If there is one thing that really changes the quality of life with older adults it is the loss of balance and fear of falling. Statistics in the US show that one adult over the age of 65 is treated in the emergency room for a fall every 18 seconds (Center for Disease Control and Prevention). Quite an alarming statistic and even more scary when you consider that hip fractures are the most common injury from a fall and the number one cause of nursing home admission. Approximately 50% of those who suffer a hip fracture never fully regain their mobility and independence, and 50% of those die within the first year! Falling for an older adult is a very serious matter, and a life-threatening situation. The good news is it can be easily prevented by adopting exercise strategies that utilize the skills of reflex stability, balance, agility, and even speed. This article we will explain exercises and methods you can use to prevent falls and provide several real-life examples of these in action.

Why Are Older Adults More Exposed To Falls?

There are many reasons why older adults are more exposed to falling, but we must not fall into the trap of believing it is part of the process of getting older. We know we cannot stop the aging process. But we can change HOW we age, by using exercise to prevent the loss of muscle and our ability to move with daily activities. A slowing of neural firing speed, (the brains message to the nerves within muscles for movement) is the main thing for older adults to focus on. Because the consequence from lack of exercise is potentially a slower response time for the initiation of movement. This slower response time may put someone at risk of injury when put in a situation of danger.

When you are in your 30's or 40's and you slip or trip there is a very rapid response from the brain and nervous system so can adjust your centre of gravity, step forward, grab a stationary object, turn or tuck your body into a safer position for impact with the ground. This all happens in the blink of an eye. Even at a younger age you will see people who play sports can do this much faster and land much more safely than people who do not play sport. This is a skill that can be trained and needs constant exposure to maintain it's fast response. A very slow response is what you see with an older person who has not spent time developing skills of balance, agility and power. The chance of an injury from a fall is very likely. The rate of decline varies greatly between people of the same age as we do not all age the same.

I have several clients training with us weekly in our Stronger For Longer program who are in their 80's who can easily run, lift heavy weights, balance on one leg, and do almost any exercise we give them with no risk or fear (see testimonials). But I also have some 60-year-old people who are already reduced to using a walking frame and can hardly move. This is not luck, but a good example of someone who has used exercise to preserve their movement skills and abilities needed to keep them above the disability threshold.

What are the factors that contribute to falling? In the book "Bending The Aging Curve" by Joseph Signorile he describes 12 factors that contribute to falls. Things like medication, environment, type of footwear and even alcohol can all contribute to a reason behind a fall. But in many cases these are not a factor, and problems like loss of strength, reaction time, mobility and vision are the real problem. Here are some of the more physical factors he describes.

• Vision - As we age it is common for our eyesight to decline. Having great vision allows us to easily see hazards and choose better positions and directions to take. Loss of depth perception and three-dimensional vision greatly increases the risk of falling
• Inner ear - If you have ever had vertigo you will know exactly what I am talking about here. Any loss or deterioration of our inner ear function greatly affects our balance. It is also something that can be learned and enhanced as is seen with ice skaters and dancers who spin quickly on a spot but do not lose their balance or get dizzy. Exercise can help to maintain this function.
• Peripheral sensation - Loss of sensitivity with the feet in particular due to poor footwear and lack of exercise leads to problems at the ankle and knee. We see this regularly with people of all ages and the risk of falls is greatly increased with older adults who now have significant loss of balance and stability. Foot stability is a massive part of our older adults training program for this very reason. See article - Exercise Solutions For Weak Feet
• Muscle strength -  Muscle strength declines after the age of 50, and accelerated if strength training is not used consistently. Loss of strength with the legs, in particular the hip muscles and ankles has been shown to have a dramatic effect on dynamic balance.
• Power - From age 65 to age 89, explosive lower limb power declines 3.5% every year and anaerobic power declines by 8.3% per decade between ages 20-70!
• Reaction time - The reaction time of a 60-year old is on average 25% slower than that of a 20-year old! People who live in extended care have even slower reaction times than those living in the community.
• Balance  - There are many problems seen here from standing on one leg to impaired gait.
• Mobility - There have been many research studies confirming a loss of ankle range of motion and hip range of motion to be a great predictor of falls.
• Coordination - Loss of coordination is something I see as a problem across all age groups and has a strong relation to injury and poor movement. This is similar to a software problem in a computer.

The thing that really stands out to me from the list above is the dramatically slow reaction time and rapid loss of muscle power. This changes everything in the way we should look at training and exercise for older adults. Where many programs focus on keeping things slow and controlled to keep it safe, I would almost argue we are making the real world more dangerous by using this approach. We must find better ways to train and develop skills in the areas that are most exposed to rapid loss.

Ironically the clues for doing this can be found in how we train elite sporting athletes who also need skills with power, agility and reaction speed. In their case it is for improved performance and not to prevent falls, but we know that exposure to this type of training greatly improves abilities in these areas. If we could somehow find a way to modify some of these drills to make them safe without reducing their impact on movement we should see a big difference in how a person handles everyday tasks with more efficiency and ease. Here are some examples of what we use.

Mobility Restrictions

Firstly before you can implement any type of agility, speed or power training you need to be certain your joints have the ability to move freely. Mobility is very important to address first as it ensures you have the capacity to move through the full range needed in more complex movements. As noted earlier loss of ankle and hip flexibility has been shown to increase the probability of falls with older adults. Both of these joints play a pivotal role in coordinating how we walk and both are similar in that they require a huge degree of mobility in multi-directional movement.

An interesting thing to make note of with regards to falls and the relation to mobility is observing the difference between a young person and an older person when they fall. Young people tend to lower the centre of gravity by bending their knees and make big, fast movements to counteract the momentum of the fall. Older people tend to do the exact opposite and apply a rigid and stiffening strategy of locking the knees and straightening their legs and stiffening all their muscles to brace for the fall. This second strategy makes falling inevitable and the consequences of one much more severe. Loss of flexibility will encourage an automatic response to "lock out" as the joints have lost their ability to bend in the way needed for a reflex lowering to the ground.

The Ankle & Big Toe

The ankle is linked very closely to what happens at the foot. If the foot is weak, or the big toe has lost it's mobility the ankle will stiffen as a compensatory reaction to provide the stability that has been lost at the foot. The big toe is a very important joint and one that is overlooked for rarely does it have any pain present. However when you understand that during walking, your entire body is moving over this single joint! It has the ability to dorsiflex, and subsequently raise the heel during single support phase while simultaneously supporting against the developing forces for forward motion that is essential for normal, efficient walking.

Some of the most common compensations from big toe dysfunction are instability in the midfoot, poor ankle mobility, and limited hip extension.

1. Limited proprioception in the mid-foot usually leads to plantar fasciitis or Achilles strains.
2. Lack of ankle mobility is a very common problem we see with knee pain. When we walk we need at least 10 degrees of ankle dorsiflexion with maximum ankle dorsiflexion occurring during late mid-stance. Limited ankle mobility can lead to a chain reaction of compensations including mid-foot pronation, knee hyperextension and an early heel rise during gait. See article - How Poor Ankle Mobility Causes Destruction To Your Knee
3. Limited hip extension can lead to abduction compensation and produce the classic over-pronated foot type and abducted stance position. The stride length shortens and reduces hip extension and glute activation which are both risk factors with falls.
   

I highly suggest reading our full article with stacks of ideas on how to improve your big toe mobility by clicking this How The Big Toe Influences Stability.

And for the ankle a simple test to use for your ankle flexibility is shown below.

1. Kneeling on the floor in front of a wall with the stiff ankle the (front) leg
2. Slowly try to move your foot back as far as possible, while still being able to dorsiflex with the heel on the ground so the knee touches the wall in front.
3. The foot should point directly ahead and the knee should move directly over this.
4. The distance from the great toe (the end of the big toe) to a wall is measured. You should be aiming to achieve 8-10cm.

Below is a great video with some ideas on how to improve mobility of the ankle and strength to the calf muscle.

Hip Mobility

The hips are designed to be very mobile, having to withstand both direct loading stresses and large rotational forces with weight-bearing activities. It is especially vulnerable to injury in sports that involve pivoting or twisting movements, such as soccer, football, tennis and golf. Because the muscles around the hip joint attach directly on to the joint capsule, they have a large influence on the range of movement. And why we need explosive rotation in sports and even in some daily activities, these forces place tremendous strain on your ligaments, tendons and muscular structures designed to protect the joint. The failure to adequately control these forces can lead to chronic pain and a lifetime of restricted movement! There are two common problems we see with hips.

Problem #1 –Restricted Hip Motion

This type of problem can produce local hip pain or cause dysfunction in the lower back, SIJ or the knee, as a result of these structures attempting to compensate for the lack of movement at the hip joint. This is more common in non-sporting people who sit too often behind computers and generally do not move around enough. We also see this with someone who has neglected mobility or stretching drills for some time allowing the ligaments, tendons and muscle fibers to become too short and stiff.

Problem #2 -  Increased Amount of Hip Movement

The second problem is more consistent with older adults and stiffness is an end result of losing stability and control of the femoral head (top of the thigh bone) in the hip socket. This will often have a feeling of clicking or clunking, or a feeling of weakness in the region. A failure to correct this lack of control can lead to joint damage and subsequent long-term restriction of movement. This lack of stability in the hip socket is caused by a lack of core strength and overall muscle mass. Which is why it is more common in elderly people and females who have lost too much strength. The correction for this condition is not from stretching, but strengthening!

Below are some great videos with ideas on how to improve hip mobility.

Additional articles with more detail on mobility are below.

• Mobility & Flexibility What Comes First & Why
• Stretching & How To Improve Flexibility Fast

Strength

There is no doubting that Strength training is absolutely vital as we age. The danger of Sarcopenia, osteoporosis, osteoarthritis, and bone density loss contributing to falls cannot be overstated, and these factors can be well managed and even prevented by applying a well-designed strength training program. Peak bone mass is reached at around 25 years of age and normally remains relatively stable until around the age of 50. However after the age of 50, progressive losses of bone mineral density begins to occur and as bones lose their density, becoming weaker the risk of fracture during regular activities increases. The value of using strength training to manage arthritis is well known as the joints improve their stability and bone density.

Below are two great pictures that describe the danger of muscle loss.

Research has found that multi-directional exercises with load improve bone density and bone strength faster due to the fact that they incorporate so many of the structural lines needed for everyday life moving. By forcing challenges with these exercises with either load or speed these lines adapt and create a structural change to the bones. This is one reason why machine training provides little to no effect. The positive effects of regular exercise appear to be largest for tasks that are more complex and which require executive control. This means that diseases like senility and dementia are less likely to be a factor by including a much more brain-like approach to exercise. Read our article on Why Movement Skills Are Better Than Isolated Training to see a detailed explanation of this concept.

There is a clear relation to poor lower body strength and falls. A combination of weak bones with poor movement is a recipe for disaster. Strengthening of the bones can not only reduce the probability of a fall but also the severity. The message here is that strength training is an absolute necessity and not a luxury, and it is never too late. There have been a countless number of studies proving the capability of people as old as 100 years to build muscle, yet this is still not common knowledge to many older adults who still believe lifting weights is dangerous. 

To ensure success with your program the body must continually be challenged with more difficult tasks or exercises in order for it to continue to adapt and grow. The body will adapt only to the level of challenge that you give it and will not improve any more until it is given a greater challenge. It is not always about lifting heavier weights, sometimes completing more repetitions, performing the exercise for a longer period of time, or completing the exercise faster or slower can be all you need to enforce change. The key is to use a lot of various methods to continually overload the body’s systems so that you continue to make improvements.

Below is a great story of one of our clients who began training two years ago who describes the impact strength training had on her life.

“About eighteen months ago I was looking to join an exercise group as, other than walking, I felt my body was lacking strength and walking was not enough.  My daughter Libby, also a client of No Regrets, suggested that I might enjoy the class called Stronger for Longer for older adults.  At first I was quite nervous taking that step and for the first few weeks after the class I was very stiff and sore as my muscles began to ‘wake up’ and get moving. Now, a year and a half later, I’m feeling the incredible benefits of the classes in my strength, balance and overall well being.  I can even see biceps!!  Apart from the physical benefits my class mates are a lot of fun and we share a good laugh as we complain about all the squats and lunges and urge one another along!  I am very optimistic that the classes will enable me to remain strong through the senior years.” - Lynn Blake.

You can read many other stories like Lynn's by going to our testimonials page.

Reflex Stability & Balance

Stability training is a very misunderstood topic. True stability is all about TIMING! Being able to react with perfect reflexes to be able to maintain joint alignment ready for efficient and smooth movement. And it not just limited to the legs or the trunk. All joints require stability! 

Remember earlier we noted that the reaction time of a 60-year-old is on average 25% slower than that of a 20-year-old!

Most of the current core workouts are all about training abdominal muscles in isolation using crunches, planks, and various other floor-based exercises. The belief here is that if you train your core as you would with a bicep curl to make a bicep stronger, you will have improved balance and function. Unfortunately it does not work this way at all. For starters there is no need for fast reflex reactions as you are already on the floor. Secondly, planks and other traditional abdominal exercises are of little use to the older adult and more likely to cause more harm than good for these exercises are all about stiffness and rigidity. The older adult already has too much stiffness and rigidity, they do not need more.

The key is in using exercises that demand a reflex response that can teach them more effective ways to restore balance and stability. Below is a video of an 80-year-old client of ours Laurie Ford completing three of our favourite drills to achieve this. I provide a quick explanation of what we are about to do at the start, if you just want to watch Laurie complete the exercises skip to the 7:30 mark of the video to see him in action.

Stability Lunge Drill For Reflex Hip Movement

The kneeling stability lunge in particular is so closely related to the exact movement of falling is a fantastic drill and one I encourage with all clients. The risk is greatly minimized as they are already on the floor but the fear in their mind of falling is still the same. The rapid firing of the hip to plant out in front of them just as it would with a slip or a trip is essential in being able to maintain balance. Many mistakes are often made but this is great as the brain searches for a more effective way of completing the task. This is a drill that we will use every session and continue ongoing to make sure the timing is not lost.

The video on the left is a quick video of me demonstrating how it works and the video on the right shows Lyn Blake completing this herself. I also show in that video how this test relates to gait (walking) and a secondary walking test I use to predict falls in older adults. I highly recommend you watch that video.

With regards to balance I don't feel there is a need to use balance boards or BOSU trainers and prefer single leg stance and lunge positions. Training barefoot is a great idea to stimulate a better response with the foot muscles and encourage a stronger base of support. Foot stability is vital with for any movement you do standing up, neural signalling begins at the feet as they are the first part of the body to feel the ground and tell the system what to do. They tell the brain where you are, if you are balanced enough to move yet and basically instigate movement before it even begins. The better the feet and ankles are functioning, the better the signal all the way up the kinetic chain.

One tool I do like to use is the Sensa Mat which is a small rubber mat with 100 little spikes on it! This is incredible for assisting anyone with foot weakness and older adults and can have a great impact on their ability to complete movements in the upcoming agility and power phases more efficiently.

Great articles with detailed information about balance, and foot stability are below

• Stability training what is it exactly?
• Balance training
• Foot stability solutions for weak feet
• Using the sensa mat to improve feet stability

Agility & Reaction Time

When we think of agility training the first image that pops into your mind is a sporting athlete using speed ladders, hurdles and cones. How can this have any relevance to an older adult?

Firstly if we should define exactly what Agility is - "The ability to perform a series of explosive power movements in rapid succession in opposing directions."

This makes perfect sense for the sporting athlete looking to improve change of direction and court speed for sporting success. These exercises are used specifically to enhance the ability to move and react that bit faster to change direction instantly! Think of tennis where players need that instant, react and explode pattern to return serve. They cannot premeditate the return or they risk being caught of position. To have better reactions they must train them! Becoming quicker than their opponent can be achieved most effectively through the development of explosive movement within the first three steps and this is where agility training is critical.

With regards to the older adult, the ability to react within a split second to correct a fall is exactly the same skill as the tennis player needs to return a serve. But instead of trying to return a serve, this ability is used to correct a slip or trip. Designing safe, yet challenging exercises can improve this reflex skill to teach the person how to control changes in direction and body position quickly greatly reducing the probability of falls.

Below is some pictures of Laurie Ford completing an agility obstacle course requiring multiple skills needing balance and reflex reactions.

The Line Drill

Another great exercise we use is the line drill. With this exercise there are 5 different levels to achieve.

This exercise challenges several aspects of balance in different positions of your feet and flexibility of your hips. As a progression you can perform this drill without looking! This will test your nervous system greatly because you are using your spatial awareness and proprioception (touch/sensation) skills to test where your body is being placed. Since vision is our strongest sense and we are cutting it off, it now forces the moving limbs to react and guide the body on how to maintain balance. A fantastic drill that every older adult completes as a warm up in our program.

We also use this extensively with people suffering walking impairments from surgery or an accident. The benefits of this drill in such a short time is incredible.

Using Power Training With Older Adults To Reduce Falls

Muscle power along with agility is another very misunderstood concept when it comes to training older adults. Power is the ability to exert maximum muscular contraction instantly in an explosive burst of movements. We need this to complete simple tasks like getting out of a chair or walking up stairs. From the age 65 to age 89, our ability to produce power with our legs declines 3.5% per year. This is much faster than our rate of decline with strength, which is 1-2% per year. We also lose 8.3% of our anaerobic power per decade from age 20 to 70 which explains why we move much slower as we age. This is a double hit to our ability to move quickly, when we really need it to prevent a fall.

A study by Skelton, Kennedy and Rutherford (2002) found that women who fall have 24% less explosive power in their weaker limb than women who did not fall.They also noted that in older women who lived independently, poor lower limb explosive power combined with power differences between limbs may be a better predictor of future falls than the traditional measurements of strength. (reference; Bending The Aging Curve)

But what exercises do you use to do this? Power training often brings to mind images of Olympic weight lifters completing snatches and clean-and-jerk movements with near-maximal weight or athletes completing explosive jumping, throwing and sprinting exercises. Great for athletes but for the senior, these are not good choices and obviously dangerous.

Power training can be easily achieved by manipulating the tempo at which regular exercise movements are completed. For example a squat with an emphasis of standing much more rapidly than normal, and then lowering at a slower more controlled speed. Equipment like medicine balls and resistance bands are excellent tools to use for developing this ability. Even use of pool work can be a great way to encourage power where the drag of the water reduces the actual speed of the movement, but the force applied by the muscles is very much explosive.

A great video below shows Laurie Ford completing various speed and power drills.

Do You Need More Help?

There is obviously a lot of information and great exercises I have not included in this article and I do suggest to grab a copy of our latest report that covers everything you need to know about older adults health. This report provides you with detailed pictures, instructions of over 50 exercises and some excellent workouts and tests to use for measuring your improvement. Many of the exercise pictures shown in this report are of clients who in their 70’s and 80’s who currently train with us at No Regrets. We also feature several of their stories for you to see how they changed their life by adopting the methods explained in this report. I hope you enjoy reading this and it helps you to enjoy your golden years.

Summary

I hope this article provides you with many great ideas and better ways to implement exercise as we age and prevent the disastrous damage of falling with the older population. The old saying "USE IT OR LOSE IT" is so true when it comes to the abilities of balance, agility and power. If we can communicate this information and begin designing programs to enhance how we move just like many of the clients featured in this article the frequency and severity of falling injuries will be greatly diminished. 

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily.

If you live in Melbourne and would like to know more about our Stronger For Longer program or any of our personal training programs please click the image below to request a free consultation. And make sure you subscribe to our FREE NEWSLETTER so you stay up to date with our latest tips and secrets relating to health and fitness.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 15 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

• Bending the Aging Curve -  Joseph Signorile
• Functional Aging Institute - Dan Ritchie & Cody Sipe
• Movement - By Gray Cook
• Functional Training for Sports - By Mike Boyle
• Corrective Exercise Solutions - by Evan Osar
• Athletic Body Balance by Gray Cook
• Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
• Low Back Disorders - by Stuart McGill
• Back Pain Mechanic - by Stuart McGill
• Anatomy Trains - by Thomas Meyers
• Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
• Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
• How To Eat, Move & Be Healthy by Paul Chek
• Scientific Core Conditioning Correspondence Course - By Paul Chek
• Advanced Program Design - By Paul Chek