Stand Tall, Don't Fall: Improve Your Strength, Balance and Posture 9780692776766, 0692776761

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ENDORSEMENTS “The best and most successful type of medicine is preventive medicine. This book is about preventive medicine discussing muscle strengthening, balance and fall prevention. Bill Case, PT as one of the premier physical therapists in Houston, TX has truly tapped into a very important problem—Older adult falls. Sherwin Siff, MD Clinical Professor of Orthopedic Surgery: –Baylor College of Medicine in Houston, TX –University of Texas Medical Branch in Galveston,TX “As an ER doctor, I know first firsthand that falls are the #1 cause of deaths in the elderly. This book, Stand Tall, Don’t Fall, and the exercises contained within, will significantly reduce these tragic accidents.” Dr. Geoffrey Varner Harvard School of Public Health Former Medical Director for Washington DC Emergency Medicine Services and author of Home Alive. “Simple, yet incredibly stunning facts to wake up the reader, as well as, to educate us on how we can help our aging parents. A must read for all ages! Bill reminds us what we know we should do to remain healthy and active, but soon forget!” Bravo, Bill, for a very important book. Deborah Artistic Director Rio Grande Valley Ballet Co “Accidents, including falling just don’t happen. Bill Case, PT has provided the reader with revealing information on why older adult falls occur and how to prevent this devastating accident. He converts complex issues affecting posture and shows how to Stand Tall and Don’t Fall!” Dan Steppe Investor Entrepreneur Served - Rice University as Executive Director of the Center for Entrepreneurship and Innvovation Age-Defying Fitness iii

STAND TALL, DON’T FALL Age-Defying Fitness v

STAND TALL, DON’T FALL Improve Your Strength, Balance, Flexibility and Posture BILL CASE, PT Stand Tall, Don’t Fall Bill Case Copyright © 2016 Bill Case All rights reserved. ISBN: 978-0-692-77676-6 No part of this book may be used or reproduced in whole or in part, in any form, whatsoever without express written permission by the publisher. Consult your physician before starting this or any other program. The exercises and information in this book are for general information only and should not be considered a substitute for the advice and information from your healthcare provider. Only your doctor can determine whether this program is appropriate for you. It is recommended to review this book with your family and physician before trying any of these exercises to determine which ones are best for you and your condition. The information in this book does not replace medical advice nor is it the author’s intent to diagnose or prescribe. The information contained herein should be used with the cooperation and advice of your physician toward your mutual quest for good health. To derive the best benefits of this program, do not mix and match the exercises contained herein with recommendations from other programs. It is imperative to carefully read and follow the directions for each exercise as explained herein to avoid injury. The exercises in this book are not for treatment purposes for a particular diagnosis, but as exercises, which have been shown to benefit some patients with various problems, such as with balance, muscle weakness, and inflexibility. As with any new exercise program, you may experience initial soreness which should dissipate in a few days. Consult your physician if the discomfort lasts beyond a reasonable time. The author assumes no responsibility for any damages of any nature associated with the use of any information contained in this book, including, but not limited to, physical, mental, emotional, or financial damages. In addition, the author does not assume responsibility and is not liable for your physician’s advice, recommendations, or prescriptions or a lack thereof. The names and ages in the stories included in this book were changed, leaving the people anonymous for their privacy. TheraBand®, the Color Pyramid Design™, and Associated Colors™ are properties of Performance Health®, and/or its subsidiaries and may be registered in the United States and other countries. Unauthorized use is strictly prohibited. ©2016— Performance Health. All rights reserved. Neither the author nor publisher are affiliated with the product or company. Consult with a physician before using any device and seek professional advice and training in the proper use.

DEDICATION THIS BOOK IS DEDICATED to my father, who inspired me to become a physical therapist when I was as young as 10 years old. He practiced physical therapy for 63 years and recently retired. He

learned the value of empathy, patience, and appreciation for helping others as he began his career treating post-polio patients. He taught me that you have to love people and always keep a drive to help others. He led by example. Early in my teens, I followed him in hospitals and nursing homes to experience how he spent his day. He always said, “You must touch a patient to understand their pain and how to heal them.” I grew up in Texarkana, Texas and have fond memories of being active with family and friends. Many days were filled with water skiing, hunting, fishing, riding horses, or just about any outdoor activity. Over the years, my activities periodically resulted in injuries with medical attention and treatment given from my father. I had an advantage when it came to recovery because Dad was always there to offer the best advice and treatment. By being active, with an assortment of injuries, I learned firsthand the power of early intervention and proper treatment from him. Recently, my father, now 91 years of age, fell and fractured his hip. After surgery, he spent two months in a rehabilitation facility before returning home—now with daily help. He now uses a walker or cane and attributes his successful and speedy recovery to maintaining an active lifestyle. Dad always practiced what he preached to his vii viii Stand Tall, Don’t Fall

patients—the key to the fountain of youth is movement. His philosophy motivates me to keep older adults active, independent, and moving to avoid falls. Bill Case January 2017

ACKNOWLEDGEMENTS I LEARNED early on that true “success in life is giving, not receiving.” With that in mind, I must acknowledge and thank my family – Karen, William, James, Michael and Christopher for their support and sacrifice. A special thanks to Alicia Dunams, founder of Bestseller in a Weekend and The Book Funnel, as well as, Adryenn Ashley founder of Wow! Is Me, Inc., and marketing strategist, for their vision in helping making this book possible.

I also wanted to thank Jimmy Kryzak, professional photographer and model who assisted me in completing this book. I acknowledge and thank models Jeannie Hughes and Susan Dotson who brought life to the exercises. Most importantly, I want to thank my patients, who have inspired me to write this book. Over the years, providing physical therapy to older adults not only confirmed but increased my awareness of the importance of physical activity to avoid preventable falls. This topic, while not glamorous, is crucial to maintaining overall health, the ability to live independently and slow the inevitable weakening of our bodies. My passion is to help older adults become and stay active. My goal is to provide information and tools for older adults, their families and caregivers to improve their quality of life. It is my privilege to have the opportunity to help so many people each day.

TABLE OF CONTENTS Introduction xiii 1. Falls—what you need to know 1 2. Posture is your “image” 11 3. Balance is your base 31 4. Flexibility 53 5. Strengthening 85 6. Nutritional considerations and the family influence 123 7. The fear of falling and next steps 131 Conclusion 143 About the author 145 Product page 147 References 149

INTRODUCTION I HAVE BEEN A physical therapist since 1982 and graduated from the Physical Therapy program at the University of Texas Medical Branch (UTMB) in Galveston, Texas. Over the last 20 years, I have been in private practice in Houston, Texas. As an athlete in high school and college, I learned the value of early treatment intervention for injuries. Initially, my passion was always treating orthopedic and sports injury patients. I started my career working with high school, collegiate, and professional athletes. My post-graduate training resulted in a specialization certificate as a Physical Therapy Specialist. I invented and patented a lower extremity exercise

machine designed to specifically strengthen the rotational components of the knee. I have had the privilege of treating a variety of international athletes over the years and lectured nationally and internationally on orthopedic injuries and rehabilitation. As a sports therapy exercise enthusiast, I co-authored the book, Sports Physical Therapy. Additionally, I have written numerous articles on fitness and healthcare which have appeared in a variety of publications, such as The Physician and Sports Medicine, Self, Men’s Health, Fitness and Prevention magazines. Today, while still treating athletes, I have also adapted my rehabilitation techniques and principles for strength, balance, and flexibility for the older adult population. Just as athletes need to prepare their bodies for competition, older adults also need to prepare themselves for everyday activities. Over the years, I have treated thousands of patients after falls, joint replacements and for painful conditions associated with xiii xiv Stand Tall, Don’t Fall

osteoarthritis. I understand the aches, pains, and concerns of the older adult. Each day, I deliver physical therapy services to older adults, providing functional skills, with the goal of preventing injuries and pains linked with weakness, poor posture and balance, resulting from a sedentary lifestyle. Each day, I observe positive physical changes in older patients when they engage in a regular exercise routine. Older adults are able to stay active and independent, if they know how to improve their health and commit themselves to a daily exercise program. Seniors express that exercising 10 minutes a day, along with a 15–20 minute walk, improve their energy, attitude and posture. I wrote this book to offer advice on how to keep older adults active, independent and avoid preventable falls. Older adults are injured from falls at an alarming rate. The common causes of an older adult falling are muscle weakness, poor posture, and issues with balance. Lack of postural awareness, physical deconditioning, and improper walking are issues that predispose someone to a fall. The good news is these weaknesses are reversible! Having the knowledge and information of how, when, and why older adults fall, that many falls can be prevented, has motivated me to write this book. Most older adults admit they need to be in better shape but do not make the commitment. So, chances are, if you’re reading this book, you or someone you know has been injured in a fall.

It is critical to be educated on older adult falls. The statistics are alarming, and the entire family is ultimately involved in the care, planning, and financial burden associated with such an unfortunate event. Introduction xv

In the past, I founded and co-sponsored a Senior Falls Prevention Day with the city of Houston, bringing awareness to this important issue. This event is held each year on the first day of Fall in September. The occasion is filled with food, dancing, healthcare information, and resources that are available to all senior and family members. * Upcoming Senior Falls Prevention Day information in Houston, Texas can be found on the www.KeepFitandMoving.com website.

Chapter 1 Falls—What You Need to Know What’s in this Chapter? 1. Fal l ing stat ist ics f romt he nat ional council on ag ing (www.ncoa.org) 2. The importance of senior independence 3. Understand an older adult’s mindset 4. Practicing daily postural awareness 5. Don’t let gravity get you down 6. There is no substitute for exercise 7. Why don’t older adults exercise more often? 8. What resources are needed for most exercises? 9. Does exercise improve independence? 10. Preventing falls 1

“To me, if life boils down to one thing, it’s movement. To live is to keep moving.” —Jerry Seinfeld Jane, a 76-year-old cancer survivor patient who had recently lost her husband, came to me for treatment following an auto accident. After suffering a broken leg, her physician released her to me for physical therapy. On her very first day, she stated, “I need to get started with these exercises right away because I do not want to fall.” She understood that life has its disappointments, but discouragement was a choice. Her positive attitude and willingness to do what it takes should motivate us all. *** The best way to stay active and independent is to know the risk factors of falls. Education is the key to prevention…. and falling is preventable. Every 11 seconds, an older adult is treated in the emergency room from a fall. Know the risk factors to prevent a fall: (www.NCOA.org-Falls Prevention) Most falls are the result of several risk factors. The risk factors listed below are assessments to be considered when determining if the older adult is at risk for a fall. 1. Exercise—Develop and commit to an exercise program to improve posture, balance, strength, and flexibility. Exercising is essential to remain independent, active, and fit. 2. Physician visit—A physician can evaluate your risk of falling and refer to appropriate medical professionals.

3. Medication checks—Review medications with your physician or pharmacist for contraindications or side effects that may increase the risk of falling. 4. Vision and hearing exams—Annual vision and hearing examinations will help keep you on your feet. 5. Open family discussions—Discuss with family members and caregivers any safety concerns to prevent a fall. 6. Environmentally safe—Conduct safety checks throughout the home that are potential tripping hazards, e.g. lighting, stairs, cords, pets and loose rugs. Installation of grab bars are essential. FALLING STATISTICS FROM THE NATIONAL COUNCIL ON AGING (WWW.NCOA.ORG) •1 out of 3 seniors, over 65 years of age, fall each year. •Every 11 seconds, an older adult is treated in an emergency room for injuries related to a fall; every 19 minutes, an older adult dies from a fall. •In 2013, the total cost of fall injuries was $34 billion. • Falls are the leading cause of fatal injuries and most common cause of nonfatal trauma-related hospital admissions among older adults. THE IMPORTANCE OF SENIOR INDEPENDENCE Early in life, older adults were taught by their parents how to care for themselves. As life passes, they teach their children how to be functionally independent people. Personal and professional success and achievements in life are the results of independence. Independence and personal responsibility are engrained in adults from adolescence through maturity and are hallmarks of the independence that all older adults relish. When assistance at home for an older adult is necessary, it is important to consider their needs and allow the maximum independence possible, keeping them involved in daily activities and tasks. Active involvement in all daily activities, such as grocery shopping, meal preparation, and household chores is very important. Also, encourage participation in activities with family and friends, such as walks, games, community service, and meal sharing. The best way to stay active and independent is to know the risk factors of falls. Education is the key to prevention…. and falling is preventable. UNDERSTAND AN OLDER ADULT’S MINDSET

One well-known fact is as the older adult ages, they see the world differently. Their world has changed socially, economically, technologically, and even child rearing or parenting. The good news is there are family, friends or neighbors to keep the older adult abreast of all the latest changes, so not to worry. Therefore, the older adult can now put their focus and energy on themselves and become more involved in the family, community and mentorship. This is a perfect opportunity to seek, develop, and enjoy new hobbies, skills, and exercises to keep fit. Some older active adults find the aging process enlightening, while growing physically, mentally, and spiritually. PRACTICING DAILY POSTURAL AWARENESS Many of my patients tell me that they don’t feel their age. Most say they don’t know who is in the mirror because they see an old person. Well, one reason that person looks old is because they are slouching and leaning over. It has been said that we actually feel 20 years younger than we look and our age is just a relative thing. However, when aches and pains of the aging process occur, the image in the mirror may show it. Encouraging older adult patients to stand upright and align their back creates huge results. When standing with an upright posture, older adults not only feel better, but experience improved selfesteem, an increase in energy and confidence with daily activities. DON’T LET GRAVITY GET YOU DOWN Gravity is the one natural force that is not a friend to the older adult. As older adults age, gravity is their greatest adversity to overcome when their posture is in a slouched position. Gravity affects the ability to stand upright, pick up their feet, and can hamper walking when muscles are weak. Understanding that our bodies perform more efficiently when we stand and walk upright are the best ways to overcome the effects of gravity. It is no secret that aging affects the body and preparation is the key to fall prevention. The guidelines included in this book can assist the older adult in becoming proactive with exercise and posture, while managing what is manageable. THERE IS NO SUBSTITUTE FOR EXERCISE Daily exercise provides the proper support and endurance needed to move around each day. Exercising doesn’t require a trip to the gym, buying expensive equipment, or even a lot of time. A proper

exercise program requires a commitment and guide to be used each day. A daily exercise routine provides your body with tools to overcome any physical limitations or challenges. Whether you are exercising to improve strength in your arms, legs, or back or back or just want to improve your posture and cardio fitness, it’s all up to you. Start today, take the first step in improving your overall fitness and quality of life. WHY DON’T OLDER ADULTS EXERCISE MORE OFTEN? The simple answer is procrastination. There is not one living senior alive who can’t benefit from some form of daily exercise. I hear from my patients that they don’t feel good, can’t find the time, or aren’t sure how to do their exercises. I realize there are always situations where it’s just a bad day, but the commitment is the first and most important step. The majority of the older adults I treat are very in tune with their bodies, excited to get started, and motivated to improve. I know that talking, listening, and understanding older adults’ concerns regarding exercising is an important consideration before developing any realistic exercise program. Any family member can take the time to listen, encourage and show compassion before inspiring an older adult to start an exercise program. Don’t make it about the exercise, but stress the importance of improving functional independence. WHAT RESOURCES ARE NEEDED FOR MOST EXERCISES? Exercises can be performed in the home or at the gym. The gym will offer a variety of resources, such as free weights, machines, balance boards, cycles, TheraBands®, and instructors to help. At home, small hand weights or a TheraBand®can be used to provide a light to heavy resistive. The resistive bands can be purchased (online) for resistive training. The majority of exercises to be performed at home can be found in this book and just require time and commitment. It is important for a family member, friend, or trainer to initiate and instruct all new exercises. The most effective plan is a safe and painfree exercise program. That’s why it is important to follow a protocol, which is discussed and reviewed in this book. Start with a few exercises, which you can build on each week. Walking is so important and should be included each day. DOES EXERCISE IMPROVE INDEPENDENCE?

In one word, YES! When older adults exercise to improve their strength, flexibility, balance, and posture, they feel better, have more energy and a positive attitude, and can’t wait to show off how good they look and feel. Exercise at any age improves performance, attitude, self-esteem and reduces fatigue for daily activities. The science is behind the benefits of exercising, and the biggest challenge is getting started. Exercise is the key to reversing poor posture, weakness, and an unstable gait. Staying independent and active is a natural result of exercising. PREVENTING FALLS Falling is not an inevitable part of aging; it is preventable. The fall risk factors (see chapter 1) serve as the initial resource in realizing how falls can be prevented. Most falls occur at home as a result of a slip, trip, stumble, or loss of balance. Postural awareness is one of the most important components in preventing a fall.When an older adult is standing upright and straight, it is easier to pick up their knees when moving around. Picking up their knees will clear their feet and ultimately prevent a trip. Walking the dog with a leash is a huge concern. I have treated many people, including young adults, who have tripped while walking a dog. Be careful to not allow too much or not enough distance with the leash when walking your dog. A leash can wrap around your legs in an instant when your dog chases another dog or bolts away, pulling you down. Always know where your dog is when walking and make sure if he decides to bolt—LET GO OF THE LEASH!

Chapter 2 Posture Is Your “Image” What’s in this Chapter? 1. Why proper posture is important 2. Assessing posture 3. Three easy exercise tips to improve posture during the day 4. Who notices your posture? 5. Simple exercises during the day to improve posture 6. Muscles that help improve posture 7. The pros/cons of maintaining good posture with activities 8. What happens to an aging posture? 9. High heels and heavy bags affect posture 10. Sleeping affects posture 11. Helpful tips for proper posture with daily activities 12. Movement is vital to a healthy posture 13. Do osteoarthritis and osteoporosis affect posture? 14. Devices to assist posture 11

“Good posture can be successfully acquired only when the entire mechanism of the body is under perfect control.” —Joseph Pilates Fred, who is 80 years old, told me following a couple of weeks of physical therapy exercises,“I finally found the secret to easing my low back pain when standing.The secret is tightening my stomach, thighs, and buttocks muscles together.” He explained that he was finally able to stand the entire time at a party without sitting. Yes, it does all come together with practice. *** Your posture speaks volumes on how others perceive you. Whether good or bad, your posture is judged by those whom you come in contact with and may or may not reflect your true self. Posture reflects your state of health, energy level, and self-awareness. Daily steps to prepare for proper postural awareness are as simple as an exercise routine, which will not only help you stand upright but also make you feel, look, and project a positive “IMAGE.” To improve your posture, try using these words, or pillars created from the initials in IMAGE. 1. Independence involves socializing with people in the community and staying active and involved. 2. Mindset is to grow mentally, physically, and spiritually in everyday interactions and tasks. 3. Alignment is your upright standing posture, promoting balance,

confidence, and self-esteem. 4. Gravity is the force to strengthen your posture and balance when standing straight to improve coordination and stability when walking. 5. Exercise improves posture, balance, strength, and flexibility to keep fit and moving. Your “IMAGE” is a culmination of your posture, balance, strength, flexibility, and how others view you. The word “IMAGE” is defined as a mental representation. Your posture is representative of how well you feel, how you take care of yourself, and how you want others to perceive you. Whether an older adult, retiree or professional, your “IMAGE” does define you, especially to those who don’t know you. I suggest that your appearance, image, and the way you carry yourself reflects your age—whether it’s a physical age, mental age, or emotional age. The way you look, stand, walk, and carry yourself can make you look young and confident, energetic, and vibrant or old, tired, in pain or sick. There are men and woman in their 40’s to 50’s who actually look older when they have low energy, a poor posture, and low self-esteem. In contrast, adults in their 60’s or more, can noticeably affect their “IMAGE” with high energy, a positive posture, and a vibrant personality. The five pillars of the word “IMAGE” describe how you can present yourself as positive, active, independent, and confident when interacting with others. This chapter lays the ground work and helps the older adult understand the importance of a positive posture with a commitment to getting fit. The best gift to an older adult is time, attention, and information on staying active and independent with a positive posture while preventing falls. WHY PROPER POSTURE IS IMPORTANT To me, proper posture is truly the fountain of youth.A proper posture not only reveals how you present yourself, but is a core foundation in preventing back, neck, shoulder, hip, knee, and ankle pains. If your posture is slouched or you are in a slumped position for an extended time, the rest of the body will react and compensate for the change. This changed posture will eventually lead to muscle or joint pain and weakness, as well as other posture imbalances which could ultimately lead to a fall.

This chapter will guide with tips, techniques, and exercises on how to find and check proper posture during the day. These are tools to use to remain upright and aligned with daily activities. Just remember, the spine is a well-fitted interlocking machine with muscles, tendons, and ligaments attached, so you can work and play effortlessly.

ASSESSING POSTURE

Forward Posture

Standing forward. Is the head straight and nose in-line with the belly button or tilted to the side? Are the shoulders and hips level, or is

one higher than the other? Are the kneecaps and feet pointing straight? Posture Side View

Sideways standing. Is the head up with the eyes looking forward? Does the bottom of earlobe align with the top of the shoulder? Are the shoulders back and knees straight? THREE EASY EXERCISE TIPS TO IMPROVE POSTURE DURING THE DAY

1 •Stand with head and back against the wall with feet close to the wall

•Hold for 5 seconds

• 2 Step away from the wall, maintaining the wall position.

3 Turn and look into a mirror and SEE what it FEELS like to stand straight. It is that simple to find the best upright posture each day. The daily goal for everyone is to reproduce this position (without using the wall) several times during the day. Think about it, whenever a mirror is passed or a reflection seen, stop and turn to see that your spine image is upright. If not, keep practicing these posture tips until it becomes second nature. Encourage the older adult to watch you and see that you practice what you preach. Food for thought: If your posture is slouched and the hours turn into weeks and weeks turn into months, there is only one end result and that is pain. It is time for a change. Postural awareness helps prevent injuries because when the joints and muscles are balanced, they work more efficiently. Improved stamina, confidence, and physical performance are all achieved with a balanced posture. To me, proper posture is truly the fountain of youth. A proper posture not only reveals how you present yourself, but is a core foundation in preventing back, neck, shoulder, hip, knee, and ankle pains. WHO NOTICES YOUR POSTURE?

Everyone notices your posture. Whether you are an older adult, teen, or professional your posture appearance is the first physical observation people make of you. How many times have you been to a social event or met someone for the first time and they presented themselves with a noticeably poor posture? An upright standing posture reflects a positive attitude, confidence, and high energy. SIMPLE EXERCISES DURING THE DAY TO IMPROVE POSTURE Chin tucks and shoulder pinches are an exercise to keep the head up and shoulders back during the day. Chin Tucks

1. Sit or stand with head/shoulders back 2. Look forward with eyes straight ahead 3. Breathe out and pull chin and shoulders back 4. Hold for 5 seconds and relax 5. Repeat 5 times Chin tucks can easily be performed during the day in a sitting or standing position. Awareness of where the head is in relationship to the rest of the body is extremely important for an upright posture. By practicing this simple exercise, you may eliminate stress, tension,

and poor posture as you conduct your activities during the day, not to mention the fact that you will stand taller and feel better. * Don’t look up or down. Keep eyes forward. If uncomfortable, don’t pull head back as far—stay in the pain-free neck range of motion. Car Tip: When getting in your car: First, put on your seatbelt and then sit up straight in the seat, while pulling chin and shoulders back. Hold for 5 seconds and relax. Adjust the backrest forward to support your upper back as you sit straight. Now, adjust the mirrors to this new posture. When driving, if traffic is hard to find in the mirrors, then you have probably strayed away from the upright posture back to that unhealthy slump. Goal Post Seated

1. Sit upright in a chair with head/shoulders back 2. Breathe out, raise arms overhead, pinching shoulders

3. Hold 5 seconds and relax 4. Repeat 3 times Stretching the neck, arms, and upper back and reaching upward is a good exercise to perform first thing in the morning or after prolonged sitting. Stand Back Extension Stretch

1. Sit upright in a chair with head/shoulders back 2. Stand straight, place hands in small of back 3. Breathe normally, slowly lean back 1–2 inches 4. Hold 10 seconds, slowly return upright 5. Repeat 3 times Standing back extension stretches are beneficial following prolonged periods of sitting. After sitting, when the back is unsupported (no pillow or low back support), a slouched back posture may result.

This poor posture may lead to upper or lower back pain, as well as, rounded shoulders when standing. This simple exercise can be performed to improve your standing posture each time you rise from a chair. Heel and Toe Raises

Heel Raises (commonly known as calf raises)

1. Stand next to a chair with knees and back straight 2. Breathe out and raise your heels up 3. Hold for 5 seconds, slowly lower and relax 4. Repeat 10 times * As the exercise becomes easy, increase the difficulty by not holding onto the chair. Standing Tip: The foot is the first part of the body to hit the ground when walking. Improved walking stability and balance occurs as a result of pushing off with the calf. The calf is also a natural circulation pump for the lower leg to the rest of the body. Furthermore, by simply raising up and down on your toes during the day, you may minimize any light headedness or dizziness when standing. Toe Raises

1. Stand up straight next to a chair 2. Breathe out and raise toes up 3. Hold 5 seconds, slowly lower and relax 4. Repeat 10 times MUSCLES THAT HELP IMPROVE POSTURE There are approximately 640 muscles in the human body that control movement and balance, while maintaining posture. 1. Spinal muscles run up and down the spine from the neck to the tailbone. These muscles help hold the spine upright in extension, keeping you from leaning over when walking or sitting. 2. Abdominals support the front of the trunk, while counteracting the opposite muscles along the back of the spine. 3. Muscles of the shoulder blades (scapular muscles) play an important role in keeping the shoulders back and assisting to maintain an upright posture. 4. Muscles in the back of the neck help hold the head upright. 5. Hip muscles contribute to your posture when standing. These muscles help support the pelvis when standing, turning, and providing stability for side-to-side movements when walking. 6. The leg muscles play a key role in maintaining an upright posture. The thigh muscle assists with stability when walking, getting out of a chair, or going up and down stairs. The calf and ankle muscles control balance when walking, as well as, to counteract instability on uneven surfaces. THE PROS/CONS OF MAINTAINING GOOD POSTURE WITH ACTIVITIES Pros: To protect your back, it is important to bend your knees and keep your back straight when leaning over for housework, yard work, or moving objects. The purpose of bending your knees is to avoid unnecessary stresses to the muscles, joints, and ligaments of your back. Cons: Repeated leaning over activities with poor posture and body mechanics will stress and strain the spine, potentially causing pain and compensatory movements, which may ultimately lead to injury. WHAT HAPPENS TO AN AGING POSTURE? As you age, your posture will take on the form of your ability or inability, to manage what you do and how you do it. Over time, habits of poor posture when walking, standing, and sitting result in weakening and tightening of the muscles in the neck, shoulders, and back.

Strength loss is associated with the aging process but may go unnoticed until normal activities become difficult. Studies have revealed that a muscle’s size can decrease as much as 50% from 20 to 90 years of age. Also, there can be strength losses of about 30% from 50 to 70 years of age. As activities are decreased due to weakness, more weakness will follow, leading to more decreased activities—and can ultimately lead to a fall. Sedentary activity can accelerate muscle weakness and poor posture, whereas exercise can reverse the muscle loss at any age, while improving posture. Flexibility is another deteriorating process with aging that affects posture. Exercises are important to improve muscle fiber flexibility to the legs, hips, back, neck, and shoulders. Loss of flexibility with aging is due to the changing collagen structure found in your body. This fibrous connective tissue that is found in the protein of muscles, bones, tendons, and ligaments becomes less elastic during the aging process, which will affect posture if left alone. A regular exercise routine can improve flexibility at any age. HIGH HEELS AND HEAVY BAGS AFFECT POSTURE • Wearing heels greater than two inches may affect your posture. Heels greater than two inches will place your posture in a forward standing or leaning position. To counteract this forward position, the body will make adjustments in your neck, back, hips, and knees. If there are presently any problems in these areas, your symptoms may be exacerbated, further affecting your posture. If high heels are a must, then wear them for a short time only and change out during the day. If standing for long periods, sit down and take a break and allow your body to rest. • Carrying a heavy shoulder bag or backpack may affect your posture because the neck and back are tightening unequally, creating a muscle imbalance. When using a shoulder bag, try alternating shoulders to eliminate repetitive overuse to one side of the body. Backpacks have two straps which should both be used to distribute the weight evenly and decrease neck strain. SLEEPING AFFECTS POSTURE When sleeping, it is important to maintain the same spine alignment as in standing. Proper cervical pillows should be considered when sleeping to avoid overstretching the neck. Large hotel pillows and

firm regular sized pillows are not best for the neck. A contoured or down pillow is good for controlling proper neck posture. Also, when side lying, place a pillow or two between the knees and feet to keep the spine in proper alignment. If you sleep on your back, use firm pillows not for the neck, but under the knees to take stress off the low back. Avoid stomach sleeping because your neck will be rotated and turned all night in an over-stretched position. HELPFUL TIPS FOR PROPER POSTURE WITH DAILY ACTIVITIES 1. Kitchen – When standing at the sink, place one foot on a phone book or inside the cabinet door. This position will help bend your knee and flex the hip, taking strain off your low back. 2. Garage – When leaning over to pick up tools, make sure to bend at the knees and keep your back straight. 3. Brushing teeth – Lean over with your knees bent or lean onto the countertop and support yourself while brushing teeth. 4. Sitting – Place a pillow in your lower back for support. Avoid soft chairs and sofas. Don’t slouch! If needed, use a small footstool to prop up your feet, while raising your knees slightly higher than your hips. 5. Driving – Adjust the car seat forward, slightly bend your knees higher than your hips and use the lumbar support. 6. Office – Use an ergonomic chair with adjustments for your arms, legs and back. Use a lumbar support and position your feet flat on the ground. Remember to face the workstation directly in front of you. Avoid spending long periods of time working with your head turned to one direction. Take breaks every 30–40 minutes and exercise. MOVEMENT IS VITAL TO A HEALTHY POSTURE Think about it: Motion is the lotion for your body. Without proper postural awareness: ligaments tighten up, muscles become weakened, joints wear out, and nerves become inflamed. Left unattended, this altered position will usually result in a painful and unhealthy posture. A proper posture is maintained by the purposeful act of daily exercise. Don’t think of it as exercise but of maintaining your independence to remain active physically, mentally, and emotionally. DO OSTEOARTHRITIS AND OSTEOPOROSIS AFFECT POSTURE?

Osteoarthritis is a joint disease involving the breakdown of the joint cartilage (covering of the bone) and the underlying bone. It is believed to be caused by mechanical stresses to the joint. Chronic bad posture places unnecessary stresses on the body. It has been reported, for every inch the head moves forward in a slouched posture, the weight of the head increases by 10 pounds. Slouching of the shoulders with the head forward creates stress on the neck vertebra. This breakdown usually occurs over years and can result in symptoms of joint pain, stiffness, swelling, and loss of range of motion. Osteoarthritis generally is found in the neck, lower back, knee, and hip regions, which affect posture. Physical therapy can provide alternative exercises for strength, range of motion, and flexibility to improve posture and function with activities of daily living. Osteoporosis relates to a decrease in bone mineral density. This decrease in bone density may affect the spine.If osteoporosis is present in the hip, there may be a spontaneous fracture during walking or following a fall on the hip. Osteoporosis most commonly affects older women. Women may lose up to 40% of their bone density by the age of 80; however, most men will lose only 15%. A bone density test by your physician is an imperative fall-risk assessment. When the spinal bones become weak, there may be a compression fracture. These fractures can make sitting and standing painful, whereas just standing upright can lead to a spinal fracture. Consult your physician first, but a diet rich in calcium and vitamin D, daily weight bearing exercises, limited alcohol drinking, no smoking, and specific strengthening exercises outlined by a physical therapist will help treat the symptoms. DEVICES TO ASSIST POSTURE An older adult may become fearful of falling and walk looking down, especially if they have already experienced a fall. Statistically, adults over 65 years of age have a 1 out of 3 chance of falling. To assist the effects of poor posture and an unsteady gait, a cane may be useful for balance. A walker is an additional supportive device that may be necessary after a fall to provide maximum support while walking upright. Many older adults are independent at home without a supportive device during the day. A cane may be used when leaving the house for greater balance, and a walker can be used at night to assist when arising out of bed to use the restroom.

Chapter 3 Balance is Your Base What’s in this Chapter? 1.Influences that affect balance 2. Achieving proper balance 3. Strengthening exercises to help balance 4. Daily balance tips 5. Balance problems 6. Exercise and postural awareness helps balance 7. What’s in your closet 8. Balancing the walk 31

“Life is like riding a bicycle. To keep your balance, you must keep moving.” —Albert Einstein John, a 69 year old, had been coming to physical therapy for 6 weeks following a total knee replacement. He was progressing well with his strength, balance, and range of motion before experiencing a terrible accident. When walking into a convenience store he lost his balance on an “unmarked” freshly mopped floor. Luckily, after slipping and sliding he finally recovered his balance. He proudly boasted that the balance exercises he was performing at home had given him the stability to overcome a fall. He was a believer in daily balance exercises and said he will continue them forever. Experience is always the best teacher! *** Exercises to improve balance consist of all the ingredients to promote strength, posture, and stability. Your physician can assess in his or her office for inner ear, visual, and muscle imbalances to determine if further balance testing is necessary. However, weakness in the posture muscles affecting stability may be helped with physical therapy and specific balance exercises for home. INFLUENCES THAT AFFECT BALANCE Maintaining an upright posture is important when controlling your balance. However, there are other factors that affect balance as you age. You may experience postural changes, reduced muscle strength and flexibility, and a decrease in sensory input to the brain that can result in loss of balance and falls.

Your body is constantly sending the brain information for feedback regarding our musculoskeletal system, joint flexibility, vision, and proprioceptive feedback (touch). The vestibular system detects motion of the head and generates reflexes that are necessary for daily activities, such as equalizing vision, maintaining head, body posture, and balance. There are beneficial exercise programs for individuals with a history of recurrent falls. Walking, balance and strength training, cycling, and community Tai Chi programs are all beneficial in improving stability. ACHIEVING PROPER BALANCE Balance and equilibrium are accomplished as you stabilize your center of gravity with continued trunk movement over your base of support. As you sit, walk, and run, you are constantly shifting your center of gravity away from your base of support. You use your visual (eyes) to send signals to the brain, vestibular system (processing gravity and motion), and proprioceptive (touch) components of the nervous system to tell the body what to do. As you age, the vestibular system declines and normal balancing responses are diminished. Your vision, a major component in balance, must be checked regularly. Without proper vision, adjustments are difficult when walking. Poor vision may lead to looking down for steadiness, only to shift the center of gravity forward and possibly causing a fall. Seek medical specialists for an inner ear, visual, and balance deficits assessment, along with a referral for balance training exercises. The (Vestibular System) Chart

Go to vestibular.org for additional information. STRENGTHENING EXERCISES TO HELP BALANCE Incorporating a daily exercise routine and lifestyle changes will help improve your flexibility, strength, and posture. All three components are necessary in maintaining balance with walking, sitting, and standing activities. When you think of lack of physical activity, you must realize there are specific exercises and activities that you can perform to counteract the diminished responses as you age. March in Place

1. Stand upright next to a chair with head and shoulders back 2. Breathe normally, picking the knee up to waist level 3. Repeat with each leg, as you are marching in place 4. Perform this exercise 10–20 times * When easy, place less hand pressure on the chair to improve balance. Improved standing balance with an upright posture is possible when marching in place. Marching reinforces picking up your feet which may prevent a trip, and ultimately a fall. Stork Stand

1. Stand upright next to a chair with head and shoulders back 2. Breathe out, picking your foot 3–6 inches off the floor

3. Hold for 5 seconds slowly lower and relax 4. Repeat on the opposite leg 5. Perform this exercise 10 times * The goal is to increase your standing time on one leg. As the exercise becomes easy, use less finger pressure on the chair. This is an excellent exercise to start your day. Whether brushing your teeth, combing your hair, or waiting for the microwave to go off, think about practicing this for 1–2 minutes. Squat with TheraBand®

1. Stand upright with head and shoulders back 2. Place TheraBand® under both feet and keep your arms straight

3. Breathe out, slowly lower, hold 5 seconds 4. Slowly stand up and relax 5. Perform 10 times Squatting exercises in general strengthen the legs. Squatting using a TheraBand® helps functionally as you push up against the resistance. Squatting exercises help with balance, walking, climbing up or down stairs, and getting out of chairs. Standing Squat at Chair

1. Standing upright next to a chair for support 2. Maintain a straight posture, breathe out and slowly lower

3. Hold for 5 seconds, slowly stand up and relax 4. Repeat 10 times * If easy, use less hand support on chair to improve balance. Squatting is a natural movement. While holding onto a chair, the focus is on the stomach, back, and hips to maintain balance and an upright posture. Heel-to-Toe Walk

1. Stand next to a wall or move your hand onto a countertop for balance and support

2. Stand straight with shoulders and head upright. Place one heel in front of the opposite foot

3. Check your balance, breathe slowly and walk

* Practice in the kitchen or hallway.

4. Repeat this pattern for 5–10 steps

This exercise can be performed safely while holding onto a table or countertop. This is an advanced balance walking activity for stability. Proper posture is necessary to balance the trunk and coordinate the feet movement. Practice this with another person. This exercise benefits posture, balance, and stability. Side-to-Side Walk

1. Stand upright, back straight and feet shoulder width apart 2. Place hands on hips and knee pointing forward 3. Slightly bend your knees, keeping back straight and step sideways

4. Step to the right 5 times, then back to the left 5 times. 5. Repeat 2–3 times The side-to-side walk benefits your hip, back, and leg muscles. Hip strengthening helps balance, as well as an upright posture when holding your back straight and lateral stepping. Sit to Stand

1. Sit straight up and move to the edge of the chair 2. Place feet shoulder width apart and slightly bent under you

3. Cross arms over chest 4. Lean forward with body weight on heel

5. Stand up 6. Repeat 3–5 times

* If the exercise is too difficult with arms crossed at first, then hold onto the armrests and stand. Your goal is to stand without holding onto the chair. Sit to standing exercises are good for your posture, balance, and trunk stability. This exercise helps strengthen your muscles needed when transitioning in and out of the car, walking up or down stairs, as well as, picking objects off the floor. You will feel your trunk strengthen as you stabilize the spine with this exercise. Planks

1. Initially, start on hands and knees, keeping your back straight 2. Breathe out and slowly lean forward on your elbows

3. Straighten your legs up off the floor. Maintain your back straight at all times 4. Hold the position for 5 seconds, slowly lower to knees and relax 5. Repeat 10 times * If easy, perform with your elbows straight.

The plank exercise is one of the best exercises for strengthening your trunk, legs, and neck muscles. The benefits of this exercise assist with your posture, balance, and trunk stability. DAILY BALANCE TIPS Practice these activities for balance during the day to improve, maintain and manage your strength, balance, flexibility, and posture. The more you practice each day, the easier it becomes to avoid a fall. On Phone

Phones require so much of your time. The next time you are talking on the phone, try standing on one leg to improve your balance and

stability. Picking Up Ball or Glasses

Proper balance and posture are necessary when leaning over to pick up an object. Before picking up an object, take a few seconds to make sure your back is straight and knees are bent with a wide base of support. Foam Pad Standing

Standing upright and balanced on a foam pad or pillow is a good exercise to improve stability. Proper standing requires an upright and

balanced posture. Weight shift movements standing and marching in place on a foam pad for 2–3 minutes is a great way to start a balanced day. Additional Suggestions: 1. Try standing on one leg while brushing your teeth, riding in an elevator or waiting in line at the grocery store. 2. Change your standing positions during the day. Stand with your feet apart and then close together. Support yourself, holding onto a steady object and stand with your eyes open and then closed. This will really test your balance. 3. Heel-toe walking can be performed walking down the hallway. 4. Walk in place or on a pillow to simulate an uneven surface. 5. High step walking with an upright posture. Stand next to a chair and practice with eyes open and closed. 6. Single leg balance standing. Your goal is to increase your time to 30 seconds of single leg standing. 7. Standing calf raises whenever possible. BALANCE PROBLEMS Balance can become a problem when you least expect it. Your balance is needed in everything from walking, standing, picking up objects, housework, dressing, and getting out of bed. The aging process comes with risks and rewards. The risks are the inherent physical and physiological changes that occur which may lead to an unhealthy lifestyle. Your rewards are the mental, physical, emotional, and physiological benefits received from committing to a daily exercise routine. EXERCISE AND POSTURAL AWARENESS HELPS BALANCE Daily exercises or (functional activities to remain independent and active) are very important to a healthy lifestyle. Proper exercising promotes a stable posture which translates to improved balance standing or sitting. Improving your strength, flexibility, balance and posture will negate the anxiety and apprehension associated with losing your balance and the fear of falling. WHAT’S IN YOUR CLOSET Posture awareness when walking and standing may be difficult at times, so use a cane for stability. Don’t be a furniture walker!

Americans are living longer and are more active. Canes are no longer for the elderly but for older adults staying active following joint replacement surgery. Today, more than 1 million Americans have a hip or knee replaced each year. Joint replacement surgery has shown to help you move around and feel better. Usually, following a joint replacement surgery, you will use a walker or a cane for a period of time. Wearing properly fitting shoes will help you maintain your balance. When your favorite shoes start to break down on the sides, buy a new pair. It is important to purchase shoes at the end of the day. Feet swell at the end of the day which makes the best time to buy shoes— so they will always fit. Changing shoes when walking on different surfaces may prevent a trip. Non-skid soles are best on hardwoods and tile floors and leather shoes are better for carpets. Limit the high heels in your wardrobe. Anything over 2 inches affects your posture and balance. So wear them sparingly and remember your body will adjust to the position of the height of your heels. Balance can become a problem when you least expect it. Your balance is needed in everything you do. BALANCING THE WALK Your walking or gait has a specific pattern which is unique to yourself. People have different walking patterns, postures, and gait strides which define their IMAGE. When walking, older adults experience changes in their posture, speed, stride, and step height. Older women tend to take smaller steps and use a more narrow walking and standing base with a pelvic side-to-side sway. Men, on the other hand, develop a wider standing and walking base with a shuffling gait. Once a fall occurs, there may be a noticeable change in the gait pattern, which can predispose to additional falls. It is important to review gait patterns and consider a cane or walker to improve balance and stability, initially after a fall. My patients have stated, that it is easier to stand straighter and pick up their feet walking with a cane following a fall, because of the additional support.

Chapter 4 Flexibility What’s in this Chapter? 1.What is flexibility? 2. Holding a stretch 3. Warm-up before stretching 4. Flexibility affects posture 5. Stretching for posture 6. Does stretching prevent injuries? 7. The best time to stretch 8. Can flexibility improve? 9. Stretching properly 10. Moving out of a sedentary lifestyle 11. Stretches for the sedentary 12. Flexibility exercises benefit a 53

painful

knee

“Setting goals is the first step in turning the invisible into the visible.” —Tony Robbins Janice, a 69-year-old grandmother, was being treated for neck pain. She spends a lot of time on the floor with her grandkids and needle pointing in a chair. She began physical therapy with tightness in her chest muscles, because she spends most of her day leaning over to needle point or play games with the grandkids. After weeks of strengthening and stretching exercises for tight chest and neck muscles, she experienced much relief of her symptoms. Most importantly, she said that she benefited mostly from standing upright and checking herself in the mirror each day. Basically, she was able to SEE what it FEELS like to be upright. Rest assured, the mirror will never lie! WHAT IS FLEXIBILITY? Flexibility of a muscle is its ability to relax following a stressful force, whether active or passive. Flexibility affects all of your joints’ range of motion that is supported by ligaments, tendons, and muscles. Flexibility affects the way you walk, sit, stand, play, and perform daily activities. The spine and associated joints are uniquely designed like a well-connected chain link fence. The joints are arranged with muscles aligned to push and pull, while working together in perfect harmony. However, once the chain link is disrupted by muscle tightness, your spine and associated joints become stressed, strained, and even injured.

Understanding this basic concept should motivate the older adult to improve overall fitness, flexibility, and awareness for a proper posture. No structure or building can stand unbalanced. No dancer or athlete can be at peak performance without muscular symmetry involving strength and flexibility. Performing flexibility exercises regularly may help counteract the negative pull when tight muscles of the spine, hip, shoulders, and neck affect posture. HOLDING A STRETCH There are various schools of thoughts on how long to hold a stretch. Some suggest as little as 10 seconds and others up to 60 seconds. Over the years, I have found when demonstrating a stretch, it is more effective when performed with a slow hold and breathing for the full 10 seconds for 3 repetitions. I have found that people are more compliant if the stretch is for a short duration and a few repetitions. WARM-UP BEFORE STRETCHING The purpose of warming up a muscle before stretching is to increase circulation, elasticity, and contractibility of the muscle. Once you warm up the muscle, it is more elastic and pliable for the stretch. A cold muscle won’t stretch; and if you perform the stretching improperly, you may even make the muscle tighter due to a reflex stretch response to overstretching. FLEXIBILITY AFFECTS POSTURE Your posture consists of about 206 bones for a stable foundation. You have 640 muscles or 320 pairs of muscles on the front and back of your spine to move and functionally stabilize your posture. There are also muscles, tendons, and ligaments placed throughout your spine and extremities for functional support. Daily exercise is needed for flexibility and mobility of the spine. When muscles become tight and inflexible, then unnecessary aches/pain may occur. STRETCHING FOR POSTURE Stretching is an important component in keeping the body mobile and flexible for daily activities. There are specific regions of our bodies, which if tight and left undetected, will affect your posture and should be stretched. Flexibility affects the way you walk, sit, stand, play, and perform daily activities. Supine Hip Flexor Stretch

1. Lie on back with both knees bent 2. Breathe normally, bring one knee to the chest 3. Slowly lower the opposite leg to the floor, hold 10 seconds 4. Return to starting position and repeat 3 times * It is important not to arch your back when extending the leg. The hip flexor muscles are located in front of your hips. Their function is to pick up your legs when going up or down stairs, walking or running. When sitting for a prolonged period, your hip flexors tighten up because the hips are bent to 90 degrees. This tightness will be apparent when you stand, because the tight hip flexors will cause the pelvis to tilt forward, resulting in a forward standing posture. Hamstring Stretch

1. Lie flat on back with knees bent 2. Reach hand behind knee and slowly pull toward body 3. Breathe normally, and slowly extend knee upwards 4. Hold 10 seconds, slowly lower 5. Relax, repeat 3 times * You may also use a belt around foot to help extend knee upwards. Don’t bounce or overstretch. Don’t hold your breath while stretching.

The hamstrings are located in the back of the leg and bend the knee when walking, as well as assist with hip extension. When the hamstrings are tight, the knee may be bent when walking, creating a leaning over posture. Stretching the hamstrings may limit low back pain and help posture. Pectoralis (Chest) Stretch in Doorway

1. Stand with head and shoulders back and with arms bent in the doorway 2. Stagger feet to support your body

3. Breathe normally, slowly lean on the front leg 4. Hold 10 seconds, slowly return back up 5. Repeat 3 times * If discomfort in shoulder is present, you may lower arms or don’t stretch as far through the door. Chest stretching in the doorway helps minimize chest tightness, which follows a slouched posture sitting or standing. Additionally, stretching the chest muscles helps with breathing. Active Knee Range of Motion

1. Sit upright in chair with head and shoulders back 2. Place feet flat on floor

3. Breathe out, slowly straighten knee 4. Hold 5 seconds, lower slowly and relax 5. Repeat 10 times, then alternate legs * When easy, add a 1-2 lbs. cuff ankle weight for resistance. Sitting during the day with your knees bent tightens up the hamstrings. This shortening may be evident when standing and walking, making it difficult to straighten your knee. Range of motion exercises during the day help increase circulation to minimize knee stiffness, as well as reduce foot/ankle swelling from hanging down all day. Calf Stretch

1. Stand upright with head and shoulders back 2. Lean against a wall with the back leg straight, front knee bent 3. Breathe normally, slowly lean forward on the front leg

4. Hold 10 seconds, slowly relax 5. Repeat 3 times, then switch legs * Remember to breathe normally and no bouncing. Your foot is the first part of your body to hit the ground when walking. If the calf is tight, walking mechanics will be altered with a decreased stride and possible bent knee, which all affect your posture. If you are a woman wearing heels every day, this shortened calf may now create problems when you wear flat shoes. You may even be susceptible to a calf injury with stairs or even walking on uneven surfaces. Seated Hip Rotation Stretch #1- Hip Rotation Stretch:

1. Sit upright in chair with head and shoulders back 2. Cross your left foot over the right knee

3. Breathe normally, slowly use left hand to push down left knee 4. Hold 10 seconds, repeat 3 times 5. Switch legs #2- Hip Rotation Stretch:

1. Sit upright in chair with head and shoulders back 2. Cross your left foot over the right knee

3. Breathe normally, slowly pull the left knee to the right shoulder while turning 4. Hold 10 seconds, repeat 3 times 5. Switch legs The muscles of your hip are attached to your pelvis. The allimportant sciatic nerve passes within the hip rotator in your pelvis, known as the Piriformis muscle. Stretching your hip not only helps hip motion while moving the leg forward and backward, but also helps with rotation or turning. Providing flexibility to the hip muscles helps walking and can minimize the tightness associated with prolonged sitting to standing. Seated Trunk Flexion Stretch

1. Sit upright at the edge of chair with head and shoulders back

2. Open legs outward past shoulders, breathe out, slowly lower hands to the floor

3. Hold 10 seconds, slowly rise, pushing up with hands on knees and relax

4. Repeat 3 times If low back discomfort is experienced following prolonged standing or walking, the first solution is to sit down. This is a good time to stretch the low back and decrease some of the muscle tightness. Hip Rotation Stretches on Floor

1. Lie on your back with knees bent 2. Breathe normally, rotate hips to the right, keeping shoulders flat 3. Rotate hips to comfortable stopping position, hold 10 seconds. 4. Slowly rotate hips back to the middle, relax and repeat to the left 5. Repeat 3 times * Rotate hips without producing leg or back pain. If discomfort is present, then rotate with less motion. Stretching your hips and low back in the morning or after an active day can improve mobility. Gently moving hips back and forth with a slow stretch helps circulation and flexibility. Rotator Cuff Stretches #1 Posterior Cuff Stretch: 1. Sit or stand with head and shoulders back 2. Breathe normally, take the right hand and place under the left elbow 3. Gently stretch your arm across chest 4. Hold 10 seconds slowly relax 5. Repeat 3 times #2 Inferior Cuff Stretch:

1. Sit or stand with head and shoulders back 2. Breathe normally, grab the left wrist with the right hand 3. Gently stretch the left arm overhead 4. Hold 10 seconds, slowly relax and repeat 3 times #3 Internal Rotation Stretch:

1. Stand with head/ shoulders back 2. Using a towel, place one end in the left hand 3. Place the other end in the right hand overhead 4. Breathe normally and extend the right hand upward, pulling the left hand up back (same movement as drying your back) 5. Hold 10 seconds, slowly relax and repeat 3 times The rotator cuff consists of four muscles that control all of the movements of the shoulder used for our daily activities. The shoulder has more motion than any other joint in the body and daily stretches are beneficial to function and posture. A flexible shoulder is a functional shoulder for all the activities and many positions that we place it. DOES STRETCHING PREVENT INJURIES?

As a physical therapist who treats many orthopedic patients with very tight muscles affecting their posture, my answer is, “Yes,” stretching exercises do help. My older population, some sedentary and some active, have all benefitted from a stretching program. Stretching the muscles, ligaments, and tendons around the spine and other joints has improved mobility that would have otherwise lead to further muscle imbalances. THE BEST TIME TO STRETCH Stretching after a brisk walk or cycle may be the best time to improve flexibility. After exercising, there is an increase in circulation to the muscles and joints which assists in the stretch. Sometimes, you don’t have the opportunity to warm up the muscles properly, and it is still okay to perform stretches, especially when you experience tightness during the day. Counteracting tightness from a sedentary seated position or tight standing posture is a good time to stretch. CAN FLEXIBILITY IMPROVE? There is no hard rule on how long it takes to improve flexibility. If you were a gymnast or a dancer when younger, you would have spent years stretching. As you grow older, you would have probably retained some flexibility and restarting a stretching routine may be easy. There are many variables that affect a person’s ability to improve muscle length extensibility when stretching. But, the first objective is to just get started. What about those people who have spent the majority of their lives sedentary and not stretching their body? Do you think they realize that their bad postural habits might have created tightness through adaptation? The good news is that if you just start moving your body in new positions every day, you will feel better, move better, and look better. STRETCHING PROPERLY Too many times, people start an exercise program and don’t know where to begin. They don’t know what exercises to do or how to stretch properly. Stretching needs to be slow and controlled, and you should be able to relax and breathe normally. If the stretch is forceful, jerky, and painful, the muscle will respond through its stretch reflex by tightening up. This may lead to an increase in pain, tighter muscles, and even an injury. It is important to seek advice on your particular needs before starting any exercise routine. MOVING OUT OF A SEDENTARY LIFESTYLE

Sitting all day, whether at work or home, is taking up more of our time than sleeping. Prolonged sitting at the computer or in a chair is never a good thing. There are many physical and physiological effects to our bodies that we don’t consider when sedentary all day. There is an increased risk of heart disease with prolonged sitting because bodies need to move. It is important to take frequent breaks to keep our mobile system working efficiently. Take a break, get up and move around every 30-45 minutes from sitting to keep your body moving. By moving tight muscles and stiff joints, a short walk in the office or home helps circulation, posture, balance, osteoporosis, and overall wellbeing. Chronic and prolonged sitting, with a slouched or rounded posture, weakens and tightens the muscles and joints of the neck, shoulders, and back regions. Repetitive poor positioning of the body may lead to some irreversible changes over time. Basic neck range of motion and posture exercises may minimize the stresses and strains associated with prolonged sitting. Subsequently, maintaining a mobile neck may help decrease headaches, dizziness, stress, and muscle tightness. STRETCHES FOR THE SEDENTARY Neck and arm problems may result from looking down at the computer all day or just sitting sedentarily while watching TV. These areas can be easily stretched with simple controlled moves. When looking down, the neck is pulled forward, the shoulders become rounded, and the low back tightens. Hands and arms also tighten with little or no movements when sitting. Stretching exercises for a few minutes during the day can provide relief and prevent tightness in the neck muscles. Seated Shrugs

1. Sit upright in chair with head and shoulders back 2. Breathe out, slowly raise shoulders up to ears 3. Hold 5 seconds, slowly lower and relax 4. Repeat 10 times * You can also slowly move your head around to decrease tension and improve neck range of motion while shrugging. Tension associated with prolonged sitting and associated poor posture accumulates in the upper neck muscles. Shoulder shrugs are a great way to reduce neck tension and improve sitting and standing posture. Chin Tucks

1. Sit with head and shoulders back 2. Look forward with eyes straight ahead 3. Breathe out and pull chin and shoulders back 4. Hold for 5 seconds and relax 5. Repeat 5 times * Don’t look up or down. Keep eyes forward. If uncomfortable, don’t pull head back as far—stay in the pain-free neck range of motion. Chin tucks can easily be performed during the day in a sitting or standing position. Awareness of where your head is in relationship to the rest of your body is extremely important for an upright posture.

By practicing this simple exercise, you may eliminate stress, tension, and poor posture with activities during the day. Active Neck Range of Motion Neck Flexion:

1. Sit upright in chair with head and shoulders back 2. Perform a chin tuck with shoulders back 3. Breathe out and gently lower head to a comfortable position 4. Hold for 5 seconds, slowly look up and relax 5. Repeat 3 times Neck Extension:

1. Same starting position 2. Breathe out and slowly lower head back, keeping mouth closed 3. Hold 5 seconds, slowly return back up and relax 4. Perform 3 times Neck Rotation:

1. Same starting position 2. Breathe out and turn head to the right, hold 5 seconds 3. Slowly return to starting position and relax 4. Repeat, turning the head to the left 5. Perform both exercises 3 times

Neck Sidebending:

1. Same starting position 2. Breathe out and sidebend head to the right, hold 5 seconds 3. Slowly return to starting position and relax 4. Repeat, sidebending head to the left 5. Perform both exercises 3 time Keeping your head and neck as mobile as possible is very important, especially when sitting all day. Reading, working at the computer, or staying in a slouched position may increase neck discomfort. Motion is the lotion for all your joints, and your head is most important to keep moving during work, leisure, or play. Open/Close Hand

1. Sit upright in chair with head and shoulders back 2. Actively open/close hand and fingers 3. Fully open and shut your hand, moving all fingers 4. Repeat 10 times * Squeezing a small foam or soft rubber ball during the day is also helpful in strengthening your grip. Finger and hand muscles and joints become tight and stiff with either sedentary or repeated use over a prolonged period. Stretching out the hand and fingers during the day helps maintain mobility and dexterity with daily activities. Forearm/Wrist Stretches Wrist Flexion Stretch:

1. Sit straight in chair with an upright posture 2. Straighten out one arm with the palm down 3. Use the opposite hand to stretch wrist down 4. Hold 5 seconds and release 5. Perform 3 times, repeat to the other wrist Wrist Extension Stretch:

1. Sit straight in chair with an upright posture 2. Straighten out one arm with the palm up 3. Use the opposite hand to stretch the fingers back 4. Hold 5 seconds and release 5. Perform 3 times, repeat to the other wrist Stretching your forearm improves the flexibility of your wrist and hand with activities. Prolonged computer use or sedentary sitting tightens up the wrist, fingers, and forearm muscles. Practicing frequent stretching may decrease overuse injuries to these muscles, resulting in hand or forearm pain. Seated Chest Stretch

1. Sit upright in chair with head and shoulders back 2. Grasp hands behind you or hold a towel in both hands 3. Breathe out, and slowly pull or pinch both shoulders back 5. Hold 5 seconds and relax 6. Repeat 3 times Stretching the chest during the day helps with your posture. Leaning over the computer reading or watching TV may tighten up the chest muscles from a forward leaning or slouched posture. This affects your standing posture and ultimately balance. Seated Neck Stretch

1. Sit in an upright posture, looking straight ahead 2. Perform chin tuck/shoulder pinch 3. Grab one hand under the chair 4. Breathe out and lean head away from the hand holding the chair 5. Hold 5 seconds, slowly return to starting position and relax 6. Repeat 3 times to each side Stretching the neck while seated can help decrease neck tightness from prolonged sitting. Gently stretching the muscles around the head/neck during the day may decrease tension from sitting. FLEXIBILITY EXERCISES BENEFIT A PAINFUL KNEE Osteoarthritis pain, as well as ligament and meniscus (cartilage) injuries, can lead to a painful, stiff, and swollen knee. Walking on a painful knee causes limping and muscle guarding, which stiffens the knee. Muscles and ligaments tighten and limit the joint’s range of motion, affecting posture and walking. Performing calf and hamstring stretches improves flexibility, which may reduce the pain and improve walking. (See Calf and Hamstring Stretches)

Chapter 5 Strengthening What’s in this Chapter? 1. Exercise will change everything 2. Before exercising, see your physician 3. The importance of strengthening your body 4. Prolonged Sitting Does Affect Your Body 5. Exercises for your legs 6. The most common types of strengthening exercises 7. What to do when you a pull a muscle 8. The difference between aerobic and anaerobic exercises 9. Back strengthening 10. Upper extremity strengthening exercises 11. Exercising to assist your posture 12. Exercises can help prevent a trip 13. Make exercising fun 14. Mix up your exercise routine 15. Creative exercise tips to help balance 16. Hand exercise tips to strengthen your grip 17. Tips moving in and out of bed 85 Age-Defying Fitness 87

“The starting point of all achievement is desire.” — Napoleon Hill Mary, a 75 year old woman, who experienced relief from her low back pain following 4 weeks of physical therapy,asked me,“How much longer do I need to continue with my home exercises, since I am feeling so much better?”I replied,“Everyday,Don’t stop now.”Her objective was to lessen her pain, her starting point was exercise, postural awareness, and activity modifications. Don’t end the celebration! *** EXERCISE WILL CHANGE EVERYTHING It goes without saying that exercise keeps the muscles toned, the tendons flexible, and the joints mobile. Initiating an exercise program which incorporates safe and effective exercises that are directed for strength, balance, and flexibility will change the way you feel. The desire to exercise will change everything, because exercises begun at any age offer benefits to all ages. People who exercise feel better, look better, are more confident, and have more energy. Exercising helps improve mental awareness, reaction time, reduces stress and anxiety, as well as improves confidence and self-esteem. Exercising has produced noticeable benefits to the immune and neurologic systems, cardiovascular systems, digestive, circulatory, and sensory systems. No one has

ever said that some form of exercise is not good for you. So where do you start? A simple exercise regime for only 10 minutes a day, along with a 15-20 minute walk, can reverse so much of the physical pain we experience in our daily lives. An annual eye and ear exam by your physician can minimize many of the fears older adults experience with daily activities. Furthermore, medications that may affect balance need to be monitored, due to their possible side effects like dizziness, feeling light-headed, and drowsiness. Surgical procedures and debilitating post-op recovery leave patients weak, painful, tight, and apprehensive about their balance. Care is necessary to gradually reverse the effects of medications, inactivity, and loss of sensory input from immobilization. Lack of sleep can also lead to balance problems. Avoid caffeine, nicotine, soft drinks, and other stimulants that may affect your sleep. Smoking disrupts sleep cycles; also avoid alcohol before going to bed. These stimulants may affect balance, coordination, vision, and necessary sensory inputs to the brain, which affect balance. BEFORE EXERCISING, SEE YOUR PHYSICIAN Even though exercising is good for your body, it is important to know if your body is ready to exercise. A physician screening will provide the necessary information about your heart, lungs, bones, strength, and flexibility to determine if you are ready to start an exercise program or if there should be any limitations. Once cleared for exercise, you can seek a professional to get you started with a program to meet your needs. THE IMPORTANCE OF STRENGTHENING YOUR BODY Strengthening of the back, lower and upper body is essential for having an upright and balanced posture. There are many variables that help prevent falls and the one truth is to generate strength. Strength not only helps promote balance, posture, and stability with activities, but it also provides a foundation for the body physically and physiologically to work more efficiently. To start your exercise program, begin with 2-3 days/week and increase to 5-7 days/week, depending on the level of intensity and consistency. I recommend 3-4 days/week for 30 minutes, including 10 minutes of exercises and a 15-20 minute walk. Begin strengthening exercises with 1 set of 10 repetitions and progress to 2 sets of 10 repetitions as strength improves.

Commitment is the fundamental key to any exercise program. Commit to 2-3 days a week and remember to start slow and gradually increase the time, frequency and intensity. Just 10 minutes a day is all that is needed to start and experience the positive effects of a daily exercise routine. PROLONGED SITTING DOES AFFECT YOUR BODY Prolonged sitting may produce tight hip muscles, found in front of the leg, which can limit hip range of motion affecting posture and the walking stride. If unchecked, this may predispose to a fall. Prolonged sitting weakens the Gluteal (buttocks) muscles because these muscles do not move when you sit. This affects trunk stability standing with a diminished walking stride. Also, sitting for prolonged periods will weaken the abdominal muscles, which may result in a slouched standing posture. Subsequently, this position may increase strain on your neck and upper back, producing rounded shoulders. When your knees are bent with prolonged sitting, poor circulation to the legs may be a problem. This is evident by the increase in leg swelling. Without adequate daily walking and standing activities, swelling increases, putting strain on the circulation system. There is no substitution for walking, standing, and moving during the day. Motion is the lotion for the body. A simple exercise regime for only 10 minutes a day, along with a 15-20 minute walk, can reverse so much of the physical pain we experience in our daily lives. EXERCISES FOR YOUR LEGS Strengthening exercises for your legs provide the stability, balance, and support necessary to walk, stand, rise from a chair, go up and down stairs, and move quickly during the day. Your posture is improved with a strong lower body because the foundation for all activities starts in the legs. One of the best ways to prevent a fall is with a strong lower body. Commit to improving your leg strength and experience how activities become easier. Standing Wall Squat Your Body Resistance:

1. Stand with your back against the wall, feet shoulder width apart and about 20-24 inches from the wall

2. Breathe out and lower down the wall, stopping with your knees over the mid foot 3. Hold 5 seconds, slowly slide back up the wall and relax 4. Perform 10 times TheraBand® Resistance:

1. Resume same starting position against the wall 2. Place TheraBand®under both feet, holding ends with arms straight

3. Slowly lower as before, pulling tension on the TheraBand® 4. Hold 5 seconds, slowly slide back up the wall and relax 5. Perform 10 times * If knee discomfort is present, don’t lower down as far. Wall squats are a great way to strengthen your leg and buttock muscles in the morning while watching the news. Strengthening these muscles will assist with walking, stairs, and getting out of the chair. Hip Flexion

1. Stand straight and hold onto a chair 2. Breathe out while lifting your knee up in front parallel to the floor

3. Hold for 5 seconds, slowly lower and relax 4. Repeat 10 times, then switch legs * When easy, add a 1-2 lbs. cuff ankle weight for resistance. The muscles in front of your hip are valuable for walking and picking up your feet, especially to prevent trips. Hip flexor muscle strength assists with stepping up to curbs, steps, stairs, and on uneven surfaces. Balance and posture are improved when properly picking up your hips. Lunges

1. Stand next to chair, legs alternated one in front of another 2. Keep back straight, breathe out, slowly lean forward on front leg 3. Don’t lean the knee past the foot 4. Hold 5 seconds, return back up and relax 5. Repeat 5-10 times * If easy, hold light hand weights. Lunges strengthen the legs for stability walking, stairs, and getting

out of a chair. Hamstring Curl

1. Stand straight and hold onto a chair 2. Breathe out and bend your knee back 3. Hold for 5 seconds, slowly lower and relax 4. Repeat 10 times, then switch legs * Start off exercise standing without a weight. When easy, add 1-2 lbs. cuff ankle weight for resistance. The hamstring muscle functions to bend the knee and assists to extend the hip when you walk.

THE MOST COMMON TYPES OF STRENGTHENING EXERCISES •An Isometric exercise is where you have a static muscle contraction without joint motion. Ex.: Pushing against the wall •An Isotonic exercise is where the muscle shortens and lengthens during a movement with the weight remaining constant. Ex.: A dumbbell curl •An Isokinetic exercise is where you have a dynamic contraction with the speed of the entire movement controlled by a machine. This equipment is usually found in physical therapy settings. WHAT TO DO WHEN YOU A PULL A MUSCLE Depending on the severity, when you pull or strain a muscle, it is important to rest and not exercise. I.C.E. (ice, compression, and elevation) is the first course of action. No strengthening or stretching until your physician or physical therapist advises it is safe. In general, all exercises should be started very slowly and controlled without pain. Initially, the goals are to improve flexibility and muscle toning with isometrics. Joint range of motion, if involved, is to be gradual and pain free until full motion is achieved. Never force motion with pain or swelling present because that will further damage the tissue. As time passes and the pain and inflammation are decreased, gradually increase exercise repetitions and stretches, all without pain. Always listen to your body and how it is responding to exercising and never push through the pain. Your body won’t lie to you. THE DIFFERENCE BETWEEN AEROBIC AND ANAEROBIC EXERCISES Aerobic exercises focus on strengthening the cardiovascular system. Aerobic means with oxygen and any exercise which uses oxygen in the energy building system. Examples of this exercise include brisk walking, cycling, running, and playing tennis, to name a few. An anaerobic exercise is for increasing short-term and high-intensity muscle activity. Examples of an anaerobic exercise are exercises with TheraBands® and weight training. Both forms of these exercises are important to utilize in an older adult exercise regime. BACK STRENGTHENING Back strengthening exercises require specific movements to target the proper muscles needed, as well as the surrounding muscles for stability. Back exercises focus on proper technique and body

mechanics for increasing strength and avoiding injury. A strong back improves your physical performance in all areas of your life. Abdominal Crunch Abdominal Crunch Reaching Position:

1. Lie flat on back with knees bent 2. Reach hands to knees, breathe out, lifting shoulders off floor 3. Hold 5 seconds, slowly lower and relax 4. Repeat 10 times Abdominal Crunch with Arms Crossed Over Chest:

Same starting position with arms crossed over chest 1. Breathe out, press chest to ceiling, lifting shoulders off floor 2. Hold 5 seconds, slowly lower and relax 3. Repeat 10 times Your abdominal muscles are very important in supporting your back and posture. Strong abdominal muscles support your trunk and assist with upright walking and getting out of a chair. Bridging

1. Lying on floor, bend knees 2. Breathe out, tighten stomach muscles while lifting hips off floor 3. Hold 5 seconds, slowly lower and relax 4. Relax and repeat 10 times * It is important to stop with trunk straight, don’t arch back. Strengthening trunk muscles when bridging helps improve leg and hip strength for stability and control walking.

Hip Abduction Standing Next to Chair:

1. Standing upright next to chair and breathe normally 2. Breathe out, raise the outside leg to side about 18 inches 3. Hold 5 seconds, slowly lower and relax 4. Perform 10 times, repeat with the other leg * Remember to keep pelvis level; don’t lean sideways. When easy, add 1-2 lbs. cuff ankle weights.

Side lying on the Floor:

1. Position yourself side lying on the floor, keeping spine in alignment 2. Bend the lower leg on the floor for support 3. Breathe out and lift the top leg up about 10-12 inches 4. Hold for 5 seconds, slowly lower and relax 5. Perform 10 times, repeat with the other leg * When easy, add a 1-2 lbs. cuff ankle weight for resistance. The side lying exercise strengthens your outside hip muscles. These muscles assist your back when walking and keep your posture and your pelvis balanced. An injury or weakness to the hip muscles may affect your walking due to pain. In time, the painful muscles may lead to a limp and subsequent back pain. Strengthening the hip muscles will support your back and improve walking stability. Hip Extension Position: On Hands and Knees

1. Start on hands and knees with head in neutral position 2. Tighten abdominal muscles to keep back straight 3. Breathe out and straighten one leg back and the opposite arm up in front 4. Hold 5 seconds, slowly lower and relax 5. Repeat to the opposite leg 6. Perform 10 times * If low back discomfort is present, then raise your leg halfway up and continue to keep your abdominals tight with the back straight. Position: Prone on Floor with Pillow

1. Lie on floor with a pillow under pelvis 2. Breathe out and lift 1 leg 2 inches off floor 3. Holding 5 seconds, squeeze buttocks, slowly lower and relax 4. Perform 10 times, repeat with opposite leg * If back discomfort is present, don’t raise leg as high or readjust pillow under pelvis to eliminate any back discomfort.

Your buttock muscles are very strong and powerful muscles that assist your back when walking, going up or down stairs, and your posture. Strengthening your buttocks muscles is important for rising out of a chair, especially following periods of sedentary sitting. UPPER EXTREMITY STRENGTHENING EXERCISES Upper extremity strengthening exercises help maintain an upright posture with walking, standing, and sitting. The stronger the upper body, the easier it is to stand upright. Most importantly, lifting, pushing, and pulling objects are easier when all of the muscles are working in harmony. All upper extremity strengthening exercises can be performed during your scheduled exercise time or when waiting for the TV commercials to end. If you can get in a habit for 30 days of regular exercising, then your body will tell you when to remember. Overhead Press Weight Resistance:

1. Sit upright in chair with head and shoulders back 2. Breathe out and press your arms up 3. Hold 5 seconds, slowly lower and relax 4. Repeat 10 times * Start off with 1-2 lbs. and increase as the exercise is easy. TheraBand® Resistance:

1. Sit upright in chair with head and shoulders back 2. Hold one end of the TheraBand® on the thigh 3. Breathe out and press the opposite arm up 4. Hold 5 seconds, slowly lower and relax 5. Repeat 10 times * If it is uncomfortable to raise arm up, then only raise up halfway. The benefits of the exercise will occur within your normal range of

motion. Overhead press strengthening provides an excellent way to strengthen your arms and shoulders for reaching activities. Rows Weight Resistance:

1. Lean over a chair or table, keeping back straight and knees bent 2. Breathe out, slowly pinch shoulder back while raising elbow up 3. Hold 5 seconds, slowly lower and relax 4. Repeat 10 times, then switch arms * Start off with 1-2 lbs. dumbbell and gradually increase. TheraBand® Resistance:

1. Repeat same starting position 2. Place one end of band under right foot, hold other with left hand 3. Breathe out, slowly pinch shoulder back while pulling elbow up 4. Hold 5 seconds, slowly lower and relax 5. Repeat 10 times, then switch arm/foot * Shortening the TheraBand® will increase the tension. This rowing exercise benefits the scapular or postural muscles. Pulling the shoulders back with this exercise produces the same movement as when you perform shoulder pinches standing. Shoulder and scapular strengthening is vitally important in assisting with an upright standing posture.

Shoulder Flexion Weight Resistance:

1. Sit upright in chair with head and shoulders back 2. Breathe out, raise both straight arms up in front to shoulder level 3. Hold 5 seconds, slowly lower and relax 4. Repeat 10 times * Start off without a weight and add 1-2 lbs. when easy. TheraBand® Resistance:

1. Sit upright in chair with head and shoulders back 2. Place one end of the TheraBand® on the thigh 3. Breathe out, raise the opposite straight arm to shoulder level 4. Hold 5 seconds, slowly lower and relax 5. Repeat 10 times, then switch arms * If shoulder is uncomfortable, then raise halfway. Shoulder flexion exercises improve shoulder strength for reaching.

Shoulder Abduction Weight Resistance:

1. Sit upright in chair with head and shoulders back 2. Breathe out, raise both straight arms out to side to shoulder level 3. Hold 5 seconds, slowly lower and relax 4. Repeat 10 times * Start off without weight and add 1-2 lbs. when easy. TheraBand® Resistance:

1. Sit upright in chair with head and shoulders back 2. Place one end of the TheraBand® on the thigh 3. Breathe out, raise straight arm out to shoulder level 4. Hold 5 seconds, slowly lower and relax 5. Repeat 10 times, then switch arms * If shoulder is uncomfortable, then raise halfway up. This exercise strengthens the shoulder when reaching out to the side. Pulling shoulders back while sitting upright also improves postural strength. Shoulder Shrugs Weight Resistance:

1. Sit upright in chair with head and shoulders back 2. Breathe out, slowly raise shoulder up to ears 3. Hold 5 seconds, slowly lower and relax 4. Repeat 10 times * Start off with 1-2 lbs and increase weight when easy. TheraBand® Resistance:

1. Stand upright with head and shoulders back 2. Stand on band with both feet, hold onto ends of band 3. Breathe out, slowly raise shoulders up to ears 4. Hold 5 seconds, slowly lower and relax 5. Repeat 10 times This exercise will help improve posture and may alleviate tension in the neck region. Bicep Curl TheraBand® Resistance:

1. Sit upright in chair with head and shoulders back 2. Hold one end of the TheraBand® on the thigh 3. Breathe out, slowly bend the opposite elbow to shoulder 4. Hold 5 seconds, slowly lower return down and relax 5. Repeat 10 times, then switch arms The biceps muscle is beneficial when bending your elbow to eat, holding a book, or picking up objects.

Tricep Extension TheraBand® Resistance:

1. Sit upright in chair with head and shoulders back 2. Hold one end of the TheraBand® next to the shoulder 3. Breathe out, slowly straighten the opposite elbow to the thigh 4. Hold 5 seconds, slowly return up and relax 5. Repeat 10 times, then switch arms

The triceps muscle assists when pushing up to get out of bed, as well as rising from a chair. Chest Press TheraBand® Resistance:

1. Stand or sit upright in chair with head and shoulders back 2. Place the band around the back and hold in both hands in front of body 3. Breathe out, slowly press arms out straight 4. Hold 5 seconds, slowly bend elbows back and relax 5. Repeat 10 times

Strengthening the chest muscles assists with posture. Scapula (Wing) Pinches TheraBand® Resistance:

1. Stand or sit upright in chair with head and shoulders back 2. Hold both ends of the TheraBand® in front of the chest 3. Breathe out, look forward and perform a chin tuck 4. Slowly pull on band and pinch both shoulders back 5. Hold 5 seconds, return to starting position and relax 6. Repeat 10 times * This exercise can also be performed without the band. Wing pinches are the key to keeping your shoulders back. Wing pinches, without the band, can be performed during the day when

seated in the car, a chair or just standing and having a casual conversation. Keeping your shoulders back not only improves posture, but helps trunk balance. Sedentary sitting during the day weakens back muscles. Periodically performing wing pinches during the day not only decreases back muscle tightness and pain, but makes standing upright easier. Tennis Stroke TheraBand® Resistance:

1. Stand upright with

head and shoulders back

2. Place one end of the TheraBand® under the left foot 3. Breathe out, raise the right arm straight out to the side and up 4. Keep head/shoulders back at all times

5. Hold 5 seconds, slowly lower and relax 6. Repeat 10 times, then switch arm and foot * If shoulder discomfort is present, raise arm halfway up, where no discomfort is present. To adjust the tension, hold the end of the band for easiest resistence. This strengthening exercise for the shoulder and upper back is necessary when performing normal functional reaching activities during the day. This exercise combines various shoulder and upper back muscles when reaching, lifting, or grabbing objects overhead. EXERCISING TO ASSIST YOUR POSTURE

I believe a strong posture is the most important goal of any exercise program. When you have a strong posture from exercising, you will experience improved muscle strength, flexibility, and balance for active and pain-free movements. A strong posture is balanced and energy efficient from the ground up. The best way to prevent a fall is to have a strong posture. EXERCISES CAN HELP PREVENT A TRIP Since falls are most commonly associated with a trip, it is important for you to practice specific exercises to avoid a fall. First, posture is the key. Proper standing posture over your center of gravity is the foundation for balance. You can easily and freely pick up your knees and feet when walking with an upright posture. The first part of the gait or walking cycle is heel strike, and it is important to be able to lift your toes up. Seated foot raises or heel walking (duck walking) will strengthen the leg muscles. The next phase is toe off, which requires your calf. Standing calf raises during the day will not only strengthen your calf, but also your ankle. MAKE EXERCISING FUN Exercising with a friend, family member, or the grandkids is fun! It is socially connecting and makes for great times together. Some people go to a ballgame, fish, watch TV, or just hang out; but exercising with a friend builds healthy relationships. There is accountability from each other to show up, and setting goals to achieve together creates a unique bond. MIX UP YOUR EXERCISE ROUTINE At times, doing the same exercises each day gets boring making it difficult to stay motivated. Varying the exercises from hand weights to a TheraBand® for a functional exercise is a good choice. Walking a different route, whether indoors or outdoors, provides new scenery. The body benefits from your exercises every day, no matter where you are or what you do, keep moving! CREATIVE EXERCISE TIPS TO HELP BALANCE 1. Standing on one leg with eyes open/closed 2. Try walking with a paper plate on your head 3. Stand or walk and throw a soft rubber ball up and catching it 4. Rise and lower up/down from a chair with eyes and closed 5. March in place with eyes closed Exercises for Your Feet/Toes

1. Sit upright in chair with head and shoulders back 2. Place a roller under your foot and roll back and forth 3. Start at the heel and roll the entire foot

4. If possible, curl toes around the roller, as well as stretch toes 5. Perform for 2-3 minutes to loosen up feet Rolling feet on a bottle, highlighter/marker, or rolling pin increases circulation and loosens up the muscles of your feet to start the day. Hand Exercise Tips to Strengthen Your Grip 1. Wring out a washcloth 2. Place a rubber band around fingers and open the hand 3. Buy a stress ball to squeeze during the day 4. Actively open/shut your fingers and make a fist 5. Move your wrists up/down and rotate back/forth Tips Moving In and Out of Bed 1. Slide heels up and down in the bed 2. Move your ankles around in all directions 3. Move your arms over your head 4. Sit off the bed, bend and straighten your knees 5. Sit off the bed, tap your feet on the floor with heel and toe raises 6. Sit off the bed, raise your arms overhead straight up and in big circles

Chapter 6 Nutritional Considerations and the Family Influence What’s in this Chapter? 1. Know a proper diet! 2. About vitamins and minerals 3. Hydrate, hydrate, and hydrate 4. Stimulating the senses 5. Feeling the love 6. Don’t sweat the small stuff 7. Making the home a no-falls zone 8. Canes and walkers for stability 123

“Start by doing what’s necessary, then do what’s possible, and suddenly you are doing the impossible.” —Francis of Assisi Velma is 73 years old and found herself in a very embarrassing situation when she couldn’t get out of her bathtub. She had no cell phone or Med Alert button close by; there were no grab bars to help her get out of the tub.The result:Velma stayed in the tub for 6 hours before a family member came by to check on her. I started treating her for low back pain from remaining in the tub so long. Planning ahead is beneficial for all activities! *** KNOW A PROPER DIET! As we age, a proper nutritional diet has many benefits. Improving the immune system, controlling blood pressure, and preventing bone loss are all part of a healthy nutritional diet. Various fruits and antioxidants may help improve memory, mental alertness, and awareness. Maintaining a healthy diet each day allows our bodies to absorb nutrients and improve our energy and mood. The key is to eat a variety of foods from all healthy food groups to supply your body with the energy it needs. Fruits and vegetables can be fresh, canned, or frozen. Whole grains are important, as well as, low fat dairy. Vary your proteins with more fish, beans, and peas. Include lean meats, poultry, fish, legumes, and nuts in your daily diet. Most important, make sure your diet is low in saturated fats, cholesterol, and salt. Diets rich in foods containing fiber, such as fruits, vegetables, and legumes, may be beneficial in reducing the risk of heart disease, as

well as improving regularity. Vary your vegetables and eat more dark vegetables, such as broccoli and kale, and orange vegetables, such as carrots and sweet potatoes. ABOUT VITAMINS AND MINERALS Vitamins are nutrients your body needs in small amounts to stay healthy and active. A good diet can easily supplement what your body needs. Talk with your physician first before taking supplemental vitamins and minerals to make sure it is appropriate for you. Supplements are never a substitute for a healthy diet. Vitamin and Mineral—Facts 1. It is important for older adults to get enough protein. More protein is needed as we age. A deficiency in protein puts older adults at risk for lower immune function and osteoporosis. 2. Older women need approximately 1,600 to 2,000 calories per day, depending on their activities, and men need 2,000 to 2,800 calories per day. 3. Vitamin B-12-is used by all the cells in your body, especially the brain and spinal cord. Since it is found primarily in animal protein, be sure to include animal protein in your diet. 4. Vitamin D-absorbs calcium and promotes bone growth. It helps regulate the immune system and plays an important role in the life cycle of human cells. 5. Minerals, including iron, calcium, and zinc, are important for your body to function properly. HYDRATE, HYDRATE, AND HYDRATE Many older adults don’t properly hydrate their bodies as they age. They become dehydrated because of their decreased sense of thirst. Drinking water throughout the day is important in preventing urinary tract infections, constipation, dry mouth, and confusion. Effects from Lack of Hydration: 1. Medication needs water to properly process. Lack of hydration makes medication less effective. 2. Lack of swallowing—when there is decreased water intake 3. Poor digestion 4. Water stimulates appetite; therefore, a lack of water may result in a lack of appetite and poor eating habits. 5. Decreased orientation, which may contribute to falls

6. Weakness 7. Constipation—inability to void toxins A simple rule is to drink eight 8-ounce glasses of water a day or half your body weight in ounces. STIMULATING THE SENSES Spending time eating with an older adult creates an opportunity to socialize and stimulate all of the senses of the body. These include the sense of touch, smell, sight, hearing, and taste. The process of cooking meals stimulates the sense of smell, which stimulates the appetite and the combined taste for food. Conversation stimulates the senses of hearing and sight, as well as touch, while eating food and receiving loving and caring hugs. What a huge impact one meal will have on someone’s health, feelings, and self-esteem! FEELING THE LOVE Compliments and conversation rule when it comes to making your older adult feel loved. “Great outfit today, Mom or Dad! I sure look forward to spending the afternoon with you. Let’s go do your favorite thing, or would you help me with the cooking? “You look happy today!” As we age, we all need assurances that we are noticed, complimented, and included in activities and events. Today is a great day to make your older adult feel loved, needed, and purposeful. Words of affirmation create neurological changes in the brain that stimulates the immune system and help ease the feelings of depression, especially on one of those “blue” days. DON’T SWEAT THE SMALL STUFF Many seniors fear losing independence. I get that, but what is really important? Paying bills, organizing a trip, or calling the plumber are all very necessary, but is that really independence? Is independence about doing everything, or is it about doing what needs to get done that only you can do? The aging process carries neurological consequences that are out of anyone’s control. That’s where the family community comes in to soften the emotional blow. There is no need for an older adult to experience a loss of independence when you can make life easier. Independence is a mindset that is supported by the family. MAKING THE HOME A NO-FALLS ZONE Making the Home a Safe Environment

The family working together can easily make the home a safe environment. Installing grab bars in the bathroom and increasing the lighting throughout the house will make getting around easier. Removing loose cords and rugs and adding handrails on all steps and stairs are additional adaptations to make the home safe. These and other necessary modifications on how to make the home safe can be found at the Centers for Disease Control and Prevention— offering a home assessment checklist. A home falls prevention checklist can be found at: http://www. cdc.gov/HomeandRecreationalSafety/pubs/English/booklet_Eng_ desktop-a.pdf Making your home safe and removing the common tripping hazards are necessary when trying to prevent falls. In the Bathroom •Keep the area well lit •Use non-skid bath mats •Grab bars in bathrooms-toilets, bath, sink •Remove small throw rugs Kitchen •Move objects in shelves to lower levels •Remove unnecessary sharp or glass objects Halls/Stairs •Light switches at top and bottom of staircase •Reflective tape to see steps •Remove clutter Bedroom •Adequate lighting (lamp on nightstand) •Lit path to bathroom •Close drawers when finished using them •Keep cell phone close for emergencies CANES AND WALKERS FOR STABILITY Families know the importance of an assistive device for independence. Canes and walkers are considered assistive devices. Their purpose is to provide support, balance, and stability when walking. Many times, older adults are averse to using an assistive device because some believe it makes them “look old.” My advice to the senior is to consider how old they are going to feel if they don’t use the recommended supportive device and experience a fall. Falls

are not inevitable but preventable knowing the fall risk factors (see Chapter One). If the older adult is in pain, has poor posture, or walks apprehensively, their gait will show it. They may walk with a leaning forward posture, a shorter stride length, as well as, not picking up their feet which all can ultimately lead to a fall. This walking pattern will only worsen with time and a cane or a walker may be necessary for additional stability. There is no need for an older adult to experience a loss of independence when you can make life easier. Using a cane or a walker will assist an unsteady gait and provide the confidence needed to stand up straight and pick up your feet when walking. Strength, balance and stability can noticeably improve when walking with an upright and purposeful gait.

Chapter 7 The Fear of Falling and Next Steps What’s in this Chapter? 1. The fear of falling 2. Talking to the physician after a fall 3. Review medications 4. Annual vision and hearing testing 5. The financial costs of a fall 6. The red flag 7. Questions to ask if you believe a fall has occurred 8. Coping after a fall 9. Forgetfulness: it happens 10. What to do if a fall occurs 11. Getting up from a fall 131

“Take time to analyze your fears, recognize how and why you have them, then come up with ways of overcoming them.” —Natalie Dawn Bob, who is 74 years old, came to me for help because of his balance problems. Initially, he mentioned that he had difficulty with stairs and steps. He was very anxious with steps because he has had several episodes of stumbling and he didn’t want to fall.Balance was assessed and exercises instructed without any problems. But it wasn’t until I asked Bob about his glasses that we made some headway with his balance issues. He had bifocal glasses, which I knew would affect his stair climbing.I suggested he remove his glasses the next time he used the stairs, and that was all it took. His anxiety and apprehension were gone. It was a simple solution to a very common problem. *** THE FEAR OF FALLING Once an older adult has fallen, the fear of falling again increases, while their confidence with walking and other activities decreases. Those who fall are two to three times more likely to fall again. Also, older adults may find themselves limiting their daily activities because of the fear of falling, which is not to their advantage. Some seniors are more aware of those everyday unsafe activities and make modifications to create a safer environment. They might use a walker or cane to become more stable and independent. However, there are others who may not modify their activities, and their fear of falling can create an unhealthy mindset, leading to poor posture in an attempt to guard against a fall.

Ultimately, with repeated falls, the older adult becomes less active, less independent, and less mobile, creating a cycle that continues to repeat itself. Loss of confidence and independence with walking leads to further immobility. Less mobility creates an increase in muscle weakness, joint stiffness, and lack of proper posture and balance when walking. Once another fall occurs as the cycle repeats itself, the mindset of the older adult becomes more dependent on others and less active mentally, physically, and emotionally. After their first fall, older adults are more likely to fall again because they are now more apprehensive and cautious. Encourage your loved one to be open and honest about a fall, so you can seek help. Talking with your physician opens the communication between the older adult and family member for a falls risk assessment. If needed, a referral can be made to begin physical therapy and exercises focusing on strength, balance, flexibility, and posture. TALKING TO THE PHYSICIAN AFTER A FALL A family member should accompany their older adult to the physician visit if a fall has occurred. Further prevention is necessary, whether the fall was with or without an injury. The physician knows the fall risks factors and can implement simple in-office tests for balance, strength, and even memory. If necessary, the physician will refer the older adult for additional testing and even to a physical therapist if indicated. REVIEW MEDICATIONS It is important to review all the medications, prescription, and overthe-counter medications with your physician or pharmacist. Many medications have side effects or contraindications (combined with other medications) that may result in dizziness, nausea, or dehydration. Balance and walking coordination may also be affected by medication interactions, and a thorough physician review is necessary. ANNUAL VISION AND HEARING TESTING Annual eye and hearing checkups are necessary to help normalize daily activities without the limitations of poor sight or diminished hearing which may alter the daily surroundings. As the eyes change, so should corrective vision prescriptions and glasses. Bifocals can be very problematic with stairs and steps. If your loved one cannot hear the dog running his way, an unnecessary trip or fall may occur. Also, your inner ear is associated with balance, and a checkup can prevent a problem that might not be obvious at the time. Physician visits are

necessary as a falls-risk indicator, so your older adult can remain active and fit. THE FINANCIAL COSTS OF A FALL (Costs from the Centers for Disease Control and Prevention— Copied from CDC): http://www.cdc.gov/homeandrecreational safety/falls/adulthipfx.html “The Centers for Disease and Control and Prevention has reported that senior falls are among the 20 most expensive medical conditions. The costs of treating fall injuries increases with age. The average cost for a fall injury is over $30,000. These costs are calculated by direct medical costs, including fees for the hospital and nursing home care, physicians, and other professional services, rehabilitation, communitybased services, use of medical equipment, prescription drugs, and insurance processing. These direct costs do not account for the longterm effects of these injuries, such as disability, dependence on others, lost time from work and household duties, and reduced quality of life.” The good news is falls are not a natural phenomenon of aging. However, falls do occur and it is important to know the fall risk factors (see Chapter One) to minimize the physical, mental, and financial burdens for the entire family. THE RED FLAG Older adult falls are not just a senior problem, but an issue affecting the entire family unit. If an older adult is not being as socially active with friends or as active in the community as they once were and they become easily agitated, a red flag should go up. Find out how they spend their time each day. If a caregiver is involved, question them about the schedule and behaviour of the older adult. Remember, direct social interaction is huge and exercise is a must for a healthy lifestyle. QUESTIONS TO ASK IF YOU BELIEVE A FALL HAS OCCURRED If your loved one exhibits a change in behavior or difficulty getting around, it may be time to question them if a fall has occured. In some instances, you may not want to ask directly, but instead indirectly, such as, “Have you had any problems with your walker? Where were you when I called? Is something hurting you? If so, I would like to look at it.” Asking questions and assessing the home and the senior’s physical body and abilities are the best ways to

determine if a fall has occurred. The good news is as long as they are moving around, the fall was minor, but it is a wakeup call. COPING AFTER A FALL Family members, friends, religious leaders, and the community are all viable resources for an older adult who has fallen and now has an additional fear of another fall. Realizing a fall has occurred, there may be anxiety or apprehension from the older adult that another fall may occur and community support is needed. Discussing the fallrisk indicators and making lifestyle and environmental changes is showing love and concern for your loved one. Lifestyle changes can include taking away burdensome tasks and providing assurances that the senior has done nothing wrong and the family is present to meet all their needs. Forgetfulness: It Happens The fear of forgetfulness is as real as the fear of falling. Comforting your loved one with affirming words and actions, while downplaying a forgetful event, is important. Repeating, forgetting, and emotional outbursts should be met with a calmness and openness of caring words and actions. Many times talking about favorite events, looking at old pictures, or just telling humorous stories will reassure they are in a safe and loving environment. Older adult falls are not just a senior problem, but an issue affecting the entire family unit. What to Do if a Fall Occurs Falling is a terrifying experience that no one expects. It is important to discuss what to do if a fall should occur. The most important part of your body you want to protect is your head. If falling face down, then turn your head. If possible, putting your arms around your head will provide added protection. If falling forward or backward, turn your body so you land on your side. Try bending your knees as you fall and lowering your center of gravity to minimize the fall impact. You may be tempted to catch yourself with your arms outstretched, but try to resist. Falling on outstretched arms may lead to wrist or arm fractures. Try breathing out and bending your knees (get low to the floor) when falling to minimize your tension and lower the center of gravity, which will allow your body to absorb the fall. Getting Up From a Fall First, if a fall occurs, try to bend your knees and get your center of gravity close to the ground. If possible, grab onto something to slow your fall. Try to land on your side and roll. When you roll after

hitting the ground, your weight is dissipated and a direct hit to your hip or other joint is minimized. Second, do not extend your arms outward to catch your fall. Landing on an outstretched arm to catch yourself is never a good idea. Fractures are common to the upper extremity and will possibly add to the injuries received. Third, protect your face. When falling, bend. If you fall and are bending your knees and are able to land on your side and roll, then place your hands over your head and face. Rising from a Fall Following a fall, initially assess if you are hurt. If you are hurt, dial 911 for help or push your Medical Alert button. 1. Following a fall, assess the situation, take some deep breaths. 2. If you are alone and not hurt, then roll over on your side.

3. Push up to your hands and knees, crawl to a chair. 4. Place both arms on chair, one foot underneath you.

5. Push up, turn, and sit on the chair.

6. Relax and take some deep breaths.

7. All is good.

A good way to prepare for getting up after a fall is to practice at home with a family member, caregiver, or friend. Here are some helpful hints to consider before getting up after a fall: * Lie still to get over the anxiety from the fall * Breathe deeply and calmly to relax * Slowly move your hands/fingers, legs, feet/toes

Falling isn’t an inevitable part of aging. Prevention is the key to any fall, and knowing how to prepare the older adult for an active and independent lifestyle is paramount. I’ve outlined in this book an action plan to minimize the physical limitations that may contribute to a fall. I believe a family’s involvement and commitment is the key to providing their older adult with the tools necessary for a healthier, independent, and active life.

CONCLUSION In Stand Tall, Don’t Fall, I trust I have made the case to inform and demonstrate the how, when, and why of staying fit and active to avoid some predictable pitfalls of growing older. The process is gradual, but the rewards are long term. Handling health issues are everyone’s concern. My goal is to shed some light on issues of older adults and to inform them, their families and caregivers of the benefits of staying active, independent and fit. The first step to a healthy and safe lifestyle is to know your “IMAGE,” know the fall risk factors and commit to a daily exercise routine. Encouraging the older adult with love and time is the best gift we can give. This is not a glamorous topic but one we will all need to know. Keeping the older adult active, independent, energetic, happy, and productive improves a quality of life the entire family can enjoy. So, start today and keep the loved one in your life fit and moving! To find out more information about me, go to my websites: www.casephysicaltherapy.com www.keepfitandmoving.com. Facebook: Keepfitandmoving

ABOUT THE AUTHOR FORMER HIGH SCHOOL and college athlete and current exercise enthusiast, Bill Case, is a physical therapist who understands the injury and recovery process. He graduated from physical therapy at the University of Texas Medical Branch (UTMB) in Galveston, TX in 1982. For more than three decades, his practice has been dedicated to assisting patients in achieving proper flexibility, muscle strengthening, balance and posture to facilitate their rehabilitation goals. A leader in physical therapy innovation, Bill invented the diagonal rotary patterning exercise machine. He is also a national and international lecturer on orthopedic injuries and a published

authority on exercise, injury, and injury prevention. Bill is a contributing writer to Self, Men’s Health, Fitness and Prevention magazines and the coauthor of SPORTS PHYSICAL THERAPY. As founder and co-sponsor of Houston’s Annual Senior Falls Prevention Day, he scripted and produced Keep Fit and Moving (DVD) for older adults to help prevent falls. As a specialist, athlete, husband and parent, physical therapy has helped Bill stay in the game, while keeping up with his wife, Karen, and four active, athletic sons, William, James, Michael, and Christopher.

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REFERENCES Price, Joanne. Fall Injury Prevention for Older Adults. Lincoln, NE: iUniverse, 2007. “Exercise for Frail Elders,” Human Kinetics, accessed 2016, www. humankinetics.com/ products/ all-products/ exercise-for-frail-elders2ndedition. Moffat, Marilyn and Carole B. Lewis. Age-Defying Fitness. Atlanta, GA: Peachtree, 2006. Smith, William. Exercises for Better Balance. Hatherleigh, 2015 Tideiksaar, Rein. Falls in Older People. Fourth Edition. Baltimore, MD: Health Professions Press, Inc. 2010 Gurian, Michael. The Wonder of Aging. New York: Atria, 2013 Schneider, Ellen. “Implementing Effective Falls Prevention Programs in Your Community: Reaching New Audiences.” National Council on Aging. August 21, 2014. “Tight hamstrings will affect posture, movement, and function.” Stretching-Exercises-Guide, accessed 2016, www.stretchingexercisesguide.com/tight-hamstrings.html

“How much physical activity do older adults need?” Centers for Disease Control and Prevention, accessed 2016, https://www.cdc.gov/ physicalactivity Lemaire, “Biomechanics of Elderly Gait.” “6 Steps for Preventing Falls Among Your Older Loved Ones.” National Council on Aging, accessed 2016, https://www.ncoa.org/ …/fallsprevention/ preventing-falls 149 150 Stand Tall, Don’t Fall

“The Importance of Independence for Seniors.” Accessed 2016, Info Center (/home/info-center) “Falls and Older Adults.” NIH Senior Health, accessed 2016, https://nihseniorhealth.gov/falls/ toc.html “A Complex Coordination of Central and Peripheral Systems,” The Human Balance System, accessed 2016, https://vestibular.org/sites/default/ files/ page_files/Documents/Human%20Balance%20System.pdf “Good Balance is often taken for granted,” The Human Balance System, accessed 2016, Vestibular.org › About Vestibular Disorders., www.healthycellsmagazine.com/articles/good-balance-is-oftentaken-for-granted “Posture Problems,” Ask the Trainer, accessed 2016, www.askthetraineronline.com Additional Resources: American Society on Aging 833 Market St., Suite 511 San Francisco, CA 94103-1824 www.asaging.org American Council on Exercise 4851 Paramount Dr. San Diego, CA 92123 www.acefitness.com Alliance for Aging Research 2021 K Street, NW, Suite 305 Washington, DC 20006 www.agingresearch.org Arthritis Foundation P.O. Box 7669 Atlanta, GA 30357-0669 www.arthritis.org National Council on Aging www.ncoa.org Centers for Disease Control and Prevention www.cdc.gov NIH Senior Health www.nihseniorhealth.gov