1. Balance and Falls Nancy V. Karp, Ed.D., P.T. Nvkarp@gmail.com

2. Normal Postural Control Postural control involves controlling the body’s position in space for: Stability Orientation

3. Falls 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

4. Incidence 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.

5. 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

6. Identification of Fall Risk Factors Risk factors for falls are divided into two categories: Intrinsic Risk Factors Dizziness, weakness, gait abnormalities, poor balance, confusion, poor coordination, ROM, cognitive impairment Extrinsic Risk Factors Floor surface, poor lighting, cluttered furniture, obstacles, non-level surface, poor shoes

7. Falls are a result of loss of postural control.

8. 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

9. Normal Postural Control Adaptive postural control requires modifying sensory and motor systems to changing tasks and environmental demands.

10. Postural Control During Quiet Stance Body aligned to minimize the effect of gravitational forces. Muscle tone Postural tone

11. Quiet Stance

12. 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.

13. Limits of Stability

14. Cone of Stability

15. Cone of Stability with Assistive Device

16. Postural 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.

17. 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.

18. Perturbed Balance Movement Strategies The “ankle strategy” occurs with minimal perturbance of balance. Control is distal- to-proximal

19. Perturbed Balance Movement Strategies Moderate instability leads to the “hip strategy”. Control is proximal-to-distal

20. Perturbed Balance Movement Strategies The “stepping strategy” is used with greater perturbance.

21. 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).

22. Perturbed Balance Central Nervous System “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.

23. Perturbed Balance Movement Strategies 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.

24. Central Processing Tests Manual Test of Postural Perturbance Therapist pulls patient, at waist level, several times with varying degrees of force. See Guccione, p. 287

25. Normal Postural Control Sensory 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.

26. Normal Postural Control Sensory System 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.

27. Normal Postural Control Sensory System The “Postural Dyscontrol” Test will be performed in class. “Foam and Dome Test” O’Sullivan, p. 193

28. Normal Postural Control Sensory System Vision provides information about the position and motion of the head in the environment. Acuity- detects subtle differences in shapes Snellen Eye Chart (min 20/200) Depth perception Finger Test, Guccione p. 286 Peripheral vision Finger Test, Guccione p. 286

29. Normal Postural Control Sensory System T he 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.

30. T he 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.

31. Normal Postural Control Sensory System 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.

32. The 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

33. Postural 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

34. Postural 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.

35. 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.

36. 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.

37. Aging Effects on Postural Control 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

38. Functional Tests Progressive Mobility Skills Assessment Task Guccione, 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

39. Other Assessments Environmental Assessments Chapter 12, O’Sullivan Psychosocial Assessment Cognitive assessments Social work assessments

40. Interventions 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.

41. Some balance exercises for older people. Exercises - National Institute on Agingl

44. Tandem Walking

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

46. Balance and Falls The End