The kinematics and strategies of recovery steps during lateral losses of balance in standing at different perturbation magnitudes in older adults with varying history of falls

Shani Batcir, Guy Shani, Amir Shapiro, Neil Alexander, Itshak Melzer, Shani Batcir, Guy Shani, Amir Shapiro, Neil Alexander, Itshak Melzer

Abstract

Background: Step-recovery responses are critical in preventing falls when balance is lost unexpectedly. We investigated the kinematics and strategies of balance recovery in older adults with a varying history of falls.

Methods: In a laboratory study, 51 non-fallers (NFs), 20 one-time fallers (OFs), and 12 recurrent-fallers (RFs) were exposed to random right/left unannounced underfoot perturbations in standing of increasing magnitude. The stepping strategies and kinematics across an increasing magnitude of perturbations and the single- and multiple-step threshold trials, i.e., the lowest perturbation magnitude to evoke single step and multiple steps, respectively, were analyzed. Fall efficacy (FES) and self-reported lower-extremity function were also assessed.

Results: OFs had significantly lower single- and multiple-step threshold levels than NFs; the recovery-step kinematics were similar. Surprisingly, RFs did not differ from NFs in either threshold. The kinematics in the single-step threshold trial in RFs, however, showed a significant delay in step initiation duration, longer step duration, and larger center of mass (CoM) displacement compared with NFs and OFs. In the multiple-step threshold trial, the RFs exhibited larger CoM displacements and longer time to fully recover from balance loss. Interestingly, in the single-stepping trials, 45% of the step-recovery strategies used by RFs were the loaded-leg strategy, about two times more than OFs and NFs (22.5 and 24.2%, respectively). During the multiple-stepping trials, 27.3% of the first-step recovery strategies used by RFs were the loaded-leg strategy about two times more than OFs and NFs (11.9 and 16.4%, respectively), the crossover stepping strategy was the dominated response in all 3 groups (about 50%). In addition, RFs reported a lower low-extremity function compared with NFs, and higher FES in the OFs.

Conclusions: RFs had impaired kinematics during both single-step and multiple-step recovery responses which was associated with greater leg dysfunction. OFs and NFs had similar recovery-step kinematics, but OFs were more likely to step at lower perturbation magnitudes suggesting a more "responsive" over-reactive step response related from their higher fear of falling and not due to impaired balance abilities. These data provide insight into how a varying history of falls might affect balance recovery to a lateral postural perturbation.

Trial registration: This study was registered prospectively on November 9th, 2011 at clinicaltrials.gov ( NCT01439451 ).

Keywords: Balance recovery reaction; Falls; Multiple-step threshold; Recurrent fallers; Single-step threshold.

Conflict of interest statement

IM and AS developed and built the BaMPer perturbation system that was used in this project. All remaining authors have nothing to declare.

Figures

Fig. 1
Fig. 1
Single-step threshold (empty hexagon) and multiple-step threshold (filled hexagon) for NFs, OFs, and RFs. Placement of symbols indicates mean values; the whiskers of each plot indicate ±1 standard deviation. * Indicates significant differences between groups (p < 0.05) based on one-way ANOVA with LSD-post-hoc test
Fig. 2
Fig. 2
Mean probabilities of stepping by perturbation magnitude for non-fallers (NFs), one-time fallers (OFs), and recurrent fallers (RFs). Placement of symbols indicates mean values of the percentages of stepping trials out of the total number of trials at each perturbation magnitude for each group. The Fisher’s exact test (observed cases less than five) and chi-squared test (five or more observed cases) were used to test for differences in probabilities of stepping between groups. a – Significant differences between NFs and OFs. b – Significant differences between NFs and RFs. C- Significant differences between of OFs and RFs. Significance adjusted for 3-pairwise comparisons with a Bonferroni adjustment for multiple comparisons (p = 0.05/3 = 0.016)
Fig. 3
Fig. 3
A mosaic plot showing the frequencies of the first recovery step strategies during single-step trials at increasing magnitudes of perturbation for non-fallers (a), one-time fallers (b), and recurrent fallers (c). Note: A mosaic plot is a graphical display of the leg strategy frequencies (Y-axis) by perturbation magnitudes (X-axis) during the single-step reactions. The widths of the boxes are proportional to the percentage of steps performed out of the total stepping reactions (the number of single-step reactions at each magnitude is presented at the top of each graph). The heights of the boxes are proportional to the percent of the strategies used to recover from balance loss at each perturbation magnitude level. The isolated right column summarizes all the frequencies of the leg strategies during all magnitudes. Abbreviations: LLSS, loaded leg side step; ULSS – unloaded leg side step; COS – crossover step; Leg Abduction – abducting the unloaded leg; Col - leg collisions
Fig. 4
Fig. 4
A mosaic plot showing the frequencies of the first recovery step strategies during multiple-step reaction trials at increasing magnitudes of perturbation for non-fallers (a), one-time fallers (b), and recurrent fallers (c). Note: A mosaic plot is a graphical display of the leg strategy frequencies (Y axis) by perturbation magnitudes (X axis) during the multiple-step reactions. The widths of the boxes are proportional to the percentage of steps performed out of the total stepping reactions (the number of multiple-step reactions at each magnitude presented at the top of each graph). The heights of the boxes are proportional to the percent of the strategies used to recover from balance loss at each perturbation magnitude level. The isolated right column summarizes all the frequencies of the leg strategies during all magnitudes. Abbreviations: LLSS, loaded leg side step; ULSS – unloaded leg side step; COS – crossover step; Leg Abduction – abducting the unloaded leg; Col - leg collisions

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