Balance & Coordination

When I take a patient history or catch up with a patient, I ask questions about why they have come to see me, and their medical history. I try to establish the onset of the problem. This can be a difficult issue as people tend to be very vague about the facts of the matter a lot of the time. So ‘when did it start’ … response ‘oh about a month ago’ seems to be a nice clear, precise answer. Drilling down into the issue further, it turns out it was ‘three months ago after tumbling out of the car in the municipal car park’ would be a more accurate answer. I also have people who fall, trip, catch themselves on something, stumble, miss a step etc and directly injure themselves or at least ‘set things off’. It is very easy to take this at face value and focus on the injury and circumstance following it exclusively, thereby ignoring the reason the incident occurred in the first place and missing out on a significant pathology. There always is a ‘reason’ and frequently it involves balance and coordination.

This is a difficult area because balance and coordination rely on many mechanisms in the body and those need to function individually and collectively and in a coordinated way. It is often the ‘collective’ part where things fail as signals from different parts of the body ‘disagree’ do not integrate with each other. 

There are lots of factors controlling balance and they all need to work together.

1. At the back of the brain there is a structure called the ‘cerebellum’. Its job is primarily coordinating complex sequences of movements, it is the body’s balance and control centre, so it controls coordination, movement and posture. Anything that damages the cerebellum can lead to loss of coordination(ataxia). Patients with this condition often walk with a wide, unsteady, stiff legged gait. It is damaged primarily through excessive alcohol consumption over a long time, but also hypothyroidism, vitamin E deficiency, auto-immune conditions, certain drugs and some brain tumours.
2. The inner ear contains a complicated structure the ‘vestibular system’ a bit like a series of bubble levels it provides information to the cerebellum regarding the heads position in space and movements of the body up, down, forward, back, nodding, rotating and where the body is in relation to gravity e.g. laying down, tilting and leaning. There are quite a few things that happen with this system such as BPPV Benign Paroxysmal Positional Vertigo, Meniere’s disease, ear infection, labyrinthitis all of them affect feedback to the cerebellum and for the people that have had episodes can be diabolically awful to live with.
3. The eyes provide incredible amounts of information to the brain and cerebellum regarding movement, position, acceleration so dysfunctions here cause lots of balance issues. A favourite visual feedback issue for me are patients who have varifocal glasses and fail to see the bottom three steps of the stairs on the way down. Additionally, patients who use a computer or read a book and have to place their head in one very, specific position for many hours so they can focus on the object in front of them. It does wonders for the neck and back.
4. Feedback from the skin, joints and muscles; here the umbrella term is ‘proprioception’. The nerves from these structures provide constant information to the brain and cerebellum. A loss of sensation for instance from the feet in diabetic patients is called ‘peripheral neuropathy’ and can cause sensory ataxia. Patients with this tend to have a high stepping, stamping gait and they trip up a lot. The feet are especially affected because the circulation here is poor, being furthest from the heart, so you get congestion that and the high sugar/glucose blood levels found in diabetes adversely affects these nerves damaging them. Other causes are spinal cord damage, multiple sclerosis, heavy metal poisoning and many other systemic diseases and the common one osteo-arthritis in joints.

So, coordination and balance rely on lots of sensory feedback from the skin, joints, muscles, ligaments, tendons, inner ear, eyes and all this is coordinated by the cerebellum. If one or more of these systems and structures is not working well or produces information conflicting with other systems information, then problems arise in the form of balance and coordination issues… and we fall down.