Balance Seminar – 2017 “There is more to balance…” John Utz, MSPT, CSCS Owner

Balance Workshop - 2017 Objectives: Participants will… Define balance and understand the functionally significant components. Discuss the sensory systems involved with establishing your “reference of correctness” (sensory perception). Learn about the conscious and unconscious mechanisms involved with preventing a fall (motor execution). Appreciate some common changes with age and pathology that can create balance problems. Participate in interactive balance tests. Q &A – Advice

Balance Definition: Ability to control body’s mass or center of gravity (COG) relative to the base of support (BOS). It is an automatic and unconscious process.

Balance: Statistics (CDC) How big is the problem? Over one in four people over 65 will fall during the next year. ~12.5 million people. Each year, 2.8 million older people are treated in emergency departments for fall injuries.5 Over 800,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture.5 Almost half of hospital admissions from falls become SNF residents (47%). Adjusted for inflation, the direct medical costs for fall injuries are $31 billion annually.10 Hospital costs account for two-thirds of the total. The average hospital cost for a fall injury is over $30,000

Balance: Statistics (CDC) How big is the problem? More than 95% of hip fractures are caused by falling,7 usually by falling sideways.8 Falls are the most common cause of traumatic brain injuries (TBI).9 Many people who fall, even those who are not injured, develop a fear of falling. This fear may cause them to limit their activities, leading to reduced mobility and physical fitness, and increasing their actual risk of falling (Vellas et al. 1997).

Functionally Significant Components of Balance: Sensory input and processing. Recognition of body position in relation to self and the environment. “reference of correctness” Motor planning and execution. Generation of movement sufficient to maintain balance and perform the chosen task.

Sensory Input and Balance Three peripheral sensory systems involved with determining your “reference of correctness” Vision – rods and cones Somatosensation / Proprioception – GTO’s, Jt. Receptors, MM Spindles, Corpuscles, and Discs. Vestibular – semicircular canals, utricle, and saccule. Central mechanisms are involved with comparing the bilateral input from the peripheral systems above.

Sensory Input Vision On your retina are Rods and Cones - Contain photoreceptors (pigments that change their 3-D structure when hit by light). Rods – pigment most sensitive to black and white (night vision mostly). Cones – pigment most sensitive to particular wavelengths of light (red, green and blue) and used during the day.

Sensory Input Vision – eye movement 5 types of eye movement that each serve a unique function. Saccades Vergence Persuit VOR

Sensory Input Somatosensation / Proprioception Afferent Nerve Fibers – toward the SC / Brain Light touch Sharp / dull Hot / Cold Vibration Pressure Pain Position sense Stereognosis Graphesthesia Info goes into the posterior root of a spinal nerve. Efferent Nerve Fibers – toward the muscles / extremities. Motor Unit – a group of muscle fibers under the control of ONE nerve fiber.

Sensory Input Vestibular

Sensory Input Vestibular

Sensory Input - Vestibular

Sensory Conflict? Eyes, Somatosensation and Vestibular all need to work together. - Car analogy. Compensations visual dependence > look down > postural changes > COG dark rooms? uneven surfaces? shuffled gait?

Motor Planning and Execution Postural Maintenance Anticipatory Reactions – postural adjustments during self-initiated movement or in anticipation of destabilizing forces. Equilibrium Reactions – postural adjustments made in response to an unexpected, external force (aka: balance strategies, automatic reactions).

Motor Execution Postural Maintenance Quiet stance and sway Width of support Deformities (kyphosis or FHP) Length-Tension of Muscles Important component to consider when evaluating a patient.

Motor Execution Anticipatory Reactions Helps counterbalance inertia of self-initiated movement. Not a reflex. Show specificity to intended movement. Dependent on: Initial conditions of body (posture, flexibility, strength, cognition, etc.) Speed of movement Direction of movement Amplitude of movement Research regarding Cordo and Nasher, 1982; Nardone and Schieppati, 1988

Motor Execution Equilibrium Reactions Four major strategies used in response to unexpected LOB. Ankle Strategy Hip Strategy Suspensory Strategy Stepping Strategy

Motor Execution Equilibrium Reactions The strategy selected (ankle vs. hip vs. step) depends on four things: Position of COG over the base of support. where is the patient within their cone of stability to start? Type of support surface (environment) soft, narrow, static, dynamic…? Speed of movement / severity of perturbation Physiologic factors Available ROM at joints Strength (especially at ankles and hips) Static postural alignment Neurologic ability to execute appropriate strategy (timing, amplitude, sequencing).

Common Changes with Age Visual System – decreased visual acuity, contrast sensitivity, dark adaptation, accommodation, color vision, and motor control. Somatosensory system - ??? Some corpuscles change in morphology. Proprioception loss is controversial and may be joint specific. Decline in afferent fibers within CNS not consistent until 90 years. Vestibular System – Definite (20-40%) decline in hair cells of saccule, utricle and semicircular canal. Presbyastasis – age related dysequilibrium when no other pathology is found. Patients with vertigo, nystagmus, and imbalance must first have vestibular pathology ruled out to ID as presbyastasis.

Common Pathology (Leading to imbalance) Inner ear dysfunction BPPV, Hypofunction Glaucoma and Cataracts Diabetes / Neuropathy Stroke / TIA Head Injury Medications? Arthritis Inflexibility Osteoporosis Poor Posture Muscle Weakness TKA, THA

How can I prevent a fall? (CDC) Exercise regularly; exercise programs like Tai Chi that increase strength and improve balance are especially good. Ask your doctor or pharmacist to review your medicines–both prescription and over-the counter–to reduce side effects and interactions. Have your eyes checked by an eye doctor at least once a year. Improve the lighting in your home. Reduce hazards in their home that can lead to falls. Participate in vestibular / balance treatment if necessary.

Interactive Drills Feet together, arms crossed. Eyes open. Eyes closed?

Interactive Drills Tandem Stance – heel to toe

Interactive Drills Stand on one foot. Goal = 30 secs

Interactive Drills On toes and reach

Interactive Drills Alternate toe taps on step (book). Add coordination drills to increase difficulty.

Q & A