Balance disorders are not isolated to dizziness or vertigo! In fact, problems in the musculoskeletal and motor systems have a major functional impact on virtually every aspect of daily life activities, physical recreation and sports. As a fundamental component in the precise performance of the human body, the highly sophisticated balance-control mechanism is essential to effective human movement.
Balance is a highly integrated process that depends on 1: somatosensory, visual and vestibular inputs for the reception of intrinsic (body) and extrinsic (environment) information; 2: the brain for the integration of this information and the formation of a motor plan; and 3: the musculoskeletal system for the production of adequate movements to execute the plan2, 3. Problems in any of these areas can lead to imbalance and poor functional performance.
Traditionally, balance control has not been assigned a high priority in treating orthopedic patients. Therapists have focused mostly on musculoskeletal structures and pathologies or injuries to these structures4. Recently, however, strong evidence has been presented demonstrating the impact of balance deficits on functional performance, and the importance of considering balance in the management of the orthopedic patient is now well recognized4, 5, 6, 7. Balance deficits in orthopedic patients exist, are often persistent, impede the return to normal function, and increase the risk of re-injury8, 9. Daily life mobility and sports tasks involve repeated impulsive contacts between the lower extremities and the support surface. When these contacts are poorly controlled, the cumulative effects of excessive vertical impact loading have been implicated as major factors contributing to lower extremity injury10. The incorporation of a proprioceptive and balance component in the assessment and retraining of orthopedic patients, especially those who have had injuries or disruptions of joints in the shoulders, spine, hips, knees and ankles is justified11.
There is also growing awareness that rehabilitation focusing on improvements in strength and range of motion alone do not necessarily produce an automatic increase in skill, or return patients to their former functional levels7, 12. Quality of movement is equally as critical as strength of movement, and the key to quality of movement is proprioception13. Even if a patient has regained full strength and range of motion, if they still have poor biomechanics, including strength, balance and proprioception, they are at risk for re-injury.
For an orthopedic rehabilitation program to be complete, it must address joint stability as well as both the mechanical and sensory functions of articular structures. Simply restoring mechanical restraints and joint range of motion, or strengthening the associated muscles, neglects the coordinated neuromuscular controlling mechanism required for balance and joint stability. This is particularly true during the sudden changes in joint position common to sports1. Rehab and/or performance programs that train coordinated movements and involve integrated, multidirectional motor control, rather than individual muscles, are more effective at increasing functional ability 13.
While the “hands-on” approach must never be lost in the practice of physical therapy, today’s healthcare arena demands documented evidence of impairments and functional limitations, as well as documentation of functional outcome. Although pure observation, exercise and other ad hoc procedures suffice in many instances, today’s technological advances have made it possible for clinicians to obtain details of physical function far beyond those provided by traditional assessments. Total functional assessment, including balance and motor control measurements, is necessary for safe return to sport or daily life activities. Assessments should evaluate the entire activity, not just one specific muscle group. Technology enables the clinician to identify underlying impairments and objectively quantify functional limitations – both addressing the need for comprehensive patient evaluation and providing the required evidence upon which to base treatment planning decisions.
Effective Orthopedic Treatment
The key to effective rehabilitation planning is accurate classification of the patient’s problem. According to the World Health Organization (WHO) disablement framework, accurate classification should be based on the patient’s pathology, impairments, and functional limitations and disabilities. Knowledge of impairments is essential, as the key to effective rehabilitation is focusing treatment on the functional manifestations of pathology.
Balance, proprioception, and reactive neuromuscular testing and training, in conjunction with isokinetic assessment and exercise, are vital components of the rehabilitation process. While traditional subjective clinical tests provide valuable information about functional limitations and disabilities, objective technology-based tests are necessary to document the impairments underlying the patient’s functional limitations. Isokinetics documents strength and range of motion impairments, while other devices assess biomechanical impairments related to joint laxity. With the addition of computerized balance, automatic (reactive) and voluntary motor control tests, the clinician is able to assess the impairment components related to the patient’s ability to sense and control movements of the lower extremities1. Impairment assessments provide unique, objective information that isolates specific causes underlying a patient’s functional limitations and disabilities, which provides a foundation for the treatment plan. Functional limitation assessmentscomplement information provided by the clinical exam and subjective tests by objectively documenting performance of critical balance and mobility activities.
Risk of Injury Screening
The ability to quantify balance and mobility in athletes before an injury occurs is an important consideration in a comprehensive orthopedic program. The objective data provided by computerized assessments provides a performance baseline against which post-injury performance can be compared, as well as expose any existing deficits which may predispose an athlete to injury. For example, studies have shown that the chance for injury is higher in individuals with abnormal or pathological sway4. With the data provided by pre-injury testing, preventative training can then be instituted to more effectively enhance performance and lower the risk of injury.
Computerized balance assessment devices are clinically important because of the need for objective evaluation, and documentation of deficits and functional limitations, as well as treatment progress and functional outcome. The visual biofeedback available on these systems also provides excellent motivation for the orthopedic patient and addresses the need for patient education – a critical component in rehabilitation15. Patients must have a full understanding of how they are performing (functionally), as well as the difference between appropriate movements/motor control and inappropriate movements. Instant visual biofeedback gives both the patient and the clinician objective information regarding the patient’s compliance with prescribed tasks and provides additional motivation for enhanced performance. The objective feedback also allows clinicians to advance patients to more challenging activity levels sooner.
For example, a vital goal in early ACL rehabilitation (second week post-op) is to train the patient to assume full-body weight on the involved leg16, 17. Immediate weight bearing is desirable because it allows for more function with less pain and makes activities of daily living easier17. Through advances in ACL rehabilitation, surgical procedures and technology, it is now possible for full knee extension, weight bearing, strengthening and proprioception retraining to be introduced much earlier in the postoperative period18. NeuroCom®, a division of Natus® assessment protocols objectively measure the percentage of body weight borne on the involved leg and provide immediate visual biofeedback of performance. NeuroCom systems include a library of systematic training protocols designed to focus the training effort on the balance and mobility impairments identified by the assessment protocols. To keep the patient challenged and maximize learning, the difficulty level of the focused exercises can be increased as the patient recovers.
With increasing demand to get patients better faster, today’s clinicians must implement efficient programs based on objective assessment data – evidence to base effective therapy decisions and tailor challenging therapy programs to patients’ individual performance levels. Insurance carriers and referring physicians require clinicians to provide clear documentation, which justifies their clinical decisions, as well as documented proof of functional outcomes. A comprehensive program that incorporates computerized assessments of balance and proprioception, addressing both underlying impairments and functional limitations, can successfully and efficiently accomplish these goals.
Mild Head Injury in Athletes
Athletes demonstrate decreased stability until 3 days post injury. This is related to a sensory interaction problem whereby the injured athlete fails to use their visual system effectively. A more severe injury can take up to five or six days.20
Deciding when an athlete has fully recovered from a concussion and can safely return to play, sports competition, etc. is a difficult challenge facing clinicians, athletic trainers and team physicians. Yet, resuming activity before full recovery can dangerously exacerbate a head injury.
Subjective signs and symptoms may resolve immediately after a mild head injury while underlying pathology may remain undetected.
The recovery of other signs and symptoms related to MHI appear to coincide with recovery of postural stability. While the signs and symptoms may not always be accurately reported, if used in conjunction with objective postural stability measures, they can provide clinicians with a more detailed portrayal of injury20.
Concussion in sports is an important public health issue in the United States, because of the large number of people who incur these injuries each year, the generally young age of patients at the time of injury (with possible long-term disability), and the potential cumulative effects and serious sequelae of sports-related TBI21.
Learn more about Concussion Manangement
- Hedenberg, Kauffman. Striking the proper balance. OTR April 2000
- Allison, et al. Contemporary management of balance deficits. NeuroCom Intl., Clackamas, OR, 1994
- Kauffman. Posture and age. Top Geriatr Rehabil 2:13-28, 1987
- Kauffman, et al. Balance is a critical parameter in orthopedic rehabilitation. Orthopedic Physical Therapy Clinics of North America; New Technologies in Physical Therapy 6:1 1059-1516, 1997
- Freeman, Wyke. Articular contributions to limb muscle reflexes. Br J Surg 53:62-68, 1966
- Wyke. Cervical articular contributions to posture and gait: Their relation to senile disequilibrium. Age Aging 8:251-267, 1979
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- Goldie, et al. Postural control following inversion injuries of the ankle. Arch Phys Med Rehabil 75:969-975, 1994
- Wilkins, Brody. Romberg’s sign. Arch Neurol 19:123-126, 1968
- Chu, et al. Objective assessment of the ACL-injured patient: Weight bearing, stepping up/down and lunging. NeuroCom Intl., Clackamas, OR, 1998
- Voight, et al. Post-surgical anterior cruciate ligament rehabilitation: Traditional rehab vs. balance only training protocols. Physical Therapy ’99: Annual Conference and Exposition of the Amer Phys Ther Assoc, 1999
- Lentell, et al. The relationship between muscle function and ankle stability. J Ortho Sports Phys Ther 11:605-611, 1990
- Gambetta. Force and function. Training and Conditioning, Jul/Aug 1999
- Milidonis, et al. Nature of clinical practice for specialists in orthopaedic physical therapy. J Ortho Sports Phys Ther 29(4):240-247, 1999
- Wilk, et al. Rehabilitation after anterior cruciate ligament reconstruction in the female athlete. J Athletic Training 34(2):177-193, 1999
- Hamley. Rehabilitation after anterior cruciate ligament reconstruction in the knee – part one. PT Products, Jul/Aug 1999
- Chu. Proprioceptive and motor control enhancement in ACL rehab. Advance for Phys Ther & PTA, March 15, 1999
- Wolfson, et al. Gait assessment in the elderly: A gait abnormality rating scale and its relation to falls. J Gerontol 45:M12, 1990
- Perin, et. al. Ankle trauma significantly impairs posture control – A study in basketball players and controls. Int J Sports Med 18:387-392, 1997
- Guskiewicz, KM, et al (1997). Alternative approaches to the assessment of mild head injury in athletes. Med Sci Sports Exerc, Vol 29, No 7 Supplement, pp S213-221.
- Thurman DJ (1998). The epidemiology of sports-related traumatic brain injuries in the US. J Head Trauma Rehabil. 13(2): 1-8 April 1998; as reported by Santiago D. Toledo, MD, proceedings from AAPM&R 1999.