Reviewed by John Baur, PT, DPT, OCS, CSCS, FAAOMPT
Why focus on trips and forward falls?
Falls are the leading cause of injurious deaths and nonfatal injuries in adults over 65. From 2007–2016, U.S. fall‑related death rates rose ~3% per year, and 20–30% of falls in this age group cause moderate to serious injury, generating billions in healthcare costs. Because many forward falls begin with a trip during walking, the authors concentrate on the biomechanics of trip recovery and how training can reduce fall risk in older adults. They emphasize a practical, gym‑floor approach that does not require costly perturbation treadmills.
Definitions and the fall‑arrest problem.
The paper distinguishes falling—“the initiation and process of losing one’s balance”—from a fall, i.e., unintentionally landing on the ground. Other key terms include base of support (BOS), center of mass (COM), maximum recoverable forward lean angle (MRFLA), and impulse (force over time). “Table 1 (p. 699)” lays out these terms, and the “diagram below the table” shows how trunk control, support limb, recovery limb, step velocity, step length, lower‑limb strength, and rate of torque development jointly determine whether a person arrests a fall or hits the ground.
What happens during a trip?
When the swinging foot is unexpectedly obstructed, the forward motion of the legs halts: stride duration lengthens for both limbs while the COM continues forward, threatening to move beyond the BOS. Successful arrest demands: (1) a faster, longer recovery step placed sufficiently far ahead; (2) a powerful push‑off from the support limb to buy time and counteract the trunk’s forward angular momentum; and (3) trunk control that limits forward flexion angle and velocity. Nonfallers, compared with fallers, display longer, faster recovery steps; a single‑step recovery becomes less likely as forward lean increases. Successful single‑step recoveries are associated with greater lower‑limb strength and higher support‑limb ground‑reaction force impulse and hip upward velocity at push‑off. Reductions in trunk flexion angle/velocity at toe‑off and at ground contact also characterize successful arrests.
Program design philosophy.
The authors propose a three‑part, multicomponent program—(a) balance training, (b) task‑specific training, and (c) resistance training—with a fourth element (safe‑landing techniques) suggested but not covered. The program targets the specific capacities identified above: step length and velocity, trunk control, lower‑limb strength, and rate of torque development (RTD). Field‑friendly assessments such as the Functional Reach and Timed Up and Go tests can establish baselines and track progress.
1) Fall prevention: balance training
Start with static two‑leg balance, then progress to single‑leg stance (SLS) and single‑leg hip hinge (SLHH) drills, which are later combined and made dynamic. The coaching progression is explicit: introduce each drill with full hand support, then partial support, then unsupported, repeating that sequence each time you introduce a harder variation (“Figure 5, p. 703”). Cue clients to fix their gaze on a stationary object and to press the stance foot firmly into the floor; regress immediately if loss of control necessitates a step for balance. “Figures 3–4 (pp. 702–703)” and “Table 2 (p. 701)” illustrate the SLS→SLHH→reach progressions, including multidirectional reaches and continuous flows between positions. These movements were chosen because they closely mimic the joint actions needed in the later lunge progressions.
2) Fall arrest: task‑specific training (without special equipment)
Random trip perturbations delivered by specialized treadmills can be effective but are costly and impractical. The authors propose the step‑forward lunge (SFL) as a practical proxy for a single‑step recovery after a trip. Although an SFL is preplanned and typically lacks the same trunk angular momentum and loading as a true trip, its joint sequencing (hip/knee flexion and dorsiflexion on contact, then extension to stabilize) is similar. By manipulating trunk angle relative to step length, cueing speed, and unpredictability (e.g., random audio/visual targets), practitioners can make the SFL more trip‑specific. The ultimate goal is an unsupported SFL with greater trunk angles, faster reach/step velocity, and, when appropriate, external load—and eventually performed in response to cues and in multiple directions. “Figures 6, 10–11 (pp. 703, 706)” and “Table 3 (p. 707)” show these ideas.
How to teach the “recovery position.”
Before lunges, start with a split squat to build unilateral capacity and teach positions (“Figure 7, p. 704”). Then introduce the hip‑hinge sliding back lunge (HHSBL) to place clients “into” the recovery position by sliding the rear foot backward while the front (recovery) limb hip‑hinges and the trunk flexes (“Figure 8, p. 704”). Coaching cues include keeping the torso “stiff,” letting the chest “fall” toward the support, and pressing lightly through the back toes—“don’t crush the eggs”—to reduce rear‑foot loading. Progress by adding isometric holds at the recovery position, loading the hands, and rear‑foot lift‑offs. Once HHSBL control is solid, teach the SFL to a target with nearby support (“Figure 9, p. 705”), then progressively reduce support, increase step length and trunk flexion, add isometrics, increase velocity, add load, and finally layer reactive cues and multidirectional targets/hurdles (“Table 3, p. 707”).
3) Resistance exercise: strength and power for trip recovery
Because single‑step recovery is time‑critical, both strength and neural speed/RTD matter. Resistance training in older adults improves neural drive and H‑reflexes, with early neural changes linked to increases in rate of force development even before large strength gains accrue. The plan targets total lower‑limb extension plus key joints/muscles implicated in trip recovery: hip extensors, hip flexors, knee extensors, ankle plantarflexors, and dorsiflexors. Stable machines (e.g., leg press, leg extension, standing heel raise) are good entry points; progress to more demanding free‑standing moves (e.g., squat, step‑ups, SFL, standing heel raises) as balance allows. For power, the authors favor high‑speed power training (HSPT)—fast concentric actions—using roughly 0–60% 1RM for 3–6 reps (not to failure), with 2–3 s eccentrics.
A sample 12‑week progression (periodized).
“Table 4 (p. 708)” details a 12‑week plan with three 4‑week blocks: endurance → strength → power, using a 3:1 loading pattern (three weeks of progressive overload, one deload). Example lower‑body prescriptions (e.g., leg press or squat or step‑up; heel raises; hip flexion; knee extension; ankle dorsiflexion) progress from 12–15 reps to 8–10 reps to 5–8 reps, and tempo in the final block includes explosive concentrics (3‑0‑X‑3). Each training day (about 1 hour, three days/week) devotes ~15 min to balance, ~15 min to task‑specific drills, and ~30 min to resistance work.
Big picture and takeaway.
High‑balance‑challenge programs and ≥3 hours/week of exercise produce the largest fall‑risk reductions. Not every facility can deliver harness‑based perturbation training, but this framework closes the gap by (1) improving static/dynamic balance with SLS/SLHH progressions, (2) using SFL/HHSBL to approximate single‑step fall arrests under increasing speed and unpredictability, and (3) building the strength and power capacities that separate nonfallers from fallers biomechanically. The authors argue this low‑cost, low‑tech approach is feasible for gyms and rehabilitation settings and aligns with evidence that exercise—especially when it challenges balance and tasks—reduces fall rates in older adults.
- B. 20–30. (Twenty to thirty percent of older‑adult falls cause moderate–serious injury.)
- C. Reacting quickly. (Strength, balance, and the ability to react quickly with appropriate step length are critical.)
- A. Falling. (“Falling” is the initiation and process of losing balance; see Table 1.)
- B. Upper‑limb strength. (Programs should address recovery step length/velocity, lower‑limb strength, RTD, and trunk control.)
- A. Stride duration. (Trips halt leg motion and increase stride duration for stance and recovery limbs.)
- B. Decreases. (Greater forward lean magnitude lowers the chance of a single‑step recovery.)
- B. Hip extensors. (Support limb must generate force via ankle plantar flexors and hip extensors to reduce COM angular momentum.)
- A. A fixed object. (During SLS/SLHH drills, cue a visual focus on a fixed object.)
- B. Step‑forward lunge. (The SFL is proposed as a practical, task‑specific proxy for a single‑step fall arrest.)
- C. An isometric hold. (Progress the HHSBL by adding an isometric hold in the recovery position.)
References:
Baylor RP, Hinkel-Lipsker JW, Jaque SV, Flanagan SP. Older people trip, some fall—a program to decrease seniors’ fall risk. Strength Cond J. 2023;45(6):698-710.