Balance has been one of my favorite areas to study and teach. I remember first learning how balance is integrated through multiple systems and I was amazed that, as humans, we could stand upright without falling over. The statement that “gait is a series of controlled falls” was used by many professors, and I could not agree more. Balance is an epitomic example of homeostasis.
Prior to PT school, I was fascinated by homeostasis. The term was coined by French physiologist Claude Bernard in the late 17th century, who recognized that organisms need to react quickly to outside stimuli. In the 18th century American physiologist Walter Cannon expanded on this concept and defined homeostasis as “a relatively stable state of equilibrium or a tendency toward such a state between the different but interdependent elements or groups of elements of an organism, population, or group.” As I have advanced in my career remembering the basic need for systems to maintain equilibrium has enhanced my approach to treatment. In contrast, reviewing current research and discussions on social media regarding physical therapy interventions, I do not see the application of a homeostatic approach. Instead of balance between different treatment strategies, I see unbalanced ideas, consisting of biased perspectives, regarding the evaluation and treatment of patients.
Physical therapy appears to have accepted the “all or none” phenomenon, which I studied in physiology. As the pendulum of care swings to different fads, the expectations for care changes. Justifying clinical prediction rules, advancing spinal manipulation, and progressing therapeutic dry needling appear to be driving our practice decisions of late. Ten years ago, interventions like core stability (Multifidus and Transverse Abdominus), utilizing diagnostic ultrasound, and Kinesotape© were in fashion. I have seen PTs go from one extreme to another in the application of therapy interventions. Don’t get me wrong, I have spent many years bogged down by biomechanics and trying to keep my head above water while at the same time attempting to apply current research to my everyday practice. But I have emerged with a clearer perspective on what works and what does not. I really enjoyed a blog post by David Butler called the “Roller Coaster of Professional Life,” which seems to describe a lot of my experiences in physical therapy.
What works for me is to apply the concept of homeostasis to evaluation and treatment of my patients. Is the person balanced in their movement patterns, in their perspective of their pain, lifestyle, stress management, medications and diet? The scanning examination is a perfect way to look at balance of movement through the history, ROM, neurological examination and stress tests. Shortcuts will arise for sure (with time and skill), but if we stick to basic algorithms presented by CPRs, we might be lead to the wrong clinical hypothesis. Hence why Dr. Flynn states “clinical prediction aid” may be more accurate than clinical prediction rules. Stating the intent was to have an informed guide to treatment not “hard and fast rules.”
The same goes for treatment. If our physical therapy interventions do not try to obtain balance in these areas, we are going to take longer and not be effective. If the patient cannot make changes in their functional movement patterns, we are not making the impact that we can on our patients and the relationship becomes codependent–they need to be fixed, we need to feel good about fixing them.
Interconnectedness is the key. Just as balance is a web of cross communication between the eyes, proprioceptors, inner ear and cerebellum, each physical therapy problem is interconnected. Loss of range of motion is one single factor, but not the whole picture. Weakness in the core stabilizers are a symptom, but are interconnected with possible loss of hip or thoracolumbar ROM, local facet irritation, loss of the feedback loop between the lumbar spine multifidi and the central nervous system and lack of psoas coordination. CPRs are trying to take us there, but are limited and cannot truly see patient apprehension, expression etc.
Research, by design has to set out to disprove a hypothesis. It is narrow in focus and cannot be balanced in its approach. It was Claude Bernard who was also one of the first researchers to suggest blind, unbiased studies. Unfortunately, research is limited to looking at measures of ROM, Strength, Neurological Status, personality type (based on questionnaires) and reaction to pain (again based on surveys)–these are building blocks, or objects to specific motions. These are objects in the process of movement dysfunction, but will never be able to represent the individual in my treatment room.
A few years back, a Harvard professor was discussing mRNA transcription. He talked at great length about the difference between objects inside a process and the process itself. He stated that current scientific research is neglecting the basic question of “what starts the process?”
When we are evaluating our patients are we looking at them as objects? As a low back pain patient with limited internal rotation and pain less than two weeks and a Fear Avoidance Belief Questionnaire of less than ….you get the point. Or can we design research which addresses the diversity of our humanity. Treatment of patients will never be a one size fits all scenario. In dentistry, one study highlights the example of how redheaded patients require more anesthesia due to a heightened pain response. This does not take into account the wide range of patients we see and the myriad of pain responses that they will have as described by Melzack in 2001 and expanded upon by Moseley in 2003.
It is all about balance! Balance of what we are seeing in our patients, beyond ROM, questionnaires and reflexes. In research and interventions are we are asking the wrong questions, leading to unbalanced answers and treatment approaches? Let’s take a fresh look at the patient in front of us and revisit the key questions of mobility and function and the interconnectedness of systems for balance and homeostasis. If we do not return to some sort of equilibrium in our approach, we may fall victim to another one of my favorite scientific terms, entropy.
–Terry Pratt, MS, PT, COMT, FAAOMPT
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