Fall Prevention

Risk Falling Fall prevention Slip and fall Wet floor sign, Lorm Ipsum ...

September is Fall Prevention Awareness month. It is estimated that one in four Americans over the age of 65 will fall every year. Falls not only can be life threatening, but they are associated with poor health outcomes and a sense of fear that can hinder independence, activity and strength in older adults. Therefore preventing falls in the first place is important. The Mayo Clinic offers the following tips for preventing falls:

  • Review your medications with your doctor. Some drug interactions may increase your risk of falling.
  • Exercise to improve strength, balance, coordination and flexibility.
  • Wear sensible shoes. Shoes like high heels and floppy slippers can contribute to a fall.
  • Remove tripping hazards from walkways in your home.
  • Secure loose rugs with double-sided tape or remove loose rugs entirely..
  • Clean up spills immediately.
  • Make sure there is adequate light in your living spaces so you can see where you are going.
  • Turn on the lights before going downstairs.

In addition to these tips for the home, aquatic fitness instructors can help with fall prevention by including some of the following exercises in their classes:

  • Gait training. People who are afraid of falling, perhaps because of a previous fall, tend to shorten their stride and look down at the floor. The hydrostatic pressure of the water supports the body and reduces the fear of falling, so a water exercise class is the perfect place for gait training. Walking is a good warm up at the beginning of class, or cool down at the end of class. Walk forward, backward and sideways. Include starts and stops. Try slow motion walking, or walk without moving the head or torso. Try walking with hands on hips to remove stabilizing arm movements. Change the tempo by walking slow for a few steps, then fast for a few steps, and slow again. Walk with quick changes of direction.
  • Strength training. Include exercises to strengthen the muscles of the back to improve posture. Examples include shoulder blade squeeze; standing rows with webbed gloves, drag bells, paddles or kickboards; bowstring pull with drag bells or resistance tubing; lat pull-down with webbed gloves, drag bells, paddles, resistance tubing or dumbbells; and chin tucks. Leg exercises against the resistance of the water will strengthen the quadriceps, hamstrings, gluteus maximus, gluteus medius and adductors.
  • Flexibility. Movements through their full range of motion promote flexibility. A form of exercise that uses full range of motion is Ai Chi created by Jun Kono of Japan and brought to the United States by Ruth Sova. Follow the link for a YouTube video of June Kono performing Ai Chi. It is also important to stretch at the end of class, while the muscles are still warm. Stretches can be static or dynamic. Examples of static stretches are clasping hands behind the back to stretch the chest, and lifting the heel in back with a pelvic tilt to stretch the quadriceps and hip flexors. Examples of dynamic stretches are swinging one leg forward and back through a full range of motion, and lifting one leg to the side, crossing the midline in front of the body, lifting it to the side again, and crossing the midline behind the body.
  • Ankle flexibility. Weak ankles or reduced range of motion in the ankles contribute to reduced stability. Some exercises to improve ankle flexibility are walking on toes or on heels – both forward and backward, rolling from heels to toes and back to heels, ankle circles, sitting on a noodle and writing your name with your foot, and squats keeping the heels on the floor. Squat with the feet in various positions, such as a narrow stance, a wide stance, toes pointing in, toes pointing out, or a tandem stance with one foot directly in front of the other.
  • Balance challenges. Asymmetrical movements require more core stabilization. Try walking, jogging, cross-country ski or jumping jacks with one hand on the hips or behind the back, or with each arm performing a different movement. Another challenge is to jog, ski or do jumping jacks with just one leg, keeping the other foot grounded. Stand and reach one arm as far forward as possible until you start to lose your balance. Reach your arm to the side and to the back until you start to lose your balance as well. Walk with one foot directly in front of the other or do a crossover step. Stand on one foot with and perform asymmetrical arm movements, or turn your head from side to side, or keep your head still and look from side to side, or close your eyes.
  • Unpredictable command. Improve your participants’ reaction time with the unpredictable command technique. Direct the class to perform unexpected movements. For example, walk diagonal, forward, backward, or sideways. Walk faster, knees higher, on toes or heels, with toes curled up or down or one of each. Look over your shoulder, tuck your chin, lower your shoulder blades, or touch your shoulder. Lift one arm to the side, front or back, lift both arms and let your fingers walk on the water. For more on the unpredictable command technique, see a previous blog post “Improve Reaction Time.”

Deep water exercise requires a lot of core stabilization, often leading to improved posture. My book, Water Fitness Progressions, includes 3 lesson plans, one for functional core strength, one for balance training, and one a Pilates fusion class for deep water. There are also variations of the same 3 lesson plans for shallow water. Now is a good time to start working on fall prevention.

See you in the pool!

Author/Instructor Photo
Chris Alexander

Improve Reaction Time

According to the Centers for Disease Control, one in four older adults reported falling in 2018. This equals about 30 million falls. Of that number, 8 million falls required medical attention or limited activity for at least a day. By 2030 there will be 72 million older adults and 52 million falls. Obviously one of the reasons for falling is a balance issue. But another contributing factor is decreased reaction time.

Robert H Schmerling, M.D., the Senior Faculty Editor for Harvard Health Publishing wrote an article in the Harvard Health blog entitled “My Last Fall: Reaction Time and Getting Older.” After he fell and suffered an injury while running, he got to wondering why falls tend to cause more serious injuries as we age. He points out that children are able to catch themselves by stretching out a hand or by making a quick turn of the body or by grabbing a railing before they land too hard. But reaction times tend to slow as we age. This is because of slowed signals from the brain to the nerves and muscles, reduced flexibility of joints and tendons, and weaker muscles. Older adults also tend to have less accurate awareness of their extremities’ position in space.

Lois A. Bowers posted an article on the McKnights Senior Living website on research published in the American Journal of Physical Medicine & Rehabilitation that confirms the importance of reaction time. The research was conducted by James Richardson, M.D at the University of Michigan Comprehensive Musculoskeletal Center. He found that senior adults who had good reaction times were able to balance on one leg for a longer period of time than those whose brains worked more slowly.

Fortunately, exercise can help improve reaction time. The Exercise and Sports Science Australia published a Position Statement on Exercise and Falls Prevention in Older People in 2011. They recommend exercises that progressively challenge the base of support, such as going from a two-legged stand, to a tandem stand, to a one-legged stand. From there move to exercises that use dynamic movements to challenge the center of gravity, such as tandem walk, circle turns, leaning and reaching activities, and stepping over obstacles. You can reduce sensory input by standing with eyes closed or standing/walking on unstable surfaces such as foam mats. Further challenges can be provided by the use of dual tasks, such as combining a memory task with a gait training exercise or a hand-eye coordination activity with a balance task. Many of these exercises can be performed in a water fitness class as well as on land (except for walking on foam mats). Participants often feel more comfortable doing the exercises in the pool because the hydrostatic pressure of the water reduces the risk of falling.

Another technique for improving reaction time is the Unpredictable Command. Ruth Sova, MS, the president of the Aquatic Therapy and Rehab Institute, wrote an article entitled “Seated and Standing, Static and Dynamic Balance” in the October/November 2019 issue of Akwa magazine. A membership in the Aquatic Exercise Association/Aquatic Therapy and Rehab Institute includes a subscription to Akwa magazine. Members can access previous issues of Akwa in the members only section of the website. Ruth Sova’s sample lesson plan in her article gives an idea of what an unpredictable command routine is like. The lesson plan is reprinted here with permission.

  • March in place.
  • Turn your head to the right.
  • March left.
  • Walk on tiptoes backwards still looking right.
  • March in place on tiptoes. Circle your right arm.
  • Walk forward normal stride while looking forward with eyes up. Reverse the circle on your right arm.
  • Center your eyes and walk on the outsides of your feet back to the right diagonal. Stop circling your arm. March in place. Look at your left hip.
  • Turn 90 degrees to the right and walk backwards. Side step to the right 4 steps. Press your hands up and down. Look forward.
  • Sidestep left, turn your palms up and continue pressing up and down. Look at your right elbow.
  • Turn 90 degrees to the right and march in place with your toes pointed in. Walk forward with your toes pointed out. Look forward.
  • Walk backwards with your right foot pointed out and your left foot pointed in.
  • Stop moving. Circle your left arm and swing your right arm forward and back. Walk forward.
  • With your arms still moving, turn 90 degrees to the right and side step right on the insides of your feet (toes pointed forward). Look up to the left.. Reverse your circling arm.
  • Do alternating knee lifts in place. Turn your right knee out. Look forward. Stop arm movement. Turn your left knee out and turn 90 degrees to the right.

By the age of 30-40 we all have postural issues and muscle imbalance that can lead to balance concerns. Adding in a section of unpredictable commands to your water fitness class will be beneficial for everyone. You can choose a section from Ms. Sova’s sample lesson plan, or make up your own. My book Water Fitness Progressions has a lesson plan on Balance that includes some unpredictable commands. Improving reaction time may prevent your participants from becoming a fall statistic in the future.

See you in the pool!

Author/Instructor Photo
Chris Alexander

Balance Training at Home

14 Exercises for Seniors to Improve Strength and Balance | Philips Lifeline

Although the pool is a great place to do balance training, with COVID-19 cases on the rise in many states, we are still being encouraged to shelter in place as much as possible. It is important to stay active during this time, and it’s a good idea to include balance training among your activities. It is especially important if you are older than 60 since balance training reduces your risk of falling.

Exercise Etc. Inc. offered a Balance & Fall Prevention webinar in 2019 describing a variety of balance exercises you can do at home. Some recommended strength training exercises include the following:

  1. Resisted rows for the upper back. If you don’t have a band, do a standing row. From a lunge position, with the R leg forward, pull a dumbbell (or water bottle) in your R hand from your knee up towards your hip, squeezing your shoulder blades. Then repeat on the L side.
  2. Toe scrunches to strengthen the toes.
  3. Standing heel lifts to strengthen the calf muscles.
  4. Deadlifts to strengthen the glutes and hamstrings. Keep your back straight. If you don’t have dumbbells, use water bottles.
  5. Chair squats to strengthen the quads.

In addition to strengthening the muscles that are important for balance, there are some specific balance training exercises you can do. First find your neutral alignment. Sit in a chair up against a wall and put a balloon behind your head. When you are able to maintain that position, try standing up against the wall with the balloon behind your head. Progress from there to walking with a book on your head.

The following exercises are done sitting in a chair:

  1. “The airplane” – Extend the arms to the side and lean slowly side to side.
  2. Alternating heel/toe lift – Lift your heels one at a time while pumping your arms with the elbows bent
  3. Seated crawling – Lift your knees one at a time while lifting the opposite hand as if you were crawling up a wall.

A one legged stand is another recommended exercise. There are a variety of ways you can practice it. At first you may need to hold on to a chair or the wall for support. Next try standing on one leg without holding on for a minimum of 5 seconds, or as long as possible. Always have support available in case you start to lose your balance. Progress to standing on one leg with one arm up. Next stand on an unstable surface, such as a one-inch thick piece of wood about the size of your shoe. You could also stand on a brick or a book. Finally try batting a balloon while you are standing on one foot on your unstable surface.

Besides strength training, practicing neutral alignment, chair exercises and one legged stands, it is important to practice walking fast. The faster you can walk, the lower your mortality rate. Shift your weight from your heel to the ball of your foot to the toes. Keep your spine in neutral and your head level. Your toes point forward and your feet are 3-5 inches apart. Your elbows are bent 90 degrees, your arms are close to your body and they pump for momentum and balance. Don’t forget to breathe! The following are some exercises you can do to improve your gait:

  1. Tap one heel at a time on the floor in front of you. Then tap the toes in front of you. This improves ankle strength and ankle range of motion.
  2. Walk with long steps to improve stride.
  3. Lift knees with arm pumps to improve your arm swing efficiency.
  4. Lift your heels up behind you towards your buttocks to improve hamstring strength.
  5. Walk with one foot in front of the other to improve stability.
  6. March to reduce shuffling.
  7. Walk with head rotations to improve balance.
  8. Walk with U-turns to strengthen hip rotators.
  9. Walk backward.
  10. Place 2 cones (or water bottles) 10-20 feet apart. Walk fast from A to B, pivot and walk fast back to A.
  11. Step sideways from A to B and back to A.
  12. Place a chair 10 feet from your cone (or water bottle); from a seated position stand up, walk to the cone, pivot and return to the chair.

All of this can be done in your living room. Pick several exercises to do at least 3 times a week, or even daily. You can also do some fast walking outside in your neighborhood. If you live in Texas, like I do, you will want to do this early in the morning since it gets too hot in our summer afternoons and evenings. Keep moving!

Chris Alexander

Chris Alexander