1. SPECIAL PROBLEMS IN GERIATRIC POPULATIONS

2. Balance Disturbance

3. Objectives 1- 2- 3- 4- 5-

4. Contents I. Balance II. Assessment of Balance 1- Berg Balance Scale (BBS 2-Functional Reach Test (FRT): 3- Reach in Four Direction Test. 4- Get-Up and Go (GUG). 5- Modified Romberg Test. IV. The Balance Control Process V. Balance Disorders. III. Balance Disorders and Falls in Elderly VI. Risk factors of fall. VII. Complications of falling

5. Balance

6. Definition: The term “balance” refers to the ability to maintain the body’s center of mass over the base of support in order to retain stability. It is the ability to react to destabilizing forces quickly and efficiently so as to regain stability. Alternatively, balance while standing and walking is the ability to maintain the body’s center of gravity over the base of support against the destabilizing effects of gravity and external disturbances.

7. Balance is a complex activity requiring input from many sensory systems; integration of this information at many levels of the nervous system, and a musculoskeletal system to implement the commands from the central nervous system. The vestibular, visual, and proprioceptive systems are the primary sensory systems. However, hearing and autonomic systems also play a role to transmit the information to the musculoskeletal system to stimulate the eyes, head, trunk, and limbs to produce coordinated eye movements, posture, stance and locomotion.

8. Sensory organs including vestibular, visual, proprioceptive, hearing, and autonomic systems, all bring sensory information to many levels of the nervous system. The central nervous system can adjust body sway and posture by integrating this information, and by controlling skeletal muscles to generate joint torque and adjust joint angles. Impairment in any component of the postural control system can lead to instability and falls in elder subjects.

9. It has been reported that proximal muscles (hip/trunk) are the primary contributors to balance control, while the distal group of muscles (leg/thigh) are important in compensating for a gait disturbance. Posture activity from bilateral leg and thigh muscles, and the coordination between the two lower extremities are the key to reactive balance control, and contribute to balance within one gait cycle.

11. Assessment of Balance

12. The most commonly used tools for the measurement of balance disorders are the Berg Balance Scale (BBS), Functional Reach Test (FRT), Reach in Four Direction Test, and the Timed Get-Up-Go Test (GUG).

13. Berg Balance Scale (BBS): The BBS was developed to measure balance disorders in elderly people and those with neurological disorders. It consists of 14 tasks which are scored from 0 to 4, where 0 indicates an inability to perform the task and 4 indicates the task was performed correctly and independently, i.e. normal performance. The possible score on this test ranges from 0 (severely impaired balance) to 56 (excellent balance). Scores below 45 indicate that the subject’s balance is impaired, with an increased risk of falls.

14. ItemDescription 1Sitting to standing 2Standing unsupported 3Sitting unsupported 4Standing to sitting 5Transfer 6Standing with eyes closed 7Standing with feet together 8Reach forward with an outstretched arm 9Retrieving object from floor 10Turning to back behind 11Turning 360 degrees 12Placing alternate foot on stool 13Standing with one foot in front of the other foot 14Standing on one foot Berg Balance Scale Test.

15. Functional Reach Test (FRT): The functional reach test (FRT) was designed to test the ability to control movement of the center of gravity over a fixed base of support. It is used as a dynamic measure of balance to measure the limit of stability in the anterior direction. It is based on measuring as the maximal distance that subjects could reach forward horizontally beyond arms length while maintaining a fixed base of support in the standing position.

16. The distance is measured in centimeters on a tape measure fixed to wall. The patient, standing with one shoulder close to a wall, is asked to extend the fist along the wall directly frontward. The subject then leans forward, fist extended in front as far as possible without taking a step or losing stability. The patient should be able to move the fist forward a distance of at least six inches; lesser distances indicate a significant risk for falling.

18. Reach in Four Direction Test (RFDT): Reach in Four Direction Test (RFDT) is a modification of the FRT, to obtain a better measure of the limits of stability, or how far the individual can move without taking a step, reaching in all four directions, namely forward, right, left and backward.

19. Get-Up and Go (GUG) and Timed Up and Go tests: The Get-Up and Go (GUG) and Timed Up and Go tests were designed as a quick measure of basic balance skill in elderly people. The subject is seated in a straight-backed high-seat chair. Then measure, in seconds, the time taken to stand up from a chair with a 48-cm seat height, without using the armrests if possible`, stand still momentarily,walk a distance of three meters to a line on the floor, adjust the center of gravity continuously over a moving base of support, turn, walk back to the chair, and sit down again. Sitting balance and transfers from sitting to standing are noted.

21. Modified Romberg Test A test for gait/ambulation: The standing patient performs tasks of increasing difficulty by observing the response to positional stress; loss of visual input and displacement. The patient assumes different standing positions, first with eyes open, then with eyes closed. With each successive maneuver, stability is observed and the patient is asked, "Do you feel steady?" A light nudge to the sternum can be helpful in assessing the response to displacement. This allows a rough estimate of balance and can help identify causative factors (e.g., osteoarthritis, peripheral neuropathy, foot problems, atherosclerosis, weakness, stroke, pain or contractures).

22. 1-Feet comfortably apart. 2- Feet together.

23. 3-Feet semi-tandem (heel-to-instep) 4- Feet tandem (heel-to-toe).

24. The Balance Control Process Balance is a critical component of mobility. The ability to maintain balance is a complex process that depends on three major components: (1) The sensory system for accurate information about the body position relative to the environment; (2) The brain's ability to process this information; and (3) The muscles and joints for coordinating the movements required to maintain balance.

25. For example, one depends on the feet and joints to tell us if the surface we are standing on is stable or moving. We depend on our eyes to tell us if the environment around us is moving or still. Additionally, we rely on our inner ears to tell us if we are upright or leaning, or standing still or moving.

26. Balance Disorders A number of diseases and impairments have been associated with balance disorders. The most commonly reported of these conditions are the following: 1-Dizziness is a frequently reported reason for falls. 2-Systemic dysfunction, as hypertension, vascular occlusions, vision and hearing losses, small vessel ischemic disease, arthritis, osteoporosis, and diabetes mellitus. 3- Proprioceptive / somato-sensory losses from peripheral neuropathy

27. 4- Decreased motor coordination due to age 5- Cerebral changes associated with poor balance among older people. 6-Peripheral arterial disease with intermittent claudication (is a clinical diagnosis given for muscle pain (ache, cramp, numbness or sense of fatigue). 7-Foot problems, particularly foot pain and deformities, impair balance and functional ability 8-Visual disturbances, as cataract. 9-Postural hypotension and metabolic disorders.

28. Balance Disorders and Falls in Elderly 1- The functions of the integrating component of balance system decline with aging, leading to decrease in the ability of subjects to interact with their daily living activities, and increase of risk factors to fall as a result of balance disturbances.

29. 2- Defects or impairments in the balance system, such as diminished vision, atrophy of the cerebral cortex, cerebro-vascular accidents, vestibular system dysfunction, peripheral neuropathy as in diabetic patients, musculo- skeletal disease usually involving multiple neuro-sensory impairments, will also lead to balance disturbance and disorders. 3- Aging also is associated with decline of physical capacity, and the development of many chronic diseases, which can lead to decline in muscle strength and in physical endurance.

30. 4-Moreover, impaired balance abilities occur with advancing age, along with changes in posture: The trunk is frequently bent forward, and the head fixed to the trunk or flexed at the neck. Such a stance limits the visual field, and places the body center of gravity at the periphery of the limits of the stability. Limitation of the visual field impairs orientation, and diminishes the ability to accurately determine the COG position. With the center of gravity at the forward periphery of the limits of stability; the righting reflexes are often inadequate to maintain equilibrium during propulsion.

31. Risk factors of fall: Risk factors associated with falls can be classified as either intrinsic (host) or extrinsic (enviromental). Host factors include symptoms such as dizzness, weakness, difficulty walking, or confusion. Enviromental factors include conditions such as slippery surface, loose rug, poor lighting, and obstacles.

32. Complications of falling: Falls may result in injury, including fractures. Up to 2% of falls result in fracture hip. Other fractures, e.g. in the humerus, wrist, and pelvis, can occur in up to 5% of falls. Serious injuries, such as head and internal injuries and lacerations can occur in up to 10% of falls. Over 50% of falls among elderly persons result in at least some minor injury.

33. Quality of life may deteriorate drastically after a fall; at least 50% of elderly persons who were ambulatory before fracturing a hip do not recover their pre-fracture level of mobility. If elderly persons remain on the floor for a time after a fall; dehydration, pressure sores, and pneumonia may result. Falls are the most prevalent cause of injuries, and the sixth leading cause of death in the elderly population.