Examination of balance PTP 565

Quote of the day The greatest crime is not developing your own potential. When you do what you do best, you are helping others. Roger Williams

Objectives Define balance terminology Recognize the use of the ICF Model in balance examination Correctly select and complete a balance examination using objective measures (SLS, Romberg/Tandem Romberg, Functional Reach, Berg, Tinetti, CTSIB, and ABC) Recognize normal versus abnormal results of balance testing (including fall risk) Document results of balance testing

Assessing a patient with balance dysfunction can be Complicated Confusing Discouraging Challenging Rewarding

What types of patients have the potential for balance impairment?

Definitions Postural control Balance Center of gravity Base of support Postural orientation Limits of stability Anticipatory postural responses Reactionary postural responses Sensory interaction/orientation

Fundamental Exam Examination – Taking a history – Systems review – Tests and Measures Body structure and function Activity Participation

Taking a History Chief complaint Medical history Recent history of falls/close falls Medications Confidence level (participation level)

Systems Review Cardiovascular Integumentary Neuromuscular Musculoskeletal

ICF Model

Body Functions and Structure ROM Ms. Strength Ms. Tone Coordination Cognition Posture Pain

Body Functions and Structure Sensory Systems (cont) – Somatosensory Light touch Proprioception/Vibration Pain – Vision – Vestibular Perception

Body Functions and Structure Sensory Strategies – Why is sensory interaction important? – How do we test sensory interaction in the lab? – How is sensory interaction testing different then sensory testing? Sensory Systems used to hold balance – Vision – Vestibular – Somatosensory

Body Functions and Structure Motor Strategies – Ankle – Hip – Stepping

Motor Strategies: Ankle Control of postural sway from ankles and feet Head and hips travel in the same direction at the same time with the body moving as a unit over the feet When it is appropriate to use an ankle strategy? – Firm surface – Foot well supported – Slow moving with minimal displacement

Motor Strategies: Hip Control of postural sway from pelvis and trunk Head and hips travel in opposite directions When is it appropriate to use a hip strategy? – Foot not completely supported – Quick and large displacements

Motor Strategies: Stepping Steps with the feet to establish a new base of support when the center of gravity has exceeded the original base of support When is it appropriate to use a stepping strategy? – When the other strategies are not sufficient enough to maintain equilibrium

Body Functions and Structure Modified CTSIB Single Leg Stance Romberg/Sharpened Romberg

Clinical Test for Sensory Interaction in Balance Clinical version of the Sensory Organization Test that does not require computerized force plate Designed to assess the patient’s ability to select and combine sensory information in different environments Does not measure the integrity of the three sensory systems

Sensory Weighting Firm Surface 70% somatosensory 20% vestibular 10% vision Unstable Surface 10% somatosensory 60% vestibular 30% vision Peterka et al, 2004

Clinical Test for Sensory Interaction in Balance Condition 1: Firm surface, eyes open Condition 2: Firm surface, eyes closed Condition 3: Firm surface, dome Condition 4: Foam surface, eyes open Condition 5: Foam surface, eyes closed Condition 6: Foam surface, dome

Single Leg Stance Person stands with knee flexed 90° (legs should not be touching each other) Arms crossed around shoulders Norms Document – Number of attempts – Time – Visual observation during trial

Romberg/Tandem Romberg Person stands with feet together (Romberg) and eyes open Repeat the test with eyes closed Person stands with one foot directly in front of the other (Tandem Romberg) Normal is the ability to hold the test position for 30 seconds Document – Number of attempts – Time – Visual observation during trial

Activity and Participation Activity Balance Measures Berg Tinetti Functional Reach Participation Balance Measures Activities Based Confidence Scale

Berg 14 test items intended to assess a person's ability to perform common ADLs safely Items are scored from 0 to 4, maximum score is 56 Scores < 36 indicate a fall risk close to 100%

Tinetti Consists of 2 subscales to screen for balance and mobility skills in older adults and determine likelihood of falls – Balance – Gait Score are at moderate risk of falls Score <19 are considered high risk for falls

Functional Reach Define maximum distance one can reach forward beyond arm’s length while maintaining fixed base of support in standing Examines limits of stability in forward direction Person stands near wall with feet parallel, raises arm nearest wall to 90° of shoulder flexion, makes a fist and leans as far forward as possible < 6 inches predicative of increased risk of falls

Activities Based Confidence Scale 16 item questionnaire that is a measure of balance self-efficacy in which subjects rate their confidence performing a variety of in home and community based functional activities such as walking in a variety of environments, reaching, picking things up from the floor. Scores range from where higher scores indicate greater balance confidence

Review Examination of a patient with balance disorder can happen at the level of Body Structure/Function, Activity, and Participation Numerous objective tools to use to examine balance No single test of balance is available that covers the multiple dimensions of balance Need to select a test that sufficiently challenges the patient being tested SAFETY – Gait belt – Closely guarded

Lab Video clips of balance examination Paper patient cases – Select the correct test – Practice performing and documenting balance examination