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BETTER BALANCE

SPECIAL HEALTH REPORT

Medical Editors

Suzanne Salamon M.D.

Associate Chief for Clinical Programs,
Beth Israel Deaconess Medical Center,
Division of Gerontology
Instructor, Division of Gerontology,
Harvard Medical School

Brad Manor. Ph.D.

Director, Aging and Balance Control Laboratory,
Beth Israel Deaconess Medical Center,
Division of Gerontology

Instructor in Medicine,
Harvard Medical School

Personal Trainers

Josie Gardiner

Master Trainer and Fitness Consultant

Joy Prouty

Master Trainer and Fitness Consultant

Writer

Francesca Coltrera

Photographer

Michael Carroll

Editor

Annmarie F. Dadoly

Editor, Special Health Reports

Kathleen Cahill Allison

Published by Harvard Medical School

Anthony L Komaroff, M.D., Editor in Chief Edward Coburn, Publishing Director

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Contents

How balance works

Why improve your balance

The body’s balance systems

Balance problems

Investigating balance problems

Age-related balance problems

Health conditions that affect balance

Medications that affect balance

How your doctor can help

SPECIAL BONUS SECTION: Preventing falls

Why do people fall?

Personal safety checklist

Home hazards checklist

Activities that enhance balance

Starting balance workouts safely

Do you need to see a doctor?

Additional safety tips

Balance workouts and your overall fitness plan

Current exercise recommendations

The health benefits of exercise

Fitting balance workouts into an overall exercise plan

Using the workouts

Choosing the right equipment

Understanding the workout instructions

Answers to four common questions

Warm-ups

Beginner Balance Workout

Standing Balance Workout

Balance in Motion Workout

Balance 360 Workout

Balance on the Beam Workout

Yoga Balance Workout

Resources

Glossary

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Dear Reader,

When a toddler tumbles, he or she may shed a few tears before surging ahead again unscathed. When an adult falls, particularly an older adult, consequences are often far worse. Every year, falls prove fatal for thousands of people. In 2009, more than 22,300 people ages 55 or older died this way. Hip fractures and head injuries from falls undermine independence and raise risk for an early death. Cuts, bruises, and hard knocks to confidence result, too.

Poor balance, a persistent problem for millions of Americans, triggers many falls. In young, healthy adults, balance is largely an automatic reflex. However, gradual changes linked to growing older—such as weak or inflexible muscles, slower reflexes, and worsening eyesight—affect the sense of balance. Certain health problems—such as inner ear disorders, neuropathy, and heart rhythm disturbances—may upset balance, too. So can alcohol and many medications. Perhaps it’s not surprising that every year, at least one out of three people over age 65 falls.

Shaky balance can spur a downward spiral. Often, people begin moving around less during the day, voluntarily cutting back activities. Confidence dips, muscles essential to balance grow weaker still, and unsteadiness rises in response. So does fear of falling.

For this report, we’ve combined our expertise to select safe, effective balance exercises that can help stop this cycle. With practice, almost anyone can achieve better balance. Strong legs and flexible ankles help prevent falls and allow you to catch yourself if you do trip. What’s more, the full blend of recommended activities can help you build better awareness of your body and surroundings, boost your confidence, and tune up your heart and lungs to keep you healthy and independent.

Falls occur for many reasons, of course. Clutter, broken pavement, dim lighting, and even essential medications can play a role. That’s why we’ve written an in-depth section on fall prevention. Our checklists offer step-by-step strategies for fall-proofing yourself and your home.

So, flip through the pages of this Special Health Report. Read the safety and fall-prevention tips. Talk to your doctor about health problems and medications that could play a role in falls. Then get started on the walking plan and balance workouts. Fewer injuries and a restored zest in life are well worth the effort.

Sincerely,

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Suzanne Salamon, M.D. Medical Editor

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Josie Gardiner Master Trainer

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Brad Manor, Ph.D. Medical Editor

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Joy Prouty Master Trainer

How balance works

Why spend precious time improving your balance? What is balance, anyway, and which systems in the body govern it? This chapter addresses these questions.

Why improve your balance?

Every year, one in three adults 65 or older falls at least once. Over the past decade, deaths from falls have risen sharply for this age group, according to the Centers for Disease Control and Prevention. Of course, most falls are not fatal. However, in 2009 alone, falls caused 2.2 million nonfatal injuries serious enough to merit a trip to the emergency room. Of these accidents, 20% to 30% involved cuts, hip fractures (broken hip bones), or head injuries, undermining independence and raising the risk for early death.

At any age, poor balance can cause falls. A whopping eight million Americans report persistent balance problems, according to the National Institutes of Health. Another 2.4 million suffer from chronic dizziness, which also makes people unsteady on their feet.

The body systems responsible for balance can be affected by health problems, medications, or gradual changes that accompany aging. Curtailing activity because of unsteadiness further weakens muscles and erodes balance in a downward spiral. As balance becomes increasingly impaired, simple acts, such as strolling through a grocery store or reaching overhead, become trickier. Stumbles occur more often. Fear of falling ticks upward and confidence declines, virtually imprisoning some people at home.

Good balance, by contrast, helps prevent potentially disabling falls. It builds confidence and fosters independence. If you love tennis, golf, running, dancing, skiing, or any number of other sports or activities, working on balance buffs your abilities. Not an athlete? Just walking across the floor or down the block requires good balance. So does rising from a chair, going up and down stairs, toting packages, and even turning to look behind you.

The balance exercises in this report will make you steadier, more confident, and less likely to fall. We designed progressive challenges, starting with a workout of safe, easy exercises that shouldn’t be out of reach for unsteady people of any age. Practicing regularly will ensure that your balance doesn’t worsen. Better still, it can help you improve your balance significantly.

Before launching into the workouts, though, it helps to understand how your sense of balance works and how aging, health issues, and various medicines affect it.

The body’s balance systems

Balance can be described as the ability to distribute your weight in a way that enables you to hold a steady position or move at will without falling. Static balance helps you control postural sway when standing still. Dynamic balance allows you to anticipate and react to changes as you move. Both types of balance work to keep your center of gravity—the point at which body weight is evenly distributed—poised over your base of support.

Our daily balancing acts require interplay among several systems: the central nervous system (brain and spinal cord), the vestibular system (brain and inner ear), the visual system (brain and eye), and a vast web of position-sensing nerves called proprioceptors in far-flung areas of the body. Muscles and bones are pressed into service as well, to turn spinal reflexes and the brain’s commands into movement.

image Brain. Together, the brain and spinal cord form the central nervous system. The cerebellum, a portion of the brain perched behind the brainstem and below the cerebral cortex, oversees balance and movement. It receives information gathered by a network of sensory nerves and issues commands. It also retrieves stored memories of movements deeply ingrained through practice—for example, like walking or kicking a soccer ball. The cerebral cortex chimes in, too. Home to the frontal lobe, which plays roles in attention, planning, and movement, it supplies other memories important to balance, such as recalled patterns of movement to surmount challenges like a slippery sidewalk or rocky path.

image Spinal cord. Housed safely in a channel carved through the vertebrae, the spinal cord serves as a bridge between brain and body. Paired nerves peppered along its length receive feedback from the peripheral nervous system, a lacework of nerve fibers branching out from the central nervous system to the hinterlands of the body. The spinal cord also gives rise to a host of reflexes, such as the quick-stepping response to an unexpected push. It delivers voluntary movement commands to the muscles, too.

image Vestibular system. Central to the sense of balance is the vestibular system of the inner ear. It contains several important structures. The labyrinth is a maze of bone and tissue. One end of it houses the cochlea, a spiral-shaped organ essential to hearing. Three semicircular canals, fluid-filled loops set at different angles, lie at the other end. At the base of each loop, a bell-shaped cupula sits above a clump of sensory hair cells, which tilt as thick fluid (endolymph) in the semicircular canal moves. Signals set off by this tilting action travel to the brain via the acoustic nerve, describing the position and rotational movements of your head: straight up and down, side to side, tilting toward one shoulder, and so forth.

Just beyond the semicircular canals are the utricle and the saccule. Dubbed the otolithic organs, these two fluid-filled pouches are also paved with sensory hair cells that inform the brain about head position when you’re sitting up, leaning back, or lying down. Inside the pouches, grains of calcium carbonate (canaliths, or otoconia) are sprinkled on top of a layer of gel overlying the hair cells. Each time your head tilts, gravity pulls on these tiny stones. Hair cells shift in response, sending signals to the brain describing the position of your head. The sensory cells in the utricle also report horizontal body movement to the brain—say, when you’re walking forward or riding a bike. Those in the saccule monitor vertical acceleration of the body, which would occur if you stood up or rode in an elevator, for example.