• Each year in the U.S., one of every three people over 65 experiences a fall, and many fall more than once
• 85% of falls occur at home, most commonly on stairs, going to the bathroom and/or bedroom
• 40% of hospital admissions among those over age 65 are fall-related
• Approximately half of the older adults hospitalized for these injuries are discharged to nursing homes

For many older adults, a fall that breaks a bone, especially a hip, causes them to lose their mobility and independence and can be the beginning of a downward spiral that ends in death.

A study done in Finland over the 25-year period from 1970 to 1995 showed a quadruple increase in the number of falls of those over age 50.  Even when they took into consideration the greater proportion of Finns who were over age 50 in 1995 compared to 1970, the researchers found that the incidence of falls had more than doubled.  And the researchers there, as well as experts here, say the problem is no different in the United States.

(By the way -- if you're thinking you're too young to worry about these statistics, read on.  Now is the time to optimize your balance in some easy ways.)

HOW OUR BODIES BALANCE
Our bodies utilize three systems to help us balance.  These systems work as a unit to sense changes in posture and balance, and to send messages to the brain.  The three systems are:

• Somatosensory
• Visual
• Vestibular

The somatosensory system provides information on body contact, and the position of the body in space.  This is done through receptors in the skin, muscles, and joints.  Recall the challenge of walking or even standing when one foot has gone to sleep, and you'll appreciate the input of this system.

The visual system provides information about the environment around us as well as the location, direction, and speed of movement of the individual.  Note the reflexive action you take when you sense an approaching ball.  The visual system helps you to respond quickly to duck or step out of the way.

The vestibular system is located in the semicircular canals of the inner ear.  It sends information to the brain about the position and movement of the head.  If you've ever experienced an inner ear infection or head trauma, you may have felt dizzy, nauseous, or had difficulty standing.  This points out the difficulty your vestibular system has in working effectively when compromised. 

SOME RISK FACTORS FOR FALLS
Risk factors for falls can be divided between intrinsic and extrinsic.  Intrinsic factors originate or are due to causes within the body, and include such things as:

• vision
• balance
• gait (your walking pattern)
• musculoskeletal system
• acute and chronic diseases
• medication use

Extrinsic factors originate from or are on the outside of the body, and include such things as:

• environmental conditions
• assistive devices
• footwear and clothing
• design of the immediate environment
• condition of and sudden change in ground surfaces
• improper lighting

ON THE HOME FRONT
Since most falls occur at home, let's examine some simple precautions you can take to make things safer. 

Flooring
Check for loose rugs, runners, and mats.  Be aware of uncarpeted, slippery areas.  Avoid waxing floors, and clean up spills as soon as they occur.  Look for obstacles such as electrical cords and other small objects that might present a hazard.  Also check carpet edges, and any area where there is a sudden change in ground surfaces (e.g., from tile to carpet).

Stairways
Do the handrails run the entire length of the stairs, and are they sturdy and well-attached?  Is the area well-lit, with a switch at both top and bottom of the stairs?  Are any steps uneven, or in need of repair?  Consider the use of tightly woven carpet here, or non-skid treads. 

Bathrooms
Grab bars in the shower and tub are a good idea, as are non-skid mats.  Check also for poor lighting, and consider a nightlight.  (Many falls occur at night, when an urge to use the bathroom sends us running.  Consider keeping a flashlight beside your bed.)

Kitchens
Avoid placing frequently used items in hard-to-reach areas, or areas where you have to bend over.  Better to place items within easy reach.  Avoid climbing if possible, but if you must, make sure your step stool is stable, with a handrail and wide steps. 

Keep all rooms free from clutter, especially the floors.  Check the condition of your shoes, and avoid loose-fitting items such as sandals and slippers, high heels, shoes with excessive cushioning, and stocking feet.  Make sure your eyeglasses are properly fitted and of the correct prescription.  These simple measures can make a world of difference in helping you avoid accidents and falls.
 
LOOKING AT THE BIG PICTURE - THE NEED TO EXERCISE
While the Finnish study mentioned earlier did not explore why falls are happening more often, the researchers did note previous research suggesting that thinning bones and decreased muscle strength associated with aging were prime factors. 

This further accents the need for resistance training as an integral part of our entire exercise program.  In fact, balance training should not be considered as a separate piece, but rather an integral part of a well-designed exercise program which already includes cardiovascular, resistance, and flexibility training.  (There is a lot of overlap between resistance/strength and balance exercises; very often, one exercise serves both purposes.)

Dr. Mary E. Tinetti, the chief of geriatrics at Yale University School of Medicine, believes that fall-prevention measures clearly work and are simple to implement.  She notes that exercises to increase strength and balance are one of the two most effective measures in preventing falls.
           
A CLOSER LOOK AT MEDICATIONS
The second most important fall-prevention measure, according to Dr. Tinetti, is medication reduction.  Studies have pointed out that people currently on four or more medications are most at risk, and Tinetti suggests working with your physician to minimize the number and doses of medications to the lowest levels required.

Furthermore, certain medications can place you at higher risk for falls due to side effects like dizziness, vision impairment, and movement disorders.  Others can contribute to a condition called orthostatic hypotension, which is a drop in blood pressure caused by a sudden change in movement or posture.

Remember, too, that older adults are more susceptible to the effects of mind-altering chemicals -- so alcohol consumption that was well-tolerated at age 35 may present a challenge at age 50.

SOME BASIC EXERCISES
If you're ready to try some exercises specifically designed to help your balance, consider the Steady Seven listed below.

Before getting started, make sure your area is safe.  Begin by holding on to the kitchen sink, a table, or a high-backed, sturdy chair with both hands for support.  As you progress, you can try using only one hand for support, then just your fingertips, and then no hands at all.  Finally, you can try the exercises with eyes closed, if steady.

As you do the exercises, look straight ahead.  Keep your chin and neck in good alignment with the rest of your spine and keep your shoulder blades pinched back slightly.  Tighten the muscles in your stomach area to help keep your mid-section supported.  Keep your breath moving naturally.


THE STEADY SEVEN


TOE STANDS/plantarflexion

1. Stand straight and tall, holding on for balance
2. Slowly rise up on your toes, as high as possible (be careful not to splay your ankles)
3. Hold the position for a count of 5
4. Slowly lower heels all the way back down
5. Repeat 8 to 15 times, adding modifications as you progress

HEEL STANDS/dorsiflexion

1. Stand straight and tall, holding on for balance
2. Slowly rise up on your heels, raising the front part of your foot
3. Hold the position for a count of 5
4. Slowly lower toes and front of foot all the way back down
5. Repeat 8 to 15 times, adding modifications

ONE LEG STAND/knee flexion

1. Stand straight and tall, holding on for balance
2. Balancing on left leg, slowly bend right knee as far as possible, so the right   heel raises up behind you
3. Hold the position for a count of 5
4. Slowly lower the right foot all the way back down
5. Repeat on the opposite side (standing on right leg, raising left)
6. Repeat both sides 8 to 15 times, adding modifications

ONE LEG STAND/hip flexion

1. Stand straight and tall, holding on for balance
2. Standing tall on left leg, slowly bend right knee toward chest,without bending waist  or hips
3. Hold the position for a count of 5
4. Slowly lower the right leg all the way back down
5. Repeat on the opposite side (standing on right leg, lifting left knee toward chest)
6. Repeat both sides 8 to 15 times, adding modifications

ONE LEG BEHIND/hip extension

1. Stand straight and tall, 12 to 18 inches from support
2. Bend at hips; hold onto support
3. Slowly lift right leg straight backwards
4. Hold the position for a count of 5
5. Slowly lower the right leg
6. Repeat on the opposite side (raising left leg behind)
7. Repeat both sides 8 to15 times, adding modifications

The following two exercises are best practiced under the watchful eye of someone to assist and supervise.


EYE EXERCISE

1. Focus your eyes on a point 10-20 feet away while going from sitting to standing and back again with eyes open (make sure you land softly as you sit)
2. Repeat with your eyes closed
3. Be aware of your posture as you move: weight forward on the front of your feet; knees apart; chest forward; spine erect
   
   NOTE:  use a steady, sturdy chair for this exercise

HIP SWAY

1. Stand straight and tall, with your feet shoulder-width apart, holding on to your support
2. Lean forward slightly from the ankles, without bending the hips, feeling about 70% of your body weight on the balls of your feet
3. Return to the neutral beginning position
4. Lean slowly to the left, feeling about 70% of weight on the left sides of your feet
5. Return to the neutral beginning position
6. Lean slowly to the right, feeling the shift to the right
7. Put it all together, making gradual sways -- left/neutral, forward/neutral, right/neutral, left/forward/right/neutral, etc.
8. Gradually increase to see how far you can move the body without taking a step

PRACTICE, PRACTICE, PRACTICE
According to the June 2000 University of California-Berkeley Wellness Letter, a major reason for diminished balance is simply lack of practice.

If you are already exercising, you may find the Steady Seven somewhat easy.  If that's the case, and you are working with a personal trainer, your trainer can provide you with more challenging exercises.  Your trainer can also get you exercising with a variety of workout tools or toys designed to improve balance.

If you're ready to move on from the Steady Seven, perhaps you'd like to try T'ai Chi, a gently-flowing sequence of postures based on an ancient Chinese discipline of meditative movements. T'ai Chi movements continually change the center of gravity, base of support, and body positions in a way that is subtle but effective.

If you've noticed a significant change in your balance, now is a good time to check in with your doctor for a more thorough evaluation and examination.  Just remember -- no matter what your present level of balance, taking some simple steps can help you increase your ability to go with the flow and avoid dangerous falls. 



Seth Swoboda is a past trainer with Solo Fitness.


REFERENCES
Chandler, J.M., Duncan, P.W., Balance and Falls in the Elderly: Issues in
Evaluation and Treatment. Geriatric Physical Therapy. 1993 Mosby Year-Book.

Exercise:   A Guide from the National Institute on Aging  Pub. No. NIH 98-4258

Fall and Related Fractures  National Osteoporosis Foundation 

Kannus, P. et al  Fall-Induced Injuries and Deaths Among Older Adults,
            JAMA 281(20): 1895-1899.  May 26, 1999

Lewis, C. B., Bottomley, J. Geriatric Physical Therapy. 1994 Appleton and Large.

Malamut, David.    Rusk Institute Vestibular Therapy Department Address
            Senior Fitness Day    May 18, 1999

Preventing Falls and Fractures  National Institute on Aging

T'ai Chi for Balance Disorders     National Institutes of Health
            Office of Alternative Medicine study (unpublished)

Tedeiksaar, R., Falls in Older Persons: Prevention and Management, second
edition. 1998  Health Professions Press, Inc.



A free brochure on fall prevention is available by calling 1-800-824-2663 or
by sending a stamped, self-addressed envelope to Don't Let a Fall Be Your Last Trip,
American Academy of Orthopaedic Surgeons, P.O. Box 1998, Des Plaines, IL 60017.


© Seth Swoboda, 2001 All Rights Reserved