On Balance: An Interview With Balance and Falls Expert Molly Roffman

by Connie Zuckerman

Molly Roffman, PT, MA, CEEAA is the founder and director of StepWISEnow Balance Fitness. She is a licensed New York State physical therapist specializing in fall prevention and balance training. Molly’s experience in the rehabilitation of patients who sustained fractures and other fall-related injuries inspired her to develop StepWISEnow. Recently agebuzz Co-Founder Connie Zuckerman sat down with Molly to discuss her work and her wisdom regarding maintaining balance and preventing falls in older adults.

Molly- Thank you so much for taking the time to share your thoughts with agebuzz readers! First, I would love to know a bit about how you came to work with older adults to help with balance and strength issues. How did you come to specialize in the work you currently do?

My interest in becoming a physical therapist and in working with older adults first began as a teenager during a volunteer position at a local nursing home. I believe I was also inspired by my close relationship with my grandmother. 

I began my physical therapy career in pediatrics working for 15 years with infants, children, and young adults with developmental disabilities in a variety of settings. Upon returning to work after a childcare hiatus, I decided to resume my career with older adults. I became certified as an Exercise Expert for Older Adults and began working in rehabilitation, nursing home, and home care settings. 

The majority of patients referred for treatment in these settings had suffered an injury from a fall, often with devastating consequences that extended beyond the injury itself. I saw firsthand what we know to be true, which is that falls are the main reason for the loss of independence in older adults. 

At that time I was discouraged by the lack of resources available in the community either to improve balance proactively or to regain balance after discharge. It became evident that there was a gap in the continuum of care for older adults and that something needed to be done to bridge that gap. 

In looking for solutions to bridge this gap, I learned that programs had already been developed that had been researched and proven to reduce fall risk for older adults. These programs were recommended by the CDC (Centers for Disease Control and Prevention) and NCOA (National Council on Aging) and yet they were not well known or readily available in the community. 

I set out to research these programs and to become certified to provide them in order to make them available and begin to build the bridge.

Can you talk about your StepWISEnow program? What is it and how does it work? 

The mission of StepWISEnow Balance Fitness is grounded in the knowledge that falls are preventable. Our goal is to provide high-quality, evidence-based balance fitness and fall prevention programming to the community and to draw awareness and resources to this vitally important mission.  

It’s important to recognize that falls are not an inevitable consequence of aging but are considered to be preventable. In fact, the New York State Department of Health states that falls are not accidents.

“Falls are not accidents! They are not random, uncontrollable acts of fate, but occur in predictable patterns, with recognizable risk factors and among identifiable populations. A fall is a predictable and preventable event.” 

 New York State Department of Health

While this definition is often met with surprise and sometimes anger, it is ultimately a hopeful definition because it means we have the power to take some measure of control over our ability to prevent a fall.

StepWISEnow combines evidence-based fall prevention programs such as Tai Chi for Arthritis & Fall Prevention, and A Matter of Balance: Managing Concerns about Falls, with balance fitness classes such as Line Dance and Balance Basics, and also balance component classes such as Core Connect and Seated Stretch & Strength, which focus primarily on strength and flexibility.

Each of our classes addresses one or more components of balance and we offer a variety of classes to meet the range of participant skill levels and preferences, which allows participants to progress and expand their balance skills. In order to improve our balance, we must continue to challenge it. 

It’s also important that our classes are fun and engaging. I believe strongly that group classes are very beneficial and potentially even more effective than individual sessions as we learn from, and are motivated and encouraged by, each other. 

Is there a “typical” person who enrolls in your program? Who would you describe as the ideal participant?

The ideal participant for StepWISEnow is really anyone over the age of 55! Balance is a complex skill that we often take for granted until we have that first misstep or fall. We know that there are often subtle changes in our balance beginning in our mid-to-late 50s, so it’s vitally important to be proactive about balance fitness. While we can improve our balance at any age, it’s always good to get a head start. 

Depending on the individual goals of the participant, one might attend for a set period to learn tai chi, which they can then do independently or they may choose to stay and continue to challenge and improve their balance with more advanced or varied classes. 

The majority of our participants are women, so we’d like to increase the number of men in our classes and to encourage more men to take balance fitness seriously. We know that men are more likely to die from a fall, so it’s important that men understand their risk and take preventative action. 

We also provide a safe, inclusive, and welcoming place for people with movement challenges, such as Parkinson’s Disease, to participate with confidence and security. 

Participants report that they enjoy and appreciate programs that are designed specifically for them at their age which they don’t routinely find at the gym. 

Your program is based in Westchester County, NY.? Can you tell us about the studio you run?

StepWISEnow is located along the Hudson River in Briarcliff Manor, NY, about 50 minutes north of New York City.

The studio is really beautiful. It was designed and renovated specifically for older adults.  It meets all Americans with Disabilities requirements and is easily accessed directly from the parking area. The flooring is cork to provide for added spring and the room is sized to allow a maximum of 12 students – the number recommended as best practice for balance classes.  In addition, we have safety features such as bench seating, a balance barre, and sturdy chairs for seated classes. All these design elements were very important to me when I was creating the space. I wasn’t seeing these features provided in other settings and I wanted people to enjoy coming to a space that put their needs first. 

Participants’ individual goals may vary, but everyone wants to improve their mobility and balance. Everyone wants to be as healthy and active as possible and enjoy doing it!

As I understand things, you now have started running some of your classes online, given current limitations on people taking classes in person. How is that going? Do you plan on continuing your online program once quarantine restrictions are lifted?

In response to Covid-19, we have moved all of our classes online. Of course, I can’t wait to re-open the studio when the time comes. The studio provides a great sense of community to our members. But we’ll definitely be keeping our online programs going forward. I’ve discovered an unexpected benefit to teaching online and I am grateful that I took the leap — I am now able to reach more people, especially those most vulnerable who are not able to attend classes in person. In a way, this pandemic has accelerated the Telehealth movement and is allowing us to reach many more people in the privacy of their homes. And for many older Americans that’s where they may feel most comfortable trying something new.   

What are the most important things older adults need to know about balance and falls? Are there factors pertaining to balance that you find your participants are unaware of? 

The most important thing to know about falls is that most are preventable – they are not a natural consequence of aging. It’s also important not to minimize the warning signs of a trip or loss of balance and discount it as unlikely to happen again. The first fall is the greatest predictor that another fall is likely.

A fall is usually the result of multiple risk factors coming together. The good news is that each of these risk factors is modifiable and can be improved. It’s important that we identify which factors put us at risk for a fall and then take action to address those factors. What puts me at risk for a fall will be different than what puts one of my students at risk for a fall. 

Risk factors can be divided into three broad categories: Behavioral (rushing), Environmental (slippery surfaces), and Physiological (leg weakness). I often tell the story of a fall I had which helped me to realize what risk factors contributed to the fall and that falls are indeed preventable and predictable:

It was a hot summer day and I left my home in Yonkers early in the morning to take the train into the city. I was in a hurry so I left without eating breakfast but I took a new medication with a cup of coffee before I left. I wore a new pair of shoes with a hard platform sole that didn’t have an ankle strap. While running errands in the city I lost track of time and realized that I had to rush to get back to Yonkers in time to pick up my sons from high school. I rushed up to Grand Central and hurried home from the train station on foot carrying lots of packages. My feet were sore by this time and I still hadn’t eaten or had much to drink. While hurrying home I had my reading glasses down and was texting my children to let them know when I’d be arriving. As I approached the long flight of steps up to the street where my car was parked I lifted my foot to the first step, caught my toe, and began to fall forward toward the stone steps. I hadn’t used the handrail as I had too much in my arms, was in a hurry, and felt I didn’t need to. As I fell, seemingly in slow motion toward the step, I realized that this perfect storm of risk factors was completely predictable and preventable. 

In retrospect, the risk factors are obvious (medication, dehydration, nutrition, uncomfortable/unstable shoes, stimulant, rushing, multitasking, stress, inaccurate depth perception/reading glasses, not using assistive devices/handrail, fatigue) and each one was preventable.

It’s important that we learn from the falls that we’ve had. Fall prevention involves some elements of detective work. We must go back to the ‘scene of the crime’ to identify all of the circumstances that contributed to the fall so we know how to prepare and what to do differently moving forward. 

What are the typical causes of balance problems in older adults? Is there anything you can do proactively to maintain or strengthen your balance?

A familiar and common cause of balance problems in older adults is inactivity (or a sedentary lifestyle) which leads to weakness, stiffness, poor posture, and loss of energy. Far too many of us spend hours sitting which makes the muscles in the front of our body tighten up and the muscles of the back become weak. Time spent watching screens — TVs, computers or cell phones — all add up. 

Adopting the 4 Cs can help. The first C is for a Commitment to oneself to act. The second C is for Consistency of practice. The third C is for Challenging oneself each day and the 4th C is for the Confidence that you can improve and succeed. Being proactive is the key to fall prevention and adopting the 4 Cs will help to make a daily balance practice part of your lifestyle and routine.   

A second, less well-recognized cause of falls is multiple medications. Many older adults are prescribed multiple medications and many of these medications have side effects that contribute to loss of balance. According to the CDC, simply being on 4 or more medications puts one at increased risk for a fall.  It’s important that older adults have regular conversations called Medication Reviews with their primary physician to determine if they are on the right medications at the right dosages.  

If someone wants to work on their balance at home, what advice would you give them? Are there exercises that can be done at home, or even outside, that are essential to anyone wanting to improve their balance? What kind of equipment would you need to have on hand?

There are many simple balance exercises one can do at the kitchen counter each day. The kitchen counter is a good height for support of one or both hands and it often provides adequate space to travel back and forth while continuing to have hand support when needed. 

These exercises can be a combination of strengthening and stretching along with standing and dynamic balance activities. Including a simple tai chi sequence or dance combination to your balance fitness practice makes it fun and energizing. 

If standing balance activities are too challenging there are still many strengthening, stretching, and postural exercises that can be done while seated until one is ready to progress to standing. Tai chi can also be done seated. 

Our Balance Basics class combines a seated warm-up with standing balance activities. Participants are also introduced to other balance programs such as tai chi and line dance. 

The most basic strengthening activity one can do at home is to practice standing and sitting from a sturdy chair with a firm seat. The repeated act of standing and returning to sitting with control builds strength, stamina, and endurance. In the beginning, one may need to use the armrests or increase the seat height with a folded blanket but over time and with consistent practice the legs become stronger and these added supports are no longer needed. 

When someone experiences a serious fall, once they recover, how do you advise them to strengthen their balance and resume an active lifestyle? 

It’s very important that people continue to strengthen their balance after a fall. A fall can be a traumatic experience and be accompanied by the fear of falling again. The fear of falling itself can contribute to inactivity as one may decide to ‘play it safe’ by not moving and restricting one’s activities in order to prevent another fall. Therefore, it’s important to be able to identify having these concerns and share them so they don’t begin to restrict your mobility and lifestyle. 

The 8 sessions evidence-based program, A Matter of Balance: Managing Concern about Falls, was developed to address the fear of falling. It’s a wonderful program that combines problem-solving, strategy building, and exercise to help participants set realistic goals for increasing activity, create a personalized fall prevention strategy, and learn simple exercises to increase strength and balance. We are hoping to develop an online version of the program soon. 

Taking a tai chi class that is designed for older adults is also a great proactive step one can take to maintain or strengthen balance. There’s a lot of evidence to support the benefits of tai chi for balance and fall prevention for older adults. Tai Chi for Arthritis and Fall Prevention, developed by Dr. Paul Lam, is one of the evidence-based programs recommended by the CDC and NCOA. Once the movement forms have been learned they can be practiced on a daily basis which leads to the additional benefits associated with tai chi such as calming the mind and energizing the spirit. 

What about feet? What foot problems can lead to balance problems or falls? Is there any particular footwear you recommend?

This is a great question. Feet are so important to our balance but so often ignored. We get lots of valuable information from our feet about our balance and yet often our footwear inhibits that information either because the sole of the shoe is too heavy or stiff or because it isn’t secure enough to our foot. 

Footwear should be well-suited to the activity and the floor surface. For example, I recommend a light flexible-soled shoe that’s secure to the foot for tai chi. A dance sneaker with a more supportive sole is better for Zumba Gold or Line Dance. 

It’s important that we appreciate and pamper our feet and begin to re-awaken the soles of our feet so that we can more readily utilize the information they provide to improve our stability. 

Never wear socks or loose slippers at home. They are a fall risk! Slippers are called slippers for a reason! 

There are some conditions that result in nerve damage and reduce our ability to gather information from our feet. If this is the case it’s important that we realize how this may affect our balance and learn to compensate with other senses, such as vision, for the loss of that information. 

The current quarantine has been difficult for many older adults. Many of us are likely not getting our usual exercise. Are you concerned about what may happen? What advice would you give to older adults who may not be undertaking their usual more active lifestyle?

I’m very concerned about what might happen as a result of older adults being isolated and not getting the usual exercise. Isolation and inactivity are two significant risk factors for falls for older adults and it’s easy to become complacent when required to be at home. 

I like to think we can turn this situation into an opportunity to try something new, to focus on balance, and to begin a balance practice in earnest. You don’t need a lot of time, space, or equipment to improve your balance. An effective balance fitness program is progressive, challenging, and fun and can be done every day. Balance fitness engages and strengthens the brain and body simultaneously because it requires true brain-body collaboration. One can’t practice balance without engaging the mind. 

It’s important to be safe when practicing your balance at home and to begin a balance practice that is well within your comfort zone before beginning to gradually progress. We offer a variety of online classes at beginner and intermediate levels and seated and standing levels as well. 

Any final words of wisdom you’d like to share with agebuzz readers? Any critical points that may not have been raised by the earlier questions?

Balance is a complex skill and it’s the key to our continued independence. Surprisingly, we are not born with good balance. We develop it over time, first as an infant gaining head balance, sitting balance, and finally standing and walking. Physical play (curb walking, skipping, etc.) is an innate way for toddlers and children to practice their balance skills. The clumsy gait of a toddler eventually becomes the efficient stride of a young adult.

Professionals such as athletes and dancers continue to refine their balance skills, but for most of us, an efficient stride is good enough throughout middle age until we begin to notice subtle changes and it’s time again to hone our balance skills.

The good news is that we can get stronger and improve our balance at any age. Willingness to identify our risk factors, to commit to a daily balance practice, and to modify our lifestyle if needed are elements of success. It may feel like a tall order but it’s the key to maintaining our independence and it’s empowering to know that we have the agency to do so. We are more powerful than we know and we can use this power to take control of how we age.