Which surface would be the easiest for a new client starting a balance training program?

Falls are common in people over 65 years of age. A fall can result in unwanted outcomes, including injury, loss of independence, and decreased ability to do the things that are most important to you. They also can result in death.

According to the Centers for Disease Control and Prevention, 3 million older adults are treated in the emergency room for fall injuries each year. The average health care cost per fall is $35,000. 

The good news is falls are preventable. Balance training is an important and effective part of falls prevention. Performing safe home exercises can help strengthen your lower body to promote balance and reduce your overall fall risk, among other health benefits. According to the Journal of the American Geriatrics Society, physical activity, including exercise, reduces falls by 13% to 40% in community‐dwelling older adults.

A physical therapist can evaluate your balance and recommend appropriate exercises that are tailored to your specific needs and goals and are safe for you to perform at home. Physical therapists are movement experts who improve quality of life through hands-on care, patient education, and prescribed movement.

Here are some exercises your physical therapist might recommend:

Always check with your health care provider before beginning a home exercise program. For safety during these exercises, position yourself near a countertop or sturdy surface that you can use for support.

1. Standing March

Standing near a sturdy support, begin marching in place slowly for 20-30 seconds. As this becomes easier, your physical therapist may challenge your balance and change up the pace and surface you are marching on: from hardwood to carpet, foam pad, grass, etc.

2. Standing 3-Way Kicks

Standing on 1 leg (with a soft, unlocked knee), slowly raise your other leg out in front of you. Keep your extended leg as straight as possible and return it to the center. Then gently lift the same leg out to the side and back down, and then extend your leg behind your body and back down. Perform as many as you can each way. Your physical therapist may increase the difficulty of this exercise by removing the supporting surface.

3. Sidestepping

Facing a countertop or wall (with your hands on the counter or wall for support as needed), step sideways in 1 direction with your toes pointed straight ahead until you reach the end of the wall or counter. Then, return in the other direction. As this becomes easier, a physical therapist may add in the use of a resistance band at the knees or just above the ankles.

4. 1-Leg Stand

Stand on 1 leg as long as you are able, up to 30 seconds. Remember to remain near a sturdy support surface that you can hold on if needed. Alternate legs and try to do this 3-5 times on each leg. As this becomes easier, challenge yourself by doing other tasks while standing on 1 leg, such as brushing your teeth, talking on the phone, or while doing the dishes. Balance exercises can easily be integrated into your daily routine this way.

5. Sit to Stand and Stand to Sit

Rise out of a chair without using your arms to push up. If this is difficult at first, place a firm pad underneath you on the chair seat to raise you. As you return to a seated position, slowly lower yourself all the way back down and ease into your seat (rather than dropping into the chair). Perform as many times as you are able. This can easily be done while watching TV.

6. Heel-to-Toe Standing or Walking

Place 1 foot directly in front of the other, so the heel of the front foot touches the toe of the back foot. Hold this position for as long as you are able, or up to 30 seconds. As this becomes easier, try taking a few steps in this heel-to-toe format, as if you are walking on a tight rope. Remember to use something to hold on to for safety.

Many factors can contribute to a lack of balance and falling. Older adults, especially those who have experienced dizziness, stumbling, or falls, should obtain a comprehensive evaluation from a PT or another qualified health professional. Some physical therapists specialize in balance and falls management.

You can contact a physical therapist directly for an evaluation. To find a physical therapist in your area, visit Find a PT.

Find a PT Near You!

Read more about falls.

Read more about balance problems.

BY LANCE DALLEK, Ph.D.

Fall incidence rates currently pose a serious health problem for older adults. Among those who are 65 or older, it has been estimated that 35 percent to 45 percent of otherwise healthy, community-dwelling adults fall at least once a year.

Decreased balance is attributable to an age-related decline in multiple physiological systems that contributes to decreased muscle flexibility and strength, reduced central processing of sensory information, and slowed motor responses (American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeon Panel on Falls Prevention, 2001). In addition to an increased risk of falls, diminished balance and mobility may limit activities of daily living or participation in leisure-time activities. Accordingly, it is essential that balance exercises be incorporated into the physical activity programs of older adults. The following article uses case studies to outline the critical components of designing individualized balance exercise programs for clients that reduce their risk of falls. Sample balance exercises and training progressions (from simple to complex) will also be presented.

Origin of Poor Balance and Falls
An understanding and knowledge of the factors contributing to impairments in balance is fundamental to designing an effective balance-training program. Poor balance is multi-factorial in origin; in particular, cognitive impairment, visual disturbances and poor reaction time increase the likelihood of falls. Moreover, balance impairments and lower-extremity skeletal muscle weakness are also well-recognized independent contributors to falls. In particular, fallers have less muscular strength in the quadriceps and ankle dorsiflexors and plantarflexors compared to non-fallers (Orr et al., 2008). It should be noted, however, that previous research exploring exercise training as a means for fall prevention in older adults has shown conflicting results (Mansfield et al., 2007). While some studies have reported a reduced risk of falls after exercise training, other research has reported limited or no benefits. Even so, there are important lessons to be learned from these incompatible findings, and the complex etiology of poor balance highlights the need for a comprehensive intervention program. With that in mind, consider the following six critical issues that must be considered when developing an all-inclusive strategy for optimizing balance training and fall prevention among older clients.

1. Multi-component training is superior to single-component balance training.
The explanations generally given for lack of a favorable adaptation from balance exercises are 1) lack of specificity with training, and 2) performance of single-component compared to multi-component training. It has been reported that training programs including only single-task activities fail to place the client in an environmental condition similar to that experienced prior to and during a fall (Silsupadol et al., 2009). Importantly, though balance training focused on improving functional tasks (e.g., heel-toe walking or standing on one leg) will be successful for enhancing performance of that specific activity, it fails to adequately replicate activities of daily living that require maintaining balance while completing several activities simultaneously or while distracted. A well-designed exercise program should feature concurrent performance of balance exercises and additional tasks. For example, in addition to performing heel-toe walking, the client may simultaneously be asked to complete a cognitive task, such as counting backward from 100 by increments of three. An additional form of dual-component training may involve combining a balance exercise with another form of physical activity. For instance, the client could be asked to balance on one leg while playing catch with a light medicine ball. In summary, multi-task balance training more closely replicates the activities of daily living in which a client’s balance performance is most likely to be challenged by a disturbance.

2. Simulate loss of balance during training.
Balance-training programs and fall-prevention interventions must include a focus on balance-recovery reactions (Mansfield et al., 2007). Ultimately it is the capability—or lack thereof—to recover from a balance perturbation (loss of balance) that eventually determines whether or not a client falls. Balance disturbances can arise from collisions, slips and trips. Additionally, loss of balance can occur during voluntary movements, including bending, reaching and turning. Our body has a natural line of defense against balance disturbances: rapid limb movements. For example, reaching out to grab a supporting object or quickly stepping forward with a lower limb are compensatory mechanisms aimed at preventing a fall. Accordingly, it is logical to address the balance-recovery skill levels of clients because effective training programs will be those that replicate sudden and unpredictable balance disturbances. Importantly, to elicit the most favorable adaptations in a client’s balance-recovery reaction capacity, the exercises and activities should be designed in a way that does not permit the client to anticipate a balance perturbation.

3. Couple resistance training with balance training.
Despite the fact that poor balance is frequently associated with reduced muscular strength, the literature does not currently support resistance training alone as a successful strategy for enhancing balance performance and fall reduction. A systematic review of the efficacy of resistance training as an isolated intervention for uniformly improving balance revealed that this approach was successful in only one of five instances (Orr et al., 2008). Therefore, it is crucial to remember that resistance training needs to also be coupled with balance training for positive modifications to be conferred on postural stability. Indeed, the integrated exercise-training approach has been found to be effective in the literature (de Bruin and Murer, 2007).

4. Correctly sequence balance exercises.
Aerobic, resistance, flexibility and balance training are each critically important for the overall health, functional capacity and quality of life of older adults. However, to fulfill the minimum frequency requirements of each form of activity, clients will need to perform at least two (or more) activities on the same day, and most likely within the same exercise session (Nelson et al., 2007). Research has reported that participation in either resistance or flexibility activities prior to balance exercise can negatively impact performance (Behm et al. 2004; Moreland et al. 2004), so balance training should precede both resistance and flexibility activities. For the senior client who may already face significant balance challenges, it would be inappropriate (and possibly harmful) to create additional perturbations due to improper activity sequencing. Balance training (when combined with resistance and flexibility activities) should be performed first or following aerobic activity.

6. Change the availability of sensory cues.
Many falls occur during conditions that are unfamiliar to the client. Poor lighting or uneven surfaces impair the sensory cues typically available, therefore temporarily compromising the balance performance. These challenges can be introduced into the training program as a means to better prepare clients for circumstances where sensory cues are unavailable (Silsupadol et al., 2009). For instance, the client might perform heel-toe walking while wearing sunglasses (inside), with eyes closed, or while slowly turning the head from side-to-side. Additionally, standing balance exercises can be completed while standing on a foam pad or balance disk in an effort to disturb the surface conditions. Regardless of which techniques are utilized, altering the sensory cues available to a client is an important consideration when preparing the overall balance-training program.

F.I.T.T. Recommendations for Balance Training
The frequency, intensity, time and type (F.I.T.T.) approach to exercise program design can also generally be applied to balance-exercise programming (ACSM, 2010). Although research has yet to identify the optimal frequency, intensity, duration and type of balance exercises, it has been recommended that balance training be performed for 10 to 15 minutes, three days per week (Nelson et al., 2007), and the intensity should be safe, but challenging. Balance training should be integrated into the overall physical activity program according to the sequencing guidelines discussed earlier.

Effectively Progressing  Balance-training Exercises
A program designed to optimize balance training and fall reduction and prevention should incorporate each of the key points discussed earlier. Clients with no previous balance-training experience should initially perform basic sitting and standing exercises as a means to improve balance performance. As these initial exercises become easier, an increase in difficulty can be accomplished in numerous ways (ACSM, 2010):

1. Arm progressions: Vary the use and position of the arms to make a given balance exercise more difficult. Initially, the client may need to grasp or touch another object, such as a wall or back of a chair, to facilitate balance. Progressively, exercises can be performed with arms spread out and raised to shoulder height to assist with stability. Ultimately, clients can move arms in from sides to a folded position across the chest.

2. Surface progressions: Alter the surface or apparatus on which clients perform balance exercises, progressively increasing the difficulty. For instance, foam pads, balance disks and BOSU balls can be substituted for a hard, flat surface while performing multiple standing balance exercises. Similarly, stability balls can be exchanged for regular chairs when performing sitting exercises.

3. Visual progressions: Try mitigating the visual sensory cues provided to the client during balance exercises. For example, the lighting of the room can be gradually dimmed, sunglasses may be worn inside, or eyes may be shut completely.

4. Tasking progressions: Require clients to initially master each balance exercise performed as a singular task. When this level of achievement is attained, additional tasks should be supplemented to the routine. Cognitive tasks or added physical tasks are a few of the readily available options.

In addition to gradually increasing the difficulty of a balance exercise, it is paramount to continuously seek novel and fun balance exercises for clients. While many clients will want to seek greater challenges, they should be cautioned about proceeding in difficulty without first demonstrating competency at the current level of balance exercise. After all, progressing too rapidly can actually contribute to a fall. Refer to Table 1 and Figures 1a–c, which feature sample balance exercises and a training progression (from simple to complex).

Figure 1a.
Sample progression of sitting balance exercises (closed eyes, arms crossed, stability ball)

Figure 1b.
Sample progression of standing balance exercises (single-leg stable surface, unstable surface, single-leg unstable surface)

Figure 1c.
Sample progression of in-rotation balance exercises (heel-to-toe, excursion, multi-tasking)

Download a PDF of a Case Study Approach to Balance Training.

References
American College of Sports Medicine. (2010). Resources for the Personal Trainer, 3rd ed. Baltimore: Lippincott Williams & Wilkins.
American Geriatrics Society, British Geriatrics Society and American Academy of Orthopedic Surgeon Panel on Falls Prevention. (2001). Guideline for the prevention of falls. Journal of the American Geriatrics Society, 49, 5, 664–672.
Behm, D.G., Bambury, A., Cahill, F. and Power, K. (2004). Effect of acute static stretching on force, balance, reaction time and movement time. Medicine & Science in Sports & Exercise, 36, 8, 1397–1402.
Betker, A.L., Szturm, T., Moussavi, Z.K. and Nett, C. (2006). Video game-based exercises for balance rehabilitation: A single-subject design. Archives of Physical Medicine & Rehabilitation, 87, 8, 1141–1149.
de Bruin, E.D. and Murer, K. (2007). Effect of additional functional exercises on balance in elderly people. Clinical Rehabilitation, 21, 2, 112–121.
Mansfield, A., Peters, A.L., Liu, B.A. and Maki, B.E. (2007). A perturbation-based balance training program for older adults: Study protocol for a randomized controlled trial. BMC Geriatrics, 7, 12.
Moreland, J.D., Richardson, J.A., Goldsmith C.H. and Clase, C.M. (2004). Muscle weakness and falls in older adults: a systematic review and meta-analysis. Journal of the American Geriatrics Society, 52, 7, 1121–1129.
Nelson, M.E., et al. (2007). Physical activity and public health in older adults: Recommendation for adults from the American College of Sports Medicine and the American Heart Association. Medicine & Science in Sports & Exercise, 39, 8, 1435–1445
Nitz, J.C., Kuys, S., Isles, R. and Fu, S. (2009). Is the Wii Fit a new-generation tool for improving balance, health and well-being? A pilot study. Climacteric, Nov 12.
Orr, R., Raymond, J. and Singh, M.F. (2008). Efficacy of progressive resistance training on balance performance in older adults: A systematic review of randomized controlled trials. Sports Medicine, 38, 4, 317–343.
Silsupadol, P., et al. (2009). Effects of single-task versus dual-task training on balance performance in older adults: A double-blind, randomized controlled trial. Archives of Physical Medicine & Rehabilitation, 90, 3, 381–387.

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Lance C. Dalleck, Ph.D., is coordinator of the Cardiac Rehabilitation/Clinical Exercise Physiology graduate program at Minnesota State University, Mankato. His research interests include improving exercise performance and health outcomes through evidence-based practice, quantifying the energy expenditure of outdoor and non-traditional types of physical activity, and studying historical perspectives in health, fitness and exercise physiology.