Chapter 17 Balance Assessment and Intervention

CH 17 Balance Assessment and Intervention Balance and Impairment in Daily Occupation Balance required in sitting and standing, functional ambulation Both client factor and performance skill High medical costs, decline in QOL, can be fatal Neurological and Physiological Basis of Balance Coordination of musculoskeletal systems and sensorimotor neural systems Balance regulated by sensory and motor systems -vestibular, visual, tactile, proprioceptive Vestibulocochlear nerve – balance and spatial orientation Proprioception – body position and movement Each time person moves, center of mass (CoM) changes relationship to BoS Postural skills allow us to stay in balance by maintaining CoM in BoS Control during postural adjustments required for all reaching from sitting or standing position If unable to bear or weight shift – neuro or ortho deficit, asymmetrical postural alignment and control Contributions – decreased trunk strength, weakness, LE weakness, decreased ability to recover from balance loss, Stroke – reduced weight bearing on affected side, postural sway during standing, reduced sensation, unilateral inattention, delayed equilibrium, impaired postural adjustments Balance disorders – dizziness, certain medications, BPPV Screening of Balance Skills Impaired when individual unable to maintain a sitting or standing position without support or assistance Signs Indicating Dysfunction in Balance Analyzing postural alignment, if leaning, if able to sit unsupported Ability to flex and extend trunk – decreased core strength Control while reaching, across midline during functional tasks Impaired righting, depth perception, dizziness Goal – maintain CoM over BoS during weight shift Weight bearing leg – 90 degrees of ankle dorsiflexion, active ext at knee, active hip extension, neutral pelvis Possible Causes of Impairment Medical hx, certain dx, anxiety regarding falls, history of falls Screening Instructions Not a commonly accepted method for sitting balance but objective skilled doc for d/c and reimbursement requires standard measurable data Standard for standing balance Review hx and profile, medications, dx, side effects, BP, dizziness, safety Grading – static and dynamic balance for both sitting and standing – Normal, Good, Fair, Poor (Refer to table 17.1) Static Sitting Balance - Determine if client can sit unsupported without balance loss and without UE support - Apply pressure to trunk in anterior, posterior, lateral directions - Determine if can maintain against min, mod, max. Increase amt of resistance if safe and comfy - If cannot sit unsupported, determine if can maintain balance with UE support or if needs min, mod, max from individual or chair Dynamic sitting Balance - If can sit unsupported, determine how far can weight shift, cross midline, reach in multiple planes, make sure not using other UE for support. Classify as min, mod, max - If can sit unsupported but has difÏculty crossing midline – determine whether can complete weight shift or reaching to ipsilateral side - If unable to sit unsupported – determine if need mod or min A – indicates that unable to reach or weight shift - If requires max A – you do not need to screen for dynamic balance – indicates Poor Static Standing Balance Screening - Determine if can stand supported without UE support and without balance loss for 1-2 min - If can do above – apply pressure to anterior, posterior, lateral - Determine if can maintain against min, mod, max - If not – determine whether can maintain without UE support and max, mod, min support from individual or AT Dynamic Standing Balance Screening - If can stand independently unsupported, determine whether to weight shift and cross midline to contralateral min, mod, max, increase distance as tolerated - If able to stand unsupported but cannot reach to contralateral side, ask to reach ipsilateral side and cross midline - If can stand with supervision and reach to ipsilateral side, determine if can weight shift - If can stand with min, mod A determine if can weight shift, reach ipsilateral, or cross midline - If require max A during standing– do not screen dynamic, Poor Another option is Kansas University Sitting and Standing Balance Scale (KUSSBS) – numerical grading from 0-5, reliable and valid – person dependently moves and returns to center in all planes >2 in Assessing Impact on Daily Occupational Function Determine impact of impairments on daily occupational performance through skilled observation and measurement of A because no standard assessments that are occupation based Determine risk for falling and impact on occupational performance If problem during screen – do in depth assessment Balance observed during movement in sitting, standing, looking and reaching, walking in various Overview of Intervention for Balance Impairment Address cause of balance deficit – underlying cause will determine treatment approach Remediation used if there is potential for deficit to improve; compensation/adaptation if no potential for improvement or to promote safety while working to improve deficit Remedial techniques = ROM, strength and/or endurance Compensatory techniques = using UE or weight shifting techniques to offset deficit Adaptation techniques = adaptive equipment or devices to environment Specific Interventions for Balance Impairment Remediation of Balance Impairments Improve core, UE, and LE strength or activity tolerance Gradually increase weight/reps of activity Preparatory methods to treat edema and/or pain include modalities, manual techniques, splinting, and positioning If soft-tissue stiffness causes impaired postural control – begin w passive stretching before balance activities If postural insecurity causes impaired postural control – provide external support via “handling” Select exercise to target muscles that have been ID as debilitated during assessment UE muscle strength specifically may be necessary for compensatory or adaptive techniques Incorporate resistive exercises or other forms of exercise i.e. yoga, tai chi, and repetitive task training Balance and Reaching improved by gradually increasing activity demand tasks For seated balance, develop client’s understanding/awareness of postural adjustments Optimal postural alignment for seated daily tasks: pelvis in neutral to anterior tilt w equal weight bearing on the ischial tuberosities, trunk extended in midline orientation, shoulders symmetrical and positioned anterior to hips, hips and knees flexed and neutrally rotated, and feet on floor ready to accept weight Provide verbal/visual cues (via mirror or recording) to help client develop awareness and recognize errors Occupation-based challenges that demand client to move in variety of planes to improve ability to look and reach for moving objects to support participation in activities such as bathing, dressing, grooming, household tasks Core is strengthened while client is moving across different planes Standing balance can be challenged by exercising LE muscles during task performance requiring weight shifting to reach for objects in different planes Compensating for Balance Impairments Education on: safe weight shift technique, brace w contralateral UE, get dressed lying in bed, complete LB dressing in sitÝng, perform standing activities in chair, position self directly in front of work space, make bed while lying in it, terry cloth robe to dry off Adapting for Balance Impairment Supports added to the home such as grab bars, railings, toilet safety handles, nonslip adhesive surfaces, use of reacher, pant clip for toileting management, bed rails Environment can be arranged to decrease reaching distances, allow for tasks to be completed in sitÝng, hygiene/grooming tools on bathroom counter within reach Functional Mobility Interventions aimed at improving ability to perform bed mobility, transition between sitÝng and standing, and perform daily activities while standing and walking Standing Up and SitÝng Down Use arm rests or grab bars to push down, reach back, pull, or steady self – not ideal for clients post CVA or brain injury Teach squat pivot for transferring from one surface to another bc not required to shift weight between LE – used for clients who will not progress to walking Environmental adaptations include raising height of seating surface, grab bars, and chair w armrest Functional Mobility Most common risk factors for impaired mobility are older age, decreased physical activity, obesity, strength or balance impairment, chronic diseases Training centers on safety and fall prevention Work with PT to maximize efÏcient gait patterns Occupation-based interventions aim to improve stability and facilitate proper postural adjustments during activities in sitÝng and standing that require weight shifting and reaching in variety of directions Compensatory techniques include use of energy conservation techniques Work with client to ensure compensatory strategies are safe and don’t cause additional structural damage Adaptive techniques commonly include canes, crutches, walkers, and wheelchairs, use of shopping cart for balance and/or object transportation Fall Prevention Individuals at risk for falls benefit from individualized, multifactorial approach including combination of functional ambulation training and advice on use of appropriate adaptive devices, exercise programs, treatment of postural hypotension, modification of environmental hazards, and treatment of cardiovascular disorders Emerging evidence supports use of virtual reality in therapy to improve balance for patients post CVA