Balance Exercises: How Much is Enough to Protect Against Falls?
Do you know there is a recommended intensity for balance training to make a functional difference and protect against falls? Training programs aimed at improving balance in older adults living in the general community should reach a threshold dosage according to research.
Of course, there is individual variation, but in general there is a magic number. Measured in terms of protecting against fall risk the research supports a dosage that many patients may not achieve. Do you know what it is?
How Much Balance Training Does it Take to Reduce Fall Risk?
Research shows that it takes 50 hours 1 of balance training to make a measurable difference and protect against fall risk. This 50-hour total dose includes time in the clinic and at home.
Originally established in a meta-analysis of 44 trials in 2008, reviews since then supported and expanded the findings. 2 It is still current according to APTA Geriatric’s Best Practices Summary issued in 2022 3 .
What Should an Effective Balance Exercise Program Include?
In addition to the 50-hour total dosage, effective balance programs should include high-intensity balance training. These 2 factors accounted for most of the variability in the studies and had the highest effect on of falls. This is why intervention should be tailored to the individual. What’s a high challenge to one may be too easy for another. Individualized high-intensity balance training can include exercises from the following categories:
- Static balance. Exercises that challenge base of support and support surface.
- Dynamic balance. Activities that challenge the center of mass while the feet are in motion, such as Tai-Chi, turning, and stepping.
- Functional activities. Stairs, perturbation training.
- Gait training. Obstacle courses, dance steps, figure 8s.
- Dual-task activities. Walking and talking, switching focus within an activity.
Because of the progressive decline in vestibular function with aging combined with increased fall risk as a result, exercises aimed at the vestibular system are also important. Exercises involving head turns, and awareness of postural orientation can be incorporated into a general program and cross a few of the categories above.
What Other Considerations Are There for Designing an Exercise Program?
50 hours of high-intensity exercise is the bulk of it, but it’s not as simple as that. Here are the key findings for a balance program that will protect against fall risk. It must be:
- 3 months or more in duration. If not, the total dose would not be sufficient. Other sources recommend that the criterion for a minimal effective exercise dose is 2x per week for greater than 25 weeks.
- Structured and progressive. The individual must be challenged over the entire intervention period.
- Balance exercises! As stand-alone interventions, strengthening, walking, and generally increasing activity are insufficient. Strengthening, however, IS a key component of falls prevention, just not as a singular intervention.
- Walking? Greatest benefits were obtained from a program that did NOT include a walking program. Walking has many benefits but if it replaces time spent doing balance exercises it is a lower priority when balance is the primary goal.
Is the Typical Visit Pattern Used in Physical Therapy Enough to Move the Needle?
Achieving the optimal dose of exercise in a therapy episode is a challenge. Insurance approval of visits is the first barrier, but optimal adherence and behavior change of the patient is of primary importance. Research supports that:
- If a training program is started but not completed, risk can be greater. Increasing mobility a little but without sufficient dosage to confer protection can be riskier.
- A program lasting over 12 months had fewer benefits. This is possibly due to inconsistent performance over the course of a longer period.
When partnering with an individual to create a plan of care, taking the following steps will go a long way toward long-term carry-over:
- Incorporating the patient’s own values and preferences. You are less likely to get buy-in with an activity that they just don’t enjoy doing.
- Assessing and addressing self-efficacy and fear of falling. Here are just a few of the many measures that can be considered 7 .
- Falls Efficacy Scale
- Activities-specific Balance Confidence Scale
- Fear of Falling Questionnaire
- Fear of Falling Avoidance Behavior Questionnaire
- Motivational interviewing. MI is a skill that takes training and practice but learning this method of communication will help you partner with your patients to foster their own goals.
- Partnering with outside parties to support continuation of gains made. This can include community-based education programs, family support, or health and wellness programs.
What are Other Balance Training Options?
Virtual Reality games have been shown to be helpful supporting rehabilitation with various diagnoses8,9 . Well-chosen rehab games provide the elements needed for balance improvement – task specificity, structure, progression, and feedback. Not to mention that they are just plain fun! People participate in activities they enjoy, so they may achieve their 50 hours more consistently.
The evidence is clear. Reducing fall risk in community dwelling older adults is achievable with proper dose. Aim for high-intensity balance training with progressive challenges for 50 hours over 3-6 months.
UprightVR provides balance assessment and rehab games.
1. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JCT. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56(12):2234-2243. doi:10.1111/j.1532-5415.2008.02014.x
2. Shubert TE. Evidence-Based Exercise Prescription for Balance and Falls Prevention: A Current Review of the Literature. J Geriatr Phys Ther. 2011;34(3):100-108. doi:10.1519/JPT.0b013e31822938ac
3. Criss MG, Wingood M, Staples WH, et al. APTA Geriatrics’ Guiding Principles for Best Practices in Geriatric Physical Therapy: An Executive Summary. J Geriatr Phys Ther. 2022;45(2):70-75. doi:10.1519/JPT.0000000000000342.
4. Lee SC. Relationship of visual dependence to age, balance, attention, and vertigo. J Phys Ther Sci. 2017;29(8):1318-1322. doi:10.1589/jpts.29.1318
5. Gazzola JM, Caovilla HH, Doná F, Ganança MM, Ganança FF. A quantitative analysis of postural control in elderly patients with vestibular disorders using visual stimulation by virtual reality. Braz J Otorhinolaryngol. 2019;86(5):593-601. doi:10.1016/j.bjorl.2019.03.001
6. Keshner EA, Lamontagne A. The Untapped Potential of Virtual Reality in Rehabilitation of Balance and Gait in Neurological Disorders. Front Virtual Real. 2021;2:1-16. doi:10.3389/frvir.2021.64165
7. Soh SLH. Falls efficacy: The self-efficacy concept for falls prevention and management.Front Psychol. 2022;13. Accessed January 16, 2023.
https://www.frontiersin.org/articles/10.3389/fpsyg.2022.1011285
8. Soltani P, Andrade R. The Influence of Virtual Reality Head-Mounted Displays on Balance Outcomes and Training Paradigms: A Systematic Review.Front Sports Act Living. 2020;2:531535. doi:10.3389/fspor.2020.531535
9. Heffernan A, Abdelmalek M, Nunez DA. Virtual and augmented reality in the vestibular rehabilitation of peripheral vestibular disorders: systematic review and meta-analysis. Sci Rep. 2021;11(1):17843. doi:10.1038/s41598-021-97370-9
