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Background Statistics Background Statistics Background Background Statistics Increased life expectancy increases the importance of maintaining mobility Death due to falls in the 80+ year old population (185.6 Keith Khoo PT per 100,000) is almost as high as MVA deaths in the accident prone 15-29 year old group (21.5 MVA deaths per 100,000)(Winter 1995) Virtually all musculoskeletal disorders result in some degradation of the balance control system (Byl 1992) Background Statistics Background Statistics CNS adapts for loss of function which may not be apparent 50% of falls occur during some form of locomotion (Ashley until patient is temporarily deprived of the compensating et al 1977, Gabell et al 1985, Overstall et al, 1977, Prudham et al 1981) system System is challenged most during: Vestibular patients that have an excessive reliance on vision Initiating and termination of gait become unstable when they close their eyes or when they are in a darkened room Turning Pathologies that affect balance include: Avoiding obstacles (altering step length, changing orthopedic problems (whether lower extremities or spine) direction or stepping over an obstacle) Neurological (head injury, stroke, cerebellar disease, PD, MS, Bumping into objects or people cerebral palsy) Peripheral neuropathies Amputations Vestibular Input Balance and Vestibular Dysfunction An inability to control the body's center of mass relative to Visual Input specified limits. Balance and gait testing in patients with complaints of instability is warranted Basford, et al. An Assessment of Gait and Balance Deficits After Traumatic Brain Injury. Arch Phys Med Rehabil Vol 84, March 2003 Proprioceptive Input 6 © Copyright K2 Seminars 1 Sensory Organization Theory Sensory Organization Theory Perception of orientation in relation to gravity, the support surface and the surrounding objects requires a combination of information from vision, the vestibular Example: when a person stands next to a large bus that system of the inner ear and the somatosensation (skin, suddenly begins to move, momentary disorientation or pressure receptors on the feet plus muscle and joint imbalance may result. A fraction of a second is required to receptors which signal movement of a particular body decide whether the bus is moving forward or the body is part) swaying back. In this sensory conflict situation, the brain must select the orientationally accurate inputs No one sense directly measures the position of the body’s (somatosensory and vestibular) and ignore the inaccurate COG one or vision. Vision measures orientation of the eyes in relation to surrounding objects Somatosensation provides information regarding the support surface Vestibular system is not referenced to external objects, but rather to internal, inertial-gravitational reference determining the orientation of the head in space 7 © Copyright K2 Seminars 8 © Copyright K2 Seminars Sensory Organization Theory Sensorimotor – Visual Input Special nerve endings or sensory receptors in the back of your eye Under most conditions, somatosensory and vision dominate the (retina) are called rods and control of orientation and balance. Both are more sensitive than cones the vestibular system to subtle movements in the COG position, These receptors are sensitive to but both are more prone to provide erroneous orientation light information as in the case of the moving visual field When light rays strike them, Somatosensory information must be ignored if the supporting their nerve fibers send impulses surface is thickly padded or moving to your brain that provide your brain with visual clues that aid in If both the somatosensory and the vision inputs are inaccurate, balance. the vestibular system is the only orientational sense. For example, when you are The combination of senses is dependent upon the condition in outside, buildings are aligned which a person is performing straight up and down, or sidewalks are straight out in Because redundant sensory orientation information is available, front of you. people can stand and walk without vision, upon unstable surfaces and even without vestibular input 9 © Copyright K2 Seminars 10 © Copyright K2 Seminars Sensorimotor – Visual Output Sensorimotor – Visual Output The motor impulses that go to eyeballs coordinate their In a person with a healthy vestibular system, normal fast eye movement so that clear vision is maintained while the movements (nystagmus) can be observed in the light when head is moving either actively (running, watching a tennis the head turns slowly from left to right and back again. match) or passively (sitting in a moving car). The The eyes will move quickly in the same direction that the movement of the eyes while the head is in motion is controlled automatically by the vestibular system. head is turning. These same eye movements occur even in the dark. When the head is not moving, the number of impulses from the right side is equal to the number of impulses coming from the left side. As the head turns toward the right, the number of impulses from the right semicircular canals increases, and the number from the left decreases. This difference controls eye movements and allows for clear vision as the head is turning. 11 © Copyright K2 Seminars 12 © Copyright K2 Seminars 2 Sensorimotor – Vestibular Input Sensorimotor – Vestibular Input The inner ear or labyrinth is a complex series of Part of each labyrinth, or inner ear, is a snail-shaped organ passageways and chambers within the bony skull. called the cochlea. It functions in hearing. Located right Within these passageways are tubes and sacs filled with a next to the cochlea is the part of the inner ear that has to fluid called endolymph. do with balance. This part is called the vestibular apparatus. On each side of the head it is composed of Around the outside of the tubes and sacs is a different fluid, the perilymph. three semicircular canals and a utricle and saccule. Each of the semicircular canals is located in a different Both of these fluids are of precise chemical compositions, and are different. plane in space. They are located at right angles to each other and to those on the opposite side of your head. At The mechanism in the inner ear regulates the amount and the base of each canal is a swelling (ampulla) and within composition of these fluids which is important to the these ampullae are located the sensory receptors for each proper functioning of your inner ear. canal. 13 © Copyright K2 Seminars 14 © Copyright K2 Seminars Sensorimotor – Vestibular Input Sensorimotor – Vestibular Input Inside a semicircular canal. The sensory receptor (cupula) is attached at its base, but the top of it remains free. When the head moves in the direction in which this canal is located, the endolymphatic fluid within the canal, because of inertia, lags behind. The same thing happens when spinning a glass of water between your hands. When the fluid lags behind, the sensory receptor within that canal is bent. The receptor then sends impulses to the brain. The receptor is only sensitive while it is actually moving -- just like the hairs on the arm. Try to move just one hair -- you can feel it as you bend it. When you stop, you don't feel anything anymore. (Clothes are continually bending hairs -- you are not aware of that.) The same thing happens in the hair cells of the cupula. 15 © Copyright K2 Seminars 16 © Copyright K2 Seminars Vestibular Input Sensorimotor – Vestibular Output In a healthy individual both sides of the vestibular system are functioning properly, the two sides of the vestibular system send symmetrical impulses to the brain. That is, the impulses coming from the right side conform to the impulses coming from the left side. All of the sensory input concerning balance, from the eyes, from the muscles and joints, and from the two sides of the vestibular system, is sent to the brain stem, where it is sorted out and integrated. © Copyright K2 Seminars 17 18 © Copyright K2 Seminars 3 Sensorimotor – Somatosensory Input Sensorimotor – Somatosensory Output The input that the brain receives from muscles and joints comes from sensory receptors that are sensitive to stretch or pressure The motor impulses that are sent from the brain to the in the tissue that surrounds them. As legs, arms, or other parts other muscles of the body control their movement so that of the body moves, the receptors respond to the stretch of the balance can be maintained whether in sitting, standing, or muscles surrounding them and send impulses through many turning cartwheels. sensory nerve fibers to the brain. Some of the impulses that leave the brain stem go back to Especially important are the impulses that come from the neck, the cerebral cortex, carrying information to the thinking which indicates the direction in which the head is turned, and centers that tell the body it's okay to see trees whirling in the impulses that come from the ankles, which indicate the circles when turning cartwheels. When practicing these movement or sway of the body in relation to the floor when and similar new activities, the brain learns to "read" standing. This kind of input provides the brain with information different kinds of sensory input as normal. about the standing surface -- whether it is hard or soft, bumpy or smooth. 19 © Copyright K2 Seminars 20 © Copyright K2 Seminars Sensorimotor – Somatosensory Output Sensorimotor - Integration This is exactly what happens as a baby learns to balance through The brain stem also receives input from two other areas of practice and repetition. The impulses from the sensory receptors to the brain -- the cerebellum(coordination center), and the the brain stem and out to the muscles form a pathway. With repetition, it becomes easier for the impulses to travel over the cerebral cortex, which functions in thinking and memory. same network or pathway, until many activities of keeping balance As the brain stem is integrating all the input it receives becomes automatic.
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