Thoracopelvic assisted movement training to improve gait and balance in elderly at risk of falling: a case series
Clinical Interventions in Aging
Thoracopelvic assisted movement training to improve gait and balance in elderly at risk of falling: a case series
shmuel springer 2
Itamar Friedman 1
Avi Ohr y 0 3
0 Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
1 ProMedoss , Charlotte, NC, UsA , USA
2 Department of Physical Therapy, Faculty of Health sciences, Ariel University , Ariel , Israel
3 r euth r ehabilitation and Medical Center , Tel Aviv , Israel
8 1 0 2 - l u J - 2 1 n o 8 1 1 . 2 2 . 8 3 . 4 5 y b / m o c . s s e r PowerdbyTCPDF(ww.tcpdf.org) Background: Age-related changes in coordinated movement pattern of the thorax and pelvis may be one of the factors contributing to fall risk. This report describes the feasibility of using a new thoracopelvic assisted movement device to improve gait and balance in an elderly population with increased risk for falls. Methods: In this case series, 19 older adults were recruited from an assisted living facility. All had gait difficulties (gait speed ,1.0 m/s) and history of falls. Participants received 12 training sessions with the thoracopelvic assisted movement device. Functional performance was measured before, during (after 6 sessions), and after the 12 sessions. Outcomes measures were Timed Up and Go, Functional Reach Test, and the 10-meter Walk Test. Changes in outcomes were calculated for each participant in the context of minimal detectable change (MDC) values. Results: More than 25% of participants showed changes .MDC in their clinical measures after 6 treatment sessions, and more than half improved .MDC after 12 sessions. Six subjects (32%) improved their Timed Up and Go time by .4 seconds after 6 sessions, and 10 (53%) after 12 sessions. After the intervention, 4 subjects (21%) improved their 10-meter Walk Test velocity from limited community ambulation (0.4-0.8 m/s) to functional community ambulation (.0.8 m/s). Conclusion: Thoracopelvic assisted movement training that mimics normal walking pattern may have clinical implications, by improving skills that enhance balance and gait function. Additional randomized, controlled studies are required to examine the effects of this intervention on larger cohorts with a variety of subjects.
rotation.5 During axial trunk rotation, older adults move the
trunk and pelvis as 1 unit, which negatively affects gait.6
Since control of trunk movement is essential to
maintaining balance, changes in trunk movement control may be one
of the factors contributing to fall risk.7 Additionally, pelvic
rotation is important in adjusting crossing stride and obstacle
clearing.8 Thus, improving pelvic and trunk rotation may
18 reduce the risk of falls and increase balance.
l-02 Exercise regimens that target pelvis and trunk rotation,
-J2u such as Tai Ji Quan, are effective in reducing falls among
o1n seniors.9 However, practical drawbacks such as lack of
811 adherence and resource intensiveness prevent these exercises
..22 from being optimal interventions.10 Exercise in a relaxed,
.438 seated position may enhance adherence, especially among
yb5 individuals with balance disorders. In settings with limited
/om resources, the use of technology may provide a cost-effective
.css approach for training.
re Thus, the purpose of this case series feasibility report
.vdoepw l.syeon is to describe the training effects of the Balanseat (Mopair
w u Technologies, Ltd., Givat Nili, Israel), a new thoracopelvic
/sw laon assisted movement device, on gait and balance in an elderly
tthp rsep population at high risk for falls.
study design and participants
Residents of an assisted living home (Lev Ganim, Netanya,
Israel) were enrolled in this rehabilitation protocol.
Enrollment criteria included 1) age 65–99 years 2) ability to
ambulate at least 10 m on a flat surface, with or without an
assistive device, 3) walking difficulty, defined as gait speed
slower than 1 m/s (gait speed ,1.0 m/s) during 10-meter
Walk Test (10MWT),11 and 4) 2 or more falls in the 6 months
prior to the intervention. A fall was defined as any
unintentional event in which any part of the body above the ankle
makes contact with the floor, the ground, or a lower surface.
Excluded were any individuals who had a major orthopedic
or neurological disorder that could affect gait speed (such as
post-stroke or amputation), or other disease that prevented
their participation. Twenty-six individuals were approached
for eligibility, and 19 subjects met the enrollment criteria and
were included in the protocol. Of the participants, 5 were
males and 14 were females. The average age was 83.3 (SD
6.2 years). Written informed consent was provided by the
participants. Data collection was approved by the institute
Treatment included 12 sessions of training with the Balanseat
thoracopelvic assisted movement training device (Figure 1).
The Balanseat is a motorized chair-like device designed to
rehabilitate walking and balance. It applies gentle
contralateral movement between the trunk, the pelvis, and the thighs
to emulate normal human walking pattern.
The Balanseat’s scientific background is based on 2
concepts. The mechanical concept reflects exertion of a passive
movement in a specific plane that may increase the ability
of relevant joints to pass through a predetermined range of
motion.12 For the motor control concept, the device increases
the sensory feedback from mechanosensory afferents to
improve the dynamic control of movement.13
Participants received treatment while sitting in the device,
which has 4 motor-controlled platforms. The pelvis and
shoulder platforms emulate the torso’s contralateral
movements, while the 2 thigh platforms move in opposite
directions from each other. All platforms move in synchronization
to emulate a slow, rotational “walking-like” pattern. When
activated, the Balanseat’s pelvis platform moves through an
angular range of 8°; the shoulder and thigh platforms range
of motion is 4°. The speed of movement can be set according
to the individual user’s needs.
Sessions took place twice a week (on the same days),
over 6 weeks. Each session included ~30 minutes of training
with the Balanseat, followed by 20 minutes of posture gait
training. The entire session was supervised by a clinician.
The default rotational speed of the device is set to complete
the platform’s total range of motion within 5 seconds.
During training, the subjects were asked to pay attention to
the rotational movement. The system enables the clinician
to increase or decrease the default velocity by 25% (down
to pause of movement or up to cycle within 2.5 seconds).
The 30 minutes of training with the Balanseat were comprised
of 7 segments, each lasting 3–5 minutes. The first and last
segments were always 25% slower than the default speed.
The second and sixth segments were set to the default speed.
The 3 remaining segments were tailored to each participant’s
gait velocity and subjective feedback (ie, for those with faster
walking speeds, the cycle speed was increased to the level
they reported they were able to concentrate on the
movement sensation). Breaks between movement segments were
provided as needed. During the 20 minutes of gait
training, participants were encouraged to walk at varied speeds
(ie, comfortable and fast), while maintaining a gait pattern
that utilized trunk movements similar to those achieved by
the Balanseat. No additional instructions or training were
Outcomes were measured before, during (after 6 sessions),
and again after the intervention (12 sessions) and included
the Timed Up and Go test (TUG), the Functional reach test
(FRT), and the 10MWT. The TUG measures the time it takes
a person to stand up from a chair, walk 3 m, turn, and return
to sit on the chair. This test was chosen because it is a
commonly used, recommended assessment of gait and balance in
older people. It is also effective in identifying elderly
individuals who are prone to falls.14 The FRT assesses patients’
stability by measuring how far they can reach forward with
their arms without taking a step. The FRT is a good
indicator to identify those at high risk of falling among elderly
individuals.15 The 10MWT measures mobility by
assessing walking speed over a short duration. Walking speed is
a valid, reliable, and sensitive measure for assessing and
monitoring functional status.16 Participants were allowed to
use their walking assistive device during the 10MWT and the
All changes in outcome measures were evaluated using each
participant as his or her own control. The changes were
compared with the minimal detectable change (MDC) values
for comparable patient populations. The MDC is defined
as the minimum change that is not likely to be attributable
to a chance variation in measurement.17 In addition,
previously established cut-off scores were adopted for the current
For the TUG, the MDC was set at 4 seconds based on
values established in adults with Alzheimer’s disease18 and
Parkinson’s disease.19 A score of $13.5 seconds was used as
a cut-off value to identify those at increased risk of falls.20
For the FRT, the MDC was set at 4.3 cm based on values
established in adults with Parkinson’s disease.21 A cut-off
value ,18.5 cm was used to indicate fall risk.15
For the 10MWT, the MDC was set at 0.1 m/s. Among
older adults without specific impairments, as well as adults
after a hip fracture, a change in gait velocity .0.1 m/s has been
determined as a minimal clinically important difference.22,23
Patients were also grouped according to the 3 common
categories of ambulation: limited household ambulators
(gait velocity ,0.4 m/s), limited community
ambulators (0.4–0.8 m/s), and functional community ambulators
(.0.8 m/s). Transitioning to a higher ambulation category
is associated with substantially better function and quality
of life, especially with regard to mobility and community
To describe the treatment effect after 12 sessions, the
results were further analyzed according to the following
5 categories: A = no improvement, B = minor improvement
(up to 10% change), C = moderate improvement (10%–20%
change), D = substantial improvement, (20%–30% change),
and E = extensive improvement (.30% change).
Participant characteristics and the clinical outcome results
(TUG, FRT, and 10MWT) before treatment (Baseline), after
6 sessions (Mid), and after 12 sessions (End) are presented
in Table 1. Table 2 shows the number and percentage of
the participants whose clinical outcomes improved .MDC
values, and/or exceeded the cut-off points during the Mid
and End sessions, as compared to Baseline.
As depicted in Table 2, .25% of subjects showed
changes .MDC in clinical measures after 6 sessions of
treatment, and .50% improved .MDC after 12 sessions.
For example, 6 subjects (32%) improved their TUG time
by .4 seconds after 6 sessions, and this increased to 10 (53%)
after 12 sessions. When the results of all outcome measures
were combined, 4 subjects (21%) improved .MDC in all
It should also be noted that some subjects enhanced
their performance above the cut-off scores for fall risk and
category of ambulation. For example, after 12 sessions,
4 subjects (21%) improved their 10MWT velocity from
limited community ambulation to functional community
Figure 2 presents the analysis of the categories describing
the treatment effect after 12 sessions. Most participants
experienced minor to extensive improvement (.10%): TUG 11
(58%), FRT 16 (84%), and 10MWT 13 (68%). At least 32%
Note: *Participants who improved .MDC compared to baseline.
Abbreviations: 10MWT, 10-meter Walk Test; FrT, Functional reach Test; MDC, minimal detectable change; TUG, Timed Up and Go; F, female; M, male.
of participants exhibited extensive improvement (.30%):
TUG 6 (32%), FRT 13 (68%), and 10MWT 9 (47%).
In this case series, an intervention with a thoracopelvic
assisted movement training device designed to improve gait
and balance was found feasible for the treatment of elderly
people with gait difficulties and history of falls. Both walking
and balance improved in a cohort of residents of an assisted
living community. Some participants progressed from high
fall-risk and limited in-house walking capabilities to a better
category of ambulation. Improvements were demonstrated
across all 3 functional tests. These results may emphasize the
therapeutic value of the investigated intervention. No adverse
side effects were observed, regardless of a participant’s
results. Furthermore, though not included as an outcome
measure, it is important to mention that all participants
expressed a desire to continue with training.
The present results are consistent with previous evidence
reporting that older adults can gain crucial adaptive skills
for resisting falls through training.25,26 The ability achieved,
as reflected by improvements in clinical outcomes, was not
examined on a long-term basis. Yet, there is evidence that
older adults can retain newly acquired fine motor skills for
years without retraining.27,28
Another important aspect is the method of training. In this
case series, training was performed primarily in the seated
position. The current results agree with those of previous
studies that showed benefits of chair-based exercises for
frail older people.29 Two reasons may support this method of
training. Fall prevention programs that involve exercises
performed only while standing and walking unassisted might be
too challenging for older people with compromised balance
and mobility. In addition, practicing and acquiring a motor
skill may be easier while performed in a relaxed position.
Yet, it should be emphasized that the current protocol also
involved gait training intended to reinforce the gait pattern
and trunk movement training provided while in a seated
position. Thus, the beneficial effects could be related to both
types of training.
In this case series, functional performance was measured
by 3 different outcomes, the TUG, FRT, and 10MWT.
While adequate correlations were found between these
outcomes,14,30 physical performance measures might not be
useful as stand-alone tests to assess fall risk among older
adults.31 For example, it was shown that short walk tests
do not exhibit a high enough degree of concurrent validity
with the 10MWT to be used interchangeably for assessing
gait speed among older adults.32 The results obtained from
the different outcome measures seem to indicate a positive
influence of the intervention on different aspects of balance
Among the elderly, age-related degeneration of joints
and ligaments may lead to stiffness.33 Improvements in the
participants’ performance could be explained by a general
decrease in stiffness in the pelvis and trunk. In addition, fear
of falling could also lead to active stiffening due to increases
in background muscle activity.34 The thoracopelvic assisted
movement training might help increase joint range of motion
and normalization of muscle activity, as documented with
other passive motion devices.12 Increased pelvic and trunk
motion may enhance stability, improve gait pattern, and
decrease expenditure of muscle energy.5,6
Another explanation for the improvements seen could be
related to the sensory feedback gained from the rotational
movement. Decreased locomotion function in the elderly
might be due to age-related deterioration of sensory feedback
systems.5 Dynamic control of movement depends on sensory
feedback from mechanosensory afferents,35 and sensory
activity could contribute to a preprogrammed motoneuronal
drive, such as coordination of the human walking pattern.36
Thus, some of the positive outcomes achieved through the
training could be related to this mechanism.
This case series has several limitations, including the
lack of control group and the relatively small number of
participants who resided in an assisted living home.
Although beneficial effects on gait and balance were
demonstrated in most participants, the degree of the effect
differed across subjects. While 68% improved their 10MW
speed .MDC after 12 sessions, only 53% improved their
TUG .MDC during the same period. Furthermore, 4 subjects
(21%) improved .MDC in all 3 outcomes; however, one
subject (5%) did not show any improvement at the 6-week
(Mid) measurement. Thus, the beneficial results cannot be
generalized to a broader population without further research
examining characteristics of older adults that may lead to
improvements in mobility and balance from this type of
training. These investigations should be undertaken with
larger samples including community-dwelling adults, with
appropriate control groups. Kinematic and myoelectrical
studies are required to understand the biomechanical effects
of the thoracopelvic assisted movement device and to clarify
the relation between these effects to changes in gait.
Furthermore, increased axial stiffness has also been implicated
in movement disorders found in patients with neurological
problems, such as hemiplegia and Parkinson’s disease.37
Thus, it is suggested that future investigations include these
patient populations. Larger studies might enable a more
comprehensive analysis as well. Yet, it should be noted that
descriptive data are indispensable, and if they are of good
quality, valid and important conclusions can be drawn.38
Finally, future research should also evaluate outcomes related
to community ambulation, participation, and quality of life.
The promising results of the present investigation suggest
that such studies are warranted.
In summary, this case series suggests that thoracopelvic
assisted movement training that mimics normal walking
patterns could have clinical implications, by facilitating skills
that enhance balance and gait. This finding should encourage
further research aimed at testing the utility of this form of
training in treating individuals with gait difficulties.
Additional clinical investigations, including randomized controlled
studies with larger cohorts and variety of subjects, are required
to accurately evaluate the clinical effect of this concept.
Shmuel Springer, Itamar Friedman, and Avi Ohry are
conw u sultants for Mopair Technologies, the company that
:s on oped the Balanseat. The authors report no other conflicts of
h ep interest in this work.
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Clinical Interventions in Aging is an international, peer-reviewed journal
focusing on evidence-based reports on the value or lack thereof of treatments
intended to prevent or delay the onset of maladaptive correlates of aging
in human beings. This journal is indexed on PubMed Central, MedLine,
1. Rubenstein LZ , Josephson KR . Falls and their prevention in elderly people: what does the evidence show ? Med Clin North Am . 2006 ; 90 ( 5 ): 807 - 824 .
2. Wood B , Bilclough J , Bowron A , Walker R . Incidence and prediction of falls in Parkinson's disease: a prospective multidisciplinary study . J Neurol Neurosurg Psychiatry . 2002 ; 72 ( 6 ): 721 - 725 .
3. Kannus P , Sievänen H , Palvanen M , Järvinen T , Parkkari J . Prevention of falls and consequent injuries in elderly people . Lancet . 2005 ; 366 ( 9500 ): 1885 - 1893 .
4. Cavanaugh JT , Shinberg M , Ray L , Shipp KM , Kuchibhatla M , Schenkman M. Kinematic characterization of standing reach: comparison of younger vs . older subjects. Clin Biomech . 1999 ; 14 ( 4 ): 271 - 279 .
5. McGibbon CA , Krebs DE . Age-related changes in lower trunk coordination and energy transfer during gait . J Neurophysiol . 2001 ; 85 ( 5 ): 1923 - 1931 .
6. Sung PS , Lee KJ , Park WH . Coordination of trunk and pelvis in young and elderly individuals during axial trunk rotation . Gait Posture . 2012 ; 36 ( 2 ): 330 - 331 .
7. van der Burg J , Pijnappels M , van Dieen JH. The influence of artificially increased trunk stiffness on the balance recovery after a trip . Gait Posture . 2007 ; 26 ( 2 ): 272 - 278 .
8. Wang Y. Angular movements of the trunk and pelvis when stepping over obstacles of different heights . Res Sports Med . 2003 ; 11 ( 4 ): 219 - 234 .
9. Li F , Harmer P , Fitzgerald K. Implementing an evidence-based fall prevention intervention in community senior centers . Am J Public Health . 2016 ; 106 ( 11 ): 2026 - 2031 .
10. Hamm J , Money AG , Atwal A , Paraskevopoulos I. Fall prevention intervention technologies: a conceptual framework and survey of the state of the art . J Biomed Inform . 2016 ; 59 : 319 - 345 .
11. Montero-Odasso M , Schapira M , Soriano ER , et al. Gait velocity as a single predictor of adverse events in healthy seniors aged 75 years and older . J Gerontol A Biol Sci Med Sci . 2005 ; 60 ( 10 ): 1304 - 1309 .
12. O 'Driscoll SW , Giori NJ . Continuous passive motion (CPM): theory and principles of clincial application . J Rehabil Res Dev . 2000 ; 37 ( 2 ): 179 - 188 .
13. Nielsen JB , Sinkjaer T. Afferent feedback in the control of human gait . J Electromyogr Kinesiol . 2002 ; 12 ( 3 ): 213 - 217 .
14. Podsiadlo D , Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons . J Am Geriatr Soc . 1991 ; 39 ( 2 ): 142 - 148 .
15. Thomas JI , Lane JV . A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients . Arch Phys Med Rehabil . 2005 ; 86 ( 8 ): 1636 - 1640 .
16. Middleton A , Fritz SL , Lusardi M. Walking speed: the functional vital sign . J Aging Phys Act . 2015 ; 23 ( 2 ): 314 - 322 .
17. Haley SM , Fragala-Pinkham MA . Interpreting change scores of tests and measures used in physical therapy . Phys Ther . 2006 ; 86 ( 5 ): 735 - 743 .
18. Ries JD , Echternach JL , Nof L , Gagnon Blodgett M. Test-retest reliability and minimal detectable change scores for the timed “up & go” test, the six-minute walk test, and gait speed in people with Alzheimer disease . Phys Ther . 2009 ; 89 ( 6 ): 569 - 579 .
19. Huang SL , Hsieh CL , Wu RM , Tai CH , Lin CH , Lu WS . Minimal detectable change of the timed “up & go” test and the dynamic gait index in people with Parkinson disease . Phys Ther . 2011 ; 91 ( 1 ): 114 - 121 .
20. Rose DJ , Jones CJ , Lucchese N. Predicting the probability of falls in community-residing older adults using the 8-foot up-and-go: a new measure of functional mobility . J Aging Phys Act . 2002 ; 10 ( 4 ): 466 - 475 .
21. Smithson F , Morris ME , Iansek R. Performance on clinical tests of balance in Parkinson's disease . Phys Ther . 1998 ; 78 ( 6 ): 577 - 592 .
22. Bohannon RW , Glenney SS . Minimal clinically important difference for change in comfortable gait speed of adults with pathology: a systematic review . J Eval Clin Pract . 2014 ; 20 ( 4 ): 295 - 300 .
23. Palombaro KM , Craik RL , Mangione KK , Tomlinson JD . Determining meaningful changes in gait speed after hip fracture . Phys Ther . 2006 ; 86 ( 6 ): 809 - 816 .
24. Perry J , Garrett M , Gronley JK , Mulroy SJ . Classification of walking handicap in the stroke population . Stroke . 1995 ; 26 ( 6 ): 982 - 989 .
25. Pai YC , Bhatt T , Wang E , Espy D , Pavol MJ . Inoculation against falls: rapid adaptation by young and older adults to slips during daily activities . Arch Phys Med Rehabil . 2010 ; 91 ( 3 ): 452 - 459 .
26. Mirelman A , Rochester L , Maidan I , et al. Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial . Lancet . 2016 ; 388 ( 10050 ): 1170 - 1182 .
27. Smith C , Walton A , Loveland A , Umberger G , Kryscio R , Gash D. Memories that last in old age: motor skill learning and memory preservation . Neurobiol Aging . 2005 ; 26 ( 6 ): 883 - 890 .
28. Bhatt T , Pai YC . Long-term retention of gait stability improvements . J Neurophysiol . 2005 ; 94 ( 3 ): 1971 - 1979 .
29. Anthony K , Robinson K , Logan P , Gordon AL , Harwood RH , Masud T . Chair-based exercises for frail older people: a systematic review . Biomed Res Int . 2013 ; 2013 : 309506 .
30. Brooks D , Davis AM , Naglie G . Validity of 3 physical performance measures in inpatient geriatric rehabilitation . Arch Phys Med Rehabil . 2006 ; 87 ( 1 ): 105 - 110 .
31. Singh DK , Pillai SG , Tan ST , Tai CC , Shahar S. Association between physiological falls risk and physical performance tests among community-dwelling older adults . Clin Interv Aging . 2015 ; 10 : 1319 - 1326 .
32. Peters DM , Fritz SL , Krotish DE . Assessing the reliability and validity of a shorter walk test compared with the 10-Meter Walk Test for measurements of gait speed in healthy, older adults . J Geriatr Phys Ther . 2013 ; 36 ( 1 ): 24 - 30 .
33. Grimby G. Muscle performance and structure in the elderly as studied cross-sectionally and longitudinally . J Gerontol A Biol Sci Med Sci . 1995 ; 50 : 17 - 22 .
34. Reelick MF , van Iersel MB , Kessels RP , Rikkert MGO . The influence of fear of falling on gait and balance in older people . Age Ageing . 2009 ; 38 ( 4 ): 435 - 440 .
35. Koch SC , Del Barrio MG , Dalet A , et al. RORβ spinal interneurons gate sensory transmission during locomotion to secure a fluid walking gait . Neuron . 2017 ; 96 ( 6 ): 1419 - 1431 . e5 .
36. Nielsen JB , Sinkjaer T. Afferent feedback in the control of human gait . J Electromyogr Kinesiol . 2002 ; 12 ( 3 ): 213 - 217 .
37. Ferrarin M , Lopiano L , Rizzone M , et al. Quantitative analysis of gait in Parkinson's disease: a pilot study on the effects of bilateral sub-thalamic stimulation . Gait Posture . 2002 ; 16 ( 2 ): 135 - 148 .
38. Spriestersbach A , Röhrig B , du Prel JB , Gerhold-Ay A , Blettner M. Descriptive statistics: the specification of statistical measures and their presentation in tables and graphs. Part 7 of a series on evaluation of scientific publications . Dtsch Arztebl Int . 2009 ; 106 ( 36 ): 578 - 583 .