Author: G.Guido Rodriguez PT, RT, about this author..⟩⟩
How to improve balance?? This is a common question. Most of us can walk and navigate effortlessly through places. Thus we do not tend to think about the millions of people having problems with balance and general mobility.
Research shows that as much as 10% of the population has some problem with mobility at some point in their lives. It is not a problem of old age for everyone.
For many people, problems with mobility start at middle age. People with mobility problem are also more prone to psychological issues and emotional distress and are at much higher risk of developing depression (Iezzoni, McCarthy, Davis, & Siebens, 2001).
Poor balance often leads to falls and serious injuries. In fact, some falls can even lead to fatal outcomes. There is a need to find a way to maintain or improve balance and prevent injuries.
What are the causes of disbalance and fall
Mobility and balance depend primarily on the proper function of the complex sensory and motor systems in our brain, and any condition that affects them would lead to a worsening of balance.
One of the primary causes of the weakening of muscles, bones and brain functioning is aging, but aging is undoubtedly not the sole factor.
The balance problem often occurs due to various diseases of the neurological system, joints, and muscles.
Including but not limited to; back problems, injuries due to accidents, cardiovascular diseases, osteoporosis, vestibular problems, metabolic disorders like diabetes, visual acuity, postural hypotension, and diseases of the central nervous system (Lezzoni et al., 2001; Shubert, 2011).
Also, some contributing factors can be some medications, either prescribed, over-the-counter or just the interaction between them may provoke dizziness, increasing the risk of a fall.
Some people age in the same house without modifications to keep them safe, it can also be another reason for a fall
- About one-third of the more elderly population >65 yrs falls each year. The Fall risk increases thus with age. At about the age of 80 y/o, over half of seniors fall annually.
- Those who fall are two to three times more prone to fall again. Falls within the last six months is a good predictor for a future fall.
- Death from fall-related injuries among the elderly is the 5th leading cause, and 87% of all fractures in the elderly population, are secondary to falls.
- The risk of falling augment with age, and it seems to be higher for women than it is for men.
- Two-thirds of people who experience a fall from loss of balance is likely to fall again within six months.
- Lack of exercise regularly results in decreased muscle tone, reduced strength, and loss of bone mass and flexibility.
- Balance problems due to disuse can be re-trained.
- The most significant adverse effect of falls is that the person may develop a fear of falling, affecting their sense of independence.
How does balance work?
When it comes to Balance, the brain is like a computer that utilizes sensors to determine the body position in the space.
When one is standing the brain is processing information from the eyes (vision) providing a spatial location through images.
The vestibular system (situated in the inner ear) has different organs sensitive to angular accelerations (head rotations) and gravity and linear acceleration with horizontal and vertical movements.
Proprioception is the ability of the human body to sense the body position through the pressure felt in the muscles, tendons, and joints.
When one or more of the sensory systems fail, we are in trouble.
Let me give you an example;
Let’s say we have Mr. Smith who is an older gentleman who has diabetes and neuropathy with poor sensation through the feet; his vision is also affected, experiencing occasional vertigo when changing body positions
He gets up at night to the bathroom in a hurry, with low light, losses his balance and fall. What happened???
Well, diabetes is affecting his vision and proprioception, so two out of the three sensory systems are chronically failing, at this point depending mostly on the vestibular system to provide the brain with good information for proper spatial positioning.
The fact that he has experienced occasional vertigo with quick movements tell us that his vestibular system was occasionally failing.
When he got up quickly, he developed some vertigo affecting the vestibular input to the brain.
He started to rely much more on his vision, but the poor light compromised this input as well, and since he had chronic neuropathy in his feet, the brain was not able to understand his position in the space with a subsequent fall.
How the brain prevent falls
The brain utilizes a series of strategies or how I prefer to call them, “Reactions,” so depending on what the brain perceives from its somatosensory systems, it decides what reaction will take place to stabilize the balance and prevent a fall.
If our balance gets minimally affected, we will probably use what is called “ankle strategy “reaction which will use the ankle stabilizer muscles to control the vertical position of the body regaining balance.
When the challenge to our balance is mild to moderate, we may use a “hip strategy” that is when our trunk will quickly bend at the hips to regain the balance.
The stepping strategy is when we take a step in any direction to prevent an imminent fall, due to the prior reactions will not compensate for the severe balance challenge we are experiencing.
Perhaps the most effective way to improve balance is a structured exercise program. One of the reports published in the BMJ reported that exercise decreases injuries due to fall by 37%, incidences of serious injuries are reduced by 43%, while fractures due to fall may be reduced by as much as 61% (El-Khoury, Cassou, Charles, & Dargent-Molina, 2013).
Exercise is not just about fall prevention; it has many other benefits (LeWine, 2013):
- Exercises improve reaction time, which means that a person can stay upright even if there is a loss of balance due to some event, by reacting quickly, preventing a fall.
- Exercise can better the coordination, which means that even if a person falls due to loss of balance, a person can easy the fall to example roll rather than crash to the ground.
- Stronger and larger muscles not only improve balance, but they also decrease the harmful impact of the fall, protect joints and bones.
- Resistance exercise can strengthen bones, thus not only improve balance but also make them more resistant to falls.
- Exercise results in clear thinking and better brain functioning, which improves balance and decreases fall-rates.
How to know if I am having balance problems?
The CDC ( Center for Disease Control and Prevention) has an interesting program called Steadi
They recommend three balance tests as per its Algorithm for Fall Risk Screening, Assessment, and Intervention tool. and prior completion of the stay independent questionnaire Stay independent brochure
Timed Up & Go (recommended)
30-Second Chair Stand (optional)
4-Stage Balance Test (optional)
Examples of exercises for improving balance
Here is a five-level exercise program developed by Lars I. E. Oddsson (Oddsson, Boissy, & Melzer, 2007).
Start with level one and slowly progress up to level five, It is best to complete the program in 10 weeks, but it can be done at one’s own pace (guided by the progress). Most exercises are done using large “balance ball”, however, if your balance is far from good or you already use an assistive device to walk, you may want to consult with a health professional for an assessment.
Level 1: sitting and standing exercises with “external support”
- Sit on the ball, wide stance, with support with one hand from the wall or a fixed object. Repeat with narrow stance and support.
- Sit on the ball, wide stance, with support, and shift weight left and right as far as possible. Repeat with a narrow stance.
- Sit on the ball and rotate trunk left and right as far as possible, with support.
- Sit on the ball, wide stance, with support, and lift one foot at a time. Repeat in narrow stance.
- Do the same exercises in standing without the ball
Level 2: sitting exercises without external support
Do all the exercises in level one, but without any external support.
Level 3: standing exercises including double leg stance and no external support
- Wide parallel stance, roll the ball in front of the body from left to right with no weight shift between legs.
- Wide parallel stance, outstretch your arm and roll the ball in a circle around you avoid shifting weight between legs. Repeat, this time shifting weight between legs, then one more time in narrow stance.
Level 4: standing exercises including single leg stance, gait, and no external support
Exercises are done as in level three, but by standing on the single leg and without any external support.
Level 5: perturbation, reactive and proactive responses
- Sit and bounce on a ball, get up to standing after the bounce, and get up and walk after the bounce.
- Walk across an unstable surface
Other methods for improving balance
Cognitive training for balance improvement
This method is more effective when the reason for disbalance is central (brain). These are computer-based exercises done under the supervision of trained medical personnel. They have shown to be effective in improving balance even in very older adults (Smith-Ray et al., 2015).
Six clinical trials involving almost 3000 participants demonstrated the effectiveness of Tai-Chi in fall prevention and balance improvement (Zhao & Wang, 2016).
Yoga has several health benefits and is easy to do for people of any age; it improves health, coordination, power, and balance (Mooney, 2015).
Walking, biking or climbing stairs
They can be done anywhere, are enjoyable, and are known to strengthen muscles, cardio-respiratory system and improve balance.
In conclusion, what the research shows is that regular physical exercise and activities can greatly improve the balance, help prevent injuries.
El-Khoury, F., Cassou, B., Charles, M.-A., & Dargent-Molina, P. (2013). The effect of fall prevention exercise programs on fall induced injuries in community-dwelling older adults: systematic review and meta-analysis of randomized controlled trials. BMJ, 347, f6234. https://doi.org/10.1136/bmj.f6…
Lezzoni, L. I., McCarthy, E. P., Davis, R. B., & Siebens, H. (2001). Mobility Difficulties Are Not Only a Problem of Old Age. Journal of General Internal Medicine, 16(4), 235–243. https://doi.org/10.1046/j.1525-1497.2001.016004235.x
LeWine, H. (2013, October 31). Balance training seems to prevent falls, injuries in seniors. Retrieved October 6, 2017, from https://www.health.harvard.edu…
Mooney, K. (2015, November 4). Fall for Yoga: 15 Poses Proven To Build Better Balance. Retrieved October 6, 2017, from https://www.yogajournal.com/pr…
Oddsson, L. I. E., Boissy, P., & Melzer, I. (2007). How to improve gait and balance function in elderly individuals—compliance with principles of training. European Review of Aging and Physical Activity, 4(1), 15–23. https://doi.org/10.1007/s11556…
Shubert, T. E. (2011). Evidence-Based Exercise Prescription for Balance and Falls Prevention: A Current Review of the Literature. Journal of Geriatric Physical Therapy, 34(3), 100–108. https://doi.org/10.1519/JPT.0b…
Smith-Ray, R. L., Hughes, S. L., Prohaska, T. R., Little, D. M., Jurivich, D. A., & Hedeker, D. (2015). Impact of Cognitive Training on Balance and Gait in Older Adults. The Journals of Gerontology: Series B, 70(3), 357–366. https://doi.org/10.1093/geronb…
Zhao, Y., & Wang, Y. (2016). Tai Chi as an intervention to reduce falls and improve balance function in the elderly: A meta-analysis of randomized controlled trials. Chinese Nursing Research, 3(1), 28–33. https://doi.org/10.1016/j.cnre…
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