describe coordination and balance of individuals.

1. COORDINATION &
BALANCE
Dr Seema Gul (PT)

2. MOTOR CONTROL
• Motor control is “the ability of the central nervous system to control or direct
the neuro motor system in purposeful movement and postural adjustment by
selective allocation of muscle tension across appropriate joint segments”
OR
• “as the ability to regulate or direct the mechanisms essential to movement”

3. COMPONENTS
NORMAL
MUSCLE
TONE
POSTURAL
RESPONSE
MECHANIS
Ms
SELECTIVE
MOVEMENT
S
COORDINATION

4. OVERVIEW OF THE MOTOR
SYSTEM
• The highest level
• Association areas of the neocortex / basal ganglia of the forebrain
• Concerned with strategy
• The middle level
• Motor cortex and cerebellum
• Concerned with tactics:
• The sequences of muscle contractions, arranged in space and time, required to smoothly and
accurately achieve the strategic goal.
• The lowest level
• Brain stem and spinal cord
• Concerned with execution
• Activation of the motor neuron and interneuron pools that generate the goal-directed movement
and make any necessary adjustments of posture

5. • PRIMARY MOTOR CORTEX: Corticospinal Tract
• SUPPLEMENTARY MOTOR AREA:
• INITIATION OF MOVEMENT
• BILATERAL GRASPING ACTIVITIES
• SEQUENTIAL TASKING
• ORENTATION OF HEAD & EYE
• PREMOTOR CORTEX:
• LINKED WITH RETICULOSPINAL TRACT TRUNK AND POSTURAL CONTROL

6. Parallel arrangement
• Information is conveyed not only from the motor cortex to the spinal cord but also directly
from premotor areas as well. Although the cerebellum and basal ganglion are involved in
movement, they have no direct output to the spinal cord. Instead, their effect on movement is
provided via connections to the motor cortex
Sensory input
• Provide the foundation on which motor programs for purposeful movements are planned,
coordinated, and implemented
• Guides selection and adaptation of motor responses and shapes motor programs for
corrective action
• Example:
• somatosensory system provides the needed information to adjust walking when moving from
a smooth surface to an uneven terrain; to maintain standing balance on a moving bus; or to
make the required adjustments when throwing a ball from a stable sitting surface (chair)
versus an unstable one (therapy ball).

7. • Descending Motor Pathways
• Corticospinal tract
• Corticobulbar Tract
• Tectospinal Tract / Colliculospinal
Tract
• Connects Midbrain with cervical Region
• Coordinates Head & Eye movement in
response to visual / auditory stimuli
• Mediate reflex postural movements of
the head in response to visual and
auditory stimuli
• Reticulospinal Tract
• Controls Thoracolumber / sacral outflow
• Facilitates and inhibits voluntary
movement; influences muscle tone
• Vestibulospinal Tract
• Promotes stabalization of neck muscles
(medial VST)
• Maintain Upright Posture & Balance
(Lateral VST)
• Rubrospinal Tract
• facilitates motor neurons in the cervical
spinal cord supplying the flexor muscles
of the upper extremities
• Disinhibition  Decorticate (Flexion
Resp)

8. COORDINATION
• Coordination is the ability to execute smooth, accurate, controlled movement.
• “Coordinated movement involves
• Multiple joints and muscles
• That are activated at the appropriate time and
• With the correct amount of force/muscle tension so that smooth, efficient, and accurate
movement occurs.
• Thus, the essence of coordination is the sequencing, timing, and grading of the
activation of multiple muscles groups.

9. • The ability to produce these responses is dependent on
• Somatosensory
• Visual, and
• Vestibular input, as well as
• A fully intact neuromuscular system from the motor cortex to the spinal cord.
• In addition, they involve appropriate synergistic influences (muscle recruitment),
reversal between opposing muscle groups and proximal fixation to allow distal
or maintenance of a posture.

10. • Awkward, extraneous, uneven, or inaccurate movements characterize coordination
impairments.
• Two terms often associated with coordination are DEXTERITY and AGILITY.
Dexterity refers to skillful use of the fingers during fine motor tasks.
Agility refers to the ability to rapidly and smoothly initiate, stop, or modify
movements while maintaining postural control

11. TYPES OF COORDINATION
INTRALIMB COORDINATION :
• MOVEMENTS OCCURING WITHIN A SINGLE LIMB
• Brushing Hair / Gait Cycle
INTERLIMB COORDINATION: Bimanual Activities
VISUAL-MOTOR COORDINATION : refers to the ability to integrate both visual and motor
abilities with the environmental context to accomplish a goal (e.g., tracing over a zigzag line,
writing a letter, riding a bicycle, or driving an automobile)
EYE-HAND COORDINATION : a subcategory of visual-motor coordination
• Using Eating utensils / personal hygiene / reaching for a visual target ( book from a shelf)
• EYE-HAND-HEAD coordination : movement of head is typically required to fixate eyes on a
particular target.

12. CEREBELLUM
1. Regulation of movement
2. Postural Control
3. Muscle Tone
4. A comparator and error-correcting mechanism
• Closed-loop System
• Open-loop System

13. BASAL GANGLIA
• Initiation and regulation of gross intentional movements, planning and execution of
complex motor responses, facilitation of desired motor responses while selectively
inhibiting others, and the ability to accomplish automatic movements and postural
adjustments muscle tone
• Play an important role in maintaining normal background muscle tone
• Perceptual and cognitive functions

14. FEATURES OF COORDINATION
IMPAIRMENTS
CEREBELLUM

15. FEATURES OF COORDINATION
IMPAIRMENTS
BASAL GANGLIA

16. AGE-RELATED CHANGES
AFFECTING COORDINATED
MOVEMENT
• Decreased Muscle Strength
• Sarcopenia / decrease nutrition / dec. protein synthesis/ altered endocrine function / lack of
exercise / chronic disease
• Loss of alpha motor neurons / fast twitch fibers type IIb /diminished oxidative capacity
• Lower extremity + back ( Lats / hip extens/ quads) > Upper Extremity
• Proximal > distal loss
• Slowed Reaction Time
• Degenerative Changes in the motor unit
• Inc. Premotor Reaction Time ( stimulus  initiation of movmt)
• Inc. Movement Time ( initiation of mov  completion of mov)
• Dual tasking / fine motor movements require cognitive resources
• Decreased Range of Motion
• Degenerative changes in joint surface/ collagen fibers / dietry defic / sedentary life style
• Postural Changes
• Kyphosis / lordosis / inc flexion at hip + knee
• Impaired Balance
• Reduction in Postural Limits of Stability

17. SCREENING
RANGE OF
MOTION
• Within normal limits
(WNL)
• Within functional
limits (WFL)
• If AROM painful 
Detailed Examination
is required
STRENGTH
• Proximal segments
should be stabalized
SENSATION
• Superficial
• Pain / Light touch
• Deep
• Kinaesthesia /
vibration
• Combined / Cortical
• 2-point
discrimination /
sterognosis

18. The purposes of performing a coordination examination of motor function are to
determine the following:
1. Muscle activity characteristics during voluntary movement
2. Ability of muscles or groups of muscles to work together to perform a task or
functional activity
3. Level of skill and efficiency of movement
4. Ability to initiate, control, and terminate movement
5. Timing, sequencing, and accuracy of movement patterns
6. Effects of therapeutic and pharmacological intervention on motor function over time

19. FEATURES OF COORDINATION
TEST
• GROSS MOTOR MOVEMENTS
1. Body Posture
2. Balance
3. Extremity Movements (large muscle group)
• Crawling, kneeling, walking , running
• GROSS MOTOR TESTS
• FINE MOTOR MOVEMENTS
• Skillful controlled manipulation of objects
• Dexterity Tasks : buttoning a shirt/typing/hand writing

20. FEATURES OF COORDINATION
TEST
• Non Equilibrium Test
• Components of limb movement
• Equilibrium Test / Balance test
• Ability to maintain the body in
equilibrium
• Static / Dynamic Balance
Transitional
Mobility
Stability ( Static
Postural Control)
Dynamic
Postural Control
( Controlled
Mobility)
Skill

21. NON EQUILIBRIUM
1. ALTERNATE OR
RECIPROCAL MOTION,
which is the ability to reverse
movement between opposing muscle
groups
2. MOVEMENT
COMPOSITION, or synergy,
which involves movement control
achieved by muscle groups acting
together
3. MOVEMENT ACCURACY,
which is the ability to gauge or judge
distance and speed of voluntary
movement
4. FIXATION OR LIMB
HOLDING, which addresses the
ability to hold the position of an
individual limb or limb segment

22. THE PROGRESSION OF DIFFICULTY OF COORDINATION TESTS
(INCREASES IN CHALLENGE TO THE PATIENT) TYPICALLY UTILIZES THE
FOLLOWING SEQUENCE:
(1) unilateral tasks;
(2) bilateral symmetrical tasks;
(3) bilateral asymmetrical tasks;
(4) multi-limb tasks (these constitute the highest level of difficulty).
Difficulty is also increased by progressively adding increased challenges to balance
(i.e., movements performed in sitting progressing to standing).

23. GATHER EQUIPMENT
The coordination exam should be administered in a quiet, well
lighted treatment area sufficiently large to accommodate walking
activities Coordination assessment form
Pen or pencil to record data
Stopwatch
Two standard chairs mat or treatment table
 Method of occluding vision

24. PATIENT PREPARATION
The coordination examination should be administered when the
patient is well rested.
 A full explanation of purpose of the testing should be provided
 Each coordination test should be demonstrated individually by
the therapist before actual testing
 Testing procedures require mental concentration & physical
activity
 Fatigue, lack of clarity or fear may adversely influence tests
results

25. TESTING PROTOCOL
 Does increased speed of performance affect quality of motor
activity ?
 Can appropriate motor adjustments made if speed & direction are
changed ?
 Can a position or posture of the body or specific extremity be
maintained without swaying, oscillations, or extraneous movements
Does occluding vision alter the quality of motor activity ?
Does patient fatigue rapidly ?

26. NON EQUILIBRIUM COORDINATION TESTS

27. NON EQUILIBRIUM COORDINATION TESTS

29. TESTS FOR COORDINATION IMPAIRMENTS
DYSDIADOCHOKINESIA
 Finger nose finger test
 Pronation/supination
 Knee flexion/extension
 Tapping
 Walking, alter speed or duration

30. TESTS FOR COORDINATION IMPAIRMENTS
DYSMETRIA
 Pointing & past pointing
 Drawing a circle
 Heel on shin
 Placing feet on floor markers while walking

31. TESTS FOR COORDINATION IMPAIRMENTS
DYSSYNERGIA
 Finger-to-nose
 Finger-to-therapist’s finger
 Alternate heel-to-knee
 Toe-to-examiner’s finger

32. TESTS FOR COORDINATION IMPAIRMENTS
TREMOR (INTENTION)
 Observation during functional activities
 Alternate nose-to-finger
 Finger-to-finger
 Finger to therapist’s finger
 Toe to examiner’s finger
 HYPOTONIA:
 PASSIVE MOVEMENT
 DTR

33. TESTS FOR COORDINATION IMPAIRMENTS
 TREMOR (RESTING)
 Observation of patient at rest; limb or jaw movements
 Observation during functional activities (tremor will disappear with movement
 Tremor (postural)
 Observation of steadiness of normal posture;
sitting, standing

34. TESTS FOR COORDINATION IMPAIRMENTS
 ASTHENIA
 Application of manual resistance to determine ability to
hold
 RIGIDITY
 Passive movement
 Observation during functional activities
 Observation of resting posture
 BRADYKINESIA
 Walking, observation of arm swing & trunk motions
alter speed & direction
 Movement or gait activity be stopped abruptly
• Observation of functional activities:
• timed tests

35. TESTS FOR COORDINATION IMPAIRMENTS
DISTURBANCE OF POSTURE
• Fixation or position holding (upper and lower extremity)
• Displace balance unexpectedly in sitting or standing (perturbation) Standing,
alter base of support (e.g., one foot directly in front of the other; standing on
one foot)
DISTURBANCE OF GAIT
 Walk along a straight line
 Walk sideways, backward
 March in place
 Alter speed & direction of ambulatory activities

36. GRADING FOR NON-EQUILIBRIUM & EQUILIBRIUM TESTS
5. Normal performance
4. Minimal impairment: Able to accomplish; slightly less than
normal speed; requires supervision/minimal contact
guarding
3. Moderate impairment: Able to accomplish activity;
movements are slow, awkward, and unsteady; requires
moderate contact guarding
2. Severe impairment: Able only to initiate activity without
completion; requires maximal contact guarding
1. Activity impossible

37. EQUILIBRIUM TEST
• Sitting in a normal comfortable position
• Sitting, weight shifting in all directions
• Sitting, multidirectional functional reach
• Sitting, picking an object up off floor
• Standing in a normal comfortable posture
• Standing, feet together (narrow base of support)
• Standing on one foot
• Standing, with one foot directly in front of the other (tandem
position)
• Standing: eyes open (EO) to eyes closed (EC) (Romberg
Test)
• Standing in tandem position: EO to EC (Sharpened
Romberg Test)
• Standing, multidirectional functional reach
• Walking, placing feet on floor markers
• Walk: sideways
• Walk: backwards
• Walk: cross-stepping
• Walk: in a circle, alternate directions
• Walk: on heels
• Walk: on toes
• March in place
• Walk with horizontal and vertical head turns
• Step over or around obstacles
• Stairclimbing with handrail
• Stairclimbing without handrail
• Stairclimbing: one step at a time
• Stairclimbing: step-over-step

38. NON-EQUILIBRIUM GRADING
4 Normal Performance
3 Minimal Impairment: Able to accomplish activity; slightly less than normal
control, speed, and steadiness
2 Moderate Impairment: Able to accomplish activity; movements are slow,
awkward, and unsteady
1 Severe Impairment: Able only to initiate activity without completion; movements
are slow with significant unsteadiness, oscillations, and/or extraneous movements
0 Activity Impossible

39. GRADE: LEFT COORDINATION TEST GRADE: RIGHT COMMENTS
Finger-to-nose
Finger–to–therapist’s finger
Finger-to-finger
Alternate nose-to-finger
Finger opposition
Mass grasp
Pronation/supination
Rebound phenomenon
Tapping (hand)
Tapping (foot)
Pointing and past-pointing
Alternate heel-to-knee; heel-to-toe
Toe–to–examiner’s finger
Heel-on-shin
Drawing a circle (hand)
Drawing a circle (foot)
Fixation/position holding (UE)
Fixation/position holding (LE)

40. GRADE: LEFT COORDINATION TEST GRADE: RIGHT COMMENTS
Finger-to-nose
Finger–to–therapist’s finger
Finger-to-finger
Alternate nose-to-finger
Finger opposition
Mass grasp
Pronation/supination
Rebound phenomenon
Tapping (hand)
Tapping (foot)
Pointing and past-pointing
Alternate heel-to-knee; heel-to-toe
Toe–to–examiner’s finger
Heel-on-shin
Drawing a circle (hand)
Drawing a circle (foot)
Fixation/position holding (UE)
Fixation/position holding (LE)
• Lack of visual input renders activity
impossible or alters quality of performance
• Verbal cuing is required to accomplish activity
• Alterations in speed affect quality of
performance
• Excessive amount of time required to complete
activity
• Changes in arm position alters sitting balance
•Postural instability is evident: unsteadiness,
oscillations, extraneous movements
• Fatigue alters consistency of response
•Performance affects patient safety; requires
contact guarding

41. GRADING FOR EQUILIBRIUM TESTS
4 Normal: Able to maintain steady balance without handhold support
(static) Accepts maximal challenge and can shift weight easily within full
range in all directions (dynamic)
3 Good: Able to maintain balance without handhold support, limited
postural sway (static) Accepts moderate challenge; able to maintain
balance while picking object off floor (dynamic)
2 Fair: Able to maintain balance with handhold support; may require
occasional minimal assistance (static) Accepts minimal challenge; able to
maintain balance while turning head/trunk (dynamic)
1 Poor: Requires handhold support and moderate to maximal assistance to
maintain position (static) Unable to accept challenge or move without loss
of balance (dynamic)
0 Absent: Unable to maintain balance

42. GRADE BALANCE TEST COMMENTS
Sitting in a normal comfortable position
Sitting, weight shifting in all directions
Sitting, multidirectional functional reach
Sitting, picking an object up off floor
Standing in a normal comfortable posture
Standing, feet together (narrow base of support)
Standing on one foot
Standing, with one foot directly in front of the other
(tandem position)
Standing: eyes open (EO) to eyes closed (EC) (Romberg
Test)
Standing in tandem position: EO to EC (Sharpened
Romberg Test)
Standing, multidirectional functional reach
Walking, placing feet on floor markers
Walk: sideways
Walk: backwards
Walk: cross-stepping
Walk: in a circle, alternate directions
Walk: on heels
Walk: on toes
March in place
Walk with horizontal and vertical head turns
Step over or around obstacles
Stairclimbing with handrail
Stairclimbing without handrail
Stairclimbing: one step at a time
Stairclimbing: step-over-step

43. GRADE BALANCE TEST COMMENTS
Sitting in a normal comfortable position
Sitting, weight shifting in all directions
Sitting, multidirectional functional reach
Sitting, picking an object up off floor
Standing in a normal comfortable posture
Standing, feet together (narrow base of support)
Standing on one foot
Standing, with one foot directly in front of the other
(tandem position)
Standing: eyes open (EO) to eyes closed (EC) (Romberg
Test)
Standing in tandem position: EO to EC (Sharpened
Romberg Test)
Standing, multidirectional functional reach
Walking, placing feet on floor markers
Walk: sideways
Walk: backwards
Walk: cross-stepping
Walk: in a circle, alternate directions
Walk: on heels
Walk: on toes
March in place
Walk with horizontal and vertical head turns
Step over or around obstacles
Stairclimbing with handrail
Stairclimbing without handrail
Stairclimbing: one step at a time
Stairclimbing: step-over-step
Lack of visual input renders activity
impossible or alters quality
of performance
• Verbal cuing is required to accomplish
activity
• Alterations in speed affect quality of
performance
• Excessive amount of time required to
complete activity
• Changes in limb position alters standing
balance/postural
stability
• Postural instability is evident: extraneous
movements,
unsteadiness, or oscillations
• Fatigue alters consistency of response
• Performance impacts patient safety, fall risk

44. HAND FUNCTION TEST
• The jebsen-taylor hand function test examines hand and finger coordination using
seven subtests of functional skills:
1. Writing;
2. Card turning;
3. Picking up small objects;
4. Simulated feeding;
5. Stacking;
6. Picking up large, lightweight objects; and
7. Picking up large, heavy objects
• Normative data are included relating to age, gender, maximum time, and hand
dominance.
• The test allows examination of hand function in seven common activities of daily
living.

45. EXAMINATION OF POSTURAL
CONTROL AND BALANCE
• Balance is the condition in which all the forces acting on the body are balanced
such that the center of mass (COM) is within the stability limits, the boundaries of
the base of support (BOS).

46. • Reactive postural
Control occurs in response to external forces acting on the body (e.g., Perturbations)
displacing the COM or moving the BOS (e.g., Moveable platform, therapy ball).
Feedback systems provide the sensory inputs required to initiate corrective responses
• Proactive (anticipatory) postural control
Occurs in anticipation of internally generated, destabilizing forces imposed on the
body’s own movements (e.g., Catching a weighted ball).

47. • Adaptive postural control allows the individual to modify sensory and motor systems
in response to changing task and environmental demands.2
Balance emerges from a complex interaction of
• (1) sensory/perceptual systems responsible for the detection of body position and
motion,
• (2) motor systems responsible for organization and execution of motor synergies,
and
• (3) higher-level CNS processes responsible for integration and action plans.
• An examination of balance must therefore focus on each of these three areas.

48. • Limits of stability is defined as the maximum distance an
individual is able or willing to lean in any direction without
loss of balance or changing the BOS.
• Using this information, the therapist can objectively
determine the patient’s postural symmetry, which is a
reflection of the amount of weight placed on each foot.
• Patients with asymmetry may present with the COP
positioned away from midline. For example, the patient with
stroke typically stands with most of the weight on the less
affected limb.
• Steadiness can be determined by using postural sway
measuresA large sway path is evidence of postural
unsteadiness

49. PATIENT WITH ATAXIA :
typically demonstrates
hypermetric responses, with
excessive sway,
uncoordinated movements,
and limited postural steadiness
PATIENT PARKINSON’S DISEASE
presents with the opposite problem,
hypometric responses with
diminished sway and excessive
stabilization.

50. • LIMITS OF STABILITY are determined by asking the patient to actively shift
weight in any direction as far as possible without losing balance or taking a step.
• Patients with deficits in motor control typically have reduced LOS (reduced COP
excursion).
• For example, the patient with stroke demonstrates reduced stability limits to the
more affected side.
• The patient with Parkinson’s disease typically demonstrates reduced LOS overall
with significant anterior stability limits if a stooped posture is evident.

51. • LOS and COM alignment are also typically altered in other pathological states (e.g.,
muscle weakness, skeletal deformity, and tonal abnormalities).
• Reexamination after training using force platform biofeedback has been used to
document recovery of postural control following stroke.
• It has also been used to demonstrate the effectiveness of training using
biofeedback force platform training devices

52. SENSORIMOTOR INTEGRATION IN POSTURAL CONTROL
• The sensory systems (vision, somatosensory, and vestibular) provide the CNS with
important information about postural control and balance, including information
about the results of our own actions and the surrounding environment
• The CNS integrates these inputs and initiates both goal-directed conscious actions
and automatic, unconscious adjustments in posture and movements

53. VISUAL SYSTEM
• The visual system serves as an important source of information for the ability to
perceive movements and detect the relative orientation of body segments and
orientation of the body in space.
• This ability has been termed visual proprioception
(1) focal vision (cognitive or explicit vision)
(2) ambient vision (sensorimotor or implicit vision)
• Focal vision plays a major role in localizing features in the environment and in our
conscious reaction to visual events.
• In contrast, ambient vision utilizes the entire visual field to provide information on
the localizing features about the environment and to guide movements using largely
nonconscious awareness

54. • optic ataxia can recognize an object using
focal vision but cannot use visual
information to accurately guide the hand to
the object (impaired ambient vision).
• The opposite occurs in a patient with stroke
experiencing visual agnosia. The patient
cannot recognize common objects, but can
use the ambient visual system to reach and
grasp an object or navigate an environment.
• Vision also contributes to righting reactions
of the head, trunk, and limbs (optical
righting reactions)

55. • ambient vision is detected by the entire visual field (central and peripheral
vision).Peripheral vision can be examined using the confrontation method
• Effective in Visual proprioception / functional performance
• The abilities to navigate safely, to localize features in the environment, and to
anticipate changes necessary to avoid obstacles and successfully reach the target
area are determined.
• Patients with stroke who exhibit topographical disorientation will have difficulty
navigating their environment and understanding the relationship of one place to
another.

58. SOMATOSENSORY INPUTS
• Cutaneous and pressure sensations from the body segments in contact with the
support surface e.g.
• The feet in standing, the buttocks, thighs, and feet in sitting
• Muscle
• Joint proprioception throughout the body
• Light touch contact from the hands on a stable surface is also used as a balance aid

59. VESTIBULAR SYSTEM
• The vestibular system is an important source of information for postural control and
balance.
• The semicircular canals (SCCs) detect angular acceleration and deceleration forces
acting on the head whereas the otolith organs detect linear acceleration and
orientation of the head with reference to gravity.
• The SCCs are sensitive to fast (phasic) movements of the head, and the otoliths
respond to slow head movements and positional change referenced to gravity.
• The vestibular system functions to stabilize gaze during head movements via the
vestibulo-ocular reflex (VOR), and to assist in the regulation of postural tone and
postural muscle activation via the vestibulo-spinal reflex (VSR).
• Tests for vestibular function include positional and movement testing. The patient is
observed for symptoms of vestibular dysfunction (e.g., dizziness, vertigo,
nystagmus)

61. SENSORY WEIGHTING THEORY
• Quiet stance is defined as standing with a stable support surface and
surroundings. Perturbed stance is defined as standing during a brief displacement
of the support surface (moving surface) or displacement of the COM over BOS
(perturbation).
• Central nervous system use of sensory inputs is flexible. Balance responses are
task and context dependent and are triggered by CNS weighting based on
availability, timing, and accuracy of specific sensory inputs.

62. SENSORY WEIGHTING THEORY
• In intact adults during quiet stance, the CNS places greater weight on
somatosensory inputs.
• During an unexpected perturbation, somatosensory inputs are activated quicker and
provide much of the early restabilizing control whereas vision and vestibular inputs
with slower processing speeds contribute to later components of the postural re-
stabilizing response.
• If somatosensory inputs are impaired (e.g., peripheral neuropathy) or if
somatosensory conflict is introduced (e.g., standing on dense foam), vision
assumes a greater role.
• If both somatosensory and visual inputs are impaired or absent, vestibular inputs
are critical to maintaining posture and resolving sensory conflict

63. • Because sensory inputs are redundant, stable balance can be maintained with
significant impairment, on unstable surfaces, or in sensory conflict situations.
• However, if more than one sensory system is deficient, substantial deficiencies in
balance control will be evident.
• For example, the patient with chronic diabetes who has significant diabetic
neuropathy (loss of somatosensory inputs from the feet and ankles) and significant
diabetic retinopathy (impaired vision) will demonstrate significant postural instability
and fall risk.
• In addition, the cognitive system plays an important role in attending to and
interpreting the information for CNS planning of effective postural responses.
• Attentional demands vary depending on the task (new learning versus familiar
response) and the environment (open versus closed or dual-tasking).
• Patients with impairments in cognition or attention demonstrate increased fall risk,
especially for those activities with high stability demands.

64. BALANCE TESTING
• Romberg Test
• EO/EC
• Feet together / apart / tandem stance
• 20-30 seconds
• Clinical Test for Sensory Interaction in Balance
• Modified version of Sensory Organization Test
• Medium density foam
• Visual dome
• Three 30 seconds Trials

65. MOVEMENT STRATEGIES FOR
BALANCE
• POSTURAL REFLEXES
• Righting Reactions
• Equilibrium Reactions
• Fixed Support Strategies
• ANKLE STRATEGY
• Moving body/trunk as a fixed pendulum
around the ankle joint
• Distal-to-Proximal Muscle Activation
• Forward Sway : Gastro  Hamstrings 
Para spinal Muscles
• Backward Sway : Tib. Anterior  Quads
 Abdominals
• Low sway frequencies / small
disturbance in COM /within LOS
• HIP STRATEGY
• Shifts in COM by flex/ext Hip
• Proximal to Distal Muscle Activation
• Forward Sway : Abd  Quads
• Backward Sway : Para spinal 
Hamstrings
• Mediolateral Stability : Hip Add/ Abd
activation to control Lateral Sway
• Faster sway Freq / larger disturbance in
COM / small support surface (< size of
feet) / compliant surfaces
• STEP STRATEGY

66. MOVEMENT STRATEGIES FOR
BALANCE
• CHANGE-IN-SUPPORT STRATEGIES
• Change-in-support strategies are defined as movements of the lower or upper limbs to make
a new contact with the support surface.
• STEP STRATEGY
• The stepping strategy realigns the BOS under the COM by using rapid steps or hops in the
direction of the displacing force, for example, forward or backward steps.
• In instances of lateral destabilization, the individual takes a side step or a cross step to bring
the BOS back under the COM.
• The stepping strategies are typically recruited in response to fast, large postural
perturbations when ankle and hip strategies are not adequate to recover balance (e.g., when
the COM exceeds the BOS)
• Change-in-support movements of the upper limbs (reach or grasp) can also assist in
stabilizing the COM over the BOS, and serve a protective function in absorbing impact and
protecting the head in a fall event.
• Reaching movements assist in extending the BOS and stabilizing posture.

67. POSTURAL STRATEGIES IN
SITTING
• Include movement of the trunk about the hips.
• Backward sway
• elicits primary responses in hip flexors along with activity of the abdominals and neck flexors.
• forward sway
• extensor muscles of the hips are activated along with the extensors of the neck and trunk.
• If the feet are in contact with the floor, tibialis anterior is recruited during forward reaching
movements of the arm and the gastrocnemius is recruited to brake forward movements and
return the body to erect sitting.
• Somatosensory inputs from backward rotation of the pelvis may have an important role in
triggering the postural strategies in sitting.
• In frontal plane movements, activity of the hip abductors and adductors along with the
quadratus lumborum is important for providing mediolateral stability.

68. EXAMINATION AND DOCUMENTATION
OF MOVEMENT STRATEGIES
1. MUSCULOSKELETAL ELEMENTS
• ROM / Postural Tone / Strength
2. ROMBERG TEST
3. SOT
4. Directional Instability
5. Movement Synergies: Proximal-to-
Distal
6. Documentation
• Strategies Present + Normal
• Present but Limited / Delayed
• Present but inappropriate for particular
task
• Abnormal / Absent
7. Anticipatory Postural Control
• Anticipatory postural control, the ability
to activate postural
• adjustments in advance of destabilizing
voluntary
• movements, should be examined
1. Dual-Task Control

69. EXAMINATION AND DOCUMENTATION
OF MOVEMENT STRATEGIES
8. ANTICIPATORY POSTURAL CONTROL
• The ability to activate postural adjustments in advance of destabilizing voluntary movements,
should be examined
• The therapist asks the patient while standing or sitting to raise both arms overhead or catch
a weighted ball.
• Impaired anticipatory postural control is found in many individuals with impairments in motor
function, including patients with stroke, Parkinson’s disease, and brain injury.
9. DUAL-TASK CONTROL
• This is the ability to perform a secondary task (motor or cognitive) while maintaining standing
or seated control.
• For example, while standing the patient is asked to count backward from 100 by 7
(simultaneous verbal-cognitive task) or pour water into a glass (secondary motor task).
• Patients with Parkinson’s disease have been shown to demonstrate significant impairment in
dual-task control.
• Patients with traumatic brain injury and stroke have also been shown to demonstrate
problems with dual-task control

70. THANK YOU