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Imagine two clients—Carol and Arlene—who are friends who live near one another in a retirement community. Carol has the balance and stability required to perform most activities of daily living but Arlene does not. Carol does her own grocery shopping, lifts items out of her shopping cart and places them into her car, and then lifts them overhead onto her pantry shelves. Arlene, on the other hand, has her groceries delivered and needs her friend’s help putting them away. Carol is a member of a walking group that meets three nights a week to walk a one-mile loop after dinner, while Arlene spends that time watching TV. Carol meets friends for dinner and trivia every Friday evening, while Arlene stays home because the stairs at the restaurant are tough to navigate and she’s embarrassed to ask for help.
These two clients have dramatically different lives, as Arlene has balance and stability deficits that negatively impact her physical-activity level, independence and social life, while Carol is thriving in all those areas. And this is vital—physical fitness, functional independence and having a supportive social network are essential components of overall wellness and quality of life, especially as we grow older.
Conversations about balance and stability training often focus on fall prevention/avoidance—and for good reason—but perhaps less understood are the connections between this type of training and lifespan, healthspan and long-term quality of life.
Chris Gagliardi, MS, ACE Scientific Education Content Manager, was struck by the evidence connecting balance to quality of life (see below). He says he’s noticed people in his own life asking for help with tasks that require balance, even if they haven’t experienced any falls. Rather, their desire for help seems more about an awareness of their sense of balance worsening as they age.
“I wonder,” says Gagliardi, “how does that trickle down? What other decisions are we making, or tasks are we deciding not to do, because we start to lose our self-efficacy with regard to balance? That could really have an impact on quality of life or the ability to lead the life you want to lead.”
Erin Nitschke, EdD, a writer, college professor and member of the ACE Scientific Advisory Panel, also connects this to mental health. “It’s about connecting [balance training] to a client’s daily life and showing how being able to do those little things that we often take for granted because they’re habitual is essential. We have to get groceries, we have to drive a car, we have to do all these things. So, I think it’s really about maintaining their independence, which is vital to good mental health.”
The following is a review of research evaluating the connections between balance and stability and quality of life, physical function/independence and all-cause mortality as we age. Collectively, the findings from this research show that developing leg strength, balance and coordination is vital to maintaining physical function and enjoying a longer healthspan.
A mini-review published in Frontiers in Aging Neuroscience evaluated studies that looked at the effect of balance and coordination exercises on older adults and found that this type of training improved postural control, cognitive performance (more on this below) and quality of life.
Another study, which was published in Frontiers in Public Health, examined the relationship between quadriceps muscle architecture and lower-limb strength and physical function in older adults and found that strength in the quadriceps directly impacts the ability to perform basic activities of daily living as we grow older—think back to Arlene, who was unable to climb stairs, shop for groceries or even socialize with friends due to leg weakness and balance deficits.
A study published in Frontiers in Public Health looked at the connection between balance ability and all-cause death in middle-aged and older adults and found that the risk of all-cause death among people in these age groups decreased as their balance abilities increased. In fact, for every one-second increase beyond a baseline duration in the ability to maintain a semi-tandem stance without moving or holding onto anything, they found that the risk of death decreased by 10%.
Another study, this one published in the Journal of the American Medical Association, evaluated the association between balance function and all-cause and cause-specific mortality among U.S. adults. This study compared individuals with and without balance disorders (e.g., deficits in vision, proprioception, and vestibular and musculoskeletal function) and looked at their risk of death from all causes, cardiovascular disease and cancer. They found that those with balance disorders had a higher risk of death in all categories.
“Stability and balance training are absolutely non-negotiable for building that very strong foundation of the body,” explains Nitschke. “We have a stability/mobility chain and we have to ensure that we keep that intact as we age.”
When you have clients perform balance and stability exercises, she explains, you’re working on very specific muscles and training clients to be coordinated, agile and resilient. The importance of maintaining those abilities is often highlighted with older clients, but it’s always best to train in anticipation of a future decline in ability rather than try to reverse that decline once it’s already begun.
Gagliardi echoes this idea: “I think it’s important to remember that balance is a skill-related component of fitness, so it’s something that can be trained and practiced.” And, importantly, this type of training is vital for clients of all ages and abilities, not only older clients—after all, there’s a reason that Functional Training, which encompasses training for balance, stability and mobility, is the foundation of the Muscular Training component of the ACE Integrated Fitness Training® Model. It’s the foundation upon which training for muscular strength, endurance and power is built.
One possible concern with talking with clients about a new type of training is the client’s perception that they’ll have to work out more often or for longer durations. However, training for balance and stability can be done in creative and subtle ways that alter a client’s existing regimen without overhauling it and or adding extra exercises or workouts.
As you’ll see with the sample workout below, training for balance and stability doesn’t require an additional session each week or even extra exercises during each workout. Instead, it can be accomplished through the modification of exercises that a client is already doing in a way that adds a balance/stability focus to a movement. For example, cueing a client to move their feet closer together during an overhead shoulder press adds a balance challenge to an exercise they already know how to perform.
The connections among balance training, cognition and quality of life are inescapable when you read through the research on healthspan and mortality, as seen in the studies cited above. And, importantly, cognitive challenges can be incorporated into an existing workout in a similar way as balance challenges—by adding an element or shifting the client’s focus during a movement they are already performing.
Jonathan Ross, creator of Funtensity and the Alzheimer’s Fitness Specialist Course, offers the following tips for adding cognitive challenges during a workout, but points out that the harder the cognitive challenge, the more familiar and less novel the exercise should be. “You don’t want to have someone doing an unfamiliar exercise,” Ross explains, “while also occupying cognitive resources on the non-movement parts of the exercise.”
Attention: Have the client perform one exercise continuously and use a single prompt word (from the exercise professional) to switch to a second movement, followed by a return to the continuous exercise. For example, the client could perform dumbbell lunges, then switch to a shoulder press when the prompt is called out, then back to the dumbbell lunges when the word is said again. Note: This allows the use of distractor words (e.g., if the prompt word is “grow,” then you can potentially use “go,” “switch,” “glow,” etc., as potential distractor words). The more similar the distractor word is to the prompt word, the harder it is for the client or participants.
Short-term Memory: Alternate between two movements for a predetermined number of repetitions. For example, have the client alternate between four dumbbell squats and two dumbbell biceps curls. Repeat the pattern for the work time or set number of cycles (three cycles would be 12 repetitions of squats and six repetitions of biceps curls).
Cognitive Processing: Have clients count repetitions aloud by twos or fives (or threes or sevens to increase the challenge). For a faster, time-based exercise, you can have the client start at 100 and subtract three for every repetition performed. If doing more than one set, challenge them to end up at the same number or perhaps try for a smaller one on successive sets—since a smaller number would mean they did more reps in the work interval time.
These strategies can be implemented when clients are performing either the Base Exercise or Balance Progression in the workout below.
The following total-body workout illustrates how balance progressions can be added to a workout a client is already performing without adding to the duration of the workout or the number of sessions needed each week.
If a client is not ready for a particular Balance Progression in the table, you can use other strategies to modify the Base Exercise, including the following:
For seated exercises:
For standing exercises:
|
Body Part |
Base Exercise |
Balance Progression |
|
Chest |
Unstable base of support: Stability Ball Push-up |
|
|
Hips |
Narrow base of support: Single-leg Glute Bridge |
|
|
Back |
Single-leg movement: Single-arm, Single-leg Romanian Dead Lift |
|
|
Legs |
Move from sitting to standing: Standing Calf Raise |
|
|
Shoulders |
Unstable base of support: Stability Ball Shoulder Stabilization |
|
|
Torso |
Decreased base of support: Prone ABC’s |
|
|
Arms |
Move from lying to standing: Standing Triceps Extension |
Note that there are countless ways to modify any exercise, so it’s essential to personalize your approach and start slowly. Nitschke recommends adding balance movements during the warm-up of a workout or class session. It could be as simple as standing on one leg and doing a calf raise or doing contralateral limb raises in an all-fours position. Balance, she says, is just like any other component of fitness and should be included in the warm-up.
Gagliardi suggests incorporating a balance assessment, especially if improving balance is one of your client’s stated goals. The unipedal stance test (for static balance) and the Y balance test (for dynamic balance) are great options that will give you a way to demonstrate balance improvements over time. Protocols for these assessments can be found in The Exercise Professional’s Guide to Personal Training. ACE Certified Professionals can also access these assessment protocols at the bonus link at the top of this page.
As Nitschke explains, consumers are often focused on things like getting in shape or losing weight, but the benefits of physical activity, including balance training, extend far beyond physical fitness and weight management and include enhancing mental health, social wellness and intellectual wellness. “When one dimension of health declines,” she says, “it’s this ripple effect throughout the other dimensions.”
Incorporating balance and stability training—and cognitive training—into a client’s routine can impact their lives now and into the future in all these dimensions and beyond. Most clients are not going to connect balance to happiness, but drawing a line from poor balance and stability to reduced mobility… to a reduced ability to perform activities of daily living… to worsened mental health… to lost social connections… and ultimately to reduced happiness may be a way to show how these types of training can slow the negative ripple effect as we age and demonstrate how these workouts align with their long-term goals and values.
Finally, both Gagliardi and Nitschke reemphasize the fact that balance training is not meant only for middle-aged or older adults. You should be incorporating these movements and modifications with all clients, as appropriate, whether they’re recovering from a fall, exercising to lose weight or get more fit, or training for sports performance. The need for balance, stability and mobility is universal.
Looking for more information on how to help your clients develop the balance and stability they need to maintain their health and well-being? Here are some great resources that also offer opportunities to earn the continuing education credits (CECs) you need to renew your certification.
Motivating Older Adults: The Key to Healthy Aging
Sedentary behavior in the United States has reached epidemic proportions, despite overwhelming evidence that physical activity can prevent or decrease the severity of disease and lead to an enhanced quality of life, especially in older adults. How do we encourage these individuals—particularly those who have spent a lifetime void of exercise—to make moving a habit? The key is understanding behavior change strategies. In this video training, you will explore Prochaska’s Stages of Change to better understand the mindset of older adults. By learning important motivational strategies, you will be prepared to design effective programs tailored to your clients and give them the support and tools they need to embrace more active lifestyles.
The Science of Programming for Older Adults
Average life expectancy has increased by 30 years in the last century. This remarkable shift means a growing population of older adults and more opportunities for you to cater to their well-being. To do this successfully, having a comprehensive understanding of aging as a distinct part of the lifecycle is key. Older adults possess a range of physical abilities and aspirations—all to be celebrated. Adopting an “age-appropriate” mindset, meaning projecting yourself into an age for context, will serve you and your clients best. By understanding their physical changes, motivations and how they differ from their younger counterparts, you will be equipped to create effective, fulfilling exercise experiences.
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