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Current Evidence on Improving Balance and Decreasing Falls in

Older Adults

Jennifer Vincenzo, PT, MPH, PhD, CHES, GCS

Assistant Professor

University of Arkansas for Medical Sciences

Objectives

1. Participants will identify aspects of the postural control system.

2. Participants will recognize postural control changes that occur in older adults.

3. Participants will become familiar with novel therapies to improve postural control in older adults.

4. Participants will chose and rationalize which novel therapy would be most useful as an intervention utilizing case scenarios.

The Problem: Falls

• 1 out of 3 people over 65 fall each year• Increases to 50% over the age of 80 years

• Falls are the leading cause of both fatal and non-fatal injuries in older adults

• The direct medical costs were $31 billion

CDC

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How do people fall?

• Most frequent cause – slips and trips while walking

• Usually involves multiple factors

• Most often occurs in own home

• Li et al., 2006, CDC 2017

What happens when people fall?

• About 1 in 5 (20% or more) sustain moderate to severe injuries that can impair mobility and increase risk of early death

• Those over 75 who fall are 4-5 times more likely than those <75 to be admitted to LTC after a fall

• Over 95% of hip fractures are caused by falls (often falling laterally)

• CDC

Other issues

• Less than half of older adults who fall will talk to their healthcare provider about it (CDC)

• Many who fall, even if uninjured, become afraid of falling. • Restricted mobility

• Fear of falling• (Legters, 2002)

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Intrinsic Etiology of Fall or Imbalanceand Model for Postural Control

ALL of these things change with age and/or post CVA (Horak, 2006)

Vision

Vestibular

Somatosensory

Neuromuscular

Musculoskeletal

Cognition

Postural

Control

PMH and disease-related

impairments

Meds

Hearing

Age

Biomechanics

Anticipatory Postural

Adjustments

Automatic Postural

Adjustments

Reactive Postural

Adjustments

Dynamic balance

Fear of falling

Extrinsic Risk Factors of Falls• Environment

• Inside• Lighting, clutter…

• Outside• Support surface, obstacles, divided attention

• Demands of task• familiarity• distractions

• Footwear

• Time of day

• Devices

Assistive Devices

• Issues with assistive devices

• 4x greater risk factor of falling. • De Mettelinge, 2015

• FIT

• Using regularly

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For patients with no risk factors, fall risk is 8%

For patients with 4 or more risk factors, fall risk is 78%

What is “Balance” or Postural Control?

• Complex interactions between (Horak & Macpherson, 1996; Horak, 2006):

• Sensory and motor systems involving perceptions of stimuli

• Responses to changes in the body’s position in the environment

• Maintenance of the body’s center of mass within the base of support

-- not merely Falling vs. not falling

Sensory Systems in Postural Control

• Sensory systems • provide input to the CNS to maintain and regain balance within and outside the LOS

to prevent falls

• Most prevalent systems• Somatosensory• Visual• Vestibular

• Systems use feed forward and feedback mechanisms to interpret and integrate the body’s position in space in order maintain posture and balance

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Somatosensory System in Postural Control

• Provide information on the relative orientation and movement of the body in space through (Lundy-Ekman, 2013; O'Sullivan et al., 2013):

• Muscle and joint and tissue proprioceptors that detect movement

• Light touch and pressure from body parts in contact with support surfaces• Just light touch (from any body part) improves balance (Martinelli, 2015)

Visual System in Postural Control

• Perceives body orientation and movements as well as changes in the environment

Vestibular System in Postural Control-input and output• Detects linear and angular

movement of the head to stabilize eye movement via the vestibulo-ocular reflex

• Assists in regulation of muscle tone for postural control through the vestibulo-spinal reflex (O'Sullivan et al., 2013)

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Vestibular outputs very rapidly influence eye, head, and postural reflexes

• Vestibulo-ocular reflex• Eye velocity compensates for

head velocity

• Vestibulo-colic• Head position maintained

despite body movements

• Vestibulospinal• Postural changes in response

to vestibular signals

Sensory ReweightingIf one system is unavailable or inaccurate

Peterka, 2002

Sensory Changes with Age

• Multiple physiological changes occur with age to the sensory systems that affect postural control (O'Sullivan et al., 2013)• Somatosensory

• Impairments with age of muscle spindle function, distal sensation (Swash & Fox, 1972), and joint proprioception (Wingert, Welder, & Foo, 2014)

• Visual• Vision declines with age (Lee & Scudds, 2003)

• Vestibular• Decline in vestibular function sensing head position and movement (Herdman, Blatt,

Schubert, & Tusa, 2000)

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Sensory Reweighting and Impairment

• Even with reweighting each system contributes unique information to postural control (O'Sullivan et al., 2013; Peterka, 2002)• An impairment in any one system will likely decrease balance

• Consider Older adults (Horak, 2006; O'Sullivan et al., 2013)• prone to deficits in the sensory systems that control posture

• Vision often declines with age

• chronic diseases such as diabetes may cause decreased sensation in the feet

Posture DecreasesCenter of mass, limits of stability

Postural Awareness decreases

• Postural Awareness is impaired in older adults with balance deficits• Impaired trunk flexion proprioception (Goldberg, Hernandez, & Alexander,

2005)

• Perception of vertical posture is significantly impaired (Barbieri, Gissot, & Pérennou, 2010)• Older adults demonstrate twice the amount of backward shift of vertical posture

• If perception of vertical posture or trunk flexion is already impaired, the ability to maintain balance may be affected.

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Motor Aspects of Postural Control

• The CNS takes feedback from the sensory systems and initiates responses to maintain posture that are task and environment specific

• These responses are conscious and unconscious alterations to maintain balance in the context of an activity

• Reactions vary (O'Sullivan et al., 2013)• Simple stretch reflexes

• Specific movement strategies

Postural Strategies

• Constantly used during daily activities in anticipation or reaction to movement• Anticipatory postural control or adjustments (APAs) (Lundy-Ekman, 2013)

• ability to adjust posture prior to a voluntary movement in order to maintain balance

• Compensatory postural adjustments (CPAs) (O'Sullivan et al., 2013)• body’s response to outside forces acting on the body, including a perturbation, slip, trip, or

fall • Can further be classified as ankle, hip, and change in support strategies

• To be effective, all these strategies require adequate muscular strength, muscular power, coordination, timing, and amplitude (Horak, 2006; Izquierdo et al., 1999; Maki & McIlroy, 2006)

Reactive Motor strategies• Ankle strategies

• Shifting COM forward and back • Response to a small disturbance within LOS

• Hip strategy• Shifts in the COM by flexing or extending at hips• Response to larger and faster disturbances of COM• Or when standing on BOS narrower than length of feet

• Suspension strategies• “I dip, you dip, we dip”

• Change-in-support strategies

• Usually termed stepping strategy• Movement of lower or upper limbs to make new contact with support surface• Realigns BOS under COM using rapid steps or hops in direction of displacing force

• Forward, backwards, side, or cross steps

• In response to fast, large postural perturbations• Upper limbs can be involved in catching self with falls

• During normal balance, combinations of strategies are used• Horak, 2006

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Neuromotor Changes with Age

• Neuromotor function is affected with age through a decline in (Doherty, 2003):• Strength

• Muscle mass

• Power

• Reaction time

• Neuromuscular activation

• Biomechanical Changes

Anticipatory and compensatory postural control changes with age• APAs and CPAs have both been shown to be impaired among older adults

(Kanekar & Aruin, 2014)

• Increase in postural sway (Era et al., 2006) and muscular latencies with perturbations and sway are also evident with age (Lin & Woollacott, 2002)

• Aging and reactive posture control - older adults exhibit (Kanekar & Aruin, 2014):• Increased sway• Delayed anticipatory muscle activity• Greater compensatory muscle activity

Strategies for strategies?

• Older adults use inappropriate CPAs (Kanekar & Aruin, 2014)• When visual and somatosensory inputs are manipulated (Manchester,

Woollacott, Zederbauer-Hylton, & Marin, 1989):• older adults use hip and stepping strategies for smaller balance perturbations

• compared to younger adults, who use ankle strategies

Though APAs are delayed and less affective, the ability to activate muscles in anticipation to movement is still preserved

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Postural control CAN BE improved in

Older Adults

Interventions have successfully improved postural control among older adults

Current Interventions

• Exercise• Can improve many of the factors related to limited

mobility (strength, power, balance, endurance) (De Vries et al., 2012; Pahor et al., 2014)

• Balance training – at least 50 hours over 6 months• (Shubert, 2011; Sherrington, 2011)

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Balance Retraining• Target the neuromuscular systems that control balance

through various levels of challenge.

• Begin with controlling the center of gravity (COG) over

the base of support (BOS).

• Progress by challenging the regulation of balance and

postural stability specifically engaging visual, vestibular,

somatosensory and cognitive systems.

• Elicit postural reactions and ankle, hip and step strategies

by altering stimuli, surfaces, secondary tasks to mimic

functional activities

APTA, 2007

Gait Training

• Include all the components of gait in addition to:

• Appropriate and accurately adjusted assistive devices, and

• Challenge and advance with changes in surfaces/terrain, elevations, time/rhythm, distance, physical load, attention, postural transition (start, stop, direction), and amount of support.

APTA, 2007

Combined Balance and Stepping Training

• Working on dynamic balance and stepping responses through structured practice. • Focus on speed of steep initiation and appropriate toe clearance and step

length.• Narrowing base of support

• Bipedal to tandem to unipedal

• External challenges to balance• Moving upper extremities and bouncing and catching ball

• Narrowing base of support while responding to challenge

• Semitandem while catching ball

• Increase the complexity of ambulatory tasks

• Changing direction

Nnodim et al, 2006

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Other CBST Examples

• Walking backwards

• Changing speed

• Walking with reduced base of support• Walking on beam

• Turning

• Bending

• Stepping on and off curbs

• Stepping over obstacles

Nnodim et al, 2006

Otago Exercise Program

• Goals• Increase strength, balance, and endurance• Produce life style change to integrate strength and balance training at least 2 hours per

week

• 8 week program delivered over 52 weeks• 4-5 visits with a physical therapists

• Including monthly phone calls for a year

• 17 exercises total (strengthening with cuff weights, more traditional balance exercises)• Therapist evaluates adult and selects appropriate exercises from the 17

• Adult completes exercise for 30 mins, 3 times a week• Walking program prescribed, if participant is strong enough to walk

• 30 minutes, 3 times a week• https://www.med.unc.edu/aging/cgec/exercise-program

Multisensory integration

• 81% who received tailored home health therapy (specific to deficits but inclusive of multisensory integration) improved the number of mCTSIB conditions they could complete (Whitney, Marchetti, Ellis, & Otis, 2013)

• Modified clinical Test of Sensory Interaction on Balance (mCTSIB)

• If your patient has peripheral neuropathy• Work on visual and vestibular

• Eyes closed, dark glasses, changing surfaces – to maximize use of visual and vestibular

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Vestibular issues

• Older adults with unexplained dizziness benefit from balance rehab AND vestibular rehab

• Gaze stability exercises

• Most often VOR x 1 is done

• Should incorporate head movement and gaze stabilization ex with other balance activities

• Jung et al., 2009; Klatt et al., 2015

Vestibular issues, Whitney et al., 2016

Vestibular exercises for older

adults with unexplained

dizziness- Jung, 2009

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Vestibular exercises

• Reference websites• Vestibular rehabilitation by physical therapy nation

• https://www.youtube.com/playlist?list=PLo4JklPFPNSQriyhB4gnij9c8OJhLPmvU

• Michigan Medicine• https://www.youtube.com/user/UMHealthSystem/search?query=vestibular

Reactive or volitional step training

• Perturbation training

• Step training

Perturbation Training/Reactive Training

• Perturbation training is aimed to increase an individuals anticipatory and compensatory postural reactions

• Perturbation training may improve postural control by translating motor learning to similar tasks (Rose & Clark, 2000)

• The goal is to destabilizes the patient’s COM

• Perturbation training improves reactions to postural perturbations in older adults

• Decrease in falls associated with trips

• Programs that have a variety of perturbation modalities may result in a greater reduction of falls compared to programs with single perturbation modalities

Mansfield et al, 2010

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Multi-target stepping program/volitional step training – compared to walking decreased falls and injuriesYamada, 2013

Took approx. 7

min 2x/wk24 wks

-all also did 30 min ex

class

Reactive or volitional step trainingOkubo, 2016

• Meta-analysis

• Improve balance recovery, reaction time, balance and gait but not strength.

• Some studies showed improved cognitive measures• Especially when conducted with distractors and choice stepping

• Reduce rate of falls by 52%

• Reduce proportion of fallers by 49%

Reactive or volitional step trainingOkubo, 2016 HOW????

• Greater fall reduction effect of step training compared to general training due to task specificity

• During trips, slips and lateral falling, quick stepping in forward, backward and sideways directions are required.

• The repetitive task-relevant exercises may generate stored motor programmes that can be accessed when anticipatory or reactive postural threats are detected.

• In contrast, significantly increased lower extremity muscle strength resulting from 16 weeks of resistance training has been shown to not transfer to better responses to laboratory-induced trips, suggesting specificity of necessary functional muscle coordination

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Reactive or volitional step trainingOkubo, 2016

• Suggestions from meta analysis:

• ▸Step training should be a major component of exercise fall prevention interventions.

• ▸ This training could be either volitional or reactive but should be performed in an upright position and undertaken in response to environmental challenges which mimic common fall situations such as stepping onto a target, avoiding an obstacle or responding to a perturbation.

• ▸ Reactive step training which requires a perturbation module and full body harness is not readily available BUT volitional step training can be applied to various settings including community exercise classes or an individual’s home.

Task Specific Training

• Single task training involves functional tasks such as standing, walking, and transfer• Practice what you want them to improve at in varying environments

• Example - Different height chairs with different dimensions and cushions…

• Practicing the actual motor skill of avoiding a fall following loss of balance• Has show to decrease fall risk in frail older adults and Parkinson patients

• Silsupadol et al, 2006 and Grabiner et al, 2012

Types of Dual Task Training

• Body stability plus manipulation• Standing on a compliant surface holding a glass of water• Tandem standing with rapid alternating hand movement• Standing and reaching in all directions• Throwing and catching a ball while standing

• Body transport plus manipulation• Walking, walking backward, walking sideways, walking under dim light

• Doing these while holding a mug or basket• Doing these while tossing a ball

• Counting while walking• *Cognitive

Silsupadol et al, 2009

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Power or High Velocity Training• Muscle power and contraction velocity have been shown to have

greater influence on functional performance, especially low intensity tasks

• Lower muscle power is an indicator for greater fall risk and balance problems• When threats to balance occur, a rapid muscle response must happen to

maintain postural stability

• Note – “Power” training tends to be high(er) load and high velocity on concentric

• High velocity training is high velocity on concentric but DOES NOT have to be high load

Orr et al, 2006

High velocity/speed training and older adults

• Power/mm weakness r/t to balance (systematic review, Orr, 2010) • *subjects in review did not have known pathologies

• “Power” training• Generally demonstrates improved power and function compared to

traditional resistance training• At 40-70% 1 RM (Marques, 2013)

• Inconsistent evidence of power training improving balance in general (systematic review, Orr, 2008)• Suggestion – do not use as sole intervention

High velocity training

• Older adults 20 weeks high velocity unweighted vs high velocity weighted • Same exercises on Kaiser machines

• 2x/wk

• Results:

• unloaded high-velocity training increased functional fitness and power the same as loaded training. • Consider when time/space is limiting factor.

• Glenn, Gray, Binns, 2015

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Yoga

• Youkhana (2016)

• Systematic review and meta-analysis showed yoga was beneficial to improve balance and mobility in older adults

Tai Chi

• Has been shown to improve balance and decrease falls in older adults (multiple articles and CDC)• May not be appropriate for frail older adults

• Low, 2008; Stevens et al., 2010;

• Improves telomere activity (Duan 2016)

Community-based Dance improvesFunction and balance

• Argentine Tango • 2 hr/wk x 10 wks

• Improvements in walking speed and sit to stands greater than or equal to a walking group• McKinley et al., 2008

• Salsa • 2x/wk x 8 wks for 1 hr each• Improved parameters of gait, but not leg power • 93% adherence to program

• Granacher, 2012

• Even one time a week of dance can benefit balance• Keogh et al., 2012

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Assistive Devices and Falls

• 262 older adults who used canes and walkers were surveyed (Luz, 2015)• 68% had never had a home safety eval• 50% were never properly trained on how to use an AD

• 75% who fell WHERE NOT USING THEIR ASSISTIVE DEVICE AT THE TIME!• This resulted in a higher proportion of injury and need for surgery compared to those

who fell using their ADs• Reasons given for non-use

• Forgot• AD made them feel old• Not easily accessible

• Low perceived risk of fall or injury without device

• EDUCATE your patients.

• So why not have patient come with their usual different footwear? Including dress shoes and slippers?

• Make sure they can do functional tasks in all of their usual footwear before d/c

Effects of footwear on balance

Falls and Environment

• Environmental factors contribute up to 41% of risk factors associated with falls among the elderly• The residential environment poses the highest risk; such as,

• Inadequate lighting

• Slippery floors

• Absence of handles in bathroom or tub

• Assessing the residential environment is important when trying to reduce fall risk

• *Feasibility?

Yoo et al, 2015

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Check for safety booklet, free from CDChttp://www.cdc.gov/HomeandRecreationalSafety/pubs/English/booklet_Eng_desktop-a.pdf

Balance-based torso-weightingBalanceWear

• Balancewear therapy (BWT) is a non-exercise intervention designed to improve postural control that results in same-day improvements in balance and mobility among people with multiple sclerosis (Gorgas et al., 2015; Hunt et al., 2014; Widener, et al, 2009a; 2009b).

• Developed by Cindy Gibson-Horn, PT

• MotionTherapeutics, Inc.

What is the basis of Balancewear????

• The function of the trunk musculature is important for maintenance of posture, mobility, and recovery from loss of balance (Horak, 1989, 1996, 2006)

• The goal of BW: to improve anticipatory and compensatory postural adjustments (APAs and CPAs) to trunk perturbations by strategic torso weighting • Thereby improving balance and mobility.

• Weighting is individualized and <1.5% of body weight

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Balance Based Torso Weighting

• After 5 days of balance wear, older adults improved in SPPB score

• Vincenzo et al., 2016

• Publications pending• Improvement in fall risk measured by TUG, gait speed … over 4 months

• Improvement in adults who wore balancewear 4 hours daily vs. not and regularly exercised

Motor Imagery

• Ability to imagine future events and estimate consequences

• With aging, ability to represent intentions and successfully plan actions declines

• Compared to younger adults (mean age of 22) older adults (66 years) were not able to accurately estimate their reach vs their actual functional reach• Older adults tend to overestimate

Gabbard and Fox 2013

Motor Imagery Practice

• Clear and effective script of instructions• Early practice stages

• Watch and feel your hand and fingers reaching and grasping the mug. How will you grasp the mug and how fast will you move as not to spill its contents?

• Goal setting

• First person internalizing• Ask participant to consider the consequences if they miss-plan. Where would

they fall?

• Concentrate on the effector• Arm/hand when reaching for object

Gabbard and Fox 2013

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Motor Imagery Practice Cont.

• Focus on visual cues• Focus on the endpoint• Where does the hand need to grasp the object securely?

• Reinforcement on kinesthetically feeling execution of movement• Feeling self perform the action

• Combine physiotherapy with mental practice• Practicing actual movements, subjects gain understanding of their capabilities and develop

movement endurance

• Mental practice combined with actual physical practice is shown to be better

• Progress from simple to more complex actions

• Practice 15-60 minutes, 3 times a week for 4 weeks

Gabbard and Fox 2013

Motor Imagery Benefits

• Improved strength

• Improved speed in arm pointing capacity

• Increased range of motion of the hip joint

• Improved postural control

• Things to consider• Challenging or unfamiliar actions are more difficult to imagine than familiar

ones• Improvements from motor imagery practice may be higher when imagery is

used at the initial or cognitive phase of motor skill acquisition.

Dickstein and Deutsch, 2007

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MiniBESTtest

The Mini-BESTest showed the highest AUC (0.84)compared with the BESTest (0.74), BBS (0.69), and TUG (0.35), suggesting that the Mini-BESTest had the highest accuracy in identifying older adult with history of falls. At the cutoff score of 16 (out of 28), the Mini-BESTest demonstrated a posttest accuracy of 85% with a sensitivity of 85% andspecificity of 75%. The Mini-BESTest had the highest posttest accuracy, with the others having results of 76% (BESTest), 60% (BBS), and 65% (TUG).Yingyongyouda, 2016

Treatment Suggestions

• Impairment• Somatosensory

• Vestibular

• Visual

Treatment Suggestions

• Impairment• Decreased anticipatory postural

control

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Treatment Suggestions

• Impairment• Decreased reactive control

Treatment Suggestions

• Decreased power• 5/5 strength

Treatment Suggestions

• Impairment• Fear of falling

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Treatment Suggestions

• Impairment• Stops walking when talking

• Worse function while performing two tasks at the same time

Balance Progressions Framework Halverson, 2015

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Vestibular and balance rehab framework for progression. Klatt, 2015

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Vestibular and balance rehab gait progression Klatt, 2015

Vestibular and balance rehab, VOR Progression, Klatt, 2015

There are more in the article!

References• Lundy-Ekman, Laurie. Neuroscience: fundamentals for rehabilitation. Elsevier Health Sciences, 2013.

• O'Sullivan, Susan B., Thomas J. Schmitz, and George Fulk. Physical rehabilitation. FA Davis, 2013.

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• Izquierdo, M., et al. "Maximal strength and power characteristics in isometric and dynamic actions of the upper and lower extremities in middle-aged and older men." Acta Physiologica Scandinavica 167 (1999): 57-68.

• Martinelli, Alessandra Rezende, et al. "Light touch modulates balance recovery following perturbation: from fast response to stance restabilization."Experimental brain research 233.5 (2015): 1399-1408.

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• Peterka, R. J. "Sensorimotor integration in human postural control." Journal of neurophysiology 88.3 (2002): 1097-1118.

• Swash, M., and Kathleen P. Fox. "The effect of age on human skeletal muscle studies of the morphology and innervation of muscle spindles." Journal of the neurological sciences 16.4 (1972): 417-432.

• Wingert, Jason R., Catherine Welder, and Patrick Foo. "Age-related hip proprioception declines: effects on postural sway and dynamic balance." Archives of physical medicine and rehabilitation 95.2 (2014): 253-261.

• Lee, Harry KM, and Rhonda J. Scudds. "Comparison of balance in older people with and without visual impairment." Age and ageing 32.6 (2003): 643-649.

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References continued • Herdman, Susan J., et al. "Falls in patients with vestibular deficits." Otology & Neurotology 21.6 (2000): 847-851.

• Goldberg, Allon, Manuel Enrique Hernandez, and Neil B. Alexander. "Trunk repositioning errors are increased in balance-impaired older adults." The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 60.10 (2005): 1310-1314.

• Barbieri, Guillaume, Anne-Sophie Gissot, and Dominic Pérennou. "Ageing of the postural vertical." Age 32.1 (2010): 51-60.

• Doherty, Timothy J. "Invited review: aging and sarcopenia." Journal of applied physiology 95.4 (2003): 1717-1727.

• Kanekar, Neeta, and Alexander S. Aruin. "The effect of aging on anticipatory postural control." Experimental brain research 232.4 (2014): 1127-1136.

• Era, P., et al. "Postural balance in a random sample of 7,979 subjects aged 30 years and over." Gerontology 52.4 (2006): 204-213.

• Lin, Sang-I., and Marjorie H. Woollacott. "Postural muscle responses following changing balance threats in young, stable older, and unstable older adults." Journal of motor behavior 34.1 (2002): 37-44.

• Manchester, Diane, et al. "Visual, vestibular and somatosensory contributions to balance control in the older adult." Journal of Gerontology 44.4 (1989): M118-M127.

• De Vries, N. M., et al. "Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: a meta-analysis." Ageing research reviews 11.1 (2012): 136-149.

• Pahor, Marco, et al. "Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial." Jama 311.23 (2014): 2387-2396.

References Continued• Shubert, Tiffany E. "Evidence-based exercise prescription for balance and falls prevention: a current review of the literature." Journal of geriatric physical therapy 34.3 (2011): 100-108.

• Nnodim, Joseph O., et al. "Dynamic balance and stepping versus tai chi training to improve balance and stepping in at‐risk older adults." Journal of the American Geriatrics Society 54.12 (2006): 1825-1831.

• Kleim, Jeffrey A., and Theresa A. Jones. "Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage." Journal of speech, language, and hearing research 51.1 (2008): S225-S239.

• Whitney, Susan L., et al. "Improvements in balance in older adults engaged in a specialized home care falls prevention program." Journal of geriatric physical therapy (2001) 36.1 (2013): 3.

• Gabbard, Carl, and Ashley Fox. "Using motor imagery therapy to improve movement efficiency and reduce fall injury risk." Journal of Novel Physiotherapies 2013 (2013).

• Dickstein, Ruth, and Judith E. Deutsch. "Motor imagery in physical therapist practice." Physical therapy 87.7 (2007): 942-953.

• Mansfield, Avril, et al. "Effect of a perturbation-based balance training program on compensatory stepping and grasping reactions in older adults: a randomized controlled trial." Physical therapy 90.4 (2010): 476-491.

• Rose, Debra J., and Sean Clark. "Can the control of bodily orientation be significantly improved in a group of older adults with a history of falls?." Journal of the American Geriatrics Society 48.3 (2000): 275-282.

• Mansfield, Avril, et al. "Does perturbation-based balance training prevent falls? Systematic review and meta-analysis of preliminary randomized controlled trials." Physical therapy 95.5 (2015): 700-709.

• Lurie, Jon D., et al. "Pilot comparative effectiveness study of surface perturbation treadmill training to prevent falls in older adults." BMC geriatrics 13.1 (2013): 1.

References Continued• Melzer, Itshak, et al. "A water-based training program that include perturbation exercises to improve stepping responses in older adults: study protocol for a randomized controlled cross-over trial."

BMC geriatrics 8.1 (2008): 1.

• Silsupadol, Patima, et al. "Training of balance under single-and dual-task conditions in older adults with balance impairment." Physical therapy 86.2 (2006): 269-281.

• Orr, Rhonda, et al. "Power training improves balance in healthy older adults." The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 61.1 (2006): 78-85.

• Granacher, Urs, et al. "Comparison of traditional and recent approaches in the promotion of balance and strength in older adults." Sports Medicine 41.5 (2011): 377-400.

• Glenn, Jordan M., Michelle Gray, and Ashley Binns. "The effects of loaded and unloaded high-velocity resistance training on functional fitness among community-dwelling older adults." Age and ageing 44.6 (2015): 926-931.

• Li, Fuzhong, et al. "Tai Chi and fall reductions in older adults: a randomized controlled trial." The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 60.2 (2005): 187-194.

• McKinley, Patricia, et al. "Effect of a community-based Argentine tango dance program on functional balance and confidence in older adults." J Aging Phys Act 16.4 (2008): 435-453.

• Granacher, Urs, et al. "Effects of a salsa dance training on balance and strength performance in older adults." Gerontology 58.4 (2012): 305-312.

• Keogh, Justin WL, et al. "Effects of different weekly frequencies of dance on older adults’ functional performance and physical activity patterns." Eur J Sports Exerc Sci 1 (2012): 14-23.

• Thomas, Susie, Shylie Mackintosh, and Julie Halbert. "Does the ‘Otago exercise programme’reduce mortality and falls in older adults?: a systematic review and meta-analysis." Age and ageing (2010): afq102.

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