Balance is a critical part of mobility and enjoying life, and loss of balance can lead to falls. When we’re young, we often brush off a fall, but with age, falls can lead to serious injury and loss of function. Every year, falls affect one in three people aged 65 and older, but often these falls could be prevented!
What is Balance
From the moment in life when we first lift our head to explore our environment, we begin to develop and use the ‘seventh sense’ – balance. The nervous system is hard-wired to keep the eyes level and to maintain a stable, upright posture. In order to stay upright in sitting and standing, a complex interplay of processes within the nervous system (the brain, nerves and sensing organs) and with the musculoskeletal system (muscles, bones and joints) takes place.
The nervous system has three main parts that contribute to the sense of balance: vision, the inner ear and positional sense (proprioception and kinesthesia). Vision provides a frame of reference of the body to the external world (think about how you feel when you try to walk in the pitch black). Vision not only tells you where you are and what is around you but whether you are moving or still, and whether you are vertical or horizontal.
The inner ear (vestibular system) contains a series of fluid-filled canals, each lined with nerve endings that feel the movement of the fluid, each acting as a spirit level inside each ear and measuring position and movement up/down, side to side and front to back. Of interest, the inner ear fluid has a particular density affecting how quickly it moves. That inner-ear fluid density is reduced with drinking alcohol and temporarily ‘de-calibrating’ the inner ear mechanism, causing a spinning sensation. When the fluid density returns to normal (the morning after, hopefully), a rather unpleasant feeling can ensue (amongst other reasons outside the scope of this article).
The third component of the balance sensing system is positional sense. With eyes closed, most people are able to determine what position their joints are in (proprioception) and whether there is movement taking place in those joints (kinesthesia). The nerve endings for positional sense are largely located in joints and a particularly important cluster are in the feet and ankles. As a joint changes position, and even in preparation for the motion, the nerves reflexively tell the muscles to support the joint and make it stable and able to take weight. The ankle is a good example of this process – with every step, muscles around the ankle joints are activated, stabilizing the joint and allowing the weight of the body to progress over the foot during walking. Stepping on an uneven surface unexpectedly can cause a greater-than-expected force to the ankle and cause it to roll over, spraining the ankle and damaging the positional sense. This can lead to a loss of stability in the joint and more ankle sprains.
From a physical standpoint, adequate strength and structural integrity of the skeleton are required to stand and to respond to changes in the center of gravity that take place with simple motions such as reaching or bending over and more complex ones such as walking. If you catch your toes on a loose carpet edge, for example, your body normally compensates by rapidly changing position and taking a protective step to maintain the base of support. At the same time, the arms may reflexively lift out for further support.
Each of the three sensory mechanisms acts as a fail-safe for the other two, ensuring that in the healthy state we can all go about our activities safely and securely.
What are the Causes and Consequences of Imbalance
Unfortunately, through various processes, the sensory mechanisms can degrade, impairing balance and leading to loss of peace of mind that we can function safely. I’ve already discussed how a sprained ankle can lead to both a loss of structural integrity as well as the protective sensory mechanism in the ankle, leading to increased risk of falls. Environmental factors including inadequate lighting, trip hazards and even cold temperatures can impair balance (a 1°C drop in room temperature can cause a 25% loss of muscle power; SOURCE: bit.ly/1kDuc0s Age and Ageing, online May 22, 2014).
Normally all three components of balance work together and are combined in the brain. Injury to the brain, such as with concussion, stroke or in dementia, can lead to an inability of the brain to integrate the required inputs with appropriate output of movement control. Congestion due to a cold can impair the inner ear mechanism; loss of sensation in the feet (such as with peripheral neuropathy in diabetes) can reduce positional sense; cataracts can affect the vision; loss of strength for whatever reason will reduce the capacity to respond to a trip or slip; joint stiffness, particularly in the legs and low back will also reduce the body’s ability to adapt to different surfaces and compensate. However, one of the most insidious problems that particularly affect older adults is the fear of falling.
Fear of falling affects as many as 50% of people aged 70 and older and can lead to self-restriction of activity as well as changes in the way the person walks. Sadly, both of these are likely to increase the risk and occurrence of falls. By restricting activity, one quickly detrains the sensory systems responsible for balance. At the same time, strength is lost very rapidly with inactivity leading to reduced ability to safely maintain an upright posture or respond to a loss of stability during day to day activities.
Get Better Balance – But How?
The good news is that both strength and balance can almost always be improved at any age. Environmental factors can be controlled to minimize fall risk (use this checklist provided by the National Center on Aging: http://bit.ly/2hSAo9E). At every age, we should be training our bodies for longevity by engaging in healthy activity – get the kids off the screens, get away from the desk at work and go for a short walk (or get a standing desk), take up Tai Chi or join a strength and balance class such as Otago. Tai Chi has been shown to reduce fall risk significantly in adults and for older, less robust adults, Otago classes have the best evidence to prevent falls.
Movements such as balancing on one foot, going up and down from a chair and walking heel to toe can all help to improve and maintain good balance. These should be done with an appropriate amount of support but also there needs to be some challenge to the movement to make it beneficial.
A physician or physical therapist can screen for fall risk and this should be done for any one at risk and everyone once they are 65 years old. Physical therapy is very effective at improving balance by identifying and addressing the risk factors. Have a drug review with your physician annually as four or more medications taken daily is a risk factor for falls. Also, ensure good blood pressure and heart rhythm with your doctor and with a healthy diet, hydration and activity, as sudden changes in these can lead to falls. Most importantly, remember that you can always improve at any age and that loss of balance is not an inevitable or normal part of aging so if you are experiencing problems don’t ignore them.
Joshua Wies is a physical therapist and certified Otago Strength and Balance exercise teacher. He has been helping people with balance disorders for the past 25 years.
Disclaimer: Remember that any unexplained change in your balance should always be reported to your primary care physician as it may be a sign of an underlying condition. The information enclosed is for educational purposes and is not intended to replace a medical consultation.