In the previous post The Body's 4 Natural Defenses to Fight Falls, I noted that patients may lack the coordination and/or leg strength needed to step quickly and sturdily (see post for more information on stepping and other balance recovery strategies). Poor stepping strategies can lead to falls. Larger disruptions to balance require steps to be taken as patients attempt to reset their base of support and recenter their body back to a steady state. As such, stepping strategies must happen quickly, with proper coordination, and with enough strength to overcome the slip, trip, bump, push, etc. Otherwise, a fall will occur.
In respect to stepping strategies, Maki & McIlroy (2006) noted the following deficiencies among older adults:
- Initiate stepping at lower levels of balance instability.
- Take more steps to regain balance.
- Experience collisions between swing foot and step foot.
- Initiate arm movements and grab for safety rails.
- Lack strength in hip abductors, hip flexors, and knee extensors for effective stepping.
As noted in previous posts, to be thorough, balance training should include reactionary balance and stepping exercises. Below are 3 suggestions for incorporating more stepping exercises into your treatments.
- Start by stepping while holding on. Holding on helps patients feel secure as they get familiar with stepping, however, it limits weight shifting. As such, I suggest progressing patients to no hands as quick as you safely can. Go from 2 hands to holding on with only one hand, and eventually no hands. See blog titled 5 Steps for Learning to Stand Without Hand Support for more ideas on learning to "let go."
- Start with stepping in the forward direction (between 9 and 3 o'clock). Patient will feel more confident stepping in this direction - they can see the targets and they are more familiar with moving in this direction. Progress patient to stepping backward (between 3 and 9 o'clock) as their coordination, confidence, and steadiness improve.
- Continue to progress stepping exercises by adding randomization (step in any direction based on random cues), increasing speed (cues appear quicker), increasing step distance (targets are further away), and/or stepping over obstacles (place object between patient and target).
Below are links to balance equipment designed specifically for improving stepping strategies:
- Clock Yourself App - This app uses randomized stepping to improve reaction speed and muscle strength in standing. As the name suggests, the use of a clock face is central to the exercise.
- ADL Balance Games - This Kit includes colored dots and balance cards for a variety of stepping and gait exercises.
- ADL Quadrant Hurdle - As the name implies, this product requires patient to step over a small hurdle. The use of primary colors helps integrate product with balance cards to add randomization and gaming to exercises.
- ADL Balance Mat - This product combines the use a clock face and primary colors for stepping and weight shifting exercises.
- Prama 3.0 - Interactive flooring (lights, sounds, and sensors) for a wide variety of high-tech stepping and agility exercises.