Posted by: seattledizzygroup | May 31, 2017

Exercise and Tai Chi Moving for Better Balance

How to Exercise with a Vestibular Disorder

by Myra Emami, PT, NCS

of Cascade Dizziness and Balance PT

(Presented to Seattle Dizzy Group on 4/8/17)

This presentation discusses the health benefits of exercise and offers exercise strategies to improve balance including modifications for overcoming the challenges of chronic vestibular impairment as well as an overview of Tai Chi Moving for Better Balance which is a research-based exercise program that has effectively demonstrated reduced falls, risk of falls, and fear of falling.

Presentation Objectives:

  • Discuss how to incorporate exercise when you have a dizziness or balance disorder
  • Different types of exercises: strengthening, balance, aerobic, community based
  • How to modify the exercises based on balance impairment or dizziness issues
  • Tai Ji Quan Moving for Better Balance
  • Practice a few Tai Chi exercises


  • Strengthen functionally: Sit to stands, walking lunges
  • Functionally strengthen with balance exercises
  • Core exercises: Reverse crunches seated, standing cross knee crunches, medicine ball lifts in standing. Upright core exercises tend to work best for patients with dizziness issues.

Aerobic Exercises Benefits

  • Improved cardiovascular pulmonary health, lower blood pressure
  • Increases endorphins to combat depression
  • Burn cortisol to combat stress
  • Improves stress
  • Improves GI system
  • Improves memory and overall brain function, increased brain volume
  • Improves immune system
  • Increased energy level, combats fatigue
  • Decreases weight

Aerobic Exercise

  • Sustained activity that increases your heart rate
  • AHA (American Heart Association) recommended guidelines: 5x/week 30 minutes moderately intense exercise or 3x/week 25 minutes intense exercise
  • Target Heart Rate: 220 – age x 0.7 (Example: 60 year old = 112)
  • BORG Scale goal 13-15 (light to somewhat hard)

Borg Scale

  • 6 No exertion
  • 7 Extremely light
  • 8 Extremely light
  • 9 Very light
  • 10
  • 11 Light
  • 12
  • 13 Somewhat hard
  • 14
  • 15 Hard
  • 16
  • 17 Very hard
  • 18
  • 19 Extremely hard
  • 20 Maximal exertion

Type of Aerobic Exercises

  • Walking, power walking, walking with poles
  • Jogging, running
  • Equipment: biking, treadmills, ellipticals
  • Swimming

Aerobic Exercise with Balance Issues

  • Recumbent biking
  • Nustep
  • Power walking with 2 poles
  • Swimming: laps with resistance boards

Aerobic Exercise with Dizziness Issues

  • MRD, dysautonomia, vestibular disorder, motion sensitivity
  • Start with short sessions and gradually build up. Short duration and decreased frequency. 2-3x/week
  • Dizziness will be the limiting factor instead of Target Heart Rate.
  • Warm up and cool down especially important.
  • Staying hydrated especially important, consider electrolytes.
  • Low sensory environment
  • Use midline visual target.
  • Limit exercise that causes head movement.
  • Recommended: recumbent biking, Nustep, slow progressive walking program with hiking poles

Balance Exercises

  • Balance: ability to control the COM (trunk) over the BOS (Base of Support = feet) in a given environment or task without taking a step.
  • Vestibular
  • Anticipatory postural control
  • Limits of stability
  • Reactive postural control

Vestibular Exercises

  • Vestibular: One of 3 main balance systems (eyes, ears, sense of touch in feet) which is located in the inner ear and orients you to where you are in space and is responsible for righting reactions that keep you upright.
  • Static: Static standing with or without head turns eyes closed standing in an unstable position.
  • Dynamic: Walking with head turns
  • Modifications for balance: Feet position
  • Modifications for dizziness: Slow reps with midline sensory orientation

Reactive Postural Control

  • Automatic shifting in COG (Center of Gravity) in response to external and unexpected disturbances. (Example: Stepping reaction when you are about to fall).
  • Ankle/hip/stepping strategies
  • Tai Chi exercise

Limits of Stability

  • How far can you move over your base of support before you fall. The boundaries within which the body can maintain stability and not change the BOS (Base of Support) without step or reach.
  • Expanding the LOS (Limits of Stability) is critical for fall prevention.
  • Tai Chi LOS exercise

Anticipatory Control

  • Ability to proactively shift your COG (Center of Gravity) over your BOS (Base of Support) to successfully achieve a motor task such as stepping over an object.
  • Single leg stand: Inability to stand greater than 5 seconds indicates a high fall risk.
  • Key is ability to shift your weight over your BOS
  • Tai Chi anticipatory control exercise

Tips for Success

  • Find an exercise buddy
  • Make it easy – exercise at home or gym close by
  • Make it successful – start out slowly and gradually build up
  • Make it safe – practice in a corner for safety
  • Make it a habit – same time (for example, first thing in the morning)
  • Make it fun – use upbeat music
  • Cognitive behavioral approach: make your brain want it by thinking about the benefits of exercise

Other Recommended Exercise: Tai Chi

  • Lowers stress, improves sense of well being
  • Calms your mind, reduces anxiety
  • Grounding – reduces dizziness
  • Increases leg strength and core muscles
  • Improves bone density
  • Turns off the sympathetic nervous system
  • Better sleep
  • Better immune system
  • Thickens brain’s cortex – improved cognitive function
  • Improves balance and reduces fear of falling

Tai Ji Quan: Moving for Better Balance


  • Designed by Fuzhong Li, a research scientist and tai chi master, published multiple research studies on Tai Ji and balance
  • 6 month program 2x/week: Significant reduction in falls with this program (55% decreased fall risk)
  • Different than traditional Tai Chi programs: Evidence and research based exercise protocol that has been shown to reduce fall risk. Designed for balance training to improve functional mobility. Fall prevention focus. Maximizes excursion of COG (Center of Gravity) around edge of BOS (Base of Support) to optimize motor control.
  • Traditional Tai Chi: Health promotion focus, designed for self defense so that the COG is constrained within the BOS to optimize force and stability for combat.

Tai Chi Balance Exercises

  • Reactionary postural control: ankle/hip/stepping strategy
  • Limits of stability training: Butterfly
  • Form one: Hold the ball. Anticipatory postural control. Active movement.

Limits of Stability Training

  • Goal: Shift your center of gravity further and further outside your base of support to improve your balance.
  • Stay safe working in a corner, in front of a chair, or countertop so you can catch yourself if you lose your balance.
  • 10x each direction 1-2x/day
  • Keep trunk straight, don’t bend at your hips!
  • Keep it challenging by working at the limits of your stability!

Forward and Backward Weight Shift

  • Stand with feet shoulder width apart.
  • Shift weight forward so that your weight is on your toes.
  • Return to center. Repeat 10x
  • Shift weight backward so that your weight is on your heels.
  • Return to center. Repeat 10x

Side to Side Weight Shift

  • Stand with feet should width apart.
  • Shift weight to the right so that all your weight is on your right outer foot.
  • Return to center. Repeat 10x
  • Shift weight to the left so that your weight is on your left outer foot.
  • Return to center. Repeat 10x
  • Hold an imaginary Tai Chi ball when you weight shift (right hand on top when you shift to the right, left hand on top with left weight shift).

Clock Turns

  • Move from center to 1:00
  • Move from center to 7:00
  • Move from center to 11:00
  • Move from center to 5:00


  • Hold an imaginary Tai Chi ball at center, right hand on top.
  • Weight shift forward and backward for the body.
  • Move left hand in a big circle to make the left upper wing.
  • Left hand on top to reform the ball.
  • Move the right hand to make a big circle for the right upper wing.
  • Right hand on top to reform the ball.
  • Left hand backwards to the left back wing.
  • Left hand back on top.
  • Right hand backwards to make the right back wing.
  • Remember to work at the limits of your stability!

Anticipatory Control Exercises

  • Goal: Be able to stand on one foot to step over obstacles, be more stable walking, be safer going up and down stairs, transferring into a tub, stepping on or off a curb, etc.
  • Practice each exercise for 5-10 minutes, 1-2x/day

Side to Side

  • Stand with feet shoulder width apart.
  • Hold a Tai Chi ball with right hand on top.
  • Weight shift all the way to the right.
  • Move the Tai Chi ball to the right.
  • Lift your left heel up.
  • Lightly balance on your left big toe.
  • See if your can lift your left foot completely off the ground.
  • Try lifting your foot off for a few seconds.
  • Move the ball out further to the right if you keep losing your balance to the left.
  • Repeat on the left side with the Tai Chi ball to the left, lifting your right foot.


  • Stand with one foot forward and one foot back, a few inches apart.
  • Hold a Tai Chi ball forward.
  • Shift your weight to your front foot so that all your weight is there.
  • Lift your back heel off the ground.
  • Lightly balance on your back toe.
  • See if you can lift your entire foot off the ground for a few seconds.
  • Move the ball further forward if you feel falling backwards.
  • Shift your weight backwards so that all your weight is on your back foot. 
  • Lift your front toe off the ground.
  • Lightly balance on your front heel.
  • See if you can lift your entire foot off the ground for a few seconds.
  • If you keep falling forward, move your hands backwards to help you weight shift.
  • Repeat with the opposite leg.

Walking with Single Leg Standing

  • Take a step.
  • Weight shift forward.
  • Single leg stand for a few seconds.
  • Take another step and repeat.
  • Move slowly and deliberately, focusing on your comlete weight shift.

Exercise and Tai Chi Handout

Additional Health & Wellness Blog Posts:


Myra Emami, PT, NCS

of Cascade Dizziness and Balance PT

Myra Emami is a graduate of the University of Washington and has been practicing physical therapy for over 15 years. She specializes in vestibular rehabilitation and balance/fall prevention and obtained her Herdman Certification in Vestibular Competency in 2012.

Myra’s passion in vestibular rehab started after a personal experience with dizziness and vertigo, which helps her understand what her patients are going through. When patients talk about their dizziness, I can relate to how they feel. It’s important for patients to understand they can get better with the right strategy. Myra utilizes the latest evidence-based research in vestibular rehab in order to develop effective treatment strategies.

Myra also specializes in neurological disorders such as strokes and Parkinson’s Disease and obtained her APTA Neurological Clinical Specialist Certification in 2013. In her clinical practice, she applies her neurological background to emphasize the concept of neuroplasticity: The brain’s remarkable ability to change and build new connections to improve function. Neuroplasticity has far-reaching implications and amazing possibilities for almost every aspect of human life including balance disorders, movement dysfunction, and for reducing symptoms such as dizziness. She believes in a holistic healing approach delivered with care and compassion, with a focus on education and self-empowerment.

Myra’s accomplishments include the development of an acoustic neuroma post-surgical inpatient physical therapy protocol and Return-to-Play concussion protocol to facilitate safe return of young athletes to sports after a concussion. She organized and leads a multi-campus vestibular study group.

More information about Myra Emami



Presentation information is not meant to be taken as medical advice.

Presentations posted online may include discussion notes, links, images, and other information added by Seattle Dizzy Group.


© Copyright 2017, Seattle Dizzy Group. All rights reserved.


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Providing support & community for people living with chronic dizziness & imbalance -- in Seattle & beyond

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