BALANCE IN MOTION
by
Andrea Wasylow PT, FAFS
The billing coordinator at the small hospital‐based rehabilitation clinic where I work is phenomenal. In addition to being one of those people who you just enjoy spending time with, she is exceptionally skilled at finding those small discrepancies that could potentially delay, or give reason for denial, of payment for services. Prior to joining our team, she worked at a well meaning, yet very “conventional,” physical therapy practice. Since coming to work with us, we have had many conversations discussing the principles, strategies, and techniques behind treatment, based on an Applied Functional Science approach.
One such discussion occurred recently when she asked, “Can you help me understand why ‘balance / stability training’ was included as part of the treatment plan for this patient being seen for a shoulder diagnosis?” The discussion that followed highlighted some of the misconceptions surrounding balance rehabilitation and training, and hopefully helped provide a better understanding of balance as an integral part of all function.
Our coordinator had become accustomed to seeing static testing on the ground, or on a less stable surface, as a common way to determine whether or not an individual had “good balance.” Unfortunately, someone who may do well standing on one foot with their eyes closed for a predetermined period of time may stumble or fall when turning to look at who just called his / her name while he / she was walking.
Though commonly used, these traditional, static tests provide limited information when the fundamental truths about balance are understood. Balance is dynamic and three‐dimensional. It is our body’s ability to integrate the information from all of our body systems during a functional task and use that information to displace our center of gravity. The system must then decelerate that motion and either bring the body back or, more likely, move in a completely different direction. Three of the main systems that feed the body information are the vestibular system, the visual system, and the proprioceptive system. Though there is a minimal amount of information generated to those systems in a static position, it is motion that truly “turns on” and feeds these systems the information required for function. Balance requires the ability of the neurological system to successfully receive information, process that information, and then convey an appropriate motor plan for task completion – all while controlling the center of mass against gravity. Balance requires range of motion and strength. If a body segment lacks motion, then not only do accommodations of additional motion in other areas need to be made to complete a task, but proper muscular loading and exploding at the restricted joint can not occur. Balance can be impaired if the surrounding musculature is unable to control movement into that motion, even when full passive range of motion is available. Most importantly, balance requirements are determined by the functional task the body is being asked to perform. In order to insure successful task completion, the individual should be able to control three‐dimensional motion beyond that required of the functional task. Balance rehabilitation and training programs should reflect that goal.
The patient whose chart our billing coordinator was reviewing happened to be an avid gardener. She loved her flowerbeds and spent significant amounts of time on her hands and knees weeding. Her balance deficits showed in this position when she would bear weight through her involved upper extremity and reach with her other hand. Frequently, she had to quickly move the reaching hand to the ground in order to avoid face‐planting into her flowers. As it turns out, she had thoracic spine and scapulo‐thoracic range of motion restrictions, as well as an inability to eccentrically control the motion that her involved shoulder needed in order to accomplish the reach distances required by the other arm for weeding. Thankfully, with training, this individual was back doing the gardening that she loved without difficulty. Also, “armed” with additional understanding about balance, our billing coordinator was able to coerce payment for services rendered.