Category Archives: Balance

Resource for Understanding Benign Paroxysmal Positional Vertigo

In my last blog post Building Blocks for Better Balance I included some exercises to help improve balance skills in older adults. As mentioned in the post, balance is related to seeing (visual system), feeling where you are in space (proprioceptive system) and the inner ear (vestibular system). Sometimes dizziness caused by inner ear issues can affect balance in older adults and should be addressed prior to introducing balance exercises. Debris in the inner ear can cause a condition called Benign Paroxysmal Positional Vertigo (BPPV). Chicago Dizziness and Hearing private medical practice, led by Dr. Timothy Hain and Dr. Marcello Cherchi, affiliated with Northwestern University, has a comprehensive description of BPPV on their website that addresses causes, diagnosis and treatment. If your client is experiencing issues with vertigo, this is an excellent resource for better understanding the condition. The link is provided below.

http://dizziness-and-balance.com/disorders/bppv/bppv.html

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BUILDING BLOCKS FOR BETTER BALANCE

Improving balance in senior populations is important for the prevention of falls and provides individuals the physical skills to perform daily tasks with confidence. Although there are many strategies to address this concern, all methods require consistent practice (i.e., the “use it or lose it” principle). It is not uncommon for an older client to express surprise at the level of difficulty with such skills as balancing on one leg, shifting weight from leg to leg, or walking on a straight line. The good news is that unsteady balance can improve dramatically with consistent practice. Yoga blocks can be used as an excellent tool to practice such balance skills as picking up one’s feet to clear an object, balancing on one foot, transferring weight from one foot to the other, and staying balanced while shifting the center of gravity.

According to the article “From Athletes to the Elderly: The Science of Trips and Falls” the body uses multiple sources for balance information.

“The visual system takes in information from the outside world and transmits it to the brain. The proprioceptive system, which incorporates sensory systems throughout the body, tells us how the body’s parts are oriented relative to each other. And the vestibular system, located in the inner ear, focuses primarily on how the head is moving”

As people age there is often deterioration in one or more of these systems. Improving core strength and regularly challenging oneself by performing balance-related exercises can allow older adults to adapt to unstable surfaces or other unanticipated obstacles to avoid falls.

In addition to preventing falls, steady balance is a quality of life issue for older adults.  Getting dressed is a basic example of this. To put on a pair of pants or to slip into shoes requires standing on one leg.  When older adults lose confidence in their abilities, they will often sit down to perform basic functions.  Fear of injury due to lack of confidence in physical skills will likely lead to moving less and doing less. Many older adults lack the knowledge and training that a physical coach or Pilates instructor can provide.  In the short term, there is often a modification or different strategy available that can be employed to approach a daily task.  In the long-term, strength and flexibility along with coordination and balance training can make a significant difference in the physical well-being of seniors. Providing guidance and strategy to seniors as they navigate the aging process allows them to continue the activities they enjoy.

YOGA BLblocksOCK BALANCE EXERCISES

Place 4 yoga blocks in a square with enough space for a person to stand in the center of them and space available to comfortably step over them.

Firmly hold the hands and wrists of your client for additional support or let your client use hiking or ski poles. Once confidence and skill improves, the exercises can be done without assistance.IMG_1604[1]

Centered Weight Shift

1.  Step the left foot over the front block with equal weight on each leg in a forward lunge position and the spine in a centered vertical position.  Return to the starting position in the center of the blocks. Repeat the step forward on the right leg.

IMG_1607[1]2.  Step the left foot over the left side block with equal weight on each leg in a centered squat position. Return to the starting position in the center of the blocks.  Repeat the step side on the right leg over the right block.

3.  Step the left fooIMG_1609[1]t backward over the block with equal weight on each leg in a back lunge position and the spine in a centered vertical position (not pictured).  Return to the starting position.  Repeat on the right leg (note the picture shows this–right foot is back).

Be aware that your client may try to “cheat” by going around the side of the block, rather than over the block.  This exercise is designed to give your client proprioceptive feedback since they will kick the block if the foot is not picked up sufficiently.

The pattern above and all subsequent ones can be varied by starting on the right leg or doing repetitions of a step (example: 4 sets of left/right over the front block before moving to the side; or stepping the left foot forward and back over the front block 4 times before stepping over the front block with the right foot). Varying the patterns requires your client to pay closer attention and apply the applicable pattern of the day.

Weight Transfer

IMG_1606[1]1.  Step the left foot over the front block landing with a bent left knee and straight right leg.  The majority of the weight is on the front leg and the spine is on a 45 degree angle forward.  Be sure your client’s knee lines up over the ankle (not off center or with the knee over the toe or beyond, which creates too much forward pressure to the quadriceps).   Return to the starting position with a rebound feeling by pressing the front heel into the floor and engaging the left hamstrings. Repeat forward lunge on the right leg over the front block.

Unlike the Centered Weight Shift version above where the core was centered equally between the legs, this version requires more core adjustment by shifting the weight off center and back to center challenging the awareness of the center of gravity.

2. Step left foot over the left side block landing with a bent left knee and sIMG_1608[1]traight right leg.  The majority of the weight is on the left side leg and the spine is on a 45 degree angle sideways to the left. Again, look for the lineup of the knee and foot. The step to the side can be done with a parallel leg (toes pointing forward) or with an externally rotated leg (toes point outward). Return to the starting position with a rebound feeling by pressing the left heel into the floor and engaging the left hamstrings. Repeat side lunge on the right leg over the right side block.

3.  Step the left foot backward over the block (not pictured) with the chest over the back leg landing with a bent left knee and straight right leg holding the core to support the low back. Return to the starting position with a rebound feeling by pressing thIMG_1610[1]e back heel into the floor and engaging the left hamstrings. Repeat this back lunge on the right leg (note the picture shows this–right foot is back).  The majority of the weight is on the back leg and the spine is at approximately a 45 degree angle backward with the chest over the back foot.  It is acceptable to slightly rotate the back foot out if needed, but since this tends to also rotate the pelvis, the exercise is more challenging if the back leg is parallel and the hips are “square” to the front.

One Leg Rebounds

This exercise can be done with either the Centered Weight Shift or Weight Transfer version above. The right foot remains in a stationary position while the left leg steps forward over the front yoga block, rebounds and returns center; steps left side over the block, rebounds and returns center; steps left back over the block, rebounds and returns center. Repeat with the right foot stepping the right foot over the front, side and back block. The pace of the exercise is a bit faster so the adjustments need to be made quicker. Vary the pattern by starting with the right leg, repeating positions more than once or starting the exercise to the back.

Stepping Over

This variation of the exercise is useful to do initially in front of a mirror since it requires that the client step backward over the block.  The mirror can be used to see the yoga block and judge the distance and size of the step better. Be sure to assist the client supporting the hands/wrists or use the hiking/ski poles until they are no longer needed.

1.  Step the right foot over the front block followed by the left foot to completely step over the yoga block.  Step the right foot backward over the front block followed by the left foot to return to the starting position in the center off all the blocks. Be sure your client goes over the block, not around it. This requires momentary balance on a single leg and picking up the feet.

2.  Step the right foot over the right side block followed by the left foot to completely step over the yoga block.  Step the left foot sideways over the side block followed by the right foot to return to the starting position in the center off all the blocks.

3.  Step the right foot over the back block followed by the left foot to completely step over the yoga block.  Step the right foot forward over the back block followed by the left foot to return to the starting position in the center off all the blocks.

4.  Repeat the entire pattern above starting with the left leg lead going completely over the front, side and back block to finish in the center of all the blocks.

Again, the patterns can be varied starting with the left leg, mixing front right/left leads before moving into the side or back positions, starting the exercise to the back, etc.

Eyes Closed

This is an advanced exercise to be completed only after the above skills are acquired and your client feels confident.  Be sure to have your client master the skill of balancing on one leg with the eyes closed and taking steps forward, side and back with the eyes closed prior to trying this exercise with the yoga blocks. Be sure to assist your client by supporting the hands/wrists or carefully spotting each step so that your client does not trip over the blocks.   Try any of the above exercises: Centered Weight Shift, Weight Transfer, One Leg Rebounds, or Stepping Over with the eyes closed while carefully assisting to make sure your client does not trip. Advise your client to feel the floor with the toes on the other side of the yoga block prior to transferring the weight.

Standing Balance

blocks verticalMove the front and back yoga blocks a quarter turn so that all of the four blocks line up in the same direction with enough space for a person to stand in the center of them.

1.  Step the right foot forward up onto the front block to balance on the block on the right leg with the left foot suspended off the floor.  Step the left foot back down to return to the starting position. RepIMG_1620eat on the left leg stepping up on the front block (shown in picture). Return to the starting position.

2.  Step the right foot up sideways onto the right side block to balance on the block on the right leg with the left foot suspended off the floor.  Step the left foot back down to return to the starting position. Repeat on the left side using the left side block.

3.  Step the right foot backward up onto the back block to balance on the block on the right leg with the left foot suspended off the floor.  Step the left foot back down to return to the starting position. Repeat on the left foot stepping up on the back block and return to the starting position with the right foot joined by the left.

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All of the above exercises require core strength, leg strength and ankle stability. If you feel that your client is deficient in one of these areas and cannot successfully perform the exercises outlined above, try doing some basic exercises that boost these skills prior to working with the yoga blocks.

Although the yoga blocks are useful tools since they are a good height and size for practice, any obstacle is acceptable.  Envelopes can work well as a target to step over if picking up the feet is too difficult. A client can practice at home stepping over books, shoes or even cracks on a sidewalk. If your client is unstable, assign a preparatory exercise to stand on one leg in a doorway holding the doorframe or holding onto a counter for stability. Make sure your client’s home practice is commensurate to skill.

The loss of balance can feel like a loss of control in the lives of older adults. It is unfortunate that many seniors begin to give up activities simply because they feel unsteady and fear they may fall. The building blocks for better balance are available to everyone, but require a commitment to practice and a systematic plan.  Getting older does not have to mean a wobbly future.  Balance can be relearned and continuously improved. Practice may not always make perfect when it comes to balance in older adults, but the progress is definitely worth the effort—ask anyone who can now put on pants one leg at a time.

Coordination and Balance through Cross-Crawling

The coordination training we received as children through the developmental stage of crawling set the foundation for right and left brain hemisphere communication. Since the right hemisphere of the brain controls the muscles on the left side of the body and visa versa, the oppositional nature of arm and leg coordination during crawling activates the nerves across the corpus callosum connecting the two brain hemispheres. As adults, the continued integration of the two sides can result in better coordination, balance and efficient movement. The nerve networks can be stimulated and developed through cross-crawling exercises that utilize oppositional movement patterns.

Although you could crawl on the floor, the “crawling” in cross-crawling does not mean you have to replicate the movement of babies.  The main intention of every exercise is to use the opposing arm and leg. The exercises can be performed in supine, quadruped, sitting, or standing positions. It is also beneficial to try variations that move the limbs in the sagittal, coronal or transverse planes for better spatial awareness.

The following are some samples, but certainly not all the possible options. Be creative and come up with your own choreography that serves the needs of your clients. Do a few repetitions of each action focusing on the ones that are most difficult for your client to achieve. A more challenging combination is to string several different variations in a row requiring quicker changes, rather than repeating one exercise several times. Even harder is to do a combination of several different variations and then decrease the time it takes to complete the entire set.

If your client has difficulty performing cross-crawl exercises, that is an indication that coordination skills are lacking and the exercises should be added to your client’s daily practice. The senior population is one that can especially benefit by preventing falls (and possible breaks) though improved balance and coordination. In addition, clients with a homolateral gait (monkey walk) where the same arm and leg swing together can also benefit. I started doing these exercises with one of my clients who has Parkinson’s and he found them to be very useful in improving his gait and spatial awareness.

CROSS-CRAWL EXERCISES

Supine:

1) Lie of the floor with knees bent and feet flat of the floor. Cross the right elbow to touch the left knee. Return to the starting position. Repeat on the opposite side touching the left elbow to the right knee.

2) Lie flat on the floor with straight legs together and straight arms by your sides. Slide open the right arm along the floor and left leg away from the midline along the floor at the same time and return them back to the center starting position (similar to the action of making a snow angel). Repeat on the other side sliding the left arm and right leg away and back.

Quadruped:

1) Start on all fours with hands below the shoulders and your face looking toward the floor. Simultaneously reach the left arm parallel to the floor by your ear and right leg off the floor in the opposite direction behind you parallel to the floor. Return them at the same time and repeat the opposite side using the right arm and left leg.

2) Try the above exercise with variations. Reach the left arm to the side (rather than overhead) parallel to the floor and take the right leg either back or sideways off the floor to the opposite side like airplane wings (leg side off the floor is more challenging to core strength). Repeat the opposite side using the right arm and left leg.

Sitting:

1) Sit in a chair with feet flat on the floor and arms down by your sides. Step the left foot forward on the floor and reach the right arm out in front of you parallel to the floor. Return to the starting position and then reach the right foot and left arm. This exercise could also be performed with the left foot stepping to the side and the right arm reaching laterally to the opposite side or the left arm reaching back while tucking the right leg under the chair (reaching behind would not be recommended for someone with shoulder issues).

2) Sit in a chair with feet flat on the floor and arms down by your side. Simultaneously step the left foot over the right foot onto the floor, take the right hand and place it on the left hip, and touch the left index finger to the nose. Return to the starting neutral position. Repeat to the other side moving the right foot across the left foot, left hand to right hip and right index finger on your nose.

Standing:

1) Stand with legs hip distance apart and arms by your sides. Raise the right arm reaching toward the ceiling while simultaneously bending the left knee and raising the knee off the floor in a marching position. Return to the starting position. Do the opposite side raising the left arm and right knee.

2) Stand with legs hip distance apart and arms by your sides. Touch the right elbow to the left knee while simultaneously touching the back of your head with the palm of your left hand. Return to the starting position. Do the opposite side touching the left elbow to the right knee while simultaneously touching the back of your head with the palm of your right hand.

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Balance can be improved in the senior population not only with cross-crawling exercises, but also exercises that cross the midline to transfer weight from one leg to another. One of my clients was going to quit her line dancing class because she was frustrated with her poor balance negatively affecting the quick transitions required by the choreography. After about a month and a half of practicing her exercises daily at home, the transition was remarkable! She no longer had problems with her balance and was able to perform more complicated steps. She would have missed out on something fun that provided exercise and social contact had she not made a commitment to practicing.

CROSSING THE MIDLINE

The “jazz square” is useful for practicing weight transfer from one leg to the other crossing the midline. Some people teach the jazz square starting with a forward step, but crossing the midline first may be more useful to practice weight transference.

Jazz Square:

Start standing with legs together. Cross the right leg over the left and transfer the weight to the right foot. Pick up the left back leg and step backward. Shift your weight right to step sideways onto the right leg. Step the left leg forward. The weight will be on the left leg (instead of on two feet as in the beginning) and the step begins again with the right leg crossing over the left to transfer the weight to the right foot. Repeat to the same side several times. Try it on the other side starting with the left crossing over the right, step back with the right, shift side with the left foot and step forward with the right foot.

Switching sides can add a level of challenge. When changing sides the last move in the step is dropped. There are a total of four moves in the step (cross, back, side, front). Perform the jazz square three times with the right foot crossing first over the left foot first. On the fourth set only do the first three moves (cross, back, side). This will put the weight on the right foot. Start the jazz square using the left foot crossing over the right for three sets. On the fourth set only do the first three moves (cross, back, side). This will put the weight on the left foot and the pattern can begin again.

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Coordination and balance are learned skills that begin in our earliest developmental stages. These abilities are perfected through movement challenges and practice. The body in its effort to be efficient will provide less wiring for these activities if they are no longer being used. As we age our activities must reflect a movement vocabulary commensurate with the quality of life we wish to maintain. Cross-crawling exercises that integrate brain function can improve coordination and balance making us more alert and aware. Once again the old adage of “use if or lose it” rings true.