loss of balance Archives - Mackarey & Mackarey PT

Several years ago, while hiking to the bottom of the Grand Canyon with my family, my wife Esther developed “canyon knee,” also known as “hiker’s knee” or in medical terms, “patellar tendonitis.” Regardless of the term, the end result was that she had severe pain in the tendon below her knee cap and was unable to walk up the trail to get out of the canyon. In addition to ice, rest, bracing, and non-steroidal anti inflammatory medications, the National Park Ranger insisted that she use two trekking poles on her ascent to the rim.

Prior to that experience, I always thought that “walking, hiking sticks or trekking poles” were for show or those in need of a walking aide. Well, I could not have been more incorrect. Needless to say, Esther made it out of the canyon safely and, with the use of our life saving trekking poles; we have lived “happily ever after!” Now, 15 years later, I rarely walk more than 5 miles without my poles.

As a result of this experience, I have been recommending walking or trekking poles to my patients. These poles are an essential part of hiking or distance walking gear, for the novice and expert alike. Specifically, for those over 50 who have degenerative arthritis and pain in their lower back, hips, knees, ankles or feet, these simple devices have been shown to improve the efficiency of the exercise and lessen the impact on the spine and lower extremities. Additionally, using poles reduces the likelihood of ankle sprains and falls during walking. Trekking poles are also a safe option for those with compromised balance. If you want to walk distances for exercise and need a little stability but don’t want the stigma of a cane, trekking poles are for you.

History of the Hiking Stick:

Early explorers, Europeans and Native Americans have been using walking sticks for centuries. More recently, in the 1968 classic hiker’s bible, “The Complete Walker,” Colin Fletcher praised his “walking staff” for its multipurpose use: for balance and assistance with walking and climbing, protection from rattlesnakes, and for use as a fishing rod. Today, these sticks are now versatile poles made from light-weight materials.

Trekking Pole Features:

Trekking poles are made of light-weight aluminum and vary in cost and quality. But, like most things, “you get what you pay for!” These hollow tubes can telescope to fit any person and collapse to pack in luggage for travel. Better poles offer multiple removable tips for various uses, conditions and terrains. For example, abasket to prevent sinking too deeply in snow, mud or sand; a blunt rubber tip for hard surfaces like asphalt or concrete, or the pointed metal tip to grip ice or hard dirt/gravel. Better quality poles offer an ergonomic hand grip and strap and a spring system to absorb shock through your hands, wrists and arms upon impact.

The poles should be properly adjusted to fit each individual. When your hand is griping the handle the elbow should be at a 90 degree angle. Proper use is simple; just walk with a normal gait pattern of opposite arm and leg swing. For example, left leg and right arm/pole swings forward to plant while the left arm/pole remain behind with the right leg .

This pattern is reciprocated with as normal gait advances (opposite arm and leg). I have been very pleased with my moderately priced poles (Cascade Mountain Tech from Dick’s Sporting Goods ($34.99 per pole). Prices range from $19.99 to 79.95 per pole. dickssportinggoods.com; montem.com; leki.com; rei.com. However, if you travel frequently to hike the State and National Parks, you may want to purchase more expensive poles that collapse and retighten more efficiently. (montem.com; leki.com;)

Montem Trekking Poles - with close-up of easy adjustable locking clasp.

Research:

There are numerous studies to support the use of trekking poles, especially research that supports their use for health and safety. One study compared hikers in 3 different conditions; no backpack, a pack with 15% body weight and a pack with 30% body weight. Biomechanical analysis was performed blindly on the three groups and a significant reduction in forces on lower extremity joints (hip, knee, and ankle) was noted for all three groups when using poles compared to those not using poles.

Another study confirmed that trekking poles reduced the incidence of ankle fractures through improved balance and stability. Additional studies support the theory that trekking poles reduce exercise induced muscle soreness from hiking or walking steep terrain and another study found that while less energy is expended in the lower body muscles using poles, increase energy is used in the upper body; therefore, the net caloric expenditure is equal as it is simply transferred from the legs to the arms.

Reasons to Use Trekking Poles:

Reduced Stress on Lower Back, Hips, Knees, Ankles and Feet – Biomechanical studies confirm that using trekking poles creates less stress on the lower back and joints of the lower body. Those with a history of degenerative arthritis and pain in these areas are wise to consider this when planning to hike or walk distances for exercise.
Improved Stability and Balance/Less Injury – Studies have found that those using trekking poles were less likely to suffer sprains, strains and even fractures of the lower body, especially the ankle, due in great part to the improved balance and stability. This benefit is found not only on uneven terrain, but also for those walking distances and may have age-related balance issues.
Upper Body Workout – One comment I have heard from those questioning the value of trekking poles is that they do not want to make their walking/hiking exercise too easy because they desire a “good workout.” Studies show that the caloric expenditure is equal to exercise without using poles as the energy is simply transferred from the legs to the arms.
Improve Walking Posture and Stride - It is common when walking distances, especially if carrying a backpack, to lean your trunk forward. Using poles has been found to promote a more upright posture while walking.
Less Perception of Cardiovascular Exertion - While cardiovascular demands increased with pole walking, subjects reported less exertion when using poles.
Reduced Exercise Induced Muscle Soreness - Studies testing the blood for chemicals associated with muscle damage found less exercise induced muscle soreness/tissue damage and delayed onset muscle soreness among pole users. This was reported to be critical in walkers and hikers who participated in their activities several days in a row to complete the task such as hiking in and out of a canyon.

In conclusion, it is important to remember that trekking poles for hiking or distance walking are much more than a style statement. They are proven to be an invaluable tool for health, safety and wellness by reducing lower extremity joint stress, improving stability and balance, and enhancing efficiency for muscle recovery.

Sources: Medicine and Science in Sports and Exercise. The Complete Walker, by Colin Fletcher

Model: Andrea Molitoris, PT, DPT at Mackarey Physical Therapy

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This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy in Scranton and Clarks Summit. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine. For all of Dr. Mackarey's articles, visit our exercise forum!

2^nd of 3 Columns on Balance Disorders and Falls Prevention

Last week we discussed the causes of balance loss. Today, we will discuss treatment for this problem. Two primary treatments are medication and vestibular rehabilitation.

1. Medication

Medication for dizziness and loss of balance requires a visit to your family doctor. In a more involved case, your family physician may refer you to a specialist such as an ear, nose and throat physician or neurologist. There are many medications available for loss of balance. While this can be complicated, the specialist will determine the most appropriate one for your balance disorder.

2. Vestibular Rehabilitation

Vestibular rehabilitation for dizziness and loss of balance is a great adjunct to medication to manage your balance disorder. It is a comprehensive program that addresses a wide range of problems that may cause imbalance such as: addressing the inability to tolerate motion, visual changes, providing balance rehabilitation, instruction in repositioning techniques for BPPV (benign paroxysmal positional vertigo), correcting postural dysfunctions, muscle weakness, joint stiffness, offering education for prevention, maintenance and self care after discharge. Through experience and motion, vestibular rehabilitation allows: formation of internal models (one learns what to expect from ones actions), learning of limits (learning what is safe and what is not) and sensory weighting (one sense, either vision, vestibular or somatosensory is selected in favor of another in maintaining balance).

In some minor cases, vestibular rehabilitation may be performed at home. However, more serious cases may require an evaluation by a physician specializing in the dizzy patient such as an ear, nose and throat physician or neurologist. These specialists will determine the nature of your problem and may enroll you in a more structured program under the direction of a physical therapist. Vestibular rehabilitation addresses not only vertigo (i.e. dizziness) but also balance problems.

Benign Paroxysmal Positional Vertigo (BBPV)

Benign paroxysmal positional vertigo (BPPV) and vestibular hypofunction (e.g. unilateral and bilateral vestibular loss) are two causes of vertigo that can be addressed by a vestibular rehabilitation. Your physical therapist will tailor a program designed to address your specific vestibular disorder (i.e. BPPV or hypofunction).

If you have been diagnosed with BPPV, your therapist may take you through an Epley maneuver. In BPPV, particles in the inner ear become displaced and get lodged in an area that produces vertigo. Vertigo is experienced with tilting head, looking up/down and rolling over in bed. The causes include: infection, head trauma and degeneration. During the Epley maneuver the patient is guided through positional changes which clear these particles from the symptomatic part of the ear.

If you have been diagnosed with either unilateral or bilateral vestibular hypofunction, your therapist will most likely design a program to “retrain” your vestibular system with special exercises, including:

Gaze Stability Exercises for unilateral hypofunction involve staring with eyes fixated on a stationary object held at eye level. The head is rotated from left to right or up and down while gaze is maintained. Once mastered, your therapist will increase the challenge by either changing your position (e.g. from sitting to standing).
Habituation Exercises are designed to “desensitize” your brain to the sensation of vertigo. Our sensory system is designed to protect our bodies from harmful stimuli. Many harmful stimuli produce painful sensations. However, vertigo (i.e. dizziness) is not painful. Therefore, if we expose ourselves to movements that produce dizziness, our bodies will eventually “get used to the sensation” and start tuning it out until the movement no longer produces “dizziness”.

If you have a vestibular problem that primarily manifests as loss of balance, exercises to stimulate your balance responses, strengthen your legs, and enhance your joint position sense may be helpful. These exercises encourage reliance on vestibular and/or visual input. The exercises are performed on unstable surfaces (i.e. tilt boards, balance beams, and foam) and include a variety of tasks from simple standing to more complex arm and leg movements requiring coordination.

Other Vestibular Treatment Options:

In addition to the above mentioned treatments, Posturography and Virtual Reality Training are computerized programs that may be used by your therapist to address your vestibular and/or balance problem. Also, Recreational Activities that involve using your eyes while head and body is in motion (i.e. dancing, golfing, tennis, walking while looking from side to side) are shown to be helpful in stimulating balance and vestibular responses. Furthermore, you may consider Alternative Balance Activities (i.e. Yoga, Tai Chi, Pilates) which incorporate slow gentle movements to improve strength, balance and posture as well as relaxation techniques for the anxiety that accompanies dizziness/off-balance.

Whatever you do, just DO NOT give into your dizziness. People that just “give up” become sedentary. A sedentary lifestyle further denies your body the necessary stimuli to challenge your vestibular system and make it stronger. Eventually, these people end up in a vicious cycle because the more they sit the dizzier and more off balance they get which only makes them sit more!

Remember, one fall increases your risk of another fall. It is imperative to determine what caused your fall and take action! Ask your physician or physical therapist to assess your fall risk.

Contributor: Janet M. Caputo, PT, DPT, OCS

Medical Reviewer: Mark Frattali, MD, ENT: Otolaryngology /Head Neck Surgery at Lehigh Valley Health Network

EVERY MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” via Blog: Next Monday Part III on Balance Disorders and Falls Prevention

EVERY SUNDAY in "The Sunday Times" - Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in hard copy

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate clinical professor of medicine at GCSOM.

For all of Dr. Mackarey's articles, check out our exercise forum!

TAKE THE TEST!

Loss of balance causes falls. Falls are a leading cause of injury and death. Thirty percent of women and thirteen percent of men over the age of sixty-five will fall. Twenty to thirty percent of these individuals suffer moderate to severe injuries. Preventing falls is not an easy task. A good understanding of the causes of loss of balance and knowledge of a few fall prevention suggestions can enhance your balance and reduce your risk of a fall.

The Falls Risk Self-Assessment below allows an individual to determine their risk of falling AND take the appropriate steps for prevention and treatment. The next three weeks will be dedicated to this topic to educate and inform readers and their families to make good decisions.

The Falls Risk Assessment is from the Centers for Disease Control (CDC).

WHAT IS YOUR RISK OF FALLING?

I HAVE FALLEN IN THE PAST YEAR. YES (2) NO (0) People who have fallen once are likely to fall again.

I USE OR HAVE BEEN ADVISED TO USE A CANE OR WALKER TO GET AROUND SAFELY. YES (2) NO (0) People who have been advised to use a cane or a walker may already be more likely to fall.

SOMETIMES I FEEL UNSTEADY WHEN I AM WALKING. YES (1) NO (0) Unsteadiness or needing support while walking are signs of poor balance.

I STEADY MYSELF BY HOLDING ONTO FURNITURE WHEN WALKING AT HOME. YES (1) NO (0) This is also a sign of poor balance.

I AM WORRIED ABOUT FALLING. YES (1) NO (0) People who are worried about falling are more likely to fall.

I NEED TO PUSH WITH MY HANDS TO STAND UP FROM A CHAIR. YES (1) NO (0) This is a sign of weak leg muscles, a major reason for falling.

I HAVE SOME TROUBLE STEPPING UP ONTO A CURB. YES (1) NO (0) This is also a sign of weak leg muscles.

I OFTEN HAVE TO RUSH TO THE TOILET. YES (1) NO (0) Rushing to the bathroom, especially at night, increases your chance of falling.

I HAVE LOST SOME FEELING IN MY FEET. YES (1) NO (0) Numbness in your feet can cause stumbles and lead to falls.

I TAKE MEDICINE THAT SOMETIMES MAKES ME FEEL LIGHT-HEADED OR MORE TIRED THAN USUAL. YES (1) NO (0) Side effects from medicines can sometimes increase your chance of falling.

I TAKE MEDICINE TO HELP ME SLEEP OR IMPROVE MY MOOD. YES (1) NO (0) These medicines can sometimes increase your chance of falling.

I OFTEN FEEL SAD OR DEPRESSED. YES (1) NO (0) Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls.

SCORE YOUR RISK.

Add up the number of points for each YES answer. If you have scored 4 or more points you may be at risk for falling. Accordingly, 0-1 = Low Risk; 1-2 = Moderate Risk; 3-4 = At Risk; 4-5 = High Risk; 5-6 = Urgent; > 6 = Severe

Low Moderate At Risk High Risk Urgent Severe

0 1 2 3 4 5 6 7 8

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” Next Monday Part I of III on Balance Disorders and Falls Prevention

Read all of Dr. Mackarey's articles at https://mackareyphysicaltherapy.com/forum/

3^rd of 3 Columns on Balance Disorders and Falls Prevention

Preventing a fall can not only save your independence but also your life! Preventing injuries from falls reduces the need for nursing home placement. Injuries from falls are the seventh leading cause of death in people over the age of sixty-five.

The following suggestions will assist you in minimizing your risk of a fall:

Diet & Hydration: Proper nutrition and hydration provides adequate amounts of vitamins and minerals to maintain energy levels and prevent drowsiness. Adequate hydration is also important. Treat dehydration from fever, diarrhea and vomiting by drinking plenty of fluids. You may need IV fluids administered in hospital.
Exercise: Exercise and activity improves strength, flexibility and balance.
Medication: Consult a pharmacist or physician regarding medications that can cause: drowsiness, dizziness, lightheadedness, faintness, fatigue, tiredness, unsteadiness, blurred vision, double vision, confusion, or otherwise affect alertness, balance or coordination.
Positional Changes: Avoid sudden drops in blood pressure by avoid sudden changes in posture and position, standing up slowly, sitting for a few minutes and tapping your toes before getting out of bed and raise head of bed with a wedge pillow.
Alcohol: Be cautious with alcohol since it interferes with alertness, balance, coordination and reflexes.
Illness: Treat respiratory infections such as ear infections, colds, flu, sinus congestion to prevent labyrinthitis and Meniere’s disease.
Frequent Urination: Be cautious with urgency, especially at night. Consider bedside commode and a grab bar by toilet. Turn lights on and put on eyeglasses to supplement vision. Night lights are recommended. A pendant alarm may be beneficial.
Vision: Check eyesight and hearing regularly. Poor eyesight makes it difficult to see potential hazards. Update old eyeglasses. Inner ear problems can affect balance. Adequate lighting is paramount. Light switches should be within reach without getting out of bed and on both ends of hallway. Nightlights in bedroom, bathroom and hallway are recommended. Keep a flashlight handy. Turn lights on when entering house and at night. Use light paint and wallpaper to reflect more light. Use 100 watt bulbs for an adequate amount of light.
Assistance Devices: Use assistive devices when negotiating uneven terrain or when you feel weak or tired. To avoid falls in the bathroom install grab bars in the shower, tub, and toilet areas. Use bathmats with suction cups or nonslip adhesive strips in tub/shower. Consider a shower stool or bench and an elevated toilet seat.
Good Footing: Proper footwear with a flat sole, wide base and nonslip grips are important. Footwear should be tied securely and fit snugly. Do not walk in stocking feet
Remove Hazards: Inspect your floors for hazards! Remove rugs and runners that slip or attach nonslip backing. Tack loose rugs. Glue vinyl flooring. Keep pathways free of electrical/telephone cords. Remove wax from floors. Mops up spills promptly.
Safety on Stairs: Install secure handrails on both sides. Improve lighting. Ensure carpeting on stairs is firmly attached. Highlight with tape or paint edges of steps especially if narrow or higher/lower than the rest. Paint outdoor steps with a mixture of paint and sand for better traction. If carrying item up or down steps, use handrail.
Walkways: Sidewalks and walkways should be clear, well lit and free of snow and ice. Salt or sand if slippery. Repair uneven paving.
Eliminate clutter: Do not store items on steps. Rearrange furniture to move around easier. Watch out for pets. Avoid stepping over pets.
Store Items Within Reach: Limit reaching by storing frequently used items where they can be reached easily. If reaching is required, use a stepstool with high, sturdy handrails. Repair or discard wobbly stools. Do not use a chair to reach for items.

Following these helpful hints will keep you safe by preventing a loss of balance and a potential fall!

Medical Reviewers: Mark Frattali, MD, ENT at Delta Medix, Division Chairman Otolaryngology – Head Neck Surgery at Commonwealth Health Regional Hospital

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!”

Read all of Dr. Mackarey's articles at https://mackareyphysicaltherapy.com/forum/

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at GCSOM.

1^st of 3 Columns on Balance Disorders and Falls Prevention

Northeastern Pennsylvania is home to a large elderly population and many of the medical problems we expect to see are age related. Dedicated medical practitioners are in constant search for new knowledge and information to prevent or delay many age related problems. One of the most devastating problems associated with aging is falling. It will be the purpose of this series of three columns to educate readers about the risks and causes of falling and the prevention and treatment of balance disorders.

The causes of loss of balance which may lead to a fall are divided into three categories: age related changes, medical conditions and medications.

Age Related Changes affecting the sensory system, the musculoskeletal system as well as psychological behavior can negatively impact balance causing a fall:

Sensory factors that impact balance are maintained through combined sensory input from the eyes, the joints and the inner ear. Sensory deprivation decreases balance and increases fall risk. Visual changes with aging include a decrease in visual acuity, visual field and depth perception. Decreased joint position sense, (joint proprioception) especially in the legs, leads to increased sway and reliance on vision, which is already impaired. Decreased input from the inner ear (vestibular system) negatively impacts eye stability and head orientation.
Musculoskeletal factors with aging can cause unsteadiness during walking: deceased leg muscle strength especially quadriceps, arthritis in low back/hips/knees resulting in leg pain, stooped posture and leg length discrepancies.
Psychological factors can also interfere with balance. Fear of falling increases with age. Denial of frailty leads to poor judgment when performing certain tasks. Anxiety and depression not only decreases attention and awareness of environment but may also cause poor sleep leading to drowsiness during the day.

Medical Conditions can also cause loss of balance increasing the risk of a fall:

Cardiovascular conditions may cause loss of balance due to dizziness or lightheadedness caused by a sudden change in blood pressure. These include: abnormal heart rhythm, heart attack and heart failure. Orthostatic hypotension is an excessive fall in blood pressure on assuming the upright position (quickly standing up after lying down). Syncope (fainting) is a sudden brief loss of consciousness due to decreased blood flow to the brain. Vertebral artery insufficiency occurs from leaning head back too far compromising arterial blood flow to the brain causing dizziness.
Neurologic conditions can negatively affect sensory input (visual, vestibular and joint proprioception) and motor (muscular) responses and result in loss of balance. These include: multiple sclerosis, epilepsy (seizures), brain tumor, stroke, Parkinson’s disease, peripheral neuropathy, cerebellar degeneration and head trauma.
Cognitive conditions contribute to loss of balance because of poor judgment and behavioral problems (e.g. dementia and Alzheimer’s disease).
Vestibular conditions cause vertigo (sensation that the room is spinning or moving) resulting in loss of balance. Benign Paroxysmal Positional Vertigo (BPPV) is caused by a change in the position of the head when debris is lodged in a symptomatic part of the inner ear. Labyrinthitis is a viral infection of the inner ear following a cold or flu. Meniere’s disease is a common inner ear problem resulting in vertigo and ringing in the ears.
Genitourinary conditions can contribute to loss of balance. For example, individuals with bladder control problems (incontinence) use poor judgment by moving quickly, especially at night, to prevent an “accident”.
Endocrine conditions can produce dizziness causing loss of balance. Hypoglycemia (low blood sugar associated with diabetes) causes dizziness.

Gastrointestinal conditions may lead to loss of balance. During defecation syncope, fainting is caused by a decrease in arterial pressure when bearing down to assist a bowel movement. Any condition resulting in dehydration (diarrhea/vomiting), decreases blood volume which may cause lightheadedness and loss of balance

Medications can also negatively effect balance and increase the risk of falls. Interactions between medications as well as the side effects of certain medications can cause dizziness or drowsiness resulting in loss of balance. Theses medications include: tranquilizers, sedatives, anti-depressants, alcohol, diuretics, blood pressure medications, cardiac medications, laxatives and pain killers.

In conclusion, determining who is at risk for a fall is a complex task since many factors including age, disease and medication can affect the outcome. Early intervention to prevent a fall can avoid many costly consequences.

Medical Reviewer: Mark Frattali, MD, ENT at Delta Medix, Division Chairman Otolaryngology – Head Neck Surgery at Commonwealth Health Regional Hospital

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” Next Monday Part II on Balance Disorders and Falls Prevention

Read all of Dr. Mackarey's Articles at: https://mackareyphysicaltherapy.com/forum/