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Principles of Balance Training for the Senior Population


Individuals 65 years of age and older are currently the largest growing segment of the population. As increasing numbers of these individuals move into their senior years, a significant proportion of them will experience a serious injury or even death related to falling. The trunk, spine and pelvis (thoracopelvic canister) play a significant role in achieving and maintaining efficient balance.

By understanding and applying the principles of the Integrative Movement System™ into a progressive exercise program, the fitness professional can help their senior clients improve alignment and control of their thoracopelvic canister and thereby improve balance. Additionally, this information will allow the fitness professional to be instrumental in helping reduce the incidence of falls while helping the senior population live active and productive lives.

Learning Objectives:

  1. Become aware of the prevalence of falls and economic impact of injuries related to falls
  2. Discover how the principles of the Integrative Movement System™ - alignment, breathing, and control - of the trunk, spine, and pelvis (thoracopelvic canister) relate to the development of an optimal balance strategy
  3. Learn how to apply alignment, breathing, and control to an exercise program designed to improve balance in the senior population

Societal Impact of Falls

We are at a crossroads not quite seen before in the history of the United States. Beginning on January 1, 2010 and continuing each day for the next 19 consecutive years, approximately 10,000 baby boomers (those individuals born between 1946 and 1964) will turn 65 years of age. While retirement is a stark reality for many of these individuals, so too is the likelihood of experiencing a debilitating fall. Nearly one in three individuals over the age of 65 in community-dwelling will suffer a fall; a number that rises to 50% in those over 80 years of age (Hester & Wei, 2013; Yoshida). Approximately 40% of individuals residing in long-term institutions will experience repeated falls (Yoshida).   

Even more disturbing than the numbers of individuals that will fall each year is the fact that nearly one in three (or between 19,700 – 21,700 individuals per year) will die due to fall-related complications (Hester & Wei, 2013; Statistics from Center for Disease Control). Additionally, the health care costs associated with falls is staggering. The direct medical costs related to falls in the U.S. totaled $19 billion in 2000 (Hester & Wei, 2013) and these numbers are estimated to dramatically rise to almost $80 billion in the coming years (Rose, 2004). 

The widespread health, economic, as well as physiological toll related to falls can not be discounted. While causes of falls are multi-factorial, an integrative strategy that focuses on developing alignment, breathing and myofascial control of the trunk, spine and pelvis (thoracopelvic canister) – the principles of Integrative Movement System™ - to improve balance can be successfully applied with the senior population.

This article will discuss and demonstrate a strategy for improving balance that focuses on these principles in promoting alignment and control of the thoracopelvic canister. This information will empower fitness professionals to be an integral part of the solution to falls in the senior population.

Defining Terminology Associated with Balance

Balance is the ability to control one’s center of mass –the relative center point where all the body’s mass is balanced – over the base of support (feet). In quiet standing or maintaining a static standing posture, when one has proper posture, the center of mass tends to be directly in front of the sacrum. Although in static posture (standing still) the center of mass tends to fall inside the base of support, during dynamic activity, it often falls outside the base of support. Seniors must have a strategy for balance that enables them to efficiently control both static and dynamic positions. 

Not only should there be an internal regulation of balance, the individual must be able to control external perturbations - or those "things" that cause movement outside one’s current position. An unsuspected push from behind while standing in line or a sudden stop while standing on a bus or train causes movement of the body that must be controlled. There are three primary strategies for dealing with these changes in balance: ankle, hip, stepping (Rose, 2004), and trunk (Lee & Lee, 2013).

During quiet standing and with small perturbations, there are movements or micro-adjustments within the ankle and foot that create postural control (Image 1). With greater perturbations, the hip musculature helps control the movement of the body (Image 2). If there is a more dramatic perturbation, for example if one trips forward while walking, they will generally use a stepping strategy to regain their balance (Image 3).

   

Images 1-3: Ankle, hip, stepping, trunk strategy for control of balance

When the center of mass is disturbed in the frontal plane (for example, when getting pushed from side to side or changing direction while running), there is a greater requirement for the trunk to control one’s balance (Lee & Lee, 2013). Trunk control is an important and relatively over-looked component to balance and will be addressed later in this article. Regardless of how significant the perturbation and which of the above strategies is used to regain one’s balance, optimal joint range of motion, muscle strength and neural coordination of the myofascial system are required to produce the appropriate balance responses. 

Causes of Falls and Current Prevention Strategies

The causes of falls tend to be multifactorial – women have a higher risk than males, muscle weakness, certain types of medications; and systemic conditions such as diabetes, Parkinson’s, and depression (Stevens et al., 2000; Yoshida). Age also seems to be a significant contributing factor as decreased control of balance has been reported as early as 40 years of age and continues during life with the greatest declines occurring between the ages of 60-70 (Bouillon & Baker, 2011). Middle-aged women demonstrate less dynamic postural/balance control compared to younger women and these balance deficits continue into their senior years (Bouillon & Baker, 2011).

Unfortunately, information related to improving balance and postural control can be quite contrasting - making it increasingly challenging to disseminate and tease out what’s useful and practical for application. Multifaceted fall prevention guidelines generally consist of a medical evaluation including an eye exam and medication review, education, exercise, modifications to residential areas, and footwear evaluation  (Center for Disease Control; Stevens and Thacker, 2000). While strengthening exercises are often cited as effective approaches for reducing the risk of falls (Center for Disease Control; Fall Prevention Task Force; Stevens & Olson, 2000), a literature review of the available research has not supported the use of resistance training as a viable option for improving balance (Orr & Singh, 2008).

Improving core stability – being ‘tight’ through the core and gluteals – has also been suggested for control of balance (Comana). However research has shown that individuals with greater trunk stiffness (tightness) are more likely to experience a fall (Gruneberg et al., 2004). Similarly, individuals with a history of low back pain demonstrate greater overall trunk muscle activation (stiffness) and tend to preferentially use their ankles rather than their hips to make postural adjustments in response to sudden perturbations as compared to those without pain (Jacobs et al., 2009; Jacobs et al. 2011). In light of this information, it seems unlikely that utilizing balance control strategies that rely simply upon increasing trunk and/or hip rigidity – in other words, over-contracting or ‘tightening’ the core or hips –provide significant long-term solutions and are very likely to create or perpetuate balance problems (Osar, 2013).

The Role of the Trunk in Balance

The trunk (thoracic spine and rib cage) appears to be significantly involved with balance control during gait. Adjustments of the trunk are one of the main strategies for dealing with sudden disturbances in one’s balance and preventing a fall (Van der Burg et al., 2007; Van der Burg et al., 2005). It has been suggested that trunk mobility and control is a primary means of adjusting for lateral and rotary disturbances in balance (Lee & Lee, 2013).

Alignment, breathing, and control of the trunk as part of the integrated thoracopelvic canister (trunk, lumbar spine, and pelvis) is instrumental in developing an optimal balance strategy (Osar, 2013). The ability to appropriately use the trunk as part of a balance control strategy requires ideal alignment (trunk and spine neutral and in line with a neutral pelvis), three-dimensional breathing to develop efficient core stabilization; and myofascial control of the head, trunk, spine and pelvis over the base of support. Additionally, aligning and maintaining control of the head and TPC regulates thoracic and abdominal pressures thus contributing to postural stability and balance (Massery et al., 2013; Osar 2012). 

Postural alterations, including but not limited to forward head position, increased/decreased thoracic curvatures, anterior/posterior pelvic tilt, and elevated or compressed ribs, require compensatory patterns of stabilization (Lee & Lee, 2013; Osar, 2012). Strength asymmetries – between left and right sides – often result from postural alterations and/or compensations and have been correlated with increased rates of injury (Sannicandro et al., 2014). These compensatory postural patterns are developed by the nervous system to deal with the asymmetries in muscle strength and ranges of motion (Osar, 2012). This is a fairly consistent pattern of events that leads to stiffness of the thoracopelvic canister thereby compromising stabilization; which leads to the loss of balance in the senior population (Osar, 2013).

Another finding associated with increased likelihood of falling is trunk (thorax) stiffness or rigidity. Gruneberg et al. (2004) demonstrated that increased trunk rigidity was associated with increased chances of falling. Seniors generally demonstrate increased trunk rigidity, and many exercises aimed at improving balance can actually contribute to the development of greater stiffness in this population. For example, individuals performing curl-ups on labile (unstable or movable) surfaces showed increase in abdominal muscle activity versus performing them on a stable surface (Vera-Garcia et al., 2000). Similarly, squats performed on a labile surface increased trunk muscle activity as compared with squats performed on a stable surface (floor) or on a Smith machine (Anderson & Behm, 2005). 

While increased muscle activity is often viewed as a benefit, increased muscle activity directly contributes to trunk stiffness; which as mentioned above has been shown to decrease compensatory trunk adjustments and increases the likelihood of falling. Frequently, seniors are placed on equipment that challenges their balance resulting in the unintended effect of increasing their trunk stiffness and decreasing efficient core stabilization thereby increasing their likelihood of falling (Osar, 2013).

Developing a Strategy for Balance

The goal is to develop a strategy for balance that helps improve the function of the trunk in maintaining and controlling balance. Incorporating the principles of alignment, breathing, and control to improve function of the thoracopelvic canister is an effective way to develop an optimal strategy for balance. How are these principles related to improving balance and reducing the chances of falling?

For more information and applications of developing the deep and superficial myofascial system, the reader is encouraged to review the information in the following link:  http://www.ptonthenet.com/articles/the-functional-role-of-fascia-in-posture-and-movement-part-1-3871

Incorporating the Principles into a Balance Progression

While there are an infinite number of exercise patterns and progressions that can be used, the step/lunge pattern will be used for purposes of this article. By adjusting variables such as the amount of movement, velocity of movement, degree of support, adding resistance, or adding dynamic variables such as throwing and catching a ball, the step/lunge pattern can be used by virtually any ambulatory client.

To ensure proper development of balance, the following guidelines will apply to the exercise progression:

If the individual is a beginner exerciser, they will perform a sagittal plane, frontal plane, and/or transverse plane step. If they have the strength, range of motion, and coordination they should perform the lunge (images 4-6 below). For beginners and/or seniors with balance challenges, these patterns may be performed while lightly holding onto a chair or wall for support. The goal is for the individual to move into and out of the pattern while maintaining alignment, three-dimensional breathing, and control.

   

Images 4-6: Sagittal plane (left); frontal plane (middle); and transverse plane lunge (right)

View the video below demonstrating both a progression and regression of the step/lunge pattern:

A variety of foot positions (split stance, in-line, and single leg), trunk positions (flexion, extension, lateral flexion, and rotation), movement of the eyes or head, or arm/leg reaches (overhead, forward, across the body, and with resistance) can be used to make the patterns as challenging as necessary (Images 7-9). Remember that regardless of the progression the goal is to develop and maintain alignment, breathing, and control required to improve balance.

   

Images 7-9: Sagittal plane lunge with rotation (left); Frontal plane lunge with resistance (middle); Crossover lunge with forward arm reach (right)

Although inclusion of labile (unstable or movable) surfaces has been shown to improve joint position and control in young athletes (Sannicandro et al., 2014), it is best to use caution when applying unstable surface challenges with senior populations that tend to generally be less adaptable (lower levels of strength, flexibility, and coordination) to increasing challenges. Postural alterations, trunk stiffness, and chronic myofascial restrictions are common compensatory strategies the nervous system adopts to improve stability. If a client has to compensate and create greater rigidity because they are exposed to greater instability, the exercise is contraindicated. Intensifying the challenge without maintaining alignment, breathing, and control leads to perpetuations of a non-optimal balance strategy and compensatory patterns that can lead to an increased risk of falls.

Once the client can effectively control their center of mass over their base of support while moving through three planes of motion, it may be appropriate to progress them to labile surfaces. The important concept to remember is that they must earn the right to progress to these higher-level challenges by maintaining their alignment, breathing, and control while on a stable surface prior to moving onto labile surface.

Conclusion

The significant injuries, health care costs, and mortality rates associated with falls require a strategic approach to deal with their impact upon the senior population. While there does not seem to be a consensus as to the best method for improving balance and/or preventing falls, anecdotal and clinical evidence compellingly suggests there must be an active strategy that includes improving alignment, breathing, and control of the thoracopelvic canister. 

This article has covered a strategy for incorporating the principles of the Integrative Movement System™ - alignment, breathing, and control - in improving balance. With disciplined adherence to ensuring the client has earned-the-right to progress to higher challenges by maintaining alignment, breathing, and control, fitness professionals can be an integral part of a multi-disciplined approach to improving balance and limiting the number of falls in the senior population. Additionally, the fitness profession can be the leaders in helping the senior population remain active and productive in their advancing years while decreasing the injury rates, health care costs, and mortality associated with falling.

References:

Barry, D. (2010). Boomers Hit New Self-Absorption Milestone: Age 65. Retrieved May 25, 2014:  http://www.nytimes.com/2011/01/01/us/01boomers.html?pagewanted=all&_r=0 

Behm, D. and Colado, JC. (2012). The Effectiveness of Resistance Training Using Unstable Surfaces and Devices for Rehabilitaiton. The International Journal of Sports Physical Therapy. 7(2): 226-241.

Comana, F. Balance Training Exercises. ACE Fitness. Retrieved May 25, 2014: https://www.youtube.com/watch?v=AWuKEt96Jjs 

Fall Prevention Task Force. Retrieved May 25, 2014 from  http://www.fallpreventiontaskforce.org/tools.htm

Falls Among Older Adults: An Overview. Retrieved May 25, 2014 from  http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html 

Gribble, PA., Hertel, J., Plisky, P. (2012). Using the Star Excursion Balance Test to Assess Dynamic Posturral-Control Deficits and Outcomes In Lower Extremity Injury: A Literature and Systematic Review. Journal of Athletic Training: 47(3): 339-357.

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Hester, AL. and Wei, F. (2013). Falls in the community: state of the science. Clinical Interventions in Aging. 8: 675-679.

Jacobs, JV., Henry, SM., Nagle, KJ. (2009). People with chronic low back pain exhibit decreased variability in the timing of their anticipatory postural adjustments. Behavioral Neuroscience. 123(2): 455-458. 

Jacobs, JV., Henry, SM., Jones, SL., Hitt, JR. Bunn, JY. (2011). A history of low back pain associates with altered electromyographic activation patterns in response to perturbations of standing balance. Journal of Neurophysiology. 106(5): 2506-2514.

Lee, LJ. and Lee, D. (2013). Treating the Whole Person with The Integrated Systems Model. Vancouver, CA: Discovery Physio course handouts. 

Massery, M. Hagins, M., Stafford, R., Moerchen, VA., Hodges, PW. (2013). The Effect of Airway Control by Glottal Structures on Postural Stability.  Journal of Applied Physiology. 115(4):483-490.

Orr, R. and Singh, RJ. Efficacy of progressive resistance training on balance performance in older adults: a systematic review of randomized controlled trials. Sports Medicine. 38(4): 317-343. 

Osar, E. (2013). Advances in Balance Training. Chicago, IL: Fitness Education Seminars Course handouts. 

Osar, E. (2012). Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction. Chinchester, UK: Lotus Publishing. 

Rose, D. (2004). Fall Proof. Champaign, IL: Human Kinetics.

Stevens, JA and Olson, S. (2000). Reducing Falls and Resulting Hip Fractures Among Older Women. Retrieved May 25, 2014 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4902a2.htm 

van der Burg, JCE., Pijnapples, M., van Dieen, JH. (2007). The influence of artificially increased trunk stiffness on the balance recovery after a trip. Gait & Posture. 26:272-278.

van der Burg, JCE., Pijnapples, M., van Dieen, JH. (2005). Out-of-plane trunk movements and trunk muscle activity after a trip during walking. Experimental Brain Research. 165: 407-412. 

Vera-Garcia, FJ., Grenier, SG., McGill, SM. (2000). Abdominal Muscle Response During Curl-ups on Both Stable and Labile Surfaces. Physical Therapy. 80:564-569.

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