Balance issue or proprioception or both?

[Fluffysmom]

Which is which, or do both play a factor?

1.  Leave table at restaurant, walking by a row of empty chairs.  Realize I forgot something, turn back to go get it, and slam my left knee into the chair at the end of the row.  I knew it was there, but I wasn't looking at it.

2.  Canister vacuum on top of file cabinet; attachments sitting loose.  I know it's all there, bend down to pick something up from in from of the file cabinet, and get a round imprint from one of the long tube attachments in the middle of my forehead.

3.  Head into kitchen to stir beans on stove; bruise right shoulder on corner of doorway.

4.  Putting something in back seat of car, go to stand up and bang my head on the top of the door frame.

5.  Walk into living room to sit on couch and watch TV; trip over cat scratching post that has been there for ages.

There are times when my balance issues are more clear, like when I fell of the box in PT, or I'm walking through a store and it feels like the floor moves underneath me.

Other times I wonder if its lack of attention to what I'm doing, or lack of true perception of where I am in relation to other things.  I'm usually pretty careful, especially since I fell in the garage not long after my tremors and stuff started more than a year ago.

I couldn't sleep, and this question popped into my head, so I thought I'd ask.

Thanks,

Kathy

[Fluffysmom]

OMG, I am so happy to see you!  I've been wondering how you're doing, if you're ever coming back to us.

Then the other day, my roommate told me I need to see Dr. House so someone can figure out what is going on with me, and I immediately remembered all the comments you made about House, made me smile.  And here you are!

I did get some great shoes from the Running Store after they did a gait evaluation on me and it showed my left foot flopping out to the side with every step I took.  The new shoes, and some physical therapy exercises have helped with that.

I've always liked Reeboks; I'll try on a pair of Easytones and see if I can actually walk in them.

I've thought of wrapping myself in bubble wrap, lol.

I used to have the nickname "Kathy the Klutz" by my dear family.  That changed after I took Judo classes and climbed a bunch of mountains.  It would  be nice if we could find out the reason for some of the Klutzy-ness and fix it.  I do try to be careful.

I'm going to see my MS specialist today; she has done nothing for me in the 8 months that I've been seeing her, and I'm going to see if I can get that to change.  Politely, of course!  :o)

Take good care of yourself, and visit more often! (please)

Kathy

[Farrahlicious]

Hi dear!
Good to see you!
what you're experience is "normal", i guess. Before i was diagnosed, I was called "Clumsy McDummy" by my brothers. I dropped glasses. I went to get sugar from the sugar bowl and spilled half the stuff. My dad is such an extremist when it comes to "ladylike manners", so, he watched in horror how i took the "mouth to fork" instead of "fork to mouth". I broke my nose banging it straight into a door, even tho i saw it. I slam my head, burn myself, and last month i lost a lovely slice off my right ankle hitting a "doggie fence". I am covered in bruises, cuts and burns. Geez, i'm such a beauty! I only need to lose a tooth to become Miss America!
Ok, so i don't work for the company. I don't believe in miracle stuff. But talking to my neuro the other day (our conversations are so relaxed, they have become like "what you doin'"? "I had sushi for lunch"... we're like girlfriends) well, we just got a new pair of Reebok shoes. He recommended me to go take a look. Their slogan is "take the gym with you". I thought it was a bad joke from my neuro, but they were cute, and they feel like walking on clouds. They demand a 30% more energy with every step you take, and for you to focus on your balance without even noticing. Oh, and the best part, they claim to tone your legs, thighs and butt. If i see any "American Gladiators" results, i'll let you know. But the way their soles are built, help a lot with balance. I love them so much, i got myself another pair! They're called Easytone.
On the bumping, hitting, slamming..mmm... i can't offer you any advice but to wear a helmet. Or a full football uniform.
Love ya!
Farrah

[AMO]

Dear KAthy,

I can relate to this welll.
Having the test to distinguish where you  r problems coming from i s a good idea. I have run the gammot too. My VNG done my neuro otolaryngologist was quiet  teelling of central problems ('very abnoraml' she said) Having the compuer platform evallutaion    can giive them more information and can be resteed to see improvements or declilne.
It was years ago. She said to me I would only gett worse. I thought she was wrong and how would slhe know... she is right.

My neuross all have tolld me through many  years this area   is one most diffiicult o treat. II had almost a years of Vestuiibular Rehab Therapy (very specific routines quiet different thaan noromal physicall therapy) unnfortuanatly with out      any help.

Ess,   When i had VNG they diid water, not air..wild ride huh??
my unnnderstanding is this reflex reaction is something they  tesst with coma patients seeing any brain activity?  Quix,,, is that right dooo you knopw?

I ihope you gals finnd someting you can get help.
take care today, amo

[Nancy T]

Upon re-reading part of the site I posted, I see that they say that "x-rays" are necessary to diagnose an acoustic neuroma (inner-ear tumor); that's somewhat, uh, aged information!! You'd think one of the leading centers in the world for acoustic neuroma wouldn't copy decades-old material onto their computer Web site.

However, a lot of the other stuff is good.

[Nancy T]

When I really started to get scared about what was happenign to me was when my "reach" went off a bit. The dizziness is just a feeling in your head, but one summer (years ago) I would invariably miss things like drawer handles, the dishwasher rack, etc. the first time--constantly had to try a second time, with my eyes and attention focused directly on the object. Otherwise I'd come up a little short, my hand flying down an inch short of its target or just brushing it with the backs of my fingers. At the same time, I would always miss my tongue when trying to lick my finger (flipping through manuscripts). I'd hit the side of my mouth instead, and bringing a glass to my mouth, I'd hit the edge of the glass under my lower lip instead of in my mouth. A failure of "fine tuning," as Quix describes it. It went away about 98 percent over a matter of months. Still have it about 2 percent, or maybe 10 percent.

I don't know whether an inner ear problem can cause that. I don't think so?

Here is a pretty good explanation from the House Ear Clinic of how the balance system works (vision, inner ear, proprioception)--not that Ashley, Quix, and others haven't already given good descriptions:

https://id315.securedata.net/houseearclinic/dizziness.htm

This site also includes good info about causes of dizziness.

I had two ENGs at the neuro-otologist's office, but had my auditory evoked potentials and fistula pressure test done at the Good Sam lab. The audiologist at that lab seemed really excellent--very careful and explained everything very thoroughly to me as she was doing it. Took a long time to get in for my tests, though; they seemed very busy.

Nancy

[rendean]

As usual an excellent explanation of how the body maintains its balance,etc. My condolences on the RSD/CRPS. I, too, have suffered from that after a long nasty battle with an incompetent PCP who fired me as a patient after I wrote her a letter  about her condenscending ways (i.e "is it that bad at home , honey? Why don't you let the maid and the cook  do that for you?) After my own self referrral to an ortho who suggested a vascular consult for the purple foot, the  vascular guy nailed the dx upon walking in the room. I digress, my sympathies as I truly know how painful hitting my right foot can be.

Nice touch about the rhino being too long.

Ren

[PastorDan]

I remember the rhino; wondered why I never hear it anymore.

My ENG was by an audiologist (M.A., if I recall correctly); my VNG a month or so later by a Doctor of Audiology.  VNG was an ENG with pricier equipment, from all appearances.  Both operators told me that both were of equivalent accuracy, so neither understood why the neuromaniac ordered the VNG with a month old ENG staring him in the face.  Well, he owns a share of that lab, but we know that's not going to influence how he treats patients.

Speaking of scientific analysis, I sure hope Al Gore shows up here tomorrow morning, to sweep all this evidence of global warming off of our front entrance ramp.

[Quixotic1]

The clumsiness Kathy is talking about is a failure of the various systems to work well together.  Proprioception is mostly knowing where your body is in space:  Are you upright?  Are you legs apart or together? Is your elbow bent?

Then there is coordination.  Does your body do what you are asking of it in motion.  I rarely go thru a doorway without hitting at least one of the doorjams.  And yes, I can see jams, but just the thought that I am going to have to turn seems to throw me off balance.

This is the fine-tuning of movement that occurs in the brain, but mostly in the cerebellum.  When I reach for that can I adjust the thrust of my arm so that it slows just in time to grab the glass of water.  Did my fingers open early enough for the grasp?  When I pick it up do I know that I have a proper grip on it?  When I bring it to my mouth am I keeping it level?  Many different systems come into play for that action.

My most obvious problem with coordination comes when I try to throw with my right hand.  My brain CANNOT get the signal to my hand to let go of the object at the proper time - even with practice. I always let go late, no matter how hard I try to let go earlier. If I am tossing a cat's toy underhand, it invariably either hits the ceiling or I throw it up and behind me.  If I am tossing the toy overhand, I throw it directly into the floor in front of me.  The cats walk away in disgust. "What a dork!" they mutter.

When we run into things we know are there it is often a failure of multitasking:  Can I walk, turn, think about what I am returning for, chide myself for forgetting it, and avoid the chair that I saw was in my way?  Several studies have shown that MSers often fail at physical mutlitasking.  If a person with MS is walking and speaking with someone at the same time, their walking speed declines and they are more likely to compensate poorly for unevenness in the ground.  They ware more likely to stumble and have more severe drop-foot (if they have it).  The quality of their gait worsens.

Balance has to do with keeping ourselves upright in the world as we move or are still.  It requires that we understand where "down" is (largely a function of the inner ear and vision) and that we are aware on some level of our direction of motion and our velocity and acceleration.  IN my case, since my inner ears are mostly shot, I depend almost solely on my vision for balance - which is very fatiguing.  In the complete dark I go over and don't know it until I fall.  I have learned to pay close attention to the tertiary systems of pressure on my feet and listening for the walls to help me at night.  Even that is failing as the sensation in my right foot decreases.

I have another problem that can be very painful.  I have RSD - Reflex Sympathetic Dystrophy in my right lower leg.  It isn't painful except when I bump my toes.  Then you would think that someone tried to take my leg off with a chainsaw!  Pain all out of proportion to the trauma.  The right leg is also the one with the drop-foot, the hip flexor weakness and the spasticity.  When I walk, I raise my hip and swing the foot out and around to get it in front.  But, I cannot seem to learn to give myself enough room and am forever swinging the foot into things and yelping.  Failure to learn.

So, Kathy you are certainly not alone in that great Cosmic Pinball Game that is life.

I would recommend that you try to get a VNG by people that specialize in treating vertigo.  There is great variation in the qulaity of how the VNG is run.  My Dr. Epley's setup was so sophisticated and elegant.  But, I have had it other places where it was sloppy and mishandled.  OHSU has a good vestibular center, as does Legacy Good Sam.

ENT's are all otolaryngologists.  It used to be otorhinolaryngologists, but they dropped the rhino - may be was too long, lol.

[shoshin]

Kathy: The test I had is called Computerized Posturography. The post where I talked about it before is at http://www.medhelp.org/posts/Multiple-Sclerosis/Physical-therapy/show/592853. I don't think it's anything like a VNG, but I haven't had one of those.

jdhecaj: I hate to say this, but I think looking at your feet is exactly the wrong thing to do because it reinforces your dependence on the visual part of the balance system and allows the other parts to deteriorate further. In a book I read on brain plasticity, they said that older people who looked at their feet to balance just made their balance worse. You might want to check out the PT in case it might help.

sho

[Fluffysmom]

Cool, thanks!  It sounds simple enough.

So I can call my ENT and see if he can have the audiologist in his office do the VNG.  He's actually and otolaryngologist, but I would assume they have the same equipment.  Doesn't hurt to call and ask.

It will be interesting to see what your results show.

Kathy

[essdipity]

Had the VNG and it was interesting. Done by an audiologist, not a tech. Took about an hour and was not uncomfortable at all.

Despite the fact that it looks for vestibular causes of vertigo, it mostly uses eyesight, following a white square around a black computer screen and that sort of thing. Nystagmus is deliberately induced. But one part of the test involves blowing warm and then cold air into the ears. Go figure.

Since the ears are only one part of the balance/vertigo equation, the others being the eyes and proprioception (at least I think I have that right), I don't think VNG can say anything conclusive if not much vestibular abnormality is seen.

As with almost all such tests these days, a great deal of it is conducted using computer connections and very specialized software. The audiologist said she would have to print out all the results and then do an analysis. I'm to call my ENT Wednesday to find out what's what, at which point I'll request a paper copy of the report. Will let you know.

ess

[jdhecaj]

Very interesting post & the replies. My current neuro has asked me if I wanted to go to PT. My former neuro had told me walking was good enough excersize for me. When my current neuro brought up the subject of PT, I told her no I wasn't interested at this time because I felt walking was better for me than PTat this time. But I would like to keep her suggestion open if I feel that changes.

A few years ago, I needed to stare at my feet to walk. I no longer have to do that, but I do find it is easier to watch my feet when I walk, so I do quite a bit. It's just easier. And I have that feeling of walking inside a 'hammock, sometimes'. I thought this was something MS, but I wasn't sure. Those things are not constant for me. They happen for a while, maybe a morning then I forget about them so they must go away until they come back.

A few years ago I always needed to stare at my feet to walk. At neuro appointment he had me walk down the hall while he watched. I stared at my feet very intently and didn't stumble or lose my balance. I turned around with a big smile on my face at my accomplishment, I hadn't stumbled at all. He wasn't smiling or even returned the smile. Just asked me if I could feel my feet. 'Of course I can feel my feet, how would I know when to sweep/vacuum if I couldn't feel my feet' :) I tracked it down to proprioception. sense. But I didn't know about a somatosensory  sense. Well I learned something to today. Its a day of accomplishment for me already this morning.

[Fluffysmom]

sho, that test sounds interesting, and different from what the VNG sounds like; I wonder if it was a similar test or something totally different.  It sounds like the physical therapy was pretty helpful.  I'd be willing to give it a try.  

ess, I certainly hope that list of "no"s doesn't include pain medication and Lyrica; don't know if I could stand 48 hours without.  I don't think you're supposed to stop taking Lyrica abruptly, so I suppose they would let you continue that.

So today is your VNG:  I'll will be looking forward to how it went for you.  I'm so tired of losing my balance and being dizzy/lightheaded that I'm ready to see if my neuro or somebody will order one for me.  Any kind of answers and possible treatment are worth the try.

Kathy

[essdipity]

Tomorrow I'm having a VNG test, so maybe I'll learn more about what info that can give. It's interesting that for 48 hours in advance I can have no sedatives, no stimulants, no aspirin or nsaids, no alcohol, no nothing. I can understand how these could affect the outcome if I were somehow 'under the influence,' but 48 hours seems really long.

I don't have your symptoms, except for the floor moving one, which of course causes me to compensate as best I can. If I'm outside and walking on uneven terrain, yikes.

With luck I'll find out whether this is peripheral or central. Would this be a good test for you?

ess

[shoshin]

FWIW, I think I bump into things both from balance problems and from proprioception problems.

Before my balance problems got so bad, I used to brush up against walls and door frames a lot. I don't think it was a balance issue. It felt like a misjudgment of where my body was so I'm pretty sure it was a kind of proprioception problem. I don't do that so often any more.

As my balance problems on flat surface increased, I have a tendency to fall into things. I think Quix once described this as being like a pinball and that's how I go down the hall sometimes. It's different from the above because I know I'm losing my balance and I am using whatever I fall up against to break my fall.

When I went to PT, I had a test that involved a booth with a moving floor that had computer sensors in it that tested how well the three elements of the balance system are working. It spits out a graph ranked from 1-100 for each element and also shows what's normal for your age.

When I started PT, my vestibular system was barely above zero and my somatosensory (which sounded to me like it's mostly the sensations on the bottom of the feet) was below normal, and my visual was well above normal. After four weeks, my vestibular went up to around thirty, which is still way below normal, but much better than it was. The somatosensory also went up a little, although the PT told me there wasn't anything that therapy could do about that.

sho

[Fluffysmom]

I think you're supposed to avoid hitting the same place more than once in a day... Yeah, if that were possible, we wouldn't be running into stuff in the first place.

It's good to see you; seems like I haven't seen much of you lately.  Not that I've been around consistently, myself.  Hope all is well with you.

Kathy

[Sunnytoday]

Kathy- great question and good answers!

I had to laugh at myself today. I whacked my head on a open cabinet door above my head hard enough to see stars and then later this afternoon I was walking past our swinging door and somehow managed to hit my head on it as I walked past it- very hard on the same side of my head. It would be NO surprise to anyone that I have a very bad left-sided head-ache tonight that tylenol isn't touching? :)

~Sunnytoday~

[Fluffysmom]

Wow, thanks, that was a good explanation.

I have had trouble with blurred vision since my symptoms began last February, but I've had a totally complete neuro-ophthalmic work-up, and everything was totally normal, even my VEP.

Would it then follow that this could all be vestibular, in line with my light-headedness, vertigo, loss of balance?  Even the blurred vision, if my vestibular reflexes aren't coordinating my vision with my postural muscles, my gaze is not fixed, or stable?

I wonder where my malfunction in fine-tuning really lies?  Would your opinion be, given that my visual processing checks out with the neuro-ophthalmologist, that there is some other miscommunication that affects my ability to adjust my movements in space to avoid things?

So many questions!

Thanks for your input!

Kathy

[ashleyPT]

Ok let's see if I can help at all.

Balance is finding a state of action and reaction in our bodies.  3 systems contribute to our balance.  1 - vision 2- vestibular 3- proprioception.

We all know about vision - Visual input is a huge factor to our balance and the system that we rely on most as we age because of the deterioration of the other two.

The vestibular system is our inner ear system which gives our body information about our  spatial orientation (turning, upright, sideways, moving, stationary etc.) There are also vestibular reflexes that coordinate with our vision and our postural muscles that help us to fixate on objects and stabilize our gaze.

I find proprioception the most difficult sensation to explain to my patients.  At it's simplest it is the internal feedback we get from our joints/muscles/ligaments.  They have there own sensory receptors just like touch or pain or temperature do.  Proprioception is also how we learn and fine tune skills.  How you can walk without looking at your feet.

All three systems work together to form our balance.  As one is declining or challenged we rely more heavily on others.  

Running into external objects for various reasons would not be proprioception since that is an internal sense.  In my opinion the senses that seem more involved in your bumps are visual processing and the ability to adjust your movements in space to avoid things.  The cerebellum is the area of your brain involved in adjusting and fine tuning movements to have your body perform the way you planned.  This happens so quickly we don't notice it - but when you do anything there is a constant monitoring from your vision and proprioception to your brain and back down to your muscles to make sure you are performing the activity correctly.  

I hope that helps and makes sense.

[saveone]

Sorry to say I also belong to this club and I have wondered which was the cause.  Either way it still causes bruises and some interesting moments...terry

[Fluffysmom]

You are soooooooo right!  Laughter IS the best medicine!  It kind of freaks my roommate out at times; I think she might think I've knocked a screw loose, lol, when I laugh when I've banged, bopped, or walloped myself!

She's getting used to it, though.  I went on a trip with her in January, and SHE packed the arnica gel for me.  :o)

Kathy

[student01]

Just what I needed you have made me laugh because everything that you just described has happened to me. Doing dishes, opening the cabinet to put a glass away not closing it and smacking my head 3 seconds later, or going to the bathroom and bending down to sit and smacking my head on the towel bar that has been there for 20 yrs. You get so upset at the time thinking to yourself how can I be so stupid, but I found that after the initial shock you wind up laughing at yourself. They say laughter is the best medicine, you just gave me a dose THANKS !

Lynn

[Fluffysmom]

Well, the banging the knee happened last week, a few days before I fell off the box at PT (have a bump/bruise on left hand where I caught myself on exercise bike).

The other things have happened over the past year, with many more incidents, like the time I was laughing and joking with my roommate and fell into the half-wall in the bathroom face-first, getting paint on my glasses and a bruised cheek and eyebrow.

I've done a lot of turning corners and hitting things, stuff like putting things in the fridge and hitting my head on the bottom of the freezer door.

My roommate has started to warn me about stuff, and she's always told me that if I give I believe I'm a clutz, I'll be one. She's given up on that project and tells me if she thinks I'm going to trip over or run into something.

I used to climb mountains, do rock climbing, hike on narrow exposed trails, practice judo (you really are aware of what your body's doing in judo!).  That was mostly quite a while ago, but I've mostly been very sure-footed.  I could walk to college along a highway while reading a book, and never trip or get hit by a car.  :o)  I did get told off by my judo instructor, who saw me doing it.  :o}

These things happen more often when my symptoms are flaring up.  They have improved somewhat since I've been taking Provigil, but in the few months I've been taking it I've still done a fair amount of banging into things.

I have Arnica gel for the bruises.  Haveyou tried it?  It can help them fade more quickly, and it feels good, too.  

The twisted knee was bad; I had visions of getting that total knee sooner rather than later, but it has calmed down, thank goodness.

Thanks,

Kathy

[Lulu54]

Wow Kathy,  you must look pretty banged up with all those bruises.   I tend to be klutzy to start with and you add in my balance issues and I accumulate some nice black and blue spots too.  

What's the time frame on all this happening? I would think that's a big clue - if it all happened in a day or two vs spread out over a week or so would be telling.

my best.
Lulu