Balance for Baby Boomers and Seniors

Senior Fitness: Understanding balance and instability in older adults can help you design effective programs from the ground up.

The Baby Boomer (45–63 years of age) and senior (64 and older) populations represent the fastest-growing sectors in America and are the economic groups with the most disposable income. What’s more, Boomers recognize the importance of achieving and maintaining their health and are willing to spend money on experts in the fields of prehabilitation (designed to improve strength, stability and/or overall general conditioning prior to surgery) and corrective exercise in order to maintain their level of activity as they age. Therefore, the fitness industry must be prepared to address the specific needs of these populations.

One of the most challenging issues that affect older adults is instability and loss of balance. As reported by the American Academy of Orthopaedic Surgeons (AAOS), falls in the senior population cost the United States more than $20 billion per year (AAOS 2007a). Dysfunctions in stabilization and improper movement patterns result in approximately 352,000 hip fractures due to falls, over 220,000 total hip replacements and more than 542,000 total knee replacements every year in the United States (AAOS 2007b and AAOS 2007c). The truth is that many falls, surgeries and missed workdays could be avoided if people received the proper intervention.

While working with Baby Boomers and seniors presents many challenges (and rewards), it’s important to be vigilant about staying within your scope of practice and not to cross the line between training and conditioning, on the one hand, and physical or occupational therapy, on the other (unless you are also a physical or an occupational therapist). For example, your client presents with low-back pain and referral of pain down the leg, which could stem from tight muscles and trigger point referral (hypertonic fibers within a muscle that refer pain to a distal site) or from a spinal disk herniation. Rather than guessing, refer that client to a physical therapist or a physician. Often the problem will be something you can address specifically through your program—but not always. This approach not only helps your client but also creates an excellent source for networking and potential referrals.

Identifying Needs and Wants

While the facts and statistics mentioned above represent just a few of the needs facing Baby Boomer and senior clients (injury prevention; improved strength, balance and flexibility), these groups also have a definable list of “wants.” They include being able to live independent lives; to perform the activities of daily living; and to participate in recreational activities such as golf, walking and exercise programs.

As a fitness professional, you are in the perfect position to cater to these clients’ needs, most specifically in the areas of strength, endurance, coordination and balance. Addressing these needs will enable clients to achieve their wants. And if clients achieve their wants, they will be more likely to adhere to their workout programs and refer others to your services.

While low-impact exercises such as yoga, swimming and biking can benefit many clients, resistance and body weight training should also be included, as they increase muscle strength and bone mass, improve range of motion and help create a sense of well-being.

Be sure to stress the fundamentals using the V.I.P. principles:

  • Visualization. This brings conscious awareness to an inhibited muscle or region. The Feldenkrais Method® and the Alexander Technique use visualization to improve the mind-body connection and to restore and improve movement patterns.
  • Isometrics. This helps activate weak or inhibited muscles, with submaximal isometric contractions being the least stressful type of contractions.
  • Proper Breathing. This increases awareness and establishes optimal respiratory patterns, leading to an improvement in general tissue oxidation.

Three Systems That Maintain Optimal Balance

Optimal balance requires input from both our body in space and our external environment. To analyze, interpret and anticipate our environment, the central nervous system (CNS) utilizes three systems: visual, somatosensory and vestibular (Rose 2003).

1. Visual. This is the system we rely on the most to provide feedback to the CNS about our body’s movement in space. It allows us to anticipate the terrain we are on, note objects around us and determine the appropriate response necessary for optimal navigation.

2. Somatosensory. This system provides us feedback about our body’s movement relative to its base of support and about the movements of one body part in relation to other parts. It relies on proprioceptors located within muscles and joints and becomes the primary operating system when input from the visual system is insufficient (e.g., when we are walking in the dark).

3. Vestibular. This system is located within the inner ear and responds to movements of the head. It becomes increasingly important for balance if data from visual and somatosensory systems are unavailable or conflicting.

The CNS takes the sensory information from these three systems, analyzes it and initiates the appropriate set of somatic motor (muscle) responses. If the information received by the CNS is faulty, then the response will be less than optimal.

What Goes Wrong?

As indicated above, the CNS will respond to sensory input whether the information presented is correct or faulty. What causes the information to be faulty? Developmental issues are one cause. Thirty percent of children never achieve optimal neuromotor development; as a result, they develop early postural changes and muscular imbalances (Liebenson 2006).

Several studies also correlate changes in muscle function to injuries of the foot and ankle. Studies of chronic-inversion ankle injuries have demonstrated the following effects on the proprioceptive and muscular systems:

1. Subjects with ankle injuries demonstrate a decrease in foot clearance during the swing phase and an increase in ankle inversion at heel strike during a normal walking cycle (Delahunt, Monaghan & Caulfield 2006). This is a common cause of chronic ankle sprains.

2. Subjects with prior ankle injuries demonstrate decreased activation in the soleus and peroneii muscles when compared with subjects who have no history of ankle injury (McVey et al. 2005).

3. There is a delayed (latent) gluteus medius activation in clients with hypermobile ankle joints (Beckman & Beuchanan 1995). This suggests that the CNS is unable to immediately recognize motion at the ankle and therefore has a delayed response in activating the hip stabilizers. This likely contributes to further injuries of the ankle and to improper stabilization patterns of the hip complex.

These studies support the need for specific motor retraining that targets activation of the inhibited muscles.

The Foot Tripod

As noted above, disruption in the proprioceptive system is directly involved in further movement dysfunctions by altering both joint stabilization and the timing of muscle contraction. Therefore, the key to restoring optimal and efficient movement patterns is to restore proprioception in crucial regions of the body. In the case of balance, we look primarily at the foot and ankle complex.

The three points of foot-to-surface contact, creating a “foot tripod” foundation, are the big toe, the small toe and the center of the heel (Osar 2008).

Strive for this contact in all the patterns in which the foot is in flat contact with the ground. Why is this so important? The weight of the foot pressing down and spreading the metatarsals (long bones of the foot) stretches the interossei muscles located between the metatarsals. This sends a reflexive signal back to the brain to contract the extensor musculature in order to stabilize the foot and lower leg (Michaud 1997).

Begin with the client’s shoes off so that you can watch the foot response and monitor for signs of toe gripping (see Figures 1 and 2). Toe gripping is a pathological response in which the individual is trying to over-recruit the long toe flexors to make up for weakness and instability in the foot’s intrinsic muscles. Clients who demonstrate dysfunction in the feet—for example, claw toes, hammertoes or bunions—generally possess weakness or inhibition of the intrinsic foot musculature.

Correct foot placement is critical during both static postures and functional movement patterns, such as lunging. The foot tripod should be established regardless of the plane of motion in which the movement pattern is performed. Proper alignment should be established between the foot, knee and hip regions (see the arrows in Figures 3 and 4), with a neutral spine. To improve stability, have the client visualize a line from the foot tripod up through the knee and directly into the hip socket.

Progressions

Single-leg rotation patterns are an excellent way to progress a client who can perform the fundamental movement patterns (squats, dead lifts, lunges) with proper form (Osar & Allen 2005). Be sure that the foot remains stable and that the motion is occurring around an axis at the hip joint (see the arrows in Figures 5 and 6) and not at the spine or knee. Again, have the client visualize the connection from the foot tripod up through the lower extremity.

A balance apparatus (see Figures 7 and 8) can be used with a client who has demonstrated an ability to balance on solid ground and progressed optimally through the movement patterns. Using balance apparatus will be appropriate with only a select few clients; in most cases, clients will demonstrate weak intrinsic foot muscles, and using a balance apparatus will just perpetuate this weakness. It is virtually impossible to utilize the intrinsic muscles of the foot properly if the foot is not in contact with a solid surface. Regardless of the movement pattern or base of support, the client must continue to demonstrate proper breathing, stabilization and mobility at the appropriate regions.

A Systematic, Progressive Approach to Success

Working with the Baby Boomer and senior populations can be incredibly rewarding. Improving balance is vital for improving the quality of their workouts. Recognizing and improving the various components of balance provides the greatest chance for success. This means improving stability (foot, knee and lumbar spine); teaching clients to dissociate at the appropriate regions (ankle, hip and thoracic spine); and progressing them through functional movement patterns. This systematic and progressive approach is key to enhancing balance while providing individuals with essential tools for a lifetime of successful movement.n

As fitness professionals, we are in the perfect position to address and improve these needs, most specifically strength, endurance, coordination and balance.

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Evan Osar, DC

IDEA Author/Presenter
Evan Osar, DC, is the head of O.S.A.R. Consulting, which specializes in treating individuals with ch... more less
References
American Academy of Orthopaedic Surgeons (AAOS). 2007a. Don’t let a fall be your last trip: Who is at risk? www.orthoinfo.aaos.org/topic.cfm?topic=A00118&

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; retrieved Aug. 14, 2009.

AAOS. 2007b. Falls and hip fractures. www.orthoinfo.aaos.org/topic.cfm?topic=A00121&return_link=0; retrieved Aug. 14, 2009.

AAOS. 2007c. Minimally invasive total knee replacement. www.orthoinfo.aaos.org/topic.cfm?topic=A00405; retrieved Aug. 14, 2009.

Beckman, S.M., & Buchanan, T.S. 1995. Ankle inversion injury and hypermobility: Effect on hip and ankle muscle electromyography onset latency. Archives of Physical Medicine and Rehabilitation, 76 (12), 1138–43.

Delahunt, E., Monaghan, K., & Caulfield, B. 2006. Altered neuromuscular control and ankle joint kinematics during walking in subjects with functional instability of the ankle joint. American Journal of Sports Medicine, 34 (12), 1970–76.

Liebenson, C. 2006. Rehabilitation of the Spine (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.

McVey, E.D., et al. 2005. Arthrogenic muscle inhibition in the leg muscles of subjects exhibiting functional ankle instability. Foot & Ankle International, 26 (12), 1055–61.

Michaud, T.C. 1997. Foot Orthoses and Other Forms of Conservative Foot Care. Newton, MA: Lippincott Williams & Wilkins.

Osar, E. 2008. Complete Rotary Conditioning. Chicago: Fitness Education Seminars.

Osar, E., & Allen, S. 2005. Complete Hip and Lower Extremity Conditioning. Chicago: Fitness Education Seminars.

Rose, D.J. 2003. Fallproof. Champaign, IL: Human Kinetics.

Rose, D.J., & Allison, L. 2009. Falling in the Elderly: Identifying & Managing Elderly Fallers. www.resourcesonbalance.com/clinical_info/assess_treat/falling.aspx; retrieved June 2009.



October 2009

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