Poor balance, a persistent problem for millions of Americans, triggers many falls. In young, healthy adults, balance is largely an automatic reflex. However, gradual changes linked to growing older—such as weak or inflexible muscles, slower reflexes, and worsening eyesight—affect the sense of balance. Certain health problems—such as inner ear disorders, neuropathy, and heart rhythm disturbances—may upset balance, too. So can alcohol and many medications. Perhaps it’s not surprising that every year, at least one out of three people over age 65 falls.
Shaky balance can spur a downward spiral. Often, people begin moving around less during the day, voluntarily cutting back activities. Confidence dips, muscles essential to balance grow weaker still, and unsteadiness rises in response. So does fear of falling—and falls.
For this report, two physicians with expertise in balance and aging team join forces with two master trainers to develop safe, effective balance exercises that can help stop this cycle. With practice, almost anyone can achieve better balance. Strong legs and flexible ankles help prevent falls and allow you to catch yourself if you do trip. What’s more, the full blend of recommended activities can help you build better awareness of your body and surroundings, boost your confidence, and tune up your heart and lungs to keep you healthy and independent.
This Special Health Report was prepared by the editors of Harvard Health Publications in consultation with Faculty Editor Suzanne Salamon M.D., Associate Chief for Clinical Programs, Beth Israel Deaconess Medical Center, Division of Gerontology Instructor, Division of Gerontology, Harvard Medical School and Brad Manor, Ph.D., Director, Aging and Balance Control Laboratory, Beth Israel Deaconess Medical Center, Division of Gerontology Instructor in Medicine, Harvard Medical School, as well as Master Trainers and Fitness Consultants Josie Gardiner and Joy Prouty. 49 pages. (2014)
Health conditions that affect balance
A lengthy list of health problems can interfere with balance. This section briefly outlines some of the more common conditions.
Many balance problems, such as those caused by arthritis or milder forms of the eye disorders described below, will respond well to the exercises in the workouts. Milder balance impairments due to stroke, Parkinson’s disease, and multiple sclerosis should respond well, too, although these conditions can cause more severe balance problems that are beyond the scope of this report (see “Starting balance workouts safely”). If you’re not sure which balance workouts will be helpful for you, talk to your doctor before starting any exercises.
No matter which underlying problems affect your balance, remember that you can do much to prevent dangerous falls by identifying hazards and fixing them, as explained in the checklists.
Ear infections, allergies, head injuries, or problems with blood circulation may temporarily or permanently affect the vestibular system. That sparks trouble with balance, dizziness, and vertigo (the sickening sensation that you or your surroundings are spinning). Treatment varies depending on the disorder. If dizziness and nausea are persistent, vestibular rehabilitation (balance retraining therapy) may be recommended. A trained vestibular rehabilitation therapist can recommend a treatment plan combining certain head, body, and eye exercises, which may help ease these symptoms. Talk to your doctor about this.
Three common vestibular disorders pose particular problems with balance, as follows.
Benign paroxysmal positional vertigo (BPPV). Sometimes the tiny stones called canaliths tumble out of the utricle and into a semicircular canal (see “Vestibular system”). This prevents the cupula and the sensory hair cells inside it from tilting properly, so that conflicting messages about the position of your head are sent to the brain. Turning your head to catch a glimpse behind you or rolling over in bed can cause the dizzy, room-spinning sensation of vertigo. Possible causes of BPPV include head injury and aging. The Epley maneuver, a series of simple movements done while sitting upright, lying down, and turning your head to one side may help shift errant canaliths out of the semicircular canal. This canalith repositioning procedure (CRP) must be guided by a trained clinician.
Labyrinthitis. When the labyrinth is infected or swollen, temporary dizziness and loss of balance may occur. An upper respiratory tract ailment like tonsillitis, sinusitis, a cold, or an ear infection is often the culprit. Allergies, smoking, alcohol use, stress, and fatigue can increase the risk of developing labyrinthitis. Washing your hands often and getting an annual flu shot can help stave off certain infections that contribute to it.
Ménière’s disease. Hearing and balance are affected by this condition, which occurs mainly in women over 40. Endolymph builds up in the inner ear to the point where it ruptures the membranes that hold it, damaging the surrounding sensory cells. Spells of Ménière’s disease come and go, lasting minutes or hours, and triggering hearing loss, vertigo, and tinnitus (persistent ringing or other noise in the ears). Sometimes this disorder stops on its own; in other cases, sufferers need medication or surgery for relief. Cutting down on salt (sodium) in your diet and limiting alcohol or caffeine can lessen the dizziness. Sometimes diuretics are used, too.
Eye disorders can blur or distort sight or even punch holes in your field of vision. When sight is impaired, balance suffers. Two eye disorders—glaucoma and diabetic retinopathy—are especially common culprits. Initially, glaucoma diminishes peripheral vision. If left untreated, it leads to increasing blindness. Diabetic retinopathy can lead to blurred central vision, and spots and floaters that create holes in the field of vision.
Stiff, sore joints hamper movement. If your ankles or knees are arthritic, for example, it’s hard to bend them, which affects your ability to balance and react when you trip. If your neck is stiff, your range of motion—how far you can move in any direction—is limited, so that you tend to move your upper body to look behind you. This can upset your balance, too. One study of seniors found that those reporting lower limb arthritis, as compared to those who did not, were 22% more likely to have fallen during a 12-month period. What’s more, researchers noted, they performed worse on tests of knee and ankle muscle strength, lower limb proprioception, and certain measures of balance.
This disorder may impede balance by impairing proprioception and muscle strength, as well as through the distracting quality of pain. Throughout the peripheral nervous system, signals shuttle toward the central nervous system, which sends instructions back to varied players in the neural network. Motor nerves control conscious movements, sensory nerves report sensations like touch and pain, and autonomic nerves regulate essential, unconscious biological functions, such as breathing and digestion. Damaged motor or sensory nerves, for example, cause a variety of unpleasant symptoms, such as muscle weakness; shooting pains; burning; or numbness, tingling, and prickling sensations called paresthesias.
Often, nerve fibers farthest from the central nervous system—in the feet and legs, or hands and arms—malfunction first. Over 100 kinds of neuropathy have been identified. These ailments may be short-lived, lasting only until damaged nerves heal, or progress slowly and permanently.
A hindrance in the speed or rhythm of the heartbeat called an arrhythmia may interfere with blood supply to the brain, spurring sudden weakness, lightheadedness, or dizziness that affects balance, or more serious problems like fainting or a heart attack.
Strokes occur when a blocked blood vessel suddenly interrupts the flow of oxygen and nutrients to part of the brain, or, less often, when a blood vessel bursts inside the brain. The compromised brain cells die off, causing many serious problems that can affect balance, including weakness, numbness, trouble seeing, trouble walking, dizziness, and loss of coordination. Often, the physical deficits are confined to one side of the body, but stroke can wreak havoc with thought processes and attention that play into balance, too.
Cells in certain areas of the brain produce dopamine. This naturally occurring neurotransmitter regulates movement, among other tasks. The loss of these brain cells causes Parkinson’s disease, which affects the system of motor nerves throughout the body. This condition impairs balance in a variety of ways: through tremors in the legs and other parts of the body, rigidity of the limbs and trunk, slowness of movement called bradykinesia, and direct hindrance of systems affecting balance and coordination. Difficulty walking occurs as the disease progresses.
Multiple sclerosis (MS)
This unpredictable central nervous system condition disrupts communication between brain and body. It often causes muscle weakness and interferes with balance and coordination, sometimes making walking, or even standing, difficult or impossible. As MS advances, it can cause partial or complete paralysis. A variety of other possible symptoms may interfere with balance, too: dizziness; tremors; trouble with concentration and attention; and pain, numbness, prickling, or “pins and needles” sensations.