Balance exercises for the elderly

Balance exercises for the elderly help preserve health and mobility as we age and are an essential area of focus for healthcare providers. Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States.

Summary

The U.S. Preventive Services Task Force confirms that exercise interventions offer a moderate net benefit in preventing falls among older adults, especially those at increased risk.
A comprehensive assessment should guide a personalized plan of care that includes static, dynamic, and strength-based balance exercises tailored to each person’s capabilities and goals.
Strong hips, knees, ankles, and effective stepping reactions are essential for maintaining balance. Incorporating strength and endurance training is key to improving these components.
Therapists must ensure exercises are challenging but safe, explain the purpose of each activity clearly to improve engagement, and use outcome measures (like TUG or the ABC scale) to monitor fall risk and progress.
Leveraging an EHR like TheraPlatform can help therapists easily access and manage their interventions.

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Most community-dwelling adults 65 and older reported at least one fall in 2018, and 10.2% reported a fall-related injury. Even more concerning, an estimated 38,742 fall-related deaths occurred in 2021.

Impairments in many body systems can contribute to fall risk in addition to environmental and medical factors like living in a home with stairs or taking certain medications. Physical therapists can identify adults at risk for falls and intervene to prevent those falls.

In 2024, the United States Preventative Task Force published a recommendation for fall prevention in community-dwelling older adults. They concluded confidently that "exercise interventions provide a moderate net benefit in preventing falls and fall-related morbidity in older adults at increased risk for falls."

Both supervised physical therapy and group exercise classes can reduce an individual's fall risk, and a comprehensive balance and physical assessment should guide the individualization of a fall-prevention plan of care.

Aerobic training, balance training, strength training, stretching, and even manual therapy interventions all have a role to play in reducing one's fall risk. Still, this blog will focus on exercises that target balance.

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Strengthening exercises for the elderly

Effective hip, knee, ankle, and stepping reactions rely on sufficient muscle performance. Strength, endurance, and power training of muscles are essential in these balance reactions, as they increase the likelihood of an effective balance reaction. Below are some intervention ideas to target these muscle groups.

Ankle Muscles	Proximal Hip Musculature	Strength Exercises with a Balance Component
Heel raises–double or single	Banded side-stepping	Step up with opposite knee raise
Heel walking	Side-lying hip abductions	Lunge
Toe raises	Clamshells	BOSU lunge
Single and double-leg hopping	Monster walks	BOSU squat
Band-resisted ankle 4-way	Sit to stands	Single leg RDL
	Squats
	Deadlifts
	Step-ups

Static balance exercise for the elderly

When your center of mass stays within your base of support, or your base of support is unmoving, a balance exercise is considered static. Static balance exercises are often easier than dynamic balance exercises, but certain groups of people, like those with neuropathy, may find standing still very challenging.

Below are some ideas for static balance exercises and suggestions for changing the focus of the exercise and increasing or regressing its challenge:

Seated without back support
Tall kneel
Half kneel
Quadruped
Feet together/Romberg
Semi-tandem
Tandem/sharpened Romberg
Single leg stance
One foot elevated on a higher surface
Slip and trip training
Tipping birds

Easier version of static balance exercises for the elderly

Firm surface with eyes open (allows for maximal weighting of visual, vestibular, and somatosensory components of balance)
Fingertip support (allows for maximization of somatosensory input)

More difficult version of static balance exercises for the elderly

Firm ground, eyes closed (challenges those with a visual reliance for balance; increases the weighting of somatosensory and vestibular systems)
Foam or unstable surface (increases reliance on the vestibular and visual system)
Foam or unstable surface with eyes closed or head turns (increases the weighting of the vestibular system)
Add a secondary task like catching a ball, counting, or naming items (dual tasking, divided attention for increasing transition of skills to procedural memory)
Reaching outside the base of support

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Dynamic balance exercises for the elderly

Dynamic balance exercises for the elderly improve balance during walking and other mobility tasks. The sky's the limit when developing these exercises. You can use the suggestions above to make these exercises easier or harder.

Sample balance exercises for the elderly

Heel-toe walking
Balance beams
Walking with head turns
Backwards walking
Sideways stepping
Braiding
Walking with changes in direction
Walking on foam, grass, gravel, cobble foam, or river stones
Stepping over obstacles
Perturbation training while walking
Carrying items or performing a cognitive task while doing one of the above
Practicing walking with a less supportive assistive device
Transfers between surfaces

Tips for recommending balance exercises for the elderly

Balance exercises for the elderly fall within the category of neuromuscular re-education, and most therapists believe that more is better. Unlike strength- or power-focused interventions that can quickly reach an over-training effect, many repetitions of balance exercises drive changes in motor control, proprioception, sensory system weighting, and balance confidence, which is needed to reduce fall risk.

It is possible to overdose on a balance exercise or miss the mark when matching an exercise with a patient. Use the following tips to help improve the effectiveness of your balance program prescription:

Safety, safety, safety: There is always a risk of falls when training balance, but we can minimize that risk through appropriate exercise prescription, guarding, and patient education.
Use gait belts or supports as needed in the clinic to reduce falls: Teach the family to guard patients at home if appropriate, and educate them on where and how to perform their HEP at home to minimize this risk.
Quality matters: An exercise that is too easy won't lead to better balance, but an exercise that is too hard might worsen a patient's confidence and reinforce maladaptive patterns, such as holding onto a counter rather than practicing their ankle strategy. Finding the "just right challenge" is a skill but an important one to develop.
Muscle performance matters: Muscles that are weak or lack endurance may be the limiting factor in dosing for balance exercises. Patients may not be able to practice as much as they would like until their muscle performance improves.
Striking salience: Balance exercises can seem silly to patients, and they may not understand how standing with their eyes closed and turning their heads will improve their balance when they wash their hair in the shower.

Take time to connect the specific benefits of your chosen exercise to the patient's needs and goals. Not only does this help with patient buy-in, but it also ensures that you select individualized exercises for your patient.

Fall prevention remains a priority in physical therapy. If you feel limited in your toolbox of balance exercises, consider taking a continuing education course to expand your knowledge.

A quick outcome measure like a Timed Up and Go or an Activities Specific Balance Confidence Scale can identify potential fallers amongst patients not seeking physical therapy specifically for balance and falls.

Your diligence in screening these patients can help them stay safe and healthy in the long run. As a profession, we can positively impact the fall-related injury statistics in this population.

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References

US Preventive Services Task Force. Interventions to Prevent Falls in Community-Dwelling Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2024;332(1):51–57. doi:10.1001/jama.2024.8481

Timed up and go. (2013, November 6). Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/timed-and-go

Activities-Specific Balance Confidence scale. (2024, August 15). Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-measures/activities-specific-balance-confidence-scale

FAQs about balance exercises for the elderly

How often should elderly patients perform balance exercises?

Most older adults benefit from balance exercises at least 2–3 times per week, with frequency adjusted based on safety, fatigue, and individual risk factors.

Are balance exercises safe for older adults at high fall risk?

Yes, when properly prescribed and supervised. Therapists should ensure appropriate difficulty, use guarding strategies, and educate patients and caregivers on safe home practice.

What outcome measures can track balance progress in older adults?

Common tools include the Timed Up and Go (TUG), Activities-Specific Balance Confidence (ABC) Scale, Berg Balance Scale, and Functional Gait Assessment.