Health-related predictors of falls and fractures in women over 40

Predictive Validity of Motor Fitness and Flexibility Tests in Adults and Older Adults: A Systematic Review

Motor fitness and flexibility have been linked to several health issues. We aimed to investigate the predictive validity of motor fitness and flexibility tests in relation to health outcomes in adults and older adults. Web of Science and PubMed databases were screened for studies published from inception to November 2020. Two authors systematically searched, evaluated, and extracted data from identified original studies and systematic reviews/meta-analysis. Three levels of evidence were constructed: strong, moderate, and limited/inconclusive evidence. In total, 1182 studies were identified, and 70 studies and 6 systematic reviews/meta-analysis were summarized. Strong evidence indicated that (i) slower gait speed predicts falls and institutionalization/hospitalization in adults over 60 years old, cognitive decline/impairment over 55 years old, mobility disability over 50 years old, disability in instrumental activities of daily living (IADL) over 54 years old, cardiovascular disease risk over 45 years old, and all-cause mortality over 35 years old; (ii) impaired balance predicts falls and disability in IADL/mobility disability in adults over 40 years old and all-cause mortality over 53 years old; (iii) worse timed up&go test (TUG) predicts falls and fear of falling over 40 years old. Evidence supports that slower gait speed, impaired balance, and worse TUG performance are significantly associated with an increased risk of adverse health outcomes in adults.

Practical and validated tool to assess falls risk in the primary care setting: a systematic review

OBJECTIVE

Although several falls risk assessment tools are available, it is unclear which have been validated and which would be most suitable for primary care practices. This systematic review aims to identify the most suitable falls risk assessment tool for the primary care setting (ie, requires limited time, no expensive equipment and no additional space) and that has good predictive performance in the assessment of falls risk among older people living independently.

DESIGN

A systematic review based on prospective studies.

METHODS

An extensive search was conducted in the following databases: PubMed, Embase, CINAHL, Cochrane and PsycINFO. Tools were excluded if they required expensive and/or advanced software that is not usually available in primary care units and if they had not been validated in at least three different studies. Of 2492 articles published between January 2000 and July 2020, 27 were included.

RESULTS

Six falls risk assessment tools were identified: Timed Up and Go (TUG) test, Gait Speed test, Berg Balance Scale, Performance Oriented Mobility Assessment, Functional Reach test and falls history. Most articles reported area under the curve (AUC) values ranging from 0.5 to 0.7 for these tools. Sensitivity and specificity varied substantially across studies (eg, TUG, sensitivity:10%-83.3%, specificity:28.4%-96.6%).

CONCLUSIONS

Given that none of the falls risk assessment tools had sufficient predictive performance (AUC <0.7), other ways of assessing high falls risk among independently living older people in primary care should be investigated. For now, the most suitable way to assess falls risk in the primary care setting appears to involve asking patients about their falls history. Compared with the other five tools, the falls history requires the least amount of time, no expensive equipment, no training and no spatial adjustments. The clinical judgement of healthcare professionals continues to be most important, as it enables the identification of high falls risk even for patients with no falls history.

TRIAL REGISTRAION NUMBER

The Netherlands Trial Register, NL7917; Pre-results.

Falls prevention at GP practices: a description of daily practice

BACKGROUND

General practitioners (GPs) can be considered the designated professionals to identify high fall risk and to guide older people to fall preventive care. Currently it is not exactly known how GPs treat this risk. This study aims to investigate GPs' daily practice regarding fall preventive care for frail older patients.

METHODS

Sixty-five GPs from 32 Dutch practices participated in this study for a period of 12 months. When a GP entered specific International Classification of Primary Care-codes related to frailty and/or high fall risk in their Electronic Health Records, a pop-up appeared asking "Is this patient frail?". If the GP confirmed this, the GP completed a short questionnaire about patient's fall history and fear of falling (FOF), and the fall preventive care provided.

RESULTS

The GPs completed questionnaires regarding 1394 frail older patients aged ≥75. Of 20% of these patients, the GPs did not know whether they had experienced a fall or not. The GPs did not know whether a FOF existed in even more patients (29%). Of the patients with a fall history and/or a FOF (N = 726), 37% (N = 271) received fall preventive care. Two main reasons for not offering fall preventive care to these patients were: I) the patient finds treatment too intensive or too much of a hassle (37%), and II) the GP identified a high fall risk but the patient did not acknowledge this (14%). When patients were treated for high fall risk, the GP and the physiotherapist were the most frequently involved health care providers. The involved health care providers most often treated mobility limitations, cardiovascular risk factors, and FOF.

CONCLUSIONS

The results from this study show that GPs were frequently not aware of their frail patient's fall history and/or FOF and that the majority of the frail older patients with a fall history and/or FOF did not receive fall preventive care. Developing systematic screening strategies for the primary care setting enhancing the identification of high fall risk and the provision of fall preventive care may improve patients' quality of life and reduce health care costs.

Criterion-Related Validity of Field-Based Fitness Tests in Adults: A Systematic Review

We comprehensively assessed the criterion-related validity of existing field-based fitness tests used to indicate adult health (19–64 years, with no known pathologies). The medical electronic databases MEDLINE (via PubMed) and Web of Science (all databases) were screened for studies published up to July 2020. Each original study’s methodological quality was classified as high, low and very low, according to the number of participants, the description of the study population, statistical analysis and systematic reviews which were appraised via the AMSTAR rating scale. Three evidence levels were constructed (strong, moderate and limited evidence) according to the number of studies and the consistency of the findings. We identified 101 original studies (50 of high quality) and five systematic reviews examining the criterion-related validity of field-based fitness tests in adults. Strong evidence indicated that the 20 m shuttle run, 1.5-mile, 12 min run/walk, YMCA step, 2 km walk and 6 min walk test are valid for estimating cardiorespiratory fitness; the handgrip strength test is valid for assessing hand maximal isometric strength; and the Biering–Sørensen test to evaluate the endurance strength of hip and back muscles; however, the sit-and reach test, and its different versions, and the toe-to-touch test are not valid for assessing hamstring and lower back flexibility. We found moderate evidence supporting that the 20 m square shuttle run test is a valid test for estimating cardiorespiratory fitness. Other field-based fitness tests presented limited evidence, mainly due to few studies. We developed an evidence-based proposal of the most valid field-based fitness tests in healthy adults aged 19–64 years old.

Does time since injury and duration matter in the benefits of physical therapy treatment for concussion?

Objective

To determine if there are differences in post-concussion symptom levels depending on 1) when physical therapy treatment is begun after the concussion and 2) the length of treatment.

Method

Retrospective chart review yielded 202 patients who sustained concussions and were referred for physical therapy. Participants/patients were assigned to independent groups based on time elapsed between concussion and physical therapy (0–14, 15–30, 31–60, 61–120, 121–365 days), and on months spent in treatment (1–4). Pre- and post- treatment scores were documented for the following measures: Sport Concussion Assessment Tool (SCAT), Convergence Insufficiency Symptom Survey (CISS), Dizziness Handicap Inventory (DHI), and Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) using ANOVAs, with a Bonferroni-corrected p-value of p < .005.

Results

All patients demonstrated improvements with treatment, with no significant differences in outcomes for time elapsed since injury (SCAT Symptom Score ( p = .80), SCAT Symptom Severity Score ( p = .97), CISS ( p = .61), DHI ( p = .65), mCTSIB ( p = .13)); or for months in treatment (SCAT Symptom Score ( p = .23), SCAT Symptom Severity Score ( p = .04), CISS ( p = .41), DHI ( p = .37), mCTSIB ( p = .50)).

Conclusions

Improvements were similar for all patients receiving post-concussive physical therapy, regardless of time between injury and treatment onset, and regardless of time spent in treatment. These results may have implications for clinical decision-making and for third party payors’ coverage of post-concussion treatment. Longer periods of treatment may not necessarily be of greater benefit and application of treatment if delayed may also be beneficial. Limitations to the study, such as its retrospective nature, lack of randomization, and convenience sample size are discussed.

Neither leg muscle strength nor balance are associated with the incidence of falls in middle-aged women: A 5-year population-based prospective study

BACKGROUND

Muscle strength and balance are major modifiable factors of falls in older adults, but their associations with falls in middle-aged adults are under investigated. We aimed to examine the association of baseline and change in leg muscle strength (LMS) and balance with the incidence of falls in a cohort of middle-aged women.

METHODS

This was a five-year follow-up of a population-based sample of 273 women aged 36-57 years at baseline (2011-2012). Data on LMS (by dynamometer) and balance (timed up and go test [TUG], step test [ST], functional reach test [FRT], and lateral reach test [LRT]) were obtained at baseline and five years later (2017-2018). After five years, falls were recorded monthly for one year by questionnaire (2017-2019). Negative binomial/Poisson and log binomial regressions were used as appropriate to assess associations of baseline and change in LMS and balance with any falls, injurious falls and multiple falls.

RESULTS

Over one-year, 115 participants (42%) reported at least one fall. Neither baseline nor 5-year change in LMS and balance measures were associated with the risk of any falls, injurious falls, or multiple falls five years later, with or without adjusting for confounders at baseline (incidence rate ratio/relative risk ranging from 0.85 to 1.19, 0.90 to 1.20, and 0.82 to 1.36, respectively; P>0.05 for all).

CONCLUSIONS

Baseline or change in LMS and balance measures are not associated with incident falls among middle-aged women. The contributions of environmental and other intrinsic factors such as chronic conditions and gait/mobility problems need to be investigated.

Association between self-rated health and the risk of hip fracture and mortality in a cohort of older women during a 10-year follow-up

Fragility fracture of the hip is associated with reduced functional status and mortality. Poor self-rated health (SRH) might be such an indicator. Our aim was to study if SRH was associated with hip fractures and all-cause mortality within the next 10 years in community-dwelling older women. A population-based sample of 350 women aged between 69 and 79 years (median 72.4) assessed their SRH by answering the question "How would you rate your health right now" by putting a mark on a visual-analogue scale (0-100 mm). Information on hip fracture and mortality over the next 10 years was retrieved from health care registers. The association between SRH and hip fracture and all-cause mortality was tested with a Cox proportional hazards regression model. SRH was divided into low, intermediate, and high (reference) assessed SRH. During the study, 40 hip fractures and 72 deaths occurred. The median value of SRH was 62 mm (IQR 50-81 mm). The age-adjusted hazard ratio (HR) for hip fracture was significantly higher in the group with low and intermediate SRH; HR: 3.17 (95% CI 1.25-8.01), and HR: 2.75 (95% CI 1.08-7.04), compared with high SRH. Adding bone mineral density (at the femoral neck) gave even greater risk. We did not find the hypothesized association between SRH and mortality. In our study, SRH indicated a higher risk of future hip fracture in older women. SRH might be a marker that could add information about the risk of hip fracture independently of bone mineral density.

Evidence-Based Practice in Rehabilitation of Myasthenia Gravis. A Systematic Review of the Literature

Myasthenia gravis is a rare neuromuscular disorder characterized by muscle weakness and fatigue. This review analyzes the most recent evidence regarding the effectiveness and safety of different rehabilitative approaches to the disease. The review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 365 articles were found in the main scientific databases. Applying the inclusion/exclusion criteria, 11 studies were admitted to the final phase of the review. Three different rehabilitative approaches were identified: physical training, respiratory training, and balance training. All rehabilitative modalities contributed to enhancing functional outcomes, reducing fatigue, and improving quality of life, but currently none can be recommended over another for the lack of cross-comparative studies. The included studies showed methodological quality from low to fair. Despite the range of rehabilitative interventions available, there is a lack of high-quality evidence. However, this review suggests that a multidisciplinary rehabilitation approach should be recommended to people with myasthenia gravis, and above all, for those with mild to moderate symptomatology.

Changes in fall risk and functional status in women aged 50 years and older after distal radius fracture: A prospective 1-year follow-up study

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

Few studies have evaluated the course of recovery after distal radius fracture (DRF) when functional decline and fracture risk may be affected.

PURPOSE OF THE STUDY

The purpose of this study was to determine changes in overall functional status over the first year after a DRF in women aged 50 years and older.

METHODS

Seventy-eight women were assessed for balance, balance confidence, lower extremity strength, gait speed, fall history, physical activity levels, and self-reported wrist pain and function (Patient-Rated Wrist Evaluation) at weeks 1, 3, 9, 12, 26, and 52 after DRF. Descriptive data were generated for all variables; a 3-way mixed analysis of variance with repeated measures was used to compare differences between participants aged 50-65 years and 65 years and older.

RESULTS

There was a significant improvement in functional status measures for both age categories except single-leg balance and fast gait speed, from 1 week after fracture extending up to 1 year after fracture (ranging from 6.1% improvement to 25% improvement, P < .05). There was no significant time × age interaction, as both age groups had the same pattern of recovery; however, there was significantly lower functional status in the older group across all time points.

CONCLUSION

Regardless of age, monitoring and addressing functional status including upper limb function, overall strength, balance, confidence, usual gait speed, and physical activity right up to 1 year after fracture is an important consideration for clinicians treating women recovering from DRF. Given the high future fracture risk for these women, identifying functional recovery patterns can help to direct future research and determine preventative strategies.

Multifactorial Assessment of Risk of Falling in 753 Post-Menopausal Women: A Multicenter Cross-Sectional Study by the Italian Group for the Study of Metabolic Bone Diseases

OBJECTIVE

To assess physical performance, number of falls, previous fragility fractures, and ongoing pharmacological therapy in a cohort of post-menopausal women, according to their risk of falling.

METHODS

In this multicenter cross-sectional study, we recruited in a 3-year period (May 2016 to April 2019), women aged >60 years referred to seven Osteoporosis and Bone Metabolism Outpatient Services of the Italian Group for the Study of Metabolic Bone Diseases. The study population was divided into three groups according to the risk of falling, assessed through the Elderly Fall Screening Test (EFST): low risk (EFST score=0-1); moderate risk (EFST=2-3); high risk (EFST=4-5). Outcome measures were: 4-meter gait speed (4MGS); unipedal stance time (UST); number of falls in the previous year; previous fragility fractures; ongoing pharmacological therapy.

RESULTS

We analyzed 753 women (mean aged 70.1±9.2 years): 378 (50.2%) at low risk of falling, 247 (32.8%) at moderate risk, and 128 (17.0%) at high risk. 4MGS and UST resulted as pathological in the 93.9% and 99.2%, respectively, of women at high risk. There were significant differences among groups for both outcomes (p<0.001). There was also a significant difference among groups (p<0.001) in terms of previous falls and fragility fractures. Lastly, there were significant differences (p<0.05) among groups in using antihypertensive drugs, antiplatelet agents, anticoagulants, antidepressants, anti-osteoporotic drugs, and vitamin D, and/or calcium supplementation.

CONCLUSION

Physical performance, prevalence of falls and fragility fractures, and an assessment of pharmacological therapy should be investigated in post-menopausal women because of their significant correlation with risk of falling.

Use of a fracture prevention screening algorithm predicts self-reported falls in postmenopausal women

Background and Purpose: The prevention of falls and fall-related fractures following menopause is an important health initiative. The Fracture Prevention Screening Algorithm (FPSA) uniquely uses fracture risk to prompt fall risk assessment to classify both fall and fracture risk in individuals. The purpose of this study was to determine whether use of the FPSA accurately predicted self-reported falls in post-menopausal women over one year. Methods: 142 postmenopausal women were recruited. Based on Fracture Risk Assessment Tool (FRAX®) scores, women with a ≥3% 10-year probability of hip fracture (high risk), or who self-identified as having balance problems or a fall history, underwent the Functional Gait Assessment (FGA) to estimate fall risk (high risk = ≤22/30). This allowed classification on the FPSA into one of four risk categories: low fall/low fracture risk; low fall/high fracture risk; high fall/low fracture risk; high fall/high fracture risk. Participants were contacted monthly for one year to determine fall and injury occurrence. Results: Fall/injury surveillance was conducted with 136 subjects over one year. Compared to women in the low fall/low fracture risk group, both high fall risk groups demonstrated significantly greater fall rates. Falls were 81-89% more likely in women with FGA scores of 22/30 or less. All injuries were rare events across all risk strata and did not differ between risk groups. Conclusion: These findings support the use of fracture risk as a trigger for fall screening to comprehensively classify risk in post-menopausal women as proposed by the FPSA.

Fall Risk Factors in Mid-Age Women: The Australian Longitudinal Study on Women's Health

INTRODUCTION

In contrast to older adults, little is known about risk factors for falls in adults aged 50-64 years, despite a high prevalence of falls in this age group. The aim was to identify risk factors for falls in mid-age women and explore how associations change with age.

METHODS

Data were analyzed in 2016 from women aged 50-55 years in 2001 (born 1946-1951) in the Australian Longitudinal Study on Women's Health. The predictor variables were health-related factors (measured 2001, 2004, 2007, 2010) and the outcome was falls in the past 12 months (measured 2004, 2007, 2010, 2013). Prospective associations between predictor variables and falls measured 3 years later were analyzed using logistic regression with complete data for 4,629, 7,096, 5,911, and 5,774 participants.

RESULTS

In surveys, 20.5% (2004), 30.7% (2007), 30.5% (2010), and 26.6% (2013) of women reported a fall in the previous 12 months. In the univariable models, most factors were associated with falls 3 years later. In the multivariable models, higher odds of falling were found for overweight and obese women compared with healthy weight women at all survey intervals (OR range, 1.15-1.43). Impaired vision (OR range, 1.25-1.35) and poor physical functioning (OR range, 1.24-1.66) were associated with falls at three survey intervals. Depression (OR range, 1.31-1.42), leaking urine (OR range, 1.25-1.49), stiff/painful joints (OR range, 1.26-1.62), severe tiredness (OR range, 1.29-1.49), osteoporosis (OR range, 1.25-1.52), and hormone replacement therapy (OR range, 0.69-0.79) were associated with falls at two survey intervals. There was no obvious age-related increase or decrease in the number of statistically significant associations.

CONCLUSIONS

Identified fall risk factors varied over time, highlighting that falling involves a complex interplay of risk factors in mid-age women.

Fracture Incidence and Characteristics in Young Adults Aged 18 to 49 Years: A Population-Based Study

Although fractures in both the pediatric and, especially, the elderly populations have been extensively investigated, comparatively little attention has been given to the age group in between. Thus, we used the comprehensive (inpatient and outpatient) data resources of the Rochester Epidemiology Project to determine incidence rates for all fractures among young adult (age range, 18 to 49 years) residents of Olmsted County, Minnesota, in 2009 to 2011, and compared the distribution of fracture sites and causes in this young adult cohort with those for older residents aged 50 years or older. During the 3-year study period, 2482 Olmsted County residents aged 18 to 49 years experienced 1 or more fractures. There were 1730 fractures among 1447 men compared with 1164 among 1035 women, and the age-adjusted incidence of all fractures was 66% greater among the men (1882 [95% confidence interval 1793-1971] versus 1135 [95% CI 1069-1201] per 100,000 person-years; p < 0.001). Of all fractures, 80% resulted from severe trauma (eg, motor vehicle accidents) compared with 33% in Olmsted County residents age ≥50 years who sustained a fracture in 2009 to 2011. Younger residents (aged 18 to 49 years), when compared with older residents (aged ≥50 years), had a greater proportion of fractures of the hands and feet (40% versus 18%) with relatively few fractures observed at traditional osteoporotic fracture sites (14% versus 43%). Vertebral fractures were still more likely to be the result of moderate trauma than at other sites, especially in younger women. In conclusion, whereas pediatric and elderly populations often fracture from no more than moderate trauma, young adults, and more commonly men, suffer fractures primarily at non-osteoporotic sites due to more significant trauma. © 2017 American Society for Bone and Mineral Research.

Both Baseline and Change in Lower Limb Muscle Strength in Younger Women Are Independent Predictors of Balance in Middle Age: A 12-Year Population-Based Prospective Study

Poor balance is a risk factor for falls and fracture in older adults, but little is known about modifiable factors affecting balance in younger women. This study aimed to examine whether lower limb muscle strength (LMS) in young women and changes in LMS are independent predictors of balance in middle age. This was an observational 10-year follow-up of 470 women aged 25 to 44 years at baseline who had previously participated in a 2-year population-based randomized controlled trial of osteoporosis education interventions. Linear regression was used to examine the association between baseline LMS (by dynamometer) and change in LMS over 12 years with balance at 12 years (timed up and go test [TUG], step test [ST], functional reach test [FRT], and lateral reach test [LRT]). LMS declined by a mean of 17.3 kg over 12 years. After adjustment for potential confounders, baseline and change in LMS were independently beneficially associated with TUG (β = -0.008 sec/kg, 95% confidence interval [CI] -0.01 to -0.006, and β = -0.006 sec/kg, 95% CI -0.009 to -0.003 for baseline and change, respectively), FRT (β = 0.057 cm/kg, 95% CI 0.030 to 0.084, and β = 0.071 cm/kg, 95% CI 0.042 to 0.101, respectively), and LRT (β = 0.030 cm/kg, 95% CI 0.012 to 0.049, and β = 0.022 cm/kg, 95% CI 0.002 to 0.043, respectively) 12 years later. There was an association between baseline LMS and ST (β = 0.044 steps/kg, 95% CI 0.022 to 0.067) but not between change in LMS and ST. Among young women, greater LMS at baseline and slower decline over time are both associated with better balance in midlife. Analogous to the contributions of peak bone mass and bone loss to fracture risk in older adults, this suggests that both improvement of muscle strength in younger age and prevention of age-related loss of muscle strength could be potentially useful strategies to improve balance and reduce falls in later life. © 2017 American Society for Bone and Mineral Research.

Association between bone mass as assessed by quantitative ultrasound and physical function in elderly women: The Fujiwara-kyo study

Objectives

This study aimed to investigate differences in physical function by bone mass category as assessed by speed of sound, and the association between bone mass and physical function in Japanese elderly women.

Methods

Participants (≥65 years, n = 954) were divided into the osteoporosis, osteopenia, and normal groups based on speed of sound values, and physical function parameters were compared among groups. In addition, the predictive ability of physical function for low bone mass was determined by area under the curve analysis. Data were collected in 4 cities in Nara, Japan, in 2007 or 2008.

Results

All physical functions were significantly lower in the osteoporotic group than in the normal group. Lower bone mass was associated with poor muscle strength and physical function after adjusting for age, height and weight. In addition, one-leg standing time and 10-m gait time were predictive of low bone mass (osteopenia and osteoporosis levels, respectively). Elderly women with low physical function, especially those with a short one-leg standing time, should be suspected of having decreased bone mass.

Conclusions

Measurements of physical function can effectively identify elderly women with low bone mass at an early stage without the need for bone mass measurements. In particular, one-leg standing time and 10-m gait time were good predictors of low bone mass, and is easy to measure, low-cost, and can be self-measured. These findings will be helpful in the prevention and treatment of osteoporosis.

Twelve weeks of BodyBalance® training improved balance and functional task performance in middle-aged and older adults

Purpose

The purpose of the study was to evaluate the effect of BodyBalance^® training on balance, functional task performance, fear of falling, and health-related quality of life in adults aged over 55 years.

Participants and methods

A total of 28 healthy, active adults aged 66±5 years completed the randomized controlled trial. Balance, functional task performance, fear of falling, and self-reported quality of life were assessed at baseline and after 12 weeks. Participants either undertook two sessions of BodyBalance per week for 12 weeks (n=15) or continued with their normal activities (n=13).

Results

Significant group-by-time interactions were found for the timed up and go (P=0.038), 30-second chair stand (P=0.037), and mediolateral center-of-pressure range in narrow stance with eyes closed (P=0.017). There were no significant effects on fear of falling or self-reported quality of life.

Conclusion

Twelve weeks of BodyBalance training is effective at improving certain balance and functional based tasks in healthy older adults.

Effects of balance strategy training in myasthenia gravis: a case study series

INTRODUCTION

Studies of exercise in patients with myasthenia gravis (MG) are sparse. Balance strategy training (BST) multimodal exercise has proven efficacy in adults for enhancing balance and functional mobility. This prospective study aims to determine if BST improves functional ability and balance in people with MG.

METHODS

Seven individuals with MG participated in a 16-session workstation intervention. Repeated measures (pre/post-intervention and 4-week follow-up) consisting of quantitative myasthenia gravis score (QMG), 6-minute walk test (6MWT), timed up and go (TUG) with dual task (TUG(manual) and TUG(cognitive)), and standing stability on foam with eyes closed (foamEC) were assessed.

RESULTS

Most measurements showed sustained improvement at follow-up. QMG, TUG(cognitive), and foam EC achieved clinically significant improvements (>15%). No adverse effects were reported.

CONCLUSIONS

BST was effective in improving balance and QMG scores in subjects with MG. A multimodal BST approach is thus suggested to target different aspects of balance and functional mobility.