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Postural Control and Balance

Common Sense Rules For Balance. Spatial Orientation. Postural Control System. Horizontal Reference. Vertical Reference. All Tasks Require Postural Control. Nystagmus. Postural Control and Balance. Postural Mechanisms. Movement Sequence. Cone of Stability. Balance Strategies.

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Postural Control and Balance

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  1. Common Sense Rules For Balance Spatial Orientation Postural Control System Horizontal Reference Vertical Reference All Tasks Require Postural Control Nystagmus Postural Control and Balance Postural Mechanisms Movement Sequence Cone of Stability Balance Strategies Attention Demands Posture Balance Tests Balance Exercises Map of Essential Concepts Fall 2006 DM McKeough

  2. Posture Control and Balance • Common sense rules of balance • Spatial orientation • Posture • Postural control system • Horizontal reference • Vertical reference • ALL tasks require postural control • Nystagmus • Postural Mechanisms • Movement sequence • Cone of stability • Balance strategies • Attentional demands • Balance tests • Balance training exercises Last Viewed Exit Posture & Balance Concept Map

  3. Common Sense Rules of Balance Last Viewed Exit Posture & Balance Concept Map

  4. Spatial Orientation 1/2 Balance = Stability + Spatial Orientation • Spatial Orientation • Cartesian coordinate system divides space into X, Y, Z planes • We orient our body in space according to its relationship to the 3 planes Last Viewed Exit Posture & Balance Concept Map

  5. Spatial Orientation 2/2 Last Viewed Exit Posture & Balance Concept Map

  6. Postural requirements change for different tasks and different environments Reading a paper while sitting, standing, or riding a bus Each individual solves postural demands with their unique movement ability Individual Posture Task Environment Posture Last Viewed Exit Posture & Balance Concept Map

  7. Postural Control System • Sensory Input • Vision • Vestibular • Somatosensation (Proprioception) • Central Integration • Spatial orientation • Motor Output • Extensor muscles Postural control system is complex interaction of musculoskeletal and neural systems Last Viewed Exit Posture & Balance Concept Map

  8. Sensory Systems in Balance • Visual System • Provides a reference for horizontal in environment • Head righting reactions • Midbrain level reflexes designed to maintain the eyes in the horizontal plane Last Viewed Exit Posture & Balance Concept Map

  9. Sensory Systems in Balance • Vestibular System • Gravity and motion receptors that provide a reference for vertical in environment • Helps determine position of head in reference to vertical Last Viewed Exit Posture & Balance Concept Map

  10. Sensory Systems in Balance • Somatosensation (Proprioception) • Mechanoreceptors provide body awareness • Neck proprioceptors connect head position with body position to provide spatial orientation (body position in space) Somatic Nervous System Extreo-ceptors provide information about the environment outside the body Visceral Nervous System Intero-ceptors provide information about the environment inside the body Last Viewed Exit Posture & Balance Concept Map

  11. Postural Control System • Central Integration • Spatial orientation • “Perception” of a body’s “posture” and its relative position in Cartesian space • Produced by central integration of visual, vestibular, and somatosensory information • Vast majority of posture and balance is regulated reflexively at subcortical levels Last Viewed Exit Posture & Balance Concept Map

  12. Postural Control System • Motor Output • Produce sufficient force to oppose gravity (Extensor muscles) and maintain LOG inside BOS • Vestibular system has direct input to antigravity muscles to maintain erect posture (vestibulospinal tract facilitates axial extensor muscles) Last Viewed Exit Posture & Balance Concept Map

  13. ALL Tasks Require Postural Control • Orientation component • Visual • Vestibular • Somatosensory • Stability component • Sufficient force production to maintain COG inside BOS • Example: reading a book while: • Sitting, standing, or riding a bus Last Viewed Exit Posture & Balance Concept Map

  14. Nystagmus • Nystagmus is rapid involuntary rhythmic eye movement, with the eyes moving quickly in one direction (quick phase), and then slowly in the other (slow phase). The direction of nystagmus is defined by the direction of its quick phase (e.g.right nystagmus is due to a right moving quick phase). • Dix-Hallpike Test Last Viewed Exit Posture & Balance Concept Map

  15. Postural Mechanisms • What mechanism does the Ventromedial Motor System use to auto-regulate balance during quiet posture? • Muscle spindles and the stretch reflex in antagonistic pairs of muscles • What must be done before the Dorsolateral Motor System can produce smooth, coordinated manipulation on top of the postural set? • Reciprocal inhibition of antagonists Last Viewed Exit Posture & Balance Concept Map

  16. Movement Sequence • During the performance of every task what component of the movement occurs first? • Postural set (anticipatory postural adjustment) • What happens next? • Manipulation is superimposed on a stable base Last Viewed Exit Posture & Balance Concept Map

  17. Cone of Stability • Distance the COG can travel before leaving the BOS • Anterior > Posterior Last Viewed Exit Posture & Balance Concept Map

  18. Balance Strategies • Anterior-Posterior Strategies • Medial-Lateral Strategies Last Viewed Exit Posture & Balance Concept Map

  19. A-P Balance Strategies 1/2 • Ankle strategy • Hip strategy • Stepping strategy Stepping Strategy Hip Strategy Ankle Strategy C of G Flat Surface Narrow Beam Last Viewed Exit Posture & Balance Concept Map

  20. A-P Balance Strategies 2/2 • Different strategies used depending on mass and displacement • Ankle, hip, stepping strategies • Muscle patterns organized in a distal-to-proximal direction • Ankle strategy: distal • Hip strategy: intermediate • Stepping strategy: proximal Last Viewed Exit Posture & Balance Concept Map

  21. Ankle Strategy 1/2 • Postural sway control from the ankles and feet • Head and hips move in the same direction, at the same time, as a unit • Response to small, slow, midline displacement • Surface broad and stable enough to allow pressure against it Last Viewed Exit A-P Strategies Concept Map

  22. Ankle Strategy 2/2 Last Viewed Exit A-P Strategies Concept Map

  23. Hip Strategy 1/2 • Postural sway control from the hip, pelvis, trunk • Head and hips travel in opposite directions (Counteract) • Used when movement is large, fast, nearing the limit of stability • Surface is too narrow or unstable to allow counter pressure Last Viewed Exit A-P Strategies Concept Map

  24. Hip Strategy 2/2 Last Viewed Exit A-P Strategies Concept Map

  25. Stepping (Reaching) Strategy • An attempt to re-establish a new base of support with the active limb when the COG has exceeded the original base of support Last Viewed Exit A-P Strategies Concept Map

  26. M-L Balance Strategies • Alternative strategies used to recover stability in mediolateral direction • Muscle patterns organized in a proximal-to-distal direction Last Viewed Exit Balance Strategies Concept Map

  27. Cognitive Systems in Postural Control • Nervous system must distribute limited attention capacity between postural, manipulative, and cognitive systems • Dual task paradigm • Attentional demands of postural control are small unless the system is stressed • When you slip on the ice you stop searching for your keys Last Viewed Exit Posture & Balance Concept Map

  28. Clinical Examination of Balance • Functional Reach • Clinical Test of Sensory Integration and Balance Last Viewed Exit Posture & Balance Concept Map

  29. Functional Reach Test 1/2 (Duncan 1990) Finish Start 25.5 -8.5 17.0 Last Viewed Exit Balance Tests Concept Map

  30. Functional Reach 2/2 • Interpretation • Normal 15 inches • < 10 inches: increased risk of fall • 5 inches: x 5 increased risk of fall • For every inch less than 10 x 1 increased risk of fall • Intervention • Although this test can identify an activity limitation (functional limitation) it does not identify the responsible body structure or function (impairment) and tell us what to treat (Duncan 1990) Last Viewed Exit Balance Tests Concept Map

  31. Clinical Test for Sensory Integration and Balance (CTSIB)(Foam and Dome Test) 1/8 EYES OPEN EYES CLOSED DOME • Functional test of the effects of various sensory systems on balance • Record the time performer is able to maintain hand contact on shoulder under various testing conditions • Maximum of 30 sec per condition FIRM SURFACE COMPLIANT SURFACE Last Viewed Exit Balance Tests Concept Map

  32. Condition 1 2/8 EYES OPEN • All three senses are available and accurate • Vision • Vestibular • Somatosensory FIRM SURFACE Last Viewed Exit Balance Tests Concept Map

  33. Condition 2 3/8 EYES CLOSED • Vision: unavailable • Accurate senses • Vestibular • Somatosensory FIRM SURFACE Last Viewed Exit Balance Tests Concept Map

  34. Condition 3 4/8 DOME • Vision is inaccurate • Accurate senses • Vestibular • Somatosensory FIRM SURFACE Last Viewed Exit Balance Tests Concept Map

  35. Condition 4 5/8 EYES OPEN • Support surface can sway (Somatosensory cues are available but inaccurate) • Accurate senses • Visual • vestibular COMPLIANT SURFACE Last Viewed Exit Balance Tests Concept Map

  36. Condition 5 6/8 EYES CLOSED • Vision: unavailable • Somatosensory cues are available but inaccurate • Accurate senses • Vestibular COMPLIANT SURFACE Last Viewed Exit Balance Tests Concept Map

  37. Condition 6 7/8 DOME • Vision: inaccurate • Somatosensory cues are available but inaccurate • Accurate sense • Vestibular COMPLIANT SURFACE Last Viewed Exit Balance Tests Concept Map

  38. Sway By Condition 8/8 Last Viewed Exit Balance Tests Concept Map

  39. Balance Training Exercises 1/4 • “Kitchen sink exercises” (Shumway-Cook) • Stand supported at kitchen sink (look out the window – stand up straight) • Toes up, heels up • Side ticks, back kicks • 1/4 squats • Knee to counter Last Viewed Exit Posture & Balance Concept Map

  40. Balance Training Exercises 2/4 • “Kitchen sink exercises” (Shumway-Cook) • Stand supported at kitchen sink (look out the window) • Toes up, heels up • Side ticks, back kicks • 1/4 squats • Knee to counter Last Viewed Exit Posture & Balance Concept Map

  41. Balance Training Exercises 3/4 • “Kitchen sink exercises” (Shumway-Cook) • Stand supported at kitchen sink (look out the window) • Toes up, heels up • Side ticks, back kicks • 1/4 squats • Knee to counter Last Viewed Exit Posture & Balance Concept Map

  42. Balance Training Exercises 4/4 • “Kitchen sink exercises” (Shumway-Cook) • Stand supported at kitchen sink (look out the window) • Toes up, heels up • Side ticks, back kicks • 1/4 squats • Knee to counter Last Viewed Exit Posture & Balance Concept Map

  43. Age-Related Changes in Balance Components Last Viewed Exit Posture & Balance Concept Map

  44. The End © DM McKeough 2006 Last Viewed Exit Posture & Balance Concept Map

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