Balance Challenge with Seniors

Question:

I have a 70-something-year-old client with painful hallux rigidus in both feet, controlled hypertension and mild diabetes and a quadruple bypass over 10 years ago. Fall prevention is the focus of our training, and I've used a very gradual progression of stability/mobility/strength exercises, etc., entry-level core work, Dynaband leg movements, 1/4 Fitball squats and weight shifting balance exercises such as the stork using a safety bar to hold. Recently, after only four weeks of the program, I spoke with the client’s doctor who informed me that balance tests on the gentleman indicated the training had been ineffective, and in fact, his balance was worse! Can you give me a brief overview of some progressions and indicate why the balance "may" be worse (short timeframe aside). The arthritis, though serious, is stabilized (via Cheilectomy), and he wears stiff-soled shoes. Obviously, this makes falls prevention exercise a challenge.

Answer:

It is clear you have a challenging client, but don’t be too quick to dismiss your current exercise program. Your question raises several issues, so let’s look at each one in turn. 

Hallux rigidus translates as a “stiff big toe” and is an arthritic condition that limits movement of the FMP (First Metartarsophalangeal) joint. It can be without apparent cause, though those with faulty foot kinematics may be at risk. Not always seen in the elderly, it also affects athletes due to repetitive stress to the FMP joint. It is a degenerative condition, and patients who are diagnosed early generally get better results from treatment. Surgical interventions such as Cheilectomy are performed to remove bone spurs and free up movement in the joint, though in severe cases, arthrodesis (fixing of bones leading to fusing) may be performed.

The predominance of research concerning hallux rigidus centers around the efficacy of various surgical protocols rather than the development of an exercise program. The paucity of research and lack of knowledge of your client makes it difficult to prescribe a set progression of exercises. As is often the case, it is more a matter of (ensuring client safety first) experimenting with different approaches and seeing if one seems more acceptable to the client.

There are many possible reasons for balance being negatively affected. These can range from impairments at a basic level such as lack of core strength or poor posture and mobility problems or pain, to sensory issues, medications, loss of neuromuscular control or even a simple fear of falling during tests. Understanding why your client’s balance has become worse will be key to improving it. In regard to your client's doctor, have you approached them yourself to seek advice? It would be difficult to say your training has been ineffective without some sort of control to measure it against. Who’s to say how the client would have performed with no training? Talk with the doctor and find out how balance was tested as this may give you a valuable insight into whether there are biomechanical issues, motor control issues or sensory causes behind your client’s poorer performance. The key factor in treating poor balance is determining the cause of the impairment.

I would suggest looking at the many other modalities open to you, such as strengthening using a combination of positions and movements, particularly PNF patterns, which can really help with overall strength and functionality by addressing multi-plane movement of both upper and lower extremities. These can be integrated into your fall prevention work and can also address core stability, posture, balance and overall strength while keeping the program fun, varied and beneficial to activities of everyday life. An example of a more varied approach is the excellent results one study found with seniors who performed Tai-Chi, reducing the risk of multiple falls by 47.5 percent compared to a control group.

Lastly, consider the many other benefits of your program, such as helping to maintain function and muscle mass, improving strength, increasing functional flexibility and joint stability, increasing self-efficacy and well being and potentially helping with diabetes control and hypertension. There is much to be gained beyond fall prevention, though it may be advisable to establish a relationship with the client’s physician and look to develop his health together.