Fall Resilience

Did you know that over 30% of people who are 65 or older experience at least one fall a year? This shows the significance falling has on our growing older population. The reason why the risk of falling is high for our older population is that their balance is impacted by physical and cognitive declines associated with aging. Examples of physical declines associated with aging include a decrease in muscle strength, ankle mobility, bone density, and coordination in the lower extremities. Examples of cognitive declines due to aging include alterations to the vestibular system, decline in vision, and sensory issues associated with the foot. 

So what can we do to help decrease the risk of falls? According to the National Library of Medicine, physical activity is the best solution for those at risk of falling. In a study conducted by Dr. Ewan Thomas for the National Library of Medicine, three groups of elderly individuals were subjected to 8 to 32 weeks of physical activity to see how each type of physical activity modality would impact fall risk. Group 1 was a combination of aerobic and resistance training, Group 2 was just resistance training, and Group 3 was no training. After 16 weeks of training, Groups 1 and 2 saw improvements in balance which led to a dramatic reduction in the number of falls. Out of the three groups, Group 1 showed the greatest improvement. Not only does physical activity decrease fall risk, but it also improves your overall health. According to the National Library of Medicine, “higher levels of physical activity reduce overall morbidity and mortality and the risk of falling” between 30% and 50%.

Even though integrating resistance and aerobic training is important for fall risk, balance training should also be prioritized. The main components of balance include vision, hearing, and proprioception. There are balance tests we can use such as the Balance Error Scoring System (BESS) to help assess individuals who are at risk of falling. Implementing regular exercise such as resistance training, aerobic training, and balance training can help improve the quality of life for our older population who are at a higher risk of falling. 

Balance is our ability to keep an upright posture or body position. Balance can be split up into two separate categories which are static and dynamic balance. Static balance is our ability to maintain a certain body position while stationary. Dynamic balance is our ability to keep a certain body position while moving. Daily activities such as walking, going upstairs, and picking up objects all require balance. As you get older, your ability to perform these tasks gets more difficult due to physiological changes that occur. Our goal is to combat these physiological changes through exercise. Physiology relates to the essential functions and mechanisms of the organ systems in the body. 

There are many physiological advantages associated with balance training. One of the main advantages is enhanced proprioception. Proprioception is the ability to relate your body position and movement to the environment surrounding you. An example of this is being able to stand on one leg and trying to hold that for 20 seconds. There are receptors in your joints that send signals to your brain to activate muscles that will help you retain body position. As you hold this position, your brain is making new connections that will remember your movement pattern. This is called neural plasticity and it is how our nervous system modifies itself. Neurons, which are the cells of the nervous system that receive and send information,  are formed when you perform a new task or exercise. The accumulation of neurons over time from consistent exercise will help increase sensitivity to the training stimulus and increase the number of synapses, or junctions between neurons, thus decreasing the time it takes for the brain to process the movement. This will result in more controlled, coordinated movements that will help improve your quality of life. With consistent training, anyone can have the ability to improve their proprioception. This is critical for our older population because the receptors in your joints desensitize over time which leads to joint instability thus increasing the risk of falling.

Many unilateral exercises are effective for balance training. Unilateral means using only one limb to perform a movement pattern. An example of this would be a single-leg hip hinge. Even though the main purpose of this movement is to activate your glutes and to work on lower body pulls, trying to balance on one leg is a challenging movement that will only improve with repetition. This exercise puts the right amount of stress on the nervous system which is beneficial for neural plasticity. Not all stress is bad so keep that in mind as you exercise. This relates to the SAID principle which means specific adaptations to imposed demands. This means that putting adequate stress on the body will lead to your body adapting to the stressor. An example of this is lifting heavy weights for several weeks and noticing significant increases in strength over time. Bilateral exercises are also very beneficial. Bilateral exercises are when you are performing a movement with two limbs. For example, squats are critical for those with balance issues because the main reason why people fall is due to not being able to get up off a toilet or chair properly. This is due to a lack of coordination in the lower extremities, improper technique, and muscle atrophy, or the loss of muscle tissue. We want to gain muscle tissue so we should perform these exercises in the hypertrophy range. Hypertrophy means an increase in the size of the muscle tissue. The hypertrophy range is 8-12 reps which is the adequate volume for building muscle.

Ankle mobility also plays a big role in balance. According to the  National Library of Medicine, “ankle mobility contributes to the performance of dynamic tasks, while the plantar-flexor muscle strength helps to develop a standing static balance”. According to the  National Library of Medicine, ankle mobility is also associated with “altered postural sway, decreased walking speed, and reduced capacity to develop other functional movements”. Without proper ankle mobility, an individual would not be able to keep an upright posture while standing or walking, would not be walking efficiently, and would not be able to perform important movement patterns effectively. Dynamic tasks such as stepping over an object can be challenging for most older individuals so we must work on ankle mobility to ensure they can move with no fear of falling. We can use the Side Hop Test to evaluate dynamic balance. For this test, the individual must bound laterally over a 30 cm line for 10 repetitions on each leg. If the individual does not meet the average for their gender and age based on normative data, there will be a heavy focus on improving ankle mobility before performing any dynamic exercises. Static tasks, such as standing on one leg, are important for maintaining proper posture. We can use the Balance Error Scoring System (BESS) to help properly assess static balance. The individual has to perform 6 trials that are each 20 seconds long and errors in their movement are recorded. For the trials, the individual must stand with feet together on the ground with eyes closed, feet together on a foam pad with eyes closed, single leg on the ground with eyes closed, single leg on the foam pad with eyes closed, and heel-toe stance on the ground with eyes closed. This challenges the visual portion of balance, thus challenging proprioception. Common errors include swaying hips, lifting your heels, and opening your eyes. If the individual scores more than 12 out of a possible 60 then the individual is at risk of injury from falling. We can use both these tests to help identify what exercises would be beneficial for improving their ankle mobility. Consistency is key for ankle mobility so implementing dorsiflexion and plantarflexion in routine exercises will help gradually improve ankle mobility. Dorsiflexion, or when you flex your toes toward your shins, can be performed when tucking your toes for bear crawls and bird dogs. Plantarflexion, or when you point your toes toward the floor, is implemented when kicking while swimming. Dorsiflexion and plantarflexion are both very important for gait which is the pattern of walking. 

Osteoporosis is a decrease in bone mineral density due to greater resorption of bone material than deposition. This is one of the main conditions associated with fall risk because older individuals are more susceptible to fractures. There are a variety of reasons why a person has osteoporosis such as a sedentary lifestyle and improper diet. Osteoporosis can not be cured but we can implement activities that can help maintain bone mineral density, thereby slowing the progression of the disease and reducing fall risk. Many older, osteoporotic individuals are too scared to exercise due to a higher likelihood of falling. This fear of falling is strongly correlated with frequent falls. It is important to note that it is never too late to start exercising. 

Despite the common fear of exercising, we actually want people with osteoporosis to perform weight-bearing exercises. Weight-bearing exercises are when an individual works against gravity such as walking. This is important because our bones grow due to the stress being placed on them by gravity. This is called Wolff’s Law which is the main mechanism for bone remodeling and growth. We want to ensure that they do low-impact weight-bearing exercises to ensure that the stress is not too high on the joints. Increased bone growth can help protect vital organs, produce red blood cells, and support soft tissue. Muscles help offset the stress put on the bone during exercises by redirecting the stress in the opposite direction so it is important to ensure that the muscles have proper stiffness to prevent injury.

Proper nutrition is also vitally important to retaining proper bone density. Many individuals are Vitamin D deficient which directly impacts calcium absorption. A lack of calcium absorption directly leads to a loss in bone mineral density. There are many ways to implement Vitamin D and calcium into your diet. Salmon, orange juice fortified with Vitamin D, and eggs are all great sources of Vitamin D. In addition, spending just a couple of minutes in the sun also gives you your daily Vitamin D intake. Great sources of calcium include leafy greens, yogurt, and broccoli. Getting measurements of your calcium and Vitamin D levels through blood work results can also be used to track your diet. Ask your doctor how to interpret these results and how you can change your diet. 

Many people live sedentary lifestyles due to working environments, school environments, and increased reliance on the Internet for leisure activities. Even though the lifespan of humans has increased dramatically over the past century, the overall health has decreased dramatically. This can be seen in an increase in cardiovascular disease, cancer, obesity, and the ever-growing number of falls recorded each year. We must ensure that our older population has an active lifestyle where they exercise regularly and move throughout the day. First, we must distinguish the difference between exercise and physical activity. Exercise is a planned, structured time for improving fitness. Physical activity is related to daily life activities such as walking to work, gardening, yard work, and taking the trash out. According to Physical Activity Guidelines for Americans, “80% of adults are not meeting the key guidelines for both aerobic and muscle-strengthening activity”. That means that 80% of adults are susceptible to chronic conditions and possibly falling when they are older. Consistently working out and remaining active throughout the day will help prevent an individual from getting a chronic condition such as cardiovascular disease through physiological adaptations. Some physiological changes that occur in the cardiovascular system include a decrease in heart rate and improved stroke volume. A decrease in heart rate indicates a healthier heart because it signifies that your heart is beating more efficiently due to more blood being pushed out per contraction of the heart. Stroke volume is the volume of blood ejected per contraction of the heart. An improved stroke volume means that your heart pumps more blood per contraction which helps working muscles receive more oxygen thus improving performance.

Many physiological adaptations that occur due to exercise help to minimize the risk of falling. One of the adaptations is an increase in the cross-sectional area of muscle. An increase in the cross-sectional area of muscle helps increase force generation to perform a movement pattern. For example, doing squats increases the cross-sectional area of the glutes, quads, and hip flexors. Glutes help with extending the hips which is critical for walking and standing so increasing the cross-sectional area would allow an individual to generate proper force generation for walking and proper muscle tone for standing upright. Another physiological adaptation is an increase in the range of motion. Having an adequate range of motion decreases the risk of injury and improves the efficiency of performing movement patterns. To increase the range of motion, you have to stretch because it releases muscle tension that allows the muscle to lengthen more. Lengthening the muscle helps to produce adequate force generation for necessary, functional movement patterns like walking. Exercise also prevents joint laxity which is when a joint is unstable. Joint laxity is another major cause of falling so improving the stability in joints such as your knees will help with an individual’s ability to move efficiently.

There are many ways that we can help our older population build fall resilience. Improving balance by implementing exercises that work on proprioception, unilateral and bilateral training, and ankle mobility. For those with osteoporosis, it is important to perform low-impact weight-bearing exercises, proper Vitamin D intake, and proper calcium intake. This will help increase or retain bone mineral density which will decrease the risk of fracture. Regular exercise and physical activity should be performed for beneficial physiological adaptations including an increased range of motion and an increase in the cross-section area of muscle which helps with force generation for performing movements. We want to ensure that the fall risk decreases so that the quality of life of people improves over time and does not decline. 

_{Thomas, Ewan, et al. “Physical Activity Programs for Balance and Fall Prevention in Elderly: A Systematic Review.” Medicine, U.S. National Library of Medicine, July 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635278/#:~:text=Various%20studies%20have%20examined%20different,climbing%2C%20vibration%20training%20to%20dancing.&text=These%20have%20all%20found%20significant,reduce%20the%20risk%20of%20falling.} 

_{Hernández-Guillén, David, et al. “Association Ankle Function and Balance in Community-Dwelling Older Adults.” PloS One, U.S. National Library of Medicine, 4 Mar. 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932177/.} 

_{Meyer, Felix, et al. “Osteoporosis, Fear of Falling, and Restrictions in Daily Living. Evidence from a Nationally Representative Sample of Community-Dwelling Older Adults.” Frontiers, Frontiers, 5 Sept. 2019, https://www.frontiersin.org/articles/10.3389/fendo.2019.00646/full.} 

_{Stutzman, Lora. “Fall Prevention: Balance and Strength Exercises for Older Adults.” Fall Prevention: Balance and Strength Exercises for Older Adults | Johns Hopkins Medicine, 8 Aug. 2021, https://www.hopkinsmedicine.org/health/wellness-and-prevention/fall-prevention-exercises.}