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1) Be familiar with definitions and key words relatedto coordination & balance.

2) Be aware of the causes of impaired balance.

3) Be oriented to the subjective and objective

assesments of coordination and balance.4) Know the progression of activities to improve

balance & coordination.

5) Be capable to apply coordination exercises with

the variuos modes, postures, movements anddosages.

6) Be aware of precautions and contra-indications forthose exercises.

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Coordination

Definition:

It is the ability to perform smooth,

accurate and controlled movements.

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1) The execution of fine motor skills andmanipulation of small objects.

2) Performing gross motor skills, e.g.walking, running, jumping, .

3) Bases of smooth and efficientmovements which often occurautomatically.

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-- Coordinated movements involve propersequencing and timing of synergistic andreciprocal muscle activity, and theyrequire proximal stability and maintenanceof posture.

- Coordination refers to using the rightmuscle, at the right time with the rightintensity.

- The concept of coordination includesbalance.

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It is :

the ability to maintain equilibrium

Or

the ability to maintain the center ofgravity over the base of support.

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Vestibular dysfunction,

Visual impairment or Diminished proprioception

can impair balance

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1) The somato-sensory system provides information

about the relative location of the body parts/ Proprioception reflects the perception of the static

position.

Kinesthesia refers to the position during movements.

Information arises from peripheral sources(muscles, jt. capsule, soft tissues):

Sensory receptors information to the medulla &brainstem through the dorsal colummediallemniscal pathway.

2) This information will assist in:1) Coordinating eye, head & neck movements to stabilize the

visual system.

2) In maintaining posture, muscle tone, & stiffness in themuscles.

3) Coordinate movement patterns

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2) The visual system :

Through the retina, the optic nerve and thalamus provide information about the position of thehead relative to the environment & orients thehead to maintain posture.

3) The vestibular system:

Provides information on orientation of the head in

space and on accelaration.Any movement, including weight shifts to adjustposture stimulate the vestibular receptors vestibular nerve cerebellum spinal cord

for postural control.

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Somato

sensory

Vestibular

system

Visual

system

Balance

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Balance requires:

The person to maintain a position, tostabilize during voluntary activities.

( needs trunk & head, neck control)

To react to external perturbations (visual andauditory awareness + cognitive skils).

Effective and efficient coordination amongmultiple sensory, biomechanical, and motorsystems.

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Causes for impaired balance:

Injury to or disease to eye, inner ear, peripheralreceptors, spinal cord,

Head injury affecting the cerebellum, basal ganglia,

cerebrum.

Damage to proprioceptors (peripheral nerveinjury).

Injury or pathology of the hip, knee, ankle, andback have been associated with postural sway anddecreased balance.

( after muscle atrophy, degenerative joint disease,total joint replacement ).

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Lesions of the cerebellum or basal ganglia.( Parkinson s disease, HuntingtonsDisease and cerebellar tumors ).

Lesions produced by tumors, cerebro vascular

accidents causing visual field losses, changing thespatial orientation and altering balance.

Age appears to affect all aspects of the stabilitytriade ( i.e. somato-sensory, visual , vestibular ).

as 30 % of the persons above 65 years old haveexperienced a fall and15% repetitive fall.

Medications could cause dizziness, drowsiness orsense of weakness ( antidepressants).

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Evaluation of Balance

Evaluation of Balance.

Subjective( Clinical ) Assessment.

Objective( Quantitative and Instrumental)

Assessment.

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Subjective ( Clinical ) assessment

Standard Romberg Test:(standing with eyesclosed: if positive= loss of proprioception)

Balance error scoring system (BESS)

Static Balance Test: ( on a firm then on afoam surface)

Dynamic Balance Test.( figure of 8, hoptest,timed beam walking with eyes closed).

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Objective or instrumental assessment Flat rigid surfaces supported on 3 or more

points with computer- interfaced forceplatewith or without visual feedback.

Steadiness: the ability to keep the body as

motionless as possible ( =postural sway). Symmetry: is the ability to distribute weight

evenly between the two feet in an uprightposition.

Dynamic Stability: is the ability to transferthe vertical projection of the COG around astationary supporting base( = the measure ofa persons perception of his/ her safe limitsof stability.

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Activities for Treating Impaired Balance

1) Remember the balance problems. e.g.:

Neuromuscular impairment.

Musculoskeletal impairment (lack of stability).

Sensory impairment.Cognitive impairment.

2) Use stable, hard, rigid, and even surface.

Then progress to uneven surface.

3) Begin with weight shifts on a firm surface then gradually

increase sway. As the patient improves, increase

compliance of the support surface.

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Use balls, foam rollers, and foam surface to provide

uneven and unstable surface and to provide a variety of

balance experience.

Train Sitting balance, trunk stability, and weightdistribution on chair, table, or therapeutic ball.

Balance beam, lines drawn on the floor, balance board

and scales can be used for balance training.

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Dosage

Environment:Train in the environment with areal stimulation he will encounter when leavingthe clinic.

Sequence:Progress from simple to complexinvolves changes in mode, posture, andmovements.

Feedback:Use external feedback,e.g., mirrors

which allows feedback about position, (must be removed at some point to allowinternalization of the balance strategies.

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Contraindication

Balance training is contraindicated for

patients with cognitive impairments, as the

patient might be unable to understand thepurpose and mechanics of the activities.

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Precautions

The patient Safety is important.

Choose activities appropriate for the patients skill

level.

Start by simpler and safer tasks then progress.

Eliminate obstacles or unsafe objects.

A gait belt, hand contacts from the clinician,

parallel bars, or stable external objects shouldbe used for the patient to hold.

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Practical Guidelines

Pt education is an ongoing process.

Safety is the most important area of education.

Teach the pt. to recognize situations at risk.

Widen the base of support and graduallydecrease it.

Evaluate the home for potential hazards.

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