In the previous blog, the concept of the balance field was presented as “the area comprising the feet and space between the feet in which the boundaries comprise a square shape extending from the heels to the 3rd metatarsal head of both feet. This is the field in which the individual’s COM or predominate weight ideally is able to easily interact to allow all static and dynamic standing balance activity including walking”
The key concept revealed previously was that a defined area in which a person’s weight will interact with, exists and was defined as displayed (image right).When balance is compromised, the individual can no longer move freely within this area and often lacks the ability to control their body (predominate weight) within the entire field, or their “new” limited field.
The technology allows a number of changes in the way we approach the rehabilitation of standing balance, walking and postural or selective muscle control. We can now objectively measure the percentage of the balance field that is intact. We can determine the control of the individual’s COM via time, adjacent grid cell control and observation with playback. We can then use traditional and established outcome tests (i.e., Berg Balance test) to correlate findings and offer practical transition advice during the rehabilitation process. This simply means that when the patient has progressed to a certain level of mastery, he can for example transition from a walker to bilateral canes.
Below is a recent example of a patient with long standing balance and gait impairment. The individual is frustrated as his perception is that his balance “should be good but is not”. He like many post injury or impaired patients also states that his walking is limited despite years of working on it both professionally with therapies and personally including with paid attendants. He describes what many patients and clinicians understand as a “plateau”.
Figure 2 shows the shape and percentage of the balance field this patient is able to access. As is typical, this was a surprise to the individual. He is 5 years post CVA with the left side of his body more involved than the right. It took 5 minutes for him to complete 44% of what should be his normal field. We know this because the field is universal. A Berg balance test revealed
his balance to be 39/56. He limits
himself to primarily indoor walking and very limited outdoor walking. He uses a right quad cane. His midline perception with visual observation is shifted to the right and clearly verified with the above Fig 2 post assessment. A PT providing traditional therapy would likely state in the assessment that the patient ambulates in a left step to pattern with clear asymmetry. His gait is characterized by a left "pegged" compensation in which he does not and is not capable of shifting all of his weight onto the left leg. He reports that despite his caution he falls 3 - 6 times per year. His Berg Balance Score at 39/56 places him in a high fall risk category.
Note how the patient’s balance field tracer ‘mirrors” his gait tracer pattern. This is typical because the walking pattern will be restricted to the available balance field.
Now, here is the key concept. From the patient’s perspective, they have a “full” balance field. They just don’t know how to get to “the control”. Patients often are not aware of the midline shift and think that the partial weight shift to the more involved side is a full weight shift. The nervous system adapted, and the new parameters are “normal.” Why? Because the new information is the predominate stimulus and that is the information the nervous system responds and adapts to. The patient at a subconscious and eventually a conscious level knows no difference. They do know though that they are impaired. This is of course frustrating. The Envision system technology though was designed to treat the problem, not just access it. Of course, in order to treat the problem, you must identify it. Assessment is the critical 2%. Treatment is the remaining vital 98%.
Below is a before and after of a patient who was given a very poor prognosis. This patient was involved in a motor vehicle accident. He started retraining his balance field and gait pattern as soon as he could tolerate standing ~2 minutes in the first weeks following his accident and release from the hospital.
This series of photos shows the patient early on in his kitchen with the PT. He is safe and contained as he uses the Envision System to guide treatment for restoration of his balance field. At this stage he is re-establishing his kinesthetic sense (how it feels) of his full balance field (see figures 5-8 above for the screen shots over a 3.5 week period). This was during the 1st week in which he was allowed to hold onto the two chairs as needed as he relearned to move his center of mass within the entire boundaries of a normal balance field. As his endurance and ability improved, the exercise was upgraded until he could fill in the entire balance field (100%) without using his hands with good adjacent grid cell control, and he was able to fill in 100% of the screen in 3 minutes or less. As stated previously, regular interval traditional Berg testing was performed as well.
The Envision technology is not limited to people with severe impairment of balance, gait, selective muscle and postural control. An individual with age related loss of balance and mild impairment due to a medical or orthopedic condition which have even resolved but have left the patient with mild impairment could readily benefit. The technology enables perception of the universal physics of balance and control and as such it applies universally.
Warm Regards
Dr Michael J. Malawey, PT
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