By Patty Winter, Grace Cottage Physical Therapist
as appeared in the Brattleboro Reformer’s Graceful Health series, January 15, 2016
In the winter, it’s easy to imagine how the weather can increase your risk of falling. Year-round, though, your physical sense of balance is affected by internal as well as exterior factors.
For example, you may have heard of the Vestibular system, which is a series of tubes in the inner ear that acts like a carpenter’s level. This system keeps us oriented as to where we are in space, telling us whether we are upright or not. Some people experience dizziness when this system gets imbalanced. Some specially trained physical therapists can work with patients on inner ear issues, but that’s not the focus for this discussion.
Balance is also dependent on our vision. Vision changes can often affect balance. Do you notice more unsteadiness when you are in the dark? This is why night lights are so important for aging people, to avoid falls due to decreased vision. While a physical therapist cannot help increase a patient’s vision, the therapist can offer ideas to accommodate for vision loss.
Physical therapy can also help with balance issues that are caused by neurological deficits. One common problem with our sensory nervous system that will affect balance is decreased sensation in the feet. This can be due to peripheral neuropathy (damage to the nerves) that most commonly affects the hands and feet. It can be caused by diabetes, by injury, by poor circulation, or it can also happen gradually over time for no apparent reason. Our vibration sense, our ability to feel vibrations, is also affected by neuropathy and contributes to poor balance.
Neurological disorders can also affect proprioception, the sense that tells us what position our joints are in at all times. For example, proprioception is what tells us, even if we are blindfolded, whether our arms are being held above our head, or are hanging by our side. Most of the time, this is an instinctive sense that we are not aware of. Our muscles and joints are constantly moving to correct subtle changes in our balance as we stand, move, or walk on uneven terrain. Our brains process all the information from the vestibular, visual and sensory systems very quickly and spontaneously send signals to correct for any changes as needed throughout our bodies.
Patients with neurological deficits can improve their balance with Physical Therapy (PT). PT can retune the brain to function with decreased input from the sensory system. By having a patient perform tasks that cause him/her to become unsteady, we challenge the vestibular and sensory systems, and over time, with practice, the brain will reset for decreased input so that it can pick up smaller changes in our equilibrium and make corrections more quickly to avoid loss of balance. With repetition, we increase the system’s awareness of smaller and smaller increments of loss of balance so there is time for the musculoskeletal system to correct.
Patients often come to PT asking us to teach them how to not fall, but in reality sometimes they are falling because their brains aren’t aware that they are losing their balance until it is too late. So in essence they are falling because they haven’t even recognized they are falling! By having PT retrain the system to notice changes more quickly, we can reset when the brain becomes aware that there is a problem and get things moving to correct for loss of balance sooner, thus preventing a fall.
Another common reason that people have loss of balance and increased falls can be due to severe arthritic changes in the ankles, knees and hips. As arthritis develops, our joints become unstable and less mobile, and the proprioceptive sense becomes impaired. The brain “tunes out” what is happening in the damaged joint. As a result people start tripping more and losing balance when they are outside on uneven terrain. Physical Therapy is less effective for this problem, and physical therapists usually encourage these patients to seek out an Orthopedic Surgeon for a joint replacement to solve this issue.
PT is vital after a joint replacement to retrain proprioception and to get the brain to tune back in. If PT does not retrain proprioception after a joint replacement, this sense does not get better, and patients will continue to have needless falls and loss of balance. PT can retrain proprioception by challenging patients to walk on soft surfaces that move or are squishy, causing the brain to focus back into the new joint.
Children can also lose proprioception during growth spurts and may become clumsy. They usually grow out of this phase as they become adjusted to their new bodies and regain their agility.
Loss of balance and falls due to brain injury from trauma, stroke, or neurological diseases such as Parkinson’s or Multiple Sclerosis (MS) are more challenging to treat. Patients with these issues can improve their balance, but progress is often limited or, in the case of disease, is temporary as the disease progresses. Physical Therapy is still very important in these situations because it can assist these patients by teaching strategies to help avoid falls and by helping patients to acquire equipment that will help them. PTs can also train family and caregivers how to assist these patients with decreased balance.
Every year, approximately one third of people over age 65 will experience a fall. This can lead to diminished activity and decreased independence. Often, those who have fallen once have an increased risk of falling again. Physical therapists are an important resource for these patients, helping them to regain mobility and teaching ways to live more safely.
Bio: Patty Winter earned her Physical Therapy degree from the University of Vermont. She has years of experience in working with patients on neurological balance problems and recovery from orthopedic injuries.
