You get up from the dinner table, stand there for a moment contemplating your next move, whether to help clear the table, or hightail it to the tv to watch the game. Sounds simple enough, an everyday occurrence, but it is not. Some amazingly complex processes have just taken place. But, due to the incredible capabilities of the human body, you are able to stand and think about all sorts of things (like which game is on, how many dishes might you have to help with), but not your balance, while standing comfortably erect.

What is involved in the act of standing? With gravity pulling at every cell in our body, maintaining an upright position is actually a difficult thing. Staying upright requires a complex combination of systems within the human body. We all have a center, the central point of our mass, and keeping that mass over our feet, our base of support, is rather important. If we regularly had problems with balance, meaning keeping our body upright and vertical, the result would be a lot of falls. But many people do fall, and consequently, this is a significant health problem.

Falls are the most common cause of injury in adults 65 years of age and older, with roughly one third of seniors falling each year. The risk of falling triples if you have a neurologic disorder like peripheral neuropathy. Twenty to thirty percent of older people who fall, suffer moderate to severe injuries, such as hip fractures and head traumas. All too often, these injuries are life altering and evenly deadly. Falls kill more than 18,000 older adults each year, per statistics compiled by the CDC.

Clearly, balance is a critically important task. Postural stability and balance, adequate muscle strength, are all requirements for stance and ambulation. Many different systems must work together to provide us with these vital functions. They include various facets of the nervous system and musculoskeletal system, including vision, the vestibular system, proprioception, and last but not least, muscular activity and strength.

The vestibular system is a part of the labyrinth that makes up the inner ear. This is a collection of delicate structures that provide you with your sense of balance and an awareness of your spatial orientation. Problems with the vestibular system are surprisingly common in the US. The chances of developing vestibular dysfunction increase significantly with age and are also 70 percent higher amongst people with diabetes mellitus. People with vestibular system problems who are symptomatic, meaning they experience problems like dizziness, have a 12-fold increase in the odds of falling.

Maintaining balance depends on information received by the brain from other essential sources as well. Vision is a highly significant factor in balance. This is reflected by the inclusion in the standard neurologic exam of standing balance, performed both with eyes open and eyes closed. We cannot compensate for a loss of visual information with the other critical systems.

Many are unfamiliar with the term ‘proprioception’, which literally means “sense of self”. In the limbs, the proprioceptors are sensors, special nerve endings, that provide information about joint angle, muscle length, and muscle tension, put together by the brain to provide us with specific knowledge about the position of our limbs in space. Proprioception is very important and plays a critical role in coordination, posture, and body awareness.

Standing is an on-going, dynamic process. Our brain is constantly sensing our position and applying corrections by activating the appropriate muscles, attempting to control sway, the side-to-side motion of the upright human body. Ankle and hip muscles fire appropriately, responding to brain’s attempt to keep one’s center of mass over the base of stance. Control of ankle joint motion provides for front to back corrections and hips manage side-to-side adjustments.

What about conditions that interfere with sensation and its neural feedback system to the brain? Malfunctioning peripheral nerves, known as “Peripheral Neuropathy”, is a common condition. So, in addition to aging, neuropathy patients are at a greater risk of falling because numbness, decreased sensitivity to touch and muscle weakness can adversely affect a person’s sense of balance.

The effects of aging on balance deserve particular attention. The risk of developing problems in one or more of the sensory, motor, or adaptive brain components of balance increases with age. Over time, the body is exposed to various degenerative or infectious diseases, or it is affected by injuries accumulated over a lifetime. Balance problems in seniors are frequently caused by a subtle combination of these processes, which, individually, would not be significant, but together, result in balance problems. Various combinations of medications, both prescription and over-the-counter, can be detrimental to the brain’s adaptive capabilities and cause either temporary or permanent damage. The presence of soft tissue or bone pain has also been found to be an important risk factor for balance issues.

The large population of patients with neuropathy have diminished sensation, but the amount and kind of sensation loss varies. The progressive loss of balance and stability is a complication of diabetes that many physicians overlook. Yet, there are many opportunities to intercede in this condition. Recognizing the problem is a critical step. We often ascribe falls to the frailty and sarcopenia of advancing age (the degenerative loss of skeletal muscle associated with aging), but do not consider them in connection with diabetic neuropathy.

Improving one’s sense of balance can be achieved through various techniques. Certain physical therapies can improve leg strength and balance. Replacing those medications causing impaired balance, when possible, can be helpful. Perhaps controversial is the use of an ankle brace, technically referred to as an AFO (ankle-foot orthosis). The concept is simple. By stabilizing that part of the body where most of the deleterious effects of diabetes occurs, making their ankle more rigid, they can more effectively use the balance mechanisms at their knees and hips. Those structures are consequently on a more stable base. Many clinicians believe the balance mechanisms above the ankle in a diabetic are actually normal. When their ankle is stabilized, they use their knees more effectively, and they become less dependent on their eyesight to maintain their balance. It is also believed these supports tend to stimulate some of those proprioceptive nerve endings to provide more information to the brain. If you fix the ankle joint in place with an AFO, you reduce the need for neuromuscular control at that joint. Imposing an ankle constraint helps them to coordinate their other movements. Interestingly, researchers aren’t certain whether AFOs work by affecting gait mechanics, sensory feedback, or both.

It should be obvious balance is a critically important but complex phenomenon. Many different systems must be working in harmony to keep us upright. When any of these are impaired, the risk of falls is greater. Yet many seniors will not list this as one of their complaints, a potentially disastrous missing piece of information. Many successful strategies exist to improve balance. We can enhance a person’s ability to walk safely and effectively, leading to better ambulation, and more of it. This reliably results in better health and improved quality of life. And that’s a health benefit we can all get behind.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.