Mechanisms leading to a fall from an induced trip in healthy older adults

BACKGROUND

Tripping is a leading cause of falls in older adults, often resulting in serious injury. Although the requirements for recovery from a trip are well characterized, the mechanisms whereby trips by older adults actually result in falls are not known. This study sought to identify such mechanisms.

METHODS

Trips were induced during gait in 79 healthy, community-dwelling, safety-harnessed, older adults (50 women) using a concealed, mechanical obstacle. Kinematic and kinetic variables describing the recovery attempts were compared between those who fell and those who recovered. Subjects were analyzed according to the recovery strategy employed (lowering vs elevating) and the time of the "fall" (during step vs after step).

RESULTS

Three apparent mechanisms of falling were identified. For a lowering strategy, during-step falls were associated with a faster walking speed at the time of the trip (91% +/- 8% vs 68% +/- 11% body height [bh] per second; p <.001) and delayed support limb loading (267 +/- 49 milliseconds vs 160 +/- 39 milliseconds; p <.001). After-step falls were associated with a more anterior head-arms-torso center of mass at the time of the trip (6.2 +/- 1.3 degrees vs 0.2 +/- 4.4 degrees; p <.01), followed by excessive lumbar flexion and buckling of the recovery limb. The elevating strategy fall was associated with a faster walking speed (93% vs 68% +/- 11% bh per second; p <.001) followed by excessive lumbar flexion.

CONCLUSIONS

Walking quickly may be the greatest cause of falling following a trip in healthy older adults. An anterior body mass carriage, accompanied by back and knee extensor weakness, may also lead to falls following a trip. Deficient stepping responses did not contribute to the falls.

Mechanisms of failed recovery following postural perturbations on a motorized treadmill mimic those associated with an actual forward trip

OBJECTIVE

To examine the recovery strategies employed during a treadmill acceleration task, to determine if mechanisms that contributed to failed recoveries on a motorized treadmill are the same general biomechanical mechanisms that contributed to falls from a trip, and to determine if failed recovery responses could be modified to allow for successful recoveries on subsequent trials.

DESIGN

A motorized treadmill was used to induce postural perturbations in healthy older adults.

BACKGROUND

Previously, we induced trips in older adults to identify the mechanisms of failed recovery. However, inducing trips is not a clinically practical test for identifying older adults who are predisposed to falling.

METHODS

Safety-harnessed older adults stood on a treadmill that was accelerated from 0 to 0.89 m/s to impose a postural perturbation. Recoveries were classified as successful (n=42) or failed (n=23). Selected biomechanical variables were calculated using motion analysis methods.

RESULTS

Initial failed recoveries had slower reaction times, shorter step lengths, and greater trunk flexion angles and velocities. Subjects who failed on the initial attempt modified their recovery strategy to successfully recover. The biomechanics of these recoveries resembled those used by subjects who successfully recovered on their initial attempt.

CONCLUSIONS

The biomechanical mechanisms involved with a failed treadmill recovery mimic those responsible for failed recoveries from an induced trip. Subjects who failed on their initial recovery response made modifications allowing successful recoveries on subsequent attempts.

RELEVANCE

This protocol may be useful as a testing and rehabilitation tool for fall recovery.

Role of feedforward control of movement stability in reducing slip-related balance loss and falls among older adults

Human upright posture is inherently unstable. To counter the mechanical effect of a large-scale perturbation such as a slip, the CNS can make adaptive adjustments in advance to improve the stability of the body center-of-mass (COM) state (i.e., its velocity and position). Such feedforward control relies on an accurate internal representation of stability limits, which must be a function of anatomical, physiological, and environmental constraints and thus should be computationally deducible based on physical laws of motion. We combined an empirical approach with mathematical modeling to verify the hypothesis that an adaptive improvement in feedforward control of COM stability correlated with a subsequent reduction in balance loss. Forty-one older adults experienced a slip during a sit-to-stand task in a block of slip trials, followed by a block of nonslip trials and a re-slip trial. Their feedforward control of COM stability was quantified as the shortest distance between its state measured at seat-off (slip onset) and the mathematically predicted feasible stability region boundary. With adaptation to repeated slips, older adults were able to exponentially reduce their incidence of falls and backward balance loss, attributable significantly to their improvement in feedforward control of stability. With exposure to slip and nonslip conditions, subjects began to select "optimal" movements that improved stability under both conditions, reducing the reliance on prior knowledge of forthcoming perturbations. These results can be fully accounted for when we assume that an internal representation of the COM stability limits guides the adaptive improvements in the feedforward control of stability.

Response time is more important than walking speed for the ability of older adults to avoid a fall after a trip

We previously reported that the probability of an older adult recovering from a forward trip and using a "lowering" strategy increases with decreased walking velocity and faster response time. To determine the within-subject interaction of these variables we asked three questions: (1) Is the body orientation at the time that the recovery foot is lowered to the ground ("tilt angle") critical for successful recovery? (2) Can a simple inverted pendulum model, using subject-specific walking velocity and response time as input variables, predict this body orientation, and thus success of recovery? (3) Is slower walking velocity or faster response time more effective in preventing a fall after a trip? Tilt angle was a perfect predictor of a successful recovery step, indicating that the recovery foot placement must occur before the tilt angle exceeds a critical value of between 23 degrees and 26 degrees from vertical. The inverted pendulum model predicted the tilt angle from walking velocity and response time with an error of 0.4+/-2.2 degrees and a correlation coefficient of 0.93. The model predicted that faster response time was more important than slower walking velocity for successful recovery. In a typical individual who is at risk for falling, we predicted that a reduction of response time to a normal value allows a 77% increase in safe walking velocity. The mathematical model produced patient-specific recommendations for fall prevention, and suggested the importance of directing therapeutic interventions toward improving the response time of older adults.

Gait characteristics as risk factors for falling from trips induced in older adults

BACKGROUND

Falls are a significant source of morbidity and mortality in older adults, with up to 53% of these falls due to tripping. To aid in preventing trip-related falls, the factors that increase an individual's risk of falling following a trip must be identified. This study investigated whether an older adult's gait influences their risk of failing following a trip.

METHODS

Trips were induced during gait in 79 healthy, safety-harnessed, community-dwelling older adults using a concealed, mechanical obstacle. Associations between selected gait kinematic characteristics, recorded during normal walking, and the likelihood of falling following the trip were determined using logistic regression.

RESULTS

Older adults who walked faster, took more rapid steps, or took longer steps relative to their body height had a significantly increased likelihood of falling following the trip. Step width, average trunk flexion during gait, and the phase of gait in which the trip occurred did not affect the likelihood of falling. A multivariable logistic regression model correctly classified 89.8% of trip outcomes based on two gait characteristics: step time and step length. As predicted from their gait characteristics, the subjects, as a group, had a low likelihood of falling following a trip, but selected individuals had a high likelihood of falling.

CONCLUSIONS

The incidence of trip-related falls in healthy older adults is determined primarily by the frequency of tripping and not the ability to recover from a trip. Older adults can reduce their likelihood of falling following a trip by not hurrying while walking.

Measures of postural stability are not predictors of recovery from large postural disturbances in healthy older adults

OBJECTIVES

To determine, in healthy older adults, the relationship between postural steadiness, stability limits, and the ability to recover balance from three postural disturbances requiring anteriorly directed stepping responses.

DESIGN

Analysis of multiple motor tasks in a cross-sectional sample of healthy older adults.

SETTING

A biomechanics research laboratory.

PARTICIPANTS

Fifty women and 29 men aged 65 or older, all healthy, living in the community, participated in this study. Subjects were examined by a geriatrician to identify the presence of exclusionary factors.

MEASUREMENTS

Anterior-posterior and medial-lateral excursion distances of the center of pressure during quiet standing (postural steadiness), static leaning (static stability limits), and dynamic swaying (dynamic stability limits) were determined from ground reaction forces measured by a strain gauge forceplate. Within the same group of subjects, the maximum angle of forward lean from which a subject could recover with a single step, the ability to recover balance in response to an accelerated support surface, and the ability to recover balance after being tripped were determined.

RESULTS

Recovery from the three types of postural disturbances were found to be statistically independent. The postural steadiness and the stability limit variables were only weakly correlated. Postural steadiness and stability limits were not related to the maximum recoverable angle of lean. The average medial-lateral center of pressure speed during the postural steadiness test was significantly slower for those who failed to recover after tripping than for the subjects who recovered successfully. However, a logistic regression model failed to achieve statistical significance, suggesting that the difference may not be functionally important. The anterior-posterior static stability limits were significantly larger for subjects who recovered successfully than for those who failed to recover during the accelerated support surface test. Although logistic regression suggested that a reduced anterior-posterior stability limit represents a risk factor for failure to recover during this task, only nine of 28 failures could be properly classified, thus diminishing the functional importance of this finding.

CONCLUSIONS

Because recovery following postural disturbances could not generally be predicted from measures of postural stability, these findings suggest that these measures of postural stability are of limited utility in identifying potential anteriorly directed fallers in healthy older adults.

Foot displacement but not velocity predicts the outcome of a slip induced in young subjects while walking

The purpose of the present study was to induce slips in healthy subjects as a means to determine if recovery from an induced slip is possible under conditions in which the displacements and velocities of the slipping foot exceed the generally accepted limits of 10cm and 50cm/s, respectively, and to determine if there are gait-related variables that predispose an individual to falling after a slip. Thirty-three young and barefoot adults, protected by an instrumented safety harness, were subjected to a single slipping trial following a series of unperturbed walking trials. The slip was induced when the bare foot contacted a vinyl sheet coated with mineral oil. Lower extremity kinematics were acquired using a video-based motion capture system. Fourteen and 12 subjects could be unambiguously categorized as having fallen or recovered, respectively. Four variables demonstrated significant between-group differences and two were used to compute the probability of the slip outcome using logistic regression. The variables were the displacement of the foot during the slip and the angle of the shank relative to the ground at the instant of ground contact just prior to the slip. Separate univariate logistic regressions using each variable were significant and correctly classified about 70% of the slip outcomes. The results demonstrated that previously published values for the displacement and velocity of the slipping foot, 10cm and 50cm/s, respectively, may not accurately represent the upper limits beyond which recovery is not possible. The results also demonstrated that heel-strike angle, reflective of stride length, exerts a significant influence on the outcome of a slip.

The sex and age of older adults influence the outcome of induced trips

BACKGROUND

Falls are a significant source of morbidity and mortality in older adults, with up to 53% of these falls due to tripping. To aid in fall prevention, there is a need to identify the factors that determine whether a trip is recoverable and those factors that increase an older adult's risk of falling.

METHODS

Trips were induced during gait in 79 healthy, community-dwelling, safety-harnessed older adults (50 women) using a concealed, mechanical obstacle. Trip outcomes were graded as recoveries, falls, rope-assists, or misses. Kinematics were recorded during normal gait, without and with the safety harness. Selected gait parameters were compared to determine whether the experimental conditions affected gait at the time of the trip.

RESULTS

Thirty-nine trip outcomes were classified as recoveries, 10 as falls, 12 as rope-assists, and 18 as misses. Women fell more than four times as frequently as men. Women younger than 70 years fell more than three times as frequently as those older. Trip outcomes in the men were essentially unaffected by age. The foot obstructed to induce the trip did not affect the trip outcome. The presence of the safety harness had almost no effect on gait. The length of the stride preceding the trip did not differ from normal.

CONCLUSIONS

The majority of trips in healthy older adults did not result in falls. Older women were more likely than men to fall following a trip. The likelihood of falling from a trip was greatest in the youngest older women.

Three-dimensional knee joint kinetics during a golf swing. Influences of skill level and footwear

This study characterized knee joint kinetics during a golf swing and determined the influence of shoe type and golfer skill on the peak knee joint loads. Thirteen golfers each hit a golf ball using a five iron under two footware conditions: spiked and spikeless golf shoes. Data from a video-based motion capture system and force plates were used to compute the knee joint kinetics. Mean peak forces and moments differed significantly between the lead and trail knees, but these peak loads were not significantly affected by shoe type. Only the lead knee flexion and internal rotation moments were significantly correlated to skill level. The magnitude of some of the peak loads at the knee during the golf swing approached those reached during activities prohibited until late-stage knee rehabilitation. We concluded the following: The type of shoe worn and the skill level of the golfer need not be considered in deciding time to return to golfing; however, the leg that is recovering from surgery or injury should be considered. The most stressful phase of the golf swing, relative to the knee, is the downswing. There is probably no "normal" swing; each golfer seems to possess consistent, characteristic, patterns of knee loading.

Maximum grip strength is not related to bone mineral density of the proximal femur in older adults

In the past decade there have been numerous publications reporting a significant and direct relationship between handgrip strength and bone mineral density (BMD) of the proximal femur in older adults. The present report challenges the appropriateness of the methods, and thus the conclusions used in these studies. Specifically, these studies failed to control for the concomitant influence of body weight on both BMD and muscle strength. In the present study, maximum handgrip strength was measured using a conventional hand-held hydraulic dynamometer. Bone mineral density of the proximal femur was measured using dual-energy X-ray absorptiometry (DXA). Using allometric scaling, the influence of body weight on the value of maximum handgrip strength was removed for the data of the women. A small, but significant relationship between BMD of the proximal femur and maximum handgrip strength was found that accounted for about 6% of the total variation. The relationship between BMD of the proximal femur and unscaled maximum handgrip strength was not significant for the men. The findings diminish the confidence in a protective effect of skeletal muscle on some nonadjacent skeletal structures and suggest that these relationships may benefit from being revisited. The results highlight the utility of allometric scaling in analyses in which the relationship between a physiological variable and a body dimension variable can be nonlinearly and simultaneously influenced by other body dimension variables that are not considered in the analysis and therefore are statistically uncontrolled.

Lower extremity muscle strength does not independently predict proximal femur bone mineral density in healthy older adults

The relationship described in the published literature between muscle strength and bone mineral density of older adults is not entirely certain. It is possible that the direct relationship reported in some studies is biased by failing to mathematically account for the biological influence of body weight and body height on both bone mineral density and muscle strength. This study sought to determine if the relationships between measures of lower extremity muscle strength and bone mineral density of the proximal femur are independent of body size (i.e., body height and body weight) in healthy older adults. We recruited 50 older women and 29 older men, all of whom were healthy community dwellers and not involved in resistance training. Quantitative analysis of the isometric strength of the bilateral ankle, knee, and hip joints and assessment of bone mineral density of the proximal femur were conducted. Muscle strength values were adjusted for the influence of body height and body weight using an allometric scaling procedure. The correlations between proximal femur bone mineral density and the unadjusted strength values were weak but statistically significant. After adjusting muscle strength to account for the influence of body height and body weight, the magnitudes of the correlations between bone mineral density and muscle strength diminished substantially and were not significantly different from zero. The results reveal that, for a typical sample of healthy older adults not involved in resistance training, the relationship between maximal isometric muscle strength of lower extremity joints and proximal femur bone mineral density is reliant on body size.

Knee strength variability between individuals across ranges of motion and hip angles

PURPOSE

Isokinetic strength is normally measured for a single range of motion and body position. This study quantified the variability, between individuals, in the relationships between a single peak knee extension moment and the isokinetic extension moments measured for different hip angles and ranges of knee motion. Effects of hip angle, and of the starting knee angle of the range of motion, on isokinetic knee extension strength were also determined.

METHODS

The isokinetic knee extension strength of 10 subjects was measured at 30 degrees x s(-1) to a knee flexion angle of 10 degrees from starting knee angles of 90, 75, 60, 45, and 30 degrees, in both the seated and supine positions. Moments were normalized to the peak moment from a reference contraction.

RESULTS

Peak moments and moments at larger knee flexion angles were greater in the seated than in the supine position. The starting knee angle affected the peak moment, the angle of peak moment, and the moments over the initial and final portions of the range of motion. Peak moments were highly correlated between all hip angle-starting knee angle combinations. However, the normalized peak moments, the angles of peak moment, and the normalized angle-specific moments all varied considerably between subjects. The pooled standard deviation and average coefficient of variation of the normalized angle-specific moments between subjects were 10.5% of the normalizing moment and 15.7%, respectively. Excluding the reference contraction, between-subject variability was unaffected by hip angle or starting knee angle.

CONCLUSIONS

Influences of hip angle, starting knee angle, and individual differences on isokinetic knee extension strength must be considered to ensure that the moments obtained from isokinetic testing adequately reflect the general strength capabilities of an individual.