Perturbation-based balance training: Principles, mechanisms and implementation in clinical practice

Abstract

Since the mid-2000s, perturbation-based balance training has been gaining interest as an efficient and effective way to prevent falls in older adults. It has been suggested that this task-specific training approach may present a paradigm shift in fall prevention. In this review, we discuss key concepts and common issues and questions regarding perturbation-based balance training. In doing so, we aim to provide a comprehensive synthesis of the current evidence on the mechanisms, feasibility and efficacy of perturbation-based balance training for researchers and practitioners. We address this in two sections: “Principles and Mechanisms” and “Implementation in Practice.” In the first section, definitions, task-specificity, adaptation and retention mechanisms and the dose-response relationship are discussed. In the second section, issues related to safety, anxiety, evidence in clinical populations (e.g., Parkinson's disease, stroke), technology and training devices are discussed. Perturbation-based balance training is a promising approach to fall prevention. However, several fundamental and applied aspects of the approach need to be further investigated before it can be widely implemented in clinical practice.

Measures of falls efficacy, balance confidence, or balance recovery confidence for perturbation-based balance training

“…Example 2: Large mechanical destabilizing perturbations to be delivered in such a way that insufficient or inadequate recovery reactions (i.e., reach-to-grasp or compensatory stepping) would result in a fall (1). This training aims to improve reactive change-in-support balance control, as shown in Figure 1: Near-fall stage.…”

“…There is a growing interest in using perturbation-based balance training (PBT) to reduce falls (1). PBT is a skill training intervention that aims to improve reactive balance control in response to destabilizing perturbations in a safe and controlled environment (2).…”

Provoking Artificial Slips and Trips towards Perturbation-Based Balance Training: A Narrative Review

“…Despite including both slips and trips, information about how these LOB events are provoked during overground walking was not provided. Furthermore, in a recent review study conducted by McCrum et al [ 26 ], key concepts and common concerns related to PBT were discussed towards the implementation of this therapy in clinical settings. Despite the authors synthetically portraying the current evidence on the efficacy and feasibility of PBT, a deep analysis on the current systems and methodologies used to apply slips and trips was not performed.…”

“…Hence, the following research questions were addressed: (i) “Which methods and walking conditions are used to provoke slip- and trip-like perturbations?”; (ii) “Is it preferable to deliver perturbations during treadmill or overground walking in PBT?”; (iii) “Is it preferable to use a single-belt or a split-belt treadmill to perturb walking?”; (iv) “What procedures are implemented to maintain responses to perturbations unbiased?”; (v) “Which limb is generally used to apply the perturbations?”; (vi) “Which was the participants’ walking speed during the trials?”; (vii) “What are the main sensor systems used to collect data during perturbation-based protocols?”; (viii) “Are there benefits to apply both slip- and trip-like perturbations?”; and (ix) What is the current feasibility of PBT implementation in clinical settings? This narrative review will provide novel literature analysis towards artificial slip and trip perturbations concerning the third, fourth, seventh, and eighth research questions since they were not addressed by McCrum et al [ 3 , 26 ] and Karamanidis et al [ 23 ]. Although the first and sixth questions have been analysed in review studies [ 3 , 23 ] and McCrum et al [ 3 ] have also considered the fifth question, the work from this manuscript represents an attempt to identify whether new trends have been adopted in recent literature studies towards these investigation topics.…”

“…Although the first and sixth questions have been analysed in review studies [ 3 , 23 ] and McCrum et al [ 3 ] have also considered the fifth question, the work from this manuscript represents an attempt to identify whether new trends have been adopted in recent literature studies towards these investigation topics. Although review [ 26 ] analysed the second question, our review provides a deeper analysis on the comparison between perturbation delivery during treadmill and overground walking. Furthermore, although McCrum et al [ 26 ] focused their analysis mainly on the ninth question, we attempted to conduct a more concise overview concerning the current stage of PBT implementation in clinical settings.…”