1
Q
what is postural orientation
A
the ability to maintain an appropriate relationship between the body segments and between the body and the environment for a task
2
Q
what is postural stability
A
ability to control movements of the COM relative to stability limits in order to maintain equilibrium
3
Q
what are stability limits
A
area in which the center or mass can be moved safely without changing the base of support
4
Q
what are the postural requirements within every task
A
- ability to generate forces and coordinate forces across joints to move COM
- ability to detect position of COM
- Internal representation of stability limits of body, task and environmnent
- adaptive postural control involves modifying sensory and motor systems in response to changing task and environmental demands
5
Q
name 3 factors that contribute to motor organization of balance and stability
A
- alignment that will allow for the least energy expenditure for maintenance of upright psoture
- normal “stiffness” of muscles via mechanoelastic properties
- normal activation of muscles in upright and sway
6
Q
describe quiet stance
A
it is dynamic; a multi-linked pendulum
there is still movement occurring
7
Q
why is sway important during quiet stance
A
it helps the brain to maintain awareness of the body
8
Q
what are the 3 movement strategies during perturbed stance
A
ankle
hip
stepping
9
Q
when is the ankle strategy used
A
used for SMALL perturbances or standing on a firm surface that is long in relation to the foot length
10
Q
What is the order of muscle activation in an ankle strategy
A
activate distal to proximal sequence to generate ankle torque while maintaining stability of knee and hip joints
11
Q
what is the order of muscle activation when pushed backward while using the ankle strategy
A
anterior tibialis -> quads -> hip flexors
12
Q
what is the order of muscle activation when pushed forward while using the ankle strategy
A
gastrocs -> hamstrings -> hip extensors
13
Q
when is the hip strategy used
A
used for standing on surfaces short in relation to foot length and to control LARGE and RAPID sway or the surface is compliant
also used when sufficient torque about the ankles is not possible
14
Q
what is the stepping strategy
A
moving the base of support when sufficient ankle torque or hip movement cannot be exerted with feet in place to maintain eqilibrium
15
Q
lateral disturbances for motor control
A
there is more variability than anterior/posterior
there is much more hip and trunk movement than ankle (more proximal muscle recruitment)
16
Q
how does the head move during a lateral disturbance
A
it moves in the opposite direction from the hips/ankles
17
Q
what is the pattern of muscle activation for lateral disturbances
A
proximal -> distal
18
Q
what is one thing the cerebellum helps to do?
A
helps modify the amplitude of the responses
19
Q
what is one thing the basal ganglia helps to do?
A
helps to change the pattern of responses when the task and environment changes
20
Q
general comments on sensory organization of balance
A
- senses contribute to postural control by giving info to the CNS so you know how and when to use motor strategies
- each sense that contributes provides a different frame of reference for postural control
- sensation provides not only feedback info but also feed forward info.
21
Q
what does vision give us?
A
provides us with info about the position (verticality) and motion of head with respect to surrounding objects
22
Q
when is somatosensory system not active
A
it is not active in a changing environment like an incline, floating pier, boat or compliant foam
23
Q
what are the important components of the vestibular system
A
- reports on linear, angular head accelerations and verticality
- gaze stabilization
- provides info to help differentiate between self motion and object motion
- cannot provide a true picutre of how whole body is moving in space
24
Q
when in vestibular system very important?
A
during certain situations such as walking in a dark room, changing surfaces or inclines or lots of motion relative to you and the moving surface
25
when on an incline which system(s) activate the response
the vision and vestibular systems
26
what information does the ankle strategy rely on
somatosensory information
27
what information does the hip strategy rely on
relies more on head senses such and vision and vestibular info
28
what are the key aspects to remember when learning new movements
- use vision a lot initially
| - as you improve and learn use somatosensory
29
what is anticipatory control
activation of postural muscles in anticipation of potentially destabilizing voluntary movement
30
what are some coordination deficits of motor responses
- sequencing problems
- reversal of muscle firing order
- elimination or long delay of proximal muscle activation
- coactivation
- delayed activation of entire postural response
- scaling problems
- motor adaptation problems
- inability to change strategies when task/environment changed
31
what is a sensory selection problem
inability to select an appropriate sense for postural control when one or more orientation cues is inaccurately reported
32
list of functional examination tests
```
falls efficacy scale
activities specific balance confidence scale
postural assessment scale for stroke patients
get up and go tests
TUG
Functional reach tests
tinetti performance oriented mobility test
berg
fullerton advanced balance scale
short physical performance battery
four square step test
BESTest
```
33
strategy examination tests
alignment- examining HOW they stay upright
| movement strategies
34
what are the 4 contexts of maintaining balance
- stability limits
- reactive
- anticipatory
- adapatability
35
what is the purpose of the Clinical Test for Sensory Interaction in Balance
the whole purpose is to test the visual misinformation
it also lets us know what sensory strategy a patient prefers
this is the foam and dome test so you must guard carefully
36
ways to improve perceptual impairments
```
mirrors
lean on stick on wall
scales
force plates with biofeedback
lining up flashlights with targets
```
37
interventions for limits of stability
lots of practice of self-initiated sway
looking over the shoulder in sitting and standing
reaching in sitting and standing
catch/hit ball
38
what is pusher syndrome
termed as contraversive pushing where the individual pushes with the stronger extremities toward the weaker side
39
what structure is damaged in someone with pusher syndrome
the posterior lateral thalamus which is the relay station
40
what are the effects of unilateral assistive devices
puts them out of alignment
| makes them rely too much on the stronger side
41
what do you need for the ankle strategy
first you must have adequate ROM then sufficient strength
42
what are some anticipatory functional activities that would typically use the ankle strategy
```
self-initiated sway
small external perturbances
look over the shoulder
lifting objects over the head
reaching
throwing gently
```
43
how to develop a coordinated hip strategy
```
larger perturbations
restrict ankle ROM
stand on narrow beam
stand heel to toe
single limb stance
stand near edge of platform
improve coordination of hips and trunk
```
44
how to develop a coordinated step strategy
tell pt. goal is to take steps
shift patients weight to one side then quickly to the other
larger pertubations
thinking about progressing to all directions
45
sensory strategies for those visually dependent
```
decrease lighting
close eyes, blindfolds
petroleum jelly on glasses
balance activities with misinformation in front of view
retrain ANKLE strategy
```
46
sensory strategies for surface dependency
retrain the HIP strategy
work on varying surfaces
close eyes and provide visual conflict for progression
47
interventions for sensory selection problem
incremental exposure to sensory conflict
| recreate clinically test conditions 3, 4, 5 and 6
48
what are the 2 goals of posture control
orientation and stability
49
what are the functions of the vestibular system
steady the gaze so you can see via the VOR
| keeps you from falling down
50
what is the function of the semicircular canals
encode rotational accleration/deceleration to help detect movement and velocity
51
what is the function of the otoliths
encodes linear acceleration/deceleration and earth vertical
52
what is the VOR responsible for
stability of gaze
| the eyes move in equal and opposite direction of the head
53
what is the VSR responsible for
helps control movement and stabilize the body when the head moves
54
what is the COR
a slower additional system for orienting the head eyes and making postural adjustments
55
types of peripheral dysfunction
```
BPPV
vestibular neuritis
labyrinthitis
meinere's
acoustic neuroma
```
56
types of central dysfunction
```
migraine
TBI
CVA
Cerebellar degeneration
tumor
MS
```
57
What is the most common cause of vertigo
BPPV; benign paroxysmal positional vertigo
| that most often involves the posterior canal
58
which type of vestibular disorder is more common
peripheral is more common than central
59
what initiates the vertigo in BPPV
very specific configurations or with rapid change in head positions such as extension with head turned to one side, rolling from side to side in bed
could also be from an overactive vestibular system- debris in the system via canalithiasis or cupulolithiasis
60
what is canalithiasis
degenerative debris floating freely in the canal
| when the head moves in provoking positons, debris in the canal moves dependent on these positions
61
characteristics of canalithiasis
- 1 to 40 sec onset of vertigo AFTER moving into provoking position
- nystagmus onset of same latency of veritigo
- fluctuation of intensity of vertigo and nystagmus
- gone in 60 sec
62
what is cuplolithiasis
degenerative debris that adheres to cupula which leads to an inappropriate deflection of cupula in provoking movements/positions
63
characteristics of cupulolithiasis
IMMEDIATE onset of vertigo as person moves into provoking positions
immediate nystagmus onset
persistence of vertigo and nystagmus as long as in provoking position
64
viral or bacterial infections result in what type of vestibular issue
vestibular neuritis or labyrinthitis
65
what are the characteristics of viral infections of the vestibular nerve
often preceded by URI by GI tract infection
usually acute onset of severe, prolonged rotational vertigo which is worsened by head movement, spontaneous nystagmus, postural instability and nausea
usually no hearing loss
symptoms disappear in 48-72 hours; normal balance in 6 weeks
66
what is Meniere's disease
disturbed endolymph flow
67
what are the typical symptoms of Menieres disease
aural fullness
decreased hearing
tinnitus followed by rotational vertigo, nystagmus, postural instability nausea and vomiting
severe symptoms for 1/2 hour to 24 hours.
slowly improve and able to ambulate within 72 hours
68
characteristics of acoustic neuroma
usually present with gradual unilateral hearing loss but can first present with vestibular symptoms or sudden hearing loss
69
What structures are involved in central vestibular disorders?
cerebellum
MLF
midbrain
vascular
70
What are vertiginous migraines
specific episodes of vestibular symptoms of moderate or severe intensity that last between 5 minutes and 72 hours
may occur with or without the typical headache but has migraine headaches 50% of the time
71
What does hypofunctioning/decreased vestibular input cause?
postural instability from having to rely on the vestibular info
72
What causes hypofunction?
head trauma, CVA,CP, Down syndrome, some learning disabilities, deafness
73
What is Mal de debarquement syndrome?
occurs after boat or airplane travel and is the illusion of moving when stationary
74
What do abnormal saccades indicate?
cerebellum or brainstem problems
75
What to do to test vergence
hold your forefinger about 2 feet away from the patient and ask them to focus on your finger while you slowly move it to the bridge of the nose
Their eyes should converge and pupils constrict
76
What does it mean if the pt. has blurry or double vision if the finger is held > 4 inches away during vergence testing?
this is a central sign
| It affects the ability to read
77
How to perform VOR cancellation
patient fixates on your nose, passively move patients head slowly horizontally while you are moving with the patient. They should be able to maintain gaze on target
78
When is the Hallpike-Dix manuever used?
for patients who complain about vertigo only in certain positions/movements (BPPV)
79
What canal is BPPV most commonly seen in?
the posterior canal
80
What side is Hallpike-Dix first performed on?
we test the side OPPOSITE of provoking symptoms first
81
What is extremely important with this type of test?
Pt. education- you must warn them in advance that this test may cause vertigo but it is the best way to evaluate and treat them
82
Which test best tests the horizontal canals?
The roll test
83
What are habituation exercises?
repeated exposure to positions/movements that evoke symptoms
| wait until symptoms return to baseline before doing the next movement
84
Which pathology has better recovery?
unilateral vestibular pathology has better recovery
85
What are the 3 major requirements for locomotion
- progression
- stability/postural control
- adaptability
86
How does progression, stability and adaptation occur in STANCE
progression occurs as a result of generating horizontal forces against the support surface
stability occurs from vertical forces and impact absorption to support the body
adaptation is used to accommodate changes in speed, direction and support surface changes
87
How does progression, stability and adaptation occur in SWING
progressions occurs via advancement of the swing leg
stability is prepared for through weight bearing
toe clearance is for both progression and stability
adaptability needed to clear objects
88
Components of somatosensory strategy
joint receptors and m. spindles
GTO
cutaneous reflexes
stretch reflexes
89
What is a proactive strategy?
Feed forward
brain appears to have certain rules it learns and follows
This pre-setting involves identifying potential obstacles using avoidance strategies, predicts potential destabilizing effects through accommodation strategies and visual monitoring
90
Where is gait initiated?
in higher centers to involve shifiting the center of gravity to set it in motion
91
What is functional ambulation?
- ability to walk 1000 feet
- ability to walk 1 m/s
- 80m/min velocity for 13-27 m (cross street safely)
- negogiate curb independently
- ability to turn head while walking without losing balance
92
Interventions for verticality problems
mirror to establish midline
somatosensory input to cue abnormal weight shift
line self up with family member in front of them
using flashlight to hit the target
pin the tail on the donkey
93
interventions for unilateral visual neglect
remind them and make them look at side of neglect
| engage them to that side
94
interventions for stability limits
challenge stability limits safely
need error signals to improve balance
knowledge of results to know what just happened
95
interventions for pusher syndrome
engage the other side
using visual vertical for feed back on orientation
take away their pushing arm safely
avoid parallel bars if possible
use vertical visual aids since they still have their visual perception intact
96
pre-ambulation skill training
ambulation must be broken down first for success
developmental sequence of rolling, prone on elbows, supine bridging, counter rotation trunk movements, all fours, kneeling, half kneeling
97
what are we looking for at the strategy level of interventions
looking for functional which implies efficient and adaptable
98
what things can trigger episodes of freezing in PD patients
- sudden direction changes
- doorways
- approaching obstacles
- turning around to sit
- change in floor pattern
- confined spaces
- crowds
- stress, anxiety
99
What is retropulsion?
backward balance loss with reduced step size and increased cadence
triggered by backing up, reaching overhead, stepping away
100
what are the 4 S's for freezing interventions
Stop
Stand tall
Sway side to side
Step long
101
What is the major component to remember for interventions with MS patients
intermittent exercise with recovery BEFORE fatigue occurs
| rest at first signs of movement difficulty and first noting of subjective fatigue
102
causes of impaired heel strike during foot contact
```
dorsiflexor weakness
PF contracture
heel pain
hamstring/gastroc hypertonicity
decreased sensation
```
103
coronal plan deviations during foot contact
weak evertors
genuvarum at the knee
hypertonic tibilis posteior
leg length discrepancy
104
excessive knee extension at foot contact
quad spasticity/weakness
105
excessive knee extension in mid stance
plantar flexor spasticity
| clonus at the ankle
106
persisting knee flexion in mid stance caused by:
hamstring spasticity/hypertonicity
knee/hip flexion contracture
PF contracture
107
excessive hip flexion in mid stance caused by
hip/knee flexor contracture
hip extensor weakness
forward trunk lean
pain
108
backward lean of trunk in midstance caused by
hip extensor weakness/ spasticity
shifts the line of gravity posterior to the
hip reducing the demands of the hip extensor
muscles
knee lock
109
lateral lean of trunk over stance leg in midstance
```
painful hip
flaccid UE
weak abductors
hypertonic adductors
severe scoliosis
dependence on assistive device
```
110
drop in pelvis (contralateral to stance leg)
weak abductors (glute med)
L5 radiculopathy
adductor contracture/hypertonicity
111
scissor gait caused by
weak abductors
hypertonicity/contractures of adductors
ataxia
112
lack of hip extension in terminal stance
hip flexion contracture
| weak glutes
113
inadequate toe-off in terminal stance
PF weakness
extensor synergy
pain in forefoot
lack of somatosensation and recruitment
114
inadequate hip flexion in initial swing
weak hip flexors
| hypertonicity in hip extensors
115
inadequate toe clearance in mid swing
decreased hip flexion
PF contracture
weak DF
stuck in extensor synery
116
excessive addcution in midswing
hip flexor weakness
| hypertonicity of adductors
117
inadequate knee extension in terminal swing
knee flexion contracture
abnormal synergies
hypertonicity of hamstrings
limited hip flexion
118
What is reactive control
response of external perturbation
119
What is adaptive control
ability to change strategies appropriate to certain tasks such as varying support surface, rate and range of perturbation, narrow BOS, single leg, tandem standing
120
Condition 1 of CTSIB
accurate vestibular, visual and somatosensory
121
Condition 2 of CTSIB
(blindfolded): accurate vestibular and somatosensory
122
Condition 3 of CTSIB
(in the dome): accurate vestibular and somatosensory; inaccurate vision
123
Condition 4 of CTSIB
(compliant surface): accurate vestibular and vision; inaccurate somatosensory
124
Condition 5 of CTSIB
(compliant surface and blindfolded): accurate vestibular; inaccurate somatosensory
125
Condition 6 of CTSIB
(compliant surface in the dome): accurate vestibular; inaccurate vision and somatosensory
126
What is the order of testing for BPPV
```
• Look for spontaneous nystagmus and skew deviation
• Eye alignment: look to see if eyes are aligned vertically or horizontally
• Eye ROM/smooth pursuits/gaze holding nystagmus
• Vergence
• Saccades
• Slow VOR
• VOR cancellation
• Head thrust
• Dynamic visual acuity test
• Positional and movement testing (hallpike-dix maneuver)
• Special forms/questionnaires
• Thorough sensory exam via CTSIB or SOT
• Thorough balance and gait exam
o Berg balance
o Dynamic gait index
o Min BESTest
```
127
what movement is usually combined with recurvatum?
forward trunk lean
128
what causes knee hyperextension during loading in stance phase
quad weakness
129
what causes knee hyperextension in mid stance
hyperactive plantarflexors
Adult Neuro
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