Lec 5

Balance & Coordination
Assessment
Lecture outline
• Functional task analysis
• Balance assessment
• Balance biomechanics
• Balance types
• Balance test
• Coordination assessment
• Coordination tests
Balnace…
• 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).
Function Task Analysis
• Function Mobility Skills
• Bed mobility
• Sitting skills
• Transfer skills
• Standing skills
• Walking
• Stair climbing
Nature of Task
• Mobility
• Key elements
• Initiation and control of movement
• Sensory, motor and cognitive strategies
• Movement termination
• Environmental constraints
• Static postural control (stability)

• COM over BOS
• Key elements
• BOS and COM
• Postural sway
• Degree of stabilization
• Number of episode of Loss of balance
• Degree of external assistance
Dynamic postural control(controlled mobility)
• Key elements
• Postural stability and weight bearing
• Range and degree of control in dynamic movement
• Level and type of assistance
Skills
• Ability to consistently perform coordinated movement sequences for the
purpose of investigation and interaction with physical and social
environment
• Key elements
• Orientation and direction of movement
• Perception, control and consistency
• Speed and timing
• Economy of effort
Postural control and balance
Postural orientation
• Balance
1. Static
2. Dynamic
3. Anticipatory
4. Reactive
5. Adaptive
• Closed motor skill

• A movement performed in stable and non changing environment
• Open motor skill
• Simultaneous task or dual task control
Limits of stability
Motor Strategies
8
Balance sensory system
• Visual
• Somatosensory
(joint…..skin….muscle….length
….tension)
• Vestibular
Assessment Tool
Assessment
• Static balance
• Anticipatory postural control
• Reactive balance
• Dynamic balance
Assessment Tools
• Static Balance Assessment
• Double limb support
• Single-Leg Stance Test
• Tandem stance
• Rhomberg’s Test
• Stork Stand Test
Static Balance Assessment
One Leg Stance Test
Single Leg Stance Criteria

• The ability to maintain SLS generally decreases with increasing age
(Bohannon et. al, 1985; Ekdahl . al, 1989).
• Single leg stance has been shown to improve over the course of 6 months of
rehabilitation (Judge et. al, 1993)
StaticBalanceAssessment
OneLegStanceTest
Instructions for the Patient (Eyes Open, SLS):

Stand on one leg, place your arms across your chest with your
hands touching your shoulders and do not let your legs touch
each other. Look straight ahead with your eyes open and focus
on an object about 3 feet in front of you. Ideally do this with
the shoes off.
Criteria to stop timing the test:

The legs touched each other, the feet moved on the floor, their
foot touches down, or the arms moved from their start position.
Should maintain for 10 sec
One Leg Stance Test
Instructions for the Patient (Eyes Closed, SLS):

Stand on one leg, place your arms across your chest with your
hands touching your shoulders and do not let your legs touch
each other. Close your eyes once you have gotten in position.
Ideally do this with the shoes off and be about 3 feet from any
wall.
Criteria to stop timing the test:
The legs touched each other, the feet moved on the floor, their
foot touches down, the eyes open during the eyes closed test, or
the arms moved from their start position. Should maintain for 10
sec
Rhomberg’s Test
• Rhomberg's test or the Rhomberg maneuver is a test
used in a neurological examination, and also as a test for
drunken driving
Procedure
• Ask the subject to stand erect with feet together &
• eyes closed. Try to stay in this position for 30 sec
• Sensory ataxia (posterior column)
• Motor ataxia (vestibular or vestibular )
• Modified in tandem stance

Stork Stand Test
Stork Stand Test
• Criteria & Result

Assessment Tools
• Anticipatory balance assessment
• Functional Reach Test
• Multidirectional Reach Test
• Observations of patient catching ball, opening doors, lifting
objects of different weights
Anticipatory balance assessment
Functional reach Test
• Requirements:
The patient must be able to
stand independently for at
least 30 seconds without
support, and be able to flex
the shoulder to at least 90
degrees.
• Document compensation
• Three trial
Functional reach Test
• Age related norms for the functional reach test:
• Interpretation:
A score of 6 or less indicates a significant increased risk for falls.
A score between 6-10 inches indicates a moderate risk for falls
Multidirectional reach Test
• This is just an extension

of FRT
• Patient standing
• Movement is checked
by swaying
• Forward
• Backward
• sideways
Assessment Tools
• Reactive balance assessment
• Backward Release or
• Pastor Day and Marsden Test
Reactive balance assessment
Backward Release
Procedure
• Patient is asked to stand with feet shoulder width apart.
• Therapist places their hand between the patient’s
scapulae. Client is asked to “lean back against hand.” Once
the patient is leaning backwards into the therapist’s hand,
the therapist unexpectedly removes the support
Backward Release
Scoring
• Steadies self independently
• Number of steps taken:
• Requires physical assistance not to fall
• Unable to perform
• The maneuver is inappropriate (e.g., extreme anxiety)
• unsafe (e.g., obesity) to be performed on a specific
patient.
Backward Release
Warning!
This Test is Dangerous. Do Not
Perform This
Test If You Will Be Unable To Catch
The Patient
D O N ’T TRY THIS AT HOME
Assessment Tools
• Dynamic Balance Assessment
• Berg Balance Scale
• Tinetti Performance-Oriented Mobility Assessment
(POMA)
• Timed Up and Go Test (TUG)
• Timed walking test
• Gait Abnormality Rating Scale (GARS)
• Dynamic Gait Index
• Step test
• 7cm block….. medio lateral stability ….15 second
• 17 times….abductor strength…
• `
• Fukkuda test
• one by one block …..50times….not more than one foot…..
• Close eye….normal not more than one foot …..45 degree……..if
more than 45 same side hypo function of vestibular……
Fukuda Step Test
CO-ORDINATION
Introduction
• Coordination:
• “ability to execute smooth, accurate, controlled

movements.”
• Coordinated movements are characterized by:
1. “Appropriate speed, distance, direction, rhythm, and muscle

tension.”
2. “Appropriate synergist influences.”
3. “Easy reversal between opposing muscle groups.”
4. “Proximal fixation to allow distal motion or maintenance of

a posture.”
• Incoordination (coordination deficit): “abnormal motor
function characterized by awkward, extraneous, uneven,
or inaccurate movements.”
• Cerebellum
• Basal ganglia
• Dorsal columns.
• Examples of diagnoses that typically demonstrate
coordination deficits:
1. Multiple sclerosis.
2. Cerebral palsy.
3. Cerebellar tumors.
4. Parkinsonism
5. Huntington’s disease
6. Sydenham’s chorea.
Assessment of coordination
• Assessment must be done bilaterally even in unilateral lesion
• Assessment must be done in quiet place to avoid distraction
• Age and psychological state must be considered
Assessment of coordination
contain:
 Motor assessment including muscle tone and muscle test
 Sensory assessment including superficial and deep
sensation
 ROM
 Orofacial function assessment including facial
expression ,lip &jaw closure
 Senstivity of face
 Coordination of respiration with swallowing and speech
• Classifications Of Coordination Tests:
1. Gross vs. fine motor activities.

2. Non-equilibrium vs. equilibrium tests.
 Coordination assessment including non equilibrium and
equilibrium subtypes
 Non equilibrium coordination tests

 Finger to nose
 Finger to finger
 Finger to doctor’s finger
 Rebound phenomenon
 Buttoning and unbuttoning
 Heel to knee
 Walking along a striaght line
Recording test results
• Arbitrary scale.
• Timed tests.
• Videotape recording.
Finger-to-Nose Test
Finger-to-nose with moving target
Stationary finger-to-nose with eyes

closed
Heel to knee test
Rapid Alternating Movements
• First with hands

• Repeat with feet
• Diadochokinesia = ability to perform RAM
• Dysdiadochokinesis = slow, irregular, clumsy
movements
Ahmad Alghadir M.S. Ph.D. P.T.
Standardized instruments for
coordination assessment
1. Jebsen-Taylor Hand Function Test:
• Measures hand function using seven functional activities:
writing; stacking; card turning; simulated feeding; picking up
small objects; picking up large, lightweight objects; and
picking up large, heavy objects.
• Minnesota Manual Dexterity Test consists of two operations:
• placing and turning. After a practice trial, scores are based on the time
required to complete each of four trials for each operation
• The Purdue Pegboard Test includes a pegboard equipped with
pins,. Scores are based on the number of assemblies
completed within either a 30- or 60-second period
4. Crawford Small Parts Dexterity Test:
• Assesses hand dexterity using a test board, screwdriver,
tweezers, pins, screws, and collars.
The Hand Dexterity Tool Test utilizes ordinary tools for removing
and remounting the nuts and bolts. The test is timed from initiation
.
of task (picking up first tool until the last bolt is secured

treatment
 Methods of treatment:
 PNF technique
1- Rhythmic stabilization to improve proximal stability

2-Reversal tech. to improve ability to alternate movement from
agonist and antagonist
3-Approximation to improve proximal fixation
 Tapping and weight bearing increasing stability
 Using ankle and wrist weight to decrease tremor
 Balance can improved in antigravity position in normal base of
support
 Postural stability is improved by using antigravity position in the
developmental sequence
 Frenkel’s exercises improve co ordination
Frenkel’s exercises
• Definition :
a series of gradual progressive exercises designed to
increase coordination
Aim :
Establishing control of movement by use of any part of sensory
mechanism which remain intact as sight & hearing to
compensate for the loss of kinethetic sensation
Frenkel’s exercises contain
• I-lying ---------
• flexion-extension
• Abduction – adduction
• Each movement will be performed unilaterally fast then slow
then interrupted by hold
• bilateral performance simultaneusely then alternatively
Frenkel’s exercises contain
• Sitting :
• 1-Slide heel to reach a mark on the floor
• 2-change standing and sit again
• Standing :
• 1-walking between parallel lines
• 2- walking side ways
• 3-placing foot on specific marks
Frenkel’s exercises cont
• For arms :
• Sitting with arm supported on a table and placing hand at
specific mark
• Try to reach an object
• Picking up objects
• Put the hand in a ring or hole

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Balance & Coordination

• Balance is the condition in which all the forces acting on the

• Static postural control (stability)

• Closed motor skill

Single Leg Stance Criteria

Instructions for the Patient (Eyes Open, SLS):

Criteria to stop timing the test:

Instructions for the Patient (Eyes Closed, SLS):

• Sensory ataxia (posterior column)

• Motor ataxia (vestibular or vestibular )

• Modified in tandem stance

Stork Stand Test

• Criteria & Result

• Age related norms for the functional reach test:

• This is just an extension

• “ability to execute smooth, accurate, controlled

1. “Appropriate speed, distance, direction, rhythm, and muscle

2. “Appropriate synergist influences.”

3. “Easy reversal between opposing muscle groups.”

4. “Proximal fixation to allow distal motion or maintenance of

1. Gross vs. fine motor activities.

 Non equilibrium coordination tests

Stationary finger-to-nose with eyes

• First with hands

Ahmad Alghadir M.S. Ph.D. P.T.

1- Rhythmic stabilization to improve proximal stability

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