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Balance is necessary to be in an upright position of sitting, standing, or walking. As babies, the first practice in balance is learning to hold the head upright against gravity. Babies work to build posture muscles in the neck and spine and to control the head. From there, they work on balancing from the belly and pushing up on the arms. Next, they work to get up onto their hands and knees, making the arms stronger and getting better control of the legs, which also benefits posture muscles. As they can stay up on their hands and knees with good stability, then they start to work on movement and function by learning to crawl. After crawling comes standing up, and eventually walking.

Balance is important to be able to sit and move safely. When balance is reduced, there is a greater risk of falling, causing injury to the body. Falls are strong predictors in nursing home placement.  When balance is lost, injury is more likely to occur as bones weaken with age. The bones are less dense, becoming weaker, and are more likely to break. Those living in climates where the sun can be hidden frequently, like in the Pacific Northwest, suffer from lower levels of vitamin D. 


Older women who lose bone mass can develop osteopenia and eventually osteoporosis. Men can also develop osteoporosis, especially those with prostate cancer. Both men and women most commonly fracture their hips, vertebrae (backbones), and wrists when they fall. 

If the balance is improved, the risk of fractures from falls decreases. Bones respond to trauma by laying down more bone. Therefore, weight-bearing exercises such as walking and dancing can build bones. Heavier people must work harder to carry the weight, so their bones are usually denser than their slender counterparts. Patients who fall and have hip fractures are more commonly slender. But heavier people may also have fractures. A good way to prevent fractures is to work to improve your balance. 


One of the main reasons people lose balance ability is that they stop moving on surfaces or in ways that would challenge and build balance ability. I have noticed that as people get older or have injuries, they are less likely to walk on grass, gravel, sand, or trails with rocks and branches. These people tend to walk only on level surfaces that have no chance of giving way. They also stop picking the feet up as high and do more shuffling. By no longer challenging the balance systems, they virtually stop working. Once the balance systems have been “asleep” long enough, walking through a grocery store and having someone bump you lightly will more likely cause you to fall over. 


Ways to improve balance systems can be difficult but can also be fun. Moving in ways you are not used to moving is an easy way to build balance capabilities. Safety first is always the priority when upright. Start balance activities in the safest position for yourself. If sitting upright is difficult, start with sitting. Practice putting your arms out to the side and shifting your body to the side, putting your weight over the hip and buttocks. As you feel more confident, move farther and farther from side to side. Always remember to prevent overuse when starting any exercise program, including balance work. Start with four shifts to each side. You can also work on forward and backward balance, but it would be best to have one hand forward and one hand back to steady you and catch your trunk if you start to fall. Initially start with hands touching the surface, but gradually work on having the hands hovering over the surface upon which you are sitting. 


As sitting balance improves, work on larger shifting movements, like moving the upper trunk into large circles in each direction. Another good exercise is to put your hands on a stable chair in front of the surface on which you are sitting. Slide your hands forward so your body shifts forward, and then sit back up and move your trunk backward over your buttocks. With the chair in front of you and someone standing by you for safety, start bringing the bodyweight forward over your toes to practice getting the buttocks off the bed or chair. As you can get weight onto your feet, work on standing upright. 

Once you can stand upright, work on your balance at a counter or a stable surface. Stand with both hands on the counter spread out like an eagle and practice weight shifting from side to side. If you watch someone stand on one foot you should notice that their pelvis and hips shift toward the side of the foot upon which they are standing. This helps get the center of gravity over the base of support. If you do not shift the weight to the side of the foot on the ground, you will not be able to maintain an upright position. This side-to-side movement of the pelvis is necessary to walk. At the counter, practice bringing the weight forward over the toes and backward over the heels. 


As standing still and slight movement shifting balance activities are getting easier, it is time to move to the next level. Now start working on shifting the weight to one side and picking up the opposite foot. If you need the support, stand at the corner of the counter and push your hip into one side of the counter, then lift the opposite foot up. Slowly bring your hips back toward the side of the foot in the air and find the balance point of standing on one foot, with the hands on the counter initially. Eventually, with one foot in the air, practice raising your hands above the counter, but keep them by the counter to grab if you need to. Safety first is always the rule. If you are not safe standing still in an upright position, you are not ready to begin lifting one foot.


Another challenge to try is putting the feet in tandem so one heel is directly in front of the other foot’s toes. The feet will be in a line. Get balanced and pick up the hands off the counter while in this position. As standing activities get easier, add movement such as walking in tandem: stand next to the counter with one hand on the counter and walk down the counter, heel to toe. Do this forward and backward. 

Face the counter and bring one foot crossed in front of the other foot. Then step out to the side and bring the foot crossed over in front again. Now cross the foot behind the opposite foot and step out to the side. Continue crossing the foot behind while stepping to the side down the counter. As this gets easier, add a braided walk: cross over in front, then step to the side, cross over behind, and step to the side. Continue doing this braided walking up and down the counter a few times. 


When these balance activities are too easy, start doing more challenging activities such as standing on one foot to brush teeth or do dishes. I used to be able to stand on one foot to put my clothes on, including my compression stockings. When I gave this up and stopped working hard at climbing stairs, my balance worsened. This was a significant challenge, and I do not recommend it if you have any balance issues. When you have good balance, however, you can work on folding laundry on one foot. Work on walking on uneven surfaces, such as trails that have gravel or tree roots, especially those that have some hills. An excellent way to work the balance systems is to walk on sand. As the foot propels you forward, the side buttocks muscle (gluteus medius) must work pushing behind and out to the side to propel the body forward.


The gluteus medius muscle is commonly a culprit of poor balance as it gets weaker. 

The gluteus medius side buttocks muscle brings the leg out behind and to the side. While standing or walking, this muscle also pulls the pelvis down toward the leg. When the gluteus medius is weak, it does not do this job and the pelvis drops to the other side. Then the other foot no longer has room to swing underneath the pelvis, so the upper body must be thrown toward the side the leg is standing on. This gives a person the appearance of waddling when they walk. Sometimes this leaning of the trunk occurs to both sides, but in others, the trunk lean only occurs to one side. This gait pattern can improve as the gluteus medius improves in strength and the muscle hypertrophies or gets bigger. 


Dancing is the most fun way to get your balance back in check. My male patients always say, “My wife will love that,” when I tell them they should dance. I respond by saying, “Yes, she will, and your body will love you for it.” I noticed that the dancers I saw in the clinic seemed to look like they were in their 60’s even if they were in their 90’s. In contrast, I have seen 60-year-olds who look 90, but none of those ever say they are dancers. 


Work to stay upright in sitting, then in standing, and eventually while moving when upright. Keeping the balance systems awake and alert can keep you living in your own home being able to do the things you want to do. 

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