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Balance For The Ages

Do you have difficulty putting on your pants or underwear while standing, or feel anxious walking on uneven surfaces? Are you dependent on handrails when climbing stairs? Have you tested your standing balance? .

Reports have shown that falls are the leading cause of injury-related death for Americans over 65 and that more than 2.4 million people over 65 were treated in emergency rooms for injuries from falls in 2012. This represented an increase of 50 percent over the previous decade. Now might be the ideal time for all of us to implement a balance program to impact the decline of balance with aging and keep from adding to the statistics.

There are many factors that can contribute to issues with balance, and it is important to see a physician if you experience symptoms like dizziness, light-headedness, a sudden loss of strength, or have experienced illness or injury.  All of these can jeopardize balance. For many, however, a lack of focus on core strength, as well as maintaining – if not improving – standing balance, are the primary factors in play. And, the decline begins earlier than you may think.

Inadequate standing balance, – particularly as we age – can be due in part to a loss of muscle strength and endurance, increased visual impairment or even as a side effect of the interactions of multiple medications. Though hazard-proofing the home minimizes risk, the best defense is to also incorporate balance training into your daily routine – no matter your age. Even those who avoid exercise can find time to practice.

There are opportunities to work on balance throughout the day that don’t require even one extra minute of your time. Try practicing while waiting for, or riding in, an elevator, when brushing your teeth or while watching TV.  Though the higher level exercises may require equipment or a partner, so many others can be done at home and without any assistance or apparatus.

There are an almost unlimited number of ways to enhance standing balance. The important thing is to begin at a level that presents a degree of challenge yet is safe and pain-free. For many, that will mean skipping the lowest level exercises. Advance your program as you improve and gain confidence.

THE PROGRAM

Below is a menu of balance exercises that begins with simple activities and progresses from there. In all cases, be attentive to your posture, avoid looking at your feet and keep the weight-bearing knee(s) unlocked. This means that if your knees can hyperextend, maintain a slight bend or neutral alignment.  If your knees are locked out when in a neutral position, maintain them in slight flexion.

FOR BEGINNERS: standing on a stable flat surface in a doorway

NOTE:  The doorframe provides a support on either side should you need to rely on your fingers touching the wall to occasionally steady yourself. After gradually lessening your reliance on the wall, progress to a one-hand–assist – only as needed – at a railing or wall. When you feel more secure, avoid the back-up altogether.

Balancing while on two feet:

1.  If your balance is very impaired, begin your program while standing on two feet – approximately shoulder width apart – while gently touching the doorframe on either side. Gradually lessen your reliance on the wall for support until you are able to stand without using it.

2.  Continue to balance while standing on two feet, placing them closer together, gradually narrowing your base of support.

3.  As you become more comfortable, simply begin to shift your weight, placing more on one foot and then the other until you’ve progressed to using one foot merely as an assist. Alternate between your right and left foot as the primary support.

4.  Stand on two feet – this time with one directly in front of the other. Maintain your balance without weight shifting.

5.  Weight shifting on two feet – one directly in front of the other. Again, alternate between feet as the primary support.

6.  Maintain your stance on one foot with the other in toe-touch weight bearing.  You can do this either with your feet side-by-side or with one in front of the other.

7.  Add reaching in various directions – with both hands moving together across the midline of your body – while balancing on two feet.

BALANCING ON ONE FOOT – ON A STABLE SURFACE

NOTE: You may want to revert to standing in a doorframe when you advance to balancing on one foot to ensure that you progress safely to this next level. Again, begin with your fingers touching the wall and progress away from using this additional support.

For all exercises requiring balancing on one leg, avoid looking at your feet and touching one extremity to the other.

8.  With upright posture, maintain your balance while standing entirely on one foot.

ONE LEGGED STANCE ON A STABLE SURFACE WITH AN ADDED CHALLENGE

9.  Balance on one foot while slowly moving the other leg forward, backward and to the side (keeping the moving knee straight). This will increase the challenges to your standing limb. Perhaps do one or two sets of 10-15 slow leg lifts in each direction (without touching the moving foot to the floor until the end of each set). Or, mix it up.

10. Add a resistive exercise band to your moving leg in exercise #9 (with one end around your ankle and the other secured to a stationary object like the foot of a table). This will further test your balance. The standing limb will be working even harder than the leg pulling on the band. Both will get a workout!

11. Reach – with both hands moving together. The further you reach across the midline and away from your body, the greater the challenge. Reach up to the right, center and left.

12. Add bending while reaching. Reach – again with both hands together – high and low, to the right, straight up and to the left. When you reach low, bend the knee of your standing limb into a mini-squat position (keeping your knee behind the plane of your toes at all times). Mix up the directions so you don’t follow a set pattern – frequently alternating between low and high diagonals for the greatest challenge. If you have shoulder or knee problems, stay within pain-free ranges of motion.

13. Reach while holding a medicine ball. Again, the further from your center that you reach with the added weight, the more difficult the exercise. If you have shoulder problems, avoid the added weight.

14. Add an element of surprise by playing catch while standing on one foot. Throw and catch the ball with two hands. Both you and your partner should have to reach in all directions to catch the ball – make this as challenging as you like by throwing the ball further from the center of the body. You can do a variation of this exercise by yourself by throwing a ball against a wall.

15. Stand on one foot with hands clasped, arms reaching forward, elbows extended. Have your partner lightly push your hands in different directions – at all angles – first very lightly and then more firmly as your balance improves. Try to keep from allowing your arms to move as you balance and withstand this added force. Add even more difficulty by holding a medicine ball in your outstretched arms. Gradually increase the ball weight as able.

BALANCING ON TWO FEET – ON AN UNSTABLE SURFACE

Increase the degree of difficulty of exercises for balance on two feet by performing them on a half foam roll or on a BOSU ball (as below though while standing on both feet).

Other exercises, such as those with weights can also be performed on the half foam roll BOSU.

BALANCING ON ONE FOOT – ON AN UNSTABLE SURFACE

NOTE:  The less stable the surface, the greater the challenge. Here are some options, listed with increasing levels of difficulty. All involve standing on one foot (without the legs touching) and can be advanced by adding reaching alone, standing leg lifts, bending & reaching, mini squats, bounce passing, playing catch or other activities such as weight lifting.

16. Standing on a half foam roll with the flat half on the floor.

17.Standing on a half foam roll with the rounded surface contacting the floor.

18.Standing on a BOSU ball – which is designed for balance training and is shaped like a half ball.

19. Performing traditional exercises while standing on the half foam roll or BOSU.

WANT COMPANY?

20. If you prefer fitness classes, consider taking up Tai Chi, which entails slow movements that require and challenge balance.

Adding exercises focused on improving core strength to your program is also likely to boost your balance. If your lower extremity strength or endurance is lacking, addressing these factors will help as well.

Here’s to good health and fall-free aging!

Follow Abby Sims on Twitter @abcsims.

Athletes’ Recovery From Injury – Are They Set Up To Fail? Part II

The healing process entails a remodeling of injured tissues, and things don’t always go as planned. Though tissues adapt well to normal stresses, chronic overuse results in maladaptation that includes an increase in scar tissue. This has a number of implications, but the end result is weakening of the tissue – be it tendon or muscle – and an inability for it to function optimally. Inadequate rest after an injury, an overly aggressive rehab program and/or premature return to activity sets the stage for this maladaptation.

A ligament generally remains lengthened after a significant Grade 2 sprain, and therefore no longer stabilizes a joint to the same degree it did before. Sufferers work to overcome injury by maximizing dynamic stability, muscle strength, and proprioception (see below), however re-injury in competitive athletics is common. Playing on an insufficiently healed

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sprain will place undue stresses on the damaged tissue as well as on other stabilizing structures, inviting further damage (see RG III).

After injury, there is also a loss of proprioception, or the body’s position sense. Impaired balance is another issue, not only after lower body injuries but after upper body injury as well. Re-training balance and proprioception is included in rehab and – like strength, range of motion and flexibility – it takes time until they are at full capacity. Functional testing to determine a sufficient degree of recovery in all areas should be what dictates a return to competition.

Articular cartilage is the cartilage that lines and cushions the ends of bones, providing smooth gliding surfaces at the joints. It is known to be resistant to compression but with less than ideal tensile strength. Articular, or hyaline cartilage lacks vascularity (blood vessels), nerves and a lymphatic supply. It derives nourishment from the soft tissue that lies between the joint capsule and the joint cavity (the synovium). When overloaded, articular cartilage becomes irreparably damaged; it does not regenerate. Permanent and disabling defects can result from a premature return to sports.

The scenario might go like this: an athlete suffers a ligament sprain that results in a loss of joint position sense (proprioception). This deficit leads to altered mechanics, which would in turn place an excessive load on articular cartilage, resulting in an acute inflammation and lesions in the tissue. Wear and tear of the smooth hyaline cartilage is cumulative and, over time, the athlete’s joint may end up losing this surfacing entirely, resulting in what is known as being “bone on bone”.

The dreaded microfracture surgery – from which not all athletes emerge victorious – is one procedure often performed in an attempt to treat articular cartilage lesions. Holes are drilled through any remaining cartilage into the bone below in an effort to create a bleed. The intention is for blood and fat droplets to migrate into the defect, form a clot, and heal into a form of cartilage that will help protect the area. Rehab after microfracture initially requires a significant protective non-weightbearing phase and, even after a lengthy and cautious program, successful return to high-impact sports may not be possible (see Greg Oden).

Fibrocartilage, present in only several joints, is most recognized for its role at the knee. Known as the menisci, these structures act as the shock absorbers at the joint, also creating a better fit for the femur and tibia. Lacking a substantial blood supply, particularly in the central regions, significant injuries to the menisci (tears) may require surgery. Because of the lack of nourishment from blood, meniscal surgery is more often performed to remove a torn segment rather than to repair the damage. Return to sports too soon after arthroscopic surgery is likely to result in impaired performance. Of even greater significance, is that it may increase the likelihood of arthritic changes down the line.

Bone contusions, and even more so fractures, may seem to be scariest to an athlete. In fact, in most cases, because bone healing generally occurs in a four to six week window, a simple fracture mends in a more straightforward fashion than soft tissue. Contusions also generally resolve by the six to eight week mark. In contrast, displaced fractures – where the ends of the broken bone are out of alignment – require surgery (typically an internal fixation with plates, rods and pins) in order to heal properly. Fractures may be accompanied by soft tissue injury as well. The time required for athletes to return to sports after fracture is obviously greater than the healing time of the bone, as it also entails restoring any joint mobility lost due to immobilization, as well as achieving all the parameters of healing and function required after other musculoskeletal injuries.

When reporters inform us how long an athlete is expected to be out of action from an injury, they are reporting what they’ve been told. No one should base a fantasy team or bet the under on these predictions. In contrast with how most of us have learned to set a low-end realistic bar on expectations in order to exceed them, pro teams generally set our expectations of their athletes’ recovery too high, positioning them for failure. I’ve no idea why.

Follow Abby Sims on Twitter @abcsims.

*Note: My thanks to Michael T. O’Donnell, PT, DPT and Stephen Reischl, PT, DPT, OCS for an excellent presentation on Musculoskeletal Tissue Healing at the APTA conference last week. I’ve taken the liberty of boiling down much of the information (while adding my own two cents) in the writing of this article.

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