Connoisseurs of Books (Knowledge is Power), by Nikolay Bogdanov-Belsky, 1920
My physical therapy practice in Sarasota, Florida, is devoted to helping people with balance and inner ear problems. So you may be wondering why I am writing about visual problems The reason is: vision is extremely important in maintaining good balance! We use our vision to understand where we are in space, and how to negotiate obstacles in our environment. As adults, we have an idea of what good vision is, and we are likely to notice if our vision changes. But what if the person we are talking about is a small child, maybe even an infant who may not be able to communicate or recognize that he/she is having a visual problem? This child, in addition to a visual problem, could also be experiencing a balance problem, because we know that good vision and good balance are closely connected.
I was lucky to be talking about this problem with my friend and associate Dr. Mohamad S. Jaafar. Dr. Jaafar is Professor of Ophthalmology and Pediatrics at the George Washington University, and Chief of the Division of Ophthalmology at the Children’s National Health System, Washington, DC. He is passionate about training young doctors to be experts in his field and is the Past-Director of Washington’s Pediatric Ophthalmology Fellowship Program, which is the oldest, largest, and most renowned such program in the world.
Dr. Jaafar and I want to help parents recognize visual problems in their children, so that they know when to seek help. Bear in mind that there is an association of eye diseases in some children who have hearing loss (such as retinal dystrophy, cataract and misalignment of the eyes). Dr. Jaafar was kind enough to provide this top 5 list, so that parents know what to look for if they suspect their child may have a visual problem.
TOP 5 Signs of Visual Problems in Children
1. Bumping into things or acting clumsy.
2. Always sitting close to the TV or holding books and I-pads too close to their face.
3. Crossed or wandering eyes.
4. Tilting or turning the head, or assuming a chin-up or chin-down posture (ocular torticollis).
5. Disliking having one eye covered but not the other (may indicate a “lazy eye” – amblyopia).
If your child is showing these signs, was born prematurely, has multiple health problems or a family history of eye diseases in childhood, it is a good idea to consult an eye doctor who is experienced in treating infants/children. Please remember, a TOP 5 list is not all inclusive. If you have questions about your child’s vision, go and see a specialist or ask your Pediatrician. Dr. Jaafar suggests that you could find a qualified doctor in your area by going to the following website: https://aaosso.aapos.org/ebusaapos/FindanEyeMD
"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.
Artwork: Here is a Sign by Forrest Best, 1970
How do you know if you or someone you love, such as an elderly parent, may need balance therapy? Below are 5 signs that balance therapy could be right for you. If it is, contact a physical therapist that specializes in balance therapy so that you can improve your health and decrease your risk of falling.
The bottom line is we want you around for a long time! A fall could cause an injury that would jeopardize your livelihood, and your functional independence. For those older folks, it could mean the difference between living independently on your own, or having to go to a nursing home- so take it seriously!
5 signs that a Person needs Balance Therapy:
1. Any fall that created a serious injury in the last 12 months.
2. Two or more falls without injury in the last 12 months.
3. Needing more that 1 attempt to rise from a chair.
4. Walking touching the walls & furniture for support.
5. Having a fear of falling is a significant risk factor for falls.
If you answered “yes” to any of these 5 signs, don’t wait to do something about it. Find a qualified vestibular specialist who can help you improve your balance. You can use these web sites to look for vestibular specialists in your area.
1. The Vestibular Disorders Association website
2. The American Physical Therapy Association Neurology section has a Vestibular Rehabilitation Section where you can search for vestibular specialists state by state.
Be empowered. Balance therapy CAN change your life!
Who can forget the commercial when fall alert buttons first came out,where the individual is lying on the floor and yells out “HELP! HELP! I’ve fallen and I can’t get up!” I do not want to make light of the situation, because being in such a vulnerable situation is awful. I know, because I once dislocated my kneecap when playing with my dog in the front yard. I didn’t have my cell phone, and I was on the only one home at the time, and I had to lie there for a half hour before some stranger walked by who could get me the help I needed.
Many times when an older person lives alone and has started to have some falls, the kids who lives out of state starts trying to get their mom or dad to get a fall alert button. It is hopefully a back up plan that they will never need to use.
When the emergency call buttons first came out, they worked through your phone. Back in the day, this was what we now call your “land line”. It meant that you had to be within 200-300 feet of the phone in order for it to work. You can still get this kind today, but I don’t recommend them. When one patient of mine from Sarasota, Florida, fell in her yard when gardening, she was too far away from the phone for it to work.
These days, there are fall alert devices that work via GPS. That means you could be anywhere, push the button, and they would find you! One of my “snow bird” patients who went back up to Maine for the summer pushed the button just to see if they would answer, and they did!
Another one of my patients fell when stepping off the curb on the way home from the theatre one night. He is a huge 6-foot tall 250 lb man, with an itsy, bitsy wife, and she was not able to help him up. All she had to do was push the button, and the paramedics knew where to find him. She didn’t have to figure out what address she was at, fiddle in her purse to find her cell phone, or risk hurting herself trying to help him up. She just had to push the button that was hanging around his neck.
So the gist of the message is that even fall alert devices are using GPS technology, and you might as well take advantage of good technology that could really save your life. The best way to compare the different plans is to do a Google search for “GPS Fall Alert Buttons”, and check out what comes up.
Painting: The Fall of Icarus- Marc Chagall, 1975.
This is the time of year when one can reflect on our lives and the things we want to improve on for the upcoming year. Why not make it your goal to improve your balance? One way to decide if your balance needs improving is by having your balance tested. Balance testing can be high tech, or low tech. The low tech testing is something that you could do at home, without fancy equipment, and it is based on a physical performance test. In other words, we ask a patient to perform a balance skill, and then see if they can do it or not. A person with good balance, and no history of inner ear pathology or neurological problems should be able to do the test.
One such test is called the Rhomberg Test. When I do this test with my balance therapy patients in Sarasota, Florida, I have the patient stand in a corner about 2 inches away from the wall, with a chair in front for safety. Then, I am standing by just in case. If you decide to try this test, have a friend or family member stand by to make sure you do not fall and get hurt.
The test is this- the person must stand with their feet together, with no space in between the feet. (If you are knock-kneed and cannot get your feet together, then put your knees as close together as you can). Next, you stand as still as you can, trying not to sway. The goal is to be able to do this for 30 seconds without falling, needing to open your eyes, take a step, or touch the wall or chair for support.
When standing with the eyes open, the person is using their vision, their inner ear system, and their somatosensory system to help them balance. Somatosensation is the sensation that allows your joints and muscles to send information to the brain to tell you if you are steady, or swaying. If a person cannot perform this test for 30 seconds, then they are at high risk for falling.
The second part of the Rhomberg Test is performed with the eyes closed. Again, the goal is to stand for 30 seconds. When the eyes are closed, the brain must rely on information from the inner ear, and feeling the ground in order to maintain balance. If a person falls in this test, they are reliant on their vision to maintain balance. This means that they would be at increased risk of falling if walking in a darkened setting, or on a complaint surface such as grass in the back yard when the sun is setting, for example.
How did you do with the testing? If the answer is “not so good”, make it your 2015 New Year’s Resolution to do something about it before you fall and get hurt. What should you do? Talk to your doctor about your balance, and find a physical therapist who specializes in treating inner ear balance problems. You could find a balance specialist in your area if you go to the Vestibular Disorders Association website. They allow you to search for a physical therapist in your area by entering your zip code. I believe you can achieve the goal of better balance in 2015! Happy New Year!
Painting: Planting the New Year’s Pine by Keisai Eisen, 1830s.
Old woman seen from behind, sketch and study in pencil by Van Gogh, 1882
Most people with balance problems want to avoid walking with a cane or rolling walker unless absolutely necessary. Even when necessary, many people refuse to use a cane because they are too proud or embarrassed for others to see them walking with one. The thing is, if a person is at risk for falling, a fall can cause serious injuries, and even death.
The Center for Disease Control estimates that one out of three adults age 65 and older falls each year, but less than half talk to their healthcare providers about it. And among older adults (those 65 or older), falls are the leading cause of injury death! This is a serious issue...
So I tell my clients, “You need, what you need, when you need it”. The purpose of the balance exercises is for the person to improve to the point where they don’t need the cane or walker. But until that time comes, the last thing a person needs is to add to their problems by falling and getting hurt... When my balance patients in Sarasota understand that the cane or walker isn’t meant to be a “forever thing”, they are usually willing to use it temporarily until their condition improves.
If you or someone you love falls into this category, I encourage you to use a cane or walker, and to seek out a physical therapist who specializes in balance disorders, so that you can address your balance problem and regain your safe and independent lifestyle again.
Generally speaking, balance therapy is a type of physical therapy that is performed to help a person with a balance problem. Different therapists may approach treating a balance problem based on their own background and expertise. For example, a therapist who comes from an orthopedic background and loves treating mainly people with joint and muscle problems, will tend to do what makes their other orthopedic patients better. That is, put the patient on a bike, and give them leg exercises. If the patient’s balance problem is caused by muscle weakness, they will improve.
However, if the problem is not weakness, they will not improve. It is not unusual for me to get a patient for balance therapy in my Sarasota office, and for the patient to say straight out that they don’t think I will be able to help them, because they have had a lot of physical therapy and did not get any better. The next question I ask is, “Well, tell me what you were doing?”, and 9 times out of 10 they will say sitting on a stationary bike and using machines to strengthen their legs. I usually tell that person, well, good, I am glad to hear that the exercises I have in mind you haven’t done before, so there is still a chance that you will get better.
What are these exercises? They include inner ear balance exercises. Our inner ear system is the major organ in our body that powers our balance. It tells our brain when our head or body is moving, so that the brain can tell the joints and muscles how to move to maintain balance. A classic inner ear exercise is to improve the vestibular-ocular reflex, or VOR. This is a reflex between the ears, the eyes, and the brain. Just to explain it a bit… If a person looks at a target and moves their head side to side, they are stimulating their VOR. The inner ear sends messages to the brain to tell the brain how far or how fast the person is turning their head, and the brain uses this information to coordinate the person’s eyes on the target while the head is turning. If the VOR was not working properly, then when the person turns their head, instead of keeping their eyes on the target, they would find that they are looking in the direction of the head turn. If the person’s VOR is not working properly, the patient could have complaints of dizziness, and be unsteady when walking, especially if turning their head to look at something to the side. Another exercises involves keeping the head still, but watching a moving target. If you would like to see this exercise demonstrated, click here to check out the segment on falls and balance that I recently did for ABC News 7.
According to the CDC, one out of three adults age 65 or older suffer falls each year.
These are only a couple of examples of exercises that improve one’s balance. I know it may sound complicated, but it makes perfect sense. If you have a good balance physical therapist, they should know these exercises and include it in your program to make your ability to use inner ear information stronger. This is just one example of how working with a qualified balance and vestibular therapist, and not just someone who went to PT school, can make all the difference.
Related Article: Trips and falls cause millions of injuries a year