Is Your Balance Therapy Missing the Point?
You feel dizzy, unsteady, and overwhelmingly tired. You go to physical therapy, and the plan seems straightforward: ‘gait and balance training‘ and ‘strengthening‘. But instead of improving, you only feel more exhausted.
Why? It is highly likely the therapy is targeting your muscles when it should be targeting your brain.
The Real Source of Your Fatigue
When a patient reports constant fatigue, many therapists logically conclude the patient has a muscular endurance problem. The solution, they assume, is strengthening.
The reality is that this fatigue is rarely a muscular issue. ‘The problem is not a lack of musculoskeletal endurance; it is a lack of balance system endurance‘.
You feel fatigued because your brain ‘is fighting a balanced problem all the time‘. This constant, internal battle to process conflicting information and remain upright is neurologically exhausting.
This is why we must use a ‘sensory strategy analysis approach‘. We need to analyze how your brain is attempting to keep you in balance. ‘Understanding the sensory strategy and the maladaptive sensory mismatch‘ is the critical first step. This analysis ‘helps us identify the treatment methodology you need for therapy‘.
When ‘Strengthening’ Makes You Worse
If the root problem is a sensory mismatch, simply trying to “push through” with muscle training will fail. ‘Recognize that it’s not always doing strengthening and endurance exercises that are going to help‘.
In this situation, ‘in fact, in many cases, [this] actually make[s] you worse‘.
The challenge is that, seeing no improvement, the therapist will often ‘prescribe harder and harder gait and balance exercises‘. This only deepens your neurological fatigue and reinforces the underlying problem.
The correct approach may be the opposite: ‘very simple, but consistent exercises at lower levels‘ that are specifically designed to rebuild your brain’s trust in its balance system, not just tax your muscles.
The ‘Repetition Trap’
We see a similar flaw when a therapist addresses a specific movement that causes you to feel dizzy. Instead of investigating the root cause, they ‘just make you do the movement over and over‘, hoping your brain will ‘get used to it.’
This approach ignores the why. That dizziness ‘may be an overcompensation of the patient’s visual system‘ or ‘an overcompensation of their surface‘ (somatosensory) system. Your brain is over-relying on one sense, ‘making [you] symptomatic‘.
‘This specific problem needs very specific training to resolve the dizziness symptom‘. ‘For instance, if a patient’s overly vision dependent, we’re going to need to do exercises that reengage and disengage vision‘. This type of training ‘is very specific versus just doing the movement‘ repeatedly.
The goal is to correct the underlying sensory conflict, which should eliminate the dizziness rather than just dull your reaction to it. Effective balance therapy demands a precise diagnosis of the sensory mismatch before any meaningful training can begin.
Brian Werner, PT, MPT, is a physical therapist who has been specializing in vestibular and balance disorders for over a quarter of a century. He is the founder of the FYZICAL Balance Paradigm and one of the co-founders of FYZICAL, LLC, Balance Center Division with Dr. Daniel Deems, MD, PhD, where he serves as the National Director of Vestibular Education & Training.