I seem to be having a lot of balance issues. Could this be related to my Sjögren’s? Are there any treatment options?
Poor balance is a risk factor for falling and warrants evaluation. 20% or more of individuals with Sjögren’s have neurological complications, many of which can impact balance. The most common is sensory neuropathy. Even in the absence of burning or tingling, careful examination may reveal loss of sensation in the toes. In an individual with poor balance, a physician will look most closely for evidence of loss of position sense. As the physician moves the patient’s toe up or down, an individual with neuropathy may exhibit no awareness of the direction of the toe. Walking in the dark or blocking ability to see one’s path (by carrying a laundry basket down stairs, for example) can greatly increase falling risk. Once a sensory deficit is discovered, other causes must be sought (such as diabetes or B12 deficiency) before the neuropathy is ascribed to Sjögren’s. Balance training may be helpful and behavior, which increases falling risk, should be eliminated (rushing, multitasking when walking, climbing to unprotected heights).
Other much less common neurological causes of poor balance in Sjögren’s include inflammation of the spinal cord (myelitis), which may result in both sensory loss and muscle spasticity, disorders of the cerebellum and inner ear, and autonomic neuropathy, which may result in inability to maintain blood pressure with standing.
The medication list should also be scrutinized for agents that may impair balance by lowering blood pressure, causing sedation, or damaging peripheral nerve function. If poor balance is present, alcohol use should be curtailed.
A consultation with a neurologist is advised because detailed evaluation of all portions of the nervous system may identify one of the less common causes of poor balance. Nerve conduction studies, MRI imaging of the brain and spinal cord, testing of inner ear function, and, rarely, examination of spinal fluid may be warranted. In instances of progressive sensory loss, immunosuppressive therapy with steroids or other agents, or intravenous immunoglobulin may be advised. Everyone with balance disorders should carefully evaluate the home environment to minimize falling risk. If there is a history of repeated falling, routine use of hip protectors should be considered and osteoporosis, if present, treated to minimize risk of fracture.
Lee Shapiro, MD, Albany, NY
My provider recommended balance therapy. What is involved and how effective is it?
Balance therapy is most typically provided by a Physical Therapist and can encompass a variety of treatment approaches depending on what is causing the loss of balance. A thorough assessment by your Physical Therapist can help to determine which treatments would be most effective. Balance therapy is used to reduce frequent falls, stumbling, vertigo, lightheadedness, difficulty walking steadily on level or uneven surfaces and motion sickness.
Balance is quite complex. There are three major systems in our bodies that constantly send balance information to the brain to be processed. Likewise, the brain is constantly receiving and processing this information and then sending a split second response to the body to tell it how to react and maintain balance. The first system is the Vision System. Vision is used to send the brain information about our surroundings. For example, if you are about to climb a flight of stairs, the vision system sends information to the brain to help prepare to position the body accordingly so that the foot is lifted higher to clear the step and weight is shifted to the opposite leg. Regular eye exams and using your prescribed glasses and contacts is an important part of keeping balance. Common balance issues caused by glasses include glare and distortion when changing between the focal points on bi or tri-focal lenses. Speak with your eye doctor to ensure your glasses are not causing a balance disturbance. Turn on the lights! Walking in dark or dimly lit rooms significantly reduce our ability to use visual feedback for balance. The second system, the somatosensory system, sends the brain information on what the body is feeling through receptors in the skin and joints. If you were to walk on a level sidewalk and then veer off onto a grassy hill, the somatosensory information sensed in your joints and skin would change. As a result the brain can tell the body how to adjust for the change to walking on an uneven and grassy surface. The third system, the Vestibular System, is located in each inner ear. It provides the body information about forces on the head so the body can sense speed, turns and direction of movement. It also coordinates eye, head and body movements so that we can focus on objects as we move. Balance may also be affected by musculoskeletal issues such as pain, weakness and poor flexibility.
The focus of treatment for a balance dysfunction is to challenge the body to perform balance tasks that will re-teach the brain how to process the information it receives. Time, patience and repetition is needed to be successful. Treatment will vary depending on what is causing your balance dysfunction. Some examples of treatment are listed below, however, there are too many treatment strategies to list all of them here. Disorders of the somatosensory system are treated with dynamic balance exercises that challenge balance such as sitting, kneeling or standing on varied surfaces (therapy ball, foam, rocker board, balance beam). Disorders of the visual and vestibular systems are treated with eye and head movement exercises known as vestibulo-ocular exercises. A specific disorder of the Vestibular System called Benign Paroxysmal Positional Vertigo (BPPV) is very successfully treated with a series of body and head positioning exercises. Musculoskeletal disorders are most typically treated with strengthening and stretching exercises along with manual therapy techniques and modalities (electric stimulation, ultra sound, kinesio taping, etc.). Pilates, yoga and tai chi and are three types of popular exercises that improve balance, strength and flexibility.
Does balance therapy work? Balance therapy does work. The degree to which it will improve your balance dysfunction is dependent on several factors. The physiological cause of the dysfunction may preclude total resolution of the symptoms, but an overall improvement in balance can be attained. The factors that you can directly affect for success are following your Physical Therapist’s recommendations, performing exercises as prescribed, being persistent, and following up with your doctor and physical therapist for program advancement.
Linda Jung, MSPT