SENIOR SCENE: The components of balance
I see it frequently in patients: walking with their feet apart and their hands outstretched, taking small, slow steps, because of course they are afraid of falling. Our balance is affected by the strength of our legs, proprioception, inner ear, vision, ankle range of motion and many other things such as brain or nerve disorders. Because there are many components to balance, it is often difficult to identify the cause of worsening balance or falls. But there’s plenty of published research to back up what most of us know, falling is bad. It is bad for your health and can lead to bone and joint damage as well as brain damage. It has been associated with an increased death rate in the elderly.
Regular exercise is good for balance. Maintaining or improving ankle range of motion is a simple way to dramatically improve vertical balance. Doing ankle push-ups and calf stretching exercises can be done while seated and can help improve your standing and walking balance.
Proprioception is your body’s ability to know where it is in space. This can be explained by a simple task. If you close your eyes, you can touch your two index fingers together. This is due to specialized nerve receptors in the joints of your elbows, wrists and hands that send signals to your brain. There are many types of nerve receptors that signal movement and help with proprioception and body awareness. The sensitivity and efficiency of these receptors and processes can be enhanced through regular movement, sports activities, and specialized exercises such as tai chi and yoga. Physiotherapy treatment can be designed to target different aspects of balance and improve your overall balance, stability and mobility.
Vertigo is a condition that affects your balance, usually due to problems with the semicircular canals of the inner ear. Symptoms of vertigo often include the sensation of motion (motion sickness) and may be accompanied by nausea, vomiting, eye movement and loss of balance. Vertigo often has a sudden onset and can be severe. If you develop symptoms of vertigo, you should see a doctor, as they may also be linked to other health issues. There are positional treatments (Epley and Semont maneuvers) that can be used to treat certain types of acute vertigo. These treatments are often performed by otolaryngologists (otolaryngologists), physical therapists or your primary care physician.
The semicircular canals inside are small circular tubes of fluid in the ear that have small hairs in the canals that detect head movement. The circular tubes are oriented in three different ways: a vertical, a horizontal and a diagonal to detect movement in all directions. This system sends information back to the brain about movement and the brain integrates this information with signals from our eyes/vision. Deficiencies in either of these systems (inner ear or vision) or information processing (brain) can affect our balance.
Why do some people look at their feet when they walk, and is it bad?
If you’ve ever had to do gait training or work on gait technique in physical therapy, you’ve probably heard your therapist say, “look up.” If you have decreased sensation in your feet and/or ankles or have had surgery or lower extremity injury, you likely have decreased proprioception or body awareness. Watching your feet as you walk can make step placement more focused. This is important and can help when stepping over an obstacle or walking on uneven surfaces. The problem with this is related to the integration of information in the brain. To help with balance and body position, our brain needs a reference. The horizon is our visual reference horizontally and vertically. If we look at our feet and the ground, it’s confusing to the brain. While this helps us position our feet better, our brain loses reference to horizontal and vertical (the horizon). Indoors, this reference point is where the wall and floor meet. The best position for our brain and our balance is to include a visual field that can see our feet and the path in front of us while looking up enough to see where the wall and the floor meet. Using a cane to touch the ground also gives a point of reference to the horizontal plane through the proprioception/feedback of the hand/wrist/arm holding the cane.
Why does my balance get worse at night and what can I do about it?
Many falls and injuries happen at night when people wake up to go to the bathroom and don’t turn on the lights. When we first wake up, our brain does not process information as quickly or as efficiently as when we are in our highest states of alert. This can lead to decreased balance due to poor integration of information from proprioception (body awareness), inner ear (movement) and vision. Increased proprioception from using a cane or walker or even touching walls or furniture while standing and walking can improve your balance at night. Also improving visual input, but installing night lights (so our brains can process horizontal and vertical by seeing where the wall and floor meet) will also improve your balance considerably.
If you feel your balance is deteriorating, please discuss this with your doctor and request a visit to physiotherapy. There are so many things to balance, and there are often many ways you can work to improve your balance. Preventing falls and injuries is much easier than recovering from a fall or injury!
Clint Crabtree is director of physical therapy at Levi’s Hospital.