I initially wrote my book in an effort to increase awareness of the risks of falls and to, hopefully, encourage at-risk individuals to take the action necessary to improve their balance and reduce the risks of falls and injury. As I took the book through the editing process, it was brought to my attention that I needed to extend my influence in order to reach more people than a self-published book could… which is why I am writing and publishing these posts. This is why I started Regain Balance. In this post, I will share why we are at an increased risk of falls as we age and what we can do about it.
I am a physical therapist working in an outpatient physical therapy office. Approximately 50% of our patients are over 60 years of age, with the oldest person I recall coming into our office being 98 years old. After 20 plus years in practice, I have come to recognize certain patterns that occur in those persons over 60 years of age who might be at risk for falls. They tend to have tightness and weakness in the muscles of the trunk, hips, and lower extremities; they exhibit shorter stride length, shuffling, and slower walking speeds; when asked to stand from a chair without using their hands to help them, they are unable or have great difficulty. Many of these individuals end up resort to using assistive devices, such as walkers and canes, for fear of falling.
Research from those working with older adults shows that over 50% of mature adults (65+ years) are at risk for falls in the United States and worldwide, and 33% actually do fall each year. These statistics motivated me with a desire to share this information with all those who seek safe independence, which includes, staying mobile, flexible, functional, and enjoying life as much as possible, particularly as we age.
In regard to some of the concepts and exercises that I share as part of my proven method for reducing the risk of falls, there are some people who have physical conditions which may prevent them from following the exercises that I describe and who may require professional guidance from a healthcare provider. Such conditions might include neurological impairments such as cerebral vascular accident (stroke), Parkinson disease, congenital birth defects, or severe osteoarthritis. And that is ok. For the most part, the information that I share can be adapted to each individual’s circumstances, but please do not hesitate to seek out professional assistance when needed.
As mentioned above, many of the mature adults who are at risk of falling tend to have common patterns. Several of the main reasons a person may be at risk for falls can be found in the image below. As I briefly go into each one in this post, please be aware of your own status and also observe family and friends that may need assistance.
Tight Muscles and Connective Tissue
Connective tissue is found throughout the body and is made up primarily of extracellular matrix, collagen, and elastin. Elastin allows the connective tissue to lengthen and recoil back to its normal length. As we age, the compound elastin tends to decrease, making it harder to maintain normal joint range of motion. Establishing a stretching program is critical to counteract this decrease in elastin. Traditionally, stretching was believed to be more for muscle than connective tissue, but they are so interconnected that it is beneficial to both. Ideally, a stretching program should be a part of our daily lives no matter what decade of life we are in. If you do not stretch your muscles on a regular basis, now is certainly the time to begin.
Muscle Weakness
There is a condition that occurs in the muscles of older adults due to decreased activity called sarcopenia, which is essentially when the muscles shrink or atrophy, leading to weakness. A vicious cycle begins to occur because the person can tell that they are not as stable on their feet, so they either stop moving to reduce their risk of falls or begin using an assistive device. While safety first is our motto, the weakness cycle will continue unless strengthening exercises are begun.
Naturally as we age, some of our muscles undergo a transition from strong, fast twitch fibers to endurance, slow twitch fibers. One way to slow down the transition is to continue to perform moderate to high intensity resistance activities or exercises that challenge the muscles as well as stimulate the hormones needed to maintain them. Certain hormones are released as we engage in these moderate to high intensity activities, helping to maintain the girth and fiber strength needed for normal everyday activities.
Many of our patients verbally express their frustration with losing a measure of their independence to an assistive device as well as the inconvenience of having to use it because of weakness and the fear of falling. Tight muscles restrict hip, knee, and ankle motion which then shortens their stride length; additionally, a lack of feedback from the nerves that send information from the feet and legs to the brain can also contribute to their fear of falling and decreased cadence (steps/minute). When individuals then add weakness to the mix, they instinctively know that if they lose their balance, they will not be able to respond quickly enough or have the strength to keep from falling.
Postural Changes
Remember the song lyrics that teach the concept that all body parts are connected? “The toe bone is connected to the foot bone; the foot bone is connected to the heel bone….” Because tight muscles in the neck, trunk, hips, and lower extremities are all connected in some way, tightness can lead to postural changes that can change a person’s center of mass, usually moving it behind them. When the center of mass is behind a person, it makes it easier to fall backward. Falling backward in mature adults can lead to compression fractures of the wrist, spine, pelvis, and hips. Many people do not like using walkers or canes as they mature, but in order to keep them from injuring themselves, it is quite important to use them until they can lengthen and strengthen the muscles involved and restore their center of mass closer to their center. A lack of flexibility of the connective tissues tends to limit motion in the joints of the ankles, knees, hips, and trunk which affects a person’s posture, walking patterns, bending, getting up and down from a chair, getting into and out of bed, and other functional activities.
For those 60 years and over, a lack of flexibility may have occurred from one’s occupation. For example, if you performed their job duties while sitting for most of the day, it is natural that certain muscle groups would become shortened and tight. Commonly, the hip flexors (Iliopsoas), knee flexors (Hamstrings), and ankle flexors (Gastrocsoleus) all become shortened after years of sitting for hours in a chair. If you then go home and sit in front of the TV to relax from work, you are assuming the same posture they just maintained for 6-10 hours, which compounds the shortening problem. For others, it may be their shoulders and neck become stiff from not reaching overhead enough during the day or not turning the head due to staring at a computer screen in front of them year after year. Joints and muscles stiffen up if we do not use our full range of motion on a regular basis. Another contributing factor to excessive tightness of the shoulders and neck is poor sitting posture. Muscles attach to all sides of the bones in the head, spine, pelvis, and extremities to provide stability, counterbalance, movement, as well as keep the body upright. Sitting in a rounded posture thrusts the head forward affecting the cervical, thoracic, and lumbar spine over time, causing the cervical spine (neck) to extend reflexively, allowing our eyes to look forward instead of at the floor. The shoulder blades naturally move forward on the ribs creating a rounded shoulder posture. If a person maintains this posture for long periods of time, certain muscles will lengthen too much, others will shorten too much, and eventually the person’s center of mass will be affected in a negative way. The negative impact of this is that imbalance results as the muscles that lengthen too much become weak, the short ones become too strong and imbalance results.
Poor posture can contribute to falls because the center of mass moves away from the center of the body and puts a person more at risk because the muscles are not operating at their optimum length and strength. One of the unseen side effects of prolonged weakness, stiffness, and postural deformities includes wedging of the vertebrae of the spine known as Kyphosis. When the bones become wedge shaped, they are more at risk of fracture, particularly if someone falls. Osteoporosis is a common term used to describe a weakening of the bones making them more vulnerable to fracture. Wedging is often associated with osteoporosis and poor posture.
Decreased Walking Speeds
Did you know that your risk for falls increases as walking speed decreases? Normal walking speeds range from 1.446 meters per second to 1.33 meters per second for males and 1.41 to 1.27 for females throughout a lifetime. Walking speeds less than 1 meter per second or 3 feet per second in people 50-79 years old is one of the sure signs that they are at high risk for falls, declining health, hospitalization, and as a result, death. For those older than 85 years, the walking speed is adjusted to 2.4 feet per second (0.73 meters/second). Increasing an older person’s walking speed by 0.1 meter per second over a one-year period has been shown to increase that person’s life expectancy by 8 years in 58% of the older population.
The researchers refer to walking speed as one of the “vital signs” that should be monitored in persons over 60 years of age.
The research likewise tells us that there are a few ways to improve walking speeds, such as resistance exercises, aerobic exercises, and, strangely enough, improving working memory capacity through computer “brain training programs” enhancing the plasticity of the brain regarding short term memory. On the reverse side of slowing down too much, it has been shown that those who are in a hurry to get somewhere, such as answering the phone or the door, crossing the street to catch a bus and other situations, put themselves more at risk to fall. Those who are active in leisure and sport are more apt to adjust to different walking speeds and environmental conditions.
The need for proper strength, flexibility, and balance are intertwined with gait speed (your walking pace). The good news is that these can be positively affected with training.
In our clinic, we have been improving gait speed in our patients through both aerobic and resistance training for many years now, and the results are promising. Some patients ask, “How long will it take to improve my balance and walking speed?” We explain that there are several factors that can determine the length of a program, factors such as the age and health of the person, whether they have had one or multiple falls, their current level of strength and endurance, their activity level (sedentary, lightly active, or moderately active), their level of static and dynamic balance, and current walking speed. Generally, we tell them to plan on 2-3 months to begin to see the benefits of the stretching, strength and power training, balance and agility training.
A more productive question and approach might be, “When can I get started?” and then, “Teach me what I need to practice at home so I can age successfully.”
Walking Speed or Activity Participation
Does it really matter how fast we walk? As older individuals begin to see a decrease in the walking rate, not only is there an increased risk of falls, declining health, hospitalization, and death as mentioned previously, but there is also an increase to functional limitations. Functional limitations might include getting out of a chair or off the toilet, getting into or out of bed, entering or exiting the shower or bathtub, just to name a few.
The old saying “don’t let grass grow under your feet” may have been the layman’s observation which lead to a recent research project revealing the decreased risk of hip fracture that comes with exercise. The correlation between how often we walk and the speeds at which we walk are directly related to risk of hip fracture. This research team investigated the relationship between risk of hip fracture and the amount of activity a person does. The amount of activity can be measured in a term known as metabolic equivalent of task or MET. It refers to the rate of energy that is expended while doing an activity. The metabolic equivalent is a measure expressing the energy cost, or calories burned, of physical activities based upon your body weight in Kilograms. As a reference point, one MET is the energy equivalent expended by an individual while seated at rest. So, if an activity is classified as 7 METS, it means that it requires seven times more energy to accomplish the task than sitting on the couch.
In the graph below entitled “Lower the risk of hip fracture with walking,” the first column is 3 MET hours/week. Three MET hours is a normal walking speed of 2.5 mph for one hour. The more vigorous the activity and or the more frequently we do the activity, the more energy we expend and the less likely we are to fracture a hip.
In summary, walking faster than 1.1 meters/second reduces our risk for falls, and participating in a brisk walking routine or other form of low to moderate intensity physical activity for more than one hour per week reduces our risk for hip fracture after age 65. Participating in more than 24 MET hours per week reduces our risk by approximately 40%. That is a great benefit for time spent on our health and well-being.
My Challenge to You
Establish a regular routine of walking or other physical activity with the determination to maintain a walking cadence above 1.1 meters/second throughout your lifetime. Walking an animal that requires a lot of stops and starts is considered more of a leisurely walk, so you may want to consider taking a separate walk without the stops and starts to maximize your health.
How many MET hours per week are you performing? This week may be a great time to start keeping a record of your activities and identify if you need to do more. Some people like to keep a notebook, others record it on a spreadsheet on the computer or an app on the phone. The important concept is to get started, record the activity, and keep it up!
