Reactive-Based Training for Fall Prevention in Older Adults

7 min read. Posted in Exercise Prescription
Written by Dr. Kathy Doubleday info

Reactive balance training is an exercise method that requires a person to react quickly to changes in their environment, to improve balance, coordination, and dynamic stability.

This training style uses unexpected stimuli, external perturbations, to disrupt stability and balance. Perturbations might include quick velocity changes, or other motions that quickly force the center of mass outside the base of support.

Due to the sudden nature of these balance challenges, a stepping strategy rather than an ankle or hip strategy is required to maintain upright control. Current research shows that this method allows older adults to adapt neuromotor patterns to form successful stepping reactions that can affect their long-term fall risk. If you’d like to learn more about exercise prescription in older adults, check out this masterclass by Dr. Mariana Wingood.


What is reactive-based training?

For optimal fall prevention benefits, the specificity of training in balance therapy requires adding reactive balance or perturbation-induced tasks. Reactive balance training, perturbation-induced training, and repeated slip training are all terms for the general category of Perturbation Based Training (PBT), a method specific to these needs.

PBT creates a heightened sensory experience requiring a large step-type reaction for the trainee to recover. This new motor learning can affect patterns in the brain leading to a new reaction strategy, preparing them for a sudden, rapid loss of balance during daily activities.

The intensity of this training can be scaled to challenge a patient at their current level, building confidence that they have the skills when a real-life balance disruption occurs.

PBT takes many forms and can be implemented with low-tech or hi-tech equipment. For therapists, reactive balance training can be applied with elastic to cause a recoil reaction, hold and release manual stimuli, pull and release, or pelvic or limb perturbations.

Our nervous system is challenged by, and adapts to, unexpected slip or trip forces and is not challenged in the same way by static postures or sway-inducing exercises that are low-intensity or volitional.

Reactive balance training uses exposure to unpredictable and challenging events that older adults rarely experience (except preceding a fall) to improve rapid-response reaction times to aid in fall prevention.


What the research says

Research shows that fall risk increases with age, and the number of falls in older adults continues to rise as our population ages. To make matters worse, susceptibility to injuries and hospitalization can lead to limited mobility and fear of falling, which in turn increases fall risk. (1)

Research shows that fall risk increases with age, and the number of falls in older adults continues to rise as our population ages. To make matters worse, susceptibility to injuries and hospitalization can lead to limited mobility and fear of falling, which in turn increases fall risk. (1)


Results with older adults

Initial tests of this style of training simulated slipping hazards to induce falls in both younger and older subjects using a slip trainer. Researchers measured various reaction measures including the number of steps to full recovery, the amount of time to regain a stable footing, and the ability to physically react to rapid loss of balance.

The slip trainer, in contrast to the treadmill-based training used primarily in research, is an example of a new perturbation training device that is financially feasible to include in an outpatient clinic setting.

While one’s ability to recognize actual slipping hazards can still be challenging, especially for older people, results show a vast improvement in neurological reaction response after participating in PBT training.

Using perturbation-based training has been shown to affect adaptation in as little as one session of therapy, with lasting retention for up to four to six months.

Early research has shown retention of benefits for fall risk prevention and has been deemed “highly effective” as a new frontier beyond current physical therapy and balance training methods for seniors.

PBT not only shows promise for preventing falls in the general population, but its application may also prove to be extremely valuable for those suffering from neurological problems like stroke or brain injury.


How does perturbation balance training work?

Perturbation-induced training is designed to train those with a high fall risk to react to simulated balance disruption techniques under the guidance of a qualified physical therapist.

While training methods like standing on an unstable surface to promote balance improvement are valuable (known as internal perturbations), they would not be considered PBT. Proper PBT exercises simulate actual hazards or variables in the training environment. Examples include introducing objects or techniques to trip the trainee deliberately or having them lean against a therapist who then steps out of the way without warning.

The purpose is not to train any specific area or muscle group, but rather to build a neurological trip-and-catch response to place one’s foot properly to avoid a fall.

These exercises can be used to train for standing, standing and walking, or going from a seated to a standing position, all of which can present challenges to older people. Most falls in elder care facilities occur while walking, but sit-to stand or simply standing can present challenges as well.

Safety is obviously extremely important for these methods, and those being trained in PBT typically do so in a safety harness, especially during larger-scale external perturbation training, and few adverse responses have been reported outside of general soreness or minor discomfort.



Advantages over other training methods

General balance training and discussions about removing dangerous obstacles in the home can reduce falls, and it is standard practice for therapists to question seniors about their history and fear of falling and to test for balance and balance reactions.

However, as noted previously, static balance training is limited in its ability to improve real-time reactions to rapid trips, slips, or other fall hazards.

PBT research illustrates a new understanding that older adults can rapidly adapt their response to perturbations and develop an effective and stable neurological response that compliments and improves upon standard balance therapy.

A successful PBT system can administer perturbations that are difficult for clients to predict through sudden but controlled destabilization and can easily adjust the magnitude of perturbations to increase or decrease difficulty.



Although it is clearly effective, repeated slip training can be intense and scary, especially for people with a fear of, or history of falling. An overhead harness support system is mandatory for the peace of mind of the patient, as well as to ensure safety during the training process.

A patient’s full presentation must be considered for contraindications, but even the frail elderly may be good candidates for this intervention.

This training paradigm has been tested with young and older patients and has implications for patients with sensory loss, neurologic compromise and cognitive difficulties. Although it may seem frightening to some patients, it has been proven to provide more benefits than drawbacks for balanced challenged seniors.


Wrapping up

In balance training and fall-risk reduction, perturbation-based therapy is an emerging staple for physical therapy treatment of older adults, fall prevention and patients with stability difficulties. The images of octogenarians tripping to take a quick step to keep from falling are dramatic and compelling. When I saw the video for the first time, I thought this would be an essential step in the future of therapy and preventing falls.

The quick recovery step is a skill that I had not been able to elicit from patients in the past due to safety and understanding the need to simulate the recovery step practice. Now, with the slip trainer’s intensity, I will be able to change the motor plan that the seniors in my community use. Several researchers have shown the efficacy of PBT and retention of these skills for up to 6 months.

Thank you for reading and if you’d like to learn more about exercise prescription in older adults, check out this masterclass by Dr. Mariana Wingood.

Want to learn how to optimise your exercise prescription for older adults?

Dr Mariana Wingood has done a Masterclass lecture series for us on:

“Exercise prescription for aging adults”

You can try Masterclass for FREE now with our 7-day trial!

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