Balance and Falls Nancy V. Karp, Ed.D., P.T. [email protected].

Balance and FallsBalance and Falls

Nancy V. Karp, Ed.D., P.T.

[email protected]

Normal Postural ControlNormal Postural Control

Postural control involves controlling the body’s position in space for:

Stability Orientation

FallsFalls

Falls in the elderly are a major cause of: morbidity Mortality

The underlying causes of falls is a complex interaction of: Biomedical factors Physiological factors Psychosocial factors Environmental factors

Incidence and Cost of Falls in the ElderlyIncidence and Cost of Falls in the Elderly

Falls of people 65+ One third of people 65+ fall each year. Elders > 75 account for 60% of fall-related deaths. 25% of elders who fracture their hip in a fall will die

within a year.

Costs Falls account for 70% of all injury-related costs for

the elderly, The average cost for a fall injury is $20,000.

Falls in the Elderly Falls in the Elderly

Most falls result in minor or no injury.

Repeat fallers tend to fall in the same manner as they did in the previous fall.

A single fall results in: Fear of falling and loss of confidence Restriction in activities Social isolation Dependence on others

Identification of Fall Risk Factors Identification of Fall Risk Factors

Risk factors for falls are divided into two categories:

Intrinsic Risk FactorsDizziness, weakness, gait abnormalities, poor balance, confusion, poor coordination, ROM, cognitive impairment

Extrinsic Risk FactorsFloor surface, poor lighting, cluttered furniture, obstacles, non-level surface, poor shoes

Falls are a result of loss of postural control.

Falls are a result of loss of postural control.

Normal Postural Control (Balance)

Normal Postural Control (Balance)

Balance requires keeping the “Center of Mass” (COM) over the “Base of Support” (BOS) during static and dynamic situations.

Neural components of postural control: Sensory processes

visual, vestibular, somatosensory Central processing

a higher-level integrative process Effector component

sometimes referred to as the neuromuscular component postural alignment, ROM, muscle force, power & endurance

Normal Postural ControlNormal Postural Control

Adaptive postural control requires modifying sensory and motor systems to changing tasks and environmental demands.

Postural Control During Quiet Stance

Postural Control During Quiet Stance

Body aligned to minimize the effect of gravitational forces.

Muscle tone

Postural tone

Quiet StanceQuiet Stance

Limits of Stability (LOS)Limits of Stability (LOS)

The maximum angle (from vertical) that can be tolerated.

How far you can shit from front to back and side to side without loosing balance? This is often called your “Cone of Stability.”

“Postural Sway” refers to small postural shifts from front to back and side to side, during quiet stance.

Limits of StabilityLimits of Stability

Cone of StabilityCone of Stability

Cone of Stability with

Assistive Device

Cone of Stability with

Assistive Device

Postural SwayPostural Sway

The larger the sway path, the greater the postural unsteadiness.

Romberg Test- Closing eyes will decrease visual input. “Standing Postural Sway” may increase, decreasing balance.

Postural Control During Perturbed Balance

Postural Control During Perturbed Balance

The recovery of stability requires movement strategies that control the COM over the BOS.

“Limits of Stability” is defined as the distance a person can move, without losing balance or taking a step.

Perturbed BalanceMovement Strategies


The “ankle strategy” occurs with minimal perturbance of balance.

Control is distal- to-proximal



Moderate instability leads to the “hip strategy”.

Control is proximal-to-distal



The “stepping strategy” is used with greater perturbance.

Perturbed Balance Central Nervous System


The response can either be protective or corrective.

“Anticipatory Postural Control” refers to postural adjustments that are made before voluntary movements to minimize disturbances in balance (feed forward).



“Reactive control” is the response to a disturbance in balance (feedback).

Corrective Strategy, such as the “ ankle strategy”

Protective Strategy, such as covering your head when you fall

This does not correct the fall, but controls the effects of the fall.



The CNS activates muscle synergies in related joints.

Force in one part of the body does not cause instability in another part of the body.

Leaning over in a chair to pick up a pen, you do not fall out of the chair.

Neck extension during the “hip strategy” prevents the body from falling forward.

Central Processing TestsCentral Processing Tests

Manual Test of Postural Perturbance

Therapist pulls patient, at waist level, several times with varying degrees of force.

See Guccione, p. 287

Normal Postural ControlSensory System


During perturbance of balance: Adults rely on somatosensory inputs. Children rely more on visual input.

The interaction of the senses allows the modification needed to maintain stability in a variety of environments.



The three different parts of the sensory system provide different sources of information about the body’s position and movement in space.

Each sense provides a different frame of reference for postural control.



The “Postural Dyscontrol” Test will be performed in class.

“Foam and Dome Test”

O’Sullivan, p. 193



Vision provides information about the position and motion of the head in the environment.

Acuity- detects subtle differences in shapesSnellen Eye Chart (min 20/200)

Depth perception Finger Test, Guccione p. 286

Peripheral visionFinger Test, Guccione p. 286



The somatosensory system provides information about the body with reference to supporting surfaces.

The somatosensory system receives information from muscle spindles, joint receptors, tendon organs, and mechanoreceptors.

The Somatosensory systemThe Somatosensory system

Gross Tests of Proprioception Detecting the subtle movement of the big

toe (< 5mm).

Vibration- Placing a tuning fork at the first metatarsal head.



The Vestibular System Provides information about the position and

movement of the head, in reference to gravity and inertial forces.

Information is received from the vestibule responsible for position and linear acceleration.

Information is received from the semi-circular canal responsible for rotational movement.

The Vestibular SystemThe Vestibular System

Gross Functional Tests

Guccione, p. 286 Looking at a object while turning head Reading a book while walking Marching in place with eyes closed

Postural ControlPostural Control

Controlling the body’s position in space is an essential part of functional skills.

Postural control requires all three: Sensory system Central processing Effector components

Postural ControlPostural Control

The three systems in postural control are complex and multifaceted. A problem or impairment in one area may affect several other areas, resulting in a greater affect than the loss of the single impairment.

The Effect of Aging on Postural Control

The Effect of Aging on Postural Control

The Sensory System With aging, vision may decrease in acuity,

contrast sensitivity, and depth perception With aging, the vestibular system may

undergo age-related changes, resulting in dizziness and unsteadiness.

With aging, there may be a decrease in proprioception and vibration.

Aging Effects on Postural Control


The Central Processing System Aging may result in a slowing of sensory

information. Aging may result in a slowing of nerve conduction

velocity. Aging may result in increased postural sway. Aging may result in an increased incidence of co-

contractions Aging may result in an increased use of proximal-to-

distal control for balance.



The Effector System Aging may result in decreased muscle

strength. Aging may result in decreased ROM and

flexibility. Aging may result in increased “stiffness” of

connective tissue Aging may result in cardiovascular

changes

Functional TestsFunctional Tests

Progressive Mobility Skills Assessment TaskGuccione, p. 288

Berg Balance Scale (note that the “Functional Reach Test” is part of this test)O’Sullivan, p. 208

Performance-Oriented Assessment of Mobility I (Tinetti)O’Sullivan, p. 210

Other AssessmentsOther Assessments

Environmental AssessmentsChapter 12, O’Sullivan

Psychosocial Assessment Cognitive assessments Social work assessments

InterventionsInterventions

Interventions should be based on assessment results.

The ultimate goal will is to maximize independence in mobility and function.

The therapist needs to identify and treat modifiable deficits.

The therapist needs to identify and help the patient compensate for deficits that cannot be modified.

Some balance exercises for older people.

Some balance exercises for older people.

Exercises - National Institute on Agingl

Tandem Walking

Fall PreventionFall Prevention

The purpose of assessment and intervention is to prevent the next fall.

Balance and FallsBalance and Falls

The End

Balance and Falls Nancy V. Karp, Ed.D., P.T. [email protected].

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Transcript of Balance and Falls Nancy V. Karp, Ed.D., P.T. [email protected].