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Systems Framework for Postural Control

This is an excerpt from FallProof! 3rd Edition With HKPropel Access by Debra Rose.

To reduce or prevent falls among older adults, we must first identify the associated risk factors and their underlying causes. To accomplish this, several fall risk screening and assessment tools have been developed and tested over the years, with the primary goal of identifying impairments and functional limitations associated with increased risk of falls. Although some tests have been designed for use with community-residing older adults (Berg et al., 1989 ; Horak et al., 2009; Podsiadlo & Richardson, 1991), others have been designed for use with older adults who have frailty (Guralnik et al., 1994; Weiner et al., 1992). Unfortunately, very few balance evaluation tools developed to date have been guided by theory. The systems framework for postural control (SFPC; Horak, 1991, 2006) identifies six domains contributing to overall balance: (1) biomechanical constraints, (2) movement strategies, (3) sensory strategies, (4) orientation in space, (5) control of dynamics, and (6) cognitive processing. Each of these domains is considered to play an important role in the maintenance and control of balance during static and dynamic movements performed in response to different task demands and environmental constraints.

In 2015, Sibley and colleagues conducted a scoping review of 66 standardized assessment tools. The review analyzed the number of components included in each test or scale described in the SFPC. The six core domains of balance originally identified in the SFPC were revised, and a list of nine operationally defined components was created. The nine components included (1) static stability, (2) underlying motor systems, (3) functional stability limits, (4) verticality, (5) reactive postural control, (6) anticipatory postural control, (7) dynamic stability, (8) sensory integration, and (9) cognitive influences. Of the standardized tests reviewed, half evaluated three or fewer components of postural control, whereas only one measurement tool evaluated all nine components—the Balance Evaluation Systems Test (BESTest), developed by Horak and colleagues (2009). This is perhaps not surprising, given that the lead test developer, Horak, also authored the most comprehensive description of the SFPC in 1986. Four standardized tests evaluated eight of the nine components, with the Fullerton Advanced Balance (FAB) scale being one of those measurement tools.

The assessment of multiple dimensions of physical function (in particular, balance and mobility) assists the instructor in many ways. Assessment not only facilitates the early identification of older adults who are beginning to experience significant changes in multiple body systems, resulting in observable changes in postural stability and mobility, but also helps you, the instructor, develop an appropriate exercise plan that targets the identified impairments. When assessments are readministered on a regular basis, the information obtained can be used to guide the selection or avoidance of certain exercises, help participants set appropriate short- and long-term goals, and motivate participants to meet each of those goals. Finally, assessment is a way of documenting the overall effectiveness of the program and your teaching.

Consistent with the SFPC, any screening and assessment of older adults, particularly those already experiencing balance and mobility impairments, should include tests that assess the multiple body systems (e.g., sensory, motor, musculoskeletal, and cognitive) that contribute to balance. Such a multisystem assessment will provide you with in-depth information that can be used to select the most appropriate exercise progressions. In addition to providing information about the multiple dimensions of balance and mobility, the assessment described in this chapter reveals important information about lifestyle and physical activity patterns. For example, Ye and colleagues (2021) found that older adults who participated in physical activities once a week or less were more likely to have physical, psychological, and social frailty when compared to more physically active older adults. Other studies have further concluded that engaging in physical activity could help older adults become more aware of their physical capabilities, increase their connections with peers, lower the prevalence of depressive symptoms, and elevate their emotional well-being (Blake et al., 2009; Tarazona-Santabalbina et al., 2016; Zhang et al., 2020).

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KEY POINT

Screening and assessment facilitate the early identification of balance impairments in an older adult and help the instructor develop a more tailored exercise plan for the individual.

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