How Balanced Are You?

Your checkbook might be. Your diet should be. If you walk a fine line, you must be. The national budget isn’t. Mental stability might be. Balanced, that is. Physical equilibrium, called equilibrioception among the experts, is what we mean here. It’s that state required for walking or standing, and is achieved by a complex interplay of opposing sets of muscles. That—opposition—is a good thing because, if muscles all pulled in the same direction, nothing would get done and you really couldn’t get up after a fall.

In order to maintain balance, the eyes, ears and sense of place work together. The eyes identify where you are and your relationship to your surroundings. The ears contain the vestibular system, in which the semi-circular canals detect rotational movement, and the otoliths (also called statoliths) that send messages of linear motion to the brain. Interestingly, the “-lith” suffix means “stone,” so we really do have rocks in our heads. In this case they’re tiny granules of calcium carbonate that impinge upon the nerve fibers connected to the brain’s center for balance, the cerebellum. The cerebellum works like a computer, continuously comparing actual movement of a muscle group with the motions intended by the motor cortex. Input comes from the eyes. The sense of place is called proprioception, which is sensing the positions of parts of the body in relation to each other. It’s this system that allows you to look at the pencil you laid on the table and to retrieve it without having to look back at the table. It’s this system that lets a person know where his feet are in relation to the rest of his body as he looks at a scene outside the house and then turns to go back to the kitchen. It helps you to put one foot in front of the other when you walk, in the direction you want to go, without your torso going elsewhere.

In walking, our motions emulate an upside down pendulum, hesitating at the peak of its arc before using its stored energy to swing back again. We pivot on the foot that’s on the floor and then thrust our center of balance forward. When the front foot hits the floor, the floor pushes back, slowing us down, which continues as we rise up on that foot to the top of our arc. At that point, we fall (in truth) forward into the next step, and we accelerate again. None of this is energy efficient. It takes about a third of the energy we consume to perform this acrobatic extravaganza. In the meanwhile, muscles are pulling against each other, wasting heat. The imperceptible pause between motions causes a loss of potential energy. During this interval we are actually falling. It’s the brain-as-computer that prevents a mishap. The optimum speed for walking, by the way, is about three miles an hour.

If any of the players in this orchestration malfunction or become impaired, things become unpredictable. This can creep up on us as we age, often without our knowledge and always without our sanction, and set the stage for falls, the leading cause of injury-related visits to the ER, and the primary cause of accidental deaths in people older than 65. It only worsens with advanced age, accounting for 70 percent of accidental deaths in those over 75 (Burt, 1998). Falls and concomitant instability are markers of poor health and declining function, and may signal the presence of acute illnesses that include pneumonia, urinary tract infections or the exacerbation of a chronic condition. Although most falls are not lethal or significantly injurious, they have a psychological side that instills a fear of falling and an increase in self-restriction of activity. This can lead to dependence and institutionalization, followed by a greater risk of falling. What a vicious circle!

The factors that increase the risk for falls among the elderly may revolve around an attitude that pushes the envelope of independence. Seniors are less likely to ask for help in their quest to test their physical boundaries, as their communications skills wane in the golden years (Haines, 2012). Aside from acute or chronic illnesses, using a walker, living alone, being housebound, or being cognitively challenged add to the list of risk factors, which also includes polypharmacy, sensory deficits and being Caucasian (Fuller, 2000). The time to prevent falls begins at a younger age, when flexibility still remains and exercise is doable. An even simpler preventive step is taking vitamin D, a sterol-like compound that reduces risk for falling by a substantial margin (Bischoff-Ferrari, 2004) (Fosnight, 2008) (Bischoff-Ferrari, 2009).

A simple, low-stress exercise that has powerful benefits on physical condition and one that can substantially reduce the risk for falls is Tai Chi Chuan, an ancient Chinese modality that offers relaxation in the process of conditioning. Although considered a martial art, its moderate intensity has considerable positive effect on balance, flexibility and cardiovascular fitness (Hong, 2000), while fine tuning strength and mental control (Li, 2001). As with any exercise regimen, there is the matter of compliance/adherence. Among the elderly, compliance is a serious issue, even after having started a supervised home exercise program perscribed by their doctor (Forkan, 2006). There seem to be more barriers than motivators. From “I don’t have the time,” through “It’s no fun,” to “I’m afraid of getting hurt,” excuses abound (CDC, 1999). Forcing oneself to recruit the energy presently in short supply will help to guarantee the energy needed to continue with an exercise program.

Physical activity that requires standing, reaching, turning and bending, such as occur in housework, cooking and shopping, can improve balance and proprioception. If you think this is sissy stuff, challenge a domestic engineer to a heel-to-toe straight-line race across the family room. One foot directly in front of the other, now, heel touching the toe, no cheating. Of course, if this exercise is part of your daily routine…

The task at hand and the environment in which it is to be performed play a role in keeping one’s balance. Have you ever seen a pro football player run sideways through an obstacle of old tires during practice?  Not that you should try this on the driveway, but at least you should try doing something that’s not common to your comfort zone, like yoga or dancing or aerobics or using a balance ball or standing on one foot with eyes shut or just standing on your toes with eyes closed or doing something, anything to keep yourself off the floor unintentionally. Regarding aging, moving from zero to 60 happens a lot faster than you think. You might not be able to change that, but you can modify the ride.

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H A Bischoff-Ferrari, B Dawson-Hughes, H B Staehelin, J E Orav, A E Stuck, R Theiler, J B Wong, A Egli, D P Kiel, J Henschkowski Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials BMJ. Oct 2009;339:b3692

Burt CW, Fingerhut LA. Injury visits to hospital emergency departments: United States, 1992-95. Vital Health Stat 13. 1998 Jan;(131):1-76.

Centers for Disease Control Content in the "Personal Barriers" section was taken from Promoting Physical Activity: A Guide for Community Action (USDHHS, 1999).

Olivier A. Coubard Fall prevention modulates decisional saccadic behavior in aging Front Aging Neurosci. 12 Jul 2012; 4: 18.

Forkan R, Pumper B, Smyth N, Wirkkala H, Ciol MA, Shumway-Cook A. Exercise adherence following physical therapy intervention in older adults with impaired balance. Phys Ther. 2006 Mar;86(3):401-10.

Fosnight SM, Zafirau WJ, Hazelett SE. Vitamin D supplementation to prevent falls in the elderly: evidence and practical considerations. Pharmacotherapy. 2008 Feb;28(2):225-34.

GEORGE F. FULLER, COL, MC, USA, Falls in the Elderly Am Fam Physician. 2000 Apr 1;61(7):2159-2168.

Haines TP, Lee DC, O'Connell B, McDermott F, Hoffmann T. Why do hospitalized older adults take risks that may lead to falls? Health Expect. 2012 Nov 29. doi: 10.1111/hex.12026.

Hong Y, Li JX, Robinson PD. Balance control, flexibility, and cardiorespiratory fitness among older Tai Chi practitioners. Br J Sports Med. 2000 Feb;34(1):29-34.

Hui EK, Rubenstein LZ. Promoting physical activity and exercise in older adults. J Am Med Dir Assoc. 2006 Jun;7(5):310-4.

Frances E Huxham1 Patricia A Goldie and Aftab E Patla Theoretical considerations in balance assessment Australian Journal of Physiotherapy 2001 Vol. 47: 89-100

James Oat Judge, MD Balance training to maintain mobility and prevent disability American Journal of Preventive Medicine. 25(3), Suppl 2; Oct 2003: 150-156

Li JX, Hong Y, Chan KM. Tai chi: physiological characteristics and beneficial effects on health. Br J Sports Med. 2001 Jun;35(3):148-56.

Yvonne L. Michael, ScD, MS, Jennifer S. Lin, MD, MCR, Evelyn P. Whitlock, MD, MPH, Rachel Gold, PhD, MPH, Rongwei Fu, PhD Elizabeth A. O’Connor, PhD, Sarah P. Zuber, MSW, Tracy L. Beil, MS, Kevin W. Lutz, MFA Interventions to Prevent Falls in Older Adults: An Updated Systematic Review AHRQ Publication No. 11-05150-EF-1. December 2010

Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R; US Preventive Services Task Force. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010 Dec 21;153(12):815-25.

Schutzer KA, Graves BS. Barriers and motivations to exercise in older adults. Prev Med. 2004 Nov;39(5):1056-61.

*These statements have not been evaluated by the FDA. These products are not intended to treat, diagnose, cure, or prevent any disease.