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Copyright 2015 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
Scheets et al JNPT r Volume 39, April 2015
Backward disequilibrium is a component of the geri- a plan for home health services. Home health services were
atric syndrome called psychomotor disadaptation syndrome initiated within a few days of her discharge from the assisted
(PDS).6,9,10 Psychomotor disadaptation syndrome is identi- living facility. At this time, it was approximately 4 months
fied by the presence of (1) BD, (2) cautious gait with a wide after her initial injury.
BOS, short stride, and retropulsive behavior, (3) fear of falling Prior to her hip fracture, the patient received minimal
identified by clutching and grabbing for support, and (4) fear verbal and occasional physical assistance from the facility staff
when moving from sitting to standing.6,9,10 When standing, in- with taking medication, bathing, and lower extremity dressing.
dividuals with PDS demonstrate greater sway amplitude in all Prior to the hip fracture, she used a walker or quad cane with-
planes than healthy older adults.11 Psychomotor disadaptation out assistance in her apartment but used a manual wheelchair
syndrome has been frequently associated with white matter for longer distances in the facility and community. She was
lesions on CT scan12 and may be similar to or the equivalent independent with wheelchair propulsion indoor on level sur-
of frontal-subcortical clinical syndrome.13,14 faces for approximately 1000 feet. The patient had a history of
The incidence and prevalence of both BD and PDS are insulin-dependent diabetes mellitus, hypertension, coronary
not known5 ; however, clinical experience suggests that the artery disease with a previous myocardial infarction, hyper-
prevalence is high among older adults receiving physical ther- lipidemia, congestive heart failure, cerebrovascular accident
apy in in-patient and home health settings. Backward disequi- without residual deficits, and hearing loss.
librium may be differentiated from other postural disorders by At the beginning of the patients home health episode of
using the Backward Disequilibrium Scale (BDS).4 The BDS care, she was evaluated by a physical therapist and received
consists of 5 items that are each scored on an ordinal scale 5 physical therapy sessions in her home with no significant
ranging from 0 to 3, where 0 means no BD and 3 means severe progress reported. We do not have access to the detail of the
BD. Total BDS scores 2 or less are considered normal, scores clinical care the patient received while in the skilled nursing
between 3 and 7 are associated with moderate BD, and scores facility or in her first 5 home health visits. At the time of her
greater than 7 are associated with severe BD.5 While PDS is return to the assisted living facility, she required assistance of
identified on the basis of results of a clinical examination, the 2 people for transfers and activities of daily living. The first
Mini Motor Test has been developed to measure the physical author evaluated the patient on the sixth home care visit. At
functioning of individuals with PDS.14 The Mini Motor Test the time of this evaluation, the facility staff reported that the
consists of 20 items that are scored as yes, 1, or no, 0.10,14 patient did not know where her feet were, and that she kept
Individuals with lower scores have more compromise in their falling backwards when sitting on the side of the bed. The
function related to PDS than persons with higher scores.14 patients stated goal was to stay in her current living situation
Published descriptions of appropriate interventions for and not to move to a nursing home. This case study focuses on
individuals with either BD or PDS lack specificity.5,6,9,10,15 the care provided by the first author starting with the patients
General recommendations have been suggested by a few sixth home care visit, which was approximately 4 months after
authors and include (1) balance education and training to her right femoral neck fracture.
correct retropulsion and alignment of COM,6,9,10 (2) func-
tional training beginning with rolling and progressing to gait
training,5,6,9,10 and (3) training to rise from the floor.5,6 In Examination
one study of 28 subjects with PDS, physical and psycholog-
The first author performed an examination of the pa-
ical interventions were provided weekly for 6 weeks.15 The
tients movement system16 on the sixth home health visit. We
14 subjects who completed the interventions improved in their
have described this examination previously8 and in this report
Mini Motor Test scores,14 dual task tests, ability to rise from
we have provided the instructions for completing the examina-
the floor, fear of falling, and rate of falling.15 While the inter-
tion, interpretive guidelines, and a clinical reporting form (see
ventions described in this report are somewhat more detailed
Supplemental Digital Content 2, Movement System Diagnosis
than other authors have provided, the detail given is insufficient
Examination, available at: http://links.lww.com/JNPT/A95).
for the intervention to be replicated.
Results of the patients examination are provided in
The purposes of this case study are to describe BD and
Table 1 with shading of those elements that contributed most
suggest a physical therapy management program for these in-
to the identification of BD and PDS. In addition to the results
dividuals. The patient consented to our using her picture and
in Table 1, the patient scored 17/30 on the Mini-Mental Status
information about her care for this case study. Her personal
Examination,18 3/28 on the Performance Oriented Mobility
health information has been de-identified.
Assessment,19,20 and 0/12 on the Short Physical Performance
Battery,21,22 and had a gait speed of 0 meter per second.
CASE DESCRIPTION
Patient History and Systems Review
The patient was an 83-year-old white woman who fell Diagnosis
and sustained a displaced right femoral neck fracture with On the basis of the patients examination results, the ex-
subsequent hemiarthroplasty. She received care in the acute aminer determined that the patient presented with Sensory De-
hospital followed by physical and occupational therapy in a tection Deficit,8 both BD and PDS,4,5,6 and Force Production
skilled nursing facility. She was discharged from the skilled Deficit.8 The supporting evidence for each of these diagnoses
nursing facility to her home in an assisted living facility with is presented later.
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JNPT r Volume 39, April 2015 What Is Backward Disequilibrium and How Do I Treat It?
Sensory Detection Deficit the patients sensory detection deficit could contribute to the
The patient presented with absent joint position sense development of BD and PDS,1 Sensory detection deficit does
in both ankles. In addition, the patient demonstrated variable not explain the patients resistance to midline correction in the
foot placement with stepping with crossing of midline with sagittal plane and fear of falling.
both feet. She reported difficulty knowing where her feet were
in standing and with attempts at stepping. All of these find-
ings were consistent with the diagnosis, Sensory Detection Force Production Deficit
Deficit.8 The patient had significant weakness of the right lower
extremity and muscle fatigue with repeated movements in
BD and PDS both upper and lower extremities. She also demonstrated signs
The patient exhibited retropulsive pushing behavior of weakness with task performance, most notably difficulty
when moving from sitting to standing, during standing, and during the initiation phase of moving sitting to standing
with attempts at ambulation. With efforts to assist her in bring- and inability to sustain right hip and knee extension during
ing her COM forward over her BOS, she resisted correction. weight bearing. This collection of movement behaviors was
Her BDS score was 15, which indicates severe BD.4 She also consistent with the movement system diagnosis, force
demonstrated fear of falling consistent with PDS.6,9,10 While production deficit.8
C 2015 Neurology Section, APTA 121
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Scheets et al JNPT r Volume 39, April 2015
INTERVENTION against the wall with her heels touching the wall was initiated
After the first authors examination, the patient received on the second visit and continued as a part of her treatment
44 physical therapy visits over 15 weeks. There was one plan. There were 2 time points at which her performance im-
interruption in care during the seventh week when the pa- proved significantly, the first at the end of week 1 and the
tient was admitted to the hospital for 2 days due to pneumo- second at the end of week 3 (see Table 3). The following are
nia. The primary treatment of her Sensory Detection Deficit the general guidelines used in implementing and progressing
began on the first visit and consisted of the use of bilateral this intervention:
ankle foot orthoses fixed in a neutral position. With the use of
1. Stand with the heels against the wall and not resist being in
the orthoses and visual guidance, the patients foot placement
the position; use an assistive device if needed for weight-
with stepping was much improved. The orthoses stabilized
bearing support or confidence.
the position of the leg relative to the foot and were intended
2. Progressively decrease upper extremity support (if being
to compensation for her loss of joint position sense. Subse-
used) but maintain the patients foot position. Increase the
quently, she was fitted for custom orthoses for ongoing use.
amount of time the patient is standing without showing
Treatment for her force production deficit began in the third
signs of resisting the position.
week of her episode of care and consisted of lower extremity
3. Produce active sway forward so that the COM moves toward
strengthening exercises with an emphasis on the hip muscula-
the forward limits of stability. Forward sway may be induced
ture. As the focus of this case study is on BD and since approxi-
by sliding a rigid or semirigid object such as a clip board or
mately 80% of the patients interventions were targeted toward
file folder between the patient and the wall with the verbal
this movement system problem, only these interventions are
cue, Let me slide this behind you. The patient does not
described in detail. In addition to the narrative given later,
need to be proficient with the previous 2 steps to attempt
the patients response to and progression of each intervention
the active sway forward.
provided for BD are described in Table 2 and illustrated in
4. Perform upper extremity movements without moving the
Table 3.
feet forward or demonstrating other signs of resisting the
Frequency of Visits position.
5. Practice walking and/or sit to stand after a bout of standing
As noted previously, several authors have suggested gen-
against the wall.
eral guidelines for treating the deficits exhibited by patients
with BD.3,5,8,23-25 All of these guidelines include increasing
the individuals awareness of his or her postural control deficit Sitting to standing. In practicing moving from sitting
and resetting the internal model of verticality. Because of the to standing, primary emphasis was placed on preventing poste-
need to reset the internal model of verticality, the interven- rior displacement of the tibia relative to the foot and promoting
tions for this patient were dosed at a higher frequency than anterior translation of the tibia during the execution phase of
is typical in the home care setting. The patient was treated the activity. Schultz and colleagues26 have demonstrated that
4 to 5 times per week for 4 weeks. The initial plan was the anterior translation of the tibia relative to the foot accounts
to treat at this frequency for 2 weeks, measure response to for more than 50% of the necessary forward movement of the
treatment by assessing the patients performance on initial at- COM over the BOS when coming to standing. The follow-
tempts at coming to standing, standing, and attempted step- ing are the general guidelines used when implementing this
ping, and extend the visits at this frequency if the patient intervention for this diagnosis:
was improving but deficits persisted. After 4 weeks of inter- 1. Practice without upper extremity support if possible; raise
vention, the patient was demonstrating enough consistency in the height of the sitting surface initially to accommodate
improved vertical alignment that the frequency of care was re- for weakness during the initiation phase.
duced to 3 times per week for the remainder of her episode of 2. If not possible to practice without upper extremity support,
care. instruct the patient to use the upper extremities only during
initiation and then have the patient let go and bring the arms
Standards of Care for BD across the chest.
The interventions for BD consisted of 5 primary com- 3. Provide a manual block to posterior translation of the tibia
ponents that we consider standards of care for this movement relative to the foot during execution by placing a hand at
system problem: (1) standing with the back against the wall the posterior aspect of the proximal tibia and preventing
with heels touching the wall, (2) practicing moving from sit- posterior movement.
ting to standing, (3) practicing moving from standing to sit- 4. Provide assistance with anterior translation of the tibia rel-
ting, (4) walking with continuous stepping, and (5) stepping ative to the foot by providing manual cues or assistance at
backward. the posterior aspect of the proximal tibia during execution.
5. Provide encouragement and support related to fear of
Standing with the back against the wall heels falling.
touching the wall. In this component of BD intervention,
the individual is aligning his or her standing position with the This component was a part of the patients plan from the
physical vertical. The objective is for the individual to relax in first week throughout her episode of care. There were 3 time
and sustain this position in an effort to reset the internal ref- points at which her performance improved significantly (see
erence for verticality. Having our patient stand with her back Table 3).
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JNPT r Volume 39, April 2015 What Is Backward Disequilibrium and How Do I Treat It?
C 2015 Neurology Section, APTA 123
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Scheets et al JNPT r Volume 39, April 2015
Table 3. Time at Which Interventions for BD Were Implemented and Indication of Rate of Observable Improvement
Table 4. Results of Initial and Final Objective Measures and Standardized Tests
Initial Result Final Result
Left Right Left Right
MMT17
Hip flexion 3+ 3 4 4
Hip extension 2+ 0 3+ 2
Hip abduction 2+ 0 4 2
Knee extension 4 3 4+ 4+
BDS5 15 (severe) 11 (severe)
Sit to/from supine Moderate assistance of 1 Independent
Sit to stand Maximal assistance SBA
Ambulation Maximal assistance with rolling walker a few steps SBA with rolling walker 50 feet
POMA19,20 3/28 14/28
SPPB21,22 0/12 1/12
OASIS28 ADL Items 12 12
Gait speed 0.0 m/s 0.11 m/s
Abbreviations: ADL, activities of daily living; BDS, Backward Disequilibrium Scale; MMT, manual muscle test; POMA, Performance Oriented Mobility Assessment; OASIS,
Outcome and Assessment Information Set; SPPB, Short Physical Performance Battery; SBA, standby assistance.
Standing to sitting. In practicing moving from stand- 4. If the patient has insufficient strength to control the de-
ing to sitting, the primary emphasis was placed on maintaining scent into the chair, practice using the upper extremities
the COM over rather than posterior to the BOS during the ex- to compensate only during the last half of the execution
ecution phase. The concern was that if the patient sat down phase.
repeatedly by shifting her COM behind her BOS, it may have
For this patient, being able to move from standing to sit-
contributed to a faulty representation of postural vertical.27
ting improved very slowly and to a limited degree. Her ongoing
The general guidelines for providing this intervention include
difficulty with this activity may reflect the limit of correction
the following:
we were able to make in her internal reference for vertical and
1. Practice initiating sitting by flexing the knees keeping, the vulnerability for ongoing postural control deficits.27
COM over the BOS during the first half of execution.
2. Avoid teaching the patient to initiate sitting down by reach- Continuous stepping. Whenever the patient practiced
ing back for the chair. ambulation, the goal was to practice continuous stepping, with-
3. Avoid teaching the patient to step back until the back of the out stopping and starting, maintaining a forward progression of
knees touch the chair. the COM. This was accomplished by the therapist pulling the
wheeled walker forward and assisting the patient with weight
When a patient with backward disequilibrium sits down by first stepping
back until the chair touches the back of the knees, he/she initiates sitting with from missing the chair. The intervention described is a skilled intervention
a posterior sway. Initiating any movement with a posterior sway reinforces provided by a licensed physical therapist or physical therapist assistant. The
the postural control problem for these patients. The patient steps back in timing of when this element is incorporated into the patients performance in
approaching a chair and begins descent from stand to sit when his/her legs are the absence of the licensed clinician is a clinical judgment made based on the
2-3 from the chair. The patient is still close enough to the chair to prevent them specific patient circumstances.
124
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JNPT r Volume 39, April 2015 What Is Backward Disequilibrium and How Do I Treat It?
shift and limb advancement as needed. The intervention was and to be consistent with our previously described movement
progressed very slowly over the 15 weeks due to the patients system diagnoses, we have grouped patients with BD with
significant right proximal lower extremity weakness. There patients with contraversive pushing behavior in a category la-
were 4 time points at which her performance improved signif- beled, Postural Vertical Deficit. An updated description of this
icantly (see Table 3). movement system diagnosis is found in Supplemental Digital
Content 3, Movement System Diagnosis Descriptions, avail-
Backward stepping. Moving backward without falling able at: http://links.lww.com/JNPT/A96.
backward seems to be a significant challenge for patients with The patient with BD who is the subject of this case study
BD. Backward stepping was attempted on several occasions made functional gains and achieved her goal of staying in her
over several sessions before it was integrated into the patients home with only a small improvement in her BDS score and
treatment plan. As shown in Table 2, she progressed with the ongoing classification of severe BD. There are no published
activity, but it continued to be difficult for her. There were 3 data on the minimal clinically important difference for the
time points at which her performance improved somewhat (see BDS. For this patient, her 4-point change was associated with
Table 3). meaningful functional outcomes. We do not know for how long
this patient had signs of BD or whether her BD contributed to
OUTCOMES her fall and subsequent hip fracture. The literature describes
The patients outcomes, as measured by objective mea- BD as a condition that worsens over time and increases fall
sures and standardized tests, are presented in Table 4. Only risk.3-6 Perhaps early detection of BD and implementation of
those measures that changed significantly are included in the the standards of care we have described in this case study
table. During the episode of care described, the patient (1) would reduce fall risk and functional decline in this group of
progressed from requiring assistance of 2 caregivers to re- patients.
quiring standby to minimal assistance of 1 caregiver for ac-
tivities of daily living and mobility, (2) achieved a minimal
clinically important improvement in gait speed29 and on the SUMMARY
Short Physical Performance Battery,22 (3) surpassed the min- In this case study, we have illustrated the use of a system-
imal detectable change30 on the Performance-Oriented Mo- atic informative clinical examination and the identification and
bility Assessment,19,20 and (4) achieved her primary goal of labeling of a condition known as BD. Because we understood
being able to stay in her own apartment at an assisted living BD as a distinct movement system condition, we developed
facility rather than move to a nursing home. She had no falls, and implemented a treatment program specific to the nature
and as of 1 year after the episode of care had continued to live of this condition. We believe that the ability to recognize and
in her apartment. appropriately manage our patients condition enabled the de-
velopment of functional skills that allowed her to remain in her
DISCUSSION home, when her condition might otherwise have led to nursing
We have described the literature on a clinical condition home placement.
known as BD. We have presented the clinical examination
of a patient with this movement system problem and have
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