Michael E. Rogers, Ph.D., CSCS

Health-care providers need evidence-based and easy-to-use programs to educate their patients on increasing physical activity. The purpose of this paper is to describe specific interventions to improve balance and flexibility as a means of improving health and functional ability, as well as to prevent chronic disease and disability, in older adults. The paper provides specific balance and flexibility exercises that are part of First Steps to Active Health, a standardized, inexpensive, turnkey program for healthcare professionals to promote physical activity among older adults.

Why should older adults perform balance training?

Performing this type of training can improve balance, postural stability and gait and reduce the risk and fear of falls. One-third of community-residing adults over 65 years of age suffer a fall each year (Tinetti et al., 1988). With more than 35 million older adults in the USA, this equates to more than 10 million falls each year. Falls are not only the leading cause of injury-related deaths in older adults, but they are also a significant cause of morbidity and disability (National Safety Council, 2000). In 2000, 1.8 million falls resulted in an emergency room visit for head trauma, soft tissue injuries, fractures, and dislocations. These falls accounted for $16.4 billion in direct medical expenses (Kochera, 2002). Of these injuries, hip fracture in older adults is the most devastating. From 1988 to 1996, the estimated number of hospital admissions for hip fracture increased from 230,000 to 340,000 (Graves & Owings, 1998).

Falls are often caused by a loss of balance. The ability to balance depends, in large part, on three sensory systems: the visual, vestibular, and somatosensory systems. With increasing age, however, sensory function decreases and negatively affects balance control (Era et al., 1996). In addition to the three sensory systems, muscle strength plays a role in balance and mobility. Deficits in leg strength are related to diminished gait velocity, stride length, and balance (Sandler et al., 1991). Hip extensor power is significantly related to the ability to rise from a chair, climb stairs, and walk (Bassey et al., 1992). Increasing strength may offset some of the contraction speed-associated deficits in the elderly and may further modify other factors (i.e., postural control, proprioceptive input, range of motion, fear, etc.) that would reduce the risk for falls (Brown et al., 1995).

What type of exercises should be performed?

Balance exercises involve maintaining standing and postural stability under a variety of conditions. A basic premise of exercise science is that in order to improve the function of a system through exercise, the exercise must stimulate that system (i.e., the principle of specificity). Therefore, in order to improve balance, the exercise intervention must target the systems that control balance (i.e., sensory and motor systems, among others). Challenging the sensory-motor systems can be accomplished with various exercise modalities. For example, several studies have shown that strengthening the lower extremity with elastic bands improves balance and prevents falls (Tinetti et al., 1994; Topp et al., 1996; Topp et al., 1993).

The effects of a 10-week program using inflatable 55-cm exercise balls (Thera-Band) on balance in older adults have been evaluated (Rogers et al., 2001). The program involved exercises in which the participants placed themselves in the prone, supine, or seated position on the balls and moved their bodies with the eyes open and closed over the ball’s shifting base of support. As a result of the training, static balance, as measured by postural sway or instability, was reduced by approximately 10%. In addition, dynamic balance (functional reach) improved by 20% after training.

The effects of a 12-week intervention program using foam stability trainers (Thera-Band) and elastic resistance bands in older adults are also under evaluation (Shores et al., 2001). Participants shifted their body weight from foot to foot, and stood with the feet in a series of positions, including the feet side-by-side, the feet heel-to-toe, and on one foot. They also closed their eyes and/or moved the head to target the visual and vestibular systems. To progressively increase the difficulty of the exercises and target the somatosensory system, the participants performed the exercises while standing on the stability trainers. To enhance muscular strength, participants performed a series of elastic band exercises for the upper and lower body. Using a method called computerized force platform posturography, which assesses the limits of balance and stability (or how far one can lean in a given direction without stepping), we observed improvements in the directions that are most associated with falls that result in hip fracture (Greenspan et al., 1998), namely the right, left, and back directions. As a result of the intervention program, limits of stability improved by 67% in both the right/back and left/back directions. In the backward direction, there was a 77% improvement. In addition, the number of times a person could stand from a chair in 30 seconds increased by 17% (from 10.5 to 12.3 repetitions). No changes were observed in any of the balance or strength variables for the control group.

It is clear that certain exercise programs can improve balance by targeting the systems that control balance, specifically the visual, vestibular, somatosensory, and musculoskeletal systems. It is also clear that balance is an important factor in reducing the risk for falls.

When Should Balance Training be Performed?

Currently, the specific dose-response is not clear. However, we recommend incorporating balance into everyday activities, as well as performing a specific program two to three days each week.

Where can the older adult start?

Simply start by incorporating balance training in daily activities, such as standing on one foot while doing dishes or brushing teeth. Having a sturdy object (e.g., kitchen or bathroom counter) in front to grab is important in case a loss of balance occurs. The older adult can begin with five balance-specific exercises, performed two times per week with each exercise lasting for 10 to 15 seconds. Exercises based on needs and abilities should be selected. With safety being a critical factor, it is necessary to clear the environment of any obstacles. It is also important to remember that someone with poor balance should not perform exercises alone.

How is an older adult to progress?

An older adult should progress by increasing the time of each exercise to 30 seconds, then by increasing to two to three sets of each exercise. They can then gradually increase the challenge of the exercise by reducing the base of support (e.g., standing on one leg), changing the base of support (e.g., stand on foam surface), performing dynamic movements that challenge the center of gravity (e.g., tandem walk with one foot directly in front of the other), and reducing sensory input (e.g., close eyes).

What is the goal for older adults?

In order for healthy older adults to improve or maintain their balance, exercises should be performed as follows:

• two to three days per week
• eight to ten specific exercises covering major muscle groups
• two to three sets of each exercise
• 15- to 30-second hold for each exercise

What are some examples of exercises that can be performed to improve balance?

Many different exercises can be performed. Again, many of these activities can be incorporated into daily activity patterns (e.g., standing in line at the grocery store). However, for safety reasons, it is important to have something sturdy nearby for support in case a loss of balance occurs. Some examples of basic balance exercises are provided below:

Tandem Standing

One Leg Balance

Standing Hip Raise.

Standing Knee Bend

Standing kick.

Standing side Kick.

Standing on foam

One Leg Standing on Foam

Sidekicks with Band

Back Kicks with Band

Why should older adults perform flexibility training?

Performing flexibility training improves range of motion for activities of daily living and may protect against pain or injury. Flexibility or joint range of motion is an important component of fitness, particularly at advanced ages when declines in joint flexibility are often associated with declines in physical health and functional status (Shepard et al., 1990; Gehlsen & Whaley, 1990). After men achieve their peak range of motion in their mid-twenties and women in their late twenties, flexibility declines significantly with age in both sexes (Smith & Walker, 1983; Bohan et al., 1999).

Range of motion depends on the bone, muscle, and connective tissue within the joint. Aging affects these structures so that range of motion is typically reduced. In addition to structural changes, pain is sometimes encountered when moving the joints and this inhibits further joint movement. Reductions in joint flexibility can then make performing physical tasks more difficult. For example, if shoulder flexibility is reduced, then reaching for objects or combing hair becomes more challenging. In addition, walking, navigating stairs, and rising from a chair may become increasingly difficult as flexibility declines. Older adults with low levels of flexibility may also put themselves at risk for falls when performing such activities (Pate & Macera, 1994).

Current evidence suggests that participation in a regular stretching program can improve flexibility, reduce joint pain, and enhance muscle performance. However, little research has been performed to develop programs that specifically target range of motion in older adults. The American College of Sports Medicine recommends that older adults participate in exercises that have been shown to increase range of motion (ACSM, 1998). These exercises include walking, aerobic dance, and stretching. Many studies report improvements of range of motion of the neck, shoulder, wrist, hip, knee, and ankle joints with such programs.

What type of exercises should be performed?

Muscular flexibility exercises include stretching for major muscle and/or tendon groups.

When should stretching exercises be performed?

Stretching exercises are typically performed before and after an exercise routine, such as aerobic exercise or strength training. Stretching should be performed a minimum of two to three days per week.

Where can the older adult start?

Older adults should begin with 5 to 10 stretches of the upper and lower body. A static (hold without bouncing) stretch should be used, holding the position at a level of mild discomfort for 10 to 30 seconds. Stretches should be repeated three to four times for each exercise. It is important to continue regular breathing while holding stretches.

How is an older adult to progress?

Stretches should be chosen based on needs (e.g., someone with functional limitations in the upper body should perform more upper-body stretches). Other stretches can be added as needed.

What is the goal for older adults?

Older adults should perform stretching exercises at least two to three days per week, preferably before and after each aerobic or strengthening exercise routine.

What are some examples of flexibility exercises that can be performed to improve balance?

Many different exercises can be performed. Some examples of basic flexibility exercises are provided below:

Overhead Stretch

A man is seated on chair demonstrating chest stretch

Midback Stretch

A woman is seated on chair demonstrating sidebends

Trunk Rotation

Hamstring Stretch

Calf Stretch

How can a well-rounded physical activity program be developed?

A well-rounded physical activity program includes cardiorespiratory, strengthening, balance, and flexibility activities. The program should be based on individual needs, abilities, and interests. Following is a sample of a well-rounded daily physical activity program:

• Monday: Cardiorespiratory exercise for 10 to 30 minutes (walk/jog, bike, swim)
• Tuesday: Strengthening and balance exercises
• Wednesday: Cardiorespiratory exercise for 10 to 30 minutes
• Thursday: Strengthening and balance exercises
• Friday: Cardiorespiratory exercise for 10 to 30 minutes
• Saturday: Gardening (or other recreational activity) for 10 to 30 minutes
• Sunday: Strengthening and balance exercises

How can an older adult make and track progress?

A person can begin by exercising for 5 minutes, three times a day, for a total of 15 minutes for that day. Over a period of time, he or she can extend the exercise program to get a total of 30 minutes for the day on most days of the week. Once this physical activity program has become easy to perform, additional progression is needed to further stimulate the body’s systems. Increases in the following progressions are commonly used:

• Frequency: The number of times per week
• Duration: The length or number of the exercise (time, sets, repetitions)
• Intensity: The level of the exercise, usually noted by resistance, heart rate, or Rate of Perceived Exertion (see Appendix A for Borg RPE Scale)

Progression is the key to improving fitness. Progression simply involves increasing the frequency, duration, and/or intensity of an exercise. In general, increase the duration of the exercise before increasing the intensity. Follow the progression guidelines in each of the steps noted above for specific recommendations.

An “activity log” can be used to track progress by noting the specific exercise performed, as well as the intensity and duration of each activity. Such a chart is used to document progress toward goals and to show to the healthcare provider on follow-up visits. A more detailed list of exercises can be kept separately. An example of an activity log follows:

WEEK 1 ACTIVITY LOG ( Y-> Yes )

How can motivation be maintained?

Many approaches can be taken to maintain sufficient levels of motivation so as to continue the exercise program, including:

• Follow an individualized program that is focused on specific goals.
• Start gradually with enjoyable activities and progress slowly.
• Emphasize lifestyle changes and incorporate activity into daily life.
• Establish regular workouts (the same time of day).
• Keep focus on short-term and long-term goals.
• Maintain activity logs to record achievements.
• Exercise with a partner or in groups.
• Gain support from family and friends.

What safety reminders should be provided?

There are several potential health risks associated with participation in physical activity. The most likely risk is the possibility of muscular-skeletal injury. Typically, these injuries involve minor muscle soreness in previously sedentary individuals who exercise without caution and are associated with overuse or abrupt changes in exercise routine (Stone, 1987). There is a very small risk of cardiovascular incident (such as heart attack, stroke, or death) during aerobic exercise. However, the risk of a cardiovascular event during exercise has only been demonstrated for individuals with established coronary artery disease and risk factors, cardiac rhythm disturbances, or other serious medical conditions (Stone, 1987). Furthermore, the risk of serious medical complications is most persistently associated with very high-intensity exertion in high-risk individuals with infrequent exercise habits (Eichner, 1983). It is worth noting that several studies have concluded that individuals who exercise regularly reduce their overall morbidity and mortality risk and that sedentary people are at much greater risk for disease and/or death at rest than healthy people during exercise (Eichner, 1983; American Medical Association, 1984). To further minimize the risk of injury during exercise, the following safety measures should be applied:

• Don’t exercise with an unstable medical condition, healing injury, or uncontrolled disease.
• Contact a doctor if chest pain or pressure, trouble breathing or shortness of breath, lightheadedness or dizziness, or nausea is experienced.
• Do not perform activities that cause sharp pain or aggravate a medical condition.
• Soreness is to be expected in the muscles following any unaccustomed exercise program. Use soreness as a guide for intensity. If the muscles are very sore the day after exercising, exercise at a lower intensity next time. If the pain persists more than 2 hours after exercise, a doctor should be contacted.
• Joint pain should be avoided. The saying, “No pain, no gain”, is not true for older adults.

What additional suggestions are there?

Several additional suggestions for exercise should be adhered to:

• Wear loose, comfortable clothing and shoes with good support.
• Perform a warm-up and cool-down with every exercise session.
• Start slowly and progress slowly as recommended by a healthcare provider.
• Use the Borg RPE Scale (Appendix A) and heart rate to monitor intensity as prescribed by a healthcare provider. If taking blood pressure or heart medication (e.g., beta blockers, diuretics, antianginals, etc.), use RPE rather than heart rate.
• Breathe properly. Never hold the breath while straining, particularly in the presence of high blood pressure. Generally, an individual should exhale during muscle exertion and inhale during relaxation.
• Drink plenty of water, particularly if sweating during activity.
• Remember to maintain proper posture and form with each exercise. Don’t “cheat” to finish any exercise.

Summary

Performing the balance and flexibility exercises described in this paper as part of First Steps to Active Health, a well-rounded exercise program designed specifically for older adults, can reduce the risk of falls and improve the ability to perform activities of daily living. It is recommended that healthcare professionals use the information provided in this paper to communicate with patients more effectively and to provide specific strategies to increase physical activity.

Appendix A

Rate of Perceived Exertion

(Borg RPE 6-20 Scale)

6 Extremely Easy
7 Very, Very Light
8
9 Very Light
10
11 Fairly Light
12
13 Somewhat Hard
14
15 Hard
16
17 Very Hard
18
19 Very, Very Hard
20 Extremely Difficult