My name is Dr. Hannah Leatherman, and I work with Dr. Laura Wazen at Equinox Physical Therapy in Sarasota, Florida during the winter months. I am a trained vestibular therapist, which is a physical therapist who specializes in treating patients with dizziness and balance problems. Balance is very important to me, because I am also a professional athlete in the sport of disc golf. I am required to have exceptional balance to have success competing on the professional disc golf tour. The sport of disc golf is similar to golf in that you must drive, approach, and putt towards a hole. Instead of hitting a ball with a club, you are throwing a small frisbee or disc. When I throw a shot with my dominant hand, my follow through forces me to stand on my right leg while maintaining good balance.
In sports and in life, we frequently use one side of our body more than the other. It is natural to have imbalances between our left and right sides, as most of us have a dominant arm and leg. If the imbalance becomes too great, it will lead to problems. Repetitive movements, habits, postures, or even injuries and surgeries can lead to abnormal imbalances on your left and right sides. As you age this can lead to serious balance problems. You may begin noticing that you are having trouble walking a straight line, are bumping into things more than you used to, or even losing your balance and falling.
As a physical therapist who specializes in treating balance problems, I have come to understand the importance of using both sides of my body when I am training in order to improve symmetry in my body. Part of my offseason training involves throwing with my non-dominant hand, which allows my left leg to balance me during the same movements I am constantly using for disc golf on my right leg. Strengthening and balance training of my left leg and core are also key elements to my program.
At Equinox Physical Therapy one of the things that we screen for is asymmetry. In addition to other tests, we analyze our patient’s walking pattern and posture, and assess their strength in both legs in order to find out if asymmetry of the body could be contributing to the patient feeling off balance. This allows us to educate our patient regarding these results as well as treatments which will create improved symmetry in the body, improved balance, and decrease risk for falls.
Whether you have been involved with sports, have had an injury or surgery on one side that has thrown off your balance, or just think that you might have asymmetry from any other activities that you have been doing for years, I encourage you to find a trained vestibular therapist and get evaluated. You might be surprised what they will find. Your body will thank you!
Image from PDGA Disc Golf
Falls in the elderly are not normal and should not be accepted as a fact of life. This week, I had a patient who was 90 years old and told me that he was doing pretty well until this last year. In the last 12 months he has fallen 6 times! These falls have happened at home and in the community. Because he is on blood thinners, falls for him are even more dangerous because of the risk of internal bleeding. I am glad he found me, but sad that it took so long to find help. It turns out that he is a retired pediatrician, and his son is an orthopedic surgeon, but neither of them thought of going to physical therapy. I hope that the patient let his primary care doctor know he was falling, but this was not the source of the referral. The person who suggested physical therapy was his audiologist, who thankfully was looking at the big picture when talking with the patient and not just focused on his or her own particular specialty.
You may be wondering, what do we know about falls in the elderly? Here are 3 simple facts from the Center of Disease Control and Prevention website.
1. One out of three adults age 65 and older falls each year, but less than half talk to their healthcare providers about it.
2. Among older adults (those 65 or older), falls are the leading cause of injury death.
3. In 2009, about 20,400 older adults died from unintentional fall injuries.
Now that you know the facts, you could be the person who helps save an elderly person from serious injury or death. If you see an elderly person with bruises on their arms, legs, or face, ask them how did it happen? If you see an elderly person who is walking and touching the walls or furniture for support, ask them if they are falling or having a balance problem. If you see an elderly person who is struggling to rise from a chair, ask them if they are having a balance problem or falling.
If the answer is yes, let the person know that a physical therapist who specializes in treating balance problems could change his or her life. Finding a local vestibular balance specialist is as easy as going to the Vestibular Disorders Association website, and searching under the tab entitled “Finding Help and Support”.
Included image: Fallen Figure, painting by Jean Helion, 1939
Levanna Doing Exercise, painting by Maria Primachenko
The Vestibular Ocular Reflex (VOR) is the mechanism that allows a person to keep their eyes on a fixed target while their head is moving, for instance when you are looking at your friend and nodding your head “yes” or “no”. The reason we are able to do this is because our inner ear system acts like little gyroscopes that tells our brain when our head is in motion. Your brain then takes that information, and tells the eye muscles what to do to keep your eyes on the target.
The VOR exercise is especially important when a person has had damage to their inner ear system. The brain, which was used to getting normal inner ear information previously, will have to relearn how to use the information that has lessened due to illness or injury.
I’ll give you a common example. Let’s say that a person has an inner ear infection that affects their Left inner ear system, and decreases responsiveness of the Left vestibular system (the balance part of the ear) to send information during head motions. When the person now moves their head, the left ear is sending less information than the healthy right ear. This difference in input to the brain being sent from the two ears can result in symptoms of dizziness, nausea, or unsteadiness. Ironically, some patients will avoid moving their head so that they don’t get dizzy, but movement is the only way for the brain to learn how to use the inner ear information again!
Vestibular Ocular Reflex exercises help the brain through this retraining process, because the exercise forces the brain to receive inner ear information and practice using it to keep the eyes on a fixed target. Patients start with slow head turns, keeping the eyes on a fixed target placed on the wall at eye level 4 feet away. They start in a seated position and move the head 20 degrees to each side in a back and forth head motion. They also do the exercise in an up and down head motion as if nodding “yes”. As they are able to do the exercise symptom free, we increase the duration of the exercise to 2 minutes.
The next step is to gradually increase the speed of the head motion. If you are doing the exercise correctly, your symptoms will decrease over the next few weeks. If you aren’t doing the exercise correctly, you may think the exercises don’t work! This is why working with a vestibular specialist is so important. If you are not improving, they can figure out what you are doing wrong and help you learn how to perform the exercise correctly, and hence, recover as much inner ear function as your body will allow.
Strangled by Growth, by Emily Carr 1931
Acoustic Neuromas are nerve sheath tumors surrounding the vestibular or cochlear nerves. The vestibular nerve is the balance nerve that goes from the inner ear to the brain. The cochlear nerve is the hearing nerve that goes from the cochlea to the brain. When the tumor grows, it can press on the nerves as they travel through a boney canal to reach the brain. This is how the tumor can damage a person’s balance and hearing. Also in this boney canal is the facial nerve. Damage to the facial nerve can result in facial paralysis.
At Equinox Physical Therapy, we specialize in treating people who have balance problems or facial paralysis as a result of acoustic neuromas. The majority of these patients come to see me following surgery, or radiation to the tumor. A few months ago, I had the pleasure of speaking to the members of the Acoustic Neuroma Association in Sarasota, Florida. They had the idea to videotape the talk for the members who were unable to attend the meeting. They were so pleased with the video, that they asked me if they could post it on their national website. The title of the talk was “The Vestibular System and How it is Affected by Acoustic Neuroma”. If you would like to learn more about this topic, you too can watch the video below.
"Woman Tying Her Shoe", Painting by Pierre-August Renoir, 1918
Do the shoes you are wearing matter when you have a balance problem or a history of falling? The answer to this question is ABSOLUTELY!
I still remember the lady who came to see me for balance therapy in Sarasota, Florida with complaints of falling. She was wearing 5-inch stilettos that didn’t even have an ankle strap! Now I ask you, do you have to be a balance specialist to know that maybe this is not such a good idea?
So what is a good idea?
1. A FLAT shoe is the best, avoid shoes with a high heel if you can tolerate a flatter shoe.
2. A shoe with a flat WIDE HEEL is better than a small pointy heel. The wide heel provides a more stable foundation when shifting your weight.
3. NO FLIP FLOPS or SLIDE style shoes. These loose shoes can cause a trip and fall.
4. A shoe with a SNUG FIT around the HEEL is important.
5. STRAPS or LACES that tighten- Don’t just slide your feet in and out of your shoes. If they have Velcro straps or laces, use them to make your shoe secure. Ankle straps should fit snuggly.
6. For people with peripheral neuropathy, avoid shoes that are too cushioning as they decrease your already limited ability to feel the ground.
7. Make sure that your toes are comfortable in the shoe, as you use your toes to stabilize your balance.