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Abstract
Balance is a crucial component of daily activity. It is a simplistic concept but the mechanisms involved in monitoring, adjusting and percieving balance are highly complex. The three systems associated with balance work together to maintain the bodys centre of mass over the base of support. This report will discuss the physiology and responsibilities of the vestibular, visual and the somatosensory systems and their role in balance. This report will also discuss closed kinetic chain exercises and their progressions to retrain balance in individuals with lower extremity injuries. The visual system is responsible for percieving movement, locating objects in space and differentiating between exafferent and reafferent information. The vestibular system is responsible for monitoring gravity changes and acceleration associated with head movement. The somatosensory system monitors many bodily changes, but this report will focus on proprioception. Proprioception is the ability to monitor and percieve the location of body parts in space with the feedback of muscle spindles and golgi tendon organs. It is concluded that closed kinetic chain exercises that progress to challenge the visual and somatosensory systems are successful in retraining balance. It is recommended that the vestibular system be challenged with rotational and lateral head movements to incorporate all three balance systems.

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Table of Contents
1.0 Introduction ........................................................................................................................... 1 1.1. Balance .......................................................................................................................... 1 1.1.1. Visual and Vestibular Systems ............................................................................. 2 1.1.2. Somatosensory System ......................................................................................... 4 1.2. Open vs. Closed Kinetic Chain Exercises ..................................................................... 6 2.0 Methods and Findings ........................................................................................................... 7 2.1. Physical Therapy for the Vestibular System ................................................................. 7 2.2. Rehabiliation of the Visual System ............................................................................... 8 2.3. Balance Exercises and the Somatosensory System ..................................................... 10 3.0 Conclusion .......................................................................................................................... 11 4.0 Recommendations ............................................................................................................... 12 5.0 Glossary .............................................................................................................................. 13 6.0 References ........................................................................................................................... 15 7.0 Appendix ............................................................................................................................. 17 8.0 Evaluation ........................................................................................................................... 19

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List of Tables and Figures

Figure 1.0. Anatomical structures of the vestibular labyrinth .................................................... 2 Figure 2.0. Diagram of the ampulla within semicircular canals ................................................. 2 Figure 3.0. Otolith organs at rest and displaced.......................................................................... 3 Figure 4.0. GTO response to over contraction of bicep muscle ................................................. 4 Figure 5.0. Patellar reflex depicting muscle spindle activity ...................................................... 5 Figure 6.0. OKC lat pull down vs. CKC pull up......................................................................... 6 Figure 7.0. Ankle strategy (left) vs. Hip strategy (right) ............................................................ 9 Table 1.0. Level progression for 26 participants at the end of a 6-week test period ................ 10

1.0 Introduction
[name of clinic here] is a multi-disciplinary clinic that deals with a wide range of personal and motor vehicle injuries to help promote and increase the rate of recovery. The role of the kinesiology department is to implement the correct stretches and exercises for each individual and progress accordingly based on therapists guidelines and assessment of injuries. A wide range of injuries are present throughout the clinic, however, those involving the lower extremities are often associated with ones inability to maintain ones balance. There are many factors that can affect ones balance, these include tramautic brain injuries, muscle or nerve damage, concussions, age or visual acuity. 1.1 Balance It is now understood that balance is maintained by three sensory systems, the vestibular, visual and somatosensory system (Mohapatra, Krishnan & Aruin, 2011). The stimulation of either of these systems evokes a deviation in balance and increases body sway. We are able to depress or remove the systems while training for balance by closing the eyes to remove vision, standing on a foam pad, one leg or uneven surface to hinder the somatosensory and vestibular system. Proprioception* can be altered in many ways. Vibration introduced to the muscle tendons will activate muscle spindles, producing a feeling of instability causing postural tilt in the direction of the muscle vibrated, also known as vibration-induced falling (Van Ooteghem, 2010). This phenomena only occurs when the individual is not looking at the vibrated limb. When vision is introduced, the sensation ceases and negates the vibrating effect (Van Ooteghem, 2010). This reflects how much one relies on the visual system for proprioceptive feedback. The vestibular system is a highly complex system that monitors head movement through a labyrinth of organs in the inner ear (Gray, n.d.). It works together with the visual system to differentiate objects moving in our visual space and the movement of ones own head. When working optimally, the three components of balance work collectively to produce a stable body, minimizing deviations from the central base of support by postural sway and reducing the risk of injury from falls and instability.

1.1.1 Vestibular and Visual Systems One cannot describe the visual system and vestibular system individually without referencing the other. This section will discuss the vestibulo-ocular pathway and its relationship with balance. The vestibular system is located in the inner ear and is made of 3 semicircular canals (SCCs) and 2 otolith organs, the saccule and utricle, making up a structure called the vestibular labyrinth, shown in Figure 1.0 (Gray, n.d.). The semicircular canals are responsible for detecting angular acceleration and are oriented 90 to each other (Gray, n.d.). Their orientation allows angular acceleration of the head to be detected in the roll*, pitch* and yaw* directions, corresponding to the x,y,z axes (Gray, n.d.). See Appendix A for a diagramatic view of each direction. Otolith organs oriented 90 from one another detect linear changes in head movement, the utricles measure mostly horizontal acceleration (ie. deceleration) while the saccules responds primarily to vertical acceleration (ie. gravity) (Gray, n.d.). All 3 SCCs and both otolith organs innervate the vestibulocochlear nerve (VIIIth CN) (Gray, n.d.). At the entrance (ampulla) of each semicircular canal there is a gelatinous liquid called cupula (Rutka, n.d.). Embedded in the cupula are stereocilia, tiny hairs that extend out from the vestibulocochlear nerve that respond to mechanical shearing* in different directions causing a chemical depolarization* or hyperpolarization* of the nerve (Rutka, n.d.). As the head moves, the cupula lags behind and bends the hairs, resulting in a reafferant* signal to the brain indicating that
Figure 1.0. Anatomical structures of the vestibular labyrinth.

Figure 2.0. Diagram of the ampulla within semicircular canals

the head has moved (Rutka, n.d.). In relation to vision, each SCC innervates two ipsi-lateral* and two contra-lateral* muscles of each eye, with six extraocular muscles in each eye, corresponding to each of the three SCCs there is an innervation ratio of 2:1 (Rutka, n.d.). This level of control allows for a fine response in eye movement, keeping a stable retina image (Rutka, n.d.). Importantly, this allows us to differentiate between subjective and objective movements. This phenomena can be demonstrated by placing your finger infront of your face and shaking your head up and down, and left and right while fixing your gaze upon your finger (Clopton, 2007). Your finger stays stationary while your head moves, but by shaking your finger while your head is fixed, the finger appears blurry (Clopton, 2007). This is an example of the SCC portion of the vestibulo-ocular pathway (Clopton, 2007). Otolith organs lie between the semicircular canals and the cochlea within the vestibular labyrinth (Rutka, n.d.). Responsible for gravitational movement, the saccule and utricle are oriented at 90 from each other, detecting linear changes in the horizontal and vertical directions (Rutka, n.d.). Otolith organs contain a gelatinous matrix* with cilia* projecting from the afferent nerve endings, similar to the SCCs (Rutka, n.d.). However, the surface of the gelatinous matrix contains a membrane with a layer of calcium carbonate crystals ontop, increasing the weight of the membrane (Rutka, n.d.). Otolith means ear stones in Greek (Rutka, n.d.). This blanket of crystals causes drag on the top of the gelatinous matrix when the head is moved causing a displacement of the matrix resulting in the hairs within the matrix to bend, similar to the function of the SCCs (Rutka, n.d.). In turn, the otolith organs also stimulate the vestibulocochlear nerve (Rutka, n.d.).

Figure 3.0 Otolith organs at rest and displaced

1.1.2 Somatosensory System The somatosensory* system is a collection of unnamed senses which includes vibration, temperature, pain and proprioception (Arezzo, Schaumburg & Spencer, 1982). This report will focus on proprioception and its involvement in balance and reafferent sensory feedback. Proprioception is termed as the ability to perceive the location of our own body in space (Van Ooteghem, 2010). It is part of the somatic division, or voluntary division, of the peripheral nervous system, which includes the sensory neurons of the skin, joints, tendons and muscles (Van Ooteghem, 2010). During balance rehabilitation there are two structures that are being targeted and are responsible for fall prevention and limiting postural sway. These are golgi tendon organs (GTOs) and muscle spindle fibers (Van Ooteghem, 2010). Golgi tendon organs are innervated by encapsulated 1B nerve endings located at the muscletendon junction and are arranged in series with the muscle and its tendon (Van Ooteghem, 2010). Since muscles contract towards the muscles belly, the most tension occurs at the tendons thus stimulating the GTOs (Van Ooteghem, 2010). Response to tension prevents the muscle from over contraction and overexertion that could cause muscular damage at its origin and insertion points as well as the muscle itself (Van Ooteghem, 2010). GTOs are associated with a negative feedback loop where an over contraction felt at an agonist muscle, the collagen fibrils of the tendons press on the 1B afferent neurons which synapses at the spinal cord shutting off the 1A motor neuron of the same agonist muscle, preventing damage from over contraction (Van Ooteghem, 2010). This feedback loop also prevents the muscle from
Figure 4.0. GTO response to over contraction of the bicep muscle

fatigue and therefore maintains muscle force (Van Ooteghem, 2010). Opposite GTOs are muscle spindle fibers. Muscle spindles are intrafusal* fibers, innervated by gamma motor neurons and are located within the muscle belly (Van Ooteghem,

2010). Intrafusal fibers are not to be confused with extrafusal* fibers which are innervated by alpha motor neurons, as they are both arranged in parallel to each other within the muscle belly (Van Ooteghem, 2010). Muscle spindle fibers contain 2 sensory components, primary (annulospiral) endings and the secondary (flower spray) endings (Van Ooteghem, 2010). Primary endings output signals to the spinal cord via 1A afferent neurons, secondary endings via Group II afferent neurons (Van Ooteghem, 2010). These components respond to stretching of the muscle, which is dependent on sarcomere* length. Muscle spindles are involved in a feedback loop, also known as the stretch reflex (Van Ooteghem, 2010). The stretch reflex is activated when the muscle spindle fibers have been stretched quickly in a short period of time (Van Ooteghem, 2010). This elicits a response of the intrafusal fibers signalling via 1A and Group II afferent neurons to the spinal cord where they synapse with alpha motor neurons of the agonist and antagonist muscles (Van Ooteghem, 2010). The stretch reflex elicits a contraction of the stretched agonist muscle and a relaxation of the antagonist muscle. A prime example is the patellar reflex. The patellar tendon is struck with a reflex hammer, causing a stretch in the muscle. This sudden stretch in the muscle causes the spindle fibers to respond. Information is sent to through the stretch reflex loop and the quadriceps contract causing the leg to rise.

Figure 5.0. Patellar reflex depicting muscle spindle activity

1.2 Open vs. Closed Kinetic Chain Exercises Exercises can be broken down into two components, open kinetic chain (OKC) and closed kinetic chain (CKC) exercises. OKC exercises are defined as an exercise where the distal* segment of a limb (ie. hands, feet) is moving freely (Hooper, Morrissey, Morrissey & King, 2001). Straight leg raise, leg press, lat pull down and knee extension are examples of OKC exercises. During CKC exercises, the distal end of the segment is fixed throughout the exercise (Hooper, Morrissey, Morrissey & King, 2001). Isometric shoulder exercises, squats, pull-ups and push ups are examples of CKC exercises. Studies have shown that CKC exercises may be more beneficial in the early rehabilitation stages because of its involvement in activating more muscle groups in a more functional way rather than isolating a single muscle group with OKC exercises (Hooper, Morrissey, Morrissey & King, 2001). CKC exercises
Figure 6.0. OKC lat pull down vs CKC pull up

are also conceived at better enhancing functional performance, more than OKC excercises (Hooper, Morrissey, Morrissey &

King, 2001). For example, a CKC exercise such as a squat recruits twice as much hamstring activity, greatest activation of quadriceps at full knee flexion as well as more vasti muscle activation than an OKC leg press exercise (Escamilla, Fleisig, Zheng, Barrentine, Wilk & Andrews, 1998). However, proper discretion must be taken into consideration when implementing primarily CKC or OKC exercises to an individuals routine. For anterior cruciate ligament injuries, studies have found that greater strain was placed on the ligament with OKC exercises than CKC exercises (Escamilla, Fleisig, Zheng, Barrentine, Wilk & Andrews, 1998). However, many studies have concluded that although CKC exercises promotes greater functional capabilities, OKC exercises must be incorporated to increase torque* in the lever muscle (ie. tricep, quadriceps) (Escamilla, Fleisig, Zheng, Barrentine, Wilk & Andrews, 1998). This report will focus on CKC exercises and their implementation in balance rehabilitation. [The name of your hometown] Physiotherapy and Rehabilitation Centre caters to a large demographic and a multitude of injuries. Treatments prescribed by the clinicians incorporate

many rehabilitation techniques and modalities to promote the healing of musculoskeletal structures and systems. The role as a kinesiologist is to prescribe exercises and stretches based on the clinicians program requests and make changes if necessary. Many individuals at the clinic experience issues with balance, whether from muscular or neural issues. This report will discuss the utilization of CKC exercises and other methods to challenge the three balance systems. This is a non-empirical report where formal reasoning and research of implemented CKC exercises and rehabilitation methods for balance will be discussed and supplemented with critical analysis.

2.0 Methods and Findings

Balance rehabilitation must incorporate many areas of expertise and treatment to be able to fully diagnose the root cause of an individuals balance disorder. At [nonames] Physiotherapy and Rehabilitation Centre there are a large majority of individuals with balance disorders stemming from musculoskeletal issues such as lower extremity fractures*, ligament* and muscular tendon* tears. Therefore, there is greater application of proprioceptive balance training. This section will discuss methods of vestibular, visual and proprioceptive rehabilitation for balance with most emphasis on proprioception through CKC exercises. 2.1 Physical Therapy for the Vestibular System There are two branches of the vestibular system, central and peripheral. Physical therapy is one method for treating vestibular system dysfunctions. Other forms of intervention include pharmacological therapy and surgical intervention. This section will discuss the physical therapy methods for treating the vestibular system. Imbalance in the peripheral vestibular system, which consists of the inner ear organs, can cause mild to severe vertigo*, nausea and gait* abnormalities which can be treated in multiple ways in the clinical setting (Brown, Whitney, Marchetti, Wristley & Furman, 2006). Central vestibular dysfunctions are more difficult to treat through physical therapy and must address the neurological issues involving the central nervous system (Brown, Whitney, Marchetti, Wristley & Furman, 2006). Those with peripheral vestibular dysfunction can benefit most from physical therapy (Brown, Whitney, Marchetti, Wristley & Furman, 2006). In a study by Brown et al, patients performed the Dynamic Gait Index (DGI), Timed Up & Go(TUG) and Five Times Sit-to-Stand (FTSTS). The DGI is composed of 8 gait tasks;

walking, walking at varying speeds, walking with head movements in the yaw and pitch directions, walking over and around objects, pivoting and stair climbing (Brown, Whitney, Marchetti, Wristley & Furman, 2006). TUG is a timed sitting, walking and standing examination where the patient is asked to stand up from a chair, walk 3 metres and return back to their chair and sit down (Brown, Whitney, Marchetti, Wristley & Furman, 2006). The FTSTS test measures balance and lower extremity strength and it requires individuals to rise from a seated position and sit back down without the aid of their arms (Brown, Whitney, Marchetti, Wristley & Furman, 2006). The tests cause angular and linear accelerations of the head, exposing the individual to movements that may cause discomfort and rehabilitating the issue. Significant improvements in gait and balance were present at patient discharge after vestibular physical therapy (Brown, Whitney, Marchetti, Wristley & Furman, 2006). Benign paroxysmal positional vertigo (BPPV) is a common issue in vestibular dysfunctions and can be treated more intensively with positional exercises and liberatory maneuvers proposed by Semont et al and Epley (Brandt, 2000). This physical therapy treatment involves rapid lateral head and trunk tilts to induce the feeling of vertigo. The patient is to remain in the tilted position until vertigo subsides or duration of 30 seconds (Brandt, 2000). This process can be repeated in different planes of the head and trunk to stimulate the different SSCs. The purpose of these maneuvers is to loosen and break down clots that have accumulated in the endolymph* of the inner ear (Brandt, 2000). The clot decreases the fluidity of the gelatinous matrix, which lags behind causing nystagmus* and vertigo (Brandt, 2000). These maneuvers can be performed in home without assistance from a clinician (Brandt, 2000). See Appendix B for a schematic of the Semont maneuvers. 2.2 Balance and the Visual System Vision is a crucial component in balance. Not only does vision allow us to detect hazards and uneven surfaces, it also communicates with the vestibular system and perceive spatial relationships with respect to objects in the environment (Lord, 2003). Without visual feedback to the vestibular system, when standing with eyes closed there is a 20-70% increase in postural sway (Lord, 2003). Impaired visual acuity also causes increases in postural sway and is associated most with decreased near-visual acuity (Lord, 2003). Decreased peripheral vision is also a cause of imbalance (Lord, 2003). People are limited in the ways they are able to increase

the acuity of their eye sight, therefore must compensate with greater demand on the vestibular and somatosensory systems (Lord, 2003). Those who are visually impaired put more emphasis on vestibular and somatosensory information to adjust and monitor balance (Ray, Horvat, Croce, Mason & Wolf, 2008). Older adults with adverse vestibular affects and lessened visual acuity place more priority on their proprioception (Ray, Horvat, Croce, Mason & Wolf, 2008). It is reported that both
Figure 7.0. Ankle strategy (left) vs. Hip strategy (right)

adolescent children and adults who are blind exhibit fear of falling and have decreased postural stability (Ray, Horvat, Croce, Mason & Wolf, 2008). In a mixed trial where individuals with full vision closed their eyes and balanced, and blind individuals closed their eyes, imbalance was similar (Ray, Horvat, Croce, Mason & Wolf, 2008). However, with eyes open, blind individuals demonstrated similar amounts of imbalance (Ray, Horvat, Croce, Mason & Wolf, 2008). This indicates that those with vision absent do not fully adapt to vision loss (Ray, Horvat, Croce, Mason & Wolf, 2008). The greater increase in postural sway was correlated to an increase in hip shifting strategy, where the individuals reacted with the hip instead of through the ankles and knees (Ray, Horvat, Croce, Mason & Wolf, 2008). Increased hip strategy can lead to an increased chance of falls (Ray, Horvat, Croce, Mason & Wolf, 2008). Therefore, greater emphasis of vestibular and somatosensory training must be implemented to adapt for an individuals visual impairment. A study by King et al proposed that rapid upper limb movement can be beneficial in fall prevention, absorption and protect against head injury and hip fractures for the visually impaired (King, McKay, Cheng & Maki, 2010). Training individuals to use their peripheral vision to grasp for stable fixtures such as a handrail can reduce the chance of falls (King, McKay, Cheng & Maki, 2010). A study was done to determine if there was a delay in timing and accuracy of central and peripheral vision. Although it is surely advantageous to reach and grasp with central vision, peripheral vision provides adequate information for balance recovery for a fall (King, McKay, Cheng & Maki, 2010).

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2.3 Balance Exercises and the Somatosensory System Postural control can be described as the attempt to maintain coordination of body segments without loss of balance for the facilitation of other actions (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). Postural sway is the continuous movement the body undergoes to maintain this control (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). Thus, it can be interpreted that minimum postural sway is required to achieve significant postural control. Balance can be improved in all demographics by training with balance-specific exercises. Balance exercises have been shown to strengthen the lower extremities as well as reduce recurring injuries (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). Holistic and progressive balance exercises can be prescribed in the clinical and rehabilitative setting to improve postural control of individuals with balance issues (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). It has been noted by researchers that a healthy postural sway reflects the individuals flexibility, adaptability and automaticity of postural control(Strang, Haworth, Hieronymus, Walsh & Smart, 2010). A limited, rigid postural sway indicates a less-adaptable, attention-demanding control of posture (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). In a study by Strang et al, the following holistic balance exercises were prescribed, within each exercises were 4 progressive stages increasing in difficulty. Single leg stance, balance path, double leg BOSU, single leg squat and reach, Bongo Board, 4way tube resist and balance, forward hop, side hop. The descriptions and progressions of each exercise are illustrated in Appendix C. Vestibular, vision and proprioception is tested in each of the exercises within their progressive stages. Trials with eyes closed tested reliance on vision. Squats, forward and lateral hops and the balance path would stimulate the vestibular system in both linear and angular directions. Proprioception is
Table 1.0. Level progression for 26 participants at the end of a 6-week test period

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tested in each of the trials by progression of exercises from a hard surface to foam surfaces, inflatable discs, BOSU balls and Bongo Boards (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). There were improvements in balance for each of the balance trials for each individual. Table 1.0 illustrates the progression of each of the 26 individuals, and the number of successful individuals to complete each task at the end of the trial period (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). Findings lead to the understanding that by training with restricted vision and diminished proprioceptive feedback, a change in postural sway in the normal stance position and improved postural control was observed (Strang, Haworth, Hieronymus, Walsh & Smart, 2010).

3.0 Conclusions
In a physical rehabilitation setting balance is a featured component in most injuries, especially those regarding the lower extremities. Composed of an elaborate system of interconnected feedback pathways, balance is a complex but crucial component in everyday life. The vestibular labyrinth within the inner ear is continuously monitoring head movement and can be manipulated and rehabilitated with simple head and trunk movements. Treating for vertigo and addressing balance issues, exercises can be administered to the individual and be self-treated in-home or more intensive physical therapy maneuvers can be performed by a clinician. The SSCs, Utricles and Saccules are targeted with these maneuvers and by reproducing the symptoms, vertigo and balance issues can be resolved. Closely linked to the vestibular system, slight alterations in vision can cause imbalance, increased postural sway by 20-70%, and issues with fall control and fall prevention. By training reach-and-grasp for the peripheral vision, one can decrease their chance of falling by increasing the accuracy of their grasp and speed at which they reached. Reducing the amount of hip strategy used by those visually impaired and instructing the use of the ankle strategy one can also reduce the chance of falls. Progressive proprioceptive balance training is an important area to train because it incorporates all components of balance as well as training the somatosensory system with perturbations, uneven and unsteady surfaces. Golgi tendons and muscle spindles are active in all movements but are specifically triggered during high velocity movements and those involved in

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re-establishing balance such as falls, wobble board training, BOSU stance and forward and lateral hops.

4.0 Recommendations
With extensive research of the physiology of each system and their corresponding methods of training, [The Cool People Rehab Clinic] should implement a balance training protocol that incorporates the vestibular as a major component of training. Removal of vision by performing exercises with eyes closed and the addition of an unstable surface to challenge the proprioceptive system is commonplace in a rehabilitative setting. However, vestibular training can be implemented to further challenge vision and the somatosensory system. By having individuals stand on one leg with eyes closed on an unstable surface while moving their head in the yaw and pitch directions, all systems are included in one exercise. There are a lot of clinical based exercises for balance focused on proprioception, by introducing a wobble board, foam mat or BOSU ball and progressing to eyes closed but few have considered introducing head movement to stimulate the vestibular system in addition to the other components. Begin with vestibular movements similar to those mentioned in Section 2.1 and progress to standing and one foot balance positions to challenge proprioception, then finally removing vision. This progression will allow for extensive balance training and incorporate all three areas of balance.

5.0 Glossary

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Cilia minute hairlike organelles lining the surface of cells Contra-lateral pertaining to the opposite side Depolarization the influx of sodium ions across a membrane, causing an action potential stimulating the nerve Distal situated away from the point of origin Endolymph fluid within the labyrinth of the inner ear Extrafusal situated outside of a muscle spindle Fracture a break in the continuity of the bone Gait a pattern of movements for walking or moving on foot Hyperpolarization efflux of potassium ions across a membrane preventing or inhibiting an action potential Intrafusal situated within a muscle spindle Ipsi-lateral pertaining to the same side Ligament fibrous tissue that connects bones to bones Matrix a material or substance that specialized structures are embedded Nystagmus fast, uncontrollable movement of the eyes Pitch forwards and backwards movement of the head on the y-axis Proprioception the bodys awareness of the position of its limbs in space Reafferent stimulation as a result of ones own body movements Roll lateral movement of the head side to side on the x-axis Sarcomere basic unit of striated muscle fibers Shear force acting parallel to the transverse plane

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Somatosensory sensations pertaining to the skin and deep tissues of the body Tendon fibrous tissue that connects muscle to bone Torque a moment of force to produce rotation about an axis Vertigo a feeling of motion, dizziness or confusion Yaw rotational movement of the head side to side on the z-axis

6.0 References

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1. Arezzo, J. C., Schaumburg, H. H., & Spencer, P. S. (1982). Structure and function of the somatosensory system: A neurotoxicological perspective. Environmental Health Perspective, 44, 23-30. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1568957/pdf/envhper00461-0029.pdf 2. Brown, K. E., Whitney, S. L., Marchetti, G. F., Wrisley, D. M., & Furman, J. M. (2006). Physical therapy for central vestibular dysfunction. American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation, 87(87), 76-81. doi: 10.1016/j.apmr.2005.08.003 3. Brandt, T. (2000). Management of vestibular disorders. 491-499. 4. Clopton, J. (2007). Balanced vision: How the visual and vestibular system interact. Unpublished manuscript, Retrieved from http://www.sifocus.com/files/Balanced Vision- How the Visual and Vestibular Systems Int.pdf 5. Escamilla, R., Fleisig, G., Zheng, N., Barrentine, S., Wilk, K., & Andrews, J. (1998). Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Medicine and science in sports and exercise, doi: 10.1097/00005768-199804000-00014 6. Gray, L. (n.d.). Chapter 10: Vestibular system: Structure and function. Informally published manuscript, Department of Communication Sciences and Disorders, James Madison University, Houston, Tx, Retrieved from http://neuroscience.uth.tmc.edu/s2/chapter10.html 7. Hooper, D. M., Morrissey, M. C., Drechsler, W., Morrissey, D., & King, J. (2001). Open and closed kinetic chain exercises in the early period after anterior cruciate ligament reconstruction. The american journal of sports medicine, 29(2), 167-174. 8. King , E. C., McKay, S. M., Cheng, K. C., & Maki, B. E. (2010). The use of peripheral vision to guide perturbation-evoked reach-to-grasp balance-recovery reactions. 105-118. doi: 10.1007/s00221-010-2434-9 9. Lord, S. R. (2003). Vision, balance and falls in the elderly. Informally published manuscript, Retrieved from http://www.cmellc.com/geriatrictimes/g031209.html 10. Mohapatra, S., Krishnan, V., & Aruin, A. (2011). Postural control in response to an external perturbation: effect of altered proprioceptive information. doi: 10.1007/s00221-011-2986-3 11. Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates; 2001. Other Afferent Feedback that Affects Motor Performance. Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK10986/ 12. Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates; 2001. The Otolith Organs: The Utricle and Sacculus. Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK10792/ 13. Ray, C. T., Horvat, M., Croce, R., Mason, R. C., & Wolf, S. L. (2008). The impact of vision loss on postural stability and balance strategies in individuals with profound vision loss. Gait & Posture, 28, 58-61.

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14. Rutka, J. A. (n.d.). Physiology of the vestibular system. Informally published manuscript, Retrieved from http://www.bcdecker.com/SampleOfChapter/1550092634.pdf 15. Strang, A. J., Haworth, J., Hieronymus, M., Walsh, M., & Smart Jr, L. J. (2010). Structural changes in postural sway lend insight into effects of balance training, vision, and support surface on postural control in a healthy population. 1485-1495. doi: 10.1007/s00421-010-1770-6 16. Van Ooteghem, K. (2010). An Introduction to Psychomotor Behaviour. University of Waterloo. 17. Vestibular exercises. Unpublished raw data, University of Mississippi, Jackson, MS, Retrieved from http://www.umc.edu/uploadedfiles/umcedu/content/education/schools/medicine/clinical_science/ otolaryngology__communicative_sciences/handouts/vestibularexercise.pdf

7.0 Appendix
A. Diagrammatic view of Roll, Pitch and Yaw directions

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B. Schematic of the Semont maneuvers

C. Description of holistic exercises and their progressions

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