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  • Writer's pictureRobin R Varghese, PT.

Ever wondered what is Backward Disequilibrium? Or are you struggling with it? We can help you!!!

Postural vertical refers to an individual's perception of upright orientation which is established by the visual, vestibular, and somatosensory systems.

Backward disequilibrium (BD) is a postural disorder observed in some older adults who have a distortion in their perception of postural vertical.

Backward disequilibrium is a component of the geriatric syndrome called psychomotor disadaptation syndrome (PDS), which is identified by the presence of:

(1) Backward Disequilibrium,

(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.

What are the causes?

Studies are yet to provide more information on what exactly leads to BD. As per the available literature,

  • Cortical and subcortical lesions of the central nervous system are the main abnormalities leading to BD.

  • Ischemic, degenerative and traumatic lesions of the cerebral trunk, the white matter, the frontal lobes, the gray matter and the cerebellum could induce BD in elderly subjects.

  • Ischemic and hemorrhagic strokes are the most frequent etiologies of BD .

  • Literature reports other subcortical abnormalities such as normal pressure hydrocephalus or amyotrophic lateral sclerosis, which could also be associated with BD.

  • Peripheral neurological lesion can lead to imbalance between the ankle extensor muscles and the ankle flexor muscles, because of hypertonia of extensor muscles, which could be caused by a cause for BD.

How do the elderly with BD present themselves?

Individuals with BD sustain their center of mass (COM) posterior to their base of support and resist correction of COM alignment and fails to shift their center of mass (COM) sufficiently forward when moving from sitting to standing.

The accuracy of postural vertical perception declines in some adults as they age. This inaccuracy of postural vertical perception results in posterior postural tilt in standing and sitting, which increases in severity with advancing years and predisposes older adults to backward falls.

The end result of this posterior bias in perception of postural vertical has been called backward disequilibrium (BD).

It has severe consequences and can compromise functional autonomy in elderly subjects.

A vicious circle of falls, psychological and social consequences and loss of autonomy can arise and this is the main consequence of backward disequilibrium.


  • The management has to be multidisciplinary including physicians, physiotherapists, psychologists, nurses, and nurse’s aides.

  • The autonomy and functional well-being of elderly subjects suffering from BD could be improved by early diagnosis and management using basic interventions.

  • Knowledge of BD coupled with a thorough clinical examination may assist physical therapists in identifying this condition and employing the specific intervention.

  • Physical therapy plays a major role during the early rehab phase. Physical Therapy, which is a major component of the management strategy, must be started early and adjusted to all of the situations of everyday life. It must be noted that rehabilitation could be limited as these patients tire easily. The physical Therapist, therefore has to control the heart rate and the breathing frequency during the sessions.

Treatment includes:

Assistive devices

Studies have shown that with the use of the orthoses and visual guidance, the patient's foot placement with stepping can improve.

extremity strengthening exercises

strength training and progressive functional training improves the physical capacities in frail geriatric patients with BD.

posture control

Postural control must improving the dynamic and static control of the center of mass (COM)

The 5 standards of care includes:

(1)standing with the back against the wall with heels touching the wall,

(2) practicing moving from sitting to standing,

(3) practicing moving from standing to sitting,

(4) walking with continuous stepping, and

(5) stepping backward.


Practicing turning over in bed is introduced very early in the rehabilitation program in order to restore autonomy in bed and the capacity to achieve transfers.

Balance training

balance training is implemented in static and dynamic positions. It is advisable to start balance rehabilitation using intrinsic exercises first, followed by extrinsic exercises in the sitting position as well as in the standing position. Balance/functional training should last 30 minutes per training session. The choice of exercise must be personalized according to the postural abilities of the subject.

At Valley Healing Hands, Brownsville, Texas, we provide the best Physical Therapy treatment for Backward Disequilibrium and other geriatric problems. We will be more than humbled to assess and to prescribe a personalized programme for all our elderly patients. We have qualified therapists who are extremely sensitive to all your needs. Our patients are completely satisfied with our services. YOU may learn about what they have to say about us here and get connected to us here. Our patients love us. You too will!!!

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