The STAB:LE Program
@stable_program
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Systematically developing the essential movement skills that older adults need at home, outside, and in the community
Joined February 2022
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Pinned Tweet
Physios… teach your clients to get off the floor. Even if they’re 90. No, ESPECIALLY if they’re 90.
This is Bill. Bill is 97. Be like Bill.
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This is Peggy. 95 yo next Friday.
1-year ago she fell. No injuries. But had a 6-hour long-lie.
She couldn't get up with her husband's assistance...even pulling up on a chair.
Physios: Teach your clients how to get up off the ground.
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This is Margaret, 93 yo, who previously fell & suffered a long lie…
1. We taught her husband how to complete a partner-assisted floor transfer ✅
2. Then she mastered chair-assisted floor transfers ✅
3. Today… hand assisted floor transfer 1RM 🥇
Next… capacity 💪
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Sideways falls and landings have the biggest association with fractures...
...yet the ability to cross-and-step to recover from a sideways loss of balance is a skill that’s absent in most balance & mobility rehab programs
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#STEPtember
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If someone is upper limb dependent for balance and unable to demonstrate integrated ankle-hip-step balance recovery strategies?
👉 The use of skill progressions enables a safe & systematic method to develop autonomy in that specific movement skill
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#STEPtember
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The ability to cross-&-step to recover from a sideways loss of balance is one of the most important mobility skills an older adult needs, yet:
⚠️ Its absent from some popular programs
🚩Some programs include practicing it without even confirming pre-requisites
Which is worse?
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👉 The inability to step quickly and correctly makes the difference between recovering balance and falling 👈
(this systematic review & meta-analysis of 61 studies shows stepping performance is significantly worse in fallers compared to non-fallers)
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#STEPtember
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If I could only prescribe one balance exercise for the rest of my life it would be Clock Yourself
A scalable method of integrating ankle-hip-step balance recovery strategies in all directions, with aspects of dual tasking
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This is Pat, 93 yo 💪
RPE and RIR are now part of her vocabulary… and one of the reasons she can now get on and off the floor independently
The FITT Principle applies to floor transfer training just as much as other physical pursuits
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Agility ladder: one of my favourite rehab tools
Unlike indoor mobility where step length & width is dictated by preference, an agility ladder replicates external environments where foot placement is dictated by external factors 1/3 🧵
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Unfortunately:
You can do as many 1kg seated leg extensions as you like…
…but they still won't help you get out of a chair
Strengthen movements.
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People don't fall over because they lose their balance
(normal healthy adults lose their balance several times per day BUT they automatically step to recover)
People fall over because they can't *recover* from a loss of balance
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#STEPtember
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Regaining normal balance recovery strategies isn't complicated BUT needs planning:
👉 Practice scaled versions of each movement skill that needs to be improved & then progressively increase the challenge until the client reaches their movement goal
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#STEPtember
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During a sideways loss of balance, bodyweight is transferred onto the lead leg which prevents it from stepping
👉 The ability to cross-&-step to recover from a sideways loss of balance is one of the most important mobility skills an older adult needs
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#STEPtember
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✅ Exercises including stepping refine ankle, hip & step balance recovery strategies
❌ Exercises isolating ankle strategy DO NOT develop the NORMAL integrated ankle-hip-step response
(and have no benefit for falls prevention except for VERY specific circumstances)
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Exercises to "improve balance" while holding onto a chair do just that:
They improve balance that involves upper limb support
(but discourage use and development of normal ankle-hip-step balance recovery strategies AND reinforce reliance on upper limbs)
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#STEPtember
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The ability to cross-&-step to recover from a sideways fall isn't just about balance
👉 Many UNAIDED older adults lack the leg dexterity to step across without their feet clipping
(even if the balance challenge is removed by having both hands supported)
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#STEPtember
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Balance rehab should NOT be about "how long can I hold this tandem or single leg stand" but rather "can I complete this functional task while maintaining or recovering my balance"
Plenty of people spend time doing "balance exercises" that have no impact on their movement goals
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Principle 1️⃣0️⃣ Balance exercises need to be FITT
👉 Balance skills are not developed unless they’re practiced with the appropriate frequency, intensity, type, and time. The specifics of these parameters need to be individualised based on each client’s existing capacity.
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The foundation of balance involves an integration of ankle, hip, and step responses...
👉 Even though Berg Balance Scale is the most popular assessment used, it doesn't assess:
⛔️ Step response in any direction
⛔️ The ability to cross-and-step
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#STEPtember
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Standing on one leg… 🦩
An assessment tool?
A reliable way of improving balance to prevent falls?
If SLS is a regular tool in your kit, then this might be worth reading… 🧵
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When it comes to preventing falls:
Balance Recovery Strategies > Balance Maintenance Strategies
👉Teach clients to step early & fast👈
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#STEPtember
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Normal balance involves an integration of ankle, hip, and step strategies
(once its impossible for ankle/hip strategies to maintain Centre Of Mass within Base of Support, we need to establish a new BOS)
Not only is stepping normal, it should be encouraged
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#STEPtember
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When a person steps out of position during a balance exercise?
❌ They haven't "lost their balance"
✅ They've used their own balance recovery strategies
(the thing we're actually trying to develop)
👉 Stepping should be encouraged and celebrated
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#STEPtember
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The movement skills required to step to recover from a loss of balance are distinctly different depending on the direction…
…the risk of fracture (and type of injury) is also direction-specific
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#STEPtember
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6 questions to routinely ask post fall:
1. What task where you doing?
2. Why did you fall?
3. What was the direction of fall?
4. Could you get up by yourself?
5. How did you call for help?
6. How did they help you get up?
The answer to each question provides A LOT of insight
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The ability to step to recover from a loss of balance is direction-specific:
The muscles used, timing, & sequence are different for each direction
(all directions must be assessed and programs structured to target specific deficits)
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To develop normal ankle-hip-step balance recovery strategies...
...you need to practice exercises that incorporate ankle-hip-step responses
(static holds with feet together, heel-toe, or standing on one leg don't achieve this)
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#STEPtember
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The app that I most highly recommend for any clinician involved in balance and mobility rehab is
@clock_yourself
:
The ability to step to recover from a loss of balance is essential, and this app provides an easy, fun, and scalable method to achieve this
Planning an episode on APPS that Physical Therapists ACTUALLY use and get value from.
What's an app that is ROI positive for you?
Could be clinical, administrative, or business.
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@CorKinetic
@mark__mcg
Not going to lie, you had me there (if I checked your user name I would've seen it was a joke, but I was too busy allowing my BP get to 250/180) 😜
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The ability to step in all directions is a prerequisite for safe INDOOR mobility
(but foot placement is mostly determined by INTRINSIC factors)
👉 The ability to vary step length, width & cadence in response to EXTERNAL factors is a prerequisite for safe OUTDOOR mobility
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Foundational balance skills include integrated ankle-hip-step responses for EACH direction
👉 A tool that individually assesses EACH direction of movement (like the BESTest) should be used
(at very least each direction should be assessed in isolation)
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Everyday indoor mobility requires the ability to step autonomously:
🔵 Forwards
🔵 Sideways
🔵 Backwards
🔵 Turning clockwise/anti-clockwise
🔵 Crossing feet
(normal walking practices fwd stepping disproportionate to need/risk in other directions)
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I ❤️ this for strength training
For balance & mobility rehab?
The 5 basic mobility groups needed to train every movement skill. Simple & prioritised:
1 Balance recovery strategies
2 Indoor mobility skills
3 ADL balance & mobility skills
4 Outdoor mobility
5 Community mobility
Something I picked up from
@Rob_NBF
I now use this all the time with my patients…
The 6 basic movements needed to train every major muscle group in the body. So simple & efficient:
1 Squat
2 Hinge
3 Vertical push
4 Vertical pull
5 Horizontal push
6 Horizontal pull
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🦵Balance recovery strategies as priority🦵
A key principle of effective rehab is the distinction between balance maintenance and balance recovery strategies
Here’s a number of things to consider when working with clients:
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While the BESTest assesses stepping in each direction, its important to note that subjects score 'normal' for lateral balance recovery if:
🟠 Crossover OR lateral
But remember, normal is the ability for:
🟢 Crossover AND lateral
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Prescribing "strength" exercises?
One of the most important questions you can ask after your client has completed a set:
"How many more do you think you could've done?"
(HINT: If the answer is 10-20, it isn't a strength exercise)
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👉 Prioritising the ability to step to recover from a loss of balance improves performance in other balance rehab exercises
❌ If someone is unable to step to recover, they'll (understandably) self-limit the balance-challenge they place upon themselves
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#STEPtember
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The most recent edition of the J of Geri PT published a systematic review reporting on the level of physical activity needed to overcome the negative effects of sedentary behavior in people in their 80’s
They found a SIGNIFICANT effect of sedentary time on disability…
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The ability to step quickly, accurately & in all directions is a foundational movement that's an essential balance strategy
Foam balance pads are often used statically (which can inhibit normal balance recovery skills)
...so check out the new balance mat by
@pt_neuro
👌
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The ability to step to recover from a loss of balance is critical even for those who use their walking frame "at all times"
This client population develops abnormal reliance on their hands for balance
(so are severely compromised during standing ADLs)
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#STEPtember
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The inability to step across your feet without them touching:
❌ Creates an inability to RECOVER from a sideways loss of balance, AND
❌ It's the CAUSE of many falls
👉 Crossing feet is NORMAL and NEEDED for falls prevention AND direction changes
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#STEPtember
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When designing balance rehabilitation programs, this is the mental checklist I use to help make sure I’m balancing evidence and client needs
Anything missing that’s on your list?
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🚼 Fall prevention vs. harm minimisation 🚼
A key principle of effective rehabilitation is that balance training doesn’t address falls outcomes
Here’s a number of things to consider when working with clients:
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Equipment ❌
Iris spent 2 hrs on the floor last week waiting for an ambulance
Today we used her chair & her cushions to assess & learn independence with floor transfers
No fancy equipment.
No barriers.
Now she has the confidence to get up using only whats in her loungeroom
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@CorKinetic
Teaching someone how to get up off the floor after a fall isn't about activating specific muscles...
...its a skill that can reduce complications associated with a long-lie, improve client confidence, reduce burden on an over-strained health system, and potentially save a life
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3 practical tools to dose strength training for older clients:
1. Select a sufficient intensity for strengthening
2. Use RPE to prescribe and monitor intensity
3. Assess strength adaptations over time
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An inability to step causes patients to overly rely on their ankle-strategy in an attempt to recover from medium or large balance disturbances
When this fails, they start reaching & grabbing
(unfortunately there's not always something there to grab)
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#STEPtember
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I can’t say this enough:
Practicing standing on one leg at the kitchen counter will not prevent falls or improve balance during tasks like hanging out the washing, opening the door, or picking objects up off the floor
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Every physio should ask their balance & mobility rehab clients AT LEAST one of these 3 questions:
1) When you fell, how did you get up?
2) When was the last time you were on the floor?
3) If you ended up on the floor for whatever reason would you be able to get up by yourself?
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Which Exercise Interventions Can Most Effectively Improve Reactive Balance in Older Adults?
Findings from this SR and MA suggest task-specific reactive balance exercise could be the optimal intervention & power training a secondary training exercise
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Overrated for Balance Rehab:
- Single leg stand
- Tandem stand
- Foam mats
- Standing hip abduction
Underrated for Balance Rehab:
- Step training
- Functional tasks
- Skill progressions
- Prioritisation
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If someone has an over-reliance on their ankle strategy and an inability to step, exercises like this:
❌ Reinforce over-reliance on ankle strategy
❌ Incentivise delay in step-response
👉 This exercise achieves the opposite of its intent
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#STEPtember
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Developing an integrated ankle-hip-step response to a loss of balance is the foundation of functional mobility:
Although it makes for a fun day at work, it makes little sense to prioritise exercises wobbling on boards, tapping balloons, or random surfaces
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#STEPtember
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A well-rounded balance rehabilitation program includes training that is:
✅ Anticipatory
✅ Reactive, and
✅ Perturbation-based
Check out this article for principles, mechanisms, how to implement perturbation-based balance training into clinical practice
Delighted to share our published article:
"Perturbation-based balance training: Principles, mechanisms and implementation in clinical practice"
w Tanvi Bhatt, Marissa Gerards, Kiros Karamanidis, Mark Rogers, Stephen Lord &
@OkuboYoshiro
@FrontSportsAL
🧵
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⚠️ Stuck on the floor for 2 hours post fall while waiting for ambulance assist
This was a client I was referred today…
…here’s the step-by-step process I used to assess and teach independence in floor transfers in one session:
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If someone has a delayed step coupled with over-reliance on ankle & grab responses:
🚩 Exercises like this reinforce over-reliance on ankle strategy AND grab-response
(and eliminate the need to step)
👉 This exercise achieves the opposite of its intent
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#STEPtember
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Balance rehabilitation need not be overly complex
Prescribe exercises that check these boxes:
✅ Actually challenges balance
✅ Functionally relevant
✅ Planned progression
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@CorKinetic
This client has a structured resistance program
(and needed to develop pre-req strength to achieve her movement goal)
She has exercises designed to improve ROM
Her primary goal is to never be stuck on the floor again, dependant on others
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Powerful feedback from a client yesterday:
“When I saw you handwrite those exercises in front of me, it made me actually want to do them.
I could see you were giving me things to do based on what I needed, not just another printed sheet”
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2) The principle of specificity:
Seated leg extensions & mini squats DO NOT replace the need to replicate the movement pattern that needs to be strengthened
If you need to improve sit to stand practice variations of sit to stand!
Especially if it's the reason for admission!
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📣 Rehab professionals📣
Next time you're doing a session with one of your clients remember:
❌The goal is not to make your client tired
✅ The goal is to help them regain movement skills
Cycling through chair-based theraband exercises will not help balance or mobility
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Error based learning:
Unless a client's allowed to practice stepping to recover from a minor loss of balance
(but in a way that's safe)
they won't have the opportunity to develop the skills to recover if they really lose their balance & really need it
17 of 30
#STEPtember
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If you work in balance rehab, remember this:
Falls don’t happen because of losing balance but because of inability to recover balance
❌ Focus on ankle strategy in static holds
❌ ❌ Focus on ankle strategy AND using hands
✅ Developing an autonomous ankle-hip-step response
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Q: At what age does it become "normal" to require the use of armrests to stand from a standard height chair?
.
.
.
.
.
A: There is no age-related-normal for the need for use of upper limbs in sit-to-stand.
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One of the most important balance skills that is rarely taught but has a DRAMATIC impact on falls prevention:
The ability to step in all directions
(including crossing feet)
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If clients lack a step response in a specific direction, a well-rounded falls prevention program should inc education on specific tasks that place them at risk
eg inability to cross-&-step
⚠️ Sudden twists & turns
⚠️ Uneven surfaces
⚠️ Unexpected forces
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#STEPtember
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How are the glutes loaded during different exercises?
Standing hip abduction...
...doesn't even make it past the qualifying heats, let alone run the main race
How are the glutes loaded during different exercises? and what are the implications for exercise selection?
Just published: EMG-informed musculoskeletal modelling of a wide range of glute-targeting exercises.
Read on for main findings..
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@SynapseRut
Peggy lacked strength & balance. She was weak & frail, is a stroke survivor with a past # pelvis.
She couldn't get up even if pulling on furniture.
This is a result of consistency, dedication, and systematically working through a structured series of skill progressions
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🎯 Task specificity 🎯
A key principle of effective rehab is that balance is task specific
Here’s a number of things to consider when working with clients:
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One of our home care clients had a fall...
And she was excited to tell me about it!
I met Ruth today for the first time today. Last week she was seen by one of our other physios:
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🧠 Balance reactions are habitual 🧠
A key principle of effective balance rehab is habit development vs. avoidance
Here’s a number of things to consider when working with clients:
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I have a dream that one day rehab professionals will stop prescribing single leg stand as a “balance exercise”
I have a dream that one day physios will recognise that practising standing with one foot in font of the other does NOT prevent fallS
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Step response training
Clock Yourself is my favourite rehab app… simple but effective to incorporate skill progressions based on:
✅ Planned to random
✅ Dual tasking / cognitive load
✅ Step speed
Plus it’s easy to quantify volume…
…and clients love it!
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A great SLS or tandem stand time should not be the MAIN focus for a balance rehab client but rather a by-product of training movement skills.
The goal of balance rehab is to improve function and prevent falls, Not increase the time that a client can hold a random position!
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Assessment tool?
A systematic review of 55 papers:
"prognostic accuracy indicators suggest that one legged-balance was a poor discriminator of falls risk"
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Standing hip abduction or extension exercises are of little value in a falls prevention strength and balance program…
…this great article also questions their utility in post THR rehabilitation:
NEW BLOG: Have you noticed that post op rehab protocols for total hip replacement look pretty much the same as they did 20 years ago? Does evidence support these traditional programs? No! Maybe it’s time to Flick the Flap after hip replacement…
LINK:
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How is this relevant to strength & balance rehab?
Quite simply:
Safe landing strategies are discrete MOVEMENT SKILLS that are DIRECTION SPECIFIC
They have prerequisites and skill progressions... and the clinical threshold to develop autonomy is quite high
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✅ The ability to cross your feet is a fundamental movement skill for both everyday mobility AND falls prevention
❌ It’s amazing how many therapists report that they‘ve been taught to coach their clients to avoid this movement
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Physios remember this next time you prescribe a "balance exercise"
✅ Normal balance recovery strategy: ankle-hip-step response
❌Abnormal: Delayed (or absent) hip & step, reliance on grab
🤦♂️Exercises that discourage stepping to "develop ankle strategy" & encourage grabbing
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“It is essential that interventions should address the different aspects of falls efficacy in terms of balance confidence, balance recovery confidence, safe landing confidence and post-fall recovery”
Great read, top work by
@ShawnSohPT
et al👌
👉 …
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@l_giangregorio
I personally prefer RIR for assessing exercise intensity rather than RPE… some clients I work with are the other way around
Neither are an exact science and are an approximation… which means a correlation chart can still be useful
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You're a rehab professional & you want to make a difference?
👉 Help older adults learn independence with floor transfers.
It has an immediate impact on:
✅ Quality of life
✅ Health outcomes
✅ Ambulance workload, and
✅ The entire health system
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If you prescribe 3 sets of 10 as a strength exercise…and the client can do them all as a set of 30?
Sorry, that’s not a strength exercise.
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If you work in balance and mobility rehab then watch this short 30sec video:
It's a good reminder that ability to cross your feet is not only an ESSENTIAL movement skill for balance recovery strategies…
...it's a NORMAL & EFFICIENT movement pattern
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Exercise Prescription 101:
If you're giving out a templated program AT LEAST go through it with the client to ensure it achieves its intent
From a 3-page "strength" prg:
❎ Client EASILY did all 2 x 10 as sets of 20
❌ There were 2 exercises the client couldn't do at all
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Standing on one leg can be an excellent choice to improve balance.
Standing on one leg can also be a complete waste of time.
How well a “balance exercise” works for someone comes down to:
✅ Is it relevant to a functional goal?
✅ Is it a progression that’s needed now?
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The ability to autonomously step in all directions (including cross-and-step) is a fundamental component of normal balance recovery strategies
Older fallers have poorer stepping ability than non-fallers. Impaired volitional and reactive stepping are significant fall risk factors in older adults.
Have you been using any step tests to predict falls in your older patients?
#geriPT
#FallPrevention
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@Martin_Nekkolai
Balance rehab doesn’t need to be over-complicated with random exercises like eyes closed on foam mats
Its simple:
Practice scaled versions of each movement skill that needs to be improved and then progressively increase the challenge until the client reaches their movement goal
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Principle 2️⃣: Balance recovery strategies are priority
👉The movement skills required to recover from a loss of balance are direction-specific. When clients gain proficiency in each of these skills, it reduces falls AND improves the effectiveness of subsequent balance training.
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“There won’t always be something to grab onto, but your feet will always be on the end of your legs”
This usually create an ‘aha moment’ when explaining to clients the importance of developing their step response
What are YOUR throwaway lines that helps get concepts across?
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Both reactive and volitional step training interventions reduce falls amongst older adults by approximately 50%…
…yet most therapists are fixated on static balance training & developing ankle response
Can’t wait for
@WaynelsChan
’s presentation 👌
I will be presenting the preliminary results of the effects of step training on people with
#dementia
at
#ADI2022
.
Looking forward to meeting everyone this week.
@AlzDisInt
@ADIConference
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🚷 Balance is sensitive to fatigue🚷
A key principle of effective balance rehab is fatigue sensitivity.
Here’s a number of things to consider when working with clients:
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🔺Hierarchy of balance needs🔺
A key principle of effective client-centred rehab is effective prioritisation using a hierarchy of needs
Here’s a number of things to consider when working with clients:
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PS - this is Bill simulating getting down to clean something off the floor. It’s not just about post-fall efficacy, it’s about independence and quality of life
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Strength asymmetry and falls risk? 🤔
This study concluded that non-fallers have better strength and proprioception symmetry than fallers
Given what we know about adaptive loading in functional tasks like sit-to-stand, don't throw out OKC exercises...
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I had moment of clarity a few years ago when I inherited a client and “their” goal was to improve their Berg score:
Several months of therapy where balance exercises were randomly assigned in each session unsurprisingly had no effect on their outcomes
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When helping older adults learn independence with floor transfers, there’s one pre-requisite skill that’s in-common for all 4 different methods:
👉 The ability to get to hands and knees
This fundamental movement skill is the difference between independence and a long-lie
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The ability to cross your feet matters.
It matters for normal direction change.
It matters for lateral balance recovery.
Be cautious of listening to anyone who teaches that crossing feet is bad; it’s a fundamental movement skill that, if lost, should be targeted in rehab
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