By Brandon Lewandowski, DPT
One of the most prevalent treatment diagnoses that physical therapists work with is impaired balance. This is because many neurological and orthopedic issues can lead to balance deficits. This, in turn, can lead to difficulties with walking function, which is also known as gait. Some of the conditions that are most linked to gait and balance dysfunction are stroke, Parkinson’s disease, amyotrophic lateral sclerosis (ALS), ankle sprain, ACL tears, and vestibular dysfunction causing dizziness. This is a very short list of diagnoses that may cause gait or balance impairment, but it illustrates how often physical therapists see these types of issues.
The reason impairments are found in so many diagnoses is because the balance system consists of three subsystems: the vestibular system (inner ear), the visual system, and the proprioceptive system (sensation). I would also argue that there is a fourth system: strength. If someone doesn’t have the strength in the legs, hips, or core, balance begins to decline as well. If any of the pillars of the system fail, balance suffers as a result. Furthermore, when there is a failure in the system, the natural reaction is to find a compensation to avoid using that system. This in turn gets expressed as gait dysfunction. For example, a high step gait is a compensation for the proprioception system to make sure the person’s foot does not stub on anything since they cannot feel it. This type of gait is generally related to nerve damage in the feet, such as a diabetic neuropathy. As stated before, balance and gait impairments are a widespread issue in physical therapy. So, how does a therapist determine or find which system is the issue, so they can guide a patient’s treatment?
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There are many types of assessments that can be done to evaluate a person’s balance system. The simplest measures are general assessment tools such as single leg stands, Romberg balance, narrow base of support, or even just unsupported standing. These all globally test the balance system and do not tell the therapist much about exactly what is happening; they just note whether the person has good, fair, or poor balance. The generally accepted time someone needs to be able to perform these tests is about 30 seconds. Then, each test has to be carefully chosen to match the population the therapist is testing. Single leg stands may not be appropriate for an 88-year-old person with Parkinson’s, but might be appropriate for a 45-year-old person with vertigo.
From these general assessment tools, the evaluator can then choose the most appropriate functional outcome measures. Some functional measures include Dynamic Gait Index, BERG balance scale, timed up and go, and much more. In an outpatient setting, these are some of the most commonly seen. The benefit of using these measurements is that a correlation can be drawn directly to the failing system (except for timed up and go). For example, a person performs very well on the Dynamic Gait Index but cannot steady themselves with walking and head turns. Their failing system would be the vestibular system, so the therapist can now further assess that specific system. Using this format of guided assessment, a therapist can get a much better overall picture of the deficits a person may have, which may lead directly to certain treatments.
Powers of Observation
Before we discuss treatment options for those with balance and gait dysfunction, it is very important to highlight one very underrated tool that all therapists have at their disposal: the power of observation. This is considered a qualitative measure, because it does not give us any measurable information but is just as important. Evaluating how someone’s gait looks, what strategies they use to regain balance, what motor patterns are present or absent, etc, can be one of the most effective ways to find the appropriate quantitative measures. For example, if someone uses a hip strategy to regain balance after a perturbation instead of an ankle strategy, it may lead a therapist the further evaluate proprioception in the lower leg. This is because there is a change the person doesn’t trust via feedback from joints in the lower leg, so they begin to compensate by using the larger muscles in the hips.
Something that therapists specifically use in our clinic is simple video capturing while walking on a basic treadmill or on our AlterG Anti-Gravity Treadmill, which is manufactured by AlterG Inc, Fremont, Calif. This gives a therapist the opportunity to look frame by frame at an issue and get a much better understanding of exactly what is happening in the area. The benefit that the AlterG provides in this case is a way to modify the environment to see whether the problem persists when a portion of the person’s weight is removed or if the problem goes away when it is unloaded. For example, I use this frequently when treating individuals who have ankle sprains. They adjust their foot striking in the acute phases to avoid any inversion moment at the ankle. However, if we take 50% of their body weight away, what happens? Sometimes the compensation will disappear, and other times it will not. This helps therapists target whether they simply need to work on pain control and stability, or perhaps will completely need to retrain the motor patterns in the ankle/foot to normalize gait and reduce risk of further injury. Not all offices will have the luxury of an AlterG to achieve this level of assessment, but using all the tools at the therapist’s disposal should create a well-rounded analysis of the deficits.
Therefore, an appropriate treatment program should be easy if the assessment portion is done with care. The deficits in the assessment should be able to guide all treatment decisions. The AlterG’s video capture or qualitative assessment is a perfect example of this. If the gait deviation subsides at a particular body weight, we just found our starting treatment. We would walk/run at the particular body weight to allow the patient to reacclimate to a more normalized gait pattern. We would then gradually add body weight back on to challenge the body’s internal systems. This process is called progressive loading. Although it is generally used in regard to tendon loading to rebuild/remodel collagen tissue, it can also be able applied to these learned gait patterns.
Functional Treatment, Functional Training
Not every clinic has access to technology such as the AlterG. However, the concept of using the deficits found in the assessment to guide treatment decisions still holds true. If someone shows poor dynamic stability in assessments such as the Dynamic Gait Index, the therapist can match a treatment to the exact problem. For example, the patient fails the obstacle clearance portion. It would be beneficial to incorporate hurdle step-overs or variable obstacle courses to train the person’s ability to clear obstacles and avoid falls. Static balance may be more difficult because if the patient cannot complete a certain position, the therapist has to find a modification to allow the person to build the failing system. A good example for this is that many people with neurological conditions cannot perform single leg stands at their initial visit. Performing tandem stance (heel to toe position) might give them enough support from the opposite leg without making the exercise too easy. However, they might need slightly more of a challenge than that. What is the middle ground between a tandem stance and a single leg stand? There is no correct answer for this question. However, there are some options.
In my own practice, I add external forces such as perturbations, ball tossing, or unstable surfaces. These challenge the body in a way that is very realistic to the world outside the clinic; it’s unpredictable. Other completely viable options would be closing the person’s eyes, having them do head turns, or multiple tasking as a distraction. These are all very important treatment ideas, but where therapists “make their money” is with functional treatments. How well can a therapist match an exercise to the activity the person is struggling with or wants to perform? I alluded to this concept with the dynamic training, such as hurdle step-overs. However, I would contend that there may even be more functional and realistic ways to train the exact same system. The therapist could take the patient outside and practice curbs, for example. This puts the patient in exact scenarios they might find themselves in after therapy, and they will have learned to perfect the movement patterns to make their balance more efficient with that specific activity of curb negotiation. This is exactly where all the subjective and objective measurements should guide treatment. The more functional treatment that addresses both the person’s complaints and their measurable deficits, the better the outcomes will be.
Risk Factors and Predictors
These discussions about assessment, treatment, and functional training lead to the most important point of why balance training is so vital. It is all an effort to reduce risk of falling, because falling leads to some of the most expensive medical costs. Between hip fractures and possible head injuries, falling can even severely impact survival among the aging populations. Therefore, training to avoid falls is much more prudent than reacting after someone has fallen. This is why some of the assessments mentioned earlier also have been researched for the ability to predict likelihood of falling. For instance, the Dynamic Gait Index shows that someone who scores 17/26 has a “higher risk of falling,” and someone who scores 13 or below has a “very high risk of falling.” This can help guide our treatment toward certain strategies that will reduce falls risk.
The simplest predictor, however, is a previous history of falls. If someone has fallen one to two times in a year, that person has a high chance of having another fall. This is more of a justification for treatment than an in-depth assessment. However, it is important to understand what puts someone at risk of falling, and then the path can be started to avoid future injuries. Another simple point is education about environmental hazards. Items such as throw rugs, rolling furniture, cords, etc, are all extrinsic factors that affect safety. Therefore, it makes a big difference if a therapist can educate about safety and remove hazards that pose a risk of falling.
Pulling It All Together
In the end, treating impairments in balance and gait is all about identification of a problem, matching and treatment, and making sure it is as realistic as possible. In other words, the better the therapist chooses treatments based on findings in the assessment, the lower the risk of further injury or falls the patient will have. This is a general concept that can be used across the board in physical therapy, but it is arguably even more important with gait and balance. That is because the therapist can physically see the system that is damaged. Gait and balance deficits are just the external expression of an internal dysfunction—whether it’s the nervous system, inner ear, or muscular-related. Therefore, identifying the relevant deficits, matching an intervention, and making it relatable to the person’s daily function is the way a therapist will succeed in treating balance and gait dysfunction. PTP
Brandon Lewandowski, DPT, is clinical supervisor of the Physical Therapy & Wellness Institute’s Horsham, Pa, location. He earned his DPT from Temple University and a bachelor’s degree in exercise science from West Chester University. Lewandowski has special interest and experience in orthopedics, and has conducted research and study of the shoulder and upper extremity rehabilitation. For more information, contact [email protected].