Dr. Pat Allen is a collaborative physician. Her patients, she believes, will be her best partners in providing diagnostic information, as long as they are asked the right questions. She also believes in consulting with the best medical minds on issues that require specialization or unique clinical experience. Today, on the problem of precarious balance, she consults with Dr. Joseph Safdieh, medical director of the Neurology Clinic at Manhattan’s New York–Presbyterian Hospital.—Ed.
Dear Dr. Pat:
“How do I know if I have just balance problems or something more serious, like ALS? My uncle had this terrible disease.” [ALS, Amyotrophic Lateral Sclerosis, often referred to as "Lou Gehrig's Disease," is a progressive neurodegenerative disorder.] “Now, even though I am only 49, I find that I am tripping over things and don’t have the same kind of fine motor control I used to have. My handwriting is not good, for example. Does menopause bring on this disease?”
Menopause does not cause the symptoms that you describe. Our resident neurologist, Dr. Joe Safdieh, will discuss your symptoms and point out what a general-practice or internal-medicine doctor should do when faced with symptoms like yours.
Thanks for writing.
Dr. Joseph Safdieh Responds:
Feeling unsteady or off-balance is a disconcerting symptom, and this symptom often leads patients to seek out medical advice.
Sorting out why a patient has poor balance is one of the most challenging tasks a physician can face. There are dozens of potential causes, many of which are treatable.
The most concerning outcome of poor balance is falling, which often leads to physical injuries. Therefore, it is imperative that physicians be thorough when evaluating patients with imbalance. When seeing a doctor for imbalance, you should expect to be fully examined from head to toe. If you suspect that you are being given a perfunctory examination (for example, if your doctor merely listens to your heart and lungs, and your shoes/socks were not removed), request a referral to a neurologist.
Your physician should assess your muscle strength; test your reflexes with a reflex hammer; assess your ability to feel sharp and vibration in the toes, and, most important watch you walk.
The most common causes of imbalance include
• nerve damage in your feet (neuropathy)
• problems with your muscles
• problems with your spine
• problems with the balance center of the brain (called the cerebellum)
• Parkinson’s disease
Diabetics are at especially high risk for neuropathy, but other common causes include vitamin B12 deficiency and thyroid problems, so make sure blood tests for these conditions are requested.
Many medications, including some of those used for seizures and heart disease, may affect the balance center in your brain, and you should make sure that your doctor has a full list of everything you are taking.
Clues to muscle problems include muscle weakness and tripping. Your specific question is about ALS. Balance problems can certainly be caused by this incurable disorder, but this would be a pretty rare explanation for balance problems in most patients. Worrisome symptoms for ALS include muscle weakness, muscle wasting, unexplained weight loss, and trouble with swallowing or speaking. ALS is usually not inherited; less than 10 percent of cases have a clearly identifiable genetic cause. Most cases are fully unexplained, which is, naturally, very frustrating to both physicians and patients.
The diagnosis of ALS can be made by a thorough neurological examination. If you have any concerns about having this diagnosis, I would suggest obtaining a consultation with a neurologist, because this disorder is relatively easy to diagnose or to exclude at the bedside. So, instead of worrying that you may have this dreaded disease, you should see a neurologist, who will more likely than not find a more benign explanation for your symptoms.
Dr. Joseph Safdieh
Joseph Safdieh, M.D., Medical Director of the Neurology Clinic at Manhattan’s New York–Presbyterian Hospital, serves as Director of Outpatient Training for the Neurology Residency Training Program at Weill Cornell Medical Center. He has developed numerous curricula for the teaching of neurology to both medical students and other physicians.