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

2. 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

3. 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.

4. 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

5. 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).

7. 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.

8. 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.

9. 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.

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

12. 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.

13. Sensory Input Vestibular

14. Sensory Input Vestibular

15. Sensory Input - Vestibular

17. 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?

18. 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).

19. 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.

20. 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

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

23. 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).

24. 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.

25. 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

26. 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.

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

28. Interactive Drills
Tandem Stance – heel to toe

29. Interactive Drills
Stand on one foot. Goal = 30 secs

30. Interactive Drills
On toes and reach

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

32. Q & A