Balance and Falls Balance and Falls

Nancy V. Karp, Ed.D., P.T. Nvkarp@gmail.com

Normal Postural Control Normal Postural Control

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

Falls 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

Incidence and Cost of Falls in the Incidence and Cost of Falls in the Elderly Elderly

Falls of people 65+

One third of people 65+ fall each year. Elders > 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.

Falls in the Elderly 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

Identification of Fall Risk Factors 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

Falls are a result of loss of postural control.

Normal Postural Control Normal Postural Control (Balance) (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

Normal Postural Control Normal Postural Control

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

Postural Control During Quiet Postural Control During Quiet Stance Stance

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

Quiet Stance Quiet Stance

Limits of Stability (LOS) 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.

Limits Limits of Stability

Cone of Cone of Stability

Cone of Cone of Stability with Stability with Assistive Assistive Device Device

Postural Sway 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.

Postural Control During Postural Control During Perturbed Balance 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.

Perturbed Balance Perturbed Balance Movement Strategies Movement Strategies

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

Perturbed Balance Perturbed Balance Movement Strategies Movement Strategies

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

Perturbed Balance Perturbed Balance Movement Strategies Movement Strategies

The stepping strategy is used with greater perturbance.

Perturbed Balance Balance Central Nervous System 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).

Perturbed Balance Perturbed Balance Central Nervous System 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.

Perturbed Balance Perturbed Balance Movement Strategies Movement 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.

Central Processing Tests 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

Normal Postural Control Normal Postural Control Sensory System Sensory 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.

Normal Postural Control Normal Postural Control Sensory System Sensory 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.

Normal Postural Control Normal Postural Control Sensory System Sensory System
The Postural Dyscontrol Test will be performed in class. Foam and Dome Test OSullivan, p. 193

Normal Postural Control Normal Postural Control Sensory System Sensory 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

Normal Postural Control Normal Postural Control Sensory System Sensory 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.

The Somatosensory system The Somatosensory system

Gross Tests of Proprioception

Detecting the subtle movement of the big toe (< 5mm). Vibration- Placing a tuning fork at the first metatarsal head.

Normal Postural Control Normal Postural Control Sensory System Sensory 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.

The Vestibular System 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

Postural Control 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

Postural Control 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.

The Effect of Aging on The Effect of Aging on Postural Control 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.

Aging Effects on Postural Aging Effects on Postural Control 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 cocontractions Aging may result in an increased use of proximalto-distal control for balance.

Aging Effects on Postural Aging Effects on Postural Control 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

Functional Tests 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

Other Assessments Other Assessments

Environmental Assessments Chapter 12, OSullivan Psychosocial Assessment

Cognitive assessments Social work assessments

Interventions 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.

Some Some balance exercises for older older people.

Exercises - National Institute on Agingl

Tandem Walking

Fall Fall Prevention

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

Balance and Falls Balance and Falls

The End