It’s no secret that good balance = safety. And even if you’ve never worked with older adults, I’m sure you’re aware that they often exhibit decreased balance both in sitting and standing.
Why do we fall more the older we are?
We will talk about this more a little later on in the month (watch our for letter ‘F’!) but here’s the basic jist: our bodies rely on our musculoskeletal strength and alignment to maintain balance, but they also rely on our vestibular (where is my head in relation to my center of gravity?) and proprioceptive (where is my body in space?) systems. As we age, our muscles tend to atrophy and our bones start to degenerate, and the same is true of our proprioceptive and vestibular systems. Those sensory nerve receptors can atrophy in the same way muscles can. Add on the presence of pathologies like peripheral neuropathy, CVA, dementia, or diabetes, and you’ve got the perfect recipe for a fall.
So then how can we improve balance?
By challenging those systems, causing those nerve receptors to fire, and those muscle fibers to contract.
Let’s start with sitting balance.
If a patient is unable to sit upright in a chair, it’s going to be really difficult for them to eat, socialize, and participate in meaningful tasks. So we start by correcting their posture.
Posture is all about pelvic alignment. If the pelvis is not aligned, then the spine is not aligned. So the first thing to do is to get the patient on a flat surface, and assess their pelvic alignment. From there, we can determine what sorts of cushions or external supports are needed to correct the pelvis and thereby correct posture.
Then we can start to work on core strength. Some patients will be able to tolerate typical core strengthening tactics while lying supine on the plinth. We’re talking sit-ups, leg lifts, bicycles, crunches, etc. For those who will not be able to tolerate that level of exercise, we can perform various functional reaching tasks and/or tabletop tasks while seated upright with the spine unsupported.
Resistance can be added through the use of weights and challenge can be added via the use of a wiggle cushion and/or by lifting the plinth just enough so that the patient’s feet cannot reach the floor. This will cause the patient to rely completely on the core muscles rather than on the total body. And remember that you can always perform any upper or lower body strengthening routines while seated upright with the spine unsupported to engage the core.
Standing balance can be easily incorporated into the patient’s daily routine.
We can work on standing balance in the shower, at the sink while addressing grooming or oral hygiene, or when completing simulated laundry or meal prep tasks.
If a patient has not been able to stand up for quite a while, I usually have them start at the parallel bar (usually because this provides a little more security). Then we work up towards a walker, then a cane, and then free-standing with contact-guard assistance (meaning that I have physical contact with a patient). A balance pad or a wedge cushion can be used to grade the standing surface, requiring the patient to stimulate more muscle contraction and use the available ankle, knee, and hip range of motion to successfully weight shift.
The fun part is varying the tasks we perform while sitting unsupported or standing.
We can play corn hole, or balloon volley, or ball toss. We can play cards, or board games, or assemble a puzzle. We can cook or paint or play a musical instrument. Whatever we do, we want to make sure that the task is meaningful for the patient while remaining challenging enough to stimulate the core and lower body to maximize balance.
In the end, it is all about getting the patient to tolerate an appropriate seated or standing position for a greater amount of time with a decreased level of assistance.
I’ve got a few fun links for you:
What are your favorite ways to improve balance?