Addressing the Fear of Falling in Seniors
With older clients, trainers can benefit from understanding the “biomechanics” of fear.
With the Baby Boomer population aging, movement professionals have to become more prepared to meet the needs of older adults. And while it may be tempting to think seniors need less when it comes to program development, clients of advanced age actually need more.
It’s not enough to modify the intensity or safety of their fitness programs. It’s also essential to understand how the mindset that older clients bring to a session—in this case a fear of falling—can influence their exercise needs. Older adults can greatly benefit from strengthening specific hip muscles, learning gait-related motor programs and understanding how their thoughts affect their bodies. Armed with this article, trainers can help seniors accomplish all three.
Personal training is no job for a one-trick pony. An effective trainer wears many hats—friend, teacher, motivator, business owner and disciplinarian. Each of these “personalities” requires a basic understanding of the psychology of exercise adherence—getting clients to show up, work hard and stay consistent.
While it’s easy to see how discipline and attitude determine the results of training, we tend to overlook the mind’s impact on movement mechanics. Research shows that our thoughts affect the particulars of gait pattern, which in turn can influence injury risk while exercising. This is why it’s so important for trainers to bone up (pun intended) on their knowledge of balance, hip strength and the mechanics of normal gait, and to understand how these all relate to fall risk in senior clients.
If we make a list of “who” falls, it is easy to put “old people” at the top of the list. And yet, while falls are one of the most serious health issues for the elderly, age is closer to the bottom of a long list of risk factors for falling (Rubenstein & Josephson 2006). Top risk factors for falls include muscle weakness, gait deficit and balance deficit, all of which are easily remedied with a thoughtful training program.
This might seem like an issue of semantics. After all, if older people are weaker and their weakness leads to wobbly walking, isn’t age really the risk factor? The answer is, no, not really. Muscle atrophy in the elderly population is, in general, not a result of aging as much as it is a result of decreased movement over a number of years—meaning, people typically stop moving and then get weak, not the other way around.
Research into falls, fall risk and fall prevention is extensive because falls are the leading cause of injuries in adults over the age of 65 (CDC 2012). But falls themselves aren’t necessarily the dangerous issue—children and athletes take repeated falls daily. The problem is the increase in mortality when a fall fractures the hip—a bone that was weak before the fall occurred. After a fracture, many patients cannot walk without assistance or live outside of an assisted-living situation. Depending on the source, 20%–30% of these patients die within a year (Wolinsky, Fitzgerald & Stump 1997). The older people get, the more a broken hip seems like a death sentence, so it’s no wonder that the very notion of falling makes those with vintage models of body afraid of moving.
Our understanding of the risks of falling improved dramatically when research demonstrated that fear can actually cause people to fall. Researchers wondering whether the fall begets the fear, or vice versa, found that those who had not fallen, but who had reported a fear of falling, were more likely to fall in the future—despite a significant decrease in their activity levels (Friedman et al. 2002). Studies over a longer time (2 years) found that while a feeling of unsteadiness coupled with previous falls was a large contributor to fear, 18% of the “fearful” group had a large fear of falling even though they had not fallen themselves (Lach 2005).
This is just a sample of a wide body of work demonstrating that fear is a risk factor for falling. The next question is, of course, why? Or, perhaps more important, how?
From a distance we can recognize that unmistakable turtle-paced shuffle of the senior brigade. But it may come as a surprise to learn that gait patterns identifying someone as a senior citizen—short stride lengths, shuffling feet and low velocities—usually have no mechanical cause (Herman et al. 2005). In fact, research has found that gait disorders of this kind—in healthy seniors with no disease, no history of falls and no more muscle weakness than their counterparts—are largely a response to fear alone.
Most of us can relate. If you’ve ever walked over a slippery surface or spent any time on ice or snow, chances are you’ve caught yourself altering your movement patterns to prevent a fall; the alteration is a natural response to fear. But if this response is natural, how can it eventually lead to a fall?
It turns out that fear-induced alterations in gait patterns can have a profound impact on the muscles used while walking. Timid walking tends to mean less clearance of the foot from the ground (shuffling), bent knees to lower the center of mass and a reduction in the natural arm swing that balances the movement of the legs.
Being afraid of falling every now and then is no big deal. But being afraid whenever you are walking can reduce the loads to the muscles of the hip, eventually atrophying them to the point where they no longer stabilize the weight of the body as it is moving. Combine instability and poor mobility with a crack in the sidewalk or the unexpected object in the kitchen and you’ve got yourself a fall.
Before discussing how fear affects variables like strength and balance, it is helpful to revisit the working definitions of these terms, so we are all talking about the same things.
It used to be pretty simple to calculate strength: The more weight you could lift, the stronger you were. And balance was just as easy to define: The longer you could stand on one leg (even if the rest of the body was gyrating wildly), the better balance you had.
Then the introduction of functional movement training redefined how we thought about strength and balance. Sure, you could toss around 40-pound dumbbells as though they were apples, but could you hold a one-armed plank while your feet were on a wobble board? If the answer was no, then it showed that previous strength-and-balance measures didn’t apply very well to everyday necessities—like those times when you needed to do a one-armed plank with your feet on a wobble board.
But really, when we talk life-specific motions, do all strength and balance exercises have equal functional benefit? Not always. Remember that when it comes to motor patterning, the more equivalent an exercise is to the desired real-world movement pattern, the better. While many exercises improve balance in a general sense, very few target the strength requirements for balance during walking.
When designing programs for older clients, it is important to consider that in addition to exercise as it meets their general health needs—reducing risk factors for cardiovascular disease, maintaining muscle mass and keeping joints mobile—the greatest concern for this population is self-efficacy, the feeling that they can rely on themselves to function during everyday activities. When it comes to health, one of the greatest indicators of longevity is one’s ability to dwell outside of assisted-living facilities. Living on one’s own requires being able to walk comfortably, which requires balance, and balance requires the strength of a particular group of muscles: those of the lateral hip.
Researchers know that those who fall typically have weak muscles as well as gait and balance deficiencies. Exercise science gives us a little insight into the obvious: This missing muscle strength can affect walking and balance patterns. When we evaluate the strength-gait-balance trinity through a biomechanical lens, their interconnectedness becomes even clearer.
Walking is essentially one bout of single-leg balance followed by another and another. When we are on a single leg, this leg—specifically its lateral hip musculature—must be strong enough to carry the load created by the rest of the body.
Personal trainers work with the lateral hip muscles, often grouped and referred to as abductors, all the time and are familiar with exercises that use the motion of abduction to build strength in the hips. The exercises used by many, however, keep the body still while moving the leg—as in seated abduction or in sideways walking with a resistance band. While exercises like these target the lateral hip, they are not specific to how the lateral hip is used during a gait cycle.
When we walk, each step ends with the weight of the body on a single leg. The abductors, in this case, generate a motion opposite to abduction—that is, moving the body relative to a leg that is planted, or weight-bearing (Martin, Burr & Sharkey 1998). Lateral hip contraction while walking results in pulling one side of the pelvis downward while slightly lifting the other. This gives the other leg room to swing through without the knee needing to bend excessively. This action results in a very high load, handled by these muscles and by the head and neck of the femur. When the hip muscles work in this way, not only is motion controlled throughout the gait cycle (aka balance), but the density of these bones is better maintained, making them less susceptible to fracture in a fall.
Ideally, lateral hip musculature should have the strength and endurance to elevate and maintain the position of the floating leg. However, most exercises that abduct the leg are not weighted enough to maintain the functional strength required for walking. If you quickly do the math, you’ll find that while abduction exercises strengthen abductors enough to lift the weight of the leg and whatever extra load a resistance tube offers, this amount is much less than the weight of the entire body (minus the leg still on the ground) under the gravitational loads (Gs) created while walking—almost double the body’s weight while standing. Because walking is an upright exercise and the muscle attachments pass over the knee joint, abductor exercises become even less effective when they’re done sitting or with the knees bent.
A whole lot of people can ride a bike without it falling over, yet only a very few can sit on an unmoving bike and say the same. Why? Because continuous forward movement can mask myriad balance deficiencies. Just as cycling involves superfast corrections to a thousand invisible almost-falls, walking with a body weakened by modern living results in one controlled fall after another. These falls occur too quickly to see by observing someone’s walk. The stance phase of a gait cycle can be isolated, however, as it is essentially the same as standing on one leg. Use this lateral hip test to determine if you or your clients are walking as opposed to falling:
Minus shoes, begin standing with both feet pointing forward, ankles positioned at pelvic width. Shift your weight back over your heels and fully extend the knees. Place your right hand on your right hip, and shift your pelvis to the right, until the weight is fully loaded on the right leg. Contract the right leg’s lateral thigh muscles, drawing the right side of the pelvis down while lifting the left side of the pelvis up. The hand resting on your hip should move slightly toward the floor. Do this until your left foot leaves the ground. Balance on your right leg, making sure you’re not bending either knee. After you’ve mastered the technique, repeat it while balancing on your left leg. Do this exercise yourself a few times before you ask a client to try it.
When teaching this “pelvic list,” observe your client: Is the standing ankle wobbling or the floating foot touching down periodically? Does the pelvis thrust or tuck, or do the knees slightly bend? Do the arms become involved to regain balance? These are all reflexes signaling that the client is not recruiting the abductors as used during gait.
This pelvic-listing exercise is not only an evaluation tool; it is also the corrective measure for the problem it identifies. To remedy wobbly bones, do the exercise more often and for longer periods of time. Please note, it is also possible to attain the look of this exercise by using the low back of the floating side. Clients with weak hip muscles will often resort to hiking one side of the pelvis up rather than pulling the opposite side down. Cue verbally or by touching the area that should be working—the lateral thigh of the standing leg.
More than other groups, older adults must continue to maintain activity levels as they age, not just for physical health reasons but to keep fear of falling at bay. Program design can continue to include movements that benefit strength, flexibility and cardiovascular measures, but it should definitely begin to address this population’s more urgent interests as well. In general, senior fitness programs modify for physiological factors such as temperature, decreased strength levels, blood pressure and low endurance. But to truly meet the needs of older adults, we have to address psychological factors. While addressing fear might seem outside the scope of a personal trainer’s practice, the development of exercise programs for this population cannot be complete without taking fear issues into consideration.
As an exercise professional, how do you fit fall education into your services? You can start by sharing this article with your clients. Add more gait-specific hip training to your clients’ programs, or offer a “Fear of Falling” series of sessions to address these issues. When teaching exercise that is specific to gait, balance or strength, initiate dialogue on the general fear of falling; this can increase confidence and encourage clients to continue with their program. Here are a few more suggestions to fuel your senior programming creativity:
No one wants to be That Guy who has fallen and can’t get up. The reality, though, is that with beds, couches and chairs abundant, many people have lost the strength to get off the floor because they just don’t get down there anymore. As simple as it sounds, getting down and back up again requires joint mobility and muscular strength. Have your clients practice doing it without using their arms and with one arm at a time. Make sure they can get up using their nondominant leg as well as their dominant one. Real-world (read: bo-ring) movements are often forgotten in these days of TRX® straps, CrossFit® and expensive machinery, but they are essential when it comes to what your clients actually need for health’s sake!
Keeping a debris-free living space is obviously beneficial to the fall-risk group, but always moving in an obstacle-free environment will result in an atrophied ability to deal with nuances in the environment should they arrive. This ounce of prevention, then, can end up becoming the actual cause of a fall later on. The best approach is, as usual, one of moderation. As it is wise not to increase fall risk with clutter, it is also smart to train for obstacles. Consider creating a safe and supervised obstacle course, or have your clients practice walking with one foot up on a curb and one on the ground. You can even end each session by having them get down on the floor, roll onto their backs and get back up again.
Sometimes, as personal trainers, we don’t need to add more exercises—we can simply change how an exercise is done. Say, for example, a client is already doing exercises that target balance. One way to up the ante is to try a balance exercise without shoes. Twenty-five percent of the muscles in the body are located from the ankle down. Invite these neglected muscles to the balance party by removing overstabilizing footwear and designing a foot-specific program.
You can also help your clients identify any muscles that are “helping” when they shouldn’t be. Slightly bending the knees, gripping the toes and tensing the neck and shoulders are common reflexes when we feel unstable, yet chronic practice of these motions eventually interferes with a healthy gait cycle.
Consider this: The muscle patterns we develop to cope with a balance exercise reappear when we actually need to balance. If a client grips her toes during yoga’s tree pose, there is great probability that she will grip during the balance phase of a gait cycle as well.
Contracted toes (gripping) reduce the foot’s ability to deal with new information, and this tension leads to an inability to respond to new environments and results in poorer balance. If a client has stiffness in the toes, as seniors often do, note that the habit is being reinforced during every exercise. Balancing requires accessing all 360 degrees of thigh muscle—this muscle does a much better job than toe gripping and leaves fewer claw marks on the floor. Clients who grip their toes as a coping mechanism over a long period of time will commonly end up with toes that can’t stop contracting and hip musculature that has never learned to contract.
Cue your clients to watch their clenching during balance exercises and point out the common “fear-of-falling” reflexes that reduce an exercise’s effectiveness. The more clients recognize their behavior, the faster they can change it themselves.
It is important to remember that the benefits of exercise go beyond the physical. Successful outcomes while negotiating small obstacles in safe environments can increase both skill level and confidence for participants. Exercises that mimic getting up off the floor build strength, but they also reassure seniors that they will be able to get themselves up if they fall. Exercise programming of this type can indirectly increase self-efficacy and reduce fear. Recognizing that exercise programs for older adults need to address such issues as confidence building, fear reduction and perseverance is critical for personal trainers—and for the field of movement science as a whole.
Katy Bowman, MS, is an internationally recognized biomechanics scientist and the director of The Restorative Exercise Institute. She is the author of Every Woman’s Guide to Foot Pain Relief: The New Science of Healthy Feet (BenBalla Books 2011) and the creator of the Aligned and Well DVD series. Read more at www.alignedandwell.com.
´╗┐CDC (Centers for Disease Control and Prevention). National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. 2012. Falls among older adults: An overview. www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html; retrieved Jan. 10, 2013.
Friedman, S.M. et al. 2002. Falls and fear of falling: Which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. Journal of the American Geriatrics Society, 50 (8), 1329ÔÇô35.
Herman, T., et al. 2005.┬áGait instability and fractal dynamics of older adults with a ÔÇ£cautiousÔÇØ gait: Why do certain adults walk fearfully?┬áGait and Posture, 21 (2), 178ÔÇô85.
Lach, H.W. 2005. Incidence and risk factors for developing fear of falling in older adults.┬áPublic Health Nursing, 22 (1), 45ÔÇô52.
Martin, R.B., Burr, D.B., & Sharkey, N.A. 1998. Skeletal Tissue Mechanics. New York: Springer-Verlag.
Rubenstein, L.Z., & Josephson, K.R. 2006. Falls and their prevention in elderly people: What does the evidence show? The Medical Clinics of North America, 90 (5), 807ÔÇô24.
Sherrington, C., & Menz, H.B. 2003. An evaluation of footwear worn at the time of fall-related hip fracture. Age and Ageing, 32 (3), 310ÔÇô14.
Wolinsky, F.D., Fitzgerald, J.F., & Stump, T.E. 1997. The effect of hip fracture on mortality, hospitalization, and functional status: A prospective study. American Journal of Public Health, March, 87 (3), 398ÔÇô403.
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