This was our journal club article for September at the hospital and since September is quickly coming to a close, I figured I had better hurry up and share it with everyone at large.
First of all, I didn’t know that what I call retropulsion had a clinical symptom name– Backward Disequilibrium (BD), nor that it was related to a pathophysiological state that can be visualized (hypothetically anyway) as a white matter lesion on CT scan. In my mind I’ve lumped this symptom in with contraversive pushing, just in the sagittal plane vs. the frontal plane, which seems to be supported by the article. I had also not heard of Psychomotor Disadaptation Syndrome (PDS), which BD is apparently a symptom of along with cautious gait with wide BOS, short stride, fear of falling, fear of sit to stands. There are 2 assessment tools mentioned in the article and as a “party favor” for the Journal Club, I looked them up and made a neat little fill in the blank sheet for the clinician to use those assessment tools — the PDS Mini Motor Test and the Backward Disequilibrium Scale. Send me a secure message with an e-mail address for you by clicking on “Contact” in the top right corner if you’d like those cheat sheets (which have been properly referenced to their authors for the reference police out there). Also, I pinky promise to promptly lose your e-mail address and will not sell it to anyone. I have too many other things to do! You promise too!
As far as this particular case went, I was hugely surprised that an assisted living would take a patient that required 2 person assist for transfers…. Unless this person had some connections or money or something, because all the assisted livings I’ve ever sent a patient to required independent-modified independent transfers. Beyond that, this patient was obviously severely effected in their functioning by this. I thought the broad categories that these authors use to diagnosis their patients was interesting and worth the additional clicking around in the Supplemental Digital content, by the way. I had never heard of using an AFO on a “sensory detection deficit” or as I would call it, poor proprioception. I had only ever seen or used an AFO for foot drop. Has anyone else used an AFO in this way? Care to share the rational?
So here’s the good part: the treatment. What do you do with these people?! I always feel like it is such a struggle with these people and any ideas are most definitely welcome. The authors focused on lower extremity strengthening, particularly the hips for this patient and then 5 items they called “the standard of care” for BD: 1) standing with the back against the wall with heels touching the wall, 2) practicing moving from sitting to standing, 3) “” standing to sitting, 4) walking with continuous stepping, 5) stepping backward. See the article for the progressions they recommend. After we read the article, the club and I brain stormed how/where we could implement these treatment strategies. (It required moving some treatment furniture around) and also which patients that were currently in house that would benefit from these types of activities. I would encourage you to do the same!
The outcomes for this patient were perhaps not huge in the assessment tool numbers, but it made a big difference for her functionality– from requiring two person assist to a minimal – stand by assist for transfers. That’s huge! And because of that, she achieved her primary goal of being able to stay in the assisted living and not have to go the nursing home. That’s what it’s all about right there, folks– meeting a patient’s goal.