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Training Reactive Balance and Fall Recovery Skills

Original Editor - SelenaHorner

Top Contributors - Selena Horner, Maitreyi Nachuri, Kim Jackson, Vidya Acharya and Stacy Schiurring  

Description

Trip and Slip Perturbation

A special category of reactive balance intervention strategies is demonstrating value in reducing falls. Inoculation against falls uses the same principle as reactive balance intervention strategies by including a moving surface. The surface movement can be a board popping up causing a trip. The surface movement can also be a fast sliding sensation after the person steps down causing a slip.[1] The best description for inoculation against falls is an intervention that introduces slips and trips for the patient to feel and learn how to respond. Because the strategy incorporates the typical mishaps that revolve around a fall, the intervention has a high specificity of training.

This is a very specific use of the term Perturbation-Based Balance Training (PBT).[2] It is used for interventions where the patient is actually walking while the surface instability is introduced. It trains fall-resistance and fall-recovery by exposing patients to sudden, unpredictable, near fall situations, in a safe and controllable environment.[2] It is different from other task-specific fall prevention programs such as gait adaptability training to real or virtual obstacles, volitional step training to stepping targets, agility training and uneven ground simulations.[2] A few of the distinguishing features of PBT when defined in such a way are[2] [3]

  • There are no changes in the environment that help the patient to anticipate the destabilization; and,
  • The perturbation should always cause a loss of stability so that fall recovery can be trained by trial and error
  • It utilises Change-in- support strategies balance reactions to very large magnitude perturbations
  • The patient's goal is not to maintain balance on an unstable surface but to recover from loss of balance

Mansfield et al define two criteria for such PBT: Utilization of external perturbations that induce a sudden motor response; and, the magnitude of the perturbation being large enough to elicit a loss of stability that will lead to a fall in the absence of a sufficient motor response or the presence of a safety harness.[2]

Stephen Lord discusses the relevance of slip or trip training to reduce falls.

[4]

Indication

Most individuals at risk of falling are candidates for reactive balance intervention strategies.

Clinical Presentation

Types of Perturbations

Clinical presentation includes information received from the patient. A patient who needs interventions that include reactive balance will share stories of having difficulty feeling safe walking outdoors, holding onto furniture or walls while walking, feeling unsteady, and report a history of slips, trips, near falls or falls.

 Confidence in balance and fear of falling are predictive of future falls.[5] A useful patient reported outcome measure is the Activities-Specific Balance Confidence Scale (ABC Scale). A score of <67% on the ABC Scale indicates an increased risk of falling. [5][6][7]

Assessment

A comprehensive initial assessment should include patient goals, medical history, neuromuscular exam to identify motor and sensory, proprioceptive deficits, visual and cognitive assessments should inform the treatment plan.[3] Functional Mobility assessment can help to identify if Reactive Balance Training is appropriate as people with lower functional mobility such as residents of long-term care facilities may face more fall risks during transitions rather than during walking.[2][8][9]

Mansfield et al recommend assessing reactive stepping by testing reactions to the Forward-fall lean and release test and/or the Reactive Postural Control subset of the Balance_Evaluation_Systems_Test_(BESTest).[3]

The Berg Balance Scale is a performance measurement tool that can be used to determine if a patient is at risk of falls. The performance measurement tool you use to determine a patient's risk of falling seems to be dependent upon the patient's current level of function. When choosing a performance measurement tool, ensure the properties of the tool indicate that the tool is appropriate for the patient you are testing. As an example, some performance tools do not actually accurately predict a risk of falling for patients who are independent community dwellers.[10]

Common Impairments Noted in Reactive Stepping

As you observe your patients, you may notice that they demonstrate some gait characteristics that could be interpreted as compensating for unsteadiness. Patients will demonstrate a slower gait speed. Patients will decrease their step length. Patients will have an increased step width.[11] You may notice that your patient does not fully pick up their feet as they ambulate.

Mansfield et al describe altered reactions such as multiple stepping, delayed arm reactions, delayed attention switching, foot collisions et cetera to perturbation tests in older adults[12] Additionally they also recommend treatment strategies to target the dysfunctions noted in healthy older adults as well as in people with sub-acute stroke.[3]

Contraindications

Cognitive inability to understand treatment purpose, inability to provide informed consent, inability to communicate adverse reactions such as pain, Acute musculoskeletal conditions (such as immediate post-op, lower extremity weight bearing restrictions, halo orthosis, fragile bones, severe joint instability, contractures), Cardiovascular conditions such as arterial dissections, abnormal responses to exercise per American College of Sports Medicine guidelines, Post-op restrictions, Colostomy bags, Indwelling catheters, Pressure sores on pelvis and trunk, Acute illness[3]

Precautions

Osteoarthritis, Rheumatoid Arthritis, Upper extremity weight bearing restrictions, Tracheostomy, High or Low BP, Orthostatic hypotension, Arterial dissection, Shouder slings, Seizures, Vertigo, Chronic subdural hemorrhage, hearing impairments, Pregnancy, High anxiety, Hernias, Hypo or hyperglycemia, Nasopharyngeal tubes, gastrostomy tubes, Infection control.[3]

Treatment Delivery

A variety of set ups have been devised and used for delivering large magnitude, unexpected, and repeated, mechanical perturbations in PBT [2]:

  • Floor obstacles in overground and treadmill set up
  • Unexpected changes in compliance of overground surface
  • Overground slips or surface translations
  • Cable or rope trips in overground and treadmill setups
  • Treadmill belt accelerations and decelerations
  • Platform translations or tilts
  • Waist or Torso pushes and pulls

For safe delivery of treatment, careful supervision, a full-body safety harness, patient specific equipment such as AFO's, slings, helmets, and monitoring of blood pressure and heart rate are necessary. Mansfield et al give guidelines on the proper application of the harness to prevent injuries from falling into the harness.[3]

The specialized equipment and expertise needed in delivering PBT means that it is possible only in lab and clinical settings.[2] At-home, group and semi-supervised settings are not conducive to the safe delivery of slip-and-trip training. Therapist-induced perturbations and pre-perturbation activities may be implemented in these settings for fall prevention. [2]

Dosage

PBT dosage is measured in terms of intensity of perturbation, number of perturbations per session and number of sessions.[2] Overground Slip training showed good retention of fall-resisting skills up to 6 months in healthy older adults when delivered with high intensity (24 slip exposures in one session) in a lab setting.[13][14] Community-dwelling elderly subjects also benefitted from a booster dose of one extra session in contrast to younger subjects.[15] However, for people with medical conditions such as COPD and poor activity tolerance, more frequent, shorter sessions may be provided with fewer perturbations in each.[16] Treadmill perturbation studies employed anywhere from 11-80 perturbations and 1 to 12 sessions.[2] There is no optimal dosage prescribed as yet as further studies are needed to determine the effect of multiple direction perturbations, treadmill-based and trip perturbation training.[2]

Outcomes

Reactive balance intervention strategies that include a category of inoculation against falls have long-term results in older adults who live independently in their communities. One session of training substantially reduced the amount of laboratory falls in the subsequent 12 months. The study was not a randomized controlled trial: the study focused on how the learned response from a single session could be retained.[14][17]

In a blinded, randomized controlled trial, falls were reduced in the group that received perturbations.[18]

Although most studies are laboratory based, clinicians are beginning to incorporate the methodology of perturbation-based interventions to cause a slip or a trip in clinical settings.

Implementation in Clinical Populations

There are still some unknowns with the amount of long-term benefit for certain populations, such as older adults who are frail or individuals who would be considered at a high risk of falling.[19] Studies have now been conducted on people with chronic stroke, Parkinsons Disease, COPD, frail older adults at higher risk of falls with follow up at up to 6 months.[20] Among people at higher risk for falls, PBT training completion was associated with a 24% reduction in the risk of experiencing 1 or more falls, and 39% fewer actual falls compared with controls according to a newer systematic review.[20]

Adverse Events

There have been no severe adverse events reported with PBT in the RCT's listed by Mansfield et al.[3] Dizziness, Fatigue Delayed onset muscle soreness, aggravation of pre-existing pains and aches were infrequently reported.[3] Headache, seizures, fall to floor without injury, and moderate musculoskeletal injuries were rarely reported.[3] However, subjects undergoing PBT training did report Anxiety and Joint pain more frequently than control subjects in these studies, some of whom withdrew due to anxiety.[3] [20] Increased age, use of treadmills rather than overground set up, were related to anxiety. To minimize anxiety and improve retention in the treatment/trials, it is necessary to use safety equipment and make sure that patients feel heard during treatment sessions.[21]The treatment parameters such as magnitude of perturbations, uncertainty of perturbations may also be progressed gradually to increase patient acceptability of treatment.[2]

Resources

In 2017 presented at the American Physical Therapy Association Combined Sections Meeting with Clive Pai (the researcher in the below video) and Tiffany Shubert about the current research on inoculation against falls. The ability to really take reactive balance intervention strategies to the next level to inoculate against falls is quite new. This video demonstrates what it may look like in the research lab.

[22]

This particular example isn't exactly like the research in laboratories. In a way, it accomplishes the same idea. Although the walking surface is not moving, in this video friction has been substantially reduced. With the reduced friction, the patient would need to control their center of gravity with their momentum to not slip and slide.

[23]

References

  1. ↑ Okubo Y, Brodie MA, Sturnieks DL, Hicks C, Carter H, Toson B, Lord SR. Exposure to trips and slips with increasing unpredictability while walking can improve balance recovery responses with minimum predictive gait alterations. PLoS one. 2018;13(9):e0202913.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 1. McCrum C, Bhatt TS, Gerards MH, Karamanidis K, Rogers MW, Lord SR, Okubo Y. Perturbation-based balance training: Principles, mechanisms and implementation in clinical practice. Frontiers in sports and active living. 2022 Oct 6;4:1015394.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 Mansfield A, Inness EL, Danells CJ, Jagroop D, Musselman KE, Salbach NM, Kochanowski J. Implementing reactive balance training in rehabilitation practice: A guide for healthcare professionals.
  4. ↑ Motor Impairment. Stephen Lord talks about fall prevention through perturbation training. https://www.youtube.com/watch?v=dyWyz_x6wF0
  5. ↑ 5.0 5.1 Merrill R. Landers, Sarrie Oscar, Jessica Sasaoka, Kyle Vaughn; Balance Confidence and Fear of Falling Avoidance Behavior Are Most Predictive of Falling in Older Adults: Prospective Analysis. Physical Therapy 2016;96:433–442.
  6. ↑ Raad, J, Moore, J, Hamby J, Lainez Rivadelo, R, Straube D. A Brief Review of the Activities-Specific Balance Confidence Scale in Older Adults. Archives of Physical Medicine and Rehabilitation 2013;94:1426-1427.
  7. ↑ Cleary K, Skornyakov E. Predicting falls in community dwelling older adults using the Activities-specific Balance Confidence Scale. Archives of gerontology and geriatrics 2017;72:142-5.
  8. ↑ Yang Y, van Schooten KS, Sims-Gould J, McKay HA, Feldman F, Robinovitch SN. Sex differences in the circumstances leading to falls: evidence from real-life falls captured on video in long-term care. Journal of the American Medical Directors Association. 2018 Feb 1;19(2):130-5.
  9. ↑ van Schooten KS, Yang Y, Feldman F, Leung M, McKay H, Sims-Gould J, Robinovitch SN. The association between fall frequency, injury risk, and characteristics of falls in older residents of long-term care: do recurrent fallers fall more safely?. The Journals of Gerontology: Series A. 2018 May 9;73(6):786-91.
  10. ↑ Strini V, Schiavolin R, Prendin A. Fall Risk Assessment scales: A systematic literature review. Nurs Rep [Internet]. 2021 [cited 2024 Sep 14];11(2):430–43.
  11. ↑ Yiou E, Caderby T, Delafontaine A, Fourcade P, Honeine JL. Balance control during gait initiation: State-of-the-art and research perspectives. World Journal of Orthopedics 2017;11:815.
  12. ↑ Mansfield A, Peters AL, Liu BA, Maki BE. A perturbation-based balance training program for older adults: study protocol for a randomised controlled trial. BMC Geriatr [Internet]. 2007 [cited 2024 Sep 14];7(1):12.
  13. ↑ Pai YC, Yang F, Bhatt T, Wang E. Learning from laboratory-induced falling: long-term motor retention among older adults. Age. 2014 Jun;36:1367-76.
  14. ↑ 14.0 14.1 Pai YC, Yang F, Bhatt T, Wang E. Learning from laboratory-induced falling: long-term motor retention among older adults. Age. 2014;36(3):9640.
  15. ↑ Bhatt T, Yang F, Pai YC. Learning to resist gait-slip falls: long-term retention in community-dwelling older adults. Archives of physical medicine and rehabilitation. 2012 Apr 1;93(4):557-64.
  16. ↑ McCrum C, Vaes AW, Delbressine JM, Koopman M, Liu WY, Willems P, Meijer K, Spruit MA. A pilot study on the feasibility and effectiveness of treadmill-based perturbations for assessing and improving walking stability in chronic obstructive pulmonary disease. Clinical Biomechanics. 2022 Jan 1;91:105538.
  17. ↑ Liu X, Bhatt T, Wang S, Yang F, Pai YC. Retention of the “first-trial effect” in gait-slip among community-living older adults. Geroscience. 2017;39(1):93-102.
  18. ↑ Okubo Y, Sturnieks DL, Brodie MA, Duran L, Lord SR. Effect of reactive balance training involving repeated slips and trips on balance recovery among older adults: A blinded randomized controlled trial. The Journals of Gerontology: Series A. 2019 Feb 5.
  19. ↑ Gerards MH, McCrum C, Mansfield A, Meijer K. Perturbation‐based balance training for falls reduction among older adults: Current evidence and implications for clinical practice. Geriatrics & gerontology international. 2017 Dec;17(12):2294-303.
  20. ↑ 20.0 20.1 20.2 5. Devasahayam AJ, Farwell K, Lim B, Morton A, Fleming N, Jagroop D, et al. The effect of reactive balance training on falls in daily life: An updated systematic review and meta-analysis. Phys Ther [Internet]. 2022 [cited 2024 Sep 14];103(1):zac154.
  21. ↑ Gerards MH, Sieben J, Marcellis R, de Bie RA, Meijer K, Lenssen AF. Acceptability of a perturbation-based balance training programme for falls prevention in older adults: a qualitative study. BMJ open. 2022 Feb 1;12(2):e056623.
  22. ↑ Associated Press. Treadmill 'Trips' May Reduce Falls for Elderly. Available from: https://www.youtube.com/watch?v=cYkyQEyhynM
  23. ↑ Industrial Biodynamics. Slip Simulator System. Available from: https://www.youtube.com/watch?v=UHdHB6cnokA
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