The effectiveness of a protective stepping class to reduce fall risk in community-dwelling older adults
Natalie Fick, SPT, Emily Lesser, SPT, and Emily Tolkamp, SPT
27 Comments on “The effectiveness of a protective stepping class to reduce fall risk in community-dwelling older adults”
I like this study, it seems that it gives rationale for preventative therapy. Especially when providing rationale to insurance companies. I have quite a few older patients that I will be seeing for shoulder pain, neck pain, or other diagnosis in which they will make a comment such as “my balance is just not what it used to be.” I have told these patients that physical therapy can address these issues as well. It would be nice to treat people for fall risk before they actually fall. More often than not, we treat patients after they fall or have significant balance issues.
I agree! I I think it would be really nice if we could see more people before they fall and prevent all the problems that come with those injuries. Thank you for the comment!
What you discussed throughout your research supports an extremely effective way to strengthen older adult balance by preventing falls which is vital as the percentage of our older population continues to increase. Thus, more older adults will be able to be seen for preventive measures instead of recovery measures from a fall which will help with their overall health while also reducing health care costs. One thing that I am curious about is if there were any limitations that you found when carrying out your study? Also what future research did this study reveal that may lead to addressing this important preventive incentive even better in the future?
Some limitations we found were that we had a fairly small sample size (30) and there were 2 separate classes taught by different instructors. We also think it would be great to do a long-term follow up with the participants. One research study being performed by the classmates in the cohort behind us is to find a safer and easier way to screen participants that can be done by a fitness instructor at a facility to make the class even safer. Thank you for the questions!
This study sounds very interesting. One question I had while reading is if participants were blinded to the balance activities? If they were not then do you think the results may be skewed because they will try to do and show you what you as researchers want to see? Also do you think you would see similar results in other locations with similar populations?
Our study was not blinded as there was only one group fitness class taken by all the participants. I agree that participants will likely try to do what we ask of them, but our balance testing was not easy for them so it would have been very hard for them to fake anything. I think this class would benefit people in other locations as well and likely other populations. Populations with poorer balance would likely need to have someone with them to make sure they are safe, but it could be beneficial to them as well! Thanks for the comment.
I really like the fact that this is preventative research that could be used in any community! What was the age range that participated in your study? I am just curious if the age range could have made a difference on your results. Also do you think that this research shows that maybe aging individuals would benefit getting in a protective stepping class early on that it might decrease their fall risk? I think that this is a great study to show how important exercise in general is great in all populations!
The age range for our study was 83.6 ±5.44 years. While we did not specifically look at the results based on age groups, that could have been a factor that affected our results. Based on our results, this protective stepping class has shown to be effective in improving the participant’s balance and their ability to take a protective step. After conducting this research, I feel that this class could be a beneficial activity for individuals who want to reduce their fall risk. Thank you for your comment!
I found this study very interesting as I am in the group that is following up on this study. Do you think that the program that was administered was efficient at significantly reducing the participants’ risk of falling, or do you think that there is components of the class that should be excluded or added in?
Great question, Nicole! We have a few things to think about the class itself, but mostly in the way in which the class was run. We would have liked to had the video playing and the instructor walking around encouraging optimal performance of the exercises throughout the class, as well as ensuring safety for the participants. The class itself is well designed, in our opinion, but we had discussions about making sure the participants got the most out of the class and making sure the instructor was making the most out of it as well. For example, verbal encouragement and tactile cues to reach outside the base of support, etc. Though we are unsure the performance of the instructor, we discussed how this could be a factor towards success. Also, you will see the data in the forward direction did not improve significantly. We discussed that this may have been due to the chair being placed in front of them for the duration of the classes. If possible, we discussed finding ways to challenge the dynamic base of support for the individuals in the anterior position while remaining safe. Hope that answers your question!
Seeing as the class was instructed by a Wellness Director, and you found significant improvements in balance through the class, how do you foresee the relationship between a PT and fitness coach with the older population if this specific class became utilized more frequently? Would you suggest those with mild balance deficits commit to the class, while those with more significant balance deficits receive PT, or encourage patients to attend PT as well as the class? Your study is super interesting, and I’m excited to hear how it progresses in the future!
This has been a point that came up several times while we were performing the initial screenings of participants. If individuals had mild deficits and met the minimum requirements for them to be safe in the class, they were encouraged to participate. If patients had more significant balance deficits and did not meet the requirements needed for them to be safe in the class, we took the time to discuss the benefits they could gain if they chose to seek physical therapy. We hope that there will be an strong and beneficial relationship between the Wellness Directors and PT if this class is used more frequently. The Wellness Directors would be able to see the participants more frequently at each class, and could refer participants to PT if they appear to have more significant balance deficits. PTs could also encourage their patients to participate in this class if they would like to further work on their balance outside of therapy. Thank you for your comment!
I have a couple questions in regards to your research.
1) due to my naivety, could you explain what “bilateral protective stepping” is? I am unfamiliar with this term and what this might look like.
2) As this class was taught by the wellness director as opposed to the PT, could you see a future program where PTs are contracted into a facility to run these types of classes, OR, do you think that the PT could play a role in teaching the wellness directors how to use the objective assessment measures (such as ABC, mini-BEST, FSST, etc) in order to foster independence as well as measure success in these classes? I can’t help but think that if these programs are able to demonstrate success (as your research shows!) that they would grow. As a fitness club owner, one of the biggest disconnects that I see in the fitness world is that classes should be geared towards “fitness” and not always functionality. The class dynamic used in this research shows exercises that are very functional to the geriatric patient. As PTs, could we play a bigger role in not only educating our patients, but also fitness instructors on what their class goals should be?
Thanks for the great Thanks for the great question, Jordan! Protective stepping is explained in the beginning as strategies used to regain balance after a perturbation or loss of balance. Bilateral protective stepping would imply that the individual is practicing stepping outside of their dynamic base of support in order to best prepare for an unexpected perturbation. We find that if the individual can practice this response in a controlled environment, they can better prepare for unexpected perturbations or losses of balance in their natural environment. Bilateral implies they are practicing with one side at a time, but ensuring both lower extremities are being used at some point.
As for number two, absolutely! In the geriatric population we often find we work towards functionality. For example, in our research we are working towards falls prevention in the elderly individual, which is a huge problem and a huge stress to the medical system. Another example would be working to fix dynamic valgus of the knees in the athletic female when jumping in sports such as volleyball and basketball in order to prevent knee injuries. Functionality is imperative as a physical therapist and we have a tremendous platform to impact the fitness community. Ideally, this program will be run through the wellness director, but a Physical Therapist could definitely be contracted to do the outcome measures and oversee the class.
question, Jordan!
This research project was very well done and interesting to read through. I am a part of the research group that is following up with this study, so I am interested to see what other things we might find through this project. The class goes for 12 weeks in the summer, so I was wondering if there are plans to continue the class throughout the whole year? Also, how long can the improvements be sustained by the participants after the class is done? Is this something that would need to be considered in order to dose protective stepping as an intervention?
As far as I know the idea was to determine if it worked and then it could be implemented in Good Sams throughout the country and have the classes run more frequently. We determined that the class is effective, but I am not sure if it was implemented throughout the year or in other Good Samaritan Societies. That is a great question though! I think as long as the participants kept up with exercising on a regular basis they would maintain the effects for a while. However, if they stopped doing any physical activity they probably wouldn’t completely maintain the benefits. A follow-up would be a great thing to add to a future study! Thanks for the great questions!
Great thought process in this research. My question would be how do you ensure there will be retention of these strategies after the class is over say a week, 3 weeks, etc.?
I’m not sure there is a way to be absolutely sure the strategies would be maintained, but I think encouragement to continue staying active would be a great start. I think if the participants stopped doing any physical activity the benefits would not be maintained as long. Adding a 3 or 6 month follow-up to the study would be a beneficial thing to have to determine how well these strategies are being maintained in those who are continuing with the classes and those who haven’t been physically active since the class ended. Thanks for the question!
Overall, seems like a great research project! Many of my questions have been already answered above, but what I was still wondering is why only forward and backward reactive stepping strategies improved in regards to the miniBEST and nothing was reported on horizontal reactive steeping strategies? If it wasn’t explored, do you think this is something that should be looked at somewhere down the road? Thanks!
Zach, great question! This is something that was of great questions for us and left it up to interpretation. Good news, the lateral stepping strategies improved, just not in a statistically significant manner. We speculate a larger sample will show a greater impact and continually striving to improve the execution of the class can help as well. This is definitely something to work on in the future!
Hi. The results of this study are exciting for sure. I do have a few questions for you.
First, the majority of your significant change occurred within the reactive subcategory of the miniBEST. There are only three components to the reactive component of the miniBEST, all of which involve the same test just in different directions. The patient leans into the examiner and the examiner releases. Perhaps, this “lean and release” was incorporated into the intervention program as well. Due to the similarity of this and the repetition. Is it possible that there was a learning effect from doing the release test that enhances their performance to this test specifically, potentially not to real life situation? Another result that may suggest this is the ABC confidence scale. Their confidence did not seem to improve significantly. Perhaps this means that they are getting better at the MiniBEST, but don’t feel they are performing much better in real life scenarios??
Secondly, were there any individuals that did not significantly improve or even worsened? If so, were you able to notice any characteristics in individuals that responded well vs. those who responded less well?
Scott, wonderful and intuitive questions. We were able to see the program and it does not include a “lean and release” portion. With any research study similar to this, there is a risk of a learning response. However, in this case I think the “learned” response would still be beneficial and show an increased ability to take protective steps when responding to a perturbation in the individual’s environment, thus continuing to test what we are looking to test to gauge improvements. The ABC scale may be a different story. We speculate that by getting this population up and moving, they may become more aware of their limitations, causing a more cautious response on the subsequent testing of the ABC scale. Again, with pre- and post- testing scenerios we will always run the risk of getting better at the specifics of the testing. However, thanks to validation in research, we trust their balance is improving through the measures we have chosen and are looking forward to a greater density of results to show more power and more precise responses.
When looking at your results as to what directions improved the most, was hand or leg dominance ever investigated? Could this have influenced which directions were improved the most due to comfort level?
We did not investigate if hand or leg dominance played a role in what directions improved the most following the protective stepping class. This could have played a role in the in a participant’s choice to test their limits of stability more to the sides that they were most comfortable. This would be an interesting thing to further investigate as the research continues. Thank you for your questions!
Great study. Balance prevention especially in this population and setting is a great idea. I may have just missed this in the poster, but were subjects excluded if they were already receiving PT at the Good Samaritan Society? If they were, couldn’t this have positively affected their balance and made it hard to identify the class as the sole reason for their improvement?
We did not ask participants at the initial screening if they were also receiving PT services at the Good Samaritan Society and because of this did not exclude participants who were receiving PT at the same time they were participating in the class. You are correct with your point that it would be hard to identify if balance gains were due to the class or from also receiving PT services. This would be an interesting point to add to research of the next classes to see how many participants were also seeing PT and further examine their gains. Thank you for your questions!
USD PT Research 
I like this study, it seems that it gives rationale for preventative therapy. Especially when providing rationale to insurance companies. I have quite a few older patients that I will be seeing for shoulder pain, neck pain, or other diagnosis in which they will make a comment such as “my balance is just not what it used to be.” I have told these patients that physical therapy can address these issues as well. It would be nice to treat people for fall risk before they actually fall. More often than not, we treat patients after they fall or have significant balance issues.
LikeLike
I agree! I I think it would be really nice if we could see more people before they fall and prevent all the problems that come with those injuries. Thank you for the comment!
LikeLike
What you discussed throughout your research supports an extremely effective way to strengthen older adult balance by preventing falls which is vital as the percentage of our older population continues to increase. Thus, more older adults will be able to be seen for preventive measures instead of recovery measures from a fall which will help with their overall health while also reducing health care costs. One thing that I am curious about is if there were any limitations that you found when carrying out your study? Also what future research did this study reveal that may lead to addressing this important preventive incentive even better in the future?
LikeLike
Some limitations we found were that we had a fairly small sample size (30) and there were 2 separate classes taught by different instructors. We also think it would be great to do a long-term follow up with the participants. One research study being performed by the classmates in the cohort behind us is to find a safer and easier way to screen participants that can be done by a fitness instructor at a facility to make the class even safer. Thank you for the questions!
LikeLike
This study sounds very interesting. One question I had while reading is if participants were blinded to the balance activities? If they were not then do you think the results may be skewed because they will try to do and show you what you as researchers want to see? Also do you think you would see similar results in other locations with similar populations?
LikeLike
Our study was not blinded as there was only one group fitness class taken by all the participants. I agree that participants will likely try to do what we ask of them, but our balance testing was not easy for them so it would have been very hard for them to fake anything. I think this class would benefit people in other locations as well and likely other populations. Populations with poorer balance would likely need to have someone with them to make sure they are safe, but it could be beneficial to them as well! Thanks for the comment.
LikeLike
I really like the fact that this is preventative research that could be used in any community! What was the age range that participated in your study? I am just curious if the age range could have made a difference on your results. Also do you think that this research shows that maybe aging individuals would benefit getting in a protective stepping class early on that it might decrease their fall risk? I think that this is a great study to show how important exercise in general is great in all populations!
LikeLike
The age range for our study was 83.6 ±5.44 years. While we did not specifically look at the results based on age groups, that could have been a factor that affected our results. Based on our results, this protective stepping class has shown to be effective in improving the participant’s balance and their ability to take a protective step. After conducting this research, I feel that this class could be a beneficial activity for individuals who want to reduce their fall risk. Thank you for your comment!
LikeLike
I found this study very interesting as I am in the group that is following up on this study. Do you think that the program that was administered was efficient at significantly reducing the participants’ risk of falling, or do you think that there is components of the class that should be excluded or added in?
LikeLike
Great question, Nicole! We have a few things to think about the class itself, but mostly in the way in which the class was run. We would have liked to had the video playing and the instructor walking around encouraging optimal performance of the exercises throughout the class, as well as ensuring safety for the participants. The class itself is well designed, in our opinion, but we had discussions about making sure the participants got the most out of the class and making sure the instructor was making the most out of it as well. For example, verbal encouragement and tactile cues to reach outside the base of support, etc. Though we are unsure the performance of the instructor, we discussed how this could be a factor towards success. Also, you will see the data in the forward direction did not improve significantly. We discussed that this may have been due to the chair being placed in front of them for the duration of the classes. If possible, we discussed finding ways to challenge the dynamic base of support for the individuals in the anterior position while remaining safe. Hope that answers your question!
LikeLike
Seeing as the class was instructed by a Wellness Director, and you found significant improvements in balance through the class, how do you foresee the relationship between a PT and fitness coach with the older population if this specific class became utilized more frequently? Would you suggest those with mild balance deficits commit to the class, while those with more significant balance deficits receive PT, or encourage patients to attend PT as well as the class? Your study is super interesting, and I’m excited to hear how it progresses in the future!
LikeLike
This has been a point that came up several times while we were performing the initial screenings of participants. If individuals had mild deficits and met the minimum requirements for them to be safe in the class, they were encouraged to participate. If patients had more significant balance deficits and did not meet the requirements needed for them to be safe in the class, we took the time to discuss the benefits they could gain if they chose to seek physical therapy. We hope that there will be an strong and beneficial relationship between the Wellness Directors and PT if this class is used more frequently. The Wellness Directors would be able to see the participants more frequently at each class, and could refer participants to PT if they appear to have more significant balance deficits. PTs could also encourage their patients to participate in this class if they would like to further work on their balance outside of therapy. Thank you for your comment!
LikeLike
Great research concept!
I have a couple questions in regards to your research.
1) due to my naivety, could you explain what “bilateral protective stepping” is? I am unfamiliar with this term and what this might look like.
2) As this class was taught by the wellness director as opposed to the PT, could you see a future program where PTs are contracted into a facility to run these types of classes, OR, do you think that the PT could play a role in teaching the wellness directors how to use the objective assessment measures (such as ABC, mini-BEST, FSST, etc) in order to foster independence as well as measure success in these classes? I can’t help but think that if these programs are able to demonstrate success (as your research shows!) that they would grow. As a fitness club owner, one of the biggest disconnects that I see in the fitness world is that classes should be geared towards “fitness” and not always functionality. The class dynamic used in this research shows exercises that are very functional to the geriatric patient. As PTs, could we play a bigger role in not only educating our patients, but also fitness instructors on what their class goals should be?
LikeLike
Thanks for the great Thanks for the great question, Jordan! Protective stepping is explained in the beginning as strategies used to regain balance after a perturbation or loss of balance. Bilateral protective stepping would imply that the individual is practicing stepping outside of their dynamic base of support in order to best prepare for an unexpected perturbation. We find that if the individual can practice this response in a controlled environment, they can better prepare for unexpected perturbations or losses of balance in their natural environment. Bilateral implies they are practicing with one side at a time, but ensuring both lower extremities are being used at some point.
As for number two, absolutely! In the geriatric population we often find we work towards functionality. For example, in our research we are working towards falls prevention in the elderly individual, which is a huge problem and a huge stress to the medical system. Another example would be working to fix dynamic valgus of the knees in the athletic female when jumping in sports such as volleyball and basketball in order to prevent knee injuries. Functionality is imperative as a physical therapist and we have a tremendous platform to impact the fitness community. Ideally, this program will be run through the wellness director, but a Physical Therapist could definitely be contracted to do the outcome measures and oversee the class.
question, Jordan!
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This research project was very well done and interesting to read through. I am a part of the research group that is following up with this study, so I am interested to see what other things we might find through this project. The class goes for 12 weeks in the summer, so I was wondering if there are plans to continue the class throughout the whole year? Also, how long can the improvements be sustained by the participants after the class is done? Is this something that would need to be considered in order to dose protective stepping as an intervention?
LikeLike
Hi Beth,
As far as I know the idea was to determine if it worked and then it could be implemented in Good Sams throughout the country and have the classes run more frequently. We determined that the class is effective, but I am not sure if it was implemented throughout the year or in other Good Samaritan Societies. That is a great question though! I think as long as the participants kept up with exercising on a regular basis they would maintain the effects for a while. However, if they stopped doing any physical activity they probably wouldn’t completely maintain the benefits. A follow-up would be a great thing to add to a future study! Thanks for the great questions!
LikeLike
Great thought process in this research. My question would be how do you ensure there will be retention of these strategies after the class is over say a week, 3 weeks, etc.?
LikeLike
Anthony,
I’m not sure there is a way to be absolutely sure the strategies would be maintained, but I think encouragement to continue staying active would be a great start. I think if the participants stopped doing any physical activity the benefits would not be maintained as long. Adding a 3 or 6 month follow-up to the study would be a beneficial thing to have to determine how well these strategies are being maintained in those who are continuing with the classes and those who haven’t been physically active since the class ended. Thanks for the question!
LikeLike
Overall, seems like a great research project! Many of my questions have been already answered above, but what I was still wondering is why only forward and backward reactive stepping strategies improved in regards to the miniBEST and nothing was reported on horizontal reactive steeping strategies? If it wasn’t explored, do you think this is something that should be looked at somewhere down the road? Thanks!
LikeLike
Zach, great question! This is something that was of great questions for us and left it up to interpretation. Good news, the lateral stepping strategies improved, just not in a statistically significant manner. We speculate a larger sample will show a greater impact and continually striving to improve the execution of the class can help as well. This is definitely something to work on in the future!
LikeLike
Hi. The results of this study are exciting for sure. I do have a few questions for you.
First, the majority of your significant change occurred within the reactive subcategory of the miniBEST. There are only three components to the reactive component of the miniBEST, all of which involve the same test just in different directions. The patient leans into the examiner and the examiner releases. Perhaps, this “lean and release” was incorporated into the intervention program as well. Due to the similarity of this and the repetition. Is it possible that there was a learning effect from doing the release test that enhances their performance to this test specifically, potentially not to real life situation? Another result that may suggest this is the ABC confidence scale. Their confidence did not seem to improve significantly. Perhaps this means that they are getting better at the MiniBEST, but don’t feel they are performing much better in real life scenarios??
Secondly, were there any individuals that did not significantly improve or even worsened? If so, were you able to notice any characteristics in individuals that responded well vs. those who responded less well?
Thank you! I enjoyed reading about your work.
Scott Strand
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Scott, wonderful and intuitive questions. We were able to see the program and it does not include a “lean and release” portion. With any research study similar to this, there is a risk of a learning response. However, in this case I think the “learned” response would still be beneficial and show an increased ability to take protective steps when responding to a perturbation in the individual’s environment, thus continuing to test what we are looking to test to gauge improvements. The ABC scale may be a different story. We speculate that by getting this population up and moving, they may become more aware of their limitations, causing a more cautious response on the subsequent testing of the ABC scale. Again, with pre- and post- testing scenerios we will always run the risk of getting better at the specifics of the testing. However, thanks to validation in research, we trust their balance is improving through the measures we have chosen and are looking forward to a greater density of results to show more power and more precise responses.
LikeLike
When looking at your results as to what directions improved the most, was hand or leg dominance ever investigated? Could this have influenced which directions were improved the most due to comfort level?
LikeLike
We did not investigate if hand or leg dominance played a role in what directions improved the most following the protective stepping class. This could have played a role in the in a participant’s choice to test their limits of stability more to the sides that they were most comfortable. This would be an interesting thing to further investigate as the research continues. Thank you for your questions!
LikeLike
Great study. Balance prevention especially in this population and setting is a great idea. I may have just missed this in the poster, but were subjects excluded if they were already receiving PT at the Good Samaritan Society? If they were, couldn’t this have positively affected their balance and made it hard to identify the class as the sole reason for their improvement?
LikeLike
We did not ask participants at the initial screening if they were also receiving PT services at the Good Samaritan Society and because of this did not exclude participants who were receiving PT at the same time they were participating in the class. You are correct with your point that it would be hard to identify if balance gains were due to the class or from also receiving PT services. This would be an interesting point to add to research of the next classes to see how many participants were also seeing PT and further examine their gains. Thank you for your questions!
LikeLike
Emily, Natalie, and Emily, Great job answering your poster questions
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