The ability to stand and walk, often taken for granted, is necessary for full independence in daily activities and integration in society. Balance and mobility often decline with aging, and specific diseases also lead to deficits. The contracted living space, need for care, falls, and injuries that result from this decline are important sources of illness in older persons, are costly to society, and are important determinants of caregiver burden and even the need for nursing home placement.
Normal walking involves propelling one's body forward as one's feet catch up and prevent a fall. Walking is, therefore, inherently unstable. A foot strikes heel-first, then rocks forward, with the toe the last part to leave the ground. Gait is divided into a stance phase, when both feet are on the ground, and a swing phase, when one foot is off the ground. Stride length is the distance from the heel strike of a particular foot to the next heel strike of that foot.
Investigation of aging-related changes in mobility was largely initiated in the late 1960s by Dr. Patricia Murray, a kinesiologist at the Medical School of Wisconsin. She found that older adults had slower walking speeds, shorter stride lengths, longer stance phases, and less foot clearance off the ground. Older adults also have less arm swing and a trunk that is bent slightly forward. Figure 1 displays these differences. Some investigators have found that older adults have an irregular cadence (step frequency).
Balance requires contributions from several systems: motor, sensory, and cognitive. Muscles, typically lower limb or hip, contract to maintain balance. Older adults may have weaker muscles, delayed reaction times, coactivation (so that muscles with opposite actions contract together, thereby stiffening a joint), and disorganized muscle contraction (so that muscle groups are not working together). The sensory system is also important. Vision, the vestibular system of the inner ear, and proprioceptive nerves (those which detect the position of joints and muscles) are all important in balance, and can all become less functional with age. Cognition also contributes, because attention, which can decline with age, is important in maintaining balance. The balance system is redundant, in that deficits in one system can be compensated for by the other systems. The changes mentioned above can occur with aging and also with specific diseases.
Transfers must also be considered. "Transferring" is the term used for moving from one condition to another, such as out of a bathtub, chair, or car, or getting into bed. The ability to transfer depends on many factors, including strength, balance, vision, and flexibility. The characteristics of the transfer surface and the presence or absence of adaptive aids can have an impact on transfer ability.
These changes with aging are averages, and not all older adults age at the same rate. A group of eighty-year-olds will have a much wider range of abilities than a group of twenty-year-olds. Some of the eighty-year-olds will have abilities that are indistinguishable from those of the average twenty-year-old, while others will be totally dependent. Heterogeneity of abilities is a characteristic of older age.
Mobility also requires energy, and so blood circulation and oxygenation must be adequate to meet the body's needs. Any impairment in heart, lung, or blood vessel function will impair mobility.
The effects of mobility deficits associated with aging or disease can often be minimized through the use of walking aids, such as canes or walkers. These aids are just that — tools that help older adults maintain their independence — though many seniors view them as restrictive signs of aging and are reluctant to use them. Similarly, a wheelchair can provide freedom and independence to someone who might otherwise be bedbound or housebound.
The role of the environment in mobility should not be forgotten. For example, it is more difficult to get out of a very low chair or one without arms. A very soft bed makes it harder to roll over. Given the multiple components of balance, a darkened room will have a negative impact.
The clinical assessment of mobility
During the clinical assessment of balance and mobility it is crucial to actually observe an individual's mobility, to watch him or her get up and walk. Mary Tinetti, a Yale geriatrician, demonstrated that a standard neurological examination — of power, reflexes, sensation, and tone — less effectively identified impaired balance and mobility when compared with examination of actual standing and walking performance.
The assessment of balance and mobility can be facilitated by use of the principle of hierarchy. Someone who can perform a difficult task, such as climbing stairs, can be assumed to be able to safely perform simple tasks, such as getting out of a chair. Of course, an individual's abilities do not always strictly follow the hierarchy, but the principle holds in most situations.
A typical assessment of balance and mobility starts with the person in bed. He or she is watched rolling over, sitting up, getting out of bed, walking, and sitting down in a chair — and sometimes also watched turning, standing still, standing still under more challenging conditions (with eyes closed, withstanding a nudge, reaching forward), and climbing stairs. Use of the usual walking aid is permitted. Using the principle of hierarchy, an individual who is known to be able to perform at a high level, for example, walking, is observed performing only more challenging tasks, such as climbing stairs, not simple tasks like rolling over in bed. Formal balance and mobility tests are sometimes used; these are described in the review by MacKnight and Rockwood (1995a).
The balance and mobility assessment has implications for a patient's treatment and care needs. Any deficits in balance or mobility will have an important impact on an older adult's daily life. All of the basic and instrumental activities of daily living depend, to some extent, on independence in balance and mobility. For example, a patient who cannot roll over in bed will need to be turned every few hours to prevent pressure sores; one who can transfer and walk, but not stand safely for any length of time, will need to have the home modified so that tasks such as cleaning oneself and cooking can be done seated. Physiotherapy, occupational therapy, and other interventions can be directed to specific deficits.
A number of common patterns of gait abnormalities are seen in older adults:
- Nonspecific gait abnormality of aging; also sometimes disparagingly called the senile gait. People who exhibit this gait have some features of parkinsonism, with flexion at the hip and knees, forward trunk flexion, decreased arm swing, narrow stance, tendency to shuffle, and decreased gait velocity. Many older adults exhibit some features of this gait.
- Deconditioned gait, which is caused by disuse. Patients with this gait have most of the features of the nonspecific gait abnormality of aging. They also have weak muscles, particularly hip flexors (the muscles used to bend the hip). Scissoring is often present during walking, with one foot straying into the path of the other, leading to decreased walking balance. Step length, path, and frequency are very irregular. The deconditioned gait may also be related to sarcopenia, a significant loss of muscle mass that may be associated with aging.
- Hemiplegic gait is caused by a stroke. A stroke leads to weakness and spasticity (increased tone, particularly when the muscles are stretched). The classic hemiplegic gait involves an arm flexed at the elbow and held close to the body, with the leg on the same side held in a straight, stiff position and moved forward in a circular pattern (circumduction). Depending on the severity and extent of the stroke, these arm and leg conditions may or may not be present to varying degrees.
- Antalgic, or painful, gait is the limping gait. In older adults it is often due to osteoarthritis of the knee or hip. Treatment involves using a walking aid to shift the body's weight off the affected limb, pain control, weight loss, exercise to strengthen surrounding muscle, and sometimes replacing the affected joint with an artificial one.
- Parkinsonian gait is most commonly caused by Parkinson's disease, although other conditions, such as late Alzheimer's disease or side effects of drugs such as antipsychotics, can sometimes cause this gait abnormality. It is characterized by a narrow stance with short shuffling steps, the body stooped forward with knees and hips bent slightly, and a tremor in both hands, which are held at the sides. It is often difficult for the patient to start walking and, once started, it is often difficult to stop. This is known as festination. Some patients need to run into a wall or other obstacle in order to stop.
- Gait apraxia is the inability to carry out the previously learned motor activity of walking, despite normal strength, sensation, and joints. These patients often have difficulty initiating gait, taking broad-based, irregular steps. Gait apraxia is often due to cerebrovascular disease in the deep white matter of the brain.
- Fear of falling, although not strictly a gait disorder, is experienced by many patients who have had an important fall or other fright, such as getting stuck in the bathtub. They develop a significant fear of falling that then limits their mobility (and can lead to deconditioning). These patients often stay close to furniture and walls, take short, tentative steps, and prefer to walk with the support of another.
Frailty and atypical illness presentations
Falls are common in older adults; approximately 50 percent of community-dwelling seniors fall each year, and 10 percent of these suffer an important injury, such as a fracture, bleeding around the brain (subdural hematoma), or skin laceration. Falls and immobility are rarely caused by a single deficit, but rather the interaction of multiple acute and chronic abnormalities. A common mistake in the care of older adults is to search for the cause of a fall, rather than addressing the multiple deficits. The presence of a stroke, orthostatic hypotension (one's blood pressure falls when one stands up), or weakness of a particular muscle group, for example, would be an unusual cause of a fall without other predisposing factors.
Falls and immobility in older adults are generally manifestations of frailty. Frailty can be thought of as the interaction among many strengths and weaknesses of an individual, giving rise to current abilities and vulnerability to further loss. Many of these weaknesses may not be detrimental by themselves, and not readily apparent — what Dr. Linda Fried calls "subclinical disability" — but when they are mixed together, they are important. For example, mild and individually unimportant impairments in vision, strength, proprioception, and reaction time can combine together to produce frequent falls.
If such an individual develops a urinary tract infection, which is relatively harmless in healthy adults, he or she may find the mobility deficit greatly exacerbated. This phenomenon of atypical illness presentations leads to the common illness behavior in older adults of "taking to bed." A senior who exhibits a change in mobility most certainly has a new illness, though not necessarily one involving the neuromuscular system. These atypical illness presentations involve symptoms and signs not expected on the basis of the underlying disease. For example, a patient with pneumonia would be expected to present with cough, fever, and shortness of breath, and to have abnormal findings on examination of the lungs. A frail older adult will commonly present with delirium, functional decline, falls, or other atypical presentations, without necessarily having symptoms or signs associated with the lungs. The atypical illness presentations are also known as "Geriatric Giants," a term coined by the British geriatrician Bernard Isaacs.
The treatment of immobility and falls involves addressing both the new problem (if one is present) and the frailty. This requires a multifactorial approach.
M. E. Tinetti demonstrated that a multidisciplinary team — a nurse addressing potentially harmful medications and orthostatic hypotension, a physiotherapist supervising exercise, and an occupational therapist making the home safer — reduced the incidence of falls in community-dwelling seniors. An approach aimed at a single component of the problem, such as weakness only, will likely prove unsuccessful.
See also Arthritis; Balance, Sense of; Disease Presentation; Dizziness; Frailty; Hip Fracture; Parkinsonism; Stroke; Walking Aids.
Bronstein, A. M.; Brandt, T.; and Woollacott, M. Clinical Disorders of Balance, Posture, and Gait. London: Arnold, 1996.
Fried, L. P.; Herdman, S. J.; Kuhn, K. E.; Rubin, G.; and Turano, K. "Preclinical Disability: Hypotheses About the Bottom of the Iceberg." Journal of Aging and Health 3 (1991): 285 – 300.
Guralnik, J. M.; Ferrucci, L.; Simonsick, E. M.; Salive, M. E.; and Wallace, R. B. "Lower-Extremity Function in Persons Over the Age of 70 Years as a Predictor of Subsequent Disability." New England Journal of Medicine 332 (1995): 556 – 561.
MacKnight, C. and Rockwood, K. "Assessing Mobility in Elderly People. A Review of Performance-Based Measures of Balance, Gait and Mobility for Bedside Use." Reviews in Clinical Gerontology 5 (1995a): 464 – 486.
MacKnight, C. and Rockwood, K. "A Hierarchical Assessment of Balance and Mobility." Age and Ageing 24 (1995b): 126 – 130.
Tinetti, M. E. and Ginter, S. F. "Identifying Mobility Dysfunctions in Elderly Patients: Standard Neuromuscular Examination or Direct Assessment?" Journal of the American Medical Association 259 (1988): 1190 – 1193.
Tinetti, M. E.; Baker, D. I.; McAvay, G.; Claus, E. B.; Garrett, P.; Gottschalk, M.; Koch, M. L.; Trainor, K.; and Horwitz, R. I. "A Multifactorial Intervention to Reduce the Risk of Falling Among Elderly People Living in the Community." New England Journal of Medicine 331 (1994): 821 – 827.
Tinetti, M. E.; Inouye, S. K.; Gill, T. H.; and Doucette, J. T. "Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes." Journal of the American Medical Association 273 (1995): 1348 – 1353.
The Oxford Companion to the Body
balance or equilibrium , is a state in which opposing tendencies are equal. To balance an object means to position it with its centre of gravity above its supports in such a way that there is no tendency for it to topple over to one side rather than to another. Toppling is not the same as falling. It is the toppling motion that gives rise to the ‘sensation of loss of balance’ and one feels ‘balanced’ when such sensations do not occur. We say that someone has a ‘good sense of balance’ when they appear able to move freely in all sorts of circumstances without obvious signs of accidental toppling. An object topples when the resultant of the stress forces acting on it does not pass through its centre of gravity (c of g). Stress forces are the forces of common experience—pushing and pulling—which are always associated with deformation of the molecular architecture of objects in contact. Gravity, on the other hand, is something quite different. It is the force to which Newton attributed the observed accelerations of objects in free fall. It acts at a distance, without contact. It is not gravity that breaks an egg when you drop it, but the stress forces on impact. The egg remains perfectly intact while it is in free fall under the action of gravity. An object can be prevented from falling if it is supported by stress forces exerted at contact with other objects, which are themselves supported in turn on the solid crust of the planet.
An object is said to be in ‘stable equilibrium’ if any small perturbation generates a force to oppose the displacement. This will be the case if the projection of the c of g falls within an ‘area of support’, defined as that polygon, with no re-entrant angles, that just encloses the projections of all the available points of support. Balance is maintained by moving the resultant of the supporting forces about in such a way as to resist perturbations. A piece of furniture, such as a table standing on its legs, is stable because, if any attempt is made to tilt it, the support thrusts in the legs alter and their resultant consequently shifts to resist the tilting. If you stand on one leg and pay attention to your standing foot, you will be able to feel changes in the foot as muscular forces alter the position of the thrust exerted between the foot and the ground to compensate for and resist the inevitable swaying arising from movements of the heart and chest.
Role of proprioception
sensory receptors of several kinds are involved in the complex process of maintaining uprightness, as well as in the recognition of the imminence of toppling. There are no ‘gravity receptors’ as such, in spite of what is generally believed. The parts of the inner ear commonly associated with this function turn out to be accelerometers; i.e. they are detectors of stress gradient, not of gravity. Proprioceptors elsewhere in the body can also act as accelerometers and thus make a contribution to indicating the direction of the resultant support thrust. The actual position of the thrust line is indicated by deformation of the soft tissues of the feet and hands at the areas of contact with the supports. Movements of the head during overbalancing are indicated by the streaming of details in the images of the environment on the peripheral retina.
Restricting the area of support diminishes the available range through which the support thrust can be moved to resist perturbations, unless the position of the support is itself appropriately moved by the perturbation. When an egg is placed on a hard surface, the area of support is restricted to the very small area of contact. It is, accordingly, very hard to balance an egg on one end, because any accidental tilting produces more movement of the c of g than of the point of support, the centre of curvature of the shell at the ends being below the c of g of the egg. The shift of the thrust line, which necessarily passes through the area of support, is thus not sufficient to correct the tilt. With the egg on its side, however, a brief push in the direction of the long axis of the egg produces temporary rocking, followed by a return to the original position. The centre of curvature in the plane of the long axis is above the c of g, so the shift of the thrust line exceeds that of the c of g. For a sideways perturbation, the centre of curvature is coincident with the c of g, and the egg just rolls away from the perturbation, with the thrust line continuing to pass through the c of g. This is what happens to a wheel: the balance is neither stable nor unstable.
If the body of an animal or of a person is to stay in more or less the same place, any accidental displacement in a particular direction will have to be corrected by a corresponding displacement in the opposite direction. This is achieved by adjusting, by muscular forces, the thrust forces exerted by the limbs against the supports — in magnitude, in direction, in timing, and in point of application.
Anticipatory pre-emptive actions
A number of reflex reactions have been identified that produce the appropriate changes in the musculature, by swaying, hopping, and stepping. In the intact subject, however, many of these reflexes are effectively replaced by ‘anticipatory pre-emptive actions’. These are voluntary actions, based on the underlying reflexes, but initiated in response to the detection that the incoming sensory information is changing in a way that might lead to a need for corrective action. Appropriate action is initiated early, before the reflex responses themselves are triggered into action. Frequent rehearsal, from a very early age, leads to these voluntary actions being performed without the subject being aware of what is going on—that is to say, they become habits. Their promptness plays an important role in maintaining smoothness of control, since they are not subject to the delays inevitable in reflex responses.
The erect posture of man, particularly when standing on one leg, is a condition of precarious equilibrium, because the area of support is small compared with the height of the c of g above the feet. The strategies for avoiding falling over are related to what happens to an egg placed on its side. Small perturbations are met by shifting the centre of pressure at the foot and thus developing an inclined thrust to oppose the perturbation, as in the egg displaced in the direction of its long axis. This strategy will fail when the thrust line reaches the edge of the area of support, because further displacement will cause the body to topple. The imminence of such toppling is detected by the proprioceptive system and a different strategy is brought into play. If another limb is available, it will be thrust out in the direction of the impending fall in a ‘rescue reaction’ that attempts to find a firm obstacle against which to develop force and thus to extend the effective area of support. This is the basis of stepping. A succession of steps, in locomotion, brings the legs into action in turn, like the spokes of a wheel, so that the body may be moved through an indefinite distance without falling over—like the egg being rolled sideways. The legs do not provide the same continuous support as a wheel because, when one leg is being swung forward in a step, the body topples forward over the stance leg and acquires some downward momentum. This toppling movement has to be corrected when the swing leg eventually touches down, so this leg then at first gives, to absorb the unwanted momentum, and later straightens again to restore the c of g to its earlier height above the ground. As the body continues to move forward over the new stance foot, that leg extends to provide extra thrust, which propels the body forward into the next step. If this thrust is strong enough, the body can be launched into a free fall phase while the free leg is still swinging. This extends the step length, as in running or jumping.
When an object is at rest on a stationary support, the thrust line is parallel to a radius of the planet, i.e. it lies in the gravitational vertical. Experiments with moving platforms reveal, however, that the direction of the thrust line appropriate to the avoidance of falling over is dependent on the accelerations associated with the movement of the platform. A person standing in a vehicle that is moving in a curved path has to lean inwards, to develop a horizontal component of thrust to accelerate his body into an equally curved path, as well as developing an upward thrust to prevent falling. The best direction for the thrust line is thus not the same as the gravitational vertical.
The thrust developed against the supports, both on moving platforms and on firm ground, is under continuous readjustment by the nervous system to suit the needs of the moment, be it to remain in one place or to move about in locomotion or athletic activity. The successful control of the necessary muscular activity is a matter of skill; the basis of this is first acquired in infancy and it is continually being revised and rehearsed throughout life as different types of activity are undertaken.
T. D. M. Roberts
Roberts, T. D. M. (1995) Understanding Balance. Chapman and Hall, London.