Reducing your risk of falling is a hot topic for those over age 65. Many articles and talks by health professionals focus on this topic – and for good reason! Each year, more than 2 million older Americans go to the emergency room because of fall related injuries (NIH Go4Life article 2017).
Most falls are related to losing your balance. So, first, let’s get a general definition of what balance consists of. The short version is …it’s complicated! Balance relies on the interaction of many body systems – neuromuscular, visual, vestibular (inner ear), proprioceptive (ability to sense where your limbs and joints are and what they are doing) and somatosensory (ability to convey information about the state of your body and its immediate environment to your brain). A problem with balance can be in one of the systems, or in the interaction between the systems.
One common recommendation to improve your balance is to participate in a balance class or a therapy program focused on balance. Here is some information based on research to help you decide whether to engage in a program, and what to look for as to the contents of the program.
TYPES OF PROGRAMS
Some programs rely primarily on the improvement of your strength, and tout that strengthening alone will improve your balance. There is definitely a documented relationship between falls and lack of muscle strength, or weakness, in the elderly (1). However other studies show minimal or no difference in strength between fallers and non-fallers (2, 3). On closer review of the studies, balance improvement related to strength appears to occur primarily in subjects that are severely compromised in strength and muscle function – those that are considered frail (4,5). Although strength needs to be addressed in a program if one is very weak, it appears that other more specific components of a program are needed for most older adults to improve balance.
Compared to most group exercise classes, a Tai Chi class looks like its being performed in slow motion. The gentle, controlled movement patterns of this ancient Chinese art actually are much more dynamic than they appear, and most practitioners will tell you that it’s “much harder and more challenging than it looks.” The components of the art – controlling your balance as you move arms and legs in different patterns, and change your foot positions – intuitively would appear to be excellent for working on your balance. Moving slowly, and keeping control, is often much more difficult than faster movements, but what does the evidence tell us about the effect on balance?
A group of researchers attempted to integrate 20 years of research on the impact of Tai Chi on balance and mobility in older adults in an article published in 2014 in the Journal of Geriatric Physical Therapy (6). The results of the compilation of the research was inconclusive for direct evidence of improvement in balance and decreased fall risk but most of the studies recommended that Tai Chi was worthy of further investigation for its effect on balance, and that practitioners in the clinic and those delivering community programs have embraced Tai Chi as an appropriate and effective exercise for older adults. They noted many other benefits such as stress reduction, improved health behaviors, flexibility and cardiovascular health. The researchers also noted the low injury rate to those who participated in Tai Chi. They also stated “Going forward…uncovering mechanisms of Tai Chi’s effects definitely may be the most important discovery in this field.” (6) Another study focused on postural stability (balance) specifically with people with Parkinson’s Disease found that Tai Chi improved performance on several measures of balance, and the effects of the training were maintained at 3 months after the intervention (7). In summary, Tai Chi seems worthy of inclusion in a program to improve your balance.
These programs can be so varied in content but specifically work to challenge your balance in different ways. A good program should include both static (standing in one place) and dynamic (moving) exercises. A group program should cover all of the bases – a one on one therapy program will be more specific on YOUR individual problems based off an individual evaluation of all of your systems. Let’s look at what the research tells us about both.
Group Balance Programs
Multiple studies and articles support balance specific group programs as an effective means of reducing risk and rate of falls in older adults (8, 9, 10, 11). However, one of the most interesting studies focused on the questions we often have of…How often? How long should the sessions be? And finally…how long until I see improvement? This systemic review by Lesinski and fellow researchers (12) recommends the following as optimal: training period minimum of 11-12 weeks, 3 sessions per week for a total of 36-40 sessions, and the duration of each session should be at least 45 minutes. You need to stick with a program to get results!
One of the benefits of an individualized program is that it can be designed specifically for you, and take into account other problems that you have. A good group instructor will try and make sure that all class participants are challenged, but cannot address one’s specific deficits. Examples are working around your arthritic knee, or focusing more on issues caused by your leg neuropathy. An individualized program can also get you started at the correct “balance Challenge” level, and progress you as you get better. Oddsson et al (13) focused on the importance of adhering to the principles of training when working on improving balance in their study entitled “How to improve gait and balance function in elderly individuals – compliance with principles of training.” To quote…”an exercise intervention targeting a certain function must provide a challenge/overload to the system and be progressive as well as specific to this function. Otherwise, a training effect should not be expected…the basic principles of prescribing exercise are also appropriate for persons with disease.” The article cites multiple studies indicating that challenge must be individualized and progressive to receive maximal gains. The thought “individualized and specific is better” is supported by another study by Halvarsson et al (14) which indicated superior results in reaction time for stepping and decreased fear of falling when a program is individually adjusted and progressed specific to the person’s condition.
So what’s the take away from all of these studies? I would summarize the literature as follows:
- Strengthening is good, but on its own, will not specifically improve balance in most individuals.
- Tai chi is most likely effective and has a low injury rate. You should also look at the other benefits of Tai Chi in addition to balance improvement in deciding if you want to include it in your program.
- Both group and individual balance programs are effective but need to follow training principles for you to get the most bang for your buck (and time!). They need to challenge you and be progressive. If you have a choice, an individualized program will give you the most benefits.
Cathleen Renkiewicz PT, DPT, GCS, CEEAA
Doctor of Physical Therapy, Geriatric Certified Specialist, Certified Exercise Expert for Aging Adults
Director of Rehabilitation
Want to learn more? Here are the research articles cited.
- Buchner DM (1997) Preserving mobility in older adults. West J Med 167 (4): 258-264
- Daubney ME et al. (1999) Lower-extremity muscle force and balance performance in adults aged 65 years and older. Phys Ther 79 (12): 1177-1185
- Wolfson L et al. (1993) Training balance and strength in the elderly to improve function. J am Geriatr Soc 41 (3): 341-343
- Chandler JM et al. (1998) Is lower extremity strength gain associated with improvement in physical performance and disability in frail, community-dwelling elders? Arch Phys Med Rehabil 79 (1): 24-30
- Fiatarone MA et al. (1993) The Boston FICSIT study: the effects of resistance training and nutritional supplementation on physical frailty in the oldest old. J Am Geriatric Soc 41 (3): 333-337
- Hackney ME et al. (2014) Impact of Tai Chi Chw’an practice on balance and mobility in older adults: an integrative review of 20 years of research. J Geriatr Phys Ther Jul-Sept; 37 (3): 127-35
- Fuzhong Li et al. (2012) Tai Chi and Postural Stability in Patients with Parkinson’s Disease. N Engl J Med Feb 9 2012; 366:511-519
- Sherrington C et al. (2008) Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatric Soc 56 (12): 2234-2243
- Sherrington C et al. (2011) Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull. 22 (3-4): 78-83
- Gilleskie LD et al. (2012) Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012: 9: CD007146
- Chodzko-Zajko WJ et al. (2009) Exercise and sports science Australia position statement on exercise and falls prevention in older adults. Med Sci Sports Exerc 2009; 41 (7): 1510-1530
- Lesinski et al. (2015) Effects of Balance Training on Balance Performance in Healthy Older Adults: A Systemic Review and Meta-analysis. Sports Med 45:1721-1738
- Oddsson et al. (2007) How to improve gait and balance function in elderly individuals – compliance with principles of training. Exer Rev Aging Phys Act 4:15
- Halvarsson A et al. (2011) Effects of new, individually adjusted progressive balance group training for elderly people with fear of falling and tend to fall: a randomized controlled trial. Clin Rehabil Nov; 25 (11): 1021-31