hadley.edu€¦ · Web viewThat stands for Exercise and Conditioning for Easier Living Program and has worked to develop a comprehensive fall prevention training that’s not only

Balancing Act: Fall Prevention forOlder Adults with Vision Impairments

Seminars@Hadley

Balancing Act:Fall Prevention for Older Adults

With Vision Impairments

Presented byAnn Cowles

Moderated by Ed Haines

March 14, 2016

EdLet me officially welcome you all to Seminars@Hadley. My name is Ed Haines and I’m an Instructor at the Hadley Institute for the Blind and Visually Impaired. Today’s seminar is titled Balancing Act: Fall Prevention for Older Adults with Vision Impairments. Fall prevention is a critical concern for older adults and their families and caregivers and when vision loss occurs falling risks often increase, unless individuals adopt specific strategies to maintain safety and independence.

Please join me in welcoming today’s presenter, Ann Cowles. Ms. Cowles is the Fitness Director with the New England College of Osteopathic Medicine’s U-ExCEL.

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That stands for Exercise and Conditioning for Easier Living Program and has worked to develop a comprehensive fall prevention training that’s not only directed at the general population, but is designed to be accessible to those with low vision so without further ado, I’m going to turn the microphone over to Ann.

AnnThank you, Ed. First of all, I hope everybody can hear me and welcome to this webinar. I’m really excited to be here. I have to tell you though. This is the first time I’ve done a webinar on this topic. Usually I have a crowd and I make you get up and exercise and do our program, so I think this might be your lucky day. Like Ed mentioned, I am the Fitness Director for a program called U-ExCEL and again, he mentioned U-ExCEL stands for Exercise and Conditioning for Easier Living, and I’m very fortunate to be able to work for the University of New England.

Being a part of a university, especially one that’s interested in research, we’re really given a lot of opportunities to utilize our program in ways that if we were just on our own, we wouldn’t have accessibility to them so I’m very grateful for UNE for having this program be under their umbrella. U-ExCEL itself and our program is considered an auxiliary program, in that all of the funding and the resources and all of our staff, we’re all under the



same hood, where we don’t actually get funding from the university specifically.

We make it all on our own so I go out to a variety of different communities, typically centered around older adults, whether it’s a life care retirement community offering a variety of services through independent living, assisted living and nursing home level care or maybe just a strict assisted living home. I even go to a church once a week and do an exercise class with those community members. Our program mission is simple and our mission is simply to improve the health and well-being of older adults through fitness and wellness programming.

To take it further, we also adopt a philosophy that anyone willing to exercise can. We always use the examples of we have people that are wheelchair dependent or even sometimes dependent in their beds and they can’t get up, but as long as you’re willing to put in some effort, exercise is something that we can offer you and in a goal to improve the quality of your life, so I think it’s always easier when talking with new people to understand a little bit about what we’re doing so you know where I’m coming from when I’m discussing where I came up with different conclusions, so I just wanted to give you a little bit of background on what I’m doing specifically which is really just to open it up a little bit more from there.



I go to these different communities and provide a bunch of different services. Some communities we focus strictly on exercise, providing group programs, individual programs, doing consultations on what different health modifications individuals can make to improve their quality of life. We go to different assisted living homes and give presentations on health-related topics. We do presentations, both statewide and in Maine, so Maine tends to be where a lot of our presentations and trainings are held, but I have started reaching out to different communities and different states as we’ve progressed in the field over the past few years.

Our programs are always either exercise-based or education-centered. We tend to now focus on balance and falls because as you well know, falls are one of the biggest threats to an older adult’s quality of life, so naturally we focus on balance improvement, trying to use it as a falls prevention strategy. Our definition of fall, I think that’s always a nice thing to talk about in the beginning because for a lot of people it can mean different things. I know when I’m working with older adults, they don’t classify a fall, unless they get hurt so they might not feel the need to tell their physician that they fell, unless it was obvious that they fell.

The definition that we use is coming to rest inadvertently on the ground or at a lower level. The reason that we had



to add the word inadvertently in there is because my boss works a lot with a nursing home here that is all run by nuns, and naturally there’s a very spiritual-centered community there and they had to change the way that they were reporting falls because people would go down to pray at the end of – before they were going to bed, and they couldn’t get back up off of the side of the bed so the nurse would go in to help them, and they would be on the ground and because they didn’t see them willingly go to the ground, they had to classify it as a fall so we added the word inadvertently there because clearly, these individuals were purposely going to kneel on the side of their bed, so we found it really important to make sure that everyone understood that it’s an inadvertent act that gets you landed at a lower level.

Falls can be associated with a lot of different things, decline in your ability to move around, needing to be placed in a nursing home or a hospital stay, increased use of medical services and the fear of falling. I’d like to talk about the fear of falling with individuals one on one to talk about if that is something that is limiting their mobility, limiting their trust in themselves, and a lot of times fear falling increases your risk of falling because you change the way that you’re living your life which is putting you more at risk.



Balance training specifically, there’s a lot of different benefits to it. Thinking muscular and physical health-wise, balance training can increase your joint stability, increase your muscle strength and increase your flexibility. It increases your functional fitness performance, and I’ll talk about functional fitness in a second. Doing balance training also stimulates your brain so you’re really thinking more specific for your balance which stimulates your brain to function a little bit more appropriately than it was before.

It also helps reduce the seriousness of your injuries if a fall were to occur, so we found that those that were practicing balance-specific exercises did reduce the seriousness of an injury if they did have a fall so balance exercises to reduce your risks for falling can really be strength-based, coordination-based, dynamic-based and static-based, and what I mean by strength-based, that’s really what most people think about when they exercise or when they’re thinking about exercise, counting to repetitions, focusing on a muscle group, squeezing, contracting.

That’s what people are thinking about with strength-based. Maybe it’s bringing your leg out to the side. Maybe it’s doing a squat. Any of those exercises are considered strength-based exercises, and they do have an improvement with your balance because the muscles that you’re targeting are stronger and able to hold you upright for a longer, safer amount of time.



Coordination-based exercises, our definition of that is any exercise that’s involving some type of coordination and movement so it might be walking slowly, lifting your knees high up, doing a march, moving location, walking heel to toe down a hallway. Any of those movement-based changing location exercises would be considered coordination.

Dynamic-based, our definition there is that it’s movement-based, standing in the same location but there’s some movement component. It may be movement with your upper extremity or your lower extremity but anytime there’s movement-based, we’re considering a dynamic-based exercise, and in the final exercise group for balance exercises is static-based exercises. Static is when you’re holding a position. No movement is associated with it, and you’re holding it for time more than anything else. In our program we use all static-based exercises.

Before I jump right into Balancing Act and what the program is and the exercises, I think it’s important to see where we came from, and why we developed Balancing Act the way that we did. When I first came to the University of New England back in 2010, there were ten pieces of paper put together that had some exercises on them, but there wasn’t really a lot of structure to it but



there was a really great foundation for what our program became and what it is now.

In 2010 when I came to UNE, they had tested the exercises with a group of older adults in one of our retirement communities that we go to. That pilot study is what turned into our Balancing Act program now. From that study I was able to put together the exercises in a way that really gave them more flow and creativity, and it allowed for those initial participants to really have a hands-on say in what the best way and methodology to continue our program was.

In 2012 we were awarded the Maine Governor’s Council on Physical Activity Special Populations Award, and that was a really big deal for us because at that time, we had nothing besides that original pilot study that wasn’t anything – it was eleven participants and they’d had the program for eight weeks and that was all we had, but we had put so much time and effort in the program that by 2012 when we received this award, we were already on our second addition of our published manual.

In 2013 we were finally awarded our first grant. We were awarded a grant from the National Institute of Health and this grant was really the kick start to what our program is today. I’ll talk more about that in a second. In 2015, this past summer, we actually for the first time tested our



Balancing Act program in a small group class setting with a lay leader model. What we mean by a lay leader model is that we had a nonprofessional lead the group class to a group of her peers, so actually, what it looked like was we went to a community. It wasn’t an assisted living. It was an all independent living community, and this one woman took control and she took her group of her peers. There were eight participants and they went through the exercises together so that’s what we mean by lay leader model, so back to my National Institute of Health, that research grant.

We tested Balancing Act on older adults with vision impairment, and this is the first time that vision impairment really came in the forefront of where we were taking Balancing Act itself so our program, U-ExCEL, partnered with the University of Maine Orono Center on Aging and the Iris Network in Portland, Maine. The Iris Network is a group that works with visual impairment and blindness through a wide spectrum of ages and abilities, so they were the ones that approached us looking for an opportunity to do research on a fall prevention program specific for vision impairment, so it was really because of them that the grant was even put together.

The Iris Network was responsible for providing the participants in the study. They were all past clients of them. The University of Maine Orono was really



responsible for the behind the scenes on the data analysis, making sure all of our T’s were crossed and I’s were dotted for the grant aspect and my program, U-ExCEL, we were responsible for, a) providing the program, providing the training and expertise on working with older adults and then being a resource for the Iris Network staff that were going out in the field and testing the Balancing Act study itself.

The criteria for the participants were that their vision had to be 20/70 or worse in their best corrected eye. They had to be older than 62. They had to be able to follow directions which this is my favorite test ever. We asked them to fold a piece of paper in half and if they could, they could follow directions, and they had to be able to walk the aisle of a grocery store. We picked that as our limit for distance because really you don’t need to walk in our program, but we needed to make sure that there was some ambulation possible. It didn’t matter if they were using a cane, a walker or the grocery cart. As long as you could move that far, you were eligible for the study.

What was really nice with this research is that we were able to involve over 100 people in the State of Maine with our Balancing Act program, whether it was just a small initial meeting or it was long-term, they made it through the six month study or they were part of our initial pilot feedback, where we went out into the field and we tested



our manual to make sure that the wording was appropriate, that our instructions were clear, that the format of the manual was appropriate for working with vision impairment and things like that, so even just before we started the program, we made huge changes to the manual’s formatting.

We took out a lot of wording, unnecessary words and we also decided, based on the Iris Network’s recommendation, to take out the pictures that we had describing each exercise. Now since then, we have added the pictures back in and in my own opinion, the pictures add a huge sense of clarity to the instructions. We also as a result of this research study, developed a large print, a bridged version of our manual. We now have an audio version so those with vision impairment that no longer can read have a way of listening to the exercises. We even made a braille copy so this research grant was really great for us and just branching out the options that we have on working with adults with vision impairment.

We focus our program, Balancing Act, on older adults simply because that’s where our focus is but like I mentioned, Balancing Act can be adapted to any population and any group. Anybody that wants to improve their balance, this program is right for them. We put it together – the reason that Balancing Act is designed the way that it is is because we see a need in our world and in



the exercise world for a program to be accessible for everyone. You don’t need to travel someplace once a week to do your exercise class, or maybe it’s you needing a personal trainer or a physical therapist to lead the sessions. We really wanted it to be accessible for all ages, for all abilities and for all groups.

We wanted it to be able to be something that you can do at home, throughout your day, not all continuous at one time and try not to discriminate against anyone who was interested in trying the program. In our full version of our manual, we have information for healthcare providers, for different agencies and organizations and then for groups or individuals looking to participate in the program itself. We worked very hard at making this an accessible program, so I’m going to move into talking about Balancing Act itself. I want to, before I move on though, give anybody the opportunity to ask a question before I move on so I’m going to log out.

There, that was my obligated five seconds to give you a chance, so we can always come back to this if you have questions afterwards so like I mentioned, Balancing Act is all standing, stability, static exercises so if we break down those words, the standing. They’re all standing exercises. Stability, focusing on that standing stable. There’s no movement component to it and then that static. That’s that there’s no movement component to the exercise itself.



We decided to do static stability versus a movement-based dynamic exercise because in the exercise science world, it is harder to do a static exercise than it is to do a dynamic exercise. However improving your static stability improves your dynamic abilities, so we focused on the static option so we could try to improve balance in both areas. Balancing Act is designed to be very progressive, meaning that you start off as easy as possible, and if you got all the way to the end, it’s very, very challenging so the ways that we did that were that we made different levels of exercises.

In our manual we have beginner, intermediate, advanced and action exercises and those are all the levels. Within each level, you can see the progression of making them easier to harder. I want to go through some key terms with our Balancing Act program before I go any further because I think I’ve already caught myself using a few of them already, so what I’m going to do is just go through a word and what our definition of that word is when thinking about Balancing Act, so the first word is balance and our definition of balance is even distribution of weight, enabling someone to remain upright and steady, so simply standing without needing to fall over, remaining upright.

The next term is base of support and our definition of base of support is it’s the location on your body where most of



your weight is supported, so if you’re sitting down right now, really your base of support is your backside. Maybe your feet are flat on the ground. They would also be offering a base of support. The chair legs on your chair, those are part of your base of support. When you’re standing your legs and feet make up your body’s base of support.

The next term is center of gravity. Our term here or our definition here is that your center of gravity is the point at which your entire body weight is concentrated. At this point, the body can maintain its equilibrium or balance, so if you were standing with your feet shoulder-width apart and your arms down at your side, your center of gravity is really straight down from your navel. I like to think of a seesaw when you’re talking about center of gravity. If you have two people that are of equal weight and they both sit on that seesaw, they’re able to stay balanced or centered. The center of gravity is straight at the middle point. If you have somebody that is a little bit heavier, the center of gravity shifts to keep it as balanced as possible.

The next term is point of contact and point of contact is the area in contact with the floor or stable object so again, if you’re sitting right now, your feet might be your point of contact. Your buttocks is your point of contact. If your elbow is on am armrest, it’s a point of contact. Anything that’s touching something stable is a providing a point of



contact which is helping you remain more stable. When you’re standing and not holding on to anything, naturally your feet are your point of contact.

The next term is proprioception and proprioception is your body’s ability to sense the position, location, orientation and movement of your body. A little bit different, if you’re like me and you have an exercise science background, proprioceptors are these little things in your muscles that read what your muscle’s doing and what your body is doing.

We tried to break it down so it wasn’t so complicated and that’s why when we talk about proprioception, we’re talking about your sense of what your body is doing. Are you moving? Are you too far forward? Are you too far back? Are there things in front of you to hold on to? Etcetera, etcetera so thinking about our Balancing Act levels, again there’s beginner, intermediate, advanced and action. The beginner level exercises all have a wide base of support, high point of contact. As you progress to the intermediate level exercises, we start to narrow that base of support, start to reduce some of your contact and start to shift your center of gravity.

By the time that you get to the advanced level exercises, you’ve narrowed your base of support as much as you can. You’ve almost eliminated a point of contact and a



more exaggerated shift in your center of gravity, and in that fourth level of exercises, the action level exercises are when we start to add in movement-based exercises.

I am going to focus for the remaining of this session more on those first three levels, the standing, stability exercises, the static level so when you’re thinking about performing the exercises, we think about your hands being a huge role with balance overall. There’s three hand positions that we use but naturally, I need to break them down even more than that. Hand position number one is when you’re holding on to a stable surface. If you’re doing it in your kitchen, I always love doing the kitchen sink because then you can wrap your fingers in the sink and have your hand on the outside of the counter as well. Maybe you’re holding on to a chair. Whatever you’re holding on, you’re gripping it with both hands.

Hand position two, you’re reducing point of contact so instead of holding on, now you’re thinking just your fingertips. That can be broken down into three fingertips, two fingertips, one, maybe one hand’s on the chair and one hand’s not on the chair. There’s a lot of variations in there to make it easier or harder and then the final hand position number three is when you’re no longer holding on, but your hands are hovering above that stable surface so you can always touch down.



The starting position for all of the exercises is to stand facing your stable object while you’re holding on, standing nice and tall, thinking your back’s straight. Hips are a little bit forward. Your knees are relaxed. What we mean by knees relaxed is that they’re not locked straight and they’re not locked bent. You’re able to move them around. I always like to loosen mine up when I’m standing that way. Your feet are at a comfortable stance, apart from each other and your weight is even on both feet, so for all the exercises, this starting position really gives you the right body position to follow the instructions from there.

This is the point in the class that I typically make my participants in my presentation get up and move around. Since I can’t see what you’re doing and you can’t see what I’m doing, I’m going to do my best to really describe the exercises and hopefully, you can visualize what I’m trying to show you, so what I’m going to do is take you through our beginner level exercises. I’m going to read through the instructions and then show you the progression on how to make that harder so exercise number one, the very first exercise in our program, is called Feet Shoulder-width Apart. You can probably guess what that looks like.

The instructions are stand in start position. Bring your feet shoulder-width apart which is about twelve inches with your weight even on both feet. Then hold the position so in this position, you’re thinking about your base of support.



You have a wide stance, high point of contact, holding on to the chair. Your center of gravity is straight down. This position is very simple to do for most people. What we say is that you should hold it for five seconds, building up to a goal of 30 seconds.

The next progression from here is exercise number two which is Feet Hip-width Apart. The only difference in this exercise is that now you’ve brought your feet in a little bit more narrow. They’re around hip-width or six inches apart. Everything else remains the same. For most individuals, doing these first two exercises, they don’t even really notice a difference. In fact I know for myself with my feet hip-width, I feel more stable because that’s just naturally the way I stand.

The next progression, if you’re following with our key terms, is to bring in your feet close together so we started with a wide base. We came in to a little bit narrow and now your feet are as close together as you can possibly make them. Everything else remains the same. Your weight is even on both feet. You have your hands in a position that you can hold on. This tends to be where everyone notices the change. It is much more difficult to stand with your feet close together than it is with a little bit of space, and that’s because we’ve narrowed that base of support.



If you think about a tripod or a pyramid, anything with those legs, the wider they are the more stable they are. The more narrow they are, the more unbalanced you are. That remains the same with us as well so that’s our first progression. Our first three exercises in the program show the first progression, starting wide to going in narrow.

Exercise number four in the beginner level exercises is called Foot Forward so you’re going back to that start position, stepping forward with your right foot, keeping both feet flat on the ground and your weight even on both feet, so simply what we’ve done here is just staggered your stance which shifts your center of gravity slightly forward. Some people struggle with this. Some people don’t.

Everyone’s different but it’s important to do the same thing on both sides, so exercise number four has two pieces. One section with your right foot forward and then repeating the exercise with your left foot forward, and then the fifth exercise in our beginner level group is called Weight Shift so again, you’re starting with your feet shoulder-width apart in that start position, shifting your weight now over towards your right foot.

In this level exercise, we ask you to keep your feet flat on the ground, so you’re shifting your weight to one foot,



standing tall, the goal being to keep your shoulders, hips, knees and that right foot all in line with each other. I like to think about drawing a straight line down from my collarbone straight down to my ankle. What we’re doing here is really exaggerating the center of gravity shift to be over your right foot more, and that makes a situation where your right leg muscles have to work a lot harder to hold you upright. Of course switch and do your left side after that. Then your left side has work equally as hard.

It’s here that a lot of people notice that you have a difference. Maybe your right foot you felt more stable or it fatigued at a slower rate than your left leg. Everyone has a right side or a left side dominance. For myself, I am right-sided dominant, meaning that when I do these balancing exercises with my right leg being my balance leg, I always feel more confident in and in control. For some people it may be your left leg. Everyone’s different and injuries of course throughout our lives play a role in how comfortable you feel with these. Those were our first five exercises, feet shoulder-width apart, feet hip-width apart, feet together, foot forward and your weight shift.

What those five exercises do is start to introduce our basic stances and basic progressions through the program, so our basic stances are there’s two different stances, your feet being in the same line with each other and your feet being staggered. When your feet are in line, we have two



different progressions that we go through there. The first one we already went through, reducing your base of support. The second one is a shift in your center of gravity. We already started that one as well.

The second stance when your feet are staggered, there are three progressions in this stance that we use to make things more difficult, reducing your base of support, reducing your point of contact with the ground and exaggerating your center of gravity so we take these concepts and build them into the components of the program, so what I’m going to walk through now is really our first progression.

There are three exercises in this progression, and if you’re progressing from a beginner to an intermediate to an advanced level exercise so exercise number four in the beginner level exercise is that foot forward exercise. In this one your feet were flat on the ground and your weight was even on both feet. To transition this exercise to the intermediate level, you shift your weight to your back foot, going on to your right heel. Now if you’re sitting in your chair you could even do this right now. Step forward with your right foot and go on to your right heel, so you won’t really notice a difference when you’re seated because your buttocks is providing most of your support but you can tell in this position that you are reducing contact with the floor, and that is the goal with this progression.



The next progression would be to lift that heel right off the ground so your other leg is holding all of your weight and is considered now your balance leg, so we progressed from having your foot forward and both feet flat to going on to your forward foot’s heel, to lifting that heel right off the ground. You can tell that we’ve reduced contact and we’ve shifted your center of gravity. When you lift your foot off of the ground, your center of gravity is still shifted forward slightly so it means that your balance leg, the leg that’s still in contact with the ground, has to work a lot harder then to pull your body weight back, so you’re using your backs of your legs a little bit more than you were before.

Progression number two is actually just the opposite. You can see it in the beginner level exercise with that foot forward stance again, except this time you’re shifting your foot forward to your front foot going on to your back toe, so we’re lifting that back heel off the ground now. The progression is harder because you’re reduced point of contact with the floor by lifting that heel up, and then the next progression would be to lift that toe up, now with your leg behind you.

This is really the exact opposite than the first progression we went through. Instead of now having your leg in front of you, or instead of having your leg in front of you, you



now have your leg behind you. What that does is it pulls your center of gravity back, so it means the front part of your balance leg muscles have to work that much harder to hold you upright and steady.

The next progression is we’re going to back to your feet being in that shoulder-width position in line with each other. We’re trying here to exaggerate your center of gravity, so that first exercise or that last exercise in the beginner level exercise is the weight shift is the first progression to this, so in the beginner level, we’re keeping feet flat on the ground, shifting your weight to one leg. In the intermediate level of these exercises, you’re going up on to your toe of that leg that you’re reducing contact with, so if you shifted your weight to your right leg, you’re going on to your left toe so your right leg is working harder to hold you upright and steady.

In the advance level exercises, we’ve reduced point of contact entirely with that left leg so you’re balancing on your right foot, and then the last progression that I’m going to talk about right now is thinking about that foot forward or feet staggered progression again, so the beginner level, we’ve already gone through a few with this being our start position. Your foot is forward. This progression is different because instead of reducing point of contact, we’re now reducing base of support in a staggered stance, so if you stepped forward with your right foot, the



intermediate level would be to step so your feet are in line with each other, almost like you’re trying to walk on a balance beam.

In the intermediate level exercise, we call this a broader stance, meaning that you have some space between your heel and toe, and then the advance level exercise would be to slide that heel to touch your toe, so you’re standing with your right foot in front, your right heel touching your left toe so those are the four basic progressions that I’m going to go through for now, but what I wanted to talk about around all of these exercises is the role that your hands play in that.

What we recommend is that you always start holding on with the beginner level exercise of the progression, so for example, if we were to go to that last progression I was just talking about, I’d be holding on with my hands, stepping forward with my right foot. If I’m comfortable doing this exercise holding on, I would try it with maybe just my fingertips. If I was still comfortable, maybe I’d lift one hand up or both hands, with the goal of having no contact with my stable object, with my hands so I’m relying entirely on my body to hold my balance.

The next progression’s stepping forward in line with my feet so my right foot is in line with my left foot. Again, we recommend that you start holding on, progressing to



maybe just your fingertips or hands hovering above, not moving on to the next level exercise until you’re confident with your hands hovering above the stable object.

The other thing that I always recommend to my participants in the study, not in the study, in this program is to feel comfortable to try to change your feet. See if you can move your feet to catch your balance versus holding on because we do not walk around with a bar or a chair in front of us to hold on. We walk around on our two feet so try to learn and teach yourself to catch with your feet is much more simple to do than to teach your body to catch with your hands, so I always try to recommend catching yourself with your feet versus grabbing or reaching to hold on.

All of that being said, always do our exercises with something stable in front of you so if you need an immediate assist, you have that to touch down, so those are the basics of just the – that’s the meat of our program, those standing exercises. I hope that I did a good enough job explaining the exercises, so you could get a visual on how they are a little bit more difficult as you progress through the program.

I wanted to briefly just touch on the action level exercises, simply so that you can hear what they are. Our recommendation for the action level exercises is that you



only do them once you’ve mastered the advance level exercises. These action exercises are all movement-based, meaning that they’re dynamic in nature and you do need a stable surface along a wall or a bar, something that you can continually have contact with as you’re moving location.

The first exercise is our sit to stand, and the reason we chose having a sit to stand be in our exercise group is that we really think that having this skillset to sit and stand using your muscles appropriately is such an important functional tool throughout your day. Also, it’s a squat in its own way and it’s a skillset that everyone needs to continue doing for as long as possible, so what our recommendation here is to slide forward in your chair. You lean forward, thinking your nose over your toes, stand all the way up tall and then reverse the process as you sit back down.

Our next action-based exercise is a standing exercise. It’s called arm swing with opposite leg swing movement, quite a confusing title but I promise the picture in the instructions clarify it. What it looks like is that you have one balanced leg. Let’s say your right leg is your balance leg. That leg stays flat on the ground. Your left leg swings in front of your body, slowly out to the side and slowly behind your body and it continues that motion, swinging in front and swinging behind. At the same time, your



opposite arm, in this case your left arm, is doing that motion in reverse so when your leg is in front, your arm is behind and vice versa.

What this motion is doing is constantly changing where your center of gravity needs to be to hold yourself upright. Your balance leg or your right leg is holding yourself stable the whole time, constantly adapting to that gravity shift. The next action exercise is a heel to toe walk so we took that heel to toe stance from our advanced level exercise and turned it into a dynamic exercise. This is the exercise that you see when you watch gymnasts on a balance beam doing. They’re walking on that, I think it’s four inches maybe three inches thick beam, walking heel to toe, straight in line with each other. If you’ve never tried doing this exercise, I highly encourage it. It’s a tough one to do, especially when you have any type of distractions along the way.

The next exercise is an exaggerated walking step so if you think about when you walk, the way that we’re designed to walk is to step forward and strike with our heel, roll on to your toe and push off from your toe. That’s the way that our muscles are designed.

What we see with working with older adults is that that changes with time, mostly associated with muscle atrophy and with a fear of falling, so we took this as a [inaudible



0:43:50] time to really focus on the exaggerated steps in your walking gait, so this one looks like you take your right knee and you lift it straight up into a marching position, straightening your heel out or your leg out, landing on your heel, shifting your weight forward to that right leg going on to your left toe, pushing off from the ground with your left toe, swinging your left knee up, left leg straight, left heel down, continuing this process.

With this exercise, the slower you do it the more you exaggerate the exercise motions, the more difficult it becomes and then the last level of exercise or the last exercise in our action is the grapevine. You may also know this as the karaoke. If you were ever an athlete in high school or in college or anything like that, you probably had to do the grapevine at some point in your life.

This motion is a side to side motion so you would step with one foot. Your back leg would step in front, step even. Your back leg would step back, step even, step in front, step, step back, step and what that is doing is just like that swing is changing your center of gravity to be forward to back, so we use all of these action exercises to try to incorporate our balance principles along the way, focusing now though on your coordination and your ability to hold balance in a slow motion.



The slower you do all of these, the more challenging they become because the less time your muscles have to swing out of it or to catch your balance by moving somewhere else, so that’s why the slower you do it the harder it is. You have to hold your balance for a longer amount of time so those are the exercises. That’s the bread and butter of the program.

We have the manual developed in a way that you are able to just take it and run. Some of the things that I like to talk about beforehand is just to give some general instructions, and we do have that and I want to just talk about that really briefly, just so you can get a little more of a feel for what it looks like so our instructions for participants are to always start with the beginner level exercises, regardless of where your balance ability is. If you can do the exercises in the beginner level easily with no problems, of course progress on but it’s always easier to start small and build up than to start too big and feel discouraged so you don’t want to continue.

We always review the hand positions because those are such an important tool for thinking about your balance. It’s important to emphasis that not holding on is the best way and really the only way to improve your standing stability for your legs. I mentioned earlier that we recommend holding the position for five seconds, building up to thirty seconds. If you can do any exercise for thirty seconds



without holding on, it’s too easy and you need to change something.

I always like to spend time talking about body sway. If you’ve ever done a standing stability exercise or maybe while I’ve talked to you, you’ve tried a couple out, you may have noticed that your body, it moves. It might shift side to side, back to back, that swaying motion. If you’ve ever been on a boat, you’ve probably felt that as well. When you’re doing balancing exercises and balance-specific exercises like these, I look for body sway. If I see somebody standing and not moving a little bit, I try to make it harder, so they do have that little bit of movement.

That movement is really important for your muscles to learn how to stand upright, and when there is that little bit of sway, it’s your muscles talking to each other and your balance improving. That being said, if it was a big side to side motion, if it was something you weren’t comfortable doing, that’s when you need to adapt the exercise to make it a little bit easier so you can feel confident.

Our recommendation is that the exercises are done three to four days a week, and I’ve never tested it out in its entirety, all five exercises for 30 seconds with the appropriate level rest time, but our guess, I’m pretty close to that, is around 15 minutes is what it would take but what we say is that it doesn’t matter when you do them and how



you do them or even where you do them, as long as you do them so maybe it’s during your favorite TV program at night, during the commercials. You get up. You do an exercise for a commercial. You do another exercise for another commercial, and then you get a glass of water and do the same thing on the next commercial, or we’ve even had people start doing them when they’re standing in line at the grocery store.

They stand with their feet together or they stand with a foot in front of each other, just trying to build in the exercises in your everyday life. I know that I’ve noticed myself, when I’m talking in front of a group of people and I’m standing, I’m constantly bringing my feet close together or standing in a staggered stance to try to challenge my own balance as I go with that, so really you can do these exercises anytime and the next piece that I wanted to review is when we make the recommendations to increase the level of exercises.

At the end of every level, we have what we call the stop page and the stop page is really just a checklist of things to complete before you move on to the next level exercises, so what the stop page instructions say is that think about these three statements before moving on to the next level for each exercise, so these three statements are: I can confidently perform these exercises. I can perform these exercises for 30 seconds. I can perform



these exercises without holding on. If you can say yes to all three of those, we recommend it’s time to move on to the next level of exercises.

In our manual we do offer a tracking sheet to keep track of how long you’re doing the exercises. What hand position you’re using and which exercises you’re actually doing. I found, being an exercise scientist, that you do better when you have a checklist or something to keep track of things so we try to provide that as a tool. We also have a support system identifier or a support identifier tool in our manual to give people an opportunity to identify who’s somebody in their life that can be a support system for them. It can be anybody really. It can be a friend, family, spouse, someone just to say, “Hey, Ann, did you do your exercises today?” Someone to keep you on track with those things.

Again, it’s been proven over time that if you have somebody that you have to report you, you tend to do them a little bit more, so those are all of the different tools that we just add in so people can have this program be as successful as possible. I see a couple questions or one question. This program is available. We have the manual and we aren’t afraid to send it out to you if you are interested in learning more about it and seeing the program itself.



I do want to talk a little bit specifically about vision and its role in balance, and you’re all the experts on that and I’m sure you know much more than I do, but one of the things that we use in our exercises and in our program is vision and how important it is with your balance so with our research, we were really able to focus on it didn’t matter what your vision was like, whether you couldn’t see much. You had the shadows or you could see lights or couldn’t see at all. The idea of having your eyes closed changes everything and that’s actually one of challenges with the exercises, is that if you were feeling confident doing them, trying to do them with your eyes closed and noticing how big of a difference that that makes.

I also try to use a tool or use the suggestion of using a visual reference, something at eye level, straight in front of you and focusing on that and seeing how that can help improve your balance as well. When you close your eyes, you lose that visual reference so your periphery and all those visual cues that your body is picking up on and that you’re stable are taken away, so you naturally just feel more unstable and you’re working those proprioceptors a lot more than you were before you closed your eyes, so your vision really does play such a huge role in your balance and it’s been a blessing that I’ve been able to work with so many wonderful professionals on vision rehabilitation, and how to make this program accessible



for them and continue to develop the program to be the best that it can be.

A new question. Is it available online? What we have right now is that we do have it printed, so we can mail it to you. That would be the best way or just get the exercises and [bridge 0:54:07] it in our minds. I would say that if you were interested in talking, we do have the audio version. My preferred version is the large print abridged. We cut out all the wordy stuff. It’s just the instruction and the picture and that tends to be the best tool.

I am working with the Division for the Blind and Visually Impaired for the Maine’s Department of Labor, and the woman that I’m working with has given this abridged large print out to a lot of her clients and they’ve had huge success with the large print, using it under their different devices, so they’ve found that it was large enough for them to feel successful. The audio version itself, I’m thinking we’re ready for it to be revamped, done a little bit more accessible and you asked about a DVD as well. We are hoping to make a DVD version. That’s my dream world.

We’re actually meeting tomorrow with the Maine Alzheimer’s Association and looking to see if we can put together a train to trainer on Balancing Act and a DVD would certainly be part of that, so my fingers are crossed



that a DVD is not too far away. I’m going to log out, Ed to see if there’s any more questions from anybody in the group.

Caller #1Do you perhaps anticipate a PDF version or something that we might be able to read on the computer?

AnnSo I’ll answer the PDF and the braille. I don’t have the authority, [laughs] as silly as that sounds, to send out the PDF without contacting my boss first. I know that we’re usually very open to sending out a Do Not Copy version. Our main concern is simply just that we are getting credit for the program. We want to get it into as many people’s hands as possible, and one thing I should have already mentioned to you is that this is really a working manual and we love suggestions and recommendations on how to continue to improve the program to make it more accessible for other people.

The braille version, that is actually in the hands of the Iris Network. We did not have any participants in our study that were interested in using the braille version, so besides our initial field tests which simply just looked at that she could read and understand the words that we were saying, it hasn’t been tested outside of that. If you were interested in having that braille version, I’m sure I could track down a



copy and share that with you. I’m interested in how they have the descriptions for the audio versions.

I would love your help on that, Mel and I’m going to share my contact information in a second and please feel free to contact me, and we can move forward with the best ways for making our audio versions. Are there any more questions before I move forward?

MelHi, Ann. This is Mel. I do have your contact and I am super interested in talking with you. I love the exercises. I think I can help out and I think our community would really, really benefit from an excellently produced audio for –

AnnMel, I 100% agree with you on that. I would love to get some good audio, and I know I need a lot of help with that so that’s all I have and I don’t know if there’s more questions coming in, so I’m going to log out just in case and if not, Ed, I’ll give you – how do I order the – oh, I didn’t give my contact. I was so excited about everything else.

The best way to order the manual or to receive more information would be to contact me directly, and I will go slow and repeat it a couple times here. I’m giving you an opportunity to get a pen and paper or write it down. My



contact information, my email is A-C-O-W-L-E-S, the number 1, at une.edu. Again, my email is A-C-O-W-L-E-S, the number 1, at une.edu. My telephone number is 207-602-2199. Again, my phone, 207-602-2199.

If you contact me, I can help you order the large print or the regular manual or answer any more specific questions about our program. Thank you, Lisa. [laughs] I guess I could have done that. That would have been a lot easier. Anything else?

EdWell, Ann, I got to say that was a fantastic presentation, and I probably burned more calories moderating this webinar than I ever have moderating any webinar. I think you did a fantastic job of verbally describing the various exercises. I’m sure the manual’s fantastic. I’m definitely going to be giving you a call and asking for one so thank you. Thank you so very much.

I just have a few comments, closing comments for folks. This seminar recording is going to be archived on the Low Vision Focus website at www.lowvisionfocus.org, as well as the Hadley Institute website, www.hadley.edu and for folks of you who are used to these webinars, you know that they are available 24/7. You also may know that each of our seminars are now available as a podcast, and you can download and listen to those on your computer or


http://www.hadley.edu/

http://www.lowvisionfocus.org/


mobile device and for those of you on Twitter, Hadley’s Twitter hashtag is Seminars@Hadley.

I really want to thank everyone for participating today. I know you enjoyed it. I sure did. We do value your feedback so please as I said before, let us know what you thought of this seminar, and also we’d love to hear suggestions for future seminar topics and you can just send an email to [email protected]. I’m now just going to hand the microphone back briefly to Ann for a final farewell and thank you so much. It was fantastic.

AnnThank you so much, Ed. This was a lot of fun, a different experience for me, and I hope that you were able to at least get a visual with the exercises themselves. I am very passionate about the field of older adults and working with people to help improve their quality of life, so thank you so much for listening to me and following along with our program. I welcome any future contact on how we can work together and continue to change the world one day at a time. Thank you.

EdGreat, great. Thank you so much and everyone, thanks for attending today’s seminar.


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