Osteoporosis, Age, Parkinson’s decrease dynamic balance and increase fall risk

Motor abilities influence an individual’s success in the performance of certain motor skills (Magill & Anderson, 2013). A motor ability of interest is dynamic balance, or the ability to maintain stability while one is in motion, as there is a strong correlation between poor balance and falls (although it is not the only factor), which are a large health concern among many populations (Ünlüsoy et. al 2011). I have had many clients with various conditions, including age, Parkinson’s disease, and osteoporosis, who were unsteady during locomotion due to poor dynamic balance.

All three of these conditions, age, Parkinson’s disease, and osteoporosis, have a negative influence on the dynamic balance category of motor abilities (Paolucci et. al 2014; Ünlüsoy et. al 2011). Age-dependent change in the musculoskeletal, sensory, and neural systems decrease balance ability in older adults (Maki & Mcllroy, 1996). Parkinson’s disease occurs in the brain’s basal ganglia when there is a lack of dopamine production in the substantia nigra, and it causes bradykinesia, akinesia, tremor, and muscular rigidity (Magill & Anderson, 2013).  Paolucci et al. (2014) state that a “balance disorder is one of the most important impairments” in this population due to statistics showing substantially greater incidence of falls among those with PD (70% of individuals with PD fall once a year and 50% of them fall twice a year in comparison to only 30% of healthy adults over the age of 65 who fall once in a year). Osteoporosis is a bone disease where bones become increasingly fragile from microstructure impairments in the bone tissue and decreases in bone mass. Ünlüsoy et. al (2011) demonstrated that dynamic balance in osteoporotic women was significantly worse than in healthy individuals.

There are many factors influencing one’s ability for dynamic balance during locomotion including muscle strength, interpretation of vestibular and proprioceptive information, and visual feedback (Paolucci et. al 2014). In terms of defining dynamic balance or any type of balance as a motor ability, Magill and Anderson (2013) state balance is a “multidimensional ability that is specific to the task or skill in which balance is involved,” and the specificity of motor abilities hypothesis postulates that individual motor abilities are relatively independent of one another. Given these assumptions, it is challenging to articulate the specific balance ability or abilities influencing locomotion.

If a client or patient came to me requesting help with dynamic balance while walking, I would perform various tests to rule out (or in) factors that may contribute to difficulty walking. I would assess muscular strength and endurance, especially in the lower extremity, observe the patient’s normal walking gait for noticeable abnormalities, and inquire into the patient’s medical history to rule out diseases or conditions, including those previously discussed, that may impact dynamic balance. I would also question the patient about lifestyle factors (i.e., recent accident or trauma, change in medication, etc.) that may be contributing to the deficit. If the patient has good muscle strength in the lower extremity, adequate gait mechanics, and no red flags in his or her medical history, this would indicate a problem with the motor ability of dynamic balance.

Additional ideas of assessments for dynamic balance related to gait were reviewed in a study by Bloem et. al (2016). This study recommended clinical tests including the UPDRS-derived Postural Instability and Gait Difficulty score, Berg Balance Scale, Mini-BESTest, Dynamic Gait Index, Freezing of Gait Questionnaire, Activities-specific Balance Confidence Scale, Falls Efficacy Scale, Survey of Activities, Fear of Falling in the Elderly-Modified, 6-minute and 10-m walk tests, Timed Up-and-Go, and Functional Reach (Bloem et. al, 2016). Further research on my part is needed into these methods, but any would be reliable assessments of dynamic balance.

Motor abilities limit a person’s success in performing a motor skill. In the case discussed, dynamic balance is a motor ability that, if affected, can decrease one’s success at walking without falling. I believe it is important to note that while motor abilities may limit achievement in another skill, motor abilities themselves can be practiced, coached, and improved which would also benefit the motor skill performance. The most important part of treating a motor ability deficit is identifying and distinguishing it from other possible causes of poor motor skill performance.


Bloem, B. R., Marinus, J., Almeida, Q., Dibble, L., Nieuwboer, A., Post., B.,…Schrag, A. (2016). Measurement instruments to assess posture, gait, and balance in Parkinson’s disease: Critique and recommendations (abstract only). Movement Disorders. doi:10.1002/mds.26572

Magill, R. A. & Anderson, D. I. (2013). Motor learning and control: Concepts and applications (10th ed.). New York, NY: McGraw Hill.

Maki, B. E. & Mcllroy, W. E. (1996). Postural control in the older adult (abstract only). Clinical Geriatric Medicine, 12(4), 635-58.

Nakano, W., Fukaya, T., Kobayashi, S., & Ohashi, Y. (2016).  Age effects on the control of dynamic balance during step adjustments under temporal constraints. Human Movement Science, 47, 29-37. doi:10.1016/j.humov.2016.01.015

Paolucci, T., Morone, G., Fusco, A., Giuliani, M., Rosati, E., Zangrando, F., & … Iosa, M. (2014). Effects of perceptive rehabilitation on balance control in patients with Parkinson’s disease. Neurorehabilitation, 34(1), 113-120. doi:10.3233/NRE-131024

Ünlüsoy, D., Aydoğ, E., Tuncay, R., Eryksel, R., Ünlüsoy, İ., & Çakcı, A. (2011). Postural Balance in Women with Osteoporosis and Effective Factors. Turkish Journal Of Osteoporosis / Turk Osteoporoz Dergisi, 17(2), 37-43.


A Case For Crawling…In Your Workout!

When was the last time you crawled?

On your hands and knees or hands and toes?
Forward, backward, sideways, clockwise, counterclockwise?oksanakuzmina7

Many haven’t crawled since they learned to walk as babies.

Go crawl right now. On your hands and toes, down and back in the nearest hallway. I DARE YOU!

I bet it’s harder than you thought it’d be!

Crawling is called a primitive movement (along with rolling, pushup, and quadruped). It’s a basic, yet critical, pattern we learn during our physical and neurological maturation as it develops the strength, coordination, and stability that translate into higher level activities such as running and climbing.

Crawling is similar to many things in life; if you don’t use, it you lose it! Your body forgets how to crawl, how to recruit muscles in those fundamental patterns, how to stabilize your body in dynamic positions, and how to coordinate arm and leg movements. Your ability to move (pain and injury free) deteriorates from there because the foundation is gone!

I’ll show you how to start rebuilding your foundation. The most fundamental of the many styles of crawling is the bear crawl (or table top crawl).


In this crawl, the opposite arm and leg move together. The left leg and right arm “step” forward, then the right leg and left arm “step” forward. The challenge is keeping your back straight and hips level through the movement. With clients, I’ll place a foam roller or light, plate-like object on their lower backs while they crawl, forcing them to stay level during movement to prevent the object from falling.

From Eric Cressey’s High Performance Handbook I learned a variation of this crawl where you inhale as you take each “step” then hold the position in place as you exhale,”crunching” your ribs down toward your pelvis.

Once you master forward crawling, then comes backward crawling, sideways crawling, and circular crawling….next add resistance!

Resistance can be added as a weight plate on top of your hips, resistance bands around your hips or shoulders, towing a kettle bell behind you, etc. Just don’t venture there until mastering the basic technique!

I like this video of some other crawling variations:

Here’s your challenge: 

  • Add 3 sets of 20 steps of bear crawls into 2 of your workouts this week, in your warm up or as a superset to another exercise.
  • Post a video and tag or hashtag K8IrelandActive bear crawling!
  • Comment below with your thoughts on crawling after giving it a try.

For more reading about crawling check out:

Functional Movement

Marks Daily Apple

The Often Overlooked Warm up

Arrive at gym. Check-in at the front desk.  Walk to treadmill. Start running.
Arrive at gym. Check-in at the front desk. Walk to bench press. Perform working sets of exercise.
What’s missing here? The warm up! And by “warmup” I don’t mean 3 arm circles before benching or a 5 second quad stretch and toe-touch before running.

Why should you warm up?

It took me a few years of working out before I started to value my warm up. I neglected it because 1) I didn’t know how to warm up, and 2) I “couldn’t” spare the time before hitting the weights. Not warming up all that time is probably one of the biggest reasons I acquired so many injuries, aches, and pains along the way. Here are some benefits to having a proper warm up:

  • Increases body temperature (literally warms up the body)
  • Lubricates joints
  • Engages the nervous system (did you know a lot of our strength gains are attributed to the nervous system?)
  • Muscle flexibility, extensibility, and ability to achieve a full range of motion
  • Educates the body about or solidifies proper movement patterns
  • Focuses the mind on the workout ahead
  • Brings awareness into the body
  • Prevents injuries

My weightlifting journey and how my warmups have progressed:

I’ve always believed I can do anything I put my mind to, and during my freshman year at UCLA, I decided to become a runner like my mom and what better, extreme way than to sign up for a marathon. I started training in January, running the longest distance I could, 1 mile. I ran my booty off over the next 5 months, and in June, I completed the marathon. I was a runner. Well, turns out, I can run, I just don’t like to. After finishing that marathon, I had no desire to run that much ever again. So, I started weight lifting (long tangent there, I know, I’m going to talk about warm ups now), and here I am almost 6 years later.

At first, there were no warm ups in my routine. It wasn’t too big of a deal, I suppose, because I was 19 years old and lifting relatively low weights. As my lifts got heavier, I started including one warm up set at about 50% of my “work” weight in the first exercise of my workout. Next, I got a little crazy (hint: sarcasm) and added 3 whole minutes of cardio before embarking on my one warmup set. Then, 3-5 minutes of cardio, foam rolling, and a warmup set. Currently, I’ve cut out the cardio, and I include foam rolling/small ball rolling and 4-8 mobility drills in my warm up before some lighter sets on my first exercise (only if it’s a heavy lift).

Foam Rolling

Foam rolling is a great way to increase circulation and flexibility/extensibility before a workout and break up adhesions in muscle tissue. It’s a better alternative to traditional stretching (holding a static position for 30 seconds) before a workout because traditional stretching has been shown to make muscles too lax (not elastic enough) when done before resistance training and can lead to decreases in strength and greater risk of injury.

If you’ve been reading a lot of my posts, you should know by now that I’m a huge fan of Eric Cressey’s coaching and articles. Here is his video of a great foam roll/small ball rolling series to include before each workout. I do this on each side of the body (give or take some of the small ball exercises and the pec foam rolling) for 10-15 seconds per body part before each strength training workout. It may take a long time to perform for the first week or two, but eventually this becomes a pretty quick routine. One tip: to avoid placing the lower back in a bad position (excessively arched), stay on your elbows when rolling in the face down positions.

This foam rolling routine can be performed any time during the day but should be done at least once a day on workout days. I find it easiest to include in my warm up.

To read more about foam rolling and how it benefits the body, check out one of Eric Cressey’s articles here.

Mobility Drills

These are dynamic movements (meaning, they aren’t held like a traditional stretch) that target different regions of the body and various movement patterns. This is a good place to put a little work into personal deficits (for me, raising my shoulders overhead) and commonly injured areas. I tend to scour Eric Cressey’s articles for mobility drills that fit my current needs. A simple Google search of “Eric Cressey [body part] mobility” tends to bring up good exercises. I also use Kelly Starrett, Bret Contreras, Sohee Lee, and Layne Norton as resources for warm up drills.

Top areas of the body to address during warm up are:

  • Ankle Mobility  (1 of these should suffice)
    • Wall Ankle Mobilization with Adduction/Abduction
    • Rocking Ankle Mobility
  • Thoracic Spine Mobility (1-2 of these, maybe 3 if it’s a weakness or an upper body day)
    • Bench T-Spine Mobilization
    • Back to Wall Shoulder Flexion
    • Bent Over T-Spine Rotation
    • Side Lying Windmill
  • Hip Mobility (3-4 exercises)
    • Wall Hip Flexor Mobilization
    • Supine Bridge with Reach
    • Yoga Pushup
    • Spiderman with Hip lift and Overhead Reach
    • Bowler Squat
    • Alternating Lunge with Overhead reach (Hips and T-Spine)

For any of these exercises, perform 5-8 reps (per side), slow and controlled. Some other tips for efficient warm up structure: Order the exercises from those done on the floor to those done standing to those done moving and go from single-joint exercises to compound/multi-joint ones. For a faster warm up, stick to the compound drills that hit multiple joint targets, like the alternating lunge with overhead reach.

My Current Warm Up:

To be honest, I can’t take credit for it; I found it in one of Sohee Lee’s articles. It’s done wonders for keeping me injury free this last month. I’m often modifying it, though, adding and subtracting certain drills to fit my specific needs. This is a great place to start.


A. Bird dogs X5/side

B. Rocking Ankle Mobility X5/side
(See video above)

C. Wall Hip Flexor Mobilization X8/side
(also in a video above)

D. Bent over T-spine Rotation X5/side
(video above)

E. Back to Wall Shoulder Flexion X8
(video above)

F. Glute Wall March with Iso Holds 2 X 5sec hold/side

G. Bowler Squat X5/side
(Video above)

H. Cradle walk to spiderman with hip lift and reach X5/side
(Video above)

This warmup takes 15-20 minutes, and by the time I’m finished, I’m sweaty, mobile, and ready to kick ass with my lifts.

For more reading about warm ups check out Eric Cressey’s 6 Characteristics of a Good Dynamic Warm-up.

What is your warm up? Let me know if you give mine a try!

Shoulder Rehab: Take #2

Shoulder injuries are common, and I encountered many patients with them while working as a physical therapy aid. Frozen shoulders, impingements, labrum tears, dislocations, separations, and rotator cuff tears are few that come to mind.

Individuals embark on fitness quests to lose weight, get strong, try a new activity, without giving a thought to shoulder health, when just a few regularly done exercises and a bit of shoulder awareness can go a long way toward keeping one out of a doctor’s office, or surgical suite.

Last week I went over some shoulder anatomy. I discussed the joints, “major mover” muscles, and smaller stability muscles. Check it out if you missed it. The last few components to cover are the ligaments and labrum.

  • Ligaments (connect bones to bones) play an important role in stabilizing the shoulder joint and help create a structure called the shoulder capsule. There are many ligaments in the shoulder joint but two to note are the Acromioclavicular (AC) ligament and Coracoacromial ligament. The AC ligament holds the clavicle (collar bone) to the acromion of the scapula (shoulder blade) and the Coracoacromial ligament holds the acromion from the back of the scapula to the coracoid process on the front of the scapula.


  • The Labrum. The tough trade off that comes into play with joint anatomy is that between mobility and stability. Joints tend to have one or the other. The shoulder is one of the most mobile joints in the body, but it lacks stability. Check out the glenoid fossa of the scapula, the “socket” that holds the arm to the body:
    It’s not deep. It doesn’t encapsulate the humerus (arm bone) either. This is where the labrum helps (a little bit). The labrum is a soft layer of connective tissue that lines the inside and rim of the glenoid fossa to give it depth and better secure the arm to the body.
    glenoid cavity and labrum

Common Shoulder Injuries

As stated in the beginning, there are quite a few injuries that can occur in the shoulder. I’ll never forget learning mechanisms of injury (methods of getting hurt) in one college class called Biomechanics of Musculoskeletal Injuries. “Falling on an outstretched arm” is one of the easiest ways to acquire shoulder injuries. So, just don’t fall like this and your shoulders should be okay ;-).


  • Frozen Shoulder, also called adhesive capsulitis, is a condition where the shoulder capsule becomes inflamed and stiff with restricted range of motion (ROM) and pain. This condition is also the source of many of my terrible physical therapy dad jokes (Oh, your shoulder is frozen? It doesn’t feel that cold). Sometimes frozen shoulder occurs from lack of use of the shoulder, usually due to pain or other injury (for example if the arm is immobilized in a sling for a long period of time). Other times, frozen shoulder may happen spontaneously without an obvious trigger. One way to prevent this condition is to move your shoulder through the entirety of its ROM on a daily basis and address pains that prevent this movement in a timely manner.
  • Shoulder Separation. One of the more common ligament injuries (also called sprains) in the shoulder occurs in the AC ligament and is known as a shoulder separation. The AC ligament connects the clavicle and the acromion of the scapula. You can feel the location easily; it’s the big bony point at the top of your shoulder.
    95362-1There are 6 grades of severity in this injury. Grade 1 is the least severe, an overstretched, partially torn AC ligament, and Grade 6 is the most severe, including a complete rupture of the AC ligament, separation of those two bones, and injury to other nearby ligaments and structures. Shoulder separation injuries occur from direct impact to the shoulder (from a fall, car accident, sports accident).
  • Muscle injuries (called strains) can occur in the bigger muscles (deltoid, latissimus dorsi, pectoralis major) or the smaller muscles (rotator cuff muscles, long head of the biceps, long head of the triceps). One reason injuries of the shoulder are easy to acquire is that there are a lot of muscle tendons (tendons are on the ends of muscles and connect muscles to bones) and ligaments running through the joint and not a lot of space between the bones. When one of these gets irritated and even slightly swollen (inflamed), the pressure from that increase in volume between the bones causes pain and irritation in a lot of nearby tissues.
  • Dislocations or partial dislocations, called luxations or subluxations, also occur in the shoulder joint, primarily because of that tradeoff between mobility and stability. The size of the muscles and structures holding the arm in the shoulder are fairly small and unstable (compared to those in other joints, for example those holding the leg in the hip).  95% of shoulder dislocations occur anteriorly, or to the front of the body from direct blows to the shoulder or falling on an outstretched arm.
    The other directions of dislocation are posteriorly (to the back of the body), often from electric shock or seizure, and inferiorly (downward) which is the rarest kind. The process of fixing a dislocation or returning the arm to its socket is called a reduction, and [PSA] if you ever find yourself with a dislocated shoulder, please fight the urge to reduce it yourself, and let a medical professional do it.
  • Labrum Tears. The labrum lines the “cup” where the arm bone is held to the shoulder blade to give a little more stability and security to the joint. It can be damaged during repetitive shoulder motions (throwing, weightlifting) or from traumatic incidents (falling on an outstretched arm, direct blow to the shoulder, sudden pulling of the arm, quickly reaching overhead to stop a fall or slide).

Prevent Shoulder Injuries

While we can’t do much to prevent injury from freak occurrences like falls and accidents, there are a few weekly or bi weekly exercises and a few avoidances as well that can help prevent shoulder injuries.

  1. Strengthen the rotator cuff muscles (teres minor and infraspinatus) with external rotations. This will increase the size of those muscles, the space in the shoulder joint, and the stability of the shoulder. Start really light with these movements, but don’t be afraid to increase strength. Don’t go to failure, though. This can leave the shoulder unsupported and more prone to injury.

    Notice how these are performed with the arm at a 30 degree angle from the body and not right alongside it.
  2. Learn how to bench press properly! Keep your shoulder blades retracted and depressed, have a little arch to your back, keep your elbows at a 45 degree angle to your body, and use your feet. Check out Eric Cressey’s Shoulder Savers Article for more information on correct form.
  3. Back Attack! Use the Seated Cable Row with strict form to train proper scapular retraction (squeezing shoulder blades together behind the body).
  4. Upright row with caution. Done with a barbell, the humerus is extremely internally rotated and is elevated into the “impingement zone” each rep.  A safer option is performing it with dumbbells (or not at all).
    upright row
  5. Maintain your mobility! Try out this awesome warmup.

For more reading on healthy shoulders check out:

Eric Cressey’s Shoulder Savers Part 1, Part 2, Part 3.

What do you do to keep your shoulders healthy?

Weekly Rehab: Neck Tension

Injury prevention and rehabilitation are major interests of mine  (hence my quest to become a physical therapist) so I’ve decided to have a weekly series addressing common pains and injuries that come with active lifestyles (because what active person wants to be stuck on the couch due to an injury from being active– the thing thats supposed to make us less likely to be sick or injured). In these posts I’ll discuss injuries, the anatomy of these injured areas, possible causes, prevention, and remedies. As a huge disclosure: I’m not a medical professional (yet), please do not follow my advice if it goes against your doctor’s orders or your better judgement.

This week I’m going to focus on the neck.


There are 2 reasons I’m starting here: 1) Pain in this area affects so many people 2) This area has given me significant trouble lately. I have always had very tense neck and shoulder muscles, and recently, it’s led to tension headaches especially after my upper body workouts (Booooo!).

Some significant contributors to tension in this region include:

  • The scalenes and sternocleidomastoids (SCMs) on the sides and front of the neck


  • The large trapezius, the levator scapulae, and lots of other little sub occipital muscles along the back of the neck


  • And the pectoralis major and minor in the chest, below the clavicle (collar bone) and attaching to the arm


My hypothesis is that a big factor of tension/tightness in the neck is poor posture and, more specifically, a forward head and associated forward-rounded shoulders.

How do we end up in such a posture? Well, 2 major culprits are this:


and this: bad-posture-620w-from-CBS-News

Despite my best efforts, I’m guilty of both. As you can see in diagram above, the more forward the head is positioned relative to the body, the heavier it pulls on stabilizing structures (i.e. the bones and muscles of the neck). The scalenes and SCMs on the front and sides of the neck spend many hours each day in a shortened state (contributing to the “tightness” we feel there). The sub occipital muscles, levator scapulae, and upper trapezius are constantly overstretched and overworked, which may be why many experience muscle spasms leading to knots and trigger points (and tightened muscles) in those areas.

And, yes, there are other causes of neck pain and tightness including stress, prior trauma, structural conditions in the vertebrae, nerve irritations, etc. but posture is the only one I’m going into now because this is a blog not a book.

Weekly Rehab Fix:  

Firstly, we are going to be mindful of our sitting and phone postures.

Secondly, here is a routine to try 1-3 times each day for the next week. Please, listen to your body as you do these activities. Pain is the body’s signal that something is not right. If you have pain with any of these, modify the range of motion to eliminate the pain or don’t do the exercise.

  1. 1-Arm Doorway Pec Stretch, 3X 30 seconds on each side
    Start with the arm against the wall, at a 90-degree angle to the body, and lean forward (keeping your head and neck in a neutral position) until a slight stretch is felt in the chest.
  2. Scalene Stretch, 3 X 30 seconds on each side
    This stretch comes from Kelly Starrett who has a youtube series called “Mobility WOD” (WOD=Workout of the Day). Place one arm behind the back. Tilt the head toward the opposite side, ear toward the shoulder, and from that position rotate the chin slightly toward the ceiling. To increase the stretch, press down gently on the tightened scalene and SCM just above the clavicle (collar bone). Follow this link  to see Kelly’s video demonstration at 2:25. He uses a band to anchor the arm behind the back. Try it that way if a band is available, but you should feel a good stretch even without the band.
  3. Levator Scapulae Stretch, 3 X 30 seconds on each side
    This is another stretch from Kelly Starrett. Place one arm overhead, bent at the elbow, as if doing the typical triceps stretch. The palm of this hand should be oriented toward the ceiling.
    Anchor the arm in this position by using a band (recommended by Kelly) or a stationary object (I place the palm of my hand against the underside of my fireplace mantle). Tilt the head toward the opposite shoulder and roll head forward until a slight stretch is felt along the back of the neck. To see Kelly’s video demonstration, click here and watch it at 3:00. Also, stay tuned into my instagram (K8IrelandActive) this week for my demonstration of the stretch. I feel this stretch very intensely, so I don’t need to apply any pressure to my head with my opposite hand. My hand also goes numb quickly in this overhead position so I only hold it for short 30 second intervals. While doing this stretch it is very important to listen to your body’s pain signals and move into and out of the stretch slowly, with caution.
  4. Small ball soft tissue work in the pecs: 1 minute each side of the chest
    Using any kind of moderately firm small ball (tennis ball, lacrosse ball, softball, racquetball), massage the chest muscles by sandwiching the ball between you and a wall and moving side to side and up and down. Make sure to focus on the area in front of the armpit where the pecs cross to the arm and the area below the clavicle (collar bone). Side Note: I try to do this exercise from the comfort and privacy of my home, especially being female.
  5. Small ball soft tissue work in the traps: 1 minute on each side of the spine
    Using the same ball as in the previous exercise, sandwich it between your upper back and the wall. Move side to side, up and down pressing against the ball to massage the area. Hug the arms across the chest to work between the scapula (shoulder blades). When you feel big “knots” or bumps in the muscles, move back and forth over them for a little bit.

I’m going to follow my own advice on this and perform this routine at least once a day for the next week, and I encourage you to give it a try because it only takes 13 minutes. Stay tuned into my instagram, K8IrelandActive, for videos and pictures of my progress, and please let me know if you give it a try!