Proprioception,Vestibular

System & Balance

DR. KRYSTAL ROBINSON-BERT
Screening: vision should be the least involved in
balance; it becomes overused as we get older
 What is Proprioception?

 The ability to sense one’s body position in space.

 Based on three systems:
 Visual System- we use visual cues to negotiate space
and know where we are in space
 Vestibular system- Semicircular canals provides
feedback regarding head position and vestibular system
has neural connections to the cerebellum to provide
feedback about head position.
 Proprioceptive system- loop between the muscle
spindles, Golgi tendon organs, joint receptors to/from
the cerebellum.
 Muscle Spindles & Golgi Tendon Organs

 Muscle spindles- proprioceptors/ sensory receptors

located in skeletal muscle that provide information
about muscle stretch. Causes the muscle to
CONTRACT.
 Golgi Tendon Organs- proprioceptors that detect
tension in the tendon of a contracting muscle.
Activation of GTOs is a protective mechanism- it
inhibits and RELAXES the muscle so it does not tear.
 Both Golgi Tendon Organs and Muscle Spindles are
also sending information to the cerebellum.
 Activity

 Reflex Testing- Knee (muscle spindles)

 A simple example of muscle spindle activity is the knee

jerk reflex (Patellar reflex), sudden kicking movement
of the lower leg in response to a sharp tap on the patellar
tendon, which lies just below the kneecap. Tapping on
the tendon of the knee extensor muscle group below the
patella stretches the muscle spindle fibers in the
quadriceps muscle. Muscle Spindles kick in and cause a
quick contraction of the quadriceps muscle. A knee jerk
occurs as these fibers actively shorten.
 Whoa tracts! (you do not need to know these!)

• There are lots of tracts that provide

information to the cerebellum.
• From the brain:
• Cortico-ponto cerebellar
• Olivocerebellar
• Vestibuolocerebellar
• Reticulocerebellar
• From the peripheral system:
• Spinocerebellar tracts
 Vestibular System

 Maintains our equilibrium and balance and head in an

upright vertical position.
 Receives input from:
 Vestibulocochlear Cranial Nerve (CN 8)
 Vestibular apparatus in the inner ear
 Cerebellum
 Oculomotor Cranial Nerve, Trochlear Cranial Nerve,
Abducens Cranial Nerve(Cranial Nerves 3,4,6) (Eye
movement nerves).
 Vestibular Nuclei in brain stem
Vestibular Pathway (not exam)

 Vestibular nuclei in the brainstem receive all of the information about balance and
equilibrium from the inner ear, eye cranial nerve nuclei and cerebellum.
 Information is sent through the spinal cord through vestibulospinal tracts.
 Motor neurons synapse in the ventral horn and send message to spinal nerves in the
peripheral nervous system.
 Information is sent to the muscles to maintain body’s upright position against gravity
(often extensors)
 Proprioceptive information is sent back to the cerebellum to make ongoing decisions
regarding improvement of balance while information is also being sent directly to head &
eyes to mediate head position/head righting.
Activity

 Romberg Test- practicing balance with eyes closed

Vestibular Dysfunction

 Nystagmus
 Tinnitus
 Vertigo
 Hearing Loss
 Loss of balance and falls
 Wide-based stance
Nystagmus

 Involuntary jerky back- and forth movement of

the eyes when the move to visual field extremes.
 Nystagmus occurs because the cerebellum has
connections to the oculomotor muscles.
 Individuals with damage to the cerebellum may
be unable to maintain steady gaze in certain
visual fields.
 (End ranges of the X and Y when testing)
Cerebellum

 Cerebellum- role in the coordination of

movement, posture, equilibrium/balance,
proprioception.
 Error-correcting device for the motor
system.
 Damage to the cerebellum causes difficulty
with fine-precision and endpoint
movement.
 Cerebellar lesions disrupt timing, rate and
force.
Cerebellum Damage

 Movement happens but it’s

just not right. It’s not
coordinated or has bad timing
or the wrong “force”.
Basal Ganglia

 Play a role in stereotypic and automated

movement pattern.
 Damage to the basal ganglia causes
involuntary, undesired movements, and a
difficulty initiating and termination
movements
Basal Ganglia Damage

 Movement won’t start, movement

won’t stop, movement happens
when you don’t want it to…often
at rest.
Basal Ganglia Deficits

 1. Resting Tremors
 2. Rigidity
 3. Akinesia
 4. Bradykinesia
 5. Cunctation-festinating gait
 6. Chorea
 7. Athetosis
 8. Hemiballismus
 9. Dystonia
 10. Tics
Tremors & Rigidity Screening

 Resting tremors decrease or disappear with voluntary movement.

 Observe for tremors, and then ask client to do a voluntary movement such as make a
sandwich, pour water into glass etc.
 Rigidity- complete PROM with client.
 Two types of rigidity are signs of basal ganglia impairment:
 Lead pipe- uniform and continuous resistance.
 Cogwheel- alternate release-resistance.
Resting Tremor
Akinesia & Bradykinesia

 Akinesia- observe if patient is unable to initiate movement.

 Bradykinesia- slow or decreased movement, often unable to quickly change movements.
 Ask patient to demonstrate different facial expressions.
 Ask patient to change inflection of voice.
 Ask to comb hair on right side then ask if they can switch to left side.
Cunctation-festinating gait

 Cunctation- resist movement.

 Festination- hurry.
 Cunctation-festinating gait includes difficulty initiating walking and stopping walking.
 Once the patient finally begins to walk it is hurried, shuffled with decreased or absent
reciprocal arm sway and is unable to stop walking or change directions.
 Ask patient to walk straight line or change direction or speed when walking.
 Ask patient to stop walking quickly or start walking quickly.
Chorea, Athetosis, Hemiballismus, Dystonia
& Tic Screening

 Chorea- observe for sudden rapid, involuntary jerky movements that primarily involve face and
extremities. Look for shoulder shrugs, hip movement, crossing/uncrossing of arms or legs,
tongue protrusions.
 Athetosis- observe for slow flailing, twisting movements. Often involves neck, face, trunk,
extremities.
 Hemiballismus- observe for violent thrashing movements. (one side)
 Dystonia- observe for increased muscle tone causing twisted postures of trunk and extremities.
Torsion spasms can last for seconds->hours.
 Torticollis
 Tics- observe for repetitive, brief, rapid involuntary movements involving single muscles or
multiple muscle groups. Eye blinks, head jerks, shoulder shrugs or sounds.
Hemiballismus
Athetosis
Chorea
Dystonia
References

 Gutman, S. A., & Schonfeld, A. B. (2019). Screening adult neurologic populations: a

step-by-step instruction manual (3rd ed.). Bethesda, MD: AOTA Press.