About a third of people 65 years and older fall at least one time each year.1-3 Falls account for over half of all injury-related hospitalizations for the elderly.2
As a community, we can help our friends and family members by assisting them with the exercises and helping them address any external factors noted below. As individuals, we can boost motivation by exercising with a friend or taking a class. Additionally, a common message that is conveyed to older folks is that they are frail and that inactivity and falls are an inevitable part of aging.6 As with many other things in life, its easy to take an aspect of truth and swing our pendulum in an extreme direction. Its true that sarcopenia, the term given to the loss of muscle mass related to age, occurs.3,6 About two percent of muscle mass is lost per year after the age of 50.6 This loss in muscle mass is one of the main contributors to decreased function, such as rising from a chair, walking, making turns, and balance at rest and while performing activities.3,6,7 However, strength training has been shown to greatly mitigate this decline.5,6 Perhaps even more exciting is that exercises and educational programs have been shown to significantly improve balance and decrease the risk of falls as well as injuries caused by falls.1-13
Aside from the exercises mentioned below, Tai Chi2,14, Pilates21, and Yoga22 have been shown to improve balance and decrease the risk of falls. If you live in the Bishop area, we’re blessed to have Tai Chi classes taught by Andy Selters and Deo Santos, Pilates at Bishop Yoga and Pilates Center and FlowMotion Pilates, and yoga at Bishop Yoga and Pilates Center, FlowMotion Pilates, Sabine Elia at Inyo Council for the Arts, and Sierra Shanti.
There are many exercise programs geared towards improving balance and decreasing fall risk. They all tend to have the common themes of addressing strength, flexibility, and balance. The general consensus recommends one hour sessions three times per week. The bulk of the program below is taken from the Otego Exercise Program. This program has been studied extensively and has been shown to decrease falls and the injuries caused by falls by over a third.5,10-12 In addition to the exercises, a discussion of the internal and external factors related to falls will be addressed first as many of these can be modified to greatly decrease a person’s risk of falling.1,4
Internal Factors Affecting Balance:
- Vision – Make sure you have the correct prescription for eye wear.
- Vestibular system – This is the sensory system in your inner ear that communicates with your brain to tell it where your body is in space. BPPV and Meniere’s Disease are examples of vestibular system disorders.
- Proprioception – These are the sensors in your joints that tell your body where it is in space.
- Strength – Weakness in the ankles, knees, hips, and low back/core region have been shown to affect balance and will be addressed below.5,8
- Flexibility – Decreased flexibility in the ankles, hips, and spine have been shown to affect flexibility and will be addressed below.5,8
- Dual tasking – Walking while adding another task, such as talking, turning your head to look at objects, or reacting to hearing or seeing something that is happening in your environment, is considered dual tasking. This is a fascinating and overlooked topic that I did my grad school thesis on. Older folks tend to have a decreased ability to dual task while walking which can increase the risk of falls. One easy way of determining if you should be working on balance is if you stop walking when you begin talking.15-18
- Medical Conditions – Some examples are poor general health, diabetes, arthritis, osteoporosis, stroke, incontinence, medication use, and cognitive/mental health issues (memory, inattention, dementia, depression).4 Many of these issues can by improved greatly by exercise, nutrition, and lifestyle changes.
- Lifestyle Choices – Some examples are exercise, footwear, alcohol use, nutrition, hydration, and fear of falling.4
External Factors Affecting Balance:
- Throw rugs and cords or other obstacles
- Lack of nightlights for bathrooms/hallways
- Lack of handrails
- Objects that are out of reach
- Uneven ground
- Decreased activity level
- Fear of falling
- Dehydration – The recommendation is about twelve eight ounce glasses of water per day for men and nine for women.19,20
- Lack of sleep – See my evidenced-based handout for sleep hygiene tips.
- Medication issues
– Did your balance issues begin around the same time as a medication change? Talk with your doctor.
– Lightheadedness/dizziness with a change of position (lying to sitting or sitting to standing) can indicate a blood pressure issue. Talk with your doctor.
- Pets – high energy dogs, for example
I. General Guidelines – click on the underlined areas for video demonstrations
- A person should be evaluated by a healthcare practitioner familiar with balance disorders and training before performing the exercise program below. All of the exercises can be modified to be made easier or more challenging and every person’s deficits will be somewhat different. The best exercise program is one specifically tailored to the individual. Safety is the most important aspect of any exercise program.
- Performing any of these exercises is better than none. If the program is taking too much time or effort, have your physical therapist remove the exercises that are not as necessary for you. It is much better to start off doing less than you are capable of and add to that program rather than starting with too much and hurting yourself or hating the program and throwing it in the garbage.
- Do not push through pain with any of the exercises, even if it feels like you are “not doing anything”. Try to avoid having expectations about being able to perform a certain number of repetitions or move in a certain range. Progress will come with consistent practice.
- Notify your physician if you experience dizziness, chest pain, or shortness of breath (ie., you are unable to speak because you are short of breath).
- Do not hold onto an object for support that may move (use your kitchen sink rather than a chair for example).
- Look ahead when walking on even surfaces or performing the exercises instead of looking down.
- Try to add walking into your daily activities as much as possible. For example, park farther away from the entrance when going to the store. Use the stairs when possible instead of an elevator.
II. Warm Up
- Walk for 20-30 minutes if time permits (stationary cycling is a good alternative if walking is too unsteady)
- Neck rotation – stand tall and turn your head to the side until you feel a stretch, repeat on the other side 5-10X each
- Chin tucks – stand tall and tuck your chin as if you are creating a double chin while imagining your spine stretching towards the ceiling, repeat 5-10X
- Trunk extension – place your hands on your low back and bend backwards until you feel a stretch, repeat 5-10X
- Trunk rotation – keeping your hips and pelvis stationary, rotate your trunk until you feel a stretch, repeat on the other side 5-10X each
- Seated ankle range of motion – bring your toes towards your nose, then push your toes down towards the floor, repeat 10X in each direction
* use a kitchen counter for support for safety and to focus on your technique, as needed
- Seated knee extension – straighten your knee and pull your toes towards your nose, feel free to add ankle weights to make more challenging, repeat 10X for 2-3 sets
- Standing knee flexion – bend your knee by bringing your heel towards your buttocks, feel free to add ankle weights to make more challenging, repeat 10X for 2-3 sets
- Toe/heel raises (double or single leg) – raise up onto the balls of your feet, lower back down and raise up onto your heels, repeat 10X for 2-3 sets
- Hip abduction – stand tall and raise your leg out sideways away from your other leg, repeat 10X for 2-3 sets on each side
- Marching – stand tall and raise a knee towards your chest, repeat 10X for 2-3 sets on each side
- Squatting – keeping a neutral spine position with your chest pointing forwards and your eyes looking straight ahead, squat down until you feel pain or unstable and return to standing (you may want to use a chair to simulate standing up from a seated position and squatting back down until your buttocks barely touches the chair before returning to stand), repeat 10X for 2-3 sets
- Lunges (more advanced)
- Single leg quarter squats (more advanced)
IV. Static (not moving) Standing Balance
*use kitchen counter for support for safety as needed
*there are 4 progressively more challenging foot positions (1. feet as wide as your hips 2. feet together 3. tandem stance 4. single leg stance) and 4 progressively more challenging variables for each foot position (1. eyes open on an even surface 2. eyes closed on an even surface 3. eyes open on an uneven surface, such as a balance board, dyna disc, or pillow 4. eyes closed on an uneven surface)
*hold all positions for 30-60 seconds and repeat 2-3X
- Feet hip width with eyes open (close eyes or stand on an uneven surface to make more challenging)
- Feet together with eyes open (close eyes or stand on an uneven surface to make more challenging)
- Tandem stance (tightrope) with eyes open (close eyes or stand on an uneven surface to make more challenging) – both sides
- Single leg stance with eyes open (close eyes or stand on an uneven surface to make more challenging) – both sides
V. Dynamic (moving) Standing Balance
*use a wall or counter (hallways can be helpful) for support for safety as needed
*perform each activity for 10 steps (or better yet, measure out 10-15 feet so the dual task of counting while you are walking is not added, at least initially) and repeat 5X
- Tandem walking (tightrope) – walk forwards placing one foot directly in front of the other as if walking on a tightrope
- Walking with head turns – turn your head side to side as if you are checking out the food on either side of you in the grocery store aisle
- Walking backwards
- Sideways walking
- Figure 8 walking – walk in a figure of 8 pattern
- Heel walking – walk on your heels
- Toe walking – walk on the balls of your feet
- Backwards tandem walking – walk backwards placing one foot directly in front of the other as if walking on a tightrope
- Stairs – use one or two rails for support until you feel comfortable walking with no support
*hold stretches for 30 seconds and repeat 2-3X on each side daily
- Calf stretches (standing) – a stretch should be felt in the calf of the back leg
- Hip flexor stretches (standing) – a stretch should be felt in the front of the hip in the back leg
- Single knee to chest (lying on back) – a stretch may be felt in the knee, hip, or back
- Trunk rotation (lying on back)
- Child’s pose (start on your hands and knees and sit back on your heels while bringing your head to the floor)
Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics. Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here. My primary motivations for Beyond Tape and any of the posts are to: 1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated 2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.
1Schwenk M, Jordan ED, et al. Effectiveness of foot and ankle exercise programs on reducing the risk of falling in older adults: a systematic review and meta-analysis of randomized controlled trials. J Am Podiatr Med Assoc. 2013 Nov-Dec;103(6):534-47.
2Sherrington C, Whitney JC, et al. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008 Dec;56(12):2234-43.
3Hamed A, Bohm S, et al. Follow-up efficacy of physical exercise interventions on fall incidence and fall risk in healthy older adults: a systematic review and meta-analysis. Sports Med Open. 2018 Dec 13;4(1):56.
4Florida Injury Prevention Program for Seniors (FLIPS) – https://slideplayer.com/slide/8680174/
5McMahon SK, Wyman JF, et al. Combining Motivational and Physical Intervention Components to Promote Fall-Reducing Physical Activity Among Community-Dwelling Older Adults: A Feasibility Study. Am J Health Promot. 2016 Nov;30(8):638-644.
6Papa EV1, Dong X2, et al. Resistance training for activity limitations in older adults with skeletal muscle function deficits: a systematic review. Clin Interv Aging. 2017 Jun 13;12:955-961.
7Gardner MM1, Buchner DM, et al. Practical implementation of an exercise-based falls prevention programme. Age Ageing. 2001 Jan;30(1):77-83.
8Emilio EJ1, Hita-Contreras F2, et al. The association of flexibility, balance, and lumbar strength with balance ability: risk of falls in older adults. J Sports Sci Med. 2014 May 1;13(2):349-57.
9El-Kashlan HK1, Shepard NT, et al. Evaluation of clinical measures of equilibrium. Laryngoscope. 1998 Mar;108(3):311-9.
10Shubert TE, Smith ML, Otago Exercise Program in the United States: Comparison of 2 Implementation Models. Phys Ther. 2017 Feb 1;97(2):187-197.
11Otego Exercise Program PDF – file:///C:/Users/Mike%20Gable/Documents/Originals/Articles/Balance/Not%20Read/Otago%20program%20PDF.pdf.
12Robertson MC1, Campbell AJ, et al. Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc. 2002 May;50(5):905-11.
13Sherrington C1, Fairhall NJ, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019 Jan 31.
14Taylor-Piliae RE1, Haskell WL, et al. Improvement in balance, strength, and flexibility after 12 weeks of Tai chi exercise in ethnic Chinese adults with cardiovascular disease risk factors. Altern Ther Health Med. 2006 Mar-Apr;12(2):50-8.
15Lajoie Y1, Teasdale N, et al. Attentional demands for static and dynamic equilibrium. Exp Brain Res. 1993;97(1):139-44.
16Wright DL1, Kemp TL. The dual-task methodology and assessing the attentional demands of ambulation with walking devices. Phys Ther. 1992 Apr;72(4):306-12; discussion 313-5.
17Chen HC1, Schultz AB, et al. Stepping over obstacles: dividing attention impairs performance of old more than young adults. J Gerontol A Biol Sci Med Sci. 1996 May;51(3):M116-22.
18Lundin-Olsson L, Nyberg L, et al. “Stops walking when talking” as a predictor of falls in elderly people. Lancet. 1997 Mar 1;349(9052):617.
19Sawka MN1, Cheuvront SN, Carter R 3rd. Human water needs. Nutr Rev. 2005 Jun;63(6 Pt 2):S30-9.
21Pata RW1, Lord K2, et al. The effect of Pilates based exercise on mobility, postural stability, and balance in order to decrease fall risk in older adults. J Bodyw Mov Ther. 2014 Jul;18(3):361-7.
22Nick N1, Petramfar P2, et al. The Effect of Yoga on Balance and Fear of Falling in Older Adults. PM R. 2016 Feb;8(2):145-51.