Slip & Fall Prevention Tools
Key Components Of Balance
Fay B. Horak Ph. D P.T. and colleagues at OHSU ( School of Medicine Department of Neurology) sum up the key components of Balance as:
Limits of stability (while standing, how far you can reach without taking a step in all directions)
Sensory Integration (internal systems i.e vestibular, vision, somatosensory)
Biomechanical challenges ( think physical strength, endurance)
Anticipatory responsive (you've just tripped, your hands shoot out to regain balance because your brain has recognized this movement from prior experience)
Reactive response (an unforeseen extra step on a stair you did not see and have to quickly recover)
Stability during gait (how well you can maintain upright posture when encountering steep, uneven trails while hiking)
Cognitive/Motor factors (walking, talking and dodging people on a crowded sidewalk)
According to Rubinstein (2006), a primary risk factor of falls is muscle weakness followed by balance and gait deficit, visual and mobility limitations, cognitive difficulties, level of functional status and postural hypotension.
Rubenstein (2006). Mak, M., & Horak, F. (2014)
Ankles, Feet & Toes - Oh My!
The act of standing in Pilates Stance, challenging the vertical line with shoulders over hips, hips over ankles while pressing the heels down facilitates ankle strategy and helps ground you.
It improves awareness of your cone of stability (how far you can shift in all directions) during any daily activity
Ankle stability is key to decreasing risk of falls.
Ankle Sway Reach (how far you can safely reach in each direction). Ideally, the ranges are:
Forward - 8 degrees
Side - 8 degrees
Backward - 4 degrees
Ankle strategy vs Hip Strategy
Imagine you are standing in the shower and you reach for your bar of soap. Ideally the first measure to kick in to maintain balance are your ankles. The ankle joints and surrounding muscles are first to support your sway. If that doesn’t work well, your hips compensate by pushing back to counter-balance. Finally if you feel you’re slipping you’ll find yourself taking a step forward to stop from falling.
What muscles fire?
Forward Sway Ankle Strategy
gastrocnemius kick in first (think calves) , then hamstrings (back of the thighs) and then paraspinals (part of back muscles)
Forward Hip Sway Strategy
abdominals (core) then quadraceps (front of the thighs)
Stepping forward
If ankle muscles are weak and/or tight, weak hips and trunk muscles, you step forward to regain balance. Your arms will also lift to restore balance and as a means of protection. Better a scraped palm than hitting your head.
Now imagine being pushed back. A gentle nudge back will result in an ankle strategy. A more forceful push back hip strategy compensates while a fast and powerful push may illicit stepping back as a last resort.
What muscles fire?
Backward Ankle Sway Strategy
tibiallis anterior (think shins), quadraceps, then abdominals
Backward Hip Sway Strategy
abdominals, then hamstrings and paraspinals
Stepping back (same as forward)
Lastly, imagine a sudden jolt on a train or bus sideways. This results in a Side (mediolateal) Sway Strategy where the hip abductors (think outer hips ) and hip adductors (inter thighs) kick in to compensate to restore balance. You may side step to increase your base of support (the wider, easier to keep upright, the narrower, more challenging to maintain postural control). Trunk muscles and arms may also be used to catch yourself.
Anticipatory and Adaptive Reactive Postural Control
Anticipatory Postural Control
Feed forward (past experiences are encoded into the brain and it sends signals to muscles before movement occurs). So go ahead let a child and jump, climb, bike and hike. The future adult will thank you.
Adaptive Reactive Postural control
Feed back (you unexpectedly loose your footing ice-skating). Your central nervous system takes in the information from your muscles and makes lightning quick adjustments to keep you upright. This in turn then gets stored in the brain and becomes a feed forward mechanism.
Before beginning any treatment program the therapist will evaluate your strengthen and weaknesses, for example, assess how well your internal systems work (vestibular, visual, somatosensory) and through evidence-based tests gauge areas that require therapeutic intervention.
An example of how internal systems shift to maintain upright posture depending on the environment:
Standing on a firm surface (hardwood floor)
70% Somatosensory input (from the feet)
20% Vestibular input
10% Visual input
Standing on an uneven surface (a squishy mat)
60% Vestibular input
30% Visual input
10% Somatosensory
Kaminskly et al., (2003). Peterka, R. J., & Loughlin, P. J. (2004). Friedrich,et al., (2008) Gouglidis,et al., (2010). Huang (2013). Lord et al., (2017). Ka et al., (2019)
Single Leg Press Down on Electric Chair
Older people have longer anticipatory adjustments (will sway side to side more) than younger people
Highest sways are side to side (media-lateral). Single leg (unilateral training) is key to improving anticipatory control
Unilateral training increases contralateral (other side of the body) strength at the cortical (think frontal lobe, parietal, temporal, occipital lobes) and subcortical (think thalamus, basil ganglia, cerebellum) levels of the brain
Fear of falling increases sway reactions
The Single leg Push down can be adjusted to the client's abilities and needs. For example, taking one hand away from the shovel handles challenges balance, two hands off even more, so does changing the rhythm of pressing down the pedal, and holding or continuously moving thorough the action. Attached springs can also be adjusted to match or challenge the client's ability. The therapist's types of cues and level of support (whether physical or verbal) also plays a role in not only supporting the client's physical journey but also emotional.
Hwang (2013),Lee, M., & Carroll, T. J. (2007). Schlenstedt et al., (2017). Son, S. M. (2018). Yiou et al., (2012). Yiou et al., (2011).
The Short Box
Hug, Flat back, Side to Side, Twist and Reach, Tree
Overall engagement of muscles during strengthening/ exercises facilitate increased functional performance during daily activities.
Studies have shown postural/ trunk control can be improved through core stability
A lack of flexibility and stability affects your ability to safely react to the constant changing environment
Spinal flexion and especially extension decreases with age
Anticipatory training movements such as side bending, twisting, reaching in all directions and single leg work are key to decreasing postural sway and increasing righting reactions and balance
Endurance and strength training, especially the deep abdominal muscles lower anticipatory sway and reactive responses
The short box series allows for safe training in weight shifting, along with spinal flexibility and strength, increase knowledge of mid-line and strengthening the deep trunk muscles that help support walking speed and regular daily activities
The series is also a great cognitive and motor challenge the therapist can challenge the client with increasing reps, range of motion, decrease verbal and tactile (physical support) cues.
Amit,et al,. (2013). Cho et al., (2014), Feigin et al., (1996), Felt et al., (2001). Golpaigay (2010). Gorman et al., (2014). Gramacher (2013). Kang et al., (2012). Maeo et al., (2013). papa et al., (2014). Saidu et al., (2011). Shnayderman & Katz (2013). Wilson et al., (2005)
In the Event of a Fall Tips
Deep Breath & Stay Calm
Click on each image to read:
References
Akbari, A., Sarmadi, A., & Zafardanesh, P. (2014). The effect of ankle taping and balance exercises on postural stability indices in healthy women. Journal of physical therapy science, 26(5), 763-9.
Amit, K., Manish, G., & Taruna, K. (2013). Effect of trunk muscles stabilization exercises and general exercises on pain in recurrent non specific low back ache. Int Res J Med Sci, 1(1), 23-26.
Cho, H. Y., Kim, E. H., & Kim, J. (2014). Effects of the CORE exercise program on pain and active range of motion in patients with chronic low back pain. Journal of physical therapy science, 26(8), 1237-1240.
Feigin, L., Sharon, B., Czaczkes, B., & Rosin, A. J. (1996). Sitting equilibrium 2 weeks after a stroke can predict the walking ability after 6 months. Gerontology, 42(6), 348-353.
Feld, J. A., Rabadi, M. H., Blau, A. D., & Jordan, B. D. (2001). Berg balance scale and outcome measures in acquired brain injury. Neurorehabilitation and neural repair, 15(3), 239-244.
Friedrich, M., Grein, H. J., Wicher, C., Schuetze, J., Mueller, A., Lauenroth, A., ... & Schwesig, R. (2008). Influence of pathologic and simulated visual dysfunctions on the postural system. Experimental Brain Research, 186(2), 305-314.
Gorman, S. L., Rivera, M., & McCarthy, L. (2014). Reliability of the function in sitting test (FIST). Rehabilitation research and practice, 2014.
Gorman, S. L., Harro, C. C., Platko, C., & Greenwald, C. (2014). Examining the function in sitting test for validity, responsiveness, and minimal clinically important difference in inpatient rehabilitation. Archives of physical medicine and rehabilitation, 95(12), 2304-2311.
Gouglidis, V., Nikodelis, T., Hatzitaki, V., & Amiridis, I. G. (2010). Changes in the limits of stability induced by weight-shifting training in elderly women. Experimental aging research, 37(1), 46-62.
Judge, J. O., Lindsey, C., Underwood, M., & Winsemius, D. (1993). Balance improvements in older women: effects of exercise training. Physical therapy, 73(4), 254-262.
Ka, S. I., Kim, S. E., & Park, D. H. (2019). Analysis of long-term outcomes after surgery in patients with severe blepharoptosis. Archives of Aesthetic Plastic Surgery, 25(1), 16-21.
Kamata, N., Matsuo, Y., Yoneda, T., Shinohara, H., Inoue, S., & Abe, K. (2007). Overestimation of stability limits leads to a high frequency of falls in patients with Parkinson's disease. Clinical Rehabilitation, 21(4), 357-361.
Kaminski, T. W., Buckley, B. D., Powers, M. E., Hubbard, T. J., & Ortiz, C. (2003). Effect of strength and proprioception training on eversion to inversion strength ratios in subjects with unilateral functional ankle instability. British journal of sports medicine, 37(5), 410-415.
Klenk, J., Kerse, N., Rapp, K., Nikolaus, T., Becker, C., Rothenbacher, D., ... & ActiFE Study Group. (2015). Physical activity and different concepts of fall risk estimation in older people– results of the ActiFE-Ulm Study. PloS one, 10(6), e0129098.
Lee, M., & Carroll, T. J. (2007). Cross education. Sports Medicine, 37(1), 1-14.
Lord, S. R., Sherrington, C., Menz, H. B., & Close, J. C. (2007). Falls in older people: risk factors and strategies for prevention. Cambridge University Press.
Lesinski, M., Hortobágyi, T., Muehlbauer, T., Gollhofer, A., & Granacher, U. (2015). Effects of Balance Training on Balance Performance in Healthy Older Adults: A Systematic Review and Meta-analysis. Sports medicine (Auckland, N.Z.), 45(12), 1721-38.
Mansfield, A., Peters, A. L., Liu, B. A., & Maki, B. E. (2010). Effect of a perturbation-based balance training program on compensatory stepping and grasping reactions in older adults: a randomized controlled trial. Physical therapy, 90(4), 476-491.
Maeo, S., Takahashi, T., Takai, Y., & Kanehisa, H. (2013). Trunk muscle activities during abdominal bracing: comparison among muscles and exercises. Journal of sports science & medicine, 12(3), 467.
Mak, M., & Horak, F. (2014). Balance training. In M. Selzer, S. Clarke, L. Cohen, G. Kwakkel, & R. Miller (Eds.), Textbook of Neural Repair and Rehabilitation (pp. 105-119). Cambridge: Cambridge University Press. doi:10.1017/CBO9780511995590.013
Morrison, S., Colberg, S. R., Parson, H. K., Neumann, S., Handel, R., Vinik, E. J., ... & Vinik, A. I. (2016). Walking-induced fatigue leads to increased falls risk in older adults. Journal of the American Medical Directors Association, 17(5), 402-409.
Papa, E. V., Garg, H., & Dibble, L. E. (2015). Acute effects of muscle fatigue on anticipatory and reactive postural control in older individuals: a systematic review of the evidence. Journal of Geriatric Physical Therapy, 38(1), 40-48.
Peterka, R. J., & Loughlin, P. J. (2004). Dynamic regulation of sensorimotor integration in human postural control. Journal of neurophysiology.
Paquette, M. R., Li, Y., Hoekstra, J., & Bravo, J. (2015). An 8-week reactive balance training program in older healthy adults: A preliminary investigation. Journal of Sport and Health Science, 4(3), 263-269.
Renaud, M., Bherer, L., & Maquestiaux, F. (2010). A high level of physical fitness is associated with more efficient response preparation in older adults. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 65(3), 317-322.
Rubenstein, L. Z. (2006). Falls in older people: epidemiology, risk factors and strategies for prevention. Age and ageing, 35(suppl_2), ii37-ii41.
Sakurai, R., Fujiwara, Y., Ishihara, M., Higuchi, T., Uchida, H., & Imanaka, K. (2013). Age-related self-overestimation of step-over ability in healthy older adults and its relationship to fall risk.BMC geriatrics, 13(1), 44.
Saidu, I. A., Maduagwu, S. M., Abbas, A. D., Adetunji, O. O., & Jajere, A. M. (2011). Lumbar spinal mobility changes among adults with advancing age. Journal of mid-life health, 2(2), 65-71.
Schlenstedt, C., Arnold, M., Mancini, M., Deuschl, G., & Weisser, B. (2017). The effect of unilateral balance training on postural control of the contralateral limb. Journal of sports sciences, 35(22), 2265-2271.
Shnayderman, I., & Katz-Leurer, M. (2013). An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clinical rehabilitation, 27(3), 207-214.
Son, S. M. (2018). Immediate Effect of Postural Control of the Contra-Lateral Side on Exercise-Induced Fatigue of the Ipsi-Lateral Plantar Flexor Muscle. The Journal of Korean Physical Therapy, 30(2), 63-66.
Wieling, W., Krediet, C. P., Van Dijk, N., Linzer, M., & Tschakovsky, M. E. (2007). Initial orthostatic hypotension: review of a forgotten condition. Clinical science, 112(3), 157-165.
Willson, J. D., Dougherty, C. P., Ireland, M. L., & Davis, I. M. (2005). Core stability and its relationship to lower extremity function and injury. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 13(5), 316-325.
Yiou, E., Caderby, T., & Hussein, T. (2012). Adaptability of anticipatory postural adjustments associated with voluntary movement. World journal of orthopedics, 3(6), 75.
Yiou, E., Deroche, T., Do, M. C., & Woodman, T. (2011). Influence of fear of falling on anticipatory postural control of medio-lateral stability during rapid leg flexion. European journal of applied physiology, 111(4), 611-620.