Finding Equilibrium
by Women’s Brain Health Initiative:
BETTER BALANCE LINKED WITH BETTER BRAIN HEALTH.
Tap into your inner child and try this: see how long you can stand on one leg. With your eyes open, shoes off, and arms crossed over your chest, raise one of your feet so that it is near (but not touching) your other ankle, and see how many seconds you can hold the position.
As soon as you uncross your arms, or touch your raised foot to the ground, or move your weight-bearing foot to maintain balance, stop counting. Now, if you feel comfortable and safe to do so, try it again with your eyes closed. Feel free to try a few times and see what your best time is after a bit of practice.
If you’re like most people, you might be shocked to discover how soon you lose your balance and begin to topple over, particularly when your eyes are closed. The older you are, the shorter your time likely will be before losing your balance.
How do your results compare to others your age? One 2007 study published in Journal of Geriatric Physical Therapy found that on average, participants maintained balance on one leg for:
45 seconds with eyes open and 15 seconds with eyes closed if they were under 40;
42 seconds with eyes open and 13 seconds with eyes closed if they were aged 40-49;
41 seconds with eyes open and 8 seconds with eyes closed if they were aged 50-59;
32 seconds with eyes open and 4 seconds with eyes closed if they were aged 60-69; and
22 seconds with eyes open and 3 seconds with eyes closed if they were aged 70-79.
That research shows a clear trend that balance deteriorates with age.
ALTHOUGH BALANCE TENDS TO BE RELATIVELY STABLE UNTIL YOUR 50S, BEYOND THAT, IT DECLINES SUBSTANTIALLY EACH DECADE.
Why does that matter, and why are we talking about it in a magazine about brain health? Well, it turns out that balance isn’t child’s play, it’s key to health as we age. Yet, it is something we tend to take for granted, until something goes awry – for example, when we fall. While falls are certainly a major public health issue for older adults, fall avoidance is not the only reason it is wise to improve your balance.
POOR BALANCE IS LINKED WITH MORTALITY
A recent study by Dr. Claudio Gil Araujo and colleagues – published in British Journal of Sports Medicine in 2022 – found that being able to complete a ten-second one-legged stance test was linked with lower risk of all-cause mortality.
Overall, 20.4% of the 1,702 participants (female and male, aged 51-75 years) were unable to stand on one leg with eyes open for ten seconds or more. The inability to stand on one leg rose in tandem with increasing age, approximately doubling every five years from ages 51-55 onwards.
“Among the participants aged 71-75, approximately 54% were unable to complete the test, making people in that age group 11 times more likely to fail compared to the participants just 20 years younger,” said Dr. Araujo, Dean of Research & Education at CLINIMEX (Exercise Medicine Clinic) in Rio de Janeiro, Brazil.
OVER A MEDIAN FOLLOW-UP PERIOD OF SEVEN YEARS, THE PROPORTION OF DEATHS WAS 3.8 TIMES HIGHER AMONG THE PARTICIPANTS WHO WERE UNABLE TO SUCCESSFULLY COMPLETE THE BALANCE TEST COMPARED TO THOSE WHO COULD SUCCESSFULLY COMPLETE IT (17.5% VS. 4.6% RESPECTIVELY).
“In general, the participants who failed the test had poorer health, so we adjusted our data to account for many potentially confounding factors. After adjusting for age, sex, and underlying health conditions (including heart disease, obesity, and diabetes mellitus), our research revealed that the inability to stand on one leg was linked with an 84% increased risk of death from any cause over the next 10 years,” explained Dr. Araujo. “It’s important to note that this was an observational study and so, it only reveals associations between variables; it does not establish cause and effect.”
The size of the association between inability to complete the test and mortality was quite big, though. “For someone aged 51-75 years, the risk of dying is – on average – higher if unable to complete a ten-second one-legged stand than if that person has coronary artery disease, obesity, arterial hypertension, or high blood cholesterol!” said Dr. Araujo.
These findings suggest that it would be useful for physicians to have patients do this balance test as part of health check-ups. Not only would such a test provide useful information to the physician, but it can also serve as motivation for patients to start some balance training (because people who are unable to do the test successfully are often surprised).
BALANCE TRAINING BOOSTS SOME BRAIN FUNCTIONS
Many research studies have shown that exercise in general is good for our brains, and much of that research has focused on aerobic exercise and resistance training. However, there is also evidence that balance training can have a positive impact on brain function, separate from the effects of any improvements in cardiovascular fitness.
A small study by Dr. Ann-Kathrin Rogge and colleagues – published in Scientific Reports in 2017 – looked at the effects of a demanding balance training program on specific cognitive functions. The participants, aged 19-65 years, were split into two groups: one that engaged in balance training twice a week for 12 weeks, and one that served as the control group.
During each 50-minute balance training session, participants completed eight different balance exercises on varying surfaces, either on one leg or both. For example, one exercise involved standing on a wobble board while throwing a medicine ball back and forth to a partner.
Another involved standing in a single-leg stance while being pulled to one side by an elastic strap around the hips. Exercises were made progressively more challenging over time, as skill level increased. Dr. Rogge, a neuroscientist and psychologist based in Germany said,
IN OUR STUDY, THE BALANCE GROUP EXPERIENCED SIGNIFICANT IMPROVEMENTS IN MEMORY AND SPATIAL COGNITION. AND THOSE GAINS HAPPENED DESPITE THE PARTICIPANTS EXPERIENCING NO CHANGE IN CARDIORESPIRATORY FITNESS OVER THE COURSE OF THE STUDY. RATHER, BALANCE SKILLS WERE SIGNIFICANTLY IMPROVED AFTER TRAINING.
“Our findings suggest that there are multiple mechanisms through which physical activity affects cognitive function. It looks like different types of exercise may benefit different aspects of brain function, so it’s ideal that people strive for variety in their exercise, engaging in balance training along with aerobic exercise and strength training.”
HOW DOES BALANCE TRAINING SUPPORT BRAIN HEALTH?
When it comes to exercise, balance is a unique category that is distinct from aerobic and strength training. Aerobic and strength exercises are “physical training”; they involve activities that are typically repetitive and automatic in nature and require high physical energy output but low mental effort.
For example, running gets your heart pumping and burns a lot of calories but can be done without much concentration. In contrast, balance is considered “motor training” and involves little physical energy but a high level of mental effort. (A lot is happening in your brain to help your body maintain balance – not the usual conscious mental effort required to play chess, for example, but rather the unconscious mental effort required by your vestibular sense and proprioception – the sensory systems that are key for balance and spatial orientation.)
A 2019 review by Dr. Yael Netz – published in Frontiers in Medicine – looked at existing research on the relationship between exercise and cognition, to shed some light on whether one mode of exercise might be more efficient in enhancing cognition than another. Dr. Netz found that both aerobic/strength training and balance training affect neuroplasticity, and thus cognitive function, but that they do so in different ways.
Aerobic and strength training appear to affect cognition through improvements in cardiovascular fitness, impacting neuroplasticity and cognition in a global way. Balance training, on the other hand, seems to affect cognition directly but its impacts are more specific, affecting select parts of the brain and certain types of cognitive function.
When it comes to aerobic and strength training, it is the intensity of the training that matters for enhanced neuroplasticity and improved cognition.
WHEN IT COMES TO BALANCE TRAINING, IT IS THE COMPLEXITY OF THE TASK THAT MATTERS.
To maximize the cognitive benefits of balance training, the activities need to change over time as one’s skills improve. It’s essential that they challenge the brain to increase neuroplasticity and improve cognition.
WHAT ARE SOME WAYS TO IMPROVE BALANCE?
If your results in the one-legged balance test indicated your balance could use some work, rest assured that it’s never too late to take action to improve your balance. And, if you did well on the one-legged balance test, remember that balance deteriorates with age, so it would be wise to continue to work on your balance, to help keep it strong.
Many formal balance training programs have been developed and shown to help improve balance and prevent falls. Some of these are quite resource-intensive, i.e., they involve trained professionals working one-on-one or in small groups to provide a particular set of balance training.
While that type of intensive and supervised balance training may be necessary for some individuals (e.g., people with conditions that affect balance like Parkinson’s disease and multiple sclerosis), many people can successfully engage in balance training on their own, at home or at the gym.
BALANCE-ENHANCING EXERCISE PROGRAM (BEEP)
The Balance-Enhancing Exercise Program (BEEP) is an example of a program that was designed to improve balance through a quick, daily routine that can be done at home without professional supervision.
It is a multimodal exercise program, meaning it involves strength building as well as balance exercises. (Strength plays an important role in balance.) It also includes exercises that help improve gaze stabilization, which is also critical for balance.
The program begins with warming up by doing three minutes of dancing to your favourite song or jogging in place. Then you do a series of exercises on a solid surface:
KNEE SQUATS. Standing with feet shoulder-width apart, hands on your hips, you bend at the knees as though you are sitting down on a chair and then stand back up. This is done ten times with eyes open and then repeated ten times with eyes closed.
HEEL/CALF RAISING. Standing with arms crossed over your chest, raise your heels to come up onto your toes and hold as long as you can (or up to approximately ten seconds) and then lower your heels back down to the ground. Hold onto something for support if needed, e.g., a wall or a table. Repeat three times with eyes open, and then three more times with eyes closed.
ONE LEG STANDING. Standing with hands on your hips and eyes open, raise one foot about 15 cm off the floor and hold, standing on one leg as long as you can (or up to one minute). Repeat on the other side. Once you are proficient at this with eyes open, perform the exercise with eyes closed.
Next, you repeat the above series but on a surface that is not 100% stable, like a double folded exercise mat.
Then, back on a solid surface, you do:
HEAD ROTATIONS. Standing with feet shoulder-width apart, looking straight ahead with eyes open, hands clasped behind your back, and keeping your trunk still, turn your head and look as far as you can over your right shoulder and hold for a few seconds. Then, turn your head quickly to look over your left shoulder and hold for a few seconds. Do this a total of ten times (right then left = one time). Repeat another ten times with eyes closed.
ROTATIONAL JUMPS. Standing with feet shoulder-width apart, looking straight ahead with eyes open and hands on your hips, jump a quarter turn to the right or left (90 degrees), keeping your body, head, and vision aligned with the direction of your feet. After finding your balance, jump a quarter turn back to the original position, find your balance there, and then jump a quarter turn in the opposite direction, find your balance, then jump back to your original position. Repeat five times or until you get dizzy or tired.
Dr. Anna Hafström and colleagues conducted a study in which 40 participants aged 60 to 80 performed the BEEP training as described. On average, the participants completed 16 minutes of BEEP exercises four times a week.
After six weeks of training, the 34 participants who were available for the final analyses showed significant improvement in balance across several measures. For example, one-legged standing time with eyes open improved by 32%, and with eyes closed on a solid surface it improved 206%! These findings were published in 2016 in Gerontology and Geriatric Medicine.
THERE ARE LOTS OF INDIVIDUAL EXERCISES THAT CHALLENGE BALANCE, INCLUDING SOME THAT CAN BE INTEGRATED INTO DAY-TO-DAY ACTIVITIES.
For example, challenge your balance while you’re washing dishes or brushing your teeth by standing with your feet right together or placed tandem (i.e., front heel touching toe of back foot), rather than the usual hip-width apart, which is more stable. Or, as you walk down a hallway, so a wall is nearby for support if needed, do a tandem walk where you shorten your stride so that your front heel touches the back toe with each step.
To improve your balance during the workday, use a standing desk and also stand on a balance board for part of the day.
There are a variety of designs to choose from, but all balance boards provide an unstable surface for you to stand on so that your balance is challenged.
You can also improve your balance by engaging in exercise that naturally includes a balance component, like dance or Tai Chi, which combine aerobic and/or strength training along with balance, thus stimulating neuroplasticity
in multiple ways.
HOW MUCH BALANCE TRAINING IS RECOMMENDED?
Experts recommend that people aged 65+ should engage in physical activity that challenges their balance, in addition to the aerobic and strength training that is recommended for all adults. The World Health Organization specifies that older adults should “do varied multicomponent physical activity that emphasizes functional balance and strength training at moderate or greater intensity, on three or more days a week.”
Even though physical activity recommendations suggest that it is older adults who need balance training, don’t wait until you’re 65 years old to begin. People of all ages benefit from strong balance, so integrating balance training into your exercise and/or your day-to-day life in early or mid-adulthood can help you age well.
Test your balance occasionally, even if there aren’t obvious signs your balance has deteriorated, and if your score falls below what is average for your age, be sure to incorporate balance training.
One study – by Dr. Marco Taubert and colleagues – found that even a little balance training appears to make a difference. In this study, 28 young and healthy participants engaged in training sessions requiring complex whole-body balancing and underwent brain scans to observe any resulting changes in brain structure.
The researchers found significant grey matter volume increases (i.e., a positive change) in frontal and parietal brain areas after just two 45-minute sessions, done a week apart. (These findings were published in 2010 in The Journal of Neuroscience.)
So, take action to improve your balance, regardless of your age and physical limitations. Every bit of challenge to your balance helps.
Women and men differ when it comes to falls
Women have a higher risk of falls. A U.K. study with 4,301 participants, by Dr. Catharine Gale and colleagues, found the prevalence of falls was higher in women than men (29.1% vs. 23.5% respectively). These findings were published in 2016 in Age and Ageing.
Women account for the majority of non-fatal fall-related injuries. A U.S. study led by Dr. Judy Stevens found that of the estimated 1.64 million older adults who were treated in hospital emergency departments for fall-related injuries in 2001, 70.5% of them were women. These findings were published in 2005 in Injury Prevention.
Research by Dr. Daniel M. LeBouthillier and colleagues, published in 2013 in Journal of Aging and Health, found that severe fall-related injuries were found to be linked with subsequent fear of falling and activity restriction in women only.