Balance has become a pop-culture buzzword. Psychologists and talk-show hosts discuss the need to balance work and play. Self-help gurus advocate the proper balance between needs and wants. Economic advisers provide feedback on balancing budgets for individuals, corporations, and governments. However, few people—even those within the medical field—focus on physical balance problems.

"Balance is probably the biggest hole in medical treatment, with physicians as guilty as patients," says Stanley Adelsberg, a PT with the New Rochelle Center of Dizziness and Balance, New Rochelle, NY. According to the Hearing and Balance Center of Loyola University of Chicago's Stritch School of Medicine, Maywood, Ill, 35% of the population has experienced dizziness by the age of 65.¹

"Physicians and the general public need to be made more aware of the services available from PTs. We have the ability to not only treat dizziness and balance but also to correct and improve it," Adelsberg says.

Better balance is achieved through a variety of methods, with the plan dependent on the diagnosis. Every patient program, therefore, starts with a thorough history and evaluation. "This process is the same for all patients," Adelsberg says.

Patients are generally examined for problems in three systems: the visual; the vestibular; and the somatosensory, which incorporates the muscles. Treatment can range from simply changing medication to employing strategies intended to improve one or more of the systems' performances. "We try to work with one system to enable it to compensate for the deficiency within that system or one of the other two," Adelsberg says.

Assessing Imbalance

Adelsberg has worked with balance and dizziness patients for roughly 50 years. He obtained his undergraduate degree as well as his graduate degree in movement science from Columbia University, New York. His earned his physical therapy degree at the School of Physical Therapy at Columbia University, College of Physicians and Surgeons.

During his studies, Adelsberg noted that patients with balance and dizziness problems formed a large population that was going untreated. "Nobody really had a solution for these patients. They could see medical doctors, ENT [ear, nose, and throat] specialists, neurologists, or ophthalmologists and still suffer balance problems," he says.

Adelsberg decided to devote his career to filling that niche; and over the years he has expanded his practice from working with various neurological patients to helping athletes improve their performance through better balance techniques to treating the general public, including older patients. "Many patients in the older population have balance problems," Adelsberg says.

A number of potential ailments cause balance and dizziness conditions to present themselves. To figure out the relevant factors, Adelsberg conducts detailed patient histories and evaluations. "Sometimes the cause is a new medication, and all that is needed is a different prescription," Adelsberg says.

Sometimes, however, the cause is more complex. "Patients may have visual problems, or vascular or neurological conditions. They may have low muscle strength or a vestibular issue," Adelsberg says. The evaluation can include medical exams.

Adelsberg is just one member of the practice's team. The New Rochelle Center of Dizziness and Balance is owned by two physicians and is staffed by 10 ENT specialists, two otolaryngologists, one audiologist, assistants, and office help. Adelsberg is the only PT on staff. He was asked to join the practice to make the drive more convenient for the group's patients, who were frequently referred to Adelsberg's office in the Bronx.

Many PTs may not work with a physician team as Adelsberg does, he notes. However, frequently an ENT or neurologist is involved. "Every patient needs to have a complete evaluation," Adelsberg says.

Tests include the Clinical Test for Sensory Integration and Balance (CTSIB); dizziness inventor; Dix-Hallpike maneuver with Frenzel lenses; Fukuda's stepping test; and electronystagmograms, which measure eye movements. Adelsberg conducts the CTSIB using the foam-and-dome method, which challenges patients to remain stable on a foam surface under different conditions; a dome obscures vision when necessary.

More advanced equipment exists for more controlled testing; for instance, computerized dynamic posturography devices provide a more advanced CTSIB evaluation, helping to quantify and identify the particular system that is impaired. "Computerized posturagraphies are effective in clinical settings, but would be especially useful for those collecting data for research," Adelsberg says.

Stabilizing Techniques

The research would be useful since there is no typical balance or dizziness patient. "There are numerous causes of balance problems, and they are addressed differently," Adelsberg says. He has seen the options improve over the years. "Fifty years ago, the knowledge about why a patient was having problems and the resulting treatment techniques were very basic," he says.

Armed with more information about function, treatment has become more targeted. Adelsberg's team first seeks to eliminate the cause of the dizziness or imbalance. However, if that is not possible, it aims to improve the three systems' abilities to detect and process information as well as to develop the motor capabilities required for postural demands. "Often, we will overload one system so that it learns to compensate and correct any deviations—or at least that is what we are striving for," Adelsberg says.

There is often crossover of treatments between patients with different conditions, but some methods are better suited to a specific diagnosis. For instance, a neurological patient will frequently be given exercises to strengthen lower muscles and to increase sensory evaluation, according to Adelsberg. Movements can include standing on one foot and holding awkward positions.

The benign paroxysmal positional vertigo (BPPV) patient will undergo completely different treatment targeting the inner ear. BPPV patients suffer vertigo as a result of calcium carbonate debris, or "ear rocks," in the inner ear. "Certain maneuvers have been designed to try to reposition the rocks. By manipulating the patient's position to move the deposits, we create a free flow of fluid and alleviate dizziness," Adelsberg says.

Specific canalith-repositioning procedures include Brandt-Daroff habituation exercises, Sermont or Liberatory maneuvers, and Epley maneuvers. "Patients can perform these on their own after receiving instruction so the problem can be corrected more effectively," Adelsberg says. The movements are very specific and have been clinically tested.

Other diagnoses are likely to benefit from different exercises. Specific habituation, balance, and gait exercises can be performed after proper instruction; these include Cawthorne-Cooksey and gaze stabilization. Clinic programs can incorporate trampolines, balance boards, treatment tables, and force plates.

Still other patients may suffer imbalance from purely physical causes, such as legs of different lengths. In these instances, patients can practice exercises intended to strengthen muscles while also incorporating devices, such as shoe lifts, which are designed to eliminate physical discrepancies.

Healthy patients can seek treatment too. Athletes often want to improve their balance in an effort to maximize their ability to shift their weight and better their performance. Adelsberg has worked with athletes from many sports, including golf, tennis, football, and basketball, frequently incorporating gaze-stabilization exercises. "Professional athletes, such as Barry Bonds [San Francisco Giants], have credited gaze-stabilization exercise with helping to improve performance," says Adelsberg, who notes that he has not personally worked with Bonds.

Balance Hangs in the Future

Athletes would also be likely to benefit—and enjoy—a therapy of the future: virtual reality. "Virtual reality techniques have been used to train astronauts to balance in space, and people are working on techniques to help patients improve balance on earth. One device features virtual reality glasses that change scenes in an effort to alter the patient's perception of space and time," Adelsberg says.

Other recent advances include noise-enhanced balance control and galvanic stimulation. Research like that under way at Boston University offers support for the idea that noise, electrical stimulation, or somatosensory vibration can improve balance in a broad selection of patients, including those suffering with diabetes, stroke, and aging.

As the new methods and corresponding equipment become available, physical therapists will need to perform a balancing act of their own, weighing evidence-based results and product claims against patient needs and practice resources.

Renee DiIulio is a contributing writer for Physical Therapy Products. For more information, contact .

Reference

1. Loyola University Chicago, Stritch School of Medicine, Department of Otolaryngology, Head, and Neck Surgery. The Hearing and Balance Center. Available at: www.luhs.org/depts/otolaryn/1a_balance.html. Accessed December 6, 2006.