Corrective Exercise for Backward Disequilibrium

Link to video on Backward Disequilibrium from JNPT: Backward Disequilibrium

Link to journal article on Backward Disequilibrium in JNPT: Backward Disequilibrium

CLINICAL OBSERVATIONS

1. Clinicians mostly fail to recognize this condition because they identify patients with this movement impairment as being uncooperative OR have either fear of falling OR dementia. The failure to recognize this condition is reflected in the paucity of clinical research done on this very debilitating condition. The article above is the only paper I am aware of which discusses this condition in a PT journal. And, in the video, one of the authors pointed out another challenge. In the few journal articles discussing this condition, it is referred to using different nomenclature.

2. The case report above illustrates the usual progression of the condition. These patients would usually stay in a SNF for 100 days without any progress. After 100 days, in some cases, patient's are discharged to a LTCF.

3. Patients with this condition, during the acute and subacute phases will always require 2 people to stand them up "safely." Once they are up, they cannot take steps. They have problems planting their feet in standing, and often in sitting also. Instead, their feet will slide forward. Standing is only performed for pivot transfers (if it can be called that because the patient's feet are sliding and not really pivoting).

4. One of the behavioral patterns I have observed among these patients is that they learn to "adapt" by giving excuses not to get out of bed. They might initially give pain as a reason for not getting out of bed, and later, feeling dizzy. The latter is consistent with orthostatic hypotension. This is another factor which can contribute to a patient's lack of progress. This results in increased debility and immobility.

5. The corrective exercise for this condition is perturbation in sitting using a large wobble board with manual cuing to shift weight with every perturbation. In one treatment session, from requiring 2 people to stand up, after the corrective exercise, a patient will be able to take a few steps with minimum assistance (among patients without any co-morbidity which can also result in movement impairment).

1. The wobble board is similar in size as the one on the left, but the surface is similar to the one on the right but carpeted.

2. I had the patient sit at the edge of the mat unsupported, elevated the mat and positioned the patient's feet on one end of the wobble board. Because patients with Backward Disequilibrium do not plant their feet on any surface, I placed 10-pound weights on each ankle.

3. Because the wobble board was big enough, I stood on the other end of the wobble board, and I held the patient's hands. When I perturbed the board going up on the patient side, I would also slightly pull the patient's arms forward which would be the correct postural response with a posteriorly-directed perturbation. When the board is down on the patient side, I would release my shoulder pull, which allows the patient to shift her weight backwards which is the appropriate postural response to anteriorly -directed perturbation.

4. I would also position the wobble board to the left and right side of the patient, following the same procedure on pulling and releasing.

5. I started the session with rhythmic rocking, which I modified through the timing and amplitude of perturbation.

6. In the SNF, since I did not have access to the same equipment, I tried the maneuvers using the BOSU. It is doable, but very difficult, especially when handling a patient with impaired postural, balance and equilibrium reaction.