Sally is a 68-year-old retired saleswoman who has gradually gained weight over the past 30 years to her lifetime maximum of 292 lbs. She struggles with balance and relies on a walker or cane to get around. Sally is part of a growing obese population that accounts for almost a third (31) of Americans (1). Very little research has been conducted on the stability and balance of obese individuals; therefore the focus of this article is to create an awareness of how to train these individuals. Generally, a fitness program includes aerobics, strength, and flexibility. These activities are prescribed to help individuals improve fitness as well as maintain a healthy weight, prevent unhealthy fat accumulation, and reduce excess body weight when present. Although not considered a main component of physical fitness, balance training is important for improving stability and should be a part of a training program for anyone – especially those who are obese.
A 2001 study conducted at the Université Laval in Canada suggests that obese individuals, especially those with a concentration of abdominal fat, may have a greater risk for falls than individuals with less body fat (2). Overweight and obese individuals are more likely to have degenerative joint disease, be less stable than those without joint disease and more susceptible to serious injury when falls do occur. Risk of falls and fall-related injuries can be reduced by activities that improve strength, balance, and coordination as reported by a number of studies on the elderly (3,4). D. F. Verfaillie et al. reported significant improvement of balance and gait in previously sedentary older individuals who participated in a 12-week program of strength and balance training versus those who performed strength training only (4). Another study found that exercise and balance training reduced the tendency to fall by 50 in healthy individuals as old as 90 years (5).
Balance is the process by which individuals maintain their position (static) and/or move (dynamic) their body in a specific relationship to the environment, requiring both stability and mobility (6). Specifically, it results from the interaction of internal processes and the influence of external forces on the body (7). External forces include anything outside the body while internal processes deal with anything inside the body, specifically physiological and psychological (see Table 1).
Balance and postural adjustments are to some extent automatic. However, for a de-conditioned obese individual, greater attention of body position and physical work to maintain stability is required. This is termed body awareness or proprioception. Proprioception can be defined as an awareness of muscle and joint condition in the body as well as the position of the body and weight and resistance of objects in relation to the body.
Stability and Mobility in Obese Individuals
Obese individuals deal with a number of physiological challenges to balance such as excess body weight, displaced center of mass, and poor physical fitness and strength. They also may have impaired proprioception from co-morbidities (for example diabetes, osteoarthritis, heart or lung disease) that cause neuropathy, edema, and lack of endurance. In addition, they also may be taking medication(s) for these co-morbid diseases that can affect their alertness and balance (4).
To have stability, individuals must be able to maintain their center of mass (the largest concentration of an individual’s mass) over their base of support (the area underneath and between the feet). Center of mass varies from person to person, but more so in the obese population due to wide variability in the amount and location of excess fat accumulation. Concentration of mass can be in the chest area, abdominal region (android shape), or through the hips and upper portion of the legs (gynoid shape), or a varied combination of all these areas. The center of mass in obese individuals can have a great effect on their stability. For instance, those with abdominal obesity have a center of mass anterior to their base of support when they stand upright. Individuals with this pattern of fat distribution tend to partially compensate by adopting a stance and gait of exaggerated lumbar lordosis.
Self-confidence is commonly a factor that influences an individual’s stability and balance. We have all had the experience of being “pysched out” of doing something for which we had the physical ability but lacked confidence. It is important to start with basic balance training skills and progress slowly based on the client’s confidence level and gradually increasing ability and strength.
Steps to Improving Balance
- proper posture
- improve strength
- assess balance
- balance train
While there is wide variability among individuals, generally speaking, obese individuals have poor physical fitness and strength. As a result, their bodies have been ‘trained’ to maintain poor posture. Sitting or standing with proper posture may be difficult for them. Fortunately, they can ‘retrain’ their muscles. The first step is teaching proper posture and improving the strength of the postural muscles (quadriceps, hamstrings, gluteals, erector spinae, and abdominals). Proper posture should be taught for sitting and standing positions (see Table 2). When one trains or works with obese individuals it is important to constantly cue and check for proper posture and positioning. A common mistake when performing standing exercises is locking the knees – cue: keep the knees soft (unlocked). When in sitting position, there is a tendency for the back to round – cue: maintain shoulders over hips.
Maintaining balance in the face of destabilizing forces (see Table 1) depends on an individual’s ability to recover through ankle and hip stability. As muscle strength declines, the ability to maintain stability is decreased (8). Strength and balance are critical for performing activities of daily living (ADL’s) such as rising from a chair or getting up off the floor (7). Strength and balance training should be developed to focus on these areas.
The location of strength training will depend on the physical condition and/or preference of the individual. Some individuals, due to stability, mobility, and strength and endurance issues, may need to start in the pool. The pool allows them to train with reduced effects of gravity, permitting movement of their body and limbs with greater ease. Table 3 lists exercises that can be done in the pool to improve the strength of the lower body. Table 4 lists some land-based body weight and ball exercises that can be beneficial in improving strength and balance. These exercises should be completed 2-3 times a week, 1-3 sets of 10-15 repetitions. For individuals who are very de-conditioned, it may be wise to begin once or twice a week, 1-2 sets of 5-10 repetitions and build up from there.
Assessing static and dynamic balance provides baseline information for monitoring improvements and comparing performance as the individual progresses. Typical static balance tests include: parallel stance, semi-tandem stance, tandem stance, and standing on one foot – eyes open and closed (4) (see Table 5). For obese individuals, depending on how their excess weight is distributed, the first three tests can be quite difficult, if not impossible, due to an inability to bring their feet together side by side while standing. A 30-second time period is recommended. If an individual is unable to perform the balance test for 30 seconds, the time achieved is recorded. If they can hold the stance for greater than 30 seconds, a level of difficulty needs to be added, such as eyes closed (one eye at a time, then both), or requiring the one-leg balance to be completed on a balance mat or a balance board. A simple test of dynamic balance requires the individual to walk the ‘balance beam’ heel-to-toe (4). The individual is assessed by counting the number of correct steps taken along a 10-foot line.
The location of balance training will depend on the individual. Severely obese individuals lack the strength to stand very long on both feet, let alone one foot. Therefore, the pool is an excellent starting point as strength and balance are being developed. A stability ball is a great option if a pool is not available or the client is not comfortable getting into a pool. (Make sure the stability ball is an appropriate size for your client with their hips and knees flexed to a 90 degree angle and feet flat on the floor). Begin with the stability ball against a wall or stable platform, thus preventing the possibility of the client rolling backward. For some, simply being able to stay seated on the ball may be the first step. Next, have them perform upper body exercises while seated on the ball, such as overhead press, lateral or front lifts, and biceps curls. Challenge your client, as you see them begin to increase their confidence in working on the ball move them away from the wall or stable platform. For greater balance challenge, have the individual walk out on the ball until their shoulders and head are supported on the ball and have them perform chest press or chest fly while maintaining a ‘bridge’ position.
Individuals with the strength to support themselves on land should begin balance training on the floor. Simple balance exercises could be completed daily, such as standing on one foot for 30 seconds to a minute, repeated 4-5 times on each foot. Once they can comfortably maintain their balance on one foot for at least 30 seconds on the floor, they should then progress to unstable surface areas, such as a balance mat or balance boards. Table 6 lists some example exercises. As the individual progresses to more challenging balance training, this can be combined with regular workout programs 2-4 times a week. Remember, exercises should always be performed with proper posture. When the client breaks form or is unable to maintain proper posture, the exercise should be stopped.
John is a 31-year-old male, 499.6 lbs, 76.5 inches in height with a body mass index (BMI) of 59.5 kg/m2 and abdominal circumference of 72 inches. He complained of low back pain, but reported no injuries. His program of exercise consisted of 5-6 days a week of aerobic activity for 45-60 minutes accumulated throughout the day by walking or using a stationary bike. He trained 3 days a week for 45-60 minutes by using body weight, a stability ball, medicine ball, free weights, and resistance tubes. Due to his size, all exercises were initially performed seated or lying down on a platform, instead of a bench. After 2 weeks of training he had no back pain or spasms during or outside of the workouts. See Table 7 for exercises and weekly progression over a three and half week program. At the end of 4 weeks, he had improved his confidence level on the ball. He progressed from a 5-minute walk on the treadmill to walking for 20 minutes on the treadmill or walking on a trail for 1 hour without pain. He also had a decrease in weight from 499.6 lb to 463 lb, decreasing BMI to 55.6 kg/m2.
Sally is a 68-year-old female, 272.2 lb, 61.5 inches in height with a BMI of 50.6 kg/m2 and abdominal circumference of 57 inches. Sally has a MET level of 3.8 and uses a walker or a cane to get around. She began with 4-5 days of exercise a week attending shallow water aerobics, chair aerobics, and using the Nustep and upper body ergometer. Initially in the pool, she would not move unless she was holding on to a noodle or onto the side of the pool. Within a few weeks, she became comfortable enough in the pool without having to rely on the noodle. She did not begin land-based training until the 4th week of her program. At that time she was still using her walker or cane, but not relying on them as she had in the beginning. Initially all exercises were performed in a seated position on a chair and resistance tubes were used for strength training. After 2 weeks of training, she had progressed from the chair to the ball against a stable platform to performing the exercises seated on the ball without the stable back support. See Table 8 for exercises and progression over four weeks. At the end of 8 weeks she was no longer using the walker or cane, she was confident on the stability ball, and her weight decreased from 272.2 lb to 253.4 lb.
Balance training increases body awareness (9) and makes better use of an individual’s strength (7). Obese individuals often have poor posture and improperly trained muscles. Individuals should be encouraged to practice and maintain proper posture throughout the day in all their activities. With greater strength and balance, an individual is able to recover more quickly with less unnecessary movement. With a program of 5-6 days a week of aerobic activity, 2-3 days of strength and balance training, obese individuals gain greater confidence in their abilities, decrease their weight, see an increase in strength, and have a greater awareness of their body in various positions and in reference to their surroundings. As an individual improves their balance and strength through training, unnecessary movements are decreased and reaction time is improved. Therefore, individuals are better able to perform ADL’s and to meet life’s demands.
Condensed Version and Bottom Line
Balance and strength training should be an integral part of an overall training program for anyone. Risk for falls may be greater in obese individuals than in normal weight individuals due to decreased stability and mobility. However, regular exercise that includes aerobic, strength, balance, and flexibility components can reduce the risk for falls and improve functional balance. It is important to improve the strength of the postural muscles in addition to balance training. Balance training can be done with little or no equipment and therefore little cost. Balance and strength training are important for increasing body awareness, improving function, reducing the risk for injury, and improving the quality of life.
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