CASE STUDIES
What Is Backward Disequilibrium and How Do I Treat it?:
A Complex Patient Case Study
Patricia L. Scheets, PT, DPT, NCS, Shirley A. Sahrmann, PT, PhD, FAPTA,
Barbara J. Norton, PT, PhD, FAPTA, Jennifer S. Stith, PT, PhD, LCSW, and
Beth E. Crowner, PT, DPT, NCS, MPPA
Background and Purpose: Postural vertical refers to a component
of an individuals perception of verticality that is derived from infor-
mation about the direction of gravitational forces. Backward disequi-
librium (BD) is a postural disorder observed in some older adults who
have a distortion in their perception of postural vertical. Individuals
with BD sustain their center of mass (COM) posterior to their base of
support and resist correction of COM alignment. The purposes of this
case study are to describe a patient with BD and propose a physical
therapy management program for this condition.
Case Description and Intervention: The patient was an 83-year-old
woman admitted for home care services 4 months after falling and
sustaining a displaced right femoral neck fracture and subsequent
hemiarthroplasty. Details of the clinical examination, diagnosis, and
intervention are provided and a treatment protocol for physical ther-
apy management is suggested.
Outcomes: During the episode of care, the patient (1) decreased her
dependence on caregivers, (2) surpassed minimal detectable change
or minimal clinically important improvements in gait speed and on
the Short Physical Performance Battery and Performance-Oriented
Mobility Assessment, and (3) achieved her primary goal of staying
in her own apartment at an assisted living facility.
Discussion: Knowledge of BD coupled with a thorough clinical ex-
amination may assist physical therapists in identifying this condition
Quality and Clinical Outcomes, Infinity Rehab, Wilsonville, Oregon (P.L.S.);
Physical Therapy/Neurology/Cell Biology & Physiology (S.A.S.), Program
in Physical Therapy, Washington University School of Medicine, St. Louis,
MO; Physical Therapy and Neurology (B.J.N.), Postprofessional Education
in Physical Therapy, Program in Physical Therapy, Washington Univer-
sity School of Medicine, St. Louis, MO; Physical Therapy and Neurology,
Education, and Professional Curriculum (J.S.S.), Washington University
School of Medicine, St. Louis, MO; Clinical Practice (B.E.C.), Physical
Therapy and Neurology, Program in Physical Therapy, Washington Univer-
sity School of Medicine, St. Louis, MO.
None of the authors has a conflict of interest related to the material in this case
study. There was no funding source for this article.
Portions of the material in this case study were presented as an educational
session at the APTA Combined Sections Meeting, 2013.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.jnpt.org).
Correspondence: Patricia L. Scheets, PT, DPT, NCS, Quality and Clinical
Outcomes, Infinity Rehab, Wilsonville, Oregon (plscheets@gmail.com).
Copyright C 2015 Neurology Section, APTA.
ISSN: 1557-0576/15/3902-0119
DOI: 10.1097/NPT.0000000000000084
JNPT r Volume 39, April 2015
Copyright 2015 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
and employing the specific intervention we have proposed. We be-
lieve that failure to recognize and manage our patients condition
appropriately would have led to nursing home placement.
Video Abstract available for more insights from the authors (see
Supplemental Digital Content 1, http://links.lww.com/JNPT/A94).
Key words: backward disequilibrium, diagnosis, movement system,
physical therapy, psychomotor disadaptation syndrome
(JNPT 2015;39: 119126)
INTRODUCTION
S ubjective vertical refers to an individuals perception of
upright orientation.1 When a neurologically healthy indi-
vidual stands upright, subjective vertical is accurately aligned
with the physical vertical through an implicit representation
of verticality.1 This internal representation of verticality is es-
tablished and updated through an integration of inputs from
visual, vestibular, and somatosensory sources.1,2 There are 3
components contributing to subjective vertical: visual-vertical,
haptic or tactile vertical, and postural vertical.2 The visual-
vertical component is dependent on visual and vestibular
information.2 The haptic vertical is mediated by touch and
pressure information from somatosensory receptors, and the
postural vertical perception is derived from information about
the direction of gravitational forces from gravireceptors.2
A decline in the accuracy of postural vertical perception
in some adults as they age has been described by Barbieri
and colleagues.3 The inaccuracy of postural vertical percep-
tion results in posterior postural tilt in standing and sitting,
which increases in severity with advancing years and predis-
poses older adults to backward falls.3,4 The end result of this
posterior bias in perception of postural vertical has been called
backward disequilibrium (BD).4,5 Individuals with BD fail to
shift their center of mass (COM) sufficiently forward when
moving from sitting to standing6 and align their erect pos-
ture with a faulty intrinsic reference for vertical in the sagittal
plane.4 Backward disequilibrium has been likened to the con-
traversive pushing behavior in the frontal plane that is observed
in some individuals with hemiplegia.2,5,7,8 Both BD and con-
traversive pushing behavior are associated with deterioration
in the representation of postural vertical,5,7 postural alignment
with the COM outside the limits of the base of support (BOS),
and resistance to correction.5,7,8
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Scheets et al
Backward disequilibrium is a component of the geri-
atric syndrome called psychomotor disadaptation syndrome
(PDS).6,9,10 Psychomotor disadaptation syndrome is identi-
fied by the presence of (1) BD, (2) cautious gait with a wide
BOS, short stride, and retropulsive behavior, (3) fear of falling
identified by clutching and grabbing for support, and (4) fear
when moving from sitting to standing.6,9,10 When standing, in-
dividuals with PDS demonstrate greater sway amplitude in all
planes than healthy older adults.11 Psychomotor disadaptation
syndrome has been frequently associated with white matter
lesions on CT scan12 and may be similar to or the equivalent
of frontal-subcortical clinical syndrome.13,14
The incidence and prevalence of both BD and PDS are
not known5 ; however, clinical experience suggests that the
prevalence is high among older adults receiving physical ther-
apy in in-patient and home health settings. Backward disequi-
librium may be differentiated from other postural disorders by
using the Backward Disequilibrium Scale (BDS).4 The BDS
consists of 5 items that are each scored on an ordinal scale
ranging from 0 to 3, where 0 means no BD and 3 means severe
BD. Total BDS scores 2 or less are considered normal, scores
between 3 and 7 are associated with moderate BD, and scores
greater than 7 are associated with severe BD.5 While PDS is
identified on the basis of results of a clinical examination, the
Mini Motor Test has been developed to measure the physical
functioning of individuals with PDS.14 The Mini Motor Test
consists of 20 items that are scored as yes, 1, or no, 0.10,14
Individuals with lower scores have more compromise in their
function related to PDS than persons with higher scores.14
Published descriptions of appropriate interventions for
individuals with either BD or PDS lack specificity.5,6,9,10,15
General recommendations have been suggested by a few
authors and include (1) balance education and training to
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
one study of 28 subjects with PDS, physical and psycholog-
ical interventions were provided weekly for 6 weeks.15 The
14 subjects who completed the interventions improved in their
Mini Motor Test scores,14 dual task tests, ability to rise from
the floor, fear of falling, and rate of falling.15 While the inter-
ventions described in this report are somewhat more detailed
than other authors have provided, the detail given is insufficient
for the intervention to be replicated.
The purposes of this case study are to describe BD and
suggest a physical therapy management program for these in-
dividuals. The patient consented to our using her picture and
information about her care for this case study. Her personal
health information has been de-identified.
CASE DESCRIPTION
Patient History and Systems Review
The patient was an 83-year-old white woman who fell
and sustained a displaced right femoral neck fracture with
subsequent hemiarthroplasty. She received care in the acute
hospital followed by physical and occupational therapy in a
skilled nursing facility. She was discharged from the skilled
nursing facility to her home in an assisted living facility with
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JNPT r Volume 39, April 2015
a plan for home health services. Home health services were
initiated within a few days of her discharge from the assisted
living facility. At this time, it was approximately 4 months
after her initial injury.
Prior to her hip fracture, the patient received minimal
verbal and occasional physical assistance from the facility staff
with taking medication, bathing, and lower extremity dressing.
Prior to the hip fracture, she used a walker or quad cane with-
out assistance in her apartment but used a manual wheelchair
for longer distances in the facility and community. She was
independent with wheelchair propulsion indoor on level sur-
faces for approximately 1000 feet. The patient had a history of
insulin-dependent diabetes mellitus, hypertension, coronary
artery disease with a previous myocardial infarction, hyper-
lipidemia, congestive heart failure, cerebrovascular accident
without residual deficits, and hearing loss.
At the beginning of the patients home health episode of
care, she was evaluated by a physical therapist and received
5 physical therapy sessions in her home with no significant
progress reported. We do not have access to the detail of the
clinical care the patient received while in the skilled nursing
facility or in her first 5 home health visits. At the time of her
return to the assisted living facility, she required assistance of
2 people for transfers and activities of daily living. The first
author evaluated the patient on the sixth home care visit. At
the time of this evaluation, the facility staff reported that the
patient did not know where her feet were, and that she kept
falling backwards when sitting on the side of the bed. The
patients stated goal was to stay in her current living situation
and not to move to a nursing home. This case study focuses on
the care provided by the first author starting with the patients
sixth home care visit, which was approximately 4 months after
her right femoral neck fracture.
Examination
The first author performed an examination of the pa-
tients movement system16 on the sixth home health visit. We
have described this examination previously8 and in this report
we have provided the instructions for completing the examina-
tion, interpretive guidelines, and a clinical reporting form (see
Supplemental Digital Content 2, Movement System Diagnosis
Examination, available at: http://links.lww.com/JNPT/A95).
Results of the patients examination are provided in
Table 1 with shading of those elements that contributed most
to the identification of BD and PDS. In addition to the results
in Table 1, the patient scored 17/30 on the Mini-Mental Status
Examination,18 3/28 on the Performance Oriented Mobility
Assessment,19,20 and 0/12 on the Short Physical Performance
Battery,21,22 and had a gait speed of 0 meter per second.
Diagnosis
On the basis of the patients examination results, the ex-
aminer determined that the patient presented with Sensory De-
tection Deficit,8 both BD and PDS,4,5,6 and Force Production
Deficit.8 The supporting evidence for each of these diagnoses
is presented later.

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Table 1. Initial Movement System Examination Results

Left Right
Mental Status Awake; Able to Follow Simple Commands Without Difficulty
Joint limitation DF 0 DF 0 ; hip abduction 25
Muscle tone Normal Normal
Spontaneous movement Present Present
Fractionated movement Normal Normal
Strength (MMT)17
Shoulder flexion 4 4
Elbow flexion 4+ 4+
Elbow extension 4 4
Wrist extension 4+ 4+
Hip flexion 3+ 3
Hip extension 2+ 0
Hip abduction 2+ 0
Knee extension 4 3
DF 4 3
Muscle fatigue Present in UE and LE Present in UE and LE
Motor planning No deficits noted No deficits noted
UE and LE nonequilibrium coordination No deficits with accuracy; slow with RAM No deficits with accuracy;
slow with RAM
JPS Absent at ankle Absent at ankle
Retropulsive pushing behavior Present; posterior displacement of COM through ankle PF in standing with
resistance to correction
BDS5 15/15 (severe BD)
Disregard None
Sensitivity to sensory stimuli None
Pain Right hip with passive abduction and lateral rotation
Activity tolerance Some SOB; vital signs stable
Quiet sitting Able to sit with feet supported without UE support once placed; decreased
weight bearing on right; assistance needed to shift trunk forward to a
vertical position
Sit to stand Initiation: Maximal assistance without UE support; pulls up using walker with
moderate assistance
Execution: Posterior translation of tibia relative to the foot early in the
execution phase bilaterally; narrow BOS; decreased weight bearing on right;
increased posterior displacement of COM relative to BOS; resisted
correction of COM forward
Termination: Unable to find stable position; COM posterior to BOS; sustained
right hip and knee flexion
Quiet standing Unable to find a stable standing position; right hip and knee flexion
Gait 2-3 steps with rolling walker; COM posterior to feet supported in standing by
therapist; resisted correction of COM alignment; variable foot placement;
both feet cross midline with advancement; right hip flexion and adduction
with right stance
Abbreviations: BDS, Backward Disequilibrium Scale; BOS, base of support; COM, center of mass; DF, dorsiflexion; JPS, joint position sense; LE, lower extremity; MMT, manual
muscle test; PF, plantarflexion; RAM, rapid alternating movements; SOB, shortness of breath; UE, upper extremity.

Sensory Detection Deficit
The patient presented with absent joint position sense
in both ankles. In addition, the patient demonstrated variable
foot placement with stepping with crossing of midline with
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
Deficit.8
BD and PDS
The patient exhibited retropulsive pushing behavior
when moving from sitting to standing, during standing, and
with attempts at ambulation. With efforts to assist her in bring-
ing her COM forward over her BOS, she resisted correction.
Her BDS score was 15, which indicates severe BD.4 She also
demonstrated fear of falling consistent with PDS.6,9,10 While
the patients sensory detection deficit could contribute to the
development of BD and PDS,1 Sensory detection deficit does
not explain the patients resistance to midline correction in the
sagittal plane and fear of falling.
Force Production Deficit
The patient had significant weakness of the right lower
extremity and muscle fatigue with repeated movements in
both upper and lower extremities. She also demonstrated signs
of weakness with task performance, most notably difficulty
during the initiation phase of moving sitting to standing
and inability to sustain right hip and knee extension during
weight bearing. This collection of movement behaviors was
consistent with the movement system diagnosis, force
production deficit.8


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Scheets et al
INTERVENTION
After the first authors examination, the patient received
44 physical therapy visits over 15 weeks. There was one
interruption in care during the seventh week when the pa-
tient was admitted to the hospital for 2 days due to pneumo-
nia. The primary treatment of her Sensory Detection Deficit
began on the first visit and consisted of the use of bilateral
ankle foot orthoses fixed in a neutral position. With the use of
the orthoses and visual guidance, the patients foot placement
with stepping was much improved. The orthoses stabilized
the position of the leg relative to the foot and were intended
to compensation for her loss of joint position sense. Subse-
quently, she was fitted for custom orthoses for ongoing use.
Treatment for her force production deficit began in the third
week of her episode of care and consisted of lower extremity
strengthening exercises with an emphasis on the hip muscula-
ture. As the focus of this case study is on BD and since approxi-
mately 80% of the patients interventions were targeted toward
this movement system problem, only these interventions are
described in detail. In addition to the narrative given later,
the patients response to and progression of each intervention
provided for BD are described in Table 2 and illustrated in
Table 3.
Frequency of Visits
As noted previously, several authors have suggested gen-
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
and resetting the internal model of verticality. Because of the
need to reset the internal model of verticality, the interven-
tions for this patient were dosed at a higher frequency than
is typical in the home care setting. The patient was treated
4 to 5 times per week for 4 weeks. The initial plan was
to treat at this frequency for 2 weeks, measure response to
treatment by assessing the patients performance on initial at-
tempts at coming to standing, standing, and attempted step-
ping, and extend the visits at this frequency if the patient
was improving but deficits persisted. After 4 weeks of inter-
vention, the patient was demonstrating enough consistency in
improved vertical alignment that the frequency of care was re-
duced to 3 times per week for the remainder of her episode of
care.
Standards of Care for BD
The interventions for BD consisted of 5 primary com-
ponents that we consider standards of care for this movement
system problem: (1) standing with the back against the wall
with heels touching the wall, (2) practicing moving from sit-
ting to standing, (3) practicing moving from standing to sit-
ting, (4) walking with continuous stepping, and (5) stepping
backward.
Standing with the back against the wall heels
touching the wall. In this component of BD intervention,
the individual is aligning his or her standing position with the
physical vertical. The objective is for the individual to relax in
and sustain this position in an effort to reset the internal ref-
erence for verticality. Having our patient stand with her back
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JNPT r Volume 39, April 2015
against the wall with her heels touching the wall was initiated
on the second visit and continued as a part of her treatment
plan. There were 2 time points at which her performance im-
proved significantly, the first at the end of week 1 and the
second at the end of week 3 (see Table 3). The following are
the general guidelines used in implementing and progressing
this intervention:
1. Stand with the heels against the wall and not resist being in
the position; use an assistive device if needed for weight-
bearing support or confidence.
2. Progressively decrease upper extremity support (if being
used) but maintain the patients foot position. Increase the
amount of time the patient is standing without showing
signs of resisting the position.
3. Produce active sway forward so that the COM moves toward
the forward limits of stability. Forward sway may be induced
by sliding a rigid or semirigid object such as a clip board or
file folder between the patient and the wall with the verbal
cue, Let me slide this behind you. The patient does not
need to be proficient with the previous 2 steps to attempt
the active sway forward.
4. Perform upper extremity movements without moving the
feet forward or demonstrating other signs of resisting the
position.
5. Practice walking and/or sit to stand after a bout of standing
against the wall.
Sitting to standing. In practicing moving from sitting
to standing, primary emphasis was placed on preventing poste-
rior displacement of the tibia relative to the foot and promoting
anterior translation of the tibia during the execution phase of
the activity. Schultz and colleagues26 have demonstrated that
the anterior translation of the tibia relative to the foot accounts
for more than 50% of the necessary forward movement of the
COM over the BOS when coming to standing. The follow-
ing are the general guidelines used when implementing this
intervention for this diagnosis:
1. Practice without upper extremity support if possible; raise
the height of the sitting surface initially to accommodate
for weakness during the initiation phase.
2. If not possible to practice without upper extremity support,
instruct the patient to use the upper extremities only during
initiation and then have the patient let go and bring the arms
across the chest.
3. Provide a manual block to posterior translation of the tibia
relative to the foot during execution by placing a hand at
the posterior aspect of the proximal tibia and preventing
posterior movement.
4. Provide assistance with anterior translation of the tibia rel-
ative to the foot by providing manual cues or assistance at
the posterior aspect of the proximal tibia during execution.
5. Provide encouragement and support related to fear of
falling.
This component was a part of the patients plan from the
first week throughout her episode of care. There were 3 time
points at which her performance improved significantly (see
Table 3).

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Table 2. Description of Initial Response and Progression of Interventions for BD

Intervention Component Patient Response and Intervention Progression
Standing with back against wall with Initiated on visit 2
heels touching the wall Initial response
Assisted to position with walker and maximal assistance
Stood with bilateral UE support only a few moments
Consistently tried to shift feet forward
Best performance: standing with heels 2 to 3 inches from wall, holding onto walker, 1 min
Improved sit-to-stand transfer from maximal assistance to minimal assistance immediately after
Able to stand with walker without additional support up to 30 s immediately after
Able to initiate 2-3 steps with forward weight shift and minimal assistance immediately after
Progression
End of week 1active sway forward and alternate UE movements
Week 4coupled with progressive loading of right LE for strengthening
Consistent part of treatment plan throughout episode of care
Sit to stand Initiated on visit 2
Initial response
Increased fear of falling behaviors with initial efforts
Required use of UE for initiation
Progression
End of week 2demonstrated forward translation of tibia during the first half of execution but posterior
translation of tibia during second half of execution
End of week 4consistently able to come to standing to walker with standby assistance; able to actively
shift COM forward if too far posterior on termination
Week 6consistently required assistance of only 1 aide at facility for all transfers; usually required only
minimal assistance
Consistent part of treatment plan throughout episode of care
Stand to sit Initiated on visit 2
Initial response:
Required moderate to maximal assistance to control descent into chair
Significant manual and verbal cues
Limited change with practice
Progression
Week 2able to keep COM over BOS during first half of execution with significant manual and verbal
cueing; unable to verbalize correct strategy
Ongoingwithout cueing demonstrated variable performance; would generally shift COM behind BOS
early in the execution phase comparable to a backward fall; little change with practice
Consistent part of treatment plan throughout episode of care
Continuous stepping Initiated during first week
Initial response
Required assistance of 2 (one to pull the walker and the other to assist with weight shift and limb placement)
Able to complete 2-3 consecutive steps
Progression
Slow due to right proximal LE weakness
Week 25 feet with continuous steps; 10 feet total in a single bout; minimal assistance for forward
progression
Week 45-7 feet with continuous steps; 20 feet total in a single bout; minimal to standby assistance for
forward progression; speed 0.05 m/s
Week 840 feet in a single bout with sustained forward progression with standby assistance
Week 1250 feet in a single bout with sustained forward progression with standby assistance
Consistent part of treatment plan throughout episode of care
Backward stepping Initiated at end of week 3
Initial response
Immediate shift of COM behind BOS with no attempted recovery; had to be caught to prevent a fall; unable
to step
No change with practice
Progression
Attempted intermittently from week 3 to week 11 with no change
Week 123-4 steps with moderate assistance; some improvement in sustaining COM over BOS with
practice
Week 13coupled with sitting down; consistently shifted COM behind BOS as soon as she thought about
sitting down
Week 1410 feet without excessive posterior sway or loss of balance; immediate loss of balance if coupled
with sitting down
No consistent change after week 14
Abbreviations: BOS, base of support; COM, center of mass; LE, lower extremity; UE, upper extremity.


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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-
ing to sitting, the primary emphasis was placed on maintaining
the COM over rather than posterior to the BOS during the ex-
ecution phase. The concern was that if the patient sat down
repeatedly by shifting her COM behind her BOS, it may have
contributed to a faulty representation of postural vertical.27
The general guidelines for providing this intervention include
the following:
1. Practice initiating sitting by flexing the knees keeping, the
COM over the BOS during the first half of execution.
2. Avoid teaching the patient to initiate sitting down by reach-
ing back for the chair.
3. Avoid teaching the patient to step back until the back of the
knees touch the chair.
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
a posterior sway. Initiating any movement with a posterior sway reinforces
the postural control problem for these patients. The patient steps back in
approaching a chair and begins descent from stand to sit when his/her legs are
2-3 from the chair. The patient is still close enough to the chair to prevent them
4. If the patient has insufficient strength to control the de-
scent into the chair, practice using the upper extremities
to compensate only during the last half of the execution
phase.
For this patient, being able to move from standing to sit-
ting improved very slowly and to a limited degree. Her ongoing
difficulty with this activity may reflect the limit of correction
we were able to make in her internal reference for vertical and
vulnerability for ongoing postural control deficits.27
Continuous stepping. Whenever the patient practiced
ambulation, the goal was to practice continuous stepping, with-
out stopping and starting, maintaining a forward progression of
the COM. This was accomplished by the therapist pulling the
wheeled walker forward and assisting the patient with weight
from missing the chair. The intervention described is a skilled intervention
provided by a licensed physical therapist or physical therapist assistant. The
timing of when this element is incorporated into the patients performance in
the absence of the licensed clinician is a clinical judgment made based on the
specific patient circumstances.

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JNPT r Volume 39, April 2015
shift and limb advancement as needed. The intervention was
progressed very slowly over the 15 weeks due to the patients
significant right proximal lower extremity weakness. There
were 4 time points at which her performance improved signif-
icantly (see Table 3).
Backward stepping. Moving backward without falling
backward seems to be a significant challenge for patients with
BD. Backward stepping was attempted on several occasions
over several sessions before it was integrated into the patients
treatment plan. As shown in Table 2, she progressed with the
activity, but it continued to be difficult for her. There were 3
time points at which her performance improved somewhat (see
Table 3).
OUTCOMES
The patients outcomes, as measured by objective mea-
sures and standardized tests, are presented in Table 4. Only
those measures that changed significantly are included in the
table. During the episode of care described, the patient (1)
progressed from requiring assistance of 2 caregivers to re-
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
Short Physical Performance Battery,22 (3) surpassed the min-
imal detectable change30 on the Performance-Oriented Mo-
bility Assessment,19,20 and (4) achieved her primary goal of
being able to stay in her own apartment at an assisted living
facility rather than move to a nursing home. She had no falls,
and as of 1 year after the episode of care had continued to live
in her apartment.
DISCUSSION
We have described the literature on a clinical condition
known as BD. We have presented the clinical examination
of a patient with this movement system problem and have
outlined a specific physical therapy management program for
this condition. Increased awareness of the characteristics of
BD facilitates clinical decision making and diagnostic accu-
racy. A growing knowledge base combined with competency
in performing an informative clinical examination may allow
for the recognition of patterns that are the building blocks
of diagnoses.31 Backward disequilibrium is an example of a
clinical pattern present in older adults. Knowledge of this pat-
tern coupled with a thorough clinical examination may assist
physical therapists in identifying this clinical condition and
employing the specific intervention we have proposed.
For clinicians engaged in clinical reasoning, how knowl-
edge is structured appears to have an impact on how rapidly
it is retrieved.32 We have long been proponents of describ-
ing the patterns of movement system problems observed in
clinical practice as a means to disseminate knowledge gained
from practice.8,33,34 Labeling common movement system con-
ditions, such as BD, provides a mechanism for organizing
knowledge so that it is clinically useful.8,32,35,36 As noted
previously, both BD and contraversive pushing behavior are
associated with deterioration in the representation of postural
vertical,5,7 postural alignment with the COM outside the limits
of the BOS, and resistance to correction.5,7,8 For these reasons

C 2015 Neurology Section, APTA
Copyright 2015 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
What Is Backward Disequilibrium and How Do I Treat It?
and to be consistent with our previously described movement
system diagnoses, we have grouped patients with BD with
patients with contraversive pushing behavior in a category la-
beled, Postural Vertical Deficit. An updated description of this
movement system diagnosis is found in Supplemental Digital
Content 3, Movement System Diagnosis Descriptions, avail-
able at: http://links.lww.com/JNPT/A96.
The patient with BD who is the subject of this case study
made functional gains and achieved her goal of staying in her
home with only a small improvement in her BDS score and
ongoing classification of severe BD. There are no published
data on the minimal clinically important difference for the
BDS. For this patient, her 4-point change was associated with
meaningful functional outcomes. We do not know for how long
this patient had signs of BD or whether her BD contributed to
her fall and subsequent hip fracture. The literature describes
BD as a condition that worsens over time and increases fall
risk.3-6 Perhaps early detection of BD and implementation of
the standards of care we have described in this case study
would reduce fall risk and functional decline in this group of
patients.
SUMMARY
In this case study, we have illustrated the use of a system-
atic informative clinical examination and the identification and
labeling of a condition known as BD. Because we understood
BD as a distinct movement system condition, we developed
and implemented a treatment program specific to the nature
of this condition. We believe that the ability to recognize and
appropriately manage our patients condition enabled the de-
velopment of functional skills that allowed her to remain in her
home, when her condition might otherwise have led to nursing
home placement.
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