BALANCE AND DIZZINESS PHYSICAL THERAPY

Physical Therapy for balance and dizziness corrects some ailments that cause dizziness, balance, and gait disorders. Be Fit Physical Therapy & Pilates has taken up the charge to be the leaders in balance disorders and gait disturbances. Unfortunately, few are aware that these can be corrected with comprehensive treatment program. Read on to learn about balance and dizziness causes as well as falls prevention.

Comprehensive Guide to Balance and Dizziness Physical Therapy

Contents

• Aging Effects
• Balance System
• Somatosensory System
• Vestibular System
• Vision
• Balance Disorders
• Falls & Falls Prevention
• Balance Physical Therapy
• Balance Retool
• Balance Exercises
• Balance Test for Seniors

Effects of aging

Aging is not what it used to be. With the advances in medicine and healthcare, people are living longer and living independently longer.

What Is Different?

We have better knowledge of nutrition and how it improves heart and brain health and strength. We are aware of scientific findings on the relationship between specific diets and cancer. There is better healthcare and medicine. Regular checkups from the doctor combine with modern healthcare to prevent or minimize conditions that would have been fatal one or two generations ago.

With better fitness habits and advances in exercise science, we can stay fit for longer. It helps that our culture and self-interest influence us to engage in physical activity.

What Is the Same?

Meanwhile, biology dictates that some things stay the same.

For instance, maintaining balance—the ability to keep from falling—is at odds with biological and medical factors.

Muscle mass and strength decline over time. Range of motion and joint mobility also decline. As a result, performing everyday activities requires greater effort, attention, and time, and the ability to move within the home and neighborhood diminishes1 (Healthy Aging: Senior’s Mobility Toolkit for Physiotherapists) (“Healthy Aging”).
Taking medications may be necessary to maintain systemic functions of the body. However, the side effects of dizziness, lethargy, or drowsiness present balance and fall risks.

There’s also declining function in sensory capacity. Declining sight, inner-ear, and proprioceptors cellular loss/neuroreceptivity cause balance issues as well.

Maintaining balance while aging is not out of one’s hands. There are things to do to address fitness and environment that help with having strong balance.

Balance System

The balance system is made up of the Somatosensory, visual, and vestibular systems.

Somatosenosry

Nervous System

No matter which system contributes to balance, there is a continuous relay of stimuli via the nervous systems. Peripheral nerves carry stimuli from the skin, the eyes, and the ears to their respective neurons near the spinal cord. In the case of the vestibular system, the path to travel is not as far, in the case of the somatic nerves. After that, the neurotransmitters send signals to the brain. There the somatosensory cortex and cerebellum process the stimuli2 (Pentilla). The brain then returns instructions to the muscles. This process and the result—staying upright—occurs constantly and mostly subconsciously.

The Somatosensory system is composed of neuroreceptors in the skin and other organs. There are other proprioceptors that, respectively, detect degrees of temperature, kinds of pressure, and levels of discomfort/pain. That’s why the phrase “sense of touch” may be more accurately phrased as, “senses of touch.” They are the somesthetic senses. (Penttila).

Proprioceptors, a kind of somesthetic nerve, take in information that is useful for maintaining balance and navigating spaces such as playing fields, bedrooms, and swimming pools. Through an intake process called proprioception, the nervous system makes us aware of the positioning of our arms and legs.

It tells you about the ground you walk on and helps you to be sure footed. Another way of thinking about it is reflexes. Let’s say you walk on sand. Proprioception helps you lean this way and that, placing your feet and swinging your arms here and there as the sand shifts underneath.

All age groups depend more on proprioception than on other sensory systems. Older individuals, however, depend the most on proprioception than on vestibular cues than on other senses1 (“Healthy Aging”).

Vestibular System

The vestibular system is a group of structures of the inner ear. Owing its meaning to the word vestibule, meaning “entrance,” the vestibular system is located just inside the entrance of the inner ear. It is also, in a sense, the entryway of stimuli that we use to maintain our balance.

These structures include otolith organs—semicircular tubes which comprise sacs of gel-like fluid, tiny crystals, and hair-like neuroreceptors on the inner-surface of the sac. The vestibular system helps us to know the position of the body in relation to the ground as well as the movement of the head.

When the head moves, crystals react, causing vibrations of the gel within the sac.

Vision

The vision system develops with the support of the vestibular system, which is the only fully myelinated and functioning system at the time of birth. While it guides movement and development of vision in first years of life. vision takes over after that and guides movement. Sight takes up two-thirds of the brain’s electrical activity while eyes are open3 (Ryan) (Ryan).

Balance Disorders

But things break down. What happens when signal transmissions are interrupted.

Balance disorders can be divided into those that affect sight and vestibular systems. In addition, there are other conditions that aren’t balance disorders per se, but which also affect balance. So for instance, foot and ankle disorders can also affect balance. Also, environmental factors such as the condition of the home can affect balance and increase risk of falling.

Spine Origin

Cervical spine injury/dysfunction may cause dizziness, headache, or difficulty with balance. It can cause unsteadiness with walking and turning. For example, postural disorders such as forward head posture, or kyphosis, can stress the spine as well as muscles responsible for posture and balance1.

Brain Origin

Structural disturbances within the brain can cause balance related symptoms. Among these are:

• Circulatory disturbances: Disturbances in circulation occur because of stroke, injury, or infection. They affect the brain stem (cerebellum). This often results in Vertigo often results.
• Nueronal disturbances: Neuronitis, inflammation of the vestibular nerve, and pressure on the nerve, (e.g., non-cancerous tumor) can result in vertigo. .4 (Medicine)

Other conditions that may cause vertigo include:

• Multiple sclerosis
• Seizures (rarely)
• Tumors (cancerous or noncancerous)Vestibular migraine (a type of migraine headache)

Vision origin

Some balance disorders originate with dysfunction of sight. Here too the vestibular system plays a role. For, in changing positions of the head, the semicircular canal sends information about head position to the brain. At that point, the vestibulo-ocular reflex (VOR) allows eye positioning to adjust in order for a person to maintain a stable gaze.5 (Land)

Doctors test this reflex during physicals when they instruct patients to keep an eye on their fingers while patients turn their heads.

Because we rely so heavily on vision for balance (it actually overrides info from other senses), even the feeling of offness in movement as a result of failure of the VOR can be very disturbing. Other symptoms can be dizziness and disequilibrium. The effect can be a decreased quality of life.

Benign Paroxysmal Positional Vertigo (BPPV)

Causes of vestibular disorders are problems with the inner-ear structures. When these problems arise, the communication between the central nervous system and the vestibular structures is disrupted. One study found that 80% of people who fell had “unidentified vestibular dysfunction”1 Also, the vestibular system is the most commonly affected when dizziness is the patient’s complaint/symptom.
Benign Paroxysmal Positional Vertigo (BPPV) is most frequently diagnosed of vestibular conditions.

The dizziness of BPPV is caused because fluid continues to swirl in the horizontal canal even though a person has stopped moving. The body registers movement while the eyes register a stop.

As a result, people have dizziness, nausea, vertigo, and disequilibrium. The symptoms of vestibular disorder may further be subdivided as: 1) rotational, the illusion of self-motion or object motion; 2) positional, precipitated by a change in head or body positioning, such as turning in bed; and 3) recurrent dizziness with nausea or visual disturbance, and imbalance.

FALLS & FALL PREVENTION

There is no single cause but often multiple risks factors that, when combined, increase the chances of a fall. Mobility limitations are the frontlines in functional decline (5 balance toolkit). (ankle range of motion, reduced function in this aspect is associate with an increased risk of falls) (6). Balance while walking or reaching forward while standing.

These risk factors include hazards at home, work, or in the community, as well as physical and neurological ailments.

fear of falling

a fall or near-fall within the last __ (weeks/months), lack of confidence, gait problems

Fall Risks

• Muscle weakness: While age is related to decreased leg strength and slower reflexes, lethargy due to medications, or muscle weakness related to chronic pain are also factors to watch out for.
• Neurological: Neurological disorders that leave one prone to confusion are cause for taking ingress and egress slowly. Going slowly is especially important when going to or waking up in unfamiliar places.
• Musculoskeletal disorders: Arthritis, disorders of the spine, etc., contribute to muscle weakness and to gait patterns that make balance and movement more difficult.
• Blood pressure: Do you ever feel dizzy or confused upon standing up? Postural hypotension, which has been linked to a number of ailments, may be the cause and a call for proceeding with caution upon standing.
• Medication: Some medications impact the nervous system because of a side effect or by intention. This can increase dizziness, sedation, confusion, blurred vision, and orthostatic hypotension.7
• Obesity: Weight negatively impacts postural stability and is positively associated with greater number of falls among obese people.8
• Nutrition: Nutrition can impact muscle and bone strength, both of which play an important role in maintaining balance. It also improves cognition, which is another role.

Balance Therapy

To have a stable posture, the somatosensory, vestibular, and visual systems must all contribute. However, a musculoskeletal response is called for in all situations. 1 In the same way, rehabilitating balance disorders requires reeducation of the nervous response, and it also demands muscle strengthening.

A tailored plan of physical therapy can address all of the factors balance and mobility: gait speed, trunk strength, and range of motion in the lower extremities. As a result of balance and dizziness physical therapy, many older adults maintain their level of function. Others improve their balance and ability to execute everyday tasks.

Vestibular and vision therapy

Vestibular rehabilitation treatment

Vestibular Rehabilitation Therapy (VRT) is an exercise program that utilizes the methods of substitution, adaptation and habituation.

• Substitution: teaches the central nervous system to adapt to weak or non-existent signals from the surrounding sensory receptors allowing it to more efficiently use the available visual input.
• Adaptation: uses the VRT exercises to adapt to uneven signals from impaired inner ear receptors.
• Habituation: exercises are based on repeated exposure to specific stimuli and movements designed to lessen the vertigo response.

A plan of vestibular rehab is can also include an exercise that maneuvers the otoconia back into the semicircular canals. This treatment is called the Epley maneuver. Vestibular specialists use it in conjunction with strengthening exercises. Epley Maneuver–used for posterior semicircular canal, where 83% of BPPV is caused.

Vision treatment

Vestibular-visual disorders may be treated by vestibular therapists. Others require treatment visual therapists. Therapy for vestibulo-ocular related dizziness is designed to stokes neuroplasticity. Neuroplasticity of the brain means that it can create new pathways for neurological connections. Through therapeutic intervention, the two systems synch again.

During this process, feedback from the visual system is key. Meanwhile, vestibular system is integrated with the movement exercises until the vestibular and ocular are linked again. This is similar to the way children develop neurologically. One system guides the other to higher power of functioning.

Gaze Stabilization

When we address dizziness for vestibular neuronitis, when the vestibula nerve is impacted. In this case, gaze stabilization exercises help address symptoms of dizziness.

It has also been useful with other conditions such as bilateral vestibular loss, tumors

Balance maintenance programs

Maintaining balance is NOT different from other health and wellness efforts. It requires maintenance. Exercises for balance ae necessary on a regular basis because they build muscle and protect against muscle loss. This is particularly important for older adults who begin to lose muscle mass during the aging process. For adults, this loss in muscle begins to occur after the age of 40.

Balance exercises

Read about Muscle Strengthening

Oxford dictionary defines balance as “an even distribution of weight enabling someone or something to remain upright and steady.”

Strength has greater effect and is more important in regaining muscle mass. Strengthening programs combat loss of strength and loss of muscle mass. In turn, it helps seniors maintain mobility and independence (1)

For Pilates strength stabilizing exercises, read:
Pilates Exercises for Balance

How to figure out if you are at risk of falling

Read our informative Blog Post:

Balance Tests Let Seniors Know if They Are at Risk for Falls

In it, you’ll discover a simple test to determine whether your balance is in tip-top shape or if you need to take action to improve it.

References

1. Healthy Aging: Senior’s Mobility Toolkit for Physiotherapists. Edmonton, Alberta: Physiotherapy Alberta College + Association, 2018. Document.
2. Land, M. Vestibulo-Ocular Reflex. 8 October 2013. Web page. 14 September 2020. <www.britannica.com/science/vestibulo-ocular-reflext>.
3. Medicine, U.S. National LIbrary of. Vertigo-Associated Disorders. 02 10 2019. Webpage. 02 08 2020. <https://www.easybib.com/project/style/mla8?id=52c987a2-5170-4a1a-84db-3131a383ebe6>.
4. Pentilla, N. The Senses: The Somatosensory System. 19 Sept. 2019. Webpage. 30 July 2020. <www.dana.org/article/the-senses-the-somatosensory-system>.
5. Ryan, C. The Connection Between Vision & Balance. 23 Dec. 2016. Webpage. 4 Aug. 2020. <www.vestibular.org/news/12-23-2016/connection-between-vision-balance>.
6. Karani MV, Haddad Y, Lee R. The Role of Pharmacists in Preventing Falls among America’s Older Adults. Front Public Health. 2016;4:250. Published 2016 Nov 9. doi:10.3389/fpubh.2016.00250
7. Fjeldstad C, Fjeldstad AS, Acree LS, Nickel KJ, Gardner AW. The influence of obesity on falls and quality of life. Dyn Med. 2008;7:4. Published 2008 Feb 27. doi:10.1186/1476-5918-7-4

Bibliography

“Balance Disorders.” National Institute of Deafness and Other Communication Disorders, U.S. Department of Health and Human Services, 15 July 2020, www.nidcd.nih.gov/health/balance-disorders.
Bennett, Howard J. “Without Your Balance, Life Feels Downside-Up.” The Washington Post, WP Company, 12 Feb. 2017, www.washingtonpost.com/lifestyle/kidspost/ever-wondered-about-your-sense-of-balance/2017/02/10/9eca2054-ef04-11e6-9973-c5efb7ccfb0d_story.html.
Fjeldstad C, Fjeldstad AS, Acree LS, Nickel KJ, Gardner AW. The influence of obesity on falls and quality of life. Dyn Med. 2008;7:4. Published 2008 Feb 27. doi:10.1186/1476-5918-7-4
Healthy Aging: Senior’s Mobility Toolkit for Physiotherapists. Edmonton, Alberta: Physiotherapy Alberta College + Association, 2018. Document.
Jahn K. The Aging Vestibular System: Dizziness and Imbalance in the Elderly. Adv Otorhinolaryngol. 2019;82:143-149. doi:10.1159/000490283
Karani MV, Haddad Y, Lee R. The Role of Pharmacists in Preventing Falls among America’s Older Adults. Front Public Health. 2016;4:250. Published 2016 Nov 9. doi:10.3389/fpubh.2016.00250
Land, M. Vestibulo-Ocular Reflex. 8 October 2013. Web page. 14 September 2020. <www.britannica.com/science/vestibulo-ocular-reflext>.
Lasisi AO, Gureje O. Prevalence and correlates of dizziness in the Ibadan Study of Ageing. Ear Nose Throat J. 2014;93(4-5):E37–E44.
Medicine, U.S. National LIbrary of. Vertigo-Associated Disorders. 02 10 2019. Webpage. 02 08 2020. <https://www.easybib.com/project/style/mla8?id=52c987a2-5170-4a1a-84db-3131a383ebe6>.
Pentilla, N. The Senses: The Somatosensory System. 19 Sept. 2019. Webpage. 30 July 2020. <www.dana.org/article/the-senses-the-somatosensory-system>.
Ryan, C. The Connection Between Vision & Balance. 23 Dec. 2016. Webpage. 4 Aug. 2020. <www.vestibular.org/news/12-23-2016/connection-between-vision-balance>.

The underlying physiological basis for VRT focuses on the plasticity of the central nervous system. VRT doesn’t regenerate or treat the damaged vestibular end-organ itself. Instead, it works by allowing the central nervous system and the brain to acclimate or adapt to asymmetrical/conflicting input from the vestibule-ocular reflex and vestibulospinal reflex.