In my physical therapy practice I often get referrals for balance disorders. Difficulty in balance usually stem from a combination of sources. Some patients come in with vestibular (inner ear) dysfunction, Parkinson’s or Parkinson-like features, cerebellar insults, post-traumatic accidents such as motor vehicle accidents or falls, post-chemotherapy (“chemo-fog”) and poor balance without any known diagnosis. And usually the diagnosis is not so specific, sometimes just reading, “Balance, Evaluate and Treat.” As an integrative rehab professional, I have to differentially diagnose from their signs and symptoms, gathering subjective and objective findings to determine a hypothesis or a “physical therapy diagnosis.”
I have tried to keep it somewhat simple below, as differential diagnosis based on the various pathologies listed above would involve a more extensive post. But I find that yoga, based on the principles noted below, can be helpful to train any of these pathologies when applied mindfully and with attention to all sensory input in combination with engagement of the patient’s own experience.
Merriam-Webster’s definition of Balance–makes it seems so simple:
- a counterbalancing weight, force, or influence
- stability produced by even distribution of weight on each side of the vertical axis
- equipoise between contrasting, opposing, or interacting elements
- an aesthetically pleasing integration of elements
- physical equilibrium
- mental and emotional steadiness
But my Neurological Rehabilitation textbook (Umphred 2001) states that balance is “the ability to control the center of gravity (COG) over the base of support in a given sensory environment.” And also as “a complex process involving the reception and integration of sensory inputs and the planning and execution of movement, to achieve a goal requiring upright posture.” And it is indeed complex…it’s amazing that we don’t fall over at any given moment, when you consider all of the components that need to be in sync to prevent us from falling.
Physical equilibrium to maintain a COG is made up of several elements. Our nervous systems are influenced by and responsive to the demands placed on it by the tasks we are trying to accomplish and the environment in which we are performing the task. There are three primary peripheral sensory inputs that contribute to our postural control.
- Somatosensory = receptors in the joints, ligaments, muscles and skin; provides information about stretch, tension, muscle length, pain, temperature, pressure and position
- Visual = receptors in the eyes; provides a scan of the environment, vertical orientation and a perception of ourselves to the environment (head movement and postural sway)
- Vestibular system = known as the “inner ear;” identifies you as moving versus the environment, provides stable vision while the head moves, and provides stability through activation of antigravity muscles (neck, trunk and extremities)
The somatosensory or visual systems, on their own, cannot distinguish body movement from the environment moving. The brain needs all three systems to discriminate. Central sensory perception describes the brain taking information from both sides with the information from the the peripheral sensory inputs to provide a match–that you are indeed upright. But there can be sensory conflict when one system is taken out of the equation or is not functioning correctly.
Say for instance you close your eyes while in Mountain Pose (tadasana) and you feel yourself starting to sway. Your somatosensory and vestibular systems are taking over to provide the sense of upright. Or if you have a sinus infection or your ears are plugged up and you feel dizzy when you move your head around. Your somatosensory and visual systems are trying to makes sense and provide a match. In more serious cases of vestibular system dysfunction, you may have experienced vertigo. One side of the vestibular system is firing and the other is not the brain senses movement of the head when no movement is occurring. The result is a spinning sensation. One needs to find out why the dysfunction is occurring to treat the problem (Benign Paroxysmal Positional Vertigo (BPPV), Meniere’s Disease, etc). However the brain can adapt to this mismatch such as in the case of a unilateral stroke.
There are other systems involved in balancing the body in upright:
- Central Motor Planning and Control: I know where I want to put my body and am able to place it in such a way that I am stable
- Peripheral Motor Execution: I have adequate strength in my muscles and adequate range of motion of my joints to obtain a position that keeps me stable
- Attention, Cognition, Memory: I am not distractible, I have good judgement and I process the risk of falls appropriately
- Automatic Postural Responses: I use an ankle strategy (sway from the ankles/feet), hip strategy (sway from the hips) or stepping strategy (stepping or reaching to reestablish upright), or some combination, to keep from falling
Yoga and Balance:
Yoga and Physical Equilibrium Perception: In our physical yoga practice (asana) we generally think of balancing with “physical equilibrium,” producing stability “by even distribution of weight on each side of the vertical axis.” And most will conjure up visions of Tree Pose (vrksasana) or Half-Moon Pose (ardha chandrasana) and working to stand on one foot. But balance can be found in all poses, as well as entry in and out of the poses. Imagine the Warrior (virabhadrasana) series with entry in/out of the poses. And then asking you to take your gaze (drishti) above the horizon. All of your primary sensory inputs are working with your central perception to match yourself to upright. You may feel your ankles wobbling or your trunk shifting from side to side. You may even feel a little dizzy as you look up until your systems adjust and you regain a sense of upright.
And your ability to balance will change depending on the environment. Ever try your same yoga routine on the beach or the grass? Or just being outside where the clouds are moving above or next to a body of water where the water is rippling beyond your gaze? Your peripheral and central systems will be in conflict with one another to provide you with a sense of true upright.
Yoga and Central Perception: The vestibular system has been shown to be linked to the limbic system (memory, emotion and motivation), as well as to the hypothalamic-adrenal-pituitary (HPN) complex (your stress response system). Our autonomic nervous system is set up to maintain homeostasis, but when our system is overloaded by stress/anxiety, the system is out of balance. Stress or insult to the vestibular system causes release of stress hormones such as cortisol and adrenaline. And stress, “experiences that are challenging emotionally and physiologically,” may affect the vestibular systems ability to compensate, that is, to adjust. Acute stress of the vestibular system is easier to compensate, but when we have repeated stress, compensation is impeded. This has been demonstrated by poor survival of new neurons in the hippocampus (brain region responsible for memory and spatial navigation) under signs of stress. It is likely that the hippocampus is important for vestibular compensation. Physical activity (ie yoga, vestibular exercises) was shown to improve new neuron growth in the hippocampus. It is well established that patients with chronic stress undergo hippocampal remodeling and display hippocampal atrophy with deﬁcits in spatial memory (Saman, et al 2012)
What does this mean? Think, occurrence of vertigo or loss of balance–> increased stress response and arousal of autonomic symptoms (shortness of breath, increased heart rate)–> increased signs of vertigo and loss of balance and neuroplastic changes at the level of the brain, hardwiring the new changes = vicious cycle.
Yoga has been known to lessen stress and anxiety. When practiced mindfully, yoga encourages relaxation, slowing the breath and focusing on the present, shifting the balance from the sympathetic nervous system to the parasympathetic system. The latter is calming, lowering breathing and heart rate, decreasing blood pressure, lowering cortisol levels, and increasing blood flow to the intestines and vital organs (Woodyard 2011). Yoga has been shown lead to an inhibition of the posterior (sympathetic area) of the hypothalamus. This inhibition optimizes the body’s sympathetic responses to stressful stimuli and restores autonomic regulatory reflex mechanisms associated with stress. Yoga practices have demonstrated inhibition to the areas responsible for fear, aggressiveness and rage, and stimulate the rewarding pleasure centers in the median forebrain leading to a state of bliss and pleasure. This inhibition results in lower anxiety, heart rate, respiratory rate, blood pressure, and cardiac output in students practicing yoga and meditation (Woodyard 2011).
Yoga postures (asana) and breath (pranayama) are a positive way to train all of your systems.
Tips to find balance (within a pose):
- Move in/out of the pose using a breath (inhale or exhale depending on the movement)
- Break the pose into segments: For instance with Tree Pose (vrksasana), balance on one leg first, then move the arms above and then take the gaze up. Don’t try to do it all at once if it’s a challenge to do so.
- Feel the connection of your entire foot or hand into the surface, sensing placement of your big toe downward
- Find a focus point (drishti) : find a point to gaze at that is stable
- Use a chair or a wall to hold on to: vary the use of your hands, progressing from 2-hand hold, to 1-hand hold, to finger-hold; or just stand close to a wall or chair which may provide the subconscious perception of security (basically tricking your brain)
- Maintain a steady breath: breathing rhythmically/diaphragmatically can initiate the parasympathetic nervous system (“rest and digest”) to lessen any internal anxiety about fallling; it also reminds you to be present in the moment and as noted above, maintains homeostasis of your autonomic system
To challenge your balance: If you get extremely dizzy while trying these, you may want to be evaluated by your physician for a vestibular imbalance
- Change your eye position looking either up or down without moving the head
- Change your head and eye positon, looking either up or down or right to left
- Close your eyes within a pose–make sure you are already stable before trying this
- Change your environment: try grass or sand or a squishy mat; outside vs inside; sun vs clouds; wind vs stillness; people vs solitude
Common yoga asana used for balance.
Please enter a practice with a skilled instructor that is willing to guide you in sensory input, breath and safe entry/exit of the pose. Balance is a complex task, both physically and mentally. Part II to follow, demonstrating how your balance in yoga asana leads to balance in your daily life.
I welcome your feedback and hope that if you find this helpful, you will share with your colleagues and your friends. Contact Tianna to see how she can help you with improving your balance through an integration of your senses via therapeutic yoga and physical therapy.
- Umphred, D. (2001). Neurological rehabilitation. (4th ed.). St Louis: Mosby Inc.
- Saman, Y., Bamiou, D., Gleeson, M., & Dutia, M. (2012). Interactions between stress and vestibular compensation – a review. Frontiers in Neuro-Ontology, 3(116), doi: 10.3389/fneur.2012.00116
- Woodyard, C (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of life. Int J Yoga, 4(2), 49-54. doi: 10.4103/0973-6131.85485.
- www.shutterstock.com for images
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