The Four Elements of Balance

Ever wonder what really goes into having “good balance?” If you’re like a lot of my physical therapy patients, you may even think it’s a yes or no question: that either you have good balance, or you don’t. 

Balance is actually multi-faceted, and there are numerous factors that affect it. And we can ALWAYS do something to improve it, regardless of comorbidities or medical history components. Need some convincing? Most of my physical therapy patients do too!

There are 4 main components that impact our balance: vision, sensation, proprioception, and vestibular. Let’s see how each of these plays an important role in our balance, and what we can do to affect each of them.

First, our vision. This may seem obvious, but our vision plays a critical role in helping us to maintain our balance. Our eyes are constantly taking in our environment and sending information to our brains about how we are situated in comparison to our surroundings. If we start to lean to one side, for example, our eyes can perceive that and let our brain know, so that our brain can tell our body to return to neutral before we lean too far that we fall over. 

A course that I recently took regarding fall prevention for older adults talked about how as we age, our visual acuity naturally declines once we hit age 50, and even more so after age 70. These vision deficits are more obvious or pronounced in low-light conditions, so older adults may require between 2 and 4 times more light compared to young adults. This places those over 50 at higher fall risk in low-light conditions: think, leaving a restaurant after dark, getting up in the middle of the night to use the restroom, or walking in a movie theater after they’ve already dimmed the lights. The American Optometric Association states “As you age, you need more light to see as well as you used to.”

Even beyond these normal age-related changes, other conditions such as macular degeneration, glaucoma, and diabetic retinopathy can impair vision even further, making it even more imperative that we keep our other balance systems up-to-par in order to prevent falls.

Physical therapy or exercise won’t improve your vision, but ensuring regular optometrist visits is important in order to keep your glasses prescription up-to-date and catch any conditions as early as possible.

The next component of our balance is our sensation, especially the sensation in the plantar aspect of our feet (the bottoms of our feet). The ability to feel our feet on the floor, and feel where we are putting more or less weight through which parts of our foot, is a significant factor when it comes to our balance. Our sensation can be impacted by nerve damage, whether from trauma to the area (like surgery), or medical conditions such as diabetic neuropathy. Like with vision changes, there isn’t an exercise we can do to fix our sensation if it is impaired. However, if you can’t feel the bottoms of your feet very well, it’s even more important for you to strengthen your other balance systems to prevent a fall.

These last 2 components of our balance are ones that physical therapy and exercise can directly impact, improve, and make a great difference in your overall stability, confidence, and balance: 

The first is proprioception, which is your brain’s ability to perceive what position your body and joints are in, at any given time. This means that without looking at my elbow, I can tell you whether it’s bent or straight- because of that proprioceptive sense. This is particularly important in the ankles, knees, and hips when it comes to balance. We want our joints and ligaments to be in good communication with our brains about what position they are in when we are standing and walking: that way, if we start to roll our ankle, for example, our brain is notified sooner rather than later, and it can tell our bodies to take a step or weight shift to prevent us from rolling that ankle or falling over. Proprioception is a huge focus of physical therapy when patients come to me for balance work, fall prevention, and rehabilitation from injuries. We can directly work with, and improve, our proprioceptive sense with positions and movements that challenge, and therefore strengthen, that proprioception. We do this by standing with a smaller base of support (example: standing with feet close together or standing on just one foot), standing or walking on an unsteady surface such as a balance cushion, and standing while adding perturbations (meaning adding small pushes to different sides of the person so they have to weight shift in order to keep their balance). 

The last component of our balance is our vestibular system. Our vestibular organs are very tiny, and located deep within our inner ear. We have one set of them on each side, left and right. Their job is to sense whether or not our heads are moving, which direction, and how quickly. This is how we bend over and stand back up, look down the different aisles of a store as we are walking, and even roll over in bed, all without getting disoriented or dizzy. The vestibular system can also weaken as we age, causing us to feel a sense of spinning, dizziness, vertigo, or even just a general sense of unsteadiness or imbalance. The good news is that we can strengthen our vestibular systems through exercises such as habituation and gaze stabilization, which we do all the time in physical therapy. 

Beyond these 4 physical aspects of our balance, of course there are a myriad of other factors that can affect our balance: what medications we are (or aren’t) taking, blood pressure being too low or too high, medical history of stroke (especially if it affected the cerebellar region), substance intake, and even our mental state, such as how anxious or calm we are- all of these can affect our balance and coordination. 

The main takeaway from this post is this: there are so many facets to our balance, which means there are many different opportunities for us to affect and improve our balance. For example, if Joe has nerve damage in his feet and can’t see as well as he used to, he can make sure he is incorporating proprioception and vestibular exercises into his routine to ensure those aspects of his balance are staying up-to-par. 

So there you have it, a brief overview of the 4 components of balance. I want to highlight that there is ALWAYS something we can do to improve balance. Even if one or more of these components is compromised, we can focus on building up the other aspects of our balance to maintain our stability and safety. 

If you want to be sure your home environment is set up for safety, check out my free guide “10 Ways to Fall-Proof Your Home" by clicking here.

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Like everyone else, I have been watching the Olympics this week, and the rugby games have been so fun to watch. I played rugby all through high school- I absolutely loved it. Somehow my only true injury over the course of 4 years was a fractured orbital (luckily no eye damage!) My coach told me that I was lucky that homecoming was over, because I had quite a nice black eye for a couple of weeks.