(light music) - [Announcer] The region's premier medical information program, "Call the Doctor".

(light music) - Balance is something most of us don't even think about most of the time.

Balance problems can be the result of any number of different medical issues or conditions, but think about how many systems in the body have to work normally in order for your balance to be good?

we'll discuss some of the more common balance issues and methods of helping you find your footing again.

Balance issues on this episode of "Call the Doctor".

Hello and welcome.

We are so glad you're with us for this season and this episode of "Call The Doctor".

I am happy to get right to tonight's panelists 'cause we have a lot to discuss here in the next 25 minutes or so.

It'd be great if you could each introduce yourself and tell people who you are and where they can find you.

We'll start with you.

- My name is Janine Fee.

I am a Vestibular Certified Physical Therapist.

That means that I specialize in inner ear dysfunction, so I collaborate with ENT and neurology and audiologist.

And I'm the lead at Evangelical Community Hospital's Balance Center.

- Welcome, it's great to have you.

- Thank you.

- What about you?

- My name is Shai Post.

I'm also a physical therapist.

I work at the Lehigh Valley Health Network Health and Wellness Center in Hazleton.

I also am a specialist, certified in vestibular rehab, certified in Parkinson's LSVT BIG, and a geriatric certified specialist.

And I'm happy to be here.

- Great, thank you so much.

And what about you?

- My name is Stephanie Collins.

I'm a physical therapist with Allied Services.

I work at our Scranton Inpatient Rehab Hospital.

There, I am on the spinal cord injury team.

I also see patients who are recovering from surgeries or cardiopulmonary deconditioning.

And I am a certified fall prevention specialist.

- Welcome to you.

- Thank you.

- I think that balance is one of those things that most people don't really much think about most of the time until they're having trouble with it.

So I think I'll start with, I mean, it's a very, very basic question, but we'll start here.

Are all balance issues inner ear issues?

- No.

I like to think of balance as a baseball field.

It's a multitude of many players not working well together or working well together, hence having either a good team or a bad team.

So think of your balance like a baseball field.

We have three outfielders and there are sensory receptors, they're our eyes, our inner ear, and our sense of touch.

And those players are important in gathering information about our balance.

And then once they gather the information, they send it to our brain.

Our brain processes that information, so I like to call him the pitcher on the mound.

And then once he figures out what's important and what's not, he then completes the play by sending information to the infielders, which represent things like, do you have good strength, are you afraid of falling, what's your posture like, what's your flexibility like, are you sedentary?

Those are all factors that can cause either somebody to have good balance or bad balance.

So the inner ear is one of the outfielders and there's lots of different things that can cause inner ear problems that can contribute to a balance problem.

- So it really is a very personal, you have to get to a doctor and figure out what's happening.

I see you nodding over there.

What might be the first thing you do if someone comes to you and says, "Hey, I'm having trouble with this?"

- So a PT's evaluation is very complex.

So we don't just look at one thing, we look at the whole body.

So we're going to use standardized outcome measures to look at your balance, give you a concrete score that tells you maybe what your risk is for falling.

From there, we'll look at things like your posture, your sensation, your strength.

Those are things that all like, you know, she just said that are factors and it balances function.

- Is there something that's more common that you see?

Just anecdotally, of course, not to put you on the spot there, but do you see something more commonly than others around here?

- So, we live in an area where we have a lot of older population.

So with that, with aging, our balance takes a hit.

So we lose muscle mass, we lose bone density, our posture changes, and we become unfortunately a little bit more sedentary.

So with those changes, that's going to impact somebody's balance.

- That leads me into a question that I actually had for Shai.

I know you work a lot with geriatric population.

Is balance, is it to be expected that it's going to get a little bit worse as we age?

Or are there things we can do to try to prevent that?

- So there's a normal changes for aging and some of those things are changes in our muscle, changes in our nerves, changes in our reaction time.

And so those are some normal changes that might come for adults that are over 65, but that doesn't mean that we can't do something about that.

You know, we can be more physically active.

If we're having a balance issue, if we have a fear of falling or if we find ourselves becoming more unsteady, it's really important to discuss that with your primary care provider.

There's a screen that the Geriatric Society recommends that they do every year called the STEADI screen and there's three important questions that the provider will ask.

One is, do you feel unsteady?

A second one is, have you fallen in the last year?

And the third is whether you use an assistive device.

And if you answer yes to any of those questions, it's recommended that the balance be screened further for any issues.

A lot of research shows that balance may be improved through physical therapy and exercise and increased physical activity by whichever method your doctor would recommend.

So it's a good discussion to start with.

- You've all mentioned falls now and fall risks a few times, so I'd like to just get into that just a bit.

When people hear a fall risk, I suppose for some it's not that big of a deal.

For the geriatric population, I keep messing up on that word tonight, population, that's a very big deal for people to fall.

What conversations do you have around falls and fear of falling, Stephanie?

- One thing I recommend is that people fall proof their homes.

So, take things out that might put them at risk for falling.

Throw rugs, extension cords, maybe you have a pet at home and their toys get in the way, pets themselves, actually.

A cat or a small dog might get in the way.

Make sure that your path to the bathroom at night is well lit.

So that way, you know, vision is one of our sensory inputs that we use for balance.

So if that is compromised, that's gonna affect our balance.

So things like that, I think, might make somebody feel a little bit more safe in their home and that might make them feel less at risk for falling.

- Just to prevent injury, I would imagine.

Any other reasons that you would want to prevent a fall?

You know, that's probably a silly question, but.

- Well, as we get older it's very detrimental, 'cause if you fall and break a hip, that often then puts people into the hospital and it can be very detrimental.

It can cause death, especially if you have some dementia.

As we get older, lots of times our cognitive function declines.

So just cognitive function in of itself can also increase your risk for falling.

- Do you make a distinction medically between dizziness and balance?

Are those two different things and how can people who are watching see that those are two different things?

- So dizziness, I think a lot of physicians don't really like that word because dizziness can mean so many things.

So it is hard to sort of differentiate that 'cause everybody may perceive dizziness differently.

So I like to say, "Do you feel like the room is spinning?

Do you feel like you're afraid you're gonna fall or your balance is off?

Or do you feel lightheaded?"

And lots of times just those three basic questions can help lead us into kind of figuring out maybe what system might be broken down.

It could be cardiovascular, so they might be having some sort of cardiovascular problem.

Or if they're having these room spinnings, the inner ear is one of the major balance mechanisms and positional vertigo, it's called positional vertigo is one of the most common inner ear dysfunctions that increases people's risk for falling because it creates this missignal that causes people to think they're in motion.

And as we get older, your balance reactions and everything become delayed and now it increases your risk for falling.

- Is that if you are lying down and you stand up or sit up too fast, is that what you mean there?

- So positional vertigo affects you.

It's called positional vertigo 'cause with changes in position it does create this kinda spinning sensation.

So, this is the inner ear and we have these little crystals that belong in this part of the ear and sometimes they can dislodge and move into these loops.

And if they move into these loops, anytime you change position, like lying down, think of it as a rock being thrown into a lake.

If you throw a rock into the lake, you get this ripple effect.

So when you lay down, everything spins, but if you stay still, it settles down.

You go to sit back up, it does it again.

So a lot of people, when they're sleeping they go to get up in the middle of the night to go to the bathroom, don't realize that this is a problem.

They go to jump out of bed and everything starts to spin and they lose their perceptions of where they're at, and down they fall.

- I definitely wanna get into this more.

I love that you brought a little model here 'cause it makes it easy for us to see.

I'll get back to that in a second, but I wanted to go over a couple other symptoms that people may have commonly or that people might come to you for.

What are some other common, other than dizziness or thinking you might fall, is there something else you see a lot?

- A lot of patients will say they feel unsteady when they're walking.

They may veer to the left or to the right.

And sometimes I also ask my patients if they've had near falls, because sometimes they'll tell you about like a fall onto the ground, but they won't realize that near falls are very important.

It's kind of a warning sign that you may need to address balance issues.

So, I think that those would be the main ones.

- Even you almost fell is enough to tell you're- - You almost fell, yeah.

You almost fell.

- [Julie] What about you?

Anything else that you see commonly?

- I think sometimes people, they might say that they're dizzy, but they're not really dizzy, they're lightheaded.

That might be maybe an issue with one of their medications that's making them feel lightheaded.

So they don't necessarily have an inner ear dysfunction, but they're lightheaded because of medications.

Maybe somebody's dehydrated and they're not getting a good water intake.

So I think that's a big part too, is differentiating are you dizzy or are you lightheaded?

And what's the cause for the lightheadedness?

- It seems as we talk, it seems there's a checklist a mile long that you would have to get through in order to get to an answer.

Does this take a long time sometimes to come up with why someone is having balance issues?

Anybody can take that, really.

- The most important thing that we can do is, I think, a good physical therapy evaluation.

In that way we can see the reasons for falling.

So we kinda look at, you know, I asked my patients like where they fell?

Was it inside, was it outside?

What type of surface were they standing on?

Some patients have harder times, like in darker environments when you take that vision away, some patients are out in their backyard and they're not on a firm surface, so they're on uneven surface, on the grass, and that takes some of those sensory cues away.

So that could be a cause of a fall.

It could be, sometimes when there's a vestibular issue, a lot of my patients will say that they turned and then they fell in the restroom, or in the kitchen I turn to get something off the countertop.

And so, there's definitely reasons that we have to find out why is this person falling and then we could address their treatment protocol in the way that will help their balance.

- I think history is probably the, we spend a lot of time, I think, we would all agree on history.

Just talking to the patient 'cause a lot of times dizziness means, again, so many different things.

Even if somebody has like diabetic neuropathy where they lose their sensation in their feet, they will often feel very off balance.

And if you think of the outfielders, your eyes, your ears, your sense of touch, if you lose your sense of touch, that player is sitting on the bench and so now you're down to two players.

And so those two players have to work harder.

And so they will perceive that as I have this increased postural sway.

So I feel a little bit more off balance, but it's because they have some neuropathy.

And then there's some things that we can do as physical therapist, that we can increase their proprioceptive input or that sensation by recommending like an assisted device.

Like if you use a cane, essentially you're taking an extra player off the bench, adding a player to the field, now they're getting some input through their hand.

So it helps to make up for that.

So, part of what we're looking at is looking at all of those systems with our evaluations and our outcome measures as they said, and then breaking it down for the patient and really kinda diving into where their problem is to better identify what might be causing their falls.

- We mentioned inner ear, we mentioned diabetic neuropathy, but I imagine the list goes on and on about of what could be causing balance issues.

What do you see?

I mean, I've asked that question a lot tonight, but I'm kinda curious what goes on clinically, the conversations you're having with your patients?

- I think sometimes, especially now we're in this post COVID era, so many people have been sedentary for so long.

Now they're starting to come out of their homes and do a little bit more.

And if you're sedentary, then that's going to cause your muscles to weaken.

It's gonna cause your endurance to weaken.

Maybe your balance reflexes aren't as sharp as they were because you haven't been getting up and moving.

So, I think, now that, like I said, people are starting to be more active, they might be noticing that maybe their balance is a little off.

- [Julie] Does that get lost fast?

- I think so, especially for those who maybe live alone or maybe don't have a great support system.

They are now emerging, coming out and they don't even have anybody to really even maybe bring it to their attention.

- Maybe that their gate is off - [Stephanie] Right.

- or perhaps they don't notice.

Do you see that a lot?

That someone's loved one will come in and say, "They're walking differently," or, "Something just seems a little off?"

- I think that's a great point.

I think that if you feel like you're having some issues or your loved one's having some issues, a good place to start is talking to your doctor and saying, "Can I try a little bit of physical therapy?"

And oftentimes they're like, "Sure."

And I feel you guys probably have the same, we see these patients two to three times a week.

So we get to know them and we really get to kind of look at all these different body systems.

So, we might only spend an hour with them the first time, but we're evolving as we keep seeing these patients that as we're watching and seeing all these different systems, there might be a point where we're like, "Hmm, this looks a little bit more like a Parkinson's disease," and maybe we need to refer back to the doctor and say, "Hey, we're seeing some signs that are indicating Parkinson's disease or a neurological problem that might need to be a little bit more looked into.

- Looked into further.

You mentioned COVID as keeping people in their homes, which now has me wondering, can you stave off balance issues if you, I know you can't ward off everything, but by and large, can you help your balance if you remain active?

And what is lifestyle factors have to do with this?

- You definitely could improve your balance, and I think that's one of the most important things, messages that we can send.

One in three patients who are over 65 have had a fall this year.

So it's almost like an epidemic - [Julie] Wow.

- for our country.

So it's definitely something that is important to be addressed.

And I think a lot of people may not realize that they could do something about their balance.

A lot of times when people think of physical therapy, they think of knee replacement or an orthopedic issue, but we have a whole group of specialists from the Louisburg area and from the Scranton area and from the Hazleton area that could help members of our community.

And we take a special interest in them so that they can continue to be active.

There was a research study that they did that said that to prevent a fall, you would need to do at least 50 hours of balance training.

And that has to occur over greater than a three month period and better off over a six to 12 month period.

So putting in that balance training at least three days a week at a minimum of practicing balance specific exercises will help decrease fall risk.

- I think what's interesting too is just gate speed.

A lot of people think of gate speed is how fast somebody walks.

And most people as we get older decide, "Ooh, if I walk slower, I'm actually gonna be safer."

When in reality, gate speed also correlates to fall risk.

And so we analyze how fast someone walks.

So community dwellers, some like Tai Chi and yoga are excellent things to kinda keep somebody in shape with that.

But also walking programs and encouraging people that actually if you walk a little bit faster, it's actually safer.

And the reason why that is, is if you think about if you walk in slow motion, you're spending more time standing on one leg.

So by the time you're spending so much time on one leg while you're pulling the other leg through, if you can't stand on one leg for more than three to five seconds, now you're gonna fall over.

Whereas if you're walking a little bit faster, you're constantly shifting your weight back and forth and spending less time on one leg.

- So people, they can walk too slow.

- Correct, yeah, which will increase their risk for falling.

So, like a preventative, as Shai was saying, some community programs like yoga or Tai Chi would be excellent to try to maintain or keep their balance in check.

- If I'm just sitting at home and I don't have balance issues that I know and I don't have one of these issues that might lead to that that I know, Stephanie, could I ask a physical therapist or someone else in your field, what can I do?

Are there preventative measures?

Are there other lifestyle choices that are not exercise?

What can you tell people to keep that?

- I would just make sure that, from a whole body perspective, make sure you're well hydrated.

Make sure that your nutrition is optimal.

Make sure that your medications are all in check.

That you're on the proper dosages for all of your medications.

If you don't wanna go out and do a class or join a gym or something like that, I always tell my patients just stay active in your own home.

Maybe every 30 minutes, set a timer and get up and walk.

Go up and down your steps, walk to your mailbox, go and walk outside on the grass, change up the surface that you're walking on.

Even though small little changes might go a long way with somebody who might be at risk for falling.

- Can we get into this just a little bit?

- Sure.

- Can you explain what it is we're looking at here and how, I mean, now that we've established that not all balance issues are inner ear, are many of them inner ear related?

- Well, since I'm a vestibular therapist, I get many that are inner ear related.

So there's a lot of different inner ear problems that can create balance issues.

The most common is what we call benign paroxysmal positional vertigo, which benign means it's not a big deal.

Paroxysmal means it sort of comes and it goes.

So it's not there all the time.

And that's what's scary about positional vertigo is if it just comes and goes, somebody could be walking along and if they bend over to pick something up for their dog and boom, all of a sudden it hits 'em and they can fall.

And then positional, it's usually brought on by a position, and vertigo means I kinda have this spinning sensation.

So, the inner ear is really about the size of the tip of your finger.

It's extremely tiny.

So even if we ordered image studies like CAT scans or MRIs, it often doesn't visualize it very well.

So what we do as vestibular therapist, the way that we examine inner ear dysfunction is through a person's eyes.

Your eyes are connected to the inner ear through reflexes.

And so there's a lot of different inner ear problems that can create this dizziness and oftentimes we use goggles in our office to highlight the eyes so that we can try to create some sort of asymmetry in the ear, and your eyes will actually do this funny little dance, it's called nystagmus.

And that's what we look for to help us to determine what type of inner ear problem you're having.

So we literally, if you have positional vertigo, the crystals can be in any one of these loops.

Usually it's in the posterior canal, but it can also be in this horizontal canal and your eyes will actually twitch differently.

It's called nystagmus, and depending on how they move tells us exactly where it's at.

And so once we can identify that, we can provide an intervention, we call it a maneuver, to maneuver those crystals that are supposed to be over here, we can maneuver them out like a marble game and move them back to where they belong where they'll reattach and then it goes away.

So, that can be a huge impact on someone's balance.

And so, all the patients that we get that just come in, even for balance issues, we always screen 'em for positional vertigo because the number one complaint isn't really that I'm having spinning or vertigo.

It's my balance is bad.

And it's literally because they may not sleep in a bed.

They might sleep in a recliner, but every time they go to get up, they, woov, feel like they're drunk getting to the bathroom.

So, we do a good job at our clinics.

I'm sure you guys do, too.

Anybody that comes in with balance issues, you always screen for this because it can be very detrimental, but it's usually one of the main causes of a balance issue.

- With the last few minutes here, I wanna talk about, I think we touched on it a little bit, about the changes over the lifetime.

What you can do for balance when you're younger versus when you're a little bit older.

You would definitely recommend, obviously sticking with that exercise and keeping up a good lifestyle.

But what else?

What else do you talk to your doctor about if you feel like this could be you?

- Usually what I tell the patients is to let them know if you're having unsteadiness or having those near falls and talk about the safest form of exercise.

You know, What would be the safest for you, because for some if their balance is not too bad, they can go to a fitness center for physical activity.

But if they're having more balance issues or vestibular issues, talk to the doctor, see if he agrees that you should see a physical therapist.

And just to know that there are things, there are interventions that we can do to help with the vestibular issues, regular balance issues, whether it's from diabetes or sometimes even orthopedic issues can cause balance problems like a spinal stenosis in the back.

So we see a lot of patients with that.

And you don't have to live with that imbalance.

That's not normal aging.

So talk to your doctor about whether they would recommend physical therapy so you could continue to do the things that you love to do.

You know, volunteer or go to your grandchildren's baseball games, play pickleball, anything like that.

(Julie laughs) - [Julie] Pickleball game.

And Stephanie, I like what you said a little bit earlier just about advocating for yourself that if there's something up, you have to say something.

- Yeah, I mean, falls are not a normal part of the aging process.

So just because you fell, you can't just write it off to being elderly.

So if you are a loved one, find that you're falling frequently, definitely speak to your doctor about it.

There's so many options out there.

You can go to an outpatient center.

For us, an inpatient rehab, we have our admit-from-home program.

So, if somebody's having a hard time navigating around their home, they're falling frequently, they can't care for themself as well as they used to, maybe you need a little bit more intensive therapy.

So there's so many options out there and it's just important to just make sure that your concerns are heard.

- It's a huge topic.

I know it's one that we have just only scratched the surface of.

But I wanted to thank you all for coming here 'cause I think you had some great perspectives and I hope at least people, if they're having an issue or see someone they love have an issue, they can give one of you a call or one of our fine medical professionals here in Northeastern Pennsylvania.

That's gonna do it for this episode of "Call the Doctor".

We are so glad you've joined us.

If you missed something or you wanna listen again, you can find the entire show at our website, wvia.org.

All you have to do is click on Watch and then "Call the Doctor".

Also, you can find us on the WVIA app.

I'm Julie Sidoni.

Thanks again for watching and for all of us here at WVIA, we'll see you next time.

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