Balance training and reducing the risk of falls

Training Q&A [Moderated]
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TLDR version: It appears that for exercise to reduce the risk of falls in older adults, there needs to be a balance training component. Do you think free-weight exercises such as squats, hip hinges, split squats, step ups, presses, rows, and isolation work such as lateral raises and curls provide enough of a challenge to balance to cover balance training requirements, or do you think there is a need to incorporate more conventional balance exercises such as standing on one leg, backwards walking, “tightrope walking”, etc? ​

I work with older adults suffering from acute mental illness such as anxiety and severe depression. My aim is to get these people more active to prevent hospital-associated deconditioning, improve health, and reduce their risk of falling. Unfortunately, adherence to physical acitvity guidelines in older adults is poor, as It appears that only ~12% of older adults meet the minimum recommendation for moderate or vigorous intensity activity. I imagine once we add in resistance training recommendations, adherence drops even lower to maybe around 5%. Common barriers older adults report are fear of falling, fear of injury, fear of adverse events, and lack of social support. Throw in the additional barrier of acute mental illness, and it becomes even more of an uphill battle to get these individuals to meet PA guidelines.

We know that resistance training is effective for preventing and treating sarcopenia, maintaining BMD, lowering blood pressure, managing blood glucose levels, and improving function (standing from a chair, walking, the ability to go up and down stairs etc). However, in my experience, most PTs massively underdose resistance exercise, often prescribing the typical 1 set of 10 for unloaded exercises such as hip flexion in standing (or even worse, seated exercises), with an RIR of like 30. If you look at the evidence base for exercise and falls prevention, it appears that balance exercise or multi-component exercise (which includes balance exercise) is most effective, or at least, the most supported. In my experience though, people find typical balance exercise (sideways walking, tightrope walking, backwards walking etc) boring. And if you look at the literature, a relatively high dose is needed to meaningfully reduce the risk of falls (~1-3+ hours per week). I was thinking that free weight exercises (with some adapted to challenge balance) could effectively help meet resistance training guidelines and improve balance / decrease falls risk simultaneously. I imagine exercises such as squats, split squats, step ups, rows, loaded carries, and even exercises like a bicep curls, lateral raises, and paloff presses (as the load is moved far away from centre of mass) significantly challenge balance and could therefore contribute towards the recommended amount of balance exercise while also providing the benefits of resistance training, and being more fun, possibly improving adherence. I’d also speculate that fear of falling would be lower for the above exercises vs exercises like backwards or sideways walking. I suspect that in these large meta-analyses, balance training is often compared to underdosed or stabilised resistance training, so balance exercises appear favourable. This is purely speculation though and I need to dig deeper. I’m interested in your guy’s thoughts on the above, and how and when you would implement balance training?

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To my knowledge, this is not well supported by evidence. I know that it is included in the guidelines, but the supporting data is not terribly convincing IMO.

To the rest of your question, yes, I think any free-standing, ground-based RT mode likely incorporates enough balance training to reduce risk of falls to the extent that’s possible. Again, I do not think that’s really well-supported, so I’d be more inclined to say that RT-induced improvements improving muscular function, muscle quality, bone mineral density, etc. would be beneficial in addition to the other health benefits.

I would not spend any precious gym time doing direct balance work. I would spend it lifting weights, doing conditioning, and strategizing dietary pattern changes to support muscular development.

PTs massively underdose resistance exercise, often prescribing the typical 1 set of 10 for unloaded exercises such as hip flexion in standing (or even worse, seated exercises), with an RIR of like 30.

I agree.

And if you look at the literature, a relatively high dose is needed to meaningfully reduce the risk of falls (~1-3+ hours per week).

Yes, my interpretation of the literature is that more training seems to reduce risk of falls in some way, but we cannot chalk this up to direct balance training.

1 Like
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Thanks, Jordan.

A related question, what would be your go-to exercises for training frail older adults with little or no equipment?

I’ve mostly been doing sit to stand progressions, step ups, and walking (with the goal being to increase distance and/or walking speed). Also been doing some ankle weight exercises (leg extensions, leg curls) if the person is weak enough for these to be challenging.

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I spend more time working on getting access to equipment, as I do not think those exercises generate enough of a response- even if detrained- to replace gym equipment. Increasing access to the gym is a very complex problem, for sure.

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Indeed.

Fortunately we have access to a pretty decent gym (by hospital gym standards) at one of our sites. We have a leg press and multi-gym with leg extension, chest press, row, and lat pulldown. The greatest challenge is when we go into care/nursing homes and have to prevent further deterioration or even improve function with no equipment.

Unfortunately, I think most HCPs believe seated exercises and simply walking is enough for these patients. Although resistance training guidelines for older adults have been around for a while, the needle doesn’t really seem to be moving.