Balance training refers to exercises that are designed to improve and maintain balance. Additionally, balance training can enhance proprioception—the ability to sense the location, orientation, position, and movement of the body and its various parts. Balance training can be performed indoors or outdoors, in a fitness center or at home, and can be learned from a professional instructor or a Web-based resource. Although balance training can be advantageous for all groups of people, it is particularly beneficial for older adults.
Falls pose a serious health problem for older adults and are the leading cause of injury-related deaths in this age group. As the American population of older adults has risen, there has been a concurrent increased incidence of fall-related injuries and deaths. In the 65 and older population, it is estimated that one out of every four otherwise healthy, community-dwelling adults falls at least once a year, and falling once doubles the chances of falling again. Those individuals who fall and fracture a hip have a one in five chance of mortality within a year. For all fallers, there is a one in four chance of being in a nursing home within a year. In addition to injury and death, falling comes with a substantial economic impact. In 2015 the cost of medically treating fatal fall injuries was estimated to be $637.5 million, and the cost of treating nonfatal fall injuries was $31 billion. The primary purpose of balance training and related fall-prevention programs is to reduce the risk of falling.
Knowledge of the factors contributing to impairments in balance is fundamental to designing an effective balance-training exercise program. Poor balance is multifactorial in origin. Cognitive impairment, visual disturbances, and poor reaction time increase the likelihood of falls. Lower-extremity skeletal muscle weakness is also a well-recognized independent contributor to falls. In particular, fallers have lower quadricep, ankle dorsiflexor, and ankle plantarflexor muscular strength compared to nonfallers.
Research exploring exercise training as a means for fall prevention in older adults has often shown conflicting results, but a study published in 2013 by researchers in France found exercise programs (some balance oriented, some more general) reduced falls that caused injuries by 37% and falls leading to serious injuries by 43%. A later study by some of the same researchers focused on balance training and found it aided in the reduction of falls of women aged 75–85. The complex etiology of poor balance highlights the need for a comprehensive balance-training program.
The general frequency, intensity, time, and type (FITT) approach to exercise prescription used for cardiorespiratory fitness program design can also be applied to balance training. Although research has yet to identify the optimal FITT for balance exercises, it is recommended that balance training be performed three days per week for 10–15 minutes each session. Balance training can be integrated into various phases of the exercise session, including the warm-up, main component, or cool-down.
Balance exercise training programs and fallprevention interventions must include a focus on balance-recovery reactions. Ultimately, it is the capability, or lack thereof, to recover from a balance perturbation (loss of balance) that eventually determines whether or not an individual falls. Balance disturbances can arise from collisions, slips, and trips. Loss of balance can also occur during voluntary movements, including bending, reaching, and turning. The body has a natural line of defense against balance disturbances that consists of rapid limb movements. For instance, reaching out to grab a supporting object or quickly stepping forward with a lower limb are compensatory mechanisms aimed at preventing a fall. Fitness and exercise professionals should address the balance-recovery skill levels of individuals; effective training programs are those that replicate sudden and unpredictable balance disturbances. It is critical that fitness and exercise professionals design exercises/ activities that do not permit the individual to anticipate a balance perturbation. This elicits the most favorable adaptations in an individual's balance-recovery reaction capacity.
Although poor balance is frequently associated with reduced muscular strength, past literature has not supported resistance training alone as a successful strategy for enhancing balance performance and fall reduction. A study published in 2014, however, compared individualized resistance training to traditional balance exercise and a combination of both, and found that resistance training focusing on the lower limbs was more effective for the study participants than traditional balance exercises alone. Therefore, fitness and exercise professionals may want to consider an integrated exercise training approach.
Clients with no previous balance training experience should initially perform basic sitting and standing exercises as a means to improve balance performance. As these initial exercises become easier, an increase in difficulty can be accomplished in numerous ways:
- Arm progressions: The use and position of the arms can be varied to make a given balance exercise more difficult. Hands may first need to be grasping or touching another object, such as a wall or back of chair, to facilitate balance. Progressively, exercises can be performed with arms spread out and raised to shoulder height to assist with stability. Ultimately, clients can move arms in from sides to a folded position across the chest.
- Surface progressions: The surface or apparatus on which clients perform balance exercises can be altered, progressively increasing the difficulty. For instance, foam pads, balance disks, and Bosu balls can be substituted for a hard, flat surface while performing multiple standing balance exercises. Similarly, physioballs can be exchanged for regular chairs when performing sitting exercises.
- Visual progressions: The visual sensory cues provided to the client during nearly all balance exercises can be altered. Lighting of the room can be gradually dimmed, sunglasses may be worn inside, or eyes may be shut completely.
- Tasking progressions: Clients should be required to initially master each balance exercise performed as a singular task. When this level of achievement is attained, the routine should be supplemented with additional tasks. Cognitive tasks or added physical tasks are a few of the readily available options.
Many falls occur during conditions to which a client is unaccustomed. Poor lighting or uneven surfaces impair the sensory cues typically available to an individual, which temporarily compromise the balance performance. The fitness and exercise professional can introduce these challenges into the training program as a means to better prepare individuals for circumstances where sensory cues are unavailable. For instance, heel-toe walking may be performed with sunglasses worn (inside), eyes closed, or while slowly turning the head from side to side. Standing balance exercises can be completed while standing on a foam pad or balance disk in an effort to disturb the surface conditions to which a client is familiar. Altering the sensory cues available to a client is an important consideration when designing the overall balance training program.
Aerobic, resistance, flexibility, and balance training are all critically important for the overall health, functional capacity, and quality of life of older adults. If the minimum frequency requirements of each form of activity are to be fulfilled, individuals need to perform at least two (or more) activities on the same day and most likely within the same exercise session. Balance training should precede both resistance and flexibility activities. Research has reported that participation in either resistance or flexibility activities prior to balance exercises can negatively impact performance. For older adults who may already face significant balance challenges, it would be inappropriate, and possibly harmful, to introduce additional changes due to improper activity sequencing. Balance training, when combined with resistance and flexibility activities, should be performed first or following aerobic activity when coupled with that mode.
The two explanations generally given for lack of a favorable adaptation from balance exercises are lack of specificity in training and performance of single-component compared to multicomponent training. Training programs including only single-task activities reportedly fail to place individuals in environmental conditions similar to those experienced prior to and during a fall. Though balance training focused on improving functional tasks, such as heel-toe walking or standing on one leg, will be successful for enhancing performance of that specific activity, it fails to adequately replicate activities of daily living that require maintaining balance while completing several activities simultaneously or while distracted. Fitness and exercise professionals must design regimens entailing concurrent performance of balance exercises and additional tasks. For example, in addition to performing heel-toe walking, individuals may be requested to simultaneously complete a cognitive task, such as counting backward from 100 by increments of three. An additional form of dual-component training may involve combining a balance exercise with another physical form of activity. For instance, balancing on one leg could be completed while playing catch with a light medicine ball. In summary, multitask balance training more closely replicates the circumstances of daily living in which individuals function and the situations in which their balance performance will most likely be challenged by a disturbance.
Conventional balance-training programs include various sitting and standing activities, which have been shown to be effective over the long term. In less motivated individuals, the performance of repetitive, basic tasks can lead to poor adherence, less effective training, and, ultimately, cessation of training. Consequently, continuously designing new and creative balance exercises for individuals should be a priority for fitness and exercise professionals. Studies have reported that utilizing interactive video games may be an effective strategy to employ in designing balance activities for older adults. The Wii Fit, for example, has various balance modules, including soccer and skiing, that can be performed at different skill levels, depending on an individual's functional capacity. Science has shown that progressively incorporating interactive video games into training can increase motivation and improve balance performance. Recent research has also addressed the use of virtual reality in balance-training regimens.
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American Society on Aging, 575 Market Street, Suite 2100, San Francisco, CA, 94105-2869, (415) 974-9600, Fax: (415) 974-0300, (800) 537-9728, http://www.asaging.org .
Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA, 30329, (800) 232-4636, cdcinfo@ cdc.gov, http://www.cdc.gov .
IDEA Health and Fitness Association, 10190 Telesis Court, San Diego, CA, 92121, (858) 535-8979, Fax: (619) 344-0380, (800) 999-4332, firstname.lastname@example.org, http://www.ideafit.com .
Lance C. Dalleck, BA, MS, PhD