How do we maintain our balance?

Maintaining balance while walking on two legs is a very tough task! Of all the animals in the world, only Human Beings are able to walk on two legs for indefinite periods of time.

It takes multiple systems in the body to prevent you from falling down:

1) Joint Position Sense: When the joints in your legs move, the nerves in your legs send signals to the spinal cord, from where they go to the brain. If this system is working, then the brain knows *exactly* where your legs are, even when your eyes are closed! This ability is called “Propioception” or “Joint Position Sense”

“Joint position” signals going from the ankle joints to the brain are very important for balance.

There are many nerves in the arms and legs (blue). These send joint position signals to the spinal cord (red), which in turn sends them to the brain (pink). A problem anywhere in this pathway can cause problems maintaining balance.

2) Ears: Our inner ears contain minute circular canals filled with fluid, which perform like the fluid levels used by carpenters. When your head moves, the fluid inside these canals moves, and the ears immediately send signals to the brain informing it of this movement.

The internal ear has delicate canals filled with fluid which detect head movement.

3) Eyes: This one is obvious. When you tend to fall, you can see that you are falling. The eyes almost instantaneously send this information to the brain, so that corrective action can be taken.

Our eyes send signals to our brain almost instantaneously.

Once the brain gets signals from any of these organs (joints/ears/eyes) which suggest that you are going to fall down, it quickly and automatically takes corrective measures such as a quick step forward to prevent falling down. These reflex movements are called “Postural reflexes”.

The brain receives information from these sources, processes it and moves body parts quickly so that we don’t fall.

 

Can falling down often indicate a “Parkinson’s Plus” syndrome?

Yes. You can read more about “Parkinson’s Plus” syndromes here.

  • If you fall often, especially backwards, then you may have a sister-disease of Parkinson’s called Progressive Supranuclear Palsy (or PSP).
  • If you become lightheaded, or feel like you will lose consciousness on getting up suddenly before you fall down, you could have a sister-disease called Multiple System Atrophy (or MSA). This lightheadedness is due to the failure of your body supply adequate blood to your brain when you get up suddenly.

    Patients with MSA may feel lightheaded, have blurring of vision or even lose consciousness if they stand up suddenly.

Please note that both these features happen in regular Parkinson’s disease as well – these problems are just much more severe in Parkinson’s Plus syndromes.

Why do patients with Parkinson’s disease fall down?

In simple terms, patients with Parkinson’s disease fall down because of poor postural reflexes.

There are two problems specific to Parkinson’s disease:

  • The brain may be slow in processing sensations from the joints/ears/eyes.
  • Even if the brain decides to make a corrective movement to prevent a fall, this movement may occur too slowly and too late to prevent a fall.

Some people believe that “freezing” while walking can lead to falls, while other people believe that the freezing before falling is an erroneous reflex by the brain which is just trying to prevent a process of falling which has already started happening. Regardless of what comes first, it is clear that proper treatment of the movement problems of Parkinson’s disease helps to prevent falls.

If your movement problems are incompletely treated, you can “Freeze” suddenly while walking and fall forwards.

But, a key point that is missed sometimes is that elderly patients with Parkinson’s disease can also have problems with the organs that produce these incoming signals – just like any other person. Therefore, it is imperative to make sure that any problems with these organs (joints, nerves, spinal cord, ears and eyes) are detected and treated as well.

Lastly, tripping over rugs, and in the bathroom is very common as in all elderly patients.

So, how can you prevent falls?

If you have understood all that we have discussed so far, it should be clear things need to be done if you are falling down often.

The relative contribution of these factors to falling is different in different patients. Thoughtful collaboration with your neurologist should help him/her to identify the most important factors. Obviously, the most important factors should be treated first.

Careful examination & collaboration usually identifies 1-3 important factors causing falls.

IMPORTANT TABLE: Preventing Falls
1. Make sure you don’t have a Parkinson’s Plus Syndrome (especially PSP & MSA)
2. Prevent a drop in Blood pressure on standing (orthostatic hypotension)
3. Make sure your movement problems are adequately treated e.g. with adequate quantities of levodopa.
4. Make sure the brain is getting good sensory feedback (from the joints/nerves/spinalcord system, the Ears & the Eyes)
5. Train your Brain
6. Modify your home appropriately

How can I prevent a drop in Blood Pressure on standing up?

There are 6 things that can be done:

1. If possible, avoid medications that may worsen this problem:

Certain medications can make it difficult to maintain adequate blood pressure on standing up. Although all blood pressure lowering medications can worsen this problem, some can be more problematic than others. The following table lists the most common ones:

Medications that can cause/worsen a drop in BP on standing up

Some psychiatric medications, particularly medications belonging to a class called Tricyclic antidepressants Examples: Imipramine, Trazodone
Some antihypertensives, particularly those that produce marked relaxation of blood vessels or cause excessive urination leading to dehdration Examples: Nitrates, Prazosin, hydralazine, Frusemide (Lasix) etc
Some other vascular relaxants Example: Sildenafil, Tadalafil
Medications given for Prostrate problems Examples: Terazosin, Doxazosin, Prazosin
Antiparkinsonian medications themselves! Examples: Levodopa, Bromocriptine, MAO-inhibitors (rasagiline and selegiline)

2. Drink enough water:

Unless you have been advised water restriction by your doctor (e.g. due to a bad kidney or a bad heart) drink at least 7-8 glasses of water per day. If you are dehydrated your blood pressure can drop suddenly when you get up, leading to a blackout and fall.

Drink 7-8 glasses of water daily.

3. Slightly increase the amount of salt in your diet:

Talk with your physician before taking this step. Salt causes retention of fluid inside the body, therefore helping to maintain blood pressure.

4. Stand up gradually:

Standing up gradually gives your body some time to adjust and maintain your blood pressure. If you are standing up from a lying position, sit in your bed first and wait for a full minute. Then stand up and stand by the side of the bed and wait for one more minute before you start walking. Some people may need to wait for more than 1 minute for their body to adjust.

Especially after sleeping, sit by the side of the bed for a minute instead of jumping out of bed.

5. Exercise:

Exercise can maintain good muscle tone, especially of your abdomen and legs and prevent pooling of blood in these areas. This prevents a drop in blood pressure.

Gentle exercise such as walking helps to maintain your leg muscles.

6. Medications:

If all else fails, medications such a pyridostigmine, midodrine and fludrocortisone can be used to stabilize your blood pressure when you get up suddenly.

In the peculiar situation where patients have high blood pressure when you are sleeping but low blood pressure when they stand, Pydridostigmine is extremely helpful. Talk to your doctor about it.

How can I make sure my movement problems are adequately treated?

As noted previously in this article, you can fall down if you have sudden “freezing” while walking or if your body’s corrective movements occur too late or too slowly to prevent a fall.

Therefore, adequate treatment of your movements so that slowness (bradykinesia) and freezing while walking are treated is absolutely essential in preventing falls.

Medications used to treat movement problems are described in a different set of articles. It is important to select these judiciously – but in most cases, the best medication happens to be levodopa.

Once it enters the brain, Levdoopa is converted into Dopamine.

How can I make sure that my brain is getting adequate sensory input?

A good neurological examination can usually reveal whether any of these feedback organs are not working well. For example, he/she may ask you to close your eyes and move your big toe up and down. If you are unable to tell whether its up or down, it indicates there is something wrong with your “joint position sense” etc..

Based on your examination, your neurologist may ask you do one/all of the following tests:

Tests to check sensory organs
1. Nerve conduction studies
2. MRI of the spine
3. Blood tests to check for levels of Vitamin B12, Thyroid hormones, Folic acid, Vitamin E and Copper. Tests to check if you have HIV or Syphilis.
4. Eye examination and correction of treatable problems such as wearing glasses or removal of cataracts.
5. Ear examination by an ENT doctor to rule out ear problems.

Can I train my brain to maintain my balance better?

YES!

Think about the time when you learnt to ride a bike – as you practiced it more and more it became automatic. In the same way, participating in physical therapy and learning strategies to maintain your balance can significantly help in preventing falls.

This premise is supported by multiple studies (e.g.  Smania 2010 & Halvarsson 2012). Any exercise is better than no exercise. However, exercise methods that focus on balance e.g. Yoga or Tai Chi can be more helpful to improve your balance (Hackney 2008 and Roland 2013).

As noted above there have been a few research studies on Yoga and Tai Chi, but these exercise methods have not been as extensively studied as western physiotherapy. I believe they have a role in the treatment of instability given the low impact nature of these exercises and their emphasis on balance.

Yoga and Tai Chi can improve your balance & prevent falls.

I will post a video with simple balance exercises that you can see by clicking here. This contains only simple balance exercises that can be done without equipment. Visiting a good physiotherapist will be even better – the physiotherapist can customize your training session for maximum benefit.

Relevant studies:

  1. Effect of balance training on postural instability in patients with idiopathic Parkinson’s disease. Smania et al Neurorehabil Neural Repair. 2010 Nov-Dec;24(9):826-34.
  2. Long-term effects of new progressive group balance training for elderly people with increased risk of falling – a randomized controlled trial. Halvarsson et al. Clin Rehabil. 2013 May;27(5):450-8.
  3. Efficacy and Safety of Tai Chi for Parkinson’s Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Xiaojia et al PLoS One. 2014
  4. Yoga Improves Balance and Low-Back Pain, but Not Anxiety, in People with Parkinson’s Disease. Myers et al Int J Yoga Therap. 2019 Oct 4

What changes should I make to my home?

Remove all loose fitting rugs, or unstable pieces of furniture that you can trip over. Excessive clutter or furniture can also cause you to freeze more frequently and then fall. So, make sure your home is as tidy and clutter-free as possible.

This living room looks nice. But removal of the rug, and the low tables in the center would help to prevent freezing and falls.

The bathroom is a common place for falling. Avoid using the bathtub – in fact, remove it completely if possible. Use anti-skid rugs. Always sit down while taking a bath. If possible, you should install support rods in the bathroom to help you to get up from your commode and after taking a bath.

Make sure any support rods you install are firmly attached and rounded.

How can I prevent injuries after falling?

Make sure your furniture is not sharp. You can buy foam padding for corners online.

Even more importantly make sure that your bones are adequately dense, so that they do not break if and when you do fall. This can be done by measuring the bone density using a test called a DEXA scan.

A DEXA scan measures bone density. If your bones are not adequately dense, they can break easily.

The medical term for less dense bones is “Osteoporosis”. Bones can be made denser and stronger by giving you medications.

Medications for Brittle Bones ('Osteoporosis')
1. Calcium & Vitamin D
2. Bisphosponates (for example: Alendronate)
3. Teriperatide
4. Calcitonin
5. Zolendronic acid
6. Many others… Your doctor can choose the appropriate medication for you based on your test results, age, gender and other characteristics.