A survey of Israeli physical therapists regarding reactive balance training.

BACKGROUND: 'Reactive balance training' (RBT) was developed to improve balance reactions to unexpected losses of balance. Although this training method is effective, its practical usage in the field of physical-therapy in Israel and world-wide is still unclear. AIMS: This study aimed to evaluate the extent of RBT use in physical-therapy clinics in Israel, to identify the significant barriers to/facilitators for implementing RBT in clinical practice among physical therapists, and to determine which aspects of RBT most interest physical therapists in Israel. METHODS: Physical therapists in Israel completed a survey using a questionnaire regarding their knowledge and use of RBT in their clinical practices. We compared the specific use of RBT among users; non-users; and open-to-use physical therapists. The odds ratios of the facilitators and barriers were calculated using univariate and multivariate logistic regression models. RESULTS: Four-hundred and two physical therapists responded to a yes/no question regarding their use of RBT. Three-quarters (75.4%) of physical therapists reported using RBT in their practices. The most prevalent barrier cited was insufficient space for setting up equipment and most prevalent facilitator was having a colleague who uses RBT. Most of the respondents wanted to learn more about RBT, and most of the non-users wanted to expand their knowledge and mastery of RBT principles. CONCLUSIONS: There are misconceptions and insufficient knowledge about RBT among physical therapists in Israel, indicating that they may falsely believe that RBT requires large and expensive equipment, suggesting they categorize RBT as external perturbation training only. Reliable information may help to improve general knowledge regarding RBT, and to facilitate the more widespread implementation of RBT as an effective fall-prevention intervention method.

Corrigendum: Correlation between kinetic and kinematic measures, clinical tests and subjective self-evaluation questionnaires of the affected upper limb in people after stroke.

[This corrects the article DOI: 10.3389/fnins.2023.1264513.].

Correlation between kinetic and kinematic measures, clinical tests and subjective self-evaluation questionnaires of the affected upper limb in people after stroke.

Introduction: Assessment of stroke recovery should include multiple sources of information in order to obtain a complete understanding of the individual's rehabilitation progress. Self-evaluation questionnaires' scores do not always correspond to the scores of commonly used clinical evaluation tools. The purpose of this study was to assess the relationship between self-evaluation questionnaires, clinical tests, and kinematic and kinetic analyses of the affected upper limb after stroke, and to determine the correlation between these measures and self-reported general function 2-4 years after the stroke. Methods: Twenty-six subjects recovering from stroke were included in the study. Spearman's correlation coefficient was used to measure the correlation between Stroke Impact Scale (SIS), Motor activity Log (MAL), Fugl-Meyer Assessment (FMA) and Action Reach Arm Test (ARAT) scores, and kinematic and kinetic analyses. A logistic regression was used to assess the extent to which these measures may predict the participants' functional self-reported status 2-4 years post stroke. Results: Sections regarding hand function, hand force and general ADL of the self-evaluation questionnaires correlated with kinematic variables. However, only questionnaires that focus on hand function correlated with clinical tests. Mean and maximal hand velocity had the strongest correlations with self-evaluation questionnaires and with the clinical tests, more than other kinematic variables. Self-evaluation questionnaires and clinical tests were found to be correlated with hand kinetic metrics force-to-time ratio and number of force peaks. SIS hand force domain, mean velocity and maximal velocity predicted self-reported general function 2-4 years after the stroke. Conclusion: Self-evaluation questionnaires should be considered for wider use in the clinical evaluation of a patient's stroke recovery, since they add important information on the individual's functional status, which is not reflected in the clinical tests.

Successful Negotiation of Anticipated and Unanticipated Obstacles in Young and Older Adults: Not All Is as Expected.

BACKGROUND: Tripping over an obstacle is one of the most common causes of falls among older adults; however, the impact of obstacle parameters and subject characteristics are not well described. OBJECTIVES: To evaluate age-associated changes in the ability to negotiate obstacles and the role of obstacle parameters (e.g., anticipated vs. unanticipated, height, and available response time [ART]), and subject characteristics. METHODS: Twenty healthy older adults (77.7 ± 3.4 years; 50% women) and 20 healthy young adults (29.3 ± 3.8 years; 50% women) underwent cognitive, gait, and balance testing before negotiating a computer-controlled obstacle course. The primary outcome measure was the ability to successfully negotiate the obstacles (without touching them). RESULTS: The success rate for all subjects was higher when the obstacle was anticipated (99.0 ± 2.8%) than when unanticipated (66.0 ± 20.2%; p < 0.001). The obstacle height had a significant effect on the success rate (p = 0.022); the success rate was lower when the obstacle height was lower. No significant interaction between group and obstacle height was observed (p = 0.096). ART had no significant effect on the success rate (p = 0.294) in both of the groups (ART × group, p = 0.136). However, a significant interaction between group, obstacle height, and ART was found (p = 0.013), reflecting a lower success rate in the older adults when the obstacles were low and unanticipated. In general, older adults demonstrated a trend towards a lower success rate in all types of obstacles compared to the young adults (p = 0.057). Among the older adults, the success rate in the anticipated obstacle condition was correlated with stride length (ρ = 0.600, p = 0.005), step time coefficient of variation (ρ = -0.635, p = 0.003), and gait speed (rho = 0.530, p = 0.016). Montreal Cognitive Assessment scores tended to be related to the difference in the success rate between the anticipated and unanticipated conditions. CONCLUSIONS: These findings support the idea that motor and, to some degree, cognitive functions are needed to successfully negotiate obstacles, and provide new insights into the ability of older adults to successfully negotiate obstacles. Furthermore, the present results suggest that when it comes to the physical properties of obstacles, not all is as expected, and low obstacles may impose a greater danger to tripping than obstacles that have a higher height.

The inter-observer reliability and agreement of lateral balance recovery responses in older and younger adults.

The purpose of this study was to evaluate the inter-observer reliability and agreement of balance recovery responses, step and multiple-steps thresholds, and kinematic parameters of stepping responses. Older and younger adults were exposed to 36 progressively challenging right and left unannounced surface translations during quiet standing. Subjects were instructed to "react naturally". Step threshold and multiple-step threshold were defined as the minimum disturbance magnitude that consistently elicited one and more than one recovery step, respectively. Fall threshold is defined as the minimum disturbance magnitude from which a fall resulted (i.e., fall into harness system or grasped one of the anchor straps of the harness, or grasped the research assistant to maintain balance). The inter-observer reliability of balance recovery responses for older adults were excellent, especially for step and multiple-step thresholds (ICC2,1 = 0.978 and ICC2,1 = 0.971, respectively; p < 0.001). Also kinematic parameters of stepping responses such as step recovery duration and step length were excellent (ICC2,1 > 0.975 and ICC2,1 = 0.978, respectively; p < 0.001), substantial reliability was found for swing phase duration (ICC2,1 = 0.693, p < 0.001). Younger adults showed similar ICCs. The Bland-Altman plots demonstrated excellent limits of agreement (LOA > 90%) for most kinematic step parameters and stepping thresholds. These results suggest that balance recovery responses and kinematic parameters of stepping including step threshold and multiple-step threshold are extremely reliable parameters. The measure of balance recovery responses from unexpected loss of balance is feasible and can be used in clinical setting and research-related assessments of fall risk.

Perturbation exercises during treadmill walking improve pelvic and trunk motion in older adults-A randomized control trial.

BACKGROUND: Most falls among older adults occur while walking. Pelvic and trunk motions are required to maintain stability during walking. We aimed to explore whether training that incorporates unexpected loss of balance during walking that evokes balance recovery reactions will improve pelvic, thorax, and trunk kinematics at different walking speeds. METHODS: Fifty-three community-dwelling older adults (age 80.1 ±â€¯5.6 years) were randomly allocated to an intervention group (n = 27) or a control group (n = 26). Both groups received 24 training sessions over 3 months. The intervention group received unexpected perturbation of balance exercises during treadmill walking, while the control group performed treadmill walking only. The primary outcome measures were the pelvic, thorax, and trunk motion. The secondary outcome measures were stride times, length, and width. RESULTS: Compared to control, participation in the intervention program led to improvement in pelvic and trunk transverse rotations especially at participants' preferred walking speed. No improvement where found in pelvic list while thorax transverse rotation improved in both groups. CONCLUSIONS: Pelvic and trunk transverse motion, parameters previously reported to deteriorate during aging, associated with gait stability and a risk factor for falls, can be improved by gait training that includes unexpected loss of balance.

Gait Coordination Deteriorates in Independent Old-Old Adults.

Human gait is symmetric and bilaterally coordinated in young healthy persons. In this study, we aimed to explore the differences in bilateral coordination of gait as measured by the phase coordination index (PCI), gait asymmetry, and stride time variability of gait between four age groups. A total of 44 older adults were recruited: nine young-old (age 70-74 years), 26 old (age 75-84 years), nine old-old (>85 years and older), and 13 young adults (age 20-30 years). Subjects walked on a treadmill; walking speed was systematically increased from 0.5 to 0.9 m/s in steps of 0.1 m/s. There were marginal effects of age on PCI, significant main effects of walking speeds without interaction between walking speeds and age group. A difference in PCI could distinguish between young's and late aging group, and only during their preferred treadmills walking speed. This study explicitly shows that bilateral coordination of walking is modified by gait speed, and deteriorates only at a very old age.

Old adult fallers display reduced flexibility of arm and trunk movements when challenged with different walking speeds.

Specific patterns of pelvic and thorax motions are required to maintain stability during walking. This cross-sectional study explored older-adults' gait kinematics and their kinematic adaptations to different walking speeds, with the purpose of identifying mechanisms that might be related to increased risk for falls. Fifty-eight older adults from self-care residential facilities walked on a treadmill, whose velocity was systematically increased with increments of 0.1meters/second (m/s) from 0.5 to 0.9m/s, and then similarly decreased. Thorax, pelvis, trunk, arms, and legs angular total range of motion (tROM), stride time, stride length, and step width were measured. Twenty-one of the subjects reported falling, and 37 didn't fall. No significant effect of a fall history was found for any of the dependent variables. A marginally significant interaction effect of fall history and walking speed was found for arms' tROM (p=0.098). Speed had an effect on many of the measures for both groups. As the treadmill's velocity increased, the non-fallers increased their arm (15.9±8.6° to 26.6±12.7°) and trunk rotations (4.7±1.9° to 7.2±2.8°) tROM, whereas for the fallers the change of arm (14.7±14.8° to 20.8±13°) and trunk (5.5±2.9° to 7.3±2.3°) rotations tROM were moderate between the different walking speeds. We conclude that walking speed manipulation exposed different flexibility trends. Only non-fallers demonstrated the ability to adapt trunk and arm ROM to treadmill speed i.e., had a more flexible pattern of behavior for arm and trunk motions, supporting the upper-body's importance for stability while walking.

Unexpected perturbations training improves balance control and voluntary stepping times in older adults - a double blind randomized control trial.

BACKGROUND: Falls are common among elderly, most of them occur while slipping or tripping during walking. We aimed to explore whether a training program that incorporates unexpected loss of balance during walking able to improve risk factors for falls. METHODS: In a double-blind randomized controlled trial 53 community dwelling older adults (age 80.1±5.6 years), were recruited and randomly allocated to an intervention group (n = 27) or a control group (n = 26). The intervention group received 24 training sessions over 3 months that included unexpected perturbation of balance exercises during treadmill walking. The control group performed treadmill walking with no perturbations. The primary outcome measures were the voluntary step execution times, traditional postural sway parameters and Stabilogram-Diffusion Analysis. The secondary outcome measures were the fall efficacy Scale (FES), self-reported late life function (LLFDI), and Performance-Oriented Mobility Assessment (POMA). RESULTS: Compared to control, participation in intervention program that includes unexpected loss of balance during walking led to faster Voluntary Step Execution Times under single (p = 0.002; effect size [ES] =0.75) and dual task (p = 0.003; [ES] = 0.89) conditions; intervention group subjects showed improvement in Short-term Effective diffusion coefficients in the mediolateral direction of the Stabilogram-Diffusion Analysis under eyes closed conditions (p = 0.012, [ES] = 0.92). Compared to control there were no significant changes in FES, LLFDI, and POMA. CONCLUSIONS: An intervention program that includes unexpected loss of balance during walking can improve voluntary stepping times and balance control, both previously reported as risk factors for falls. This however, did not transferred to a change self-reported function and FES. TRIAL REGISTRATION: ClinicalTrials.gov REGISTRATION NUMBER: NCT01439451 .

Age-related differences in pelvic and trunk motion and gait adaptability at different walking speeds.

This study aimed at investigating age-related changes in gait kinematics and in kinematic adaptations over a wide range of walking velocities. Thirty-four older adults and 14 younger adults walked on a treadmill; the treadmill velocity was gradually increased in increments of 0.2miles/hour (mph) (1.1-1.9mph) and then decreased in the same increments. Pelvic, trunk, upper limbs and lower limbs angular total ranges of motion (tROM), stride time, stride length, and step width were measured. The older adults had lower pelvic, trunk tROM and shorter strides and stride time compared with the younger adults. As the treadmill speed was gradually increased, the older adults showed an inability to change the pelvic list angular motions (3.1±1.3° to 3.2±1.4°) between different walking velocities, while the younger adults showed changes (5.1±1.8° to 6.3±1.7°) as a function of the walking velocity. As the walking velocity increased, the older adults increased their stride length (from 57.0±10cm to 90.2±0.1cm) yet stride times remained constant (from 1.17±0.3sec to 1.08±0.1sec), while the younger adults increased stride length and reduced stride times (from 71.4±10cm to 103.0±7.9m and from 1.45±0.2sec to 1.22±0.1sec, respectively). In conclusion, the older adults were unable to make adaptations in pelvic and trunk kinematics between different walking speeds (rigid behavior), while the younger adults showed more flexible behavior. Pelvic and trunk kinematics in different walking speeds can be used as variables in the assessment of gait in older adults.

Characteristics of balance control in older persons who fall with injury--a prospective study.

OBJECTIVE: Older adults who have recently fallen demonstrate increased postural sway compared with non-fallers. However, the differences in postural control between older adults who were seriously injured (SI) as a result of a fall, compared with those who fell but were not injured (NSI) and non-fallers (NFs), has not been investigated. The objective of the present study was to investigate the underlying postural control mechanisms related to injuries resulting from a fall. METHODS: Both traditional postural sway measures of foot center-of-pressure (CoP) displacements and fractal measures, the Stabilogram-Diffusion Analysis (SDA), were used to characterize the postural control. One hundred older adults aged 65-91years were tested during narrow base upright stance in eyes closed condition; falls were monitored over a 1-year period. RESULTS: Forty-nine older adults fell during the 1-year follow-up, 13 were seriously injured as a result of a fall (SI), 36 were not injured (NSI), and 49 were non-fallers (NFs); two passed away. The SDA showed significantly higher short-term diffusion coefficients and critical displacements in SI in the anterior-posterior direction compared with both NSI and NF. However, in the medio-lateral direction there were no statistically significant differences between groups. For the traditional measures of sway, the average anterior-posterior CoP range was also larger in SI individuals. CONCLUSIONS: This work suggests that older fallers with a deterioration of anterior-posterior postural control may be at higher risk of serious injury following fall events.

Frontal plane instability following rapid voluntary stepping: effects of age and a concurrent cognitive task.

BACKGROUND: Quick step execution may prevent falls when balance is lost. Lateral steps often emerge as a consequence of frontal plane instability arising after the first rapid step. In this study, we suggest a new analysis, focusing on the variability of the frontal plane fluctuations of center of pressure (CoP), that is, mediolateral instability, and their changes over time during and immediately following rapid voluntary stepping in older and younger adults in single- and dual-task conditions. This may be useful in understanding age-related alterations in the locomotor control system. METHODS: Seventeen older adults, who live independently in the community, and 16 younger adults performed rapid forward voluntary stepping under single- and dual-task conditions. The average mediolateral CoP fluctuations, that is, the average distance the CoP travels from side to side in the frontal plane over time, standard deviation, and the coefficient of variation of mediolateral CoP fluctuation were extracted and calculated from CoP data during and immediately following rapid voluntary stepping using a force plate. RESULTS: We found an age-related increase in the coefficient of variation that represents the variability of frontal plane fluctuations and no significant differences in the average and standard deviations of frontal plane fluctuations. Cognitive task had no influence on measures of frontal plane fluctuations in both age groups. CONCLUSION: The study showed frontal plane instability during and immediately following rapid stepping in older persons. This may be a factor contributing to lateral balance loss and the large number of lateral falls seen in the older population.

A retrospective analysis of balance control parameters in elderly fallers and non-fallers.

BACKGROUND: A cross-sectional retrospective study of parameters reflecting balance function in elderly fallers and non-fallers was conducted to better understand postural control mechanisms in individuals prone to falls. METHODS: Ninety-nine old adults (65-91 years, mean age 78.4 (SD 5.7)) from two self-care residential facilities participated in the study. Foot center-of-pressure (CoP) displacement data were collected during narrow base upright stance eyes closed conditions and analyzed using summary statistics and Stabilogram-Diffusion Analysis (SDA) for mediolateral (ML) and anteroposterior (AP) directions. Subjects were instructed to minimize body sway. FINDINGS: Twenty-nine of the subjects reported at least one fall and 69 subjects reported no falls in the past six months. The SDA showed significantly higher short-term diffusion coefficients and critical displacements in fallers in the ML but not the AP direction. Mean sway area and ML-CoP sway range were also larger in fallers. INTERPRETATION: The greater ML critical displacement seen in fallers suggests that balance corrections on average occurred at higher sway amplitudes in this population. This is consistent with an ML decrease in the sensitivity of their postural control system. A higher short-term diffusion coefficient is consistent with increased muscle stiffness, a possible compensation for lost control sensitivity. Testing balance function under narrow stance conditions provides a modest increase in task difficulty that may help reveal pre-conditions of the balance control system that could increase the risk of falls.

Do voluntary step reactions in dual task conditions have an added value over single task for fall prediction? A prospective study.

BACKGROUND AND AIMS: Stepping reactions play a critical role in responding to balance perturbations, whether they are a consequence of external perturbation or self-induced in nature. The aim of the present study was to determine prospectively the capacity of voluntary stepping performance in singleand dual-task conditions, to predict future falls among older community-dwelling persons. We also aimed to assess whether dual task conditions have an added value over single tasks for fall prediction. METHODS: A total of 100 healthy old volunteers (mean age 78.4±5.7 yrs), from two self-care protected retirement homes for older adults, performed the Voluntary Step Execution Test in single- and dual-task conditions as a reaction time task while standing on a single force platform. Step initiation, preparatory and swing phases, and foot-contact time were extracted from data on center of pressure and ground reaction force. One-year fall incidences were monitored. RESULTS: Ninety-eight subjects completed the one-year follow-up, 49 non-fallers, 32 one-time fallers, and 17 recurrent fallers (two or more falls). Recurrent fallers had significantly slower voluntary step execution times in both single- and dual-task conditions, especially due to a slower preparation phase. Two stepwise (backward) logistic regression models showed that longer step execution times have strong predictive value for falls in both single- and dual-task conditions (odds ratio (OR) 8.7 and 5.4, respectively, p<0.05). CONCLUSIONS: Voluntary Step Execution Test in both single- and dual-task conditions is a simple and safe examination which can potentially and effectively predict future falls, with no added value to dual- over single-task condition.

Self reported function and disability in late life: a comparison between recurrent fallers and non-fallers.

PURPOSE: To compare self-reported function and disability between fallers and non-fallers. METHOD: Self-reported late life function and disability (LLFDI) were evaluated among 100 elderly persons who live independently in the community in a cross sectional study. The function component evaluates difficulty in performing physical activities in upper and lower extremity and the disability component evaluates limitations in life activities and frequency in taking part in life tasks. Falls, cognitive function, berg balance test (BBS), and timed up and go (TUG) were also evaluated. RESULTS: Eighteen subjects reported one fall (F), 11 fell twice or more (RF) and 71 did not report retrospective fall (NF). There were significant differences in overall function of LLFDI between RF and NF (56.8 +/- 5.7 vs. 63.7 +/- 11.4, P = 0.04), mainly due to decreased basic lower extremity function scores (66.2 +/- 8.6 vs. 75.3 +/- 13.5, P = 0.03); no significant differences were found in disability component scores. RF subjects showed high to moderate correlations between overall function of LLFDI, BBS and TUG (r = 0.77, P = 0.006 and r = -0.62, P = 0.04, respectively), moderate correlation between disability limitation and BBS (r = 0.60, P = 0.05) but weaker with TUG (r = -0.38, P = 0.28). Both BBS and TUG were not correlated with disability frequency (r = -0.18, P = 0.61 and r = 0.14, P = 0.68, respectively) in RF. RF demonstrated high correlation between overallfunction and disability limitation (r = 0.76, P = 0.007) and low with disability frequency (r = 0.39, P = 0.23). CONCLUSIONS: Balance function, self-reported function and disability limitation are strongly associated in RF but not related to the disability frequency, suggesting that the frequency of performing life tasks was not influenced only by functional capabilities.

Regular exercise in the elderly is effective to preserve the speed of voluntary stepping under single-task condition but not under dual-task condition. A case-control study.

BACKGROUND: Stepping response may be considered the most important postural reaction to prevent a fall because it is the inability to respond effectively to a loss of balance that ultimately determines whether a fall occurs. However, very little has been studied on the effect of exercising on step execution behavior in the elderly. OBJECTIVES: To explore whether older persons who exercise regularly have faster voluntary stepping times than sedentary elderly persons. Additionally, we investigated the association between step execution behavior, self-reported physical function, and balance performance. METHODS: Case-control study of 48 elderly adults aged 65-91 years who live independently in retirement homes. Participants were classified as 24 exercisers (reporting >2 exercise training activities/week) and 24 age- and gender-matched inactive elderly individuals (who do not exercise regularly). The Voluntary Step Execution Test was performed as a reaction time task while standing on a force platform under single-task and dual-task conditions. Step initiation phase, foot off time, foot contact time, preparatory, and swing phases were extracted from center of pressure and ground reaction force data. Self-reported function was examined using Late-Life Function and Disability Instrument; Berg Balance Test was also performed. RESULTS: Exercisers had significantly faster voluntary step times in single-task condition (959 vs. 1,158 ms) but not during dual-task condition (1,170 vs. 1,303 ms). Exercisers had a significantly higher Berg Balance Test (53.7 +/-3.6 vs. 49.8 +/-5.3), consumed less medication (3.3 +/-2.3 vs. 5.6 +/-2.9), and their lower extremity function scores were higher (88.61 +/-2.3 vs. 73.1 +/-2.7) than those of inactive subjects. CONCLUSION: Exercising regularly protects from physical functioning loss in older persons and against a decrease in voluntary step execution times during single-task but not during dual-task conditions. Lack of specificity (dual-task exercises) during the training may be the cause of insignificant differences in dual-task stepping performance. Thus, adding dual-task training may improve dual-task performance in the elderly.

Relationship between self-reported function and disability and balance performance measures in the elderly.

This study evaluated the reliability and validity of the Hebrew version of the Late-Life Function and Disability Instrument (LLFDI). Fifty-five older adults (mean age 79.7 +/- 5.2) participated. We calculated test-retest reliability with intraclass correlation coefficients (ICCs). Partial correlations determined the construct validity with a balance measure (Berg Balance Scale [BBS]) and a mobility measure (Timed Up and Go [TUG] test). We examined known-group validity by comparing the scores of cane and noncane users. Test-retest ICCs ranged from good to excellent (0.77-0.90) for the function component and fair to good for the disability component (0.63-0.83), except for the disability management role subscale (0.46). BBS and TUG were associated with LLFDI overall function (r = 0.48, p < 0.001 and r = -0.52, p < 0.001, respectively). TUG and BBS were weakly associated with disability limitations (r = -0.26 and 0.32, respectively) and disability frequency (r = -0.16 and 0.24, respectively). Cane users showed significantly lower function scores than noncane users. We demonstrated that the Hebrew version of the LLFDI reliably and validly assesses older adults' function and disability. The LLFDI is recommended as an outcome instrument in studies in which older adults' function and disability are outcomes of interest.