the ability to maintain equilibrium; maintain center of mass over the BOS
What is the difference between static and dynamic balance?
static is still dynamic is movement.
awareness of static posture is known as?
Kinesthesia is relative to ____________ and how does it happen?
joint motion; sensory receptor signals from muscle, tendon, and joints.
the overall function of joint receptors to deliver input concerning joint position movement, direction, speed and amplitude is known as?
limits of stability can also be described as?
limits of stability
the perimeter of the contact area between the body and its support surface and can be altered by foot placement?
The ground "pushing back" in an equal and opposite direction is also known as?
ground reaction force
What is it called when your body respones to external forces acting on the body?
reactive postural control
anticipated response to internally generated, destabilizing forces imposed on body movements are known as?
proactive postural control
T/F: if something interfers with sensory it will interfer with balance?
What allows an individual to appropriately "modify sensory and motor systems in response to changing task and environmental demands?
adaptive postural control
What roles does the nervous system play in balance?
sensory processing regarding movement, and orientation through the vestibular, visual, and somatosensory.
sensorimotor intergration for linking sensation to motor responses and for anticipatory and adaptive aspects of postural control.
development of motor strategies for planning, programming, and executing balance responses
how does the musculoskeletal system play a role in balance?
postural alignment, flexibility, joint ROM and mobility, muscle recruitment and performance.
What are the contextual effects on balance?
closed vs. open environment
amount of lighting
effects of gravity and inertial forces on the body
how does your visual system help with balance?
position of head relative to environment
orientation of the head to maintain level gaze
direction and speed of head movement
How does the somatosensory/propreoception system help with balance?
What does the vestibular system do for balance?
info regarding the movement of the head in relationship to gravity and inertial forces.
The seamless intergration of the information received from all three systems is what allows for the maintenance of balance. The intergration follows...?
supplementary motor systems
What is the sensory level for condition 1?
eyes open, stable surface
what is the sensory level for condition2?
eyes closed, stable surface
what is the sensory level for condition 3?
visual conflict with moving surround, stable surface
what is the sensory level for condition 4?
eyes open, moving surface
what is the sensory level for condition 5?
eyes closed, moving surface
what is the sensory level for condition 6?
visual conflict with moving surround and moving platform.
What does the mechanoreceptors provide information for?
velocity and amplitude of joint motion
which mechanoreceptor responds slowly to static joint position?
ruffini type 1
which mechanoreceptor adapts quickly to chages in joint position?
pacinian type 2
Which mechanoreceptor is active at all extemes of joint motion and is stimiulated with manipulation?
Which type of mechanoreceptor transmit info related to pain and inflammation?
free nerve endings- type 4
There are two different types of balance reflexes, what are they?
vestibuoocular reflex- VOR
vestibulospinal reflex -VSR
Which balance reflex allows for coordination of head and eye movements; allows for gaze stabilization and visual tracking?
Which balance reflex attempts to stabilize the bod and control movements; coordination of the trunk in upright movement?
There are 6 general types of motor stratigies for balance. Wht are they?
change in support
The strategy that would most commonly be used for small disturbances would be?
the strategy that would most commonly be used for large and rapid disturbances; commonly associated with rotational perturbation of trunk?
the strategy that would most commonly be involved with quickly lowering the body by flexing the knees with secondary flexion at ankles and hips?
What common balance strategy would respond to fast and large postural perturbation; following a stumble?
What kind of strategy would you be using if you broke your fall with your hands?
change in support
Balance impairments can result from several different things. What are they?
sensory input impairment
motor output & biomechanical output deficits
What is the major cause for morbidity, mortality, reduced functioning, and premature placement in nursing home?
You have an 80 y/o pt. in an acute care setting who has been on bed rest due to an upper respiratiory infection. You have orders from the Dr. to get this patient up today. You're reading their chart and you see that they have gait deficits that require use of an AD, they have arthritis in their hip, and they wear glasses. What would be your major concern with this patient?
Risk of falling
T/F: balances tests can also be used at balance exercises?
double leg stance, rhomberg & sharpened rhomberg, single leg stance and tandem walking are all examples of what?
balance test and exercises
KAT, physioball, BAPS, minitramp and UE prioprioceptive training are examples of?
specific balance task tools
What are some of the things you need to do and look out for when balance training with a patient?
use a gait belt & guard appropriately with as many people as necessary
use // bars and hand rails when available and necessary
clear the area of any hazardous objects
make sure the equipment is in good shape and works properly before you begin treatment
visual, vestibular, and proprioceptive factors contribute to what type of input for balance?
sensorimotor intergration, anticipatory balance control and reactive balance control are factors that contribute to what type of balance processing?
Postural alignment, muscle recruitment, strength, and endurance, joint mobility, flexibility, coordination and pain are what type of factors that contribute to balance?
motor and biomechanical
What are the variable that you can manipulate with balance training?
environment- open vs. closed
support surface- stable vs. unstable surface
BOS- wide vs. narrow
COM- low vs. high
What are the variables commonly used for beginning stages of balance training?
all senses involved
How would you progress standing balance?
wide BOS with double stance
feet together (rhomberg)
standing in tandem
single leg stance/stork stance
* with all of these you would include:
eyes open vs. closes
UE rotational exercises
progess to unstable surface
How would you progress walking balance?
gait in // bars
forward and backward walking
stepping over obstacles
up and down stairs
How would you prepare a patient for home and community ambulation?
walking on uneven terrain
lifting objects from high and low
pushing and pulling doors
carrying common objects
anticipatory timing activities
boarding an elevator
getting on an escalator
What is the main thing you need to keep in mind before progressing balance training?
they do not have to master all activites at one level prior to including higher level activites- you mix and match between levels depending on what the patient can do.
T/F: the CNS takes 1000's of repetitions before it is "re-trained"
T/F: you want your goal of balance skills to progress to situations that are patient specific functions?
Some of the things that you should incorporate with balance training would include?
survial maneuver education
fall prevention education
intermediate balance training levels would include what kind of activities?
movement transitions: sit-to-stand
standing: decreased BOS, eyes open and closed
gait activities: narrow BOS, side stepping
advanced level balance activites would include?
standing: open enviro., unstable, eyes open and closed
gait: same as standing; tandem walking, side stepping
elevation activities: step-up and down, lat. step-up's
community activities: pushing/pulling doors, car transfers
What are some of the functional balance tests?
berg balance scale
functional reach test
What are some central vestibular issues that could interfer with balance?
what are some of the peripheral vestibular issues that could interfer with balance?
BPPV- loose ear rocks; true spinning; flat to upright
from heel contact/strike of the same foot again
the period of time during the gait cycle where both feet are in contact with the ground and supporting the body
the period of time where only one foot supports the body during the gait cycle
distance between one foot contact to the opposites foots contact (ave. for adult is 13-16 inchs)
what is the average stride for an adult?
What is the cadence/speed of the average adult?
What is the average width of the BOS for an adult?
What is the average degree of toe out for an adult?
opposite from the thorax; 4* forward on swing LE and 4*backward on stance LE is what?
increased cadence until no period of double support
distance covered per unit of time in meters; average 82 meters a minute/ 3mph
rate change in respect to time
acceleration & deceleration
what is heel strike in RLA?
what is foot flat in RLA?
what is heel off in RLA?
what is toe off in RLA?
what is acceleration in RLA?
what is decerleration in RLA?
what are the two primary stages of the gait cycle?
Weight acceptance, single LE support and swing LE advancement are what?
outward circular motion utilized to advance the LE
typically on the toes or high stepping
LE crosses midline upon advancement- mostly neuro
high step utilizing exessive hip and knee flexion to clear the foot; foot slap may be associated with
excessive lateral flexion of the trunk or marilyn monroe walk
stance leg has to elevate thru excess PF and hip hike to advance swing LE
high steppin ataxic gait with foot slapping
walks on toes as if has been pushed forward and falling, gains speed. commonly seen in parkinsons patients
abduct and swing LE around to advance it for gait
increased turnk forward flexion and knee flexion; shuffling, quick small steps
What are the things you would want to prep for pre-ambulation?
ability to tolerate an erect position
length of immobility
strengthen the muscle of the UE and LE
improve cardiopulm function and endurance
train in sitting and standing balance
teach and practive ambulation patterns and functional skills
What are some examples of pre-ambulation activities?
bed exercises working on ROM, strength, activation and control
progressions of development through use of PNF and NDT
strengthening and ROM to allow proper gait
What are some specific gait training activites that can be done in the bed/
PNF in bridging
What are some specific gait training activities that can be done in plantigrade/ // bars?
weight shift side-> side and stagger stance w/ & w/o PNF
stepping forward and backward w/ w/o PNF
heel <> toe rocks/rises
What are some specific gait training activities that can be done with the patient standing alone?
tape on floor-cue for step length
cone or cups- step over-can be used for any gait defect
What is the typical progression for forward and backward walking techniques?
assistance: // bars > AD > unassisted
step length: shortened> lengthened
speed: reduced > normal
BOS: wide > narrow
acceleration and deceleration
environment: flat > carpet > variable
What is the most restictive AD to the least restrictive?
Which weight bearing statsus require an AD?
T/F: No matter what the Dx, not matter what the specific exercise is for, you must ALWAYS perform exercises with proper alignment and recruitment from a stable base.
T/F: repetive movements and sustained positions will cause faults in the movment system elements (musculoskeletal, neurological, biomechanical) which lead to movement imbalance.
T/F: improper central neuromuscular programming of movement can cause impaired function of peripheral tissue leading to pain syndromes.
over lengthened muscles become weak in normal position and strong in lengthened position.
only strong in the shortened position and weak at normal length
What muscles are typically shortened and lengthened in a hyperlordotic posture?
short: erector spinae; lumber hyperflexion, hip flexors; ant. pelvic tilt
length: low abs and hip extensors;
hyper extended kneers
what muscles are typically shortened and lengthened in a hyperkyphosis posture?
short: upper abs, lat dorsi
length: thoracic erector spinae
mid and low traps
what is the treatment for hyperlordotic posture?
stretch low back muscles
strengthen lower abs
stretch hip flexors
strengthen hip extensors
what is the treatment for hyperkyphosis posture?
strengthen thoracic erector spinae, mid and lower traps
stretch lat dorsi's
train and strengthen abs
What is typically shortened and lengthened in a flat back posture?
short: upper abs, hip extensors
length: lumbar erector spinae, upper back muscles, hip flexors
What is the treatment for flat back?
strengthen low back and hip flexors
stretch hamstrings and gluteal musculature
What is typically shortened and lengthened in swayback posture?
short: upper abs, hams, and glutes
length: lower abs, upper back and hip flexor
What is the treatment for sway back?
LLD- stand on short LE
short LE iliopsoas strengthening with lower abs
short LE posterior glute med strengthening
stretch right lumbar paravertbral mscles
what is typically shortened and lengthened with a forward head posture?
short: cervical erector spinae and UT
length: cervical flexors
What is the treatment for forward head posture?
almost always scapular and thoracic intervention (mid-low traps, SA, RC, thoracic extension, and abs)
what is typically shortened and lengthened with forward shoulder posture?
short: pec minor and UT
length: mid and low trap
What are the things you need to address to truly intervene with posture?
postural alignment, balance, and gait
muscular endurance and strength related to postural poition and proper motor control
proper body mechanics
ergonomic assessment if indicated
cardio and aerobi capacity training
What do you need to restore to truly intervene with posture?
what is the common joint mobility restriction for the suboccipitals?
what is the common joint mobility restriction for the mid cervical spine?
what is the common joint mobility restriction for the thoracic spine?
general or specific
what is the common joint mobility restriction for the hip?
dependent upon the posture
What are some of the commonly tight muscles that need a good stretch?
pect minor and major
What are some of the common weak muscles due to posture faults?
UT, MT, LT
ER of shoulder
TA's & OA's
What do these things all have in common:
pivot prone progressions
supine on foam roller
steam boats for LE
they are exercises that address multiple issues
joints, nerve roots, spinal cord, bone, ligaments & capsule, and muscles have want in common?
they are general anatomic considerations of the spine.
synovial planar joints are what when t comes to the spine?
vertebral joints and the discs
T/F: in regards to facets, orientation dictates the motion available.
There are two different types of spinal stenosis. what are they?
What are some common spine pathologies?
acute & mechanical dysfunctions
instability vs. hypermobility
T/F: typically see a combination of pathologies either occurring secondary to each other or in conjunction with each other.
Originating from a nerve root
radiating pain, numbness and tingling
centralizations: symptoms move back to central spine (good thing)
peripheralization: symptoms radiate away from proximal spine (bad thing)
theses are descriptions for what type of spine presentation?
What are some potential causes for nerve root impingement?
scarring after surgical intervention
What is the main concern for nerve root impingement?
monitor both motor and sensory function to determine if any progression occurs.
What is the intervention for nerve root impingement?
dependent upon the degree of impingement and if progressing. ranges from nerve glides (typically accompanies ST work and stab trng) to surgical intervention if sever disc or instability.
if you have a LBP pt. when HNP, spondy's, stenosis, and sciatica, what must you always monitor for?
cauda equina syndrome
What changes would you monitor for with cauda equina?
difficulty with micturation, urination
widespread of progressive motor weakness in the LE or gait disturbances
degree of sensory loss
T/F: spinal stenosis is typically secondary to DJD in the spine when osteophytes form around the facet joints and interfere with the lateral foramen
T/F: Yarjanian JA et al. said "symptomatic spinal stenosis results in greater paraspinal ms atraphy than LBP alone... not significantly explained by the degree of denervation... thus, may be reversible..."
T/F: the conclusion to yarjaninas experiment was that 62% of the manual therapy and 41% of the exercise alone groups had still showed gains from Tx a year later.
T/F: in people with HNP serial MRI's show gradual resorption of the herniated material explaining why 75% of pts with HNP recover non surgically within 6 months
In the study by Jensen what % of people wth no LBP who underwent MRI's had disc abnormailites?
What is the most common level of herniation for HNP?
How much greater risk are pt's who undergo fusion for HNP than those who dont for developing another HNP?
the quick functional test for L4 is _________ and the test for L5 is ______________?
L4- heel walking
L5- toe walking
What is the key intervention method with HNP?
stabilization training and movement retraining as indicated.
How would you know if a pt. is weight bearing sensitive for traction?
trial and assess response
What is the medical management for HNP?
epidural steroid injection (ESI)
laminectomy & disectomy "decompression"
automated percutaneous disectomy
pars interarticularis stress fracture- "scotty dog". It is a hereditary predisposition + stork test, LBP that occasionally radiates into buttocks and thigh with no true neuro deficit.
when varying degrees of forward slippage of the involved vertebra occur secondary to the presence of the spondylosis.
What is the intervention for acute mechanical LBP?
manipulation if indicated
main goal: prevent recurrence and develpment of chronic recurrent LBP
What are the different types of fusions for the lumbar spine?
interbody; posterior, anterior and cages
What are the most important considerations for rehab post fusion?
know whether the patient was fused with instrumentation or not
know the individual MD's restrictions and time frames
know the contra's for the particular technique utilized
post fusion phase 1 is what time frame?
what are the goals for phase 1 post fusion?
pt. education re: precautions and movement, gentle nerve gliding, and home care principles.
what are some of the interventions for phase 1 post fusion?
proper bed mobility and transfers; log roll
amubulation starts day 1 post op
be exervises; QS, HS, GS, heel slides, hip abd/add, ankle pumps; 5-10X each/day
gentle nerve glides/mobilization
body mechanics trng
pt. education: avoid driving, prolonged sitting, lifting, beings and rotating
what is the time frame for post fusion phase 2?
what are the goals for phase 2 post fusion?
increase activity, promost proper tissue healing, control scar tissue, stabilization trng, further body mechanics trng, and conditioning.
what are some of the interventions for phase 2 post fusion?
increase intensity of stab trng but w/o loading through the spine
ROM: pelvic tilts in limited range w/o stressing the fusion
body mechanics in all functional activites
What is the time frame for phase 3 post fusion?
what are the goals for phase 3 post fusion
return to work
advance exercise program
secific skills program
can implement a weight trng program
what the interventions for phase 3 post fusion?
proper movement and body mechanics should be becoming automatic
normalize UE and LE strength
improve aerobic fitness
decrease pain and swlling
what are the progressions for functional activites/exercises for phase 3 post fusion?
What is the impairment based classifications for PT Dx and & intervention for non surgical Lbp?
stabilization: all LBP pt.s need stab trgn
traction: you trial this
specific exercise: mcKenzie based approach
What are the indicators for manipulation for non-surgical LBP?
more recent onset of s/s <16 days
hypomobility at any level
LBP only; no distal s/s
FABQ work subscale <19 (fear avoidance behavior questionaire)
bilateral or quadralateral limb paresthesia, either constantly or reproducd/aggravated by head or neck movements
positive hoffmans or shimizues reflex
these are all examples of what?
cervical cord compression
what are some of the MOI;s for cerivial cord compression?
blows to the head
systemic conditions that affect ligamentous system
what are the places the PT assesses for ligament stability for the cerivical spine?
What is VBI?
vertebral basilar insufficency
What are the things you should monitor for with VBI?
hx of neck trauma
dizziness or nausea
hi of ra, htn, or stroke
increasing s/s with specific cervical movements
dizziness, dysarthria, dysphagia, diplopia, drop attacks are what?
the 5D's for VBI
nystagmus nausea and numbness are what?
the 3N's for VBI
an unsteady gait is a sign for what?
a C1-2 dislocation can only occur with?
or transverse ligament rupture (trauma)
A spontaneous dislocation of the cervical spine can occur with?
forgotten/undiagnosed traumatic injury
what is the clinical indicator for a cerival dislocation?
bilateral or quadiliateral limb paresthesiae and/or weakness
positive hoffmans and/or babinski
sensroy disturbance of the hands
muscle wasting of hand intrinsic muscles
bowel and bladder distubances
these are are s/s of what?
T/F: whiplash is Dx by itself.
What is the MOI for whiplash?
either hyperflexion or hyperextension; hyperextension is more disabling.
what are the injury possiblities for whiplash?
tears of ligaments
neuro, vestibular and vascular damage
Why are MD diagnostics not good for Dx whiplash?
they dont show tissue damage. They can show up fine but the pt has s/s.
when we say radiculopathy, what do we mean is involved?
What are some of the causes for cervical radiculopathy?
Why do we use pt. presentation for diagnosing cervical rediculopathy?
large % of asymptomatic subjects will exhibit pathoanatomic changes xonsistent with the suposed nderlying causes of cervical radic on diagnostic imaging studies.
What are the CPR's for cervical radiculopathy?
when 2 of these findings are positive there is a _____ % probility of cervical radic
3 tests______ %
4 tests______ %
cervical rotation < 60* affected side
distraction relieves s/s (never a good thing)
2 tests: 21%
3 tests: 65%
4 tests: 90%
cervical lateral glides, strengthening of DNF's, t-manip, and intermittent traction are the interventions for?
what is the criteria to determine if a HA is from a cervicogenic issue?