January Meeting Notes–Joy Mclaughlin, PT–All About Balance

We welcomed physical therapist Joy Mclaughlin as our guest speaker to our January 15 meeting (delayed a week due to snow). In addition to being LSVT-BIG therapy certified, we learned from the introduction prepared by one of our members that Joy is also hula hoop certified!

Joy began her talk by defining BALANCE, per Webster’s Dictionary, as an even distribution of weight enabling someone or something to remain upright and steady. Balance requires a support base: your feet when you are standing; your pelvis and feet when you are sitting. Balance also involves a center of gravity or mass, generally around the level of your belly button, which moves as you move.

To practice and be aware of balance when standing, Joy said to think about your feet: Are they far apart or close together? Are they flat on the ground? Are you leaning toward the front (on your toes) or the back (your heels) or somewhere in the middle of them? Are your toes flat? If they are not or your feet are clawing, Joy suggests trying to relax and open the toes to get better contact with the floor or, when sitting, flicking the toes to help relax them. You should also think about your belly button, which should stay within the center of your support base for you to remain balanced. If your hips are leaning forward or backward, you could lose your balance and fall, especially when reaching overhead.

How Balance Works:
In order for balance to happen to begin with, information is fed to your brain from several body systems:
     1.  Eyes: provide visual information about the environment around you.
     2.  Feet: provide tactile sensation information about the surface you’re standing on and joint perception about the angle that your body is standing.
     3.  Inner Ear: provides vestibular information.
Your brain correlates all this information coming in and sends messages to your muscles to react appropriately to maintain stability. If the brain perceives you’re leaning too far forward, for example, it tells you to step forward to prevent a fall.

Balance reactions are automatic movement patterns that occur when balance is disturbed and are faster responses than movements under voluntary control. Depending on the size of the disturbance, the body has varying strategies to right itself:
     1.  Ankle strategies for smaller, slower disturbances.
     2.  Hip strategies for larger, more rapid disturbances–your hips must move over your support base or you will fall backward.
     3.  Stepping strategies for even larger, faster disturbances (that can’t be corrected by the angle of hips)–you take a step backward, sidewise, or to the front.

These automatic balancing strategies are the first things Joy checks when evaluating someone with balance issues. She’ll ask about any falls in the last six months and, if so, how many? If there have been multiple falls, were there similar circumstances? Were you dizzy when you fell? Were you turning? Were you in a crowded environment and your brain overwhelmed? Near falls are evaluated the same way, as they are a loss of balance. What was the situation and what was going on around you when you lost your balance or nearly fell? 

Problems with DIZZINESS that can Affect Balance:
Dizziness can be a room-spinning sensation, a lightheadedness, or a feeling of just being off balance. Two potential causes are low blood sugar low or dehydration, both fairly quickly corrected by eating or hydrating. Other causes can be anemia, an ear infection, or medication. Blood pressure medications, sedatives, mental health medications, certain antibiotics, anti-seizure medications, and Parkinson’s medications (levodopa and dopamine agonists) can all cause dizziness and vertigo. So can DBS. Stress and anxiety can also make you dizzy as the areas of the brain that cause stress/anxiety interact with the areas responsible for dizziness.

Vertigo, that sensation of the room spinning, can be caused when the microscopic crystals that normally float in the fluid in the three canals of the inner ear get stuck–after scuba diving or an airplane ride, for example–or as we get older. A vestibular therapist can determine which canal is affected and show you exercises that can help. There are two at Inova Fair Oaks where Joy works. They can also determine whether or not it’s an eye issue.

Eye movement and gaze stability issues can also cause a motion-sickness-type of dizzy feeling. Most motion sickness is visual. With eye movement issues, you may see things on the periphery but not in front of you. With gaze stability issues, your eyes can’t focus and if you turn your head while walking, you can get dizzy or visual blurring.

Circulation issues can cause dizziness and could be orthostatic hypotension (PDF) if your dizziness gets worse when you stand up. Everyone’s blood pressure changes when they stand due to activation of the flight-or-fight response in the parasympathetic nervous system. But in people with Parkinson’s, this response is slowed down and blood doesn’t rush back into their limbs when they stand. To determine if this is the cause of your dizziness, Joy advises taking your blood pressure while sitting, then standing and staying still for four minutes and taking it again to see if it’s lower. Joy estimates that 15% to 50% of people with Parkinson’s develop orthostatic hypotension. You can lessen the associated dizziness by:
1.  Moving your legs when you stand up–squeeze your thighs, wiggle your toes, bend your knees, any movement that gets your blood moving (being sure to hold onto something if you need to for balance).
2.  Eating salty snacks.
3.  Drinking lots of water.
4.  Exercising.
5.  Compression hose can help; Joy recommends thigh-high hose.

GOOD POSTURE IS ESSENTIAL FOR BALANCE!
      1.  Are your feet sitting flat on the ground (when standing and sitting)?
     2.  Is your chair a good height for you (so that you feet can sit flat on the ground)?
     3.  Are hips and knees at a 90 degree angle (when sitting)?
     4.  Are you tilted to one side? Parkinson’s-related shifts in muscle tone can cause an unequal pull on your spinal column.

      Balance starts with the pelvis. Pelvic position is important.
  JoyStanding   1.  When standing, you should be slightly in front of your pelvic bones, which puts a slight curve in your lower back. Ankles over hips. Lift your chest up, like you’re showing off a gorgeous necklace, and hold your head back in a straight line with the back. Stand up tall to stay on your support base.
     2.  Make an effort to sit taller. If you can’t sit tall for long, you can use a rolled up towel for support wherever you need it.
     3.  Work on flexibility. Tight and rigid muscles affect posture and movement. You need flexibility for balance. Exercise to maintain shoulder, trunk, pelvic, hip and ankle flexibility.
     4.  Work on core strength. The more core strength in your hips, back, shoulders and abdominals, the better your balance.
     5.  Interrupt whatever you are doing several times daily to remind yourself about posture. Doing so with enough duration, repetition, effort, intensity, and frequency will improve your brain though neuroplasticity!
     6.  Use good conscious control to change position. When distracted, as when you are socializing and talking to someone, or otherwise thinking about something else while moving, you might lose your balance. Amazon sells a patch that affixes to the back of your neck and buzzes when you are not standing or sitting upright: Upright GO Original Posture Trainer and Upright GO 2 Posture Trainer. 

Other Things that can Affect Balance:
Diminished hip strategies (to catch yourself when balance is lost) affect balance reaction time. Neurologists check to see how long it takes you to catch yourself when they pull you backward. They are also checking the size of your steps.

Lack of big movements seen in small shuffling steps, trunk not rotating, and lack of arm swing as you walk. Oftentimes, you don’t realize you are taking small steps because your brain has reset and these small movements feel ‘normal’. BIG therapy can help.
Practice standing tall and taking big steps in all directions (backward, forward, and to each side). When going from sitting to standing, you want to be like an airplane taking off, moving up and forward, and not like a helicopter. Parkinson’s is not a strength but a sensory issue.

Closed or open environment:
1.  Clutter and crowds can affect the brain’s processing and your responses.
2.  Trouble in low lighting–as a population, we are visually reliant for our balance.
3.  When walking through small, narrow, or crowded spaces, many people take smaller steps.
4.  Turning while walking is a big problem for many people with Parkinson’s.
5.  Walking while talking and especially when turning their head throws off many people’s balance. Doing two things at once divides your attention between the tasks of walking and talking, or turning, talking, and thinking, causing movement to fall apart.
6.  Anxiety can cause people to unconsciously hold their breath and become dizzy.

Dyskinesia, although preferable to many than the inability to move, can impact balance.

Freezing of movement can trigger balance issues. Freezing usually occurs during transition movements–when you first stand up, begin to walk across a threshold, enter or exit an elevator, or begin to turn–especially during off times. Joy suggests when you feel frozen, to stop whatever you are doing and give yourself a different cue (like when you can’t think of a word). Freezing happens when there’s a lot of stimulus or you are over-trying. When freezing does occur, stop, stand tall, step big. If your right side doesn’t work, try the left. Shift your hips or squat to give your brain something else to think about.

Physical Therapy can’t fix a medication issue (if that’s the source of your imbalance), but it can work on posture, short steps, and small movements, as well as individual strategies for freezing and on/off times.

BIG Therapy: by increasing the size of movements through practice and repetition, you will automatically increase your speed. Joy recommends doing BIG exercises during on times, but picking one or two to do during off times to develop strategies and practice working through with big steps.

5 Exercises (PDF) for flexibility and posture (attached)
Joy suggests exercising on all sorts of floor surfaces to work on balance. Remember to move your eyes as your turn your head and look in that direction. Hold each exercise for 20 seconds.