1. 05/08/20151 بسم الله الرحمن الرحيم

2. 05/08/20152 Balance and Coordination Exercises

3. 05/08/20153 1)Be familiar with definitions and key words related to coordination & balance. 2)Be aware of the causes of impaired balance. 3)Be oriented to the subjective and objective assesments of coordination and balance. 4)Know the progression of activities to improve balance & coordination. 5)Be capable to apply coordination exercises with the variuos modes, postures, movements and dosages. 6)Be aware of precautions and contra-indications for those exercises.

4. 05/08/20154 Coordination Definition: It is the ability to perform smooth, accurate and controlled movements.

5. 05/08/20155 1)The execution of fine motor skills and manipulation of small objects. 2)Performing gross motor skills, e.g. walking, running, jumping, ………. 3)Bases of smooth and efficient movements which often occur automatically.

6. 05/08/20156 -- Coordinated movements involve proper sequencing and timing of synergistic and reciprocal muscle activity, and they require proximal stability and maintenance of posture. - Coordination refers to using the right muscle, at the right time with the right intensity. - The concept of coordination includes balance.

7. 05/08/20157 Balance: It is : the ability to maintain equilibrium Or the ability to maintain the center of gravity over the base of support.

8. 05/08/20158 Vestibular dysfunction, Visual impairment or Diminished proprioception can impair balance

9. 05/08/20159 1)The somato-sensory system provides information about the relative location of the body parts/ Proprioception reflects the perception of the static position. Kinesthesia refers to the position during movements. Information arises from peripheral sources (muscles, jt. capsule, soft tissues): Sensory receptors→ information to the medulla & brainstem through the dorsal colummedial lemniscal pathway. 2) This information will assist in: 1)Coordinating eye, head & neck movements to stabilize the visual system. 2)In maintaining posture, muscle tone, & stiffness in the muscles. 3)Coordinate movement patterns

10. 05/08/201510 2) The visual system : Through the retina, the optic nerve and thalamus → provide information about the position of the head relative to the environment & orients the head to maintain posture. 3) The vestibular system: Provides information on orientation of the head in space and on accelaration. Any movement, including weight shifts to adjust posture stimulate the vestibular receptors → vestibular nerve → cerebellum → spinal cord for postural control.

11. 05/08/201511 Balance Visual system Vestibular system Somato sensory

12. 05/08/201512 Balance requires: The person to maintain a position, to stabilize during voluntary activities. ( needs trunk & head, neck control) To react to external perturbations (visual and auditory awareness + cognitive skils). Effective and efficient coordination among multiple sensory, biomechanical, and motor systems.

13. 05/08/201513 Causes for impaired balance: Injury to or disease to eye, inner ear, peripheral receptors, spinal cord, Head injury affecting the cerebellum, basal ganglia, cerebrum. Damage to proprioceptors (peripheral nerve injury). Injury or pathology of the hip, knee, ankle, and back have been associated with postural sway and decreased balance. ( after muscle atrophy, degenerative joint disease, total joint replacement ).

14. 05/08/201514 Lesions of the cerebellum or basal ganglia. ( Parkinson s disease, Huntingtons Disease and cerebellar tumors ). Lesions produced by tumors, cerebro vascular accidents causing visual field losses, changing the spatial orientation and altering balance. Age appears to affect all aspects of the stability triade ( i.e. somato-sensory, visual, vestibular ). as 30 % of the persons above 65 years old have experienced a fall and15% repetitive fall. Medications could cause dizziness, drowsiness or sense of weakness ( antidepressants).

15. 05/08/201515 Evaluation of Balance Evaluation of Balance. Subjective ( Clinical ) Assessment. Objective ( Quantitative and Instrumental) Assessment.

16. 05/08/201516 Subjective ( Clinical ) assessment Standard Romberg Test:(standing with eyes closed: if positive= loss of proprioception) Balance error scoring system (BESS) Static Balance Test: ( on a firm then on a foam surface) Dynamic Balance Test.( figure of 8, hoptest, timed beam walking with eyes closed).

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18. 05/08/201518 Objective or instrumental assessment Flat rigid surfaces supported on 3 or more points with computer- interfaced forceplate with or without visual feedback. Steadiness: the ability to keep the body as motionless as possible ( =postural sway). Symmetry: is the ability to distribute weight evenly between the two feet in an upright position. Dynamic Stability: is the ability to transfer the vertical projection of the COG around a stationary supporting base( = the measure of a persons’ perception of his/ her safe limits of stability.

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20. 05/08/201520 Activities for Treating Impaired Balance 1) Remember the balance problems. e.g.: Neuromuscular impairment. Musculoskeletal impairment (lack of stability). Sensory impairment. Cognitive impairment. 2) Use stable, hard, rigid, and even surface. Then progress to uneven surface. 3) Begin with weight shifts on a firm surface then gradually increase sway. As the patient improves, increase compliance of the support surface.

21. 05/08/201521 Use balls, foam rollers, and foam surface to provide uneven and unstable surface and to provide a variety of balance experience. Train Sitting balance, trunk stability, and weight distribution on chair, table, or therapeutic ball. Balance beam, lines drawn on the floor, balance board and scales can be used for balance training.

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23. 05/08/201523 Dosage Environment: Train in the environment with a real stimulation he will encounter when leaving the clinic. Sequence: Progress from simple to complex involves changes in mode, posture, and movements. Feedback: Use external feedback,e.g., mirrors which allows feedback about position, (must be removed at some point to allow internalization of the balance strategies.

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25. 05/08/201525 Contraindication Balance training is contraindicated for patients with cognitive impairments, as the patient might be unable to understand the purpose and mechanics of the activities.

26. 05/08/201526 Precautions The patient Safety is important. Choose activities appropriate for the patient‘s skill level. Start by simpler and safer tasks then progress. Eliminate obstacles or unsafe objects. A gait belt, hand contacts from the clinician, parallel bars, or stable external objects should be used for the patient to hold.

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28. 05/08/201528 Practical Guidelines Pt education is an ongoing process. Safety is the most important area of education. Teach the pt. to recognize situations at risk. Widen the base of support and gradually decrease it. Evaluate the home for potential hazards.

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