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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (June 2023) The Underlying Precursor to Many Orthopedic Injuries ...Optimizing Best Practices for Fall Prevention by Karen Napierala, MS, AT, PT, CAFS Clinical Scenario…What would you do? John, a 67 year old golfer, presents in your office with a painful and weak L non-dominant shoulder. He reports stumbling over a threshold while getting up to use the bathroom at night, causing him to catch himself on his L hand at the countertop. He heard a small “pop” or a “snap” sound and noted difficulty with elevation ADL the next morning along with pain locally in the shoulder. Upon further questioning about his stumble, he admits to increasing frequency of falls this past 6 months but has had no other major injuries. Plain films are (-) for fracture but he does show mild DJD at the GH and AC joints. Clinical exam reveals elevation AROM limited to ~ 1500 with pain, Jobe/Abd > flexion and neutral ER MMT are 3+/5 and painful. IR, ext and adduction are strong. My clinical thinking is… Order an MRI to R/O a RC tear and determine if surgery necessary. Perform intra-articular subacromial cortisone injection and FU in 2 wks to consider starting PT. Likely partial RC tear. Non-dominant arm may not require surgery with his present ROM and rehab potential. Prescribe shoulder PT and FU in 4 wks for possible MRI if not improving adequately. Likely partial RC tear. Non-dominant arm may not require surgery with his present ROM and rehab potential. Prescribe shoulder PT plus Silver Sneakers or other similar balance program - FU in 4 wks for possible MRI if not improving adequately. Likely partial RC tear. Non-dominant arm may not require surgery with his present ROM and rehab potential. Prescribe shoulder PT + customized fall prevention including Reactive Balance Training to address underlying risk factors for re-injury - FU in 4 wks for possible MRI if not improving adequately. CURRENT EVIDENCE: Okubo Y, Sturnieks D et al. Effect of Reactive Balance Training Involving Repeated Slips and Trips on Balance Recovery Among Older adults: A Blinded Randomized Controlled Trial. J of Gerontology. Series A, 74(9), 2019, 1489-1496. SUMMARY: Falls due to slips and trips, especially in older people, can result in fractures and other injuries that potentially cause significant decline in independence. Finding safe and effective, and ideally measurable, ways to minimize this trend is crucial. Physicians play a key role in identifying patients where both a fall may have contributed to injury but also that fall risk is present moving forward and needs to be addressed. Okubo et al utilized locomotion based reactive balance training (RBT) via induced slips and trips on a 10m walkway to determine its training/preventive effect on perturbation -induced falls. Secondarily, they examined how reactive balance training effects balance recovery kinematics. Slips involved sliding tiles within the floor track while trips involved tripping boards that would spring up. Training reduced perturbation-induced falls in the lab by 60% (Rate ratio RR = 0.40). Physicians determining and prescribing care for patients with injuries related to fall risk should consider ordering RBT where indicated. Because overhead harness systems are infrequently or rarely available in outpatient clinics to match the lab conditions of studies like this, it is imperative that therapists be well versed in alternative methods for training dynamic balance including perturbation responsiveness. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Falls in older people can lead to serious injury that may trigger and overall decrease of function and then independence. Use of mechanical postural perturbations has been proposed as a training method to improve reactive balance toward the goal of reducing falls. Mansfield and Wong et al found this type of training may reduce falls by 46-48%. It is important that training regulate predictive behavior (gait cadence) and then superimpose unpredictable perturbations (slips and trips). Prior studies have used perturbations generated using a low friction plate on a walkway, treadmill accelerations, waist or ankle cable pulls, but all of those perturbations usually occur at a fixed location which results in loss of “unpredictability”. Gait alterations that only involve trips only or slip only are not as effective in creating balance changes. Also, to maximize learning of reactive balance control (the final defense against falls in everyday life), training should regulate predictive behavior (gait cadence) and then superimpose unpredictable perturbations. This group developed a walkway that would allow gait at a static cadence and unpredictable slips and trips. Purpose: This study examined whether reactive balance training thru exposure to slips and trips could improve balance recovery and reduce perturbation-induced falls among older adults. The authors were examining whether these patients would develop predictive locomotor strategies to the various conditions. Methods: Forty-four adults aged 65-90 were recruited thru a flyer in their community center and participated in this blinded randomized control trial study. Subjects all were exercising for at least 90 min / week over at minimum the past three months and could walk for 20 minutes without an aid. Exclusion criteria included h/o fractures or total joint arthroplasty within the past 12 months. Subjects walked on a 10m perturbation walkway (strapped into an overhead harness system to prevent actual falls) that was equipped with sensors along with a trip inducing board that sprung up as well as a movable tile that could slide up to 70cm on foot contact. Step length and cadence were regulated. The 14 cm tall tripping obstacle was triggered 50ms before the foot was to land in that sensor. Each of three sessions (trip, slip, combination of both) performed over 2 days included six trials on the walkway (< 40 min total). At the end of the sessions perceived anxiety and difficulty levels were assessed and confirmed to create a reaction. A trip or slip was defined as the load thru the harness that exceeded 30% of BW. The entire session was recorded and kinematic data was collected. The margin of stability (MOS) was calculated - with a (+) number indicating a stable body and (-) number indicating increased magnitude of COG motion. The control group undertook sham “target step training” on the same walkway without perturbations while still in a harness for safety. The final assessment was conducted after a 1 hour lunch break from the final slip and trip or sham training session. Findings: Fifty-one falls were recorded at post-assessment (23 slips, 27 trips). RBT reduced perturbation-induced falls by 60%. During a recovery step from a trip, the intervention group’s COM position was less anterior. The recovery stepping foot was higher and the trunk sway was smaller than that of the control group. Authors Conclusion: Results indicate that RBT decreased falls induced by trips and slips in the laboratory by 60%. The lower reduction rate observed here may indicate reactive balance is harder to train than predictive gait strategies, and more sessions may be required to lower fall rates further. THE PEAK PERFORMANCE PERSPECTIVE: Whether you are a primary care/family practice or internal medicine physician, an orthopedist, neurologist, or even a sports medicine specialist there’s a good chance that you will see patients over 60 years old. Falls in this population can be dangerous. For people over age 60 studies show that 30% will fall yearly and these risk percentages will rise quickly with each passing year. One way this is often missed is that patients may engage with health professionals over the result of the fall(s), thus leading to the key focus being the fracture or tear/strain/sprain or contusion they’ve suffered. Patients often are also embarrassed to admit they are knowingly struggling with balance control or may be in some denial and therefore miss the “connection” between increasing balance issues and their injury. A key consideration for physicians becomes the hybrid demand for treatment planning and recommendations that address the injury/condition itself but also discovery of and specific prescribing related to addressing the balance dysfunction underlying their main reason for seeking a physician. With age it is normal to lose more fast twitch muscle fibers. These muscle fibers play a key role in the body’s response to various perturbations – contributing to effective “reaction time.” Oftentimes traditional balance training will focus on static holds or intentional or pre-planned movements as training challenges designed to improve balance. While these can be effective the incorporation of more fast twitch fiber stimulating activities, like those noted in this study by Phi Yam, Bhatt.et al can be utilized to improve and maintain reactivity. Reactive Balance Training (RBT) in this study, accomplished via unexpected “slip” and “trip” occurrences during locomotion were shown to be advantageous for preventing falls. Their RBT was particularly impressive in that only 3 < 40 min sessions were adequate in affecting dynamic balance and fall prevention. Traditional balance training must start with static balance (for safety reasons) and progress to dynamic movement patterns to create a conscious competency of moment. The basis of these movement patterns is a foundation of strength that helps later on tolerate quicker and eventually reactive movements to an unexpected perturbation of the COG relative to the base of support (BOS). During the aging process, after a stroke, or with neurologic disease these proprioceptive and neuromuscular capacities are compromised. This can leave a patient unable to access movements quickly enough to prevent a fall. Rasmossen et al found that slips that occur in the early stance phase occur faster and are harder to recover from than those in the late phase of gait. As with any sport, practicing these patterns will produce a wide array of movement strategies available to cope with changing needs during activities. Also as with sports, there are times where the unexpected happens, and we expect that our bodies will be able to handle them and keep our center of gravity close to home so that we don’t fall. Reactive Balance Training (RBT) appears to be more advantageous for prevention of slips, trips, and falls than traditional balance training. RBT incorporates unconscious reactions to stimulus that are unknown creating a pattern of coping with losses of balance. Rosenblatt and Hunt et al noted studies that show a 21% reduction in falls a year later after only 4 sessions of RBT! While the method of RBT used in this study was appropriate and effective in its focus on ambulation related stimuli and training, it does have some clinical shortcomings. First, they utilize an overhead safety harness to prevent injury. This brings some external validity concerns to the findings because most patients/clinics do not have access to such a safety device. Also, it is possible that the patients’ normal gait patterns and tendencies were altered knowing the harness was there ready to protect them. This study does not provide evidence that alternative means to create a RBT environment would be comparably effective in falls reduction. Outpatient clinicians would creatively provide other means of inducing a perturbation stimuli and training opportunity. That requires a second person to be involved at home to produce the external perturbations. The partner would thus have to be physically capable of producing an adequate stimulus while still being capable of not producing an actual fall where no harness safety system was available. It must be remembered also that all falls do not occur during locomotion but also during other ADL such as reaching or lifting or simple change of direction. Referring physicians have four key considerations to be appreciated in these cases. First, foundational abilities must be trained not only in proprioception/static balance but also in adequate movement capacity and functional strength. For example, a person experiencing a LOB who trips or stumbles may need to utilize a lunge movement to catch themselves. Training reactively cannot adequately be done without prior lunge strength in this case which then allows for faster movements. This also includes appreciation for training vestibular and visual systems as well. A second consideration or progression must involve training in all three planes in order to prepare the joints/tissues but also global body for life demands that include stumbles or trips that may involve sideways or twisting movements and not merely sagittal plane only. The third is intentional fast twitch muscle performance training – we call this “speed day” for patient home programs. Using lighter loads through quick movement patterns optimizes fast twitch stimuli for these patients, many of whom may even do fitness work slowly with weights but have lost higher speed contraction ability, especially for deceleration needs. Finally, it is critical that RBT be authentic to a patient’s needs. This, for even basic human movement needs, will consider head/upper body driven motions and also ipsi or contralateral lower extremity driven stimuli – progressing to external perturbations thru the trunk/arms and eventually to uneven surfaces (often incorporated early on in traditional approaches, prior to adequate foundational work being done). These are first predictable and then eventually reactive or unpredictable with external bands, various wobble boards, reactions to verbal or physical cues, or using technology like BlazePods. The case below illustrates the benefits of using a 3D functional approach to dynamic balance training where an overhead harness treadmill system was not available yet profound improvements were generated. THE PEAK PERFORMANCE EXPERIENCE: Eleanor said: “I feel like my balance is improving. I don’t feel like I’ll fall anymore inside, or on the tennis court. I can get to the ball more often now also!” History: over the years, her balance has slowly deteriorated. An ankle sprain during tennis two years ago left her with a pattern of avoidance on the L side. Subjective: She states that she felt an inability to try to get certain balls on the tennis court, and at night she was often tentative at foot placement and uses her hands on the walls and furniture for safety. She likes a fully clean house with no throw rugs or shoes lying around. If things were messy, her level of fear of falling increased. Objective: (*=pain) Initial Eval Reeval (6 weeks) Hip extension R/L 20/15 25/22 Single leg squat knee angle R/L 40/60 55/68 Ankle dorsiflexion 11/15 18/22 Single leg balance static R/L sec 7/0 sec 12/5 sec Sit stand to seat 15 sec 9 12 Single leg balance with trunk rotation 15 sec R/L 2/0 13/5 Calf raises R/L 10/6 25/15 Key Findings: Eleanor didn’t even realize that she had an avoidance strategy on the L side until static and dynamic training were initiated. Treatment: Static balance, especially on the L had to be achieved first and then visual disturbances, head turns, and body movements were added on. She began a lunge “matrix” in a star pattern with single stepping, double stepping, and various hand reach patterns. After four weeks of strengthening, she was able to include external perturbations using the Airex foam pad via single leg balancing with added leaning in lateral and forward directions to move her COM out of her BOS enough to generate a stepping response. External forces with bands were also used to generate top-down (proximal - - - >distal) perturbations. Outcome: Eleanor is now proficient with reacting to stimuli that force her to step on her L foot quickly. She can stand on her left leg easily now, and is feeling very confident walking even when her head is turned to one side instead of straight. She hasn’t reported any falls or trips in over 6 months! You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com