Depending on your stage in life, the thought of poor balance and falling could be at the center of your universe or something you think will never be a concern.

Most people’s concerns and issues surrounding balance are almost always avoidable and almost always correctable, no matter how late in life they are discovered.

The best plan is to work on certain strategies before balance becomes an issue. Read on to learn more. 

Origins of balance-related issues

The onset of balance issues or the concern with falling starts years before you are aware that there is a problem.

As we get older, our movements become more predictable and we move less, in general. 

Our daily movements are all in the same plane of motion.

We sit and stand.

We walk.

We climb stairs.

Maybe we jog occasionally.

We do almost no lateral (side-to-side) movements or any type of quality rotational movements.

This, coupled with a more sedentary lifestyle, starts us down a path of weakness and instability that ultimately leads to us feeling unsure if our legs will support us as we move around. 

Unfortunately, this will go on for years before any signs show up indicating there may be a problem. And, it happens so subtly that it is almost impossible to perceive as it’s happening.

This is where the eyes of a skilled clinician can be helpful.

The slow descent into balance issues

I’ve spent some time working in a vestibular physical therapy rehab clinic. These patients I worked with presented with true neurological balance disorders.

What most people present with when they complain of their balance being poor is more of a weakness issue, not a neurological one. 

Muscular power in 65-84-year-old subjects showed a decline of approximately 3.5% per year. This, of course, can be offset with proper resistance training.

Muscle weakness is extremely common among the aged population:

• 48% among community-dwelling older persons.

• 57% among residents of an intermediate-care facility.

• >80% among nursing home residents.

Weakness in the hip and glute area are the key players here. When these muscles are weak, any time spent in a single-leg stance (like when we walk) will make the individual question whether or not they are going to fall.

The hip doesn’t stabilize properly and the person feels like the leg is going to give out underneath them.

This is one of the reasons why people start to shuffle their feet when they walk.

By shuffling their feet, both feet are always on the ground so they feel more stable. This is not ideal and creates other issues that can increase the risk of falls. 

Gait (a fancy word for how you walk)

How we walk, like all other movements, including our posture, is a learned behavior.

Over time, we learn to move a certain way. As we get weaker and move less, our movements become more compensatory in nature. 

The body will always move through the path of least resistance. This path is typically not ideal and leads to movement dysfunction which can be the catalyst for muscle tightness, weakness, and even pain.

20-50% of the elderly population (people aged 65 and older) display a gait disorder. The most common issue is weakness which can be captured as a lateral sway/shift during propulsion.

20-30% of those who fall suffer injuries that reduce mobility and independence and increase the risk of premature death.

The fear of falling then becomes paralyzing and the individual will do less and less as a result leading to a more rapid decline. 

The gait problems that show up in the elderly population started years, sometimes decades, earlier. It is never too early to start addressing the potential issues. 

Most healthy older people have stiffer, less-coordinated, and more-precarious gaits than do younger people.

Posture control, speed of body-orienting reflexes, muscle strength and tone, and stepping height all decrease with aging and impair an individual’s ability to avoid a fall after an unexpected trip or while reaching or bending.

The energy cost of walking at a comfortable speed has been shown to differ between older and young adults, with older adults having a greater energy cost of walking than young adults.

Lack of hip extension (often due to weakness) during walking explained a substantial proportion of the variance in the energy cost of walking.

Decreased stride length in elderly people coincides with weakness in hip extensors (glutes and hamstrings) and ankle plantar flexors (calf muscles) and reduced push-off phase.

The propulsion (push-off) phase in gait is known to generate the largest medio-lateral (side-to-side) momentum that is resisted by the gluteus medius muscle to maintain the center of mass within the base of support.

Gluteus medius muscle weakness in elderly fallers may have urged them to adopt a pattern that minimizes the medio-lateral forces.

What adoptive pattern? Smaller steps and shuffling of the feet.

Postural strategies.

You have three strategies for correcting your balance.

Which one your body uses can be determined by your current position, strength and mobility, and the magnitude of the force causing you to lose your balance in the first place.

Older adults may be unable to generate the necessary counterbalancing muscle torques, either in magnitude or in rate of muscle torque development, to control the body’s horizontal momentum

During forward loss of balance, older adults experience larger horizontal accelerations of the head than younger adults per unit of perturbation acceleration.

The cutaneous receptors on the plantar surface of the foot deliver information about the site and force of weight-bearing activities, and research has demonstrated that cutaneous receptors influence muscle activity in the lower extremities.

Reduction of this cutaneous information (somatosensory input from the bottom of the foot) is associated with an increase in postural sway.

A lot of older individuals who fall didn’t realize they were falling until they hit the ground. Their reaction time or awareness that there was a problem was so delayed they never had a chance to react.

Risk factors

So, what types of things should one be on the lookout for when it comes to balance and fall risk?

Age-related decreases in muscle strength and muscle power will diminish the ability to stop trunk flexion following a trip.

Increased reaction/response time will lengthen the time required to generate the response. This is bad. You want your body to react immediately to any perturbation. A delayed response, as I have already mentioned, leads to the individual not even realizing they were falling until they already hit the ground. 

Here is a summary of multivariate analysis and the average increase in odds of falling (16 studies):

• Muscle weakness (4-fold)

• History of falls, balance deficits, cognitive impairments, age over 80, and visual impairments (3-fold each)

• Gait deficits (2-fold)

Muscle weakness has a 4-fold increase in the risk of falls. Higher than any other risk factor. Muscle weakness plays a huge role in balance issues, fall risk, and the fear of falling.

Elderly fallers have a 15% reduction in muscle strength and a 21% reduction in power with respect to non-fallers.

Psychological consequences of falls are not less important than physical ones. The fear of falling and the anxiety after a fall produce a loss of self-confidence and cause functional limitations in people.

Surveys have reported 30%–73% of older persons, who have fallen acknowledge a fear of falling. 

Loss of confidence in the ability to ambulate safely can result in further functional decline, depression, feelings of helplessness, and social isolation.

Interventions and treatments

Enough with all the doom and gloom. What can be done to improve outcomes and prevent the loss of balance and potential fall risk?

This is a difficult situation to resolve. It is best if you get the assistance of a qualified clinician to help you get going in the right direction. 

As you may have guessed, strength (or lack thereof) is a big part of the equation. 

Exercise targeting strength, power, and reaction time should be part of any program to reduce fall-specific incidence.

A properly designed training program should also teach you how to resist movement as well as initiate it.

Exercise programs decrease the incidence of falls by older adults but do not, however, necessarily decrease the incidence of fall-related injuries.

Part of the explanation for that is how you perform all activities really matters. Remember, the body will follow the path of least resistance.

If we move poorly, just moving more will not bring us to the outcome we desire. It is possible to get stronger and still have poor-quality movement patterns. 

When starting an exercise program, using surfaces or other devices to provide a little extra help with your balance, when performing your exercises, is a great idea. 

Fatigue when exercising is not your friend. Manage fatigue by keeping your volume low. That means do not do a lot of reps per set. If you start to get tired, stop and take a break. 

Stretching and foam rolling of certain muscle groups may be warranted. 

Treadmill walking can be helpful in retraining the gait cycle while allowing you additional support (rails of the treadmill). The belt of the treadmill will help to pull the leg back which will help increase your stride length.

Learn how to resist rotation and how to properly rotate. When I first meet clients, almost none of them know how to rotate properly. It is a little more complicated than you may think.

Balance impairment/fall risk is a multidimensional problem. It took years to develop so it is going to take some time to resolve it. 

Until next time,

Dr. Tom

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