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Personal Balance Training in Focus, Part 1

Sanders, Mary E. Ph.D., FACSM, RCEP, CDE®

doi: 10.1249/FIT.0000000000000045
COLUMNS: On the Floor

Mary E. Sanders, Ph.D.

Mary E. Sanders, Ph.D., FACSM, RCEP, CDE®, is a clinical exercise physiologist and diabetes educator at the Division of Wellness and Weight Management in the School of Medicine and adjunct professor of the School of Public Health, University of Nevada, Reno. She is an associate editor of ACSM’s Health & Fitness Journal® and editor of the YMCA Water Fitness for Health trainingmanual. Dr. Sanders is ACSM Certified Clinical Exercise SpecialistSM and an ACSM Registered Clinical Exercise Physiologist®.

Bob and Helen Benson hit the gym regularly at Saint Mary’s Center for Health and Fitness, Reno, NV. They are committed to take charge of their health by adhering to a routine of cardio, weights, and flexibility training, 3 to 5 days a week. However, when their trainer measured their balance and mobility skills, he discovered deficits that potentially could limit the Bensons’ active lifestyle. To minimize the risk of falls and maximize the areas that needed improvement, they decided to zoom in on the areas of weakness using targeted training. By matching the right exercise to the training objective, trainers and participants can focus a lens on those specific areas that are most important. Did I mention that the Bensons are busy 86-year-olds who like to train in a time-efficient manner?

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Neuromotor exercises that include balance, agility, and proprioceptive training (body awareness during movement) is effective in reducing falls and preventing falls if performed 2 to 3 days per week (1). The Berg Balance Scale is a common assessment tool used to identify neuromotor skills and proprioception skills important for living independently and to ensure safety for active older adults. The test measures static and dynamic balance during a variety of movements that include challenges such as agility; getting up and down from a chair; reaching up, down, and around; and head and trunk rotation. It’s a useful assessment for any older participant but is especially effective in low-functioning older adults (3).

Drs. Carole Lewis and Keiba Shaw (2) identified exercises for each of the 14 areas measured by the Berg Balance Scale, so physical therapists and trainers could provide task-specific improvements to patients based on individual needs. We’ll apply some of their suggestions to zero in on a few specific exercises designed to target possible deficits within each area effectively. For more information on scoring the Berg Balance Scale, check out the Resources section at the end of the article.

Results from balance exercises are enhanced when participants “wake up” the proprioceptive receptors that provide feedback and awareness describing body position in space and about the speed and type of movement. “Sensational cues” developed by Sue Scott (4) help participants turn up the volume of the movement feel as they “tune into their senses” for valuable feedback. Activities can be made more sensory by using words or phrases such as “feel the weight shifting,” “notice if the ground is firm or soft,” “focus your eyes on the corner.” Ask questions such as “Do you feel the pressure over your toes or heels?” “Which foot do you feel the weight?” Participants develop a sense about where their arms or legs are without even looking.

The purpose of this two-part article is to identify the 14 tasks (Part 1: tasks 1 to 5) on the Berg Balance Scale, with the objective of focusing on possible deficits. We’ll then explore specific exercise ideas that target improvements and suggest some cues to help participants develop their somatosensory skills.

1. Sit-to-Stand: Please stand up. Try not to use assistance.

Training objectives: Improve muscle strength/endurance (upper and lower body) and dynamic balance control (3).

Cues: Feel your weight shift forward off your hips and center the pressure on the bottom of your feet. Stretch the spine to a fully extended stand, and push hips forward. Focus eyes forward.

Sit-to-stand from chairs of different heights

Add a phone book or a balance pad on the chair to change the seat height, then practice chair stands, with hands crossed and feet shoulder-width apart, slightly rotated outward (harder) or hands on thighs, with feet in a lunge position (easier).

Reach and chair push-ups

With hands forward, practice standing up and sitting down. Perform chair push-ups, with hands at the side, push down, and contract the upper back, holding for 8 to 12 counts. Keep breathing!

Forward reach

Reach over a small ball and roll forward and back. Notice that the pressure on your buttocks changes as you shift your reach forward and back, pushing and pulling with the ball. Focus eyes forward. Other suggestions (2): Mini squats.

2. Standing unsupported: Please stand for 2 minutes without support.

Training objectives: Improve gaze stabilization, muscle strength/endurance (upper and lower body), and dynamic balance control (3).

Cues: Feel the pressure of your feet, trying to center the weight. Absorb the weight onto each foot as you shift from one position to another. Where is the center of gravity (toes, heels, or full foot)? Focus on working your ankles to stabilize. Lengthen the spine, tall stance, and feel the weight centered over your feet. Keep knees soft to absorb the wobble.

Resisted side step

Step both feet into a resistance band, long enough to allow a fully extended standing position. For participants with arthritis, Thera-Band® offers a new latex-free design that includes pockets for a comfortable no-grip hand position. Step out to the side and bring feet together. Repeat by alternating feet (side to side) or by stepping to the same side.

Stand still

Practice standing still by using different bases of support (wide, narrow, tandem stand) and by changing the surface from the floor to foam pad. Practice transferring your weight, foot to foot, as you shift positions.

Lateral swaying

An exercise ribbon makes lateral sways fun and provides movement feedback. Practice mirroring each other and then going in opposite directions.

Other suggestions (2): Narrow base of support, head and trunk turns, and arm reaches.

3. Sitting unsupported: Please sit with arms folded (2 minutes)

Training objectives: Postural stabilization in vertical position, muscle strength/endurance (upper and lower body) (3).

Cues: Sit tall with your back away from the chair, feet on the floor. Feel the weight centered on your “sit” bones. Stretch the spine upward as you stretch the chest open. Notice how the pressure on your buttocks changes as you shift your hips. Pull shoulder blades back and down.

I surrender!

Practice sitting tall and prepare for the exercises with hands up! Feel your feet on the ground.

Pelvic tilting

Practice hip shifts side to side and forward and back. Scoot forward and then back on the chair.

Sitting PNF diagonals

Patty cake. Start seated close together, clapping straight ahead. Then move further apart. Add challenge by progressing to cross over claps, high and low, slow and fast!

Band it reaches

Challenge with pulls, first with bands straight, then with bands crossed. Challenge with the same side pulls and challenge with reciprocal pulling. Touch the floor with toes only or close eyes and surprise your buddy.

Steady candles

Balance a tennis ball and move slowly to “light up” the room — above, below, and across your body. Other suggestions (2): Partial sit-ups, pointing with laser light on their heads, toes only on the ground, turning head and trunk.

4. Stand to sit: Please sit down on a chair.

Training objectives: Muscular strength/endurance (upper and lower body), dynamic balance control, and trunk flexibility (3).

Cues: Lengthen the spine and stretch through the hips to extend. Feel the weight shift on your feet as you bend your ankles and hips to sit. Notice how you contract your upper leg muscles to slow the movement. Focus eyes forward.

Mini squats

Mini squat practice from standing to seated with or without a resistance band. Incorporate different chair heights for challenge and have participants touch their buttocks to the seat or pad and power back to a stand (touch and goes).

Wall slide

Perform wall slides up and down with or without a ball. Slide only to the point of comfort, pressing navel into the spine, weight on heels with toes light.

Cues: Stand tall. Feel weight shift onto the heels as you push the navel to the spine while the leg muscles tighten during the slide downward.

Other suggestions (2): Stand to sit at different heights, standing forward hip thrusts.

5. Transfers: Please move from chair to chair.

Training objectives: Dynamic balance control, muscular strength/endurance (upper and lower body) (3).

Cues: Focus eyes in the direction of the head. Feel the weight changes on your feet as you change positions.

Marching with head turns

March and turn head to look in the direction of the cue.

Head turn through movement

Practice turning the head in the direction of the seat transfers, creating different patterns around and between the chairs, moving in both directions.

One-legged standing

Include one-legged or narrow base of support stand skills and make it more challenging and fun with a balloon or ball volley. Other suggestions (2): Side steps

Bob and Helen continue to work with their trainer Nebojša Bikic` to address areas needing improvement. In Part 2, we’ll examine items 6 through 14 in the Berg Balance Scale.

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* Be sure to provide appropriate individualized progression, with assistance as needed (4).

* Encourage the use of assistive devices or support (chair, bar, wall) as needed.

* Help participants modify activities by performing exercises seated.

* Provide plenty of safe chairs for resting and allow enough space to move.

* Remind participants during each exercise that they are in charge! For example, during eyes closed exercises, remind them to open their eyes at any time!

* Allow participants to watch a demonstration before participating.

* At the tipping point of losing balance, teach and practice with participants how to take a self-arresting step forward to maintain balance and keep from falling.

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A big thank you to our models Bob and Helen Benson for inspiring us to live active healthy lives. Married for 62 years, they continue to stretch and strengthen to keep pace with their family of eight (two children, five grandchildren, and one great-grandchild).

Thank you to our coach Nebojša Bikic`, personal trainer, Saint Mary’s Center for Health and Fitness, Reno, NV. He was born in Belgrade, Serbia, and is a world-class swimmer, competing in both the World Championships (Moscow, 2002) and in the Olympic games (Sydney, 2000). As a personal trainer, he enjoys working with participants on land or in water.

All photos courtesy of WaterFit®.

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1. ACSM’s Guidelines for Exercise Testing and Prescription. 9th Edition. Pescatello LS, senior editor. Baltimore (MD): Lippincott Williams & Wilkins.
2. Lewis C, Shaw K. The Berg Balance Scale: treatment ideas. ADVANCE Phys Ther PT Assist. 2006; 26: 6.
3. Rose DJ. Fall Proof! A Comprehensive Balance and Mobility Training Program. Champaign (IL): Human Kinetics; 2003. p. 76–7.
4. Scott S. Sensational activities that improve balance. FUNCTIONAL U Exerc Activity Healthy Aging. 2008; 6 (3): 1–10.
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ABLE Bodies Balance Training by Sue Scott. Human Kinetics. Available from:
Balance training: a program for improving balance in older adults by Susan Bovre. Available from: professional education.
Fall proof! by Debra J. Rose. Berg Balance Scale: Administration, Scoring and Interpretation. Human Kinetics. 2003. p. 73–77. Available from:
Thera-Band®Academy Balance Training Programs. Available from:
© 2014 American College of Sports Medicine.