Balance issues can be a tricky thing to self assess, until there is a fall that causes injury, or unfortunately more serious conditions such as fractures of ankle or hips. Balance issues can affect all ages, and often gets ignored in the elderly or just attributed to getting older. There are several different systems that play significant roles, and knowing which one is the culprit (or culprits) will directly lead to the appropriate intervention.
Balance and coordination are complex and often involve the intertwining of several systems. The three major ones are vision, vestibular, and proprioception. For the purposes of this article, I’d like to discuss the two systems that we often see in physical therapy and are most likely to affect balance, even in the healthy individual.
The first system is called the vestibular system, and is comprised of three small bones in the inner ear named ossicles. These bones, like most in our body, can become degenerative or get out of alignment. The resulting interruption in feedback loops from the ossicles can lead to vertigo, loss of balance, dizziness, loss of neck rotation and headache. Often times these symptoms may require evaluation from an ear nose and throat specialist. In the case of vertigo from ossicle alignment, our physical therapists administer an advanced technique called the Epley’s maneuver in the office to help re-align the ossicles to stop the vertigo symptoms. Usually this technique is followed with other manual therapy to restore the likely precipitated loss of neck rotation. There are studies that have directly linked patients who suffer with vertigo with a loss of neck rotation, suggesting that the loss of rotation may actually increase likelihood of developing vertigo.
The other system that affects balance is the most common one addressed in physical therapy, called proprioception. There are receptor cells in our joints and muscles that tell our brain instinctively where our body is in space. This feedback loop is developed by our general movements. In instances where movement is impaired (acute swelling, immobilization from a cast, pain, spinal tightness, postural changes from aging), this information is fragmented and can alter balance. In the elderly, postural changes in the spine cause a flexed position with a loss of rotation, along with hip and lower extremity tightness. The lack of flexibility does not feed the system the appropriate feedback so when the person rotates too far, they can be at a much higher risk of fall. Generally, restoring rotation in the neck, spine, and hips can greatly help increase stability and reduce risk of fall.
Proprioception problems are not limited to the elderly. When athletes get hurt and have a period of immobilization (like a surgical recovery or use of a cast and crutches), the affective area does not move throughout the normal range of motion. Thus the receptors become inhibited from providing the same proprioceptive feedback to the brain to interpret. Physical therapists spend much of the treatment sessions performing joint mobilization techniques, flexibility and balance oriented exercises that not only increase range of motion, but directly increase proprioception. Restoration of movement is also necessary to increase muscular strength. You have to have motion available to use it. The further a muscle is elongated, the more potential force it can produce.
It is important to recognize that balance issues are not exclusive to just getting older and should not be overlooked. Recognizing which systems are compromised is the first step in helping reduce balance issues. Should you experience any balance related symptoms, it is advisable to seek the opinion of your primary care physician, ENT specialist, or local physical therapist.
Michael Dow MSPT is founder and Clinical Director of Amity Physical Therapy, now with three offices in Woodbridge, Hamden and Branford. He received his degree from Fairfield University and is recognized by the U.S. Dep’t of Health and Human Services for his work with the national Multiple Sclerosis Society. He works with patients of all ages, pediatrics to geriatrics, as well as local high school and college athletes. Michael can be reached at 203-389-4593 or www.amitypt.com.