Can Treadmill Slip-Perturbation Training Reduce Longer-Term Fall Risk Upon Overground Slip Exposure?

Perturbation-based balance training of older adults and effects on physiological, cognitive and sociopsychological factors: a secondary analysis from a randomised controlled trial with 12-month follow-up

BACKGROUND

Perturbation-based balance training (PBT) has shown promising, although diverging, fall-preventive effects; however, the effects on important physical, cognitive and sociopsychological factors are currently unknown. The study aimed to evaluate these effects on PBT at three different time points (post-training, 6-months and 12-months) in community-dwelling older adults compared with regular treadmill walking.

METHODS

This was a preplanned secondary analysis from a randomised, controlled trial performed in Aalborg, Denmark, between March 2021 and November 2022. Community-dwelling older adults aged ≥65 were randomly assigned to participate in four sessions (lasting 20 min each) of either PBT (intervention) or regular treadmill walking (control). All participants were assigned to four testing sessions: pretraining, post-training, 6-month follow-up and 12-month follow-up. At these sessions, physical, cognitive and sociopsychological measures were assessed.

RESULTS

In total, 140 participants were randomly allocated to either the PBT or control group. Short-term (pretraining to post-training) between-group differences were seen for choice stepping reaction time (-49 ms, 95% CI -80 to -18), dual-task gait speed (0.05 m/s, 95% CI 0.01 to 0.09) favouring the PBT group. However, these improvements were not sustained at the 6-month and 12-month follow-up. No significant between-group differences were found in other physical, cognitive or sociopsychological factors.

CONCLUSIONS

This study showed that PBT, in the short term, improved choice stepping reaction time and dual-task gait speed among community-dwelling older adults. Yet, these improvements were not retained for 6- or 12-months. The healthy state of the study's population may have imposed a ceiling effect limiting the ability to show any clinically relevant effects of PBT.

TRIAL REGISTRATION NUMBER

NCT04733222.

Biomechanical strategies for mitigating unexpected slips: A review

Slips are the leading cause of falls, and understanding slip biomechanics is crucial for preventing falls and mitigating their negative consequences. This study analyses human biomechanical responses to slips, including kinetic, kinematic, spatiotemporal, and EMG variables. We reviewed 41 studies investigating slip-induced falls in lab settings, computational models, and training approaches. Our analysis focused on reactions and effects of factors like age, fatigue, strength, perturbation intensity, and gait speed. Trailing limbs' hip extension and knee flexion interrupt the swing phase earlier, increasing the support base. The slipping leg responds with two phases: hip extension and knee flexion, then hip flexion and knee extension. Furthermore, our analysis revealed that the medial hamstring muscles play an active role in slip recoveries. Their activation in the slipping limb allows for hip extension and knee flexion, while in the trailing limb, their activation results in the foot touching down. Additionally, successful slip recoveries were associated with co-contraction of the Tibialis Anterior (TA) and Medial Gastrocnemius (MG), which increases ankle joint stability and facilitates foot contact with the ground. Our review identifies various factors that influence biomechanical and muscular responses to slips, including age, perturbation intensity, gait speed, muscular fatigue, and muscular strength. These findings have important implications for designing interventions to prevent slip-related falls, including cutting-edge technology devices based on a deeper understanding of slip recoveries. Future research should explore the complex interplay between biomechanics, muscle activation patterns, and environmental factors to improve slip-fall prevention strategies.

A Systematic Review of the Effect of Physical Rehabilitation on Balance in People with Diabetic Peripheral Neuropathy Who are at Risk of Falling

Background

Falls are a significant issue in people with diabetic peripheral neuropathy. Balance interventions have been broadly administered in individuals with diabetic peripheral neuropathy, but the effects on static and dynamic balance in those who are at risk of falling have not yet been comprehensively reviewed.

Objective

To provide a synthesis of the literature regarding the effectiveness of physical rehabilitation interventions to improve balance in people with diabetic peripheral neuropathy who are at risk of falling.

Methods

Four databases (PubMed, Embase, the Cochrane Central Register of Controlled Trials, Cumulated Index in Nursing and Allied Health Literature) were systematically searched from inception to July 2022. Articles meeting the eligibility criteria (ie, participants with diabetic peripheral neuropathy and at risk of falling based on validated fall balance outcome risk cut off scores; inclusion of physical rehabilitation intervention) underwent a quality assessment using the Physiotherapy Evidence Database scale. Data regarding fall risk was extracted.

Results

Sixteen studies met the eligibility criteria. Participants in six studies improved balance such that their fall risk was reduced from a moderate-high risk of falls to no or low risk of falls from pre- to post-intervention. Interventions within these six studies were variable and included balance exercise, gait training, endurance, tai-chi with mental imagery, proprioceptive training, aerobic training, and yoga. Participants in seven of the remaining studies showed no improvement and participants in three studies showed mixed results regarding improved balance and reduced fall risk status by post-intervention.

Conclusion

While physical rehabilitation is sufficient to improve balance in individuals with diabetic peripheral neuropathy who are at risk of falling, few interventions led to improved balance and reduced fall risk. Interventions involving intentional weight shifting, manipulation of the base of support, and displacement of the center of mass such as tai-chi and yoga appear to provide the most consistent results in terms of decreasing fall risk. To better understand the effectiveness of rehabilitation on balance and fall risk, future studies should examine the impact of physical interventions on prospective fall rates.

Functional electrical stimulation to enhance reactive balance among people with hemiparetic stroke

BACKGROUND

Individuals with stroke demonstrate a twofold higher fall incidence compared to healthy counterparts, potentially associated with deficits in reactive balance control, which is crucial for regaining balance from unpredictable perturbations to the body. Moreover, people with higher stroke-related motor impairment exhibit greater falls and cannot recover balance during higher perturbation intensities. Thus, they might need supplemental agents for fall prevention or even to be included in a perturbation-based protocol. Functional electrical stimulation is a widely used clinical modality for improving gait performance; however, it remains unknown whether it can enhance or interfere with reactive balance control.

METHODS

We recruited twelve ambulatory participants with hemiparetic stroke (61.48 ± 6.77 years) and moderate-to-high motor impairment (Chedoke-McMaster Stroke Leg Assessment ≤ 4/7). Each participant experienced 4 unpredicted paretic gait-slips, with and without functional electrical stimulation (provided 50-500 ms after perturbation) in random order. The paretic quadriceps muscle group was chosen to receive electrical stimulation, considering the role of support limb knee extensors for preventing limb-collapse. Outcomes including primary (laboratory falls), secondary (reactive stability, vertical limb support) and tertiary (compensatory step length, step initiation, execution time) measures were compared between the two conditions.

RESULTS

Participants demonstrated fewer falls, higher reactive stability, and higher vertical limb support (p < 0.05) following gait-slips with functional electrical stimulation compared to those without. This was accompanied by reduced step initiation time and a longer compensatory step (p < 0.05).

CONCLUSION

The application of functional electrical stimulation to paretic quadriceps following gait-slips reduced laboratory fall incidence with enhanced reactive balance outcomes among people with higher stroke-related motor impairment. Our results lay the preliminary groundwork for understanding the instantaneous neuromodulatory effect of functional electrical stimulation in preventing gait-slip falls, future studies could test its therapeutic effect on reactive balance. Clinical registry number: NCT04957355.

A Cross-Sectional Study on Fall Direction and Lower Limb Loading in Response to a Perturbation on Laterally Inclined Platform

Perturbation-based balance training (PBT) improves reactive stepping in older adults and people with neurological disorders. Slip-induced falls are a threat to older adults, leading to hip fractures. Fall-prone individuals must be trained to regain balance during a fall in the posterolateral direction. This study aims to analyze the characteristics of the reactive step induced by a laterally inclined platform. This cross-sectional study included 46 healthy participants who performed a "lean and release" backward fall using a platform with two inclined angles on each side. Kinovea software was used to analyze the step width. Reactive steps, characterized by crossover or medial foot placement, are preventive measures against posterolateral falls. The first objective was on the narrowed step width that was subjected to analysis using analysis of variance (ANOVA) and Tukey's post hoc assessment, indicating a tendency toward posterolateral falls. As part of our second objective, the inclined platform resulted in uneven loading between the legs, with a preference for the unloaded leg as the reactive leg (p < 0.001), as determined by Fisher's exact test and Cramer's V. These characteristics align closely with those observed in modified constraint-induced movement therapy (mCIMT). The angled platform had a significant effect on selecting the reactive leg, particularly at higher angles (p < 0.001). Thus, the study suggested that the device is capable of inducing posterolateral falls and exhibited mCIMT characteristics.

Effect of Aging and Cortical Stroke on Motor Adaptation to Overground Gait-Slips: Quantifying Differences in Adaptation Rate and Adaptation Plateau

We examined the effect of aging and cortical stroke on the rate of motor adaptation (adaptation rate) and amount of performance gains (adaptation plateau) in balance skills. Fourteen older (≥60 years) and fifteen younger (<60 years) adults with chronic stroke, and thirteen healthy older adults (≥60 years) participated. Participants experienced 8 consecutive gait-slips (≤45 cm) to their non-paretic/dominant limb. Slip outcome (backward/no balance loss) was compared using generalized estimating equations (GEE). Proactive (pre-slip stability) and reactive adjustments (post-slip stability, slip displacement and velocity, and compensatory step length) were compared using non-linear regression models. GEE showed the main effect of group, trial, and group × trial interaction for slip outcome (p < 0.05). There were no differences in the adaptation rate for proactive and reactive variables and plateau for proactive variables (p > 0.05). However, both stroke groups demonstrated a smaller adaptation plateau for the majority of reactive variables compared to healthy older adults (p < 0.05). The rate of adaptation to gait-slips does not slow with aging and cortical stroke; however, cortical stroke, age notwithstanding, may reduce performance gains in reactive balance skills, possibly hindering retention and transfer to real-life scenarios. People with stroke may need adjunctive therapies/supplemental agents to apply laboratory-acquired balance skills to daily life.

Provoking Artificial Slips and Trips towards Perturbation-Based Balance Training: A Narrative Review

Humans' balance recovery responses to gait perturbations are negatively impacted with ageing. Slip and trip events, the main causes preceding falls during walking, are likely to produce severe injuries in older adults. While traditional exercise-based interventions produce inconsistent results in reducing patients' fall rates, perturbation-based balance training (PBT) emerges as a promising task-specific solution towards fall prevention. PBT improves patients' reactive stability and fall-resisting skills through the delivery of unexpected balance perturbations. The adopted perturbation conditions play an important role towards PBT's effectiveness and the acquisition of meaningful sensor data for studying human biomechanical reactions to loss of balance (LOB) events. Hence, this narrative review aims to survey the different methods employed in the scientific literature to provoke artificial slips and trips in healthy adults during treadmill and overground walking. For each type of perturbation, a comprehensive analysis was conducted to identify trends regarding the most adopted perturbation methods, gait phase perturbed, gait speed, perturbed leg, and sensor systems used for data collection. The reliable application of artificial perturbations to mimic real-life LOB events may reduce the gap between laboratory and real-life falls and potentially lead to fall-rate reduction among the elderly community.

Perturbation-based balance training: Principles, mechanisms and implementation in clinical practice

Since the mid-2000s, perturbation-based balance training has been gaining interest as an efficient and effective way to prevent falls in older adults. It has been suggested that this task-specific training approach may present a paradigm shift in fall prevention. In this review, we discuss key concepts and common issues and questions regarding perturbation-based balance training. In doing so, we aim to provide a comprehensive synthesis of the current evidence on the mechanisms, feasibility and efficacy of perturbation-based balance training for researchers and practitioners. We address this in two sections: "Principles and Mechanisms" and "Implementation in Practice." In the first section, definitions, task-specificity, adaptation and retention mechanisms and the dose-response relationship are discussed. In the second section, issues related to safety, anxiety, evidence in clinical populations (e.g., Parkinson's disease, stroke), technology and training devices are discussed. Perturbation-based balance training is a promising approach to fall prevention. However, several fundamental and applied aspects of the approach need to be further investigated before it can be widely implemented in clinical practice.

Identification of balance recovery patterns after slips using hierarchical cluster analysis

Accidental falls often result from loss of balance initiated by slips. People may adopt different balance recovery patterns after slips which could affect recovery outcomes. The present study aimed to identify balance recovery patterns after slips and to determine whether these balance recovery patterns could be associated with different levels of slip-induced fall likelihood. Sixty young (age 24.2 ± 2.1 years) participants were involved in an experimental study. They were instructed to walk on a linear walkway, where unexpected slips were induced when stepping onto a removable vinyl tile sheet covered with water-detergent mixture. One hundred and fifty slip trials were obtained, including 85 successful balance recovery trials and 65 failed balance recovery trials (i.e., fall trials). Hierarchical cluster analysis was used to classify balance recovery patterns based on the kinematic measures of both feet over the period from 100 to 300 ms after heel contact of the slipping foot. Three balance recovery patterns were identified, and these balance recovery patterns were found to be associated with different levels of slip-induced fall likelihood. Findings from the present study can contribute to better understanding of balance recovery mechanisms associated with slips, and guide developing and evaluating fall prevention interventions.

Severity of Unconstrained Simultaneous Bilateral Slips: The Impact of Frontal Plane Feet Velocities Relative to the Center of Mass to Classify Slip-Related Falls and Recoveries

Targeted interventions to prevent slip-related falls may be informed by specific kinematic factors measured during the reactive response that accurately discriminate recoveries from falls. But reactive responses to diverse slipping conditions during unconstrained simultaneous bilateral slips, which are closely related to real-world slips, are currently unknown. It is challenging to identify these critical kinematic factors due to the wide variety of upper and lower body postural deviations that occur following the slip, which affect stability in both the sagittal and frontal planes. To explore the utility of kinematic measurements from each vertical plane to discriminate slip-related falls from recoveries, we compared the accuracy of four Linear Discriminant Analysis models informed by predetermined sagittal or frontal plane measurements from the lower body (feet velocities relative to the center of mass) or upper body (angular momentum of trunk and arms) during reactive responses after slip initiation. Unconstrained bilateral slips during over-ground walking were repeatedly administered using a wearable device to 10 younger (24.7 ± 3.2 years) and 10 older (72.4 ± 3.9 years) adults while whole-body kinematics were measured using motion capture. Falls (n = 20) and recoveries (n = 40) were classified by thresholding the dynamic tension forces measured in an overhead harness support system and verified through video observation. Frontal plane measurements of the peak feet velocities relative to the center of mass provided the best classification (classification accuracy = 73.3%), followed by sagittal plane measurements (classification accuracy = 68.3%). Measurements from the lower body resulted in higher accuracy models than those from the upper body, but the accuracy of all models was generally low compared to the null accuracy of 66.7% (i.e., predicting all trials as recoveries). Future work should investigate novel models that include potential interactions between kinematic factors. The performance of lower limb kinematics in the frontal plane in classifying slip-related falls demonstrates the importance of administering unconstrained slips and measuring kinematics outside the sagittal plane.

Compensatory Responses During Slip-Induced Perturbation in Patients With Knee Osteoarthritis Compared With Healthy Older Adults: An Increased Risk of Falls?

Background: Functional impairment of the knee joint affected by osteoarthritis and loss of muscle strength leads to a significant increase in the number of falls. Nevertheless, little is known about strategies for coping with gait perturbations in patients with knee osteoarthritis (KOA). Thus, this study aimed to examine the compensatory strategies of patients with KOA in response to a backward slip perturbation compared with healthy older adults.

Methods: An automated perturbation program was developed by using D-Flow software based on the Gait Real-time Analysis Interactive Lab, and an induced backward slip perturbation was implemented on nine patients with severe KOA (68.89 ± 3.59 years) and 15 age-matched healthy older adults (68.33 ± 3.29 years). Step length, gait speed, range of motion, vertical ground reaction forces, lower extremity joint angles, and joint moments were computed and analyzed.

Results: Compared with older adults, patients with KOA had significantly lower step length, gait speed, and vertical ground reaction forces in both normal walking and the first recovery step following backward slip perturbations. Inadequate flexion and extension of joint angles and insufficient generation of joint moments predispose patients with KOA to fall. Hip extension angle and flexion moment, knee range of motion, and vertical ground reaction forces are key monitoring variables.

Conclusion: The risk of falls for patients with KOA in response to backward slip perturbations is higher. Patients with KOA should focus not only on quadriceps muscle strength related to knee range of motion but also on improving hip extensor strength and activation through specific exercises. Targeted resistance training and perturbation-based gait training could be better options.

Effects of treadmill slip and trip perturbation-based balance training on falls in community-dwelling older adults (STABILITY): study protocol for a randomised controlled trial

INTRODUCTION

Falls among older adults are most frequently caused by slips and trips and can have devastating consequences. Perturbation-based balance training (PBT) have recently shown promising fall preventive effects after even small training dosages. However, the fall preventive effects of PBT delivered on a treadmill are still unknown. Therefore, this parallel-group randomised controlled trial aims to quantify the effects of a four-session treadmill-PBT training intervention on falls compared with treadmill walking among community-dwelling older adults aged 65 years or more.

METHODS AND ANALYSIS

140 community-dwelling older adults will be recruited and randomised into either the treadmill-PBT or the treadmill walking group. Each group will undergo three initial training sessions within a week and an additional 'booster' session after 26 weeks. Participants in the treadmill-PBT group will receive 40 slip and/or trip perturbations induced by accurately timed treadmill belt accelerations at each training session. The primary outcome of interest is daily life fall rates collected using fall calendars for a follow-up period of 52 weeks. Secondary outcomes include physical, cognitive and social-psychological fall-related risk factors and will be collected at the pre-training and post-training test and the 26-week and 52-week follow-up tests. All outcomes will be analysed using the intention-to-treat approach by an external statistician. A Poisson's regressions with bootstrapping, to account for overdispersion, will be used to compare group differences in fall rates.

ETHICS AND DISSEMINATION

The study protocol has been approved by the North Denmark Region Committee on Health Research Ethics (N-20200089). The results will be disseminated in peer-reviewed journals and at international conferences.

TRIAL REGISTRATION NUMBER

NCT04733222.

Small directional treadmill perturbations induce differential gait stability adaptation

Introducing unexpected perturbations to challenge gait stability is an effective approach to investigate balance control strategies. Little is known about the extent to which people can respond to small perturbations during walking. This study aimed to determine how subjects adapted gait stability to multidirectional perturbations with small magnitudes applied on a stride-by-stride basis. Ten healthy young subjects walked on a treadmill that either briefly decelerated belt speed (“stick”), accelerated belt speed (“slip”), or shifted the platform medial-laterally at right leg mid-stance. We quantified gait stability adaptation in both anterior-posterior and medial-lateral directions using margin of stability and its components, base of support, and extrapolated center of mass. Gait stability was disrupted upon initially experiencing the small perturbations as margin of stability decreased in the stick, slip, and medial shift perturbations and increased in the lateral shift perturbation. Gait stability metrics were generally disrupted more for perturbations in the coincident direction. Subjects employed both feedback and feedforward strategies in response to the small perturbations, but mostly used feedback strategies during adaptation. Subjects primarily used base of support (foot placement) control in the lateral shift perturbation and extrapolated center of mass control in the slip and medial shift perturbations. These findings provide new knowledge about the extent of gait stability adaptation to small magnitude perturbations applied on a stride-by-stride basis and reveal potential new approaches for balance training interventions to target foot placement and center of mass control.

NEW & NOTEWORTHY Little is known about if and how humans can adapt to small magnitude perturbations experienced on a stride-by-stride basis during walking. Here, we show that even small perturbations disrupted gait stability and that subjects could still adapt their reactive balance control. Depending on the perturbation direction, subjects might prefer adjusting their foot placement over their center of mass and vice versa. These findings could help potentially tune balance training to target specific aspects of balance.

The ability to increase the base of support and recover stability is limited in its generalisation for different balance perturbation tasks

Background

The assessment of stability recovery performance following perturbations contributes to the determination of fall resisting skills. This study investigated the association between stability recovery performances in two perturbation tasks (lean-and-release versus tripping).

Methods

Healthy adults (12 young: 24 ± 3 years; 21 middle-aged: 53 ± 5 years; 11 old: 72 ± 5 years) were suddenly released from a forward-inclined position attempting to recover stability with a single step. In a second task, all participants experienced a mechanically induced trip during treadmill walking. To assess dynamic stability performance, the antero-posterior margin of stability (MoS), the base of support (BoS), and the rate of increase in BoS were determined at each foot touchdown (TD) for both tasks.

Results

Only weak to moderate correlations in dynamic stability performance parameters were found between the two tasks (0.568 > r > 0.305, 0.001 < p < 0.04). A separation of participants according to the number of steps required to regain stability in the lean-and-release task revealed that multiple- (more than one step) compared to single-steppers showed a significantly lower MoS at TD (p = 0.003; g = 1.151), lower BoS at TD (p = 0.019; g = 0.888) and lower rate of increase in BoS until TD (p = 0.002; g = 1.212) after release. Despite these profound subgroup differences in the lean-and-release task, no differences between multiple- and single-steppers were observed in the stability recovery performance during tripping.

Conclusion

The results provide evidence that the ability to effectively control dynamic stability following a sudden balance disturbance in adults across a wide age range is limited in its generalisation for different perturbation tasks.

Effect of Multisession Progressive Gait-Slip Training on Fall-Resisting Skills of People with Chronic Stroke: Examining Motor Adaptation in Reactive Stability

Background: This study examined whether a multisession gait-slip training could enhance reactive balance control and fall-resisting skills of people with chronic stroke (PwCS). Methods: A total of 11 PwCS underwent a four-week treadmill-based gait-slip training (four sessions). Pre- and post-training assessment was performed on six intensities of gait-slips (levels 1–6). Training consisted of 10 blocks of each progressively increasing intensity (four trials per block) until participants fell at >2 trials per block (fall threshold). In the next session, training began at a sub-fall threshold and progressed further. Fall outcome and threshold, number of compensatory steps, multiple stepping threshold, progression to higher intensities, pre- and post-slip center of mass (CoM), state stability, clinical measures, and treadmill walking speed were analyzed. Results: Post-training, PwCS demonstrated a reduction in falls and compensatory steps on levels 5 and 6 (p < 0.05) compared to pre-training. While an increase in pre-slip stability was limited to level 6 (p < 0.05), improvement in post-slip stability at lift-off was noted on levels 2, 3, and 5 (p < 0.05) along with improved post-slip minimum stability on levels 5 and 6 (p < 0.05). Post-training demonstrated improved fall (p < 0.05) and multiple stepping thresholds (p = 0.05). While most participants could progress to level 4 between the first and last training sessions, more participants progressed to level 6 (p < 0.05). Participants’ treadmill walking speed increased (p < 0.05); however, clinical measures remained unchanged (p > 0.05). Conclusions: Multisession, progressively increasing intensity of treadmill-based gait-slip training appears to induce significant adaptive improvement in falls, compensatory stepping, and postural stability among PwCS.

The retention of fall-resisting behavior derived from treadmill slip-perturbation training in community-dwelling older adults

The purpose of this study was to determine whether and to what extent the immediate generalization of treadmill slip-perturbation training could be retained over 6 months to resist overground slip-induced falls. Four protocols (Tc: treadmill control; Tt: treadmill slip-perturbation training; Oc: overground control; Ot: overground slip-perturbation training) from two randomized controlled trials were compared in which two training protocols were executed with single-session repeated slip-perturbation training on the treadmill or overground context, while two control protocols were executed without repeated training. A total of 152 community-dwelling older adults (≥ 65 years) who were trained by one of the four protocols and tested by an overground slip in the initial session attended a retest session 6 months later. Falls were detected by a load cell. Data collected from motion analysis system and force plates were used to calculate stability. Tt group had no significant change in fall incidence from initial post-training test to retest. Tt group had significantly lower fall incidence (p < 0.05) and higher reactive stability (p < 0.05) than Tc group in retest. Tt group had significantly higher fall incidence (p < 0.05) and lower reactive stability (p < 0.01) than Ot group. The generalization of a single session of treadmill slip-perturbation training to overground slip resulted in inferior outcomes compared with overground slip-perturbation training (absolute retention), although the training generalization could be retained over 6 months (relative retention). Thus, treadmill slip-perturbation training could be more convenient to use if future dose-response studies indicate better or equal efficacy to overground slip-perturbation training.