The Balance Trifecta


How can I improve my balance? This is one of my favorite questions patients ask because there are so many ways to improve balance. It is not just a single physiological system we can exercise, but is the interplay of multiple systems we can improve upon. I call them the Balance Trifecta: vision, sensation, and vestibular.


Vision is the one that probably makes the most sense. With vision, we are able to see where we are in space compared to our surroundings. We can tell which direction we are moving, turning, or falling. It is estimated that up to 70% of our brain is utilized to process vision. And in my experience, most people are heavily reliant on their vision for their balance. This is why balancing with your eyes open is easier than with your eyes closed. Or why when you are walking in the dark, you might feel a little more unsteady than in broad daylight. This is also why vision problems like macular degeneration or cataracts can affect your balance. Therefore, it's important to get your vision assessed on a regular basis as it not only affects how you see the world, but how effectively you can move through it.


Sensation helps us feel where our body is in space by sensing the surface we are sitting, standing, or walking on. The sensation on the bottom of our feet tell our brain if we are walking on a firm surface like a sidewalk or an uneven, softer surface like sand. We also have sensors at every joint in our body that tell our brain the exact position of that joint. This is call proprioception. For example, if you close your eyes and bend your elbow to 90 degrees, you can sense when your elbow is at 90 degrees without seeing it. These are our proprioceptors at work. They send messages to your brain such as the position of your ankle joint -- are you leaning forward, backward, towards one side or the other? Conditions like peripheral neuropathy, stroke, aging, or even a sprained ankle can alter your sensation and proprioception causing you to feel more off-balance.


The vestibular system is my favorite system, obviously. It is like a gyroscope in our inner ear telling our brain which way is up and in which direction we are moving. It is comprised of five sense organs: two that sense translational or linear movement and three that sense angular acceleration. If you ever find yourself getting out of the cold ocean after a long swim at night, chances are you are relying heavily on your vestibular system to keep you upright. How so? Your feet are numb so they can't sense the surface you are walking upon. And since it's nighttime, your vision isn't able to clearly identify where you are in your environment. So, because 2 out of 3 of your balance systems (vision and sensation) don't have enough information to tell your brain where you are in space, you can turn to your vestibular system to help you out. (Apologies for the seemingly random example, but as a cold water swimmer, I often find myself in this very situation.)


All these systems come together in various parts of the brain. The brain takes in information from vision, sensation, and your vestibular system and synthesizes it to get a clear understanding of where you are in space. Your brain also can choose to trust certain systems over others depending on the situation. So when you get up to go to the bathroom at night without good lighting, your brain will choose to trust your sensation and vestibular system more than your vision. Once your brain gets a clear picture of where you are in space, it immediately sends messages to specific muscles to keep you upright and stable. So, if one of these systems is weakened from age, injury, or disease, you may experience difficulties with balance. A vestibular physical therapist can help you identify which system(s) may be weak and provide strategies and exercises on how to strengthen and integrate these systems more efficiently.


If you are interested in learning more about which systems of balance you can improve upon and specific ways to do it, book an evaluation with Dr. Brooke Lindsley.