I see it frequently in patients: walking with their feet spread apart and hands out, taking small, slow steps, because admittedly, they are worried about falling. Our balance is affected by strength in 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 single out the cause of worsening balance or falls. But there is much research published to support what most of us know, falling is bad. It is bad for your health and can lead to bone and joint injury as well as brain injury. It has been associated with increased mortality rate in the elderly population.
Regular exercise is good for balance. Maintaining or improving ankle range of motion is a simple way to improve upright balance significantly. Doing ankle pumps and stretching exercises for the calves can be performed while seated and can help improve your standing and walking balance.
Proprioception is your body's ability to know where it is in space. It can be explained with a simple task. If you close your eyes, you can touch your two index fingers together. This is because of specialized nerve receptors in the joints in your elbows, wrists and hands that send signals to your brain. There are many different types of nerve receptors that signal movement and help with proprioception and body awareness. The sensitivity and effectiveness of these receptors and processes can be improved through regular movement, sporting activities, and specialized exercises such as tai chi and yoga. Physical therapy 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 because of problems with the semicircular canals in the inner ear. Vertigo symptoms often include the sensation of movement (motion sickness) and can be accompanied by nausea, vomiting, eye movement and loss of balance. Vertigo often has a sudden onset and can be severe. If you develop vertigo symptoms, you should see a doctor, as they can also be related to other health conditions. There are positional treatments (Epley's and Semont's maneuvers) that can used to treat some types of acute vertigo. These treatments are often performed by otolaryngologists (ear/nose/throat specialists), physical therapists or your primary care physician.
Semicircular canals in the inner are small circular tubes of fluid in the ear that have small hairs in the canals that sense movement of the head. The circular tubes are oriented in three different ways: one vertical, one horizontal and one diagonal to sense 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. Impairments with either of these systems (inner ear or vision), or the processing of information (brain) can affect our balance.
Why do some people look down at their feet when they walk, and is that bad?
If you have ever had to have gait training or work on the technique of walking in physical therapy, you have likely heard your therapist say, "look up." If you have decreased sensation in your feet and/or ankles or have had surgery or injury of the lower extremities, you likely have some decreased proprioception or body awareness. Looking down at your feet while stepping can make the placement of the step more on target. 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 assist with balance and body position, our brain needs a reference. The horizon is our visual reference to horizontal and vertical. If we look down at our feet and the floor, it is confusing to the brain. Although it helps us place our feet more effectively, our brain loses the reference to horizontal and vertical (the horizon). Inside, 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 also looking up enough to see where the wall and the floor meet. Using a cane to touch the floor also gives a reference point to the horizontal plane through the proprioception/feedback from the hand/wrist/arm that is holding cane.
Why is my balance worse at night and what can I do about it?
Many falls and injuries occur at night when people wake up to use the bathroom and don't turn on the lights. When we first awaken, our brains don't process information as quickly or as effectively as when we are in our most alert states. This can result in decreased balance due to poor integration of information from proprioception (body awareness), inner ear (motion), and vision. Increased proprioception from using a cane or walker or even touching walls or furniture while upright and walking can improve your balance at night. Also improving visual input but installing nightlights (so that our brains can process horizontal and vertical by seeing where the wall and floor meet) will also greatly improve your balance.
If you feel like your balance is worsening, please discuss it with your doctor, and request a visit to physical therapy. There are so many aspects to balance, and often there are many ways to work on improving your balance. Preventing fall and injury is much easier than recovering from fall or injury!
Clint Crabtree is director of Physical Therapy at Levi Hospital.