Many of you that have been into the office within the last 3 months likely noticed the tape line we had down the middle of our hallway. Although, many thought I was directing traffic down the hall to one side or the other, or checking on patients’ sobriety (as was the next most common answer), I have actually been working on improving balance with a patient. This article will review what we initially found and how we have worked to restore her balance.
Meet Sarah! Sarah is a 25-year old book keeper that has recently pursued horseback riding. She initially came in with an injury to her sacral iliac joints (SI joint). This is an injury that is usually fairly simple to treat; adjust the joint to get better movement and treat the muscles in the area to support the joint and keep it moving well. After a few treatments, she had no further pain. I then took her through a secondary movement screen to determine what movements she struggles with and what type of exercises we needed to focus on with her.
There are 2 main movement screening tests that I use in my assessments. The first is the SFMA or Selective Functional Movement Assessment. This takes the patient through 10 motions to assess full body movement and is done when there is pain with movement either reported by the patient or another therapist. Because the majority of my patients initially come in with pain, I have incorporated this into my initial assessment with almost everyone and also for reassessments. The Functional Movement Screen is a secondary screening test that
looks at 7 multi-joint movements. I use this screen less often, but will utilize it when a patient can pass through the SFMA without pain and can do all of the motions. So after the first few treatments and when Sarah was no longer in pain, I took her through the Functional Movement Screen or FMS.
Without going into the details of scoring for the FMS, Sarah had 3 areas that scored low; trunk stability, rotational stability and active hip flexion. This gave me an idea of where to start with her for strengthening to improve her balance.
A. 1st Test. Notice the bar drops to the R, her R hip kicks out and her R foot lateral turns to maintain stability.
B. 2nd Test, 6 months later. Notice the straight bar across her shoulders and the foot is not turned out.
The first major deficiency we saw was her active straight leg raise or hip flexion motion. Because this was asymmetrical, one leg scored less than the other, we addressed this first. She mainly felt tightness in her hamstrings when doing this hip flexion motion. We addressed this by foam rolling the lower extremity; mainly to the hamstrings, but also, the quads, ITB, and calves. We then added some assisted straight leg raises to activate her core which improved her straight leg raise. Next, we did some assisted leg lowering, where she activated her core with a band, then brought both legs up together and lowered one, bringing it back up, then lowering the other. This deficiency was the first to improve and remain functional.
The biggest thing that we took away from Sarah’s FMS test was her poor balance in the rotatory stability test. This test is done on your hands and knees, maintaining constant spacing between hand and knees (see photo below), then with same side arm and leg, the hand reaches back to touch the same side ankle and both limbs extended out, come back to the touch position then to the starting position as in the image below.
Sarah was barely able to lift the same side hand and knee off the ground for more than 1 second, let alone complete the remainder of the motion to perform the whole test. And one side was a lot harder to just initiate the movement than the other. This movement requires there to be strength in the core to maintain good positioning. This tells me that Sarah was having balance and muscle coordination issues.
To address her balance I first wanted her to stand on an uneven surface with eyes open and then with eyes closed. She wasn’t able to maintain balance with 2 feet on an Airex pad with eyes closed for more than 4 seconds. I knew that without the visual system giving her feedback, she has a very hard time using the ground stimulus to tell her brain how her joints are positioned in space. When she went to 1 foot with eyes open it was not surprisingly harder, but eyes closed again, she could barely stand up. One side was very different than the other. We started with this exercise, 2 feet with eyes open on an uneven surface aiming for 10 seconds. When she was able to hit her goal of 10 seconds, she closed her eyes. Slowly she improved and she went to 1 foot with eyes open, and now, if she gets to 10 sec, she tries closing her eyes and she is up to about 7 seconds.
Another component to balance that we introduced a few months ago was walking in tandem. This is where the tape in the clinic comes into play. She does forward, backwards, lateral, up and over, down and under all while walking tandem on the tape. And I am happy to say that I recently removed the tape, as Sarah has progressed to a raised beam 4 inches off the ground! Once we started this tandem walking on a beam, the crossed body movement with control, really helped her coordination and balance.
Her trunk stability pushup helped me identify that she had little connection between her lower extremities, core and upper extremity strength. To address her core, we started her with some beginner pilates exercises first to learn how to contract her core properly. She worked hard on practicing the neutral and imprint positions. We added a few beginner pilates mat work movements that she continues to work on. She also works on planks, dead bug exercises, and she is now doing pushups on the wall and able to maintain her core contraction.
In Sarah’s workouts now, we have started to incorporate some weights to make the exercises that she has been already doing more difficult. Her latest FMS testing has shown improvement in all areas. However, I prefer the high 5 we give each other after she sees that she has done the movement correctly.
This is an example of a case where we have mainly done exercise in the office to improve strength as a minor component, but improving her balance was our major objective. As the foot hits the ground and balance is not able to be maintained, the body will make compensations all the way up the chain in order to prevent you from falling over. Think about how many steps you take in one day, either through walking or running. Gait involves 50% of the time to be in a single leg stance on the R then the other 50% of the time to be in a single leg stance on the L. For whatever the reason, if you are unbalanced on 1 leg, and you walk a lot or run, you are continually making compensations thousands of times over and over. Muscles shorten or lengthen and movement patterns change, usually for the worst. Then these take time to reverse or change back. This is why balance and ankle motion are key things to assess on everyone.
If you or someone you know have any questions about assessing for balance or ankle mobility I would like to help you move better. Did you know I do exercise sessions in office for 30 minutes with patients? This is guided corrective exercise workout and is specific to your FMS testing results or your particular injury. Want to work on power, strength, or mobility? Inquire at firstname.lastname@example.org if you have any further questions.