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.

Perturbation-based balance assessment: Examining reactive balance control in older adults with mild cognitive impairments.

BACKGROUND: Older adults with mild cognitive impairment (OAwMCI) present subtle balance and gait deficits along with subjective memory decline. Although these presentations might not affect activities of daily living (ADLs), they attribute to a two-folded increase in falls. While changes occurring in volitional balance control during ADLs have been extensively examined among OAwMCI, reactive balance control, required to recover from external perturbations, has received little attention. Therefore, this study examined reactive balance control in OAwMCI compared to their healthy counterparts. METHODS: Fifteen older adults with mild cognitive impairment (OAwMCI), fifteen cognitively intact older adults (CIOA) (>55 years), and fifteen young adults (18-30 years) were exposed to stance perturbations at three different intensities. Behavioral outcomes postural COM state stability, step length, step initiation, and step execution were computed. RESULTS: Postural COM state stability was the lowest in OAwMCI compared to CIOA and young adults, and it deteriorated at higher perturbation intensities (P < 0.001). Step length was the lowest among OAwMCI and was significantly different from young adults (P < 0.001) but not from CIOA. Unlike OAwMCI, CIOA and young adults increased their step length at higher perturbation intensities (P < 0.001). OAwMCI showed longer recovery step initiation times and shorter execution times compared to CIOA and young adults at higher perturbation intensities (P < 0.001). CONCLUSION: OAwMCI exhibit exacerbated reactive instability and are unable to modulate their responses as the threat to balance control altered. Thus, they are at a significantly higher risk of falls than their healthy counterparts.

Repeated-slip training: an emerging paradigm for prevention of slip-related falls among older adults.

Falls frequently cause injury-related hospitalization or death among older adults. This article reviews a new conceptual framework on dynamic stability and weight support in reducing the risk for falls resulting from a forward slip, based on the principles of motor control and learning, in the context of adaptation and longer-term retention induced by repeated-slip training. Although an unexpected slip is severely destabilizing, a recovery step often is adequate for regaining stability, regardless of age. Consequently, poor weight support (quantified by reduction in hip height), rather than instability, is the major determinant of slip-related fall risk. Promisingly, a single session of repeated-slip training can enhance neuromechanical control of dynamic stability and weight support to prevent falls, which can be retained for several months or longer. These principles provide the theoretical basis for establishing task-specific adaptive training that facilitates the development of protective strategies to reduce falls among older adults.