Physical Therapist's Guide to
Balance problems make it difficult for people to maintain stable and upright positions when standing, walking, and even sitting. Older people are at a higher risk of having balance problems; 75% of Americans older than 70 years are diagnosed as having "abnormal" balance. Older women are more likely than older men to develop balance problems, although the difference between the genders is small. Balance problems increase by almost 30% in people aged 80 years or more. Mexican-Americans have the highest rate of balance problems among all Americans. Physical therapists develop individualized physical activity plans to help improve the strength, stability, and mobility of people with balance problems.
Also see: Physical Therapist's Guide to Falls | Health Center on Falls
What are Balance Problems?
A balance problem exists when an individual has difficulty maintaining a stable and upright position. A range of factors can cause balance problems, including:
- Muscle weakness
- Joint stiffness
- Inner ear problems
- Certain medications (such as those prescribed for depression and high blood pressure)
- Lack of activity or a sedentary lifestyle
- Simple aging
Balance problems can also be caused by medical conditions, such as:
Balance problems occur when 1 or more of 4 systems in the body are not working properly:
- Inner ear
- Muscular system
- Awareness of one's own body position (called “proprioception”)
Poor vision can result from age, eye tracking problems, or eye diseases. Inner ear problems, also called vestibular problems, can develop from trauma, aging, poor nutrition, or disease. Body-position sense can become abnormal as a result of trauma or a disease, such as diabetes. Muscle strength and flexibility can decline due to lack of exercise, a sedentary lifestyle, or disease.
The brain coordinates impulses from the eye, inner ear, and body-position senses, and sends signals to the muscular system to move or make adjustments to maintain balance. If one or more of the senses is not sending correct signals to the brain, or if the muscular system cannot carry out the necessary movements, a person may not be able to maintain or correct their balance.
How Does it Feel?
A person with balance problems may experience tripping, swaying, stumbling, dizziness, vertigo, and falling. Although a person’s "static" balance may be fine when standing still or only performing a single task at a time, “dynamic” balance problems may become apparent when the person is moving about or trying to do more than 1 thing at a time (ie, walking, while turning the head to talk to another person), or when there is not much light (at night, or in a darkened room). If someone’s dynamic balance is abnormal, it can cause a fall and possible injury.
Balance problems can make a person fearful of performing simple daily activities. As a result, they may lose muscle strength and become frail because they avoid strenuous or challenging movements. A person who has balance problems may start to feel frustration about the condition, and become depressed.
How Is It Diagnosed?
If you see your physical therapist first, the physical therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist will also ask you detailed questions about your condition, such as:
- How often do you experience problems with your balance?
- What are you doing when you experience balance problems?
- Is your balance worse at nighttime or in dark rooms?
- Does the room spin, or do you feel off-balance?
- How many times have you fallen in the past year?
- Have you suffered injuries from falling?
- Have you changed or limited your daily activities because of your balance problems?
- What medications do you take?
- Have you had a vision or ear checkup recently?
- Do you have difficulty with any daily activities?
- How much, and what kind of daily exercise do you get?
- Do you have any other medical conditions or problems?
- Are you under the care of a physician?
- What are your goals?
Your physical therapist will perform tests, such as motion, strength, coordination, visual tracking, and balance tests, to help assess your overall physical ability. Your physical therapist may collaborate with your physician or other health care providers, who may order further tests to rule out any underlying conditions that may exist.
How Can a Physical Therapist Help?
Physical therapists offer numerous options for treating balance problems, based on each person’s needs. They are trained to evaluate multiple systems of the body, including the muscles, joints, inner ear, eye tracking ability, skin sensation, and position awareness in the joints (proprioception). Physical therapists are experts in prescribing active movement techniques and physical exercise to improve these systems, including strengthening, stretching, proprioception exercises, visual tracking, and inner ear retraining.
Your physical therapist can help treat your balance problems by identifying their causes, and designing an individual treatment program to address your specific needs, including exercises you can do at home. Your physical therapist can help you:
Reduce Fall Risk. Your physical therapist will assess problem footwear and hazards in your home that increase your risk of balance problems or falling. Household hazards include loose rugs, poor lighting, unrestrained pets, or other possible obstacles.
Reduce Fear of Falling. By addressing specific problems that are found during the examination, your physical therapist will help you regain confidence in your balance and your ability to move freely, and perform daily activities. As you build confidence in your balance and physical ability, you will be better able to enjoy your normal daily activities.
Improve Mobility. Your physical therapist will help you regain the ability to move around with more ease, coordination, and confidence. Your physical therapist will develop an individualized treatment and exercise program to gradually build your strength and movement skills.
Improve Balance. Your physical therapist will teach you exercises for both static balance (sitting or standing still) and dynamic balance (keeping your balance while moving). Your physical therapist will progressively increase these exercises as your skills improve.
Improve Strength. Your physical therapist will teach you exercises to address muscle weakness, or to improve your overall muscle strength. Strengthening muscles in the trunk, hip, and stomach (ie, “core”) can be especially helpful in improving balance. Various forms of weight training can be performed with exercise bands, which help avoid joint stress.
Improve Movement. Your physical therapist will choose specific activities and treatments to help restore normal movement in any of your joints that are stiff. These might begin with "passive" motions that the physical therapist performs for you, and progress to active exercises that you do yourself.
Improve Flexibility and Posture. Your physical therapist will determine if any of your major muscles are tight, and teach you how to gently stretch them. The physical therapist will also assess your posture, and teach you exercises to improve your ability to maintain proper posture. Good posture can improve your balance.
Increase Activity Levels. Your physical therapist will discuss activity goals with you, and design an exercise program to address your individual needs and goals. Your physical therapist will help you reach those goals in the safest, fastest, and most effective way possible.
Once your treatment course is completed, your physical therapist may recommend that you transition to a community group to continue your balance exercises, and maintain a fall-proof home environment. Many such community groups exist, hosted by hospitals, senior centers, or volunteer groups.
Your physical therapist may recommend that you consult with other medical providers, including:
- An eye doctor, to check your current vision needs.
- An ear doctor, to check your outer and inner ear status.
- Your personal physician, to review your current medications to see if any of them may be affecting your balance.
Can this Injury or Condition be Prevented?
To help prevent balance problems, your physical therapist will likely advise you to:
- Keep moving. Avoid a sedentary lifestyle. Perform a challenging physical activity each day to keep your muscles strong and flexible, and your heart and lungs strong. Use your body as much as you can to walk, climb stairs, garden, wash dishes by hand, and other daily activities that keep you moving. If you work out or follow a fitness program, keep it up!
- Have yearly checkups for vision and hearing. Make sure your vision prescription is up-to-date.
- Carefully manage chronic diseases like diabetes, whose long-term side effects can include balance problems. These side effects can be greatly reduced by following the recommended diet and medication guidelines given to you by your physician.
- Monitor your medications. Make note of any medications that you think may be affecting your sense of balance, and talk to your physician about them.
- Report any falls to your physician and physical therapist immediately. They will evaluate and address the possible causes.
Your physical therapist will also prescribe a home exercise program specific to your needs to prevent future problems or injuries. This program can include strength and flexibility exercises, posture retraining, eye-tracking and vestibular exercises, and balance exercises.
Real Life Experiences
Margaret is a 70-year-old retiree. She and her husband have lived in the same house for 30 years. Margaret is as active around the house as ever, taking care of all the household cleaning and maintenance, growing vegetables in her garden, cooking, and tackling light landscaping.
One night recently, Margaret tried to close the bathroom window when it turned chilly outside. She didn't bother to switch on the bathroom light. In order to reach the window, she had to step into the tub with her right foot. She found that she had to push harder on the stubborn window, and lifted her left leg to place it in the tub. The next thing she recalled was explosive pain in her ribs. She realized that she was on her side, sprawled half in and half out of the tub. She did not recall falling. Her husband got her to the doctor.
Margaret's doctor x-rayed her ribs, shoulder, and toe, and found no broken bones. He instructed Margaret on how to care for her many bruises. He bandaged a torn toenail on her right foot, and told Margaret that she would not be able to wear a closed-toe shoe for awhile.
When her doctor asked Margaret if she had fallen before, she admitted that she had lost her balance while going upstairs recently. She admitted that she felt more off-balance in the dark. Margaret also mentioned that she and her husband attended ballroom dancing sessions each week, and joked that she never could learn to “spot a turn.” The physician, knowing that the dancer technique of “spotting a turn” requires inner ear and vision function, recommended that Margaret consult with her eye doctor, and her physical therapist.
Margaret met with her eye doctor and got her vision prescription updated; she noted that she felt somewhat more balanced with proper eyeglasses. She then met with her physical therapist.
Margaret's physical therapist took her medical history and performed a full battery of tests, assessing Margaret's muscle strength, balance, body-position sense (proprioception), eye-tracking ability, and inner ear (vestibular) function.
She noted Margaret's bruises from her fall. In addition, she found that Margaret lacked the ability to keep her eyes focused on an object while turning her head, and that her balance was severely affected when her eyes were closed. She asked what Margaret's personal goals were for therapy; Margaret said she wanted to avoid falling, return to her normal vigorous household activities, and attend her ballroom dance sessions 3 times per week.
Margaret's treatment began with simple eye-tracking exercises, and moved on to standing and walking balance exercises. Her physical therapist then added specific strengthening exercises to the routine. She also performed hands-on therapy, somewhat like massage, to increase the healing speed of the shoulder and rib muscles that were bruised and strained. She also applied electrical stimulation and cold packs to those areas to reduce swelling and pain.
Margaret continued her physical therapy sessions for 4 weeks, increasing her exercises as her strength returned. She learned about fall-proofing her home, including installing night lights in the bathrooms, and about wearing proper footwear.
At the end of her treatment program, Margaret was able to return to all her household tasks, and maintain a home-based exercise program designed by her physical therapist. She reported that she felt much more confident about maintaining her balance, even at night. She and her husband returned to ballroom dancing—and she was able to gently “spot a turn” for the first time in her life!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat balance problems. However, you may want to consider:
- A physical therapist who is experienced in treating people with balance or vestibular problems. Some physical therapists have a practice with a balance or vestibular focus.
- A physical therapist who is a board-certified clinical specialist, or who completed special training in vestibular physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapist’s experience in helping people who have your type of problem.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of balance problems. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Cho SI, An DH, Yoo WG. Effects of recreational exercises on the strength, flexibility, and balance of old-old elderly individuals. J PhysTher Sci. 2014;26(10):1583–1584. Free Article.
Exercise programme aims to cut number of falls across Europe. Nurs Older People. 2014;26(9):7. Article Summary on PubMed.
Rice LA, Ousley C, Sosnoff JJ. A systematic review of risk factors associated with accidental falls, outcome measures and interventions to manage fall risk in non-ambulatory adults. Disabil Rehabil. 2014;29:1-9. Article Summary on PubMed.
Jefferis BJ, Iliffe S, Kendrick D, et al. How are falls and fear of falling associated with objectively measured physical activity in a cohort of community-dwelling older men? BMC Geriatr. 2014;14(1):114. Free Article.
Jalali MM, Gerami H, Heidarzadeh A, Soleimani R. Balance performance in older adults and its relationship with falling. Aging Clin Exp Res. 2014 October 7 [Epub ahead of print]. Article Summary on PubMed.
Thomas S, Mackintosh S. Use of the theoretical domains framework to develop an intervention to improve physical therapist management of the risk of falls after discharge. Phys Ther. 2014;94(11):1660–1675. Article Summary on PubMed.
Fischer BL, Gleason CE, Gangnon RE, Janczewski J, Shea T, Mahoney JE. Declining cognition and falls: role of risky performance of everyday mobility activities. Phys Ther. 2014;94(3):355–362. Free Article.
Granacher U, Gollhofer A, Hortobágyi T, Kressig RW, Muehlbauer T. The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: a systematic review. Sports Med. 2013;43(7):627–641. Article Summary in PubMed.
Pardasaney PK, Slavin MD, Wagenaar RC, Latham NK, Ni P, Jette AM. Conceptual limitations of balance measures for community-dwelling older adults. Phys Ther. 2013;93(10):1351–1368. Free Article.
Clemson L, Fiatarone Singh MA, Bundy A, et al. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. BMJ. 2012;345:e4547. Free Article.
Dillon CF, Gu Q, Hoffman HJ, Chia-Wen K. Vision, Hearing, Balance, and Sensory Impairment in Americans Aged 70 Years and Over: United States, 1999-2006. Published April 2010. Accessed November 29, 2014. NCHS Data Brief Number 31.
Lord SR, Smith ST, Menant JC. Vision and falls in older people: risk factors and intervention strategies. Clin Geriatr Med. 2010;26(4):569–581. Article Summary on PubMed.
Orr R, Raymond J, Fiatarone Singh M. Efficacy of progressive resistance training on balance performance in older adults: a systematic review of randomized controlled trials. Sports Med. 2008;38(4):317–343. Article Summary on PubMed.
American Physical Therapy Association. Falls risk reduction in older adults. Published July 2007. Accessed February 4, 2015.
Barnett A, Smith B, Lord SR, Williams M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomised controlled trial. Age Ageing. 2003;32(4):407–414. Free Article.
National Osteoporosis Foundation. Preventing falls. Accessed November 28, 2014.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Andrea Avruskin, PT, DPT. Reviewed by the editorial board.