Can training methods from the Performing Arts be used to prevent falls and fall-related injuries
In later life, physical changes to our body make it more difficult to maintain mobility and independence. For example, adults over the age of 65 commonly experience a loss of strength, along with impaired balance and gait. These changes lead to an increased risk of falling and fall-related injuries. In fact, falls are the leading cause of fatal and nonfatal injuries among adults 65 and older (older adults) (1). An estimated 29 million falls among older adults occur annually in the United Stated (2), with Medicare costs exceeding $30 billion (3). Falls and fall-related injuries remain a major problem despite substantial and widespread efforts to reduce their occurrence. New exercises or training methods are thus needed to help reduce these falls and injuries.
Two training methods often employed in the performing arts have the potential to reduce these falls and injuries. One is the Alexander Technique, which is a method of training posture, muscular effort, and coordination through tactual and verbal cues to improve movement efficiency, balance, and support (4-6). It can be applied to ordinary daily movement tasks, such as standing, sitting, bending, and walking. Alexander Technique is taught and used by vocal coaches, musicians, dancers, actors, and other performing artists to improve stage performance, balance their sense of effort, reduce stage fright, and decrease tension (7-9). Alexander Technique may help reduce falls among older adults by improving balance while standing and walking. Alexander Technique has been shown to improve some measures related to balance, and posture-related muscle activity, among older adults (10-14). However, these studies were limited due to small sample sizes or poor experimental control (7). As such, there remains limited quantitative understanding of the effects of Alexander Technique on balance, walking, and fall risk.
A second training method employed in the performing arts is falling technique, which also has the potential to reduce fall related injuries. Falling technique is a method of training body movements and posture during a fall to reduce forces upon impact with the floor, and thus reduce the risk of injury. Falling technique has been used to train actors and stunt actors to fall realistically, but in ways that avoid injury. Falling technique may help reduce injuries suffered by older adults when falling. However, there is limited quantitative understanding of if/how falling technique reduces impact forces, and if such training could be safely applied to older adults.
The overall objective of our proposed work is to quantitatively assess the effects of: 1) Alexander Technique on standing balance and gait to reduce the incidence of losses of balance and falls; and 2) falling technique on impact forces to reduce the risk of injury from a fall. These two techniques may complement each other, in that Alexander Technique aims to reduce the incidence of losing balance and starting to fall, while falling technique aims to reduce the risk of injury resulting from a fall. If successful, these techniques could form a novel training approach to help reduce falls and fall-related injuries among older adults. The proposed work will only include young adults to assess the safety and feasibility of these techniques, but it will provide critical pilot data for planning a follow-up study with older adults. We propose two aims:
Aim 1: Investigate Alexander Technique training to improve balance and gait to reduce the risk of falling. Balance and gait measures related to the risk of falling will be assessed before and after Alexander Technique training, and compared to a control group that receives no training. Improvements in these balance and gait measures after Alexander Technique training would suggest a reduction in the risk of falling.
Aim 2: Investigate falling technique training to reduce forces upon impact with the floor to reduce the risk of injury from falling. Forces upon impact with the floor will be measured before and after fall technique training, and compared to a control group that receives no training. A reduction in these forces would suggest a reduction in injury risk from falling.
A single experiment will be used to address both aims. Subjects will include a convenience sample of 45 students recruited from the university population. This pilot study will not include older adults, to allow us to evaluate the potential risks of applying this novel training to older adults who may have a higher risk of injury during training. No formal sample size analysis was performed due to the pilot nature of this work, and the lack of data in the literature for such an analysis from well-controlled studies. All subjects will be required to have no self-reported injuries or medical conditions that affects their balance or gait. All procedures will be approved by the Virginia Tech Institutional Review Board prior to the start of the study.
A three-group repeated-measures experimental design will be employed. All subjects will first complete a testing battery that assesses their balance, gait, and fall mechanics. Subjects will then be randomly assigned to receive Alexander Technique training (n = 15), falling technique training (n = 15), or no training (control group; n = 15). Subjects in the Alexander Technique and falling technique groups will then receive 4 sessions of training over 2 weeks to learn their respective technique. Lastly, one week following the completion of training, all subjects will repeat the testing battery performed before training. Changes in balance, gait, and fall impact forces will be compared between groups to evaluate the efficacy of the two types of training.
The testing battery will involve assessments of balance, gait, and fall mechanics in the Occupational Ergonomics and Biomechanics Laboratory (Whittemore 556), of which Madigan, Srinivasan, and Nussbaum are co-Directors. This state-of-the-art lab includes all of the necessary equipment and supplies for these measurements, and these investigators have employed the proposed methods in several prior studies. Unlike the training described below, the testing battery will be performed on one subject at a time.
Balance testing will involve subjects standing as still as possible on a force platform to measure forces under the feet. Six 2-minute trials will be performed. From these data, multiple measures of postural sway will be determined to characterize multiple aspect of balance and postural control that have been shown to be sensitive to training and fall risk (15).
Gait testing will involve subjects walking barefoot continuously at a comfortable, self-selected pace for six minutes in a figure-8 pattern in our laboratory. Their movements will be recorded using an 11- camera motion capture system (Qualisys, Goteborg, Sweden) and reflective markers at appropriate anatomical landmarks. As in our previous work, we will compute average and stride-to-stride variability of spatiotemporal gait characteristics (e.g. stride time, step time, swing time, stance time, step length, stride width etc) and hip, knee and ankle joint movement kinematics. Stride-to-stride variability in specific spatiotemporal characteristics such as stride length and swing time have been shown to be sensitive to both training and fall risk (16, 17).
Fall mechanics testing will involve subjects falling forward onto a mattress-size, dense foam pad, and measuring the forces applied to the pad upon impact using force platforms. Subjects will be asked to fall three times in each direction of forward, sideways, and backward. Instructions will be to fall naturally as if you lose balance and your shoe laces are tied together (to prevent stepping responses). During these falls, force platforms under the pad will measure forces applied at impact. The effectiveness of fall mechanics training will be assessed by the ability of this training to reduce the peak forces at impact by modifying the body movements and body position at impact with the pad.
Subjects will complete four training sessions over two weeks (two sessions per week). Each session will involve 60 minutes of Alexander Technique training or falling technique training. A Certified Master Teacher in Alexander Technique will be recruited from outside of VT/Blacksburg to travel here to conduct Alexander Technique training. (Three individuals have been tentatively identified, and one will be selected based upon availability.) Co-Investigator Rawlings will teach the falling technique, and is a Certified Stage Combat Instructor. Both types of training will be provided in group format to 5-7 subjects at a time. Both types of training involve repeatedly performing the activities (standing and walking for Alexander Technique, and falling for falling technique), and refining performance based upon verbal and manual direction from the teacher.