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A severe personal injury occurred as a 70-year-old client in a health club fell and broke his arm while doing an exercise to improve his balance. The injured client was the plaintiff in a suit in which the personal trainer was named as the defendant. I assisted the attorney representing the plaintiff.

On numerous occasions, the plaintiff informed the defendant that his balance was getting worse. The defendant had the plaintiff do lunging exercises and the plaintiff often lost his balance and fell to the left and right. When the plaintiff asked the defendant if there were other balance exercises, the defendant stood ~10 feet away and threw a small ball while the plaintiff stood and tried to balance on one foot. While the plaintiff was standing on his left foot, the defendant threw the ball too far to the plaintiff's left. While trying to catch the ball, the plaintiff lost his balance, stumbled 5 feet, and fell to the floor onto a row of kettle ball weights and broke his arm.

Poor balance can be the result of three factors: age, disease and deconditioning. In this case, one can rule out disease. Age: Muscles of the body are composed of two types of fibers, namely, fast-twitch (FT) fibers associated with strength and speed and slow-twitch (ST) fibers associated with endurance. With age, there is a loss of muscle fibers, especially in the lower extremities. In addition, there is a greater loss of FT fibers, resulting in decreased strength and speed of contraction. Combined with a reduced function of the nervous system, there is a slower speed of reaction to a disturbance in equilibrium. Deconditioning: As people age, they generally become less active. This increases the loss of strength and this reduced lower-body strength is an important factor associated with falls in the elderly. In addition, older people do fewer activities that require balance and quick reactions; these factors are also associated with falls. There are a number of exercises that can be done to improve lower-body strength. For a person with poor balance, these are best done on an exercise machine where balance is not a problem, compared with lifting free weights.

Balance training exercises are an example of "controlled instability", that is, they should be done in an environment that is safe and supervised. When working with an older client who has balance problems, one should always start with exercises that are relatively easy to do and are supervised until it is clear that the client can do them with little or no difficulty. The difficulty of the balance training exercises then should be gradually increased to be part of an effective program. However, more important than efficacy, client safety is the first priority. Most programs and exercises designed to improve balance in the elderly suggest strongly that they be done next to a bar, rail, table, chair, etc. for safety reasons. As an alternative, another person could be close by to provide support. Generally speaking, programs to improve balance in the older person begin with such static balance tasks as standing on one leg with eyes open and closed. In all cases, there should be something nearby that the person can use for support if there is a loss of balance. Dynamic balance tasks also can be done. An example would be walking along a narrow line with eyes open and closed. In this case, something or someone should always be nearby in case there is a loss of balance. Thus, it is obvious that for safety reasons, these exercises should always be done with nearby support, especially in the case of an older person who has impaired balance.

The expert witness for the defendant argued that lunges and catching a ball while standing on one foot were appropriate balance exercises. My opinion was that lunges can be done safely by a young person with no balance problems. In the present case, lunges were inadequate to improve strength and an unsafe way to improve balance because the plaintiff often fell while attempting to do them. Asking a client to catch a ball while standing on one foot also might be a good balance exercise for a young person, but the balance demands are too great for an older man with impaired balance. Given that there was no support nearby and that the defendant was ~10 feet away (that is, not close enough to assist when the plaintiff lost his balance), this was an unsafe exercise. The fact that the plaintiff had difficulty doing lunges, it was imprudent and unreasonable to expect that he could do an even more difficult exercise. This is analogous to expecting a client to lift 200 pounds when he had difficulty lifting 150 pounds.

Attorneys for the plaintiff and the defendant settled the case out of court. I was not informed about the settlement.

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James Skinner, PhD specializes in the field of Exercise Physiology and is a Professor Emeritus, Department of Kinesiology at Indiana University. A former president of the American College of Sports Medicine (ACSM), he is one of five investigators of the HERITAGE Family Study on the role of genetics in the response of cardiovascular disease and diabetes risk factors after training. He received the 2014 ACSM Honor Award, the highest award in his field. In 2011, he received the Doctor Honoris Causa from Semmelweis University in Budapest, Hungary.

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