Preventing falls in older adults: New interventions to promote more effective change-in-support balance reactions

Centre fo Studies in Aging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Journal of Electromyography and Kinesiology (Impact Factor: 1.65). 05/2008; 18(2):243-54. DOI: 10.1016/j.jelekin.2007.06.005
Source: PubMed


"Change-in-support" (CIS) balance-recovery reactions that involve rapid stepping or reaching movements play a critical role in preventing falls; however, age-related deficits in the neuro-musculoskeletal systems may impede ability to execute these reactions effectively. This review describes four new interventions aimed at reducing fall risk in older adults by promoting more effective CIS reactions: (1) balance training, (2) balance-enhancing footwear, (3) safer mobility aids, and (4) handrail cueing systems. The training program uses unpredictable support-surface perturbations to counter specific CIS control problems associated with aging and fall risk. Pilot testing has demonstrated that the program is well-tolerated by balance-impaired older adults, and a randomized controlled trial is now in progress. The balance-enhancing footwear insole improves control of stepping reactions by compensating for age-related loss of plantar cutaneous sensation. In a clinical trial, subjects wore the insole for 12 weeks with no serious problems and no habituation of the balance-enhancing benefits. The mobility-aid intervention involves changes to the design of pickup walkers so as to reduce impediments to lateral stepping. Finally, work is underway to investigate the effectiveness of handrail cueing in attracting attention to the rail and ensuring that the brain registers its location, thereby facilitating more rapid and accurate grasping.

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Available from: Brian Edward Maki, Sep 24, 2014
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    • "This last point seems remarkable given that APRs are delayed relative to an autogenic stretch reflex but faster than muscle onsets associated with standard measures of voluntary reaction time, which tends to indicate an important role for fast-acting subcortical networks in coordinating this class of behaviour. An important feature of APRs is that they persist even when subjects try to supplant these actions with separate motor commands or attempt to suppress them altogether (Burleigh and Horak, 1996; McIlroy and Maki, 1993; Weerdesteyn et al., 2008). Thus, to a certain degree the initial postural response is immutable, at least in terms of the directionally tuned response pattern and onset. "
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    ABSTRACT: The ease with which we avoid falling down belies a highly sophisticated and distributed neural network for controlling reactions to maintain upright balance. Although historically these reactions were considered within the sub cortical domain, mounting evidence reveals a distributed network for postural control including a potentially important role for the cerebral cortex. Support for this cortical role comes from direct measurement associated with moments of induced instability as well as indirect links between cognitive task performance and balance recovery. The cerebral cortex appears to be directly involved in the control of rapid balance reactions but also setting the central nervous system in advance to optimize balance recovery reactions even when a future threat to stability is unexpected. In this review the growing body of evidence that now firmly supports a cortical role in the postural responses to externally induced perturbations is presented. Moreover, an updated framework is advanced to help understand how cortical contributions may influence our resistance to falls and on what timescale. The implications for future studies into the neural control of balance are discussed. Copyright © 2015. Published by Elsevier Ltd.
    Full-text · Article · Aug 2015 · Neuroscience & Biobehavioral Reviews
    • "standing with eyes closed) (Chodzko-Zajko et al., 2009 ). Perturbationbased balance training concentrates on compensation strategies to recover from unexpected disturbances using exercises matching real life conditions (Maki et al., 2008). Multitask balance training focuses on balance control during dual task activities, as instability increases when shared attention is needed (Granacher et al., 2010). "
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    ABSTRACT: Impaired balance may limit mobility and daily activities, and plays a key role in the elderly falling. Maintaining balance requires a concerted action of the sensory, nervous and motor systems, whereby cause and effect mutually affect each other within a closed loop. Aforementioned systems and their connecting pathways are prone to chronological age and disease-related deterioration. System redundancy allows for compensation strategies, e.g. sensory reweighting, to maintain standing balance in spite of the deterioration of underlying systems. Once those strategies fail, impaired balance and possible falls may occur. Targeted interventions to prevent falling require knowledge of the quality of the underlying systems and the compensation strategies used. As current clinical balance tests only measure the ability to maintain standing balance and cannot distinguish between cause and effect in a closed loop, there is a clear clinical need for new techniques to assess standing balance. A way to disentangle cause-and-effect relations to identify primary defects and compensation strategies is based on the application of external disturbances and system identification techniques, applicable in clinical practice. This paper outlines the multiple deteriorations of the underlying systems that may be involved in standing balance, which have to be detected early to prevent impaired standing balance. An overview of clinically used balance tests shows that early detection of impaired standing balance and identification of causal mechanisms is difficult with current tests, thereby hindering development of well-timed and target-oriented interventions as described next. Finally, a new approach to assess standing balance and to detect the underlying deteriorations is proposed.
    No preview · Article · Mar 2014 · Neuroscience
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    • "Furthermore, Palleul et al. [16] maintained a consistent order of testing (“spike” followed by “without spike” – their Figure 2) which might have introduced a systematic order effect in their results. Previous research by Maki et al. [23] suggested that textured insoles were effective in improving postural stability by controlling lateral stability during walking in older people. In accordance with the findings presented by Maki et al. [23], the results of the current study showed a similar tendency for textured insoles to decease ML postural sway in people with PD in standing. "
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    ABSTRACT: Degradation of the somatosensory system has been implicated in postural instability and increased falls risk for older people and Parkinson's disease (PD) patients. Here we demonstrate that textured insoles provide a passive intervention that is an inexpensive and accessible means to enhance the somatosensory input from the plantar surface of the feet. 20 healthy older adults (controls) and 20 participants with PD were recruited for the study. We evaluated effects of manipulating somatosensory information from the plantar surface of the feet using textured insoles. Participants performed standing tests, on two different surfaces (firm and foam), under three footwear conditions: 1) barefoot; 2) smooth insoles; and 3) textured insoles. Standing balance was evaluated using a force plate yielding data on the range of anterior-posterior and medial-lateral sway, as well as standard deviations for anterior-posterior and medial-lateral sway. On the firm surface with eyes open both the smooth and textured insoles reduced medial-lateral sway in the PD group to a similar level as the controls. Only the textured insole decreased medial-lateral sway and medial-lateral sway standard deviation in the PD group on both surfaces, with and without visual input. Greatest benefits were observed in the PD group while wearing the textured insoles, and when standing on the foam surface with eyes closed. Data suggested that textured insoles may provide a low-cost means of improving postural stability in high falls-risk groups, such as people with PD.
    Full-text · Article · Dec 2013 · PLoS ONE
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