).
• Corrective Strategy, such as the ankle
  strategy
• Protective Strategy, such as covering your head
  when you fall
• This does not correct the fall, but controls the
  effects of the fall.

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Perturbed BalanceMovement Strategies

• The CNS activates muscle synergies in related
  joints.
• Force in one part of the body does not cause
  instability in another part of the body.
• Leaning over in a chair to pick up a pen, you do
  not fall out of the chair.
• Neck extension during the hip strategy
  prevents the body from falling forward.

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Central Processing Tests

• Manual Test of Postural Perturbance
• Therapist pulls patient, at waist level, several
  times with varying degrees of force.
• See Guccione, p. 287

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Normal Postural ControlSensory System

• During perturbance of balance
• Adults rely on somatosensory inputs.
• Children rely more on visual input.
• The interaction of the senses allows the
  modification needed to maintain stability in a
  variety of environments.

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Normal Postural ControlSensory System

• The three different parts of the sensory system
  provide different sources of information about
  the bodys position and movement in space.
• Each sense provides a different frame of
  reference for postural control.

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Normal Postural ControlSensory System

• The Postural Dyscontrol Test will be performed
  in class.
• Foam and Dome Test
• OSullivan, p. 193

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Normal Postural ControlSensory System

• Vision provides information about the position
  and motion of the head in the environment.
• Acuity- detects subtle differences in shapes
• Snellen Eye Chart (min 20/200)
• Depth perception
• Finger Test, Guccione p. 286
• Peripheral vision
• Finger Test, Guccione p. 286

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Normal Postural ControlSensory System

• The somatosensory system provides information
  about the body with reference to supporting
  surfaces.
• The somatosensory system receives information
  from muscle spindles, joint receptors, tendon
  organs, and mechanoreceptors.

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The Somatosensory system

• Gross Tests of Proprioception
• Detecting the subtle movement of the big toe (lt
  5mm).
• Vibration- Placing a tuning fork at the first
  metatarsal head.

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Normal Postural ControlSensory System

• The Vestibular System
• Provides information about the position and
  movement of the head, in reference to gravity and
  inertial forces.
• Information is received from the vestibule
  responsible for position and linear acceleration.
• Information is received from the semi-circular
  canal responsible for rotational movement.

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The Vestibular System

• Gross Functional Tests
• Guccione, p. 286
• Looking at a object while turning head
• Reading a book while walking
• Marching in place with eyes closed

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Postural Control

• Controlling the bodys position in space is an
  essential part of functional skills.
• Postural control requires all three
• Sensory system
• Central processing
• Effector components

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Postural Control

• The three systems in postural control are
  complex and multifaceted. A problem or impairment
  in one area may affect several other areas,
  resulting in a greater affect than the loss of
  the single impairment.

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The Effect of Aging on Postural Control

• The Sensory System
• With aging, vision may decrease in acuity,
  contrast sensitivity, and depth perception
• With aging, the vestibular system may undergo
  age-related changes, resulting in dizziness and
  unsteadiness.
• With aging, there may be a decrease in
  proprioception and vibration.

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Aging Effects on Postural Control

• The Central Processing System
• Aging may result in a slowing of sensory
  information.
• Aging may result in a slowing of nerve conduction
  velocity.
• Aging may result in increased postural sway.
• Aging may result in an increased incidence of
  co-contractions
• Aging may result in an increased use of
  proximal-to-distal control for balance.

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Aging Effects on Postural Control

• The Effector System
• Aging may result in decreased muscle strength.
• Aging may result in decreased ROM and
  flexibility.
• Aging may result in increased stiffness of
  connective tissue
• Aging may result in cardiovascular changes

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Functional Tests

• Progressive Mobility Skills Assessment Task
• Guccione, p. 288
• Berg Balance Scale (note that the Functional
  Reach Test is part of this test)
• OSullivan, p. 208
• Performance-Oriented Assessment of Mobility I
  (Tinetti)
• OSullivan, p. 210

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Other Assessments

• Environmental Assessments
• Chapter 12, OSullivan
• Psychosocial Assessment
• Cognitive assessments
• Social work assessments

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Interventions

• Interventions should be based on assessment
  results.
• The ultimate goal will is to maximize
  independence in mobility and function.
• The therapist needs to identify and treat
  modifiable deficits.
• The therapist needs to identify and help the
  patient compensate for deficits that cannot be
  modified.

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Some balance exercises for older people.
Exercises - National Institute on Agingl
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Tandem Walking
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Fall Prevention

• The purpose of assessment and intervention is to
  prevent the next fall.

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Balance and Falls

• The End