Background: While efforts have been made to differentiate fall risk in older adults using wearable devices and clinical methodologies, technologies are still infancy. We applied a decision tree (DT) algorithm using inertial measurement unit (IMU) sensor data and clinical measurements to generate high performance classification models of fall risk of older adults. Objects: This study aims to develop a classification model of fall risk using IMU data and clinical measurements in older adults. Methods: Twenty-six older adults were assessed and categorized into high and low fall risk groups. IMU sensor data were obtained while walking from each group, and features were extracted to be used for a DT algorithm with the Gini index (DT1) and the Entropy index (DT2), which generated classification models to differentiate high and low fall risk groups. Model’s performance was compared and presented with accuracy, sensitivity, and specificity. Results: Accuracy, sensitivity and specificity were 77.8%, 80.0%, and 66.7%, respectively, for DT1; and 72.2%, 91.7%, and 33.3%, respectively, for DT2. Conclusion: Our results suggest that the fall risk classification using IMU sensor data obtained during gait has potentials to be developed for practical use. Different machine learning techniques involving larger data set should be warranted for future research and development.

Background: Despite fall prevention strategies suggested by researchers, falls are still a major health concern in older adults. Understanding factors that differentiate successful versus unsuccessful balance recovery may help improve the prevention strategies. Objects: The purpose of this review was to identify biomechanical factors that differentiate successful versus unsuccessful balance recovery in the event of a fall. Methods: The literature was searched through Google Scholar and PubMed. The following keywords were used: ‘falls,‘ ‘protective response,‘ ‘protective strategy,’ ‘automated postural response,’ ‘slips,’ ‘trips,’ ‘stepping strategy,‘ ‘muscle activity,’ ‘balance recovery,‘ ‘successful balance recovery,‘ and ‘failed balance recovery.’ Results: A total of 64 articles were found and reviewed. Most of studies included in this review suggested that kinematics during a fall was important to recover balance successfully. To be successful, appropriate movements were required, which governed by several things depending on the direction and characteristics of the fall. Studies also suggested that lower limb muscle activity and joint moments were important for successful balance recovery. Other factors associated with successful balance recovery included fall direction, age, appropriate protective strategy, overall health, comorbidity, gait speed, sex and anticipation of the fall. Conclusion: This review discusses biomechanical factors related to successful versus unsuccessful balance recovery to help understand falls. Our review should help guide future research, or improve prevention strategies in the area of fall and injuries in older adults.

Background: Posterior capsule tightness (PCT), commonly seen in overhead athletes, is a soft tissue adaptation that is also noted in non-throwers. PCT is associated with scapular and humeral kinematic alterations, significant restriction of shoulder internal rotation (IR) range of motion (ROM), and significant scapular anterior tilting. Sleeper and cross-body stretches (CBS) are suggested for PCT and IR deficits, and have been modified since introduction. A novel modified sleeper stretch (NMSS) was designed in this study to prevent the risk of anterior translation of the humeral head. Though the effects of posterior shoulder stretching exercise have been widely studies, to the best of our knowledge, no previous studies have investigated the effectiveness of posterior shoulder exercises in decreasing scapular anterior tilting. Objects: To compare the immediate effects of two posterior shoulder stretching exercises (NMSS and CBS) on scapular anterior tilting and shoulder IR ROM. Methods: Thirty-two subjects with anteriorly tilted scapula and IR deficits [mean age: 24.3 ± 2.5 years; 15 males and 17 females] participated in this study. Subjects were randomly assigned to either the NMSS or CBS groups. Scapular anterior tilting (at rest and at shoulder 60° active IR) and shoulder IR ROM were measured before and immediately after intervention. Results: Scapular anterior tilting significantly decreased, while the shoulder IR ROM significantly increased in both groups. However, there was no significant group-by-time interaction effect or significant difference between the groups. Conclusion: Both stretching exercises were effective in restoring shoulder IR ROM and decreasing scapular anterior tilting.

Background: Like many other countries, falls and related injuries in older adults are great concerns in South Korea. In particular, falls are common in medical institutions, often causing the increase of the length of hospitalization. Objects: The purpose of this review was to help understand and address falls in hospitalized individuals in South Korea. Methods: The review was conducted on literature published in Korean from 2010 to 2022, searched in the Korea Citation Index and PubMed. Keywords used for the search were as follows: falls, fall risk, fall risk assessment, hospital, inpatient, intervention, Korea, and prevention. Results: A total of 54 articles were found and reviewed. The most common place of fall accidents was the inpatient room, where there were many cases of falls while walking. Loss of balance was the most common cause of falls, and many falls occurred in patients admitted to the internal medicine. Furthermore, a risk of falling increased with the type of medications taken. In terms of tools to assess patients’ fall risk, the Morse Fall Scale (MFS) was commonly used. Patient-specific fall prevention activities were common to address falls, and they decreased the frequency of falls and the fear of falling. Factors influencing the effectiveness of the fall prevention activities included attitudes toward falls, education, environmental factors, patient safety culture, and self-efficacy in preventing falls. Conclusion: Our results should help understand and address falls and injuries in medical institutions.

Background: Neuromuscular electrical stimulation (NMES) is used for muscle strengthening. While voluntary muscle contraction follows Henneman et al.’s size principle, the NMES-induced muscle training disrespects the neurophysiology, which may lead to unwanted changes (i.e., declined balance ability). Objects: We examined how the balance was affected by abdominal muscle training with the NMES. Methods: Fifteen young adults (10 males and 5 females) aged between 21 and 30 received abdominal muscle strengthening with NMES for 23 minutes. Before and after the training, participants’ balance was measured through one leg standing on a force plate with eyes open or closed. Outcome variables included mean distance (MDIST), root mean square distance (RDIST), total excursion (TOTEX), mean velocity (MVELO), and 95% confidence circle area (AREA) of center of pressure data. Two-way repeated measures analysis of variance was used to test if these outcome variables were associated with time (pre and post) and vision. Results: All outcome variables were not associated with time (p > 0.05). However, all outcome variables were associated with vision (p = 0.0001), and MVELO and TOTEX were 52.4% (45.5 mm/s versus 95.6 mm/s) and 52.4% (364.1 mm versus 764.5 mm) smaller, respectively, in eyes open than eyes closed (F = 55.8, p = 0.0005; F = 55.8, p = 0.0005). Furthermore, there was no interaction between time and vision (F = 0.024, p = 0.877). Conclusion: Despite the different neurophysiology of muscle contraction, abdominal muscle strengthening with NMES did not affect balance.

Background: Neuromuscular electrical stimulation (NMES) is a physical modality used to activate skeletal muscles for strengthening. While voluntary muscle contraction (VMC) follows the progressive recruitment of motor units in order of size from small to large, NMES-induced muscle contraction occurs in a nonselective and synchronous pattern. Therefore, the outcome of muscle strengthening training using NMES-induced versus voluntary contraction might be different, which might affect balance performance. Objects: We examined how the NMES training affected balance and proprioception. Methods: Forty-four young adults were randomly assigned to NMES and VMC group. All participants performed one-leg standing on a force plate and sat on the Biodex (Biodex R Corp.) to measure balance and ankle proprioception, respectively. All measures were conducted before and after a training session. In NMES group, electric pads were placed on the tibialis anterior, gastrocnemius, and soleus muscles for 20 minutes. In VMC group, co-contraction of the three muscles was conducted. Outcome variables included mean distance, root mean square distance, total excursion, mean velocity, 95% confidence circle area acquired from the center of pressure data, and absolute error of dorsi/plantarflexion. Results: None of outcome variables were associated with group (p > 0.35). However, all but plantarflexion error was associated with time (p < 0.02), and the area and mean velocity were 37.0% and 18.6% lower in post than pre in NMES group, respectively, and 48.9% and 16.7% lower in post than pre in VMC group, respectively. Conclusion: Despite different physiology underlying the NMES-induced versus VMC, both training methods improved balance and ankle joint proprioception.

Background: Robot-assisted gait training (RAGT) is an effective method for walking rehabilitation. Additionally, the body weight support (BWS) system reduces muscle fatigue while walking. However, no previous studies have investigated the effects of RAGT with BWS on isokinetic strength of quadriceps and hamstring muscles. Objects: The purpose of this study was to investigate the effects of torque, work, and power on the quadriceps and hamstring muscles during RAGT, using the BWS of three conditions in healthy subjects. The three different BWS conditions were BWS 50%, BWS 20%, and full weight bearing (FWB). Methods: Eleven healthy subjects (7 males and 4 females) participated in this study. The Walkbot_S was used to cause fatigue of the quadriceps and hamstring muscles and the Biodex Systems 4 Pro was used to measure the isokinetic torque, work, and power of them. After RAGT trials of each of the three conditions, the subjects performed isokinetic concentric knee flexion and extension, five at an angular velocity of 60°/s and fifteen at an angular velocity of 180°/s. One-way repeated analysis of variance was used to determine significant differences in all the variables. The least significant difference test was used for post-hoc analysis. Results: On both sides, there were significant differences in peak torque (PT) of knee extension and flexion between the three BWS conditions at an angular velocity of 60°/s and 180°/s conditions. A post-hoc comparison revealed that the PT in the BWS 50% was significantly greater than in the BWS 20% and the FWB and the PT in the BWS 20% was significantly greater than in the FWB. Conclusion: The results of this study suggest that the lower BWS during RAGT seems to lower the isokinetic torque, work, and power of the quadriceps and hamstring muscles because of the muscle fatigue increase.

Understanding sciences behind fall-related hip fractures in older adults is important to develop effective interventions for prevention. The aim of this review is to provide biomechanical understanding and prevention strategies of falls and related hip fractures in older adults, in order to guide future research directions from biomechanical perspectives. While most hip fractures are due to a fall, a few of falls are injurious causing hip fractures, and most falls are non-injurious. Fall mechanics are important in determining injurious versus non-injurious falls. Many different biomechanical factors contribute to the risk of hip fracture, and effects of each individual factors are known well. However, combining effects, and correlation and causation among the factors are poorly understood. While fall prevention interventions include exercise, vision correction, vitamin D intake and environment modification, injury prevention strategies include use of hip protectors, compliant flooring and safe landing strategies, vitamin D intake and exercise. While fall risk assessments have well been established, limited efforts have been made for injury risk assessments. Better understanding is necessary on the correlation and causation among factors affecting the risk of falls and related hip fractures in older adults. Development of the hip fracture risk assessment technique is required to establish more efficient intervention models for fall-related hip fractures in older adults.

Background: Theoretically, balance is affected by the height of center of mass (COM) during quiet standing. However, no one examined this in humans with variables derived from the center of pressure (COP). Objects: We have conducted balance experiment to measure COP data during quiet standing, in order to examine how the COP measures were affected by the height of COM, vision, floor conditions, and gender. Methods: Twenty individuals stood still with feet together and arms at sides for 30 seconds on a force plate. Trials were acquired with three COM heights: 1% increased or decreased, and not changed, with two vision conditions: eyes closed (EC) and eyes open (EO), and with two floor conditions: unstable (foam pad) and stable (force plate) floor. Outcome variables included the mean distance, root mean square distance, total excursion, mean velocity, and 95% confidence circle area. Results: All outcome variables were associated with the COM height (p < 0.0005), vision (p < 0.0005), and floor condition (p < 0.003). The mean velocity and 95% confidence circle area were 5.7% and 21.8% greater, respectively, in raised COM than in lowered COM (24.6 versus 23.2 mm/s; 1,013.4 versus 832.3 mm2). However, there were no interactions between the COM height and vision condition (p > 0.096), and between the COM height and floor condition (p > 0.183) for all outcome variables. Furthermore, there was no gender difference in all outcome variables (p > 0.186). Conclusion: Balance was affected by the change of COM height induced by a weight belt in human. However, the effect was not affected by vision or floor condition. Our results should inform the design of balance exercise program to improve the outcome of the balance training.

Background: Only 2% of falls in older adults result in serious injuries (i.e., hip fracture). Therefore, it is important to differentiate injurious versus non-injurious falls, which is critical to develop effective interventions for injury prevention. Objects: The purpose of this study was to a. extract the best features of surface electromyography (sEMG) for classification of injurious falls, and b. find a best model provided by data mining techniques using the extracted features. Methods: Twenty young adults self-initiated falls and landed sideways. Falling trials were consisted of three initial fall directions (forward, sideways, or backward) and three knee positions at the time of hip impact (the impacting-side knee contacted the other knee (“knee together”) or the mat (“knee on mat”), or neither the other knee nor the mat was contacted by the impacting-side knee (“free knee”). Falls involved “backward initial fall direction” or “free knee” were defined as “injurious falls” as suggested from previous studies. Nine features were extracted from sEMG signals of four hip muscles during a fall, including integral of absolute value (IAV), Wilson amplitude (WAMP), zero crossing (ZC), number of turns (NT), mean of amplitude (MA), root mean square (RMS), average amplitude change (AAC), difference absolute standard deviation value (DASDV). The decision tree and support vector machine (SVM) were used to classify the injurious falls. Results: For the initial fall direction, accuracy of the best model (SVM with a DASDV) was 48%. For the knee position, accuracy of the best model (SVM with an AAC) was 49%. Furthermore, there was no model that has sensitivity and specificity of 80% or greater. Conclusion: Our results suggest that the classification model built upon the sEMG features of the four hip muscles are not effective to classify injurious falls. Future studies should consider other data mining techniques with different muscles.

Background: A hip fracture may occur spontaneously prior to the hip impact, due to the muscle pulling force exceeding the strength of the femur. Objects: We conducted falling experiments with humans to measure the activity of the hip muscles, and to examine how this was affected by the fall type. Methods: Eighteen individuals fell and landed sideways on a mat, by mimicking video-captured real-life older adults’ falls. Falling trials were acquired with three fall directions: forward, backward, or sideways, and with three knee positions at the time of hip impact, where the landing side knee was free of constraint, or contacted the mat or the contralateral knee. During falls, the activities of the iliopsoas (Ilio), gluteus medius (Gmed), gluteus maximus (Gmax) and adductor longus (ADDL) muscles were recorded. Outcome variables included the time to onset, activity at the time of hip impact, and timing of the peak activity with respect to the time of hip impact. Results: For Ilio, Gmed, Gmax, and ADDL, respectively, EMG onset averaged 292, 304, 350, and 248 ms after fall initiation. Timing of the peak activity averaged 106, 96, 84, and 180 ms prior to the hip impact, and activity at the time of hip impact averaged 72.3, 45.2, 64.3, and 63.4% of the peak activity. Furthermore, the outcome variables were associated with fall direction and/or knee position in all but the iliopsoas muscle. Conclusion: Our results provide insights on the hip muscle activation during a fall, which may help to understand the potential injury mechanism of the spontaneous hip fracture.

Background: A pressure ulcer is common in soft tissue over the greater trochanter (GT) in side-lying position, and sustained tissue deformation induced by the prolonged external force is a primary cause, which can be discussed with soft tissues’ viscoelastic properties (i.e., stress relaxation, creep response). Objects: Using an automated hand-held indentation device, we measured the viscoelastic properties of soft tissue over the hip area, in order to examine how the properties are affected by site with respect to the GT. Methods: Twenty participants (15 males and 5 females) who aged from 21 to 32 were participated. An automated hand-held indentation device was used to measure the stress relaxation time and creep response. Trials were acquired for three different locations with respect to the GT (i.e., right over the GT, 6 cm anterior or posterior to the GT). For each location, five trials were acquired and averaged for data analyses. Results: Soft tissues’ stress relaxation time and creep response were associated with site (F = 23.98, p < 0.005; F = 24.09, p < 0.005; respectively). The stress relaxation time was greatest at posterior gluteal region (19.22 ± 2.49 ms), and followed by anterior region (15.39 ± 2.47 ms) and right over the GT (14.40 ± 3.18 ms). Similarly, creep response was greatest at posterior gluteal region (1.16 ± 0.14), and followed by anterior region (0.95 ± 0.14) and right over the GT (0.89 ± 0.18). Conclusion: Our results showed that the stress relaxation and creep were greatest at the posterior gluteal region and least at right over the GT, indicating that the gluteal soft tissue is more protective to the prolonged external force, when compared to the trochanteric soft tissue. The results suggest that a risk of pressure ulcer over the GT may decrease with slightly posteriorly rotated side-lying position.

While efforts have been made to address fall-related injuries in older adults, the problem is unsolved to date. The purpose of this review is to provide a guideline for fall and injury prevention programs in older adults, based on evidence generated over the past 30 years. Research articles published between 1990 and 2020 have been searched on PubMed, using keywords, including but not limited to, falls, hip fracture, injuries, intervention, older adults, prevention, hip protector, vitamin D, safe landing strategy, and exercise. Total of 98 articles have been found and categorized into five intervention areas: exercise program, hip protector, safe landing strategy, vitamin D intake, and compliant flooring. Furthermore, the articles have been rated based on their study design: class 1, randomized controlled trials; class 2, nonrandomized controlled trials; class 3, experimental studies; class 4, all other studies. Exercise programs have shown to decrease the risk of fall, and associated injuries. Hip protectors, safe landing strategy, and vitamin D intake were effective in reducing a risk and incidence of hip fracture during a fall. Furthermore, compliant flooring has also decreased hip fracture risk without affecting balance. An integrated approach combining exercise program, wearing a hip protector, teaching safe landing strategies, scheduled vitamin D intake, and compliant flooring installation, is suggested to address fall-related injuries in older adults.

Background: The consequences of falls are often debilitating, and prevention is important. In theory, the lower the center of mass (COM), the greater postural stability during standing, and a weight belt at the waist level may help to lower the COM and improve the standing balance. Objects: We examined how the limit of stability (LOS) was affected by the lowered center of mass with the weight belt. Methods: Twenty healthy individuals participated in the LOS test. After calculating each participant’s COM, a weight belt was fastened ten centimeters below the COM. Trials were acquired with five weight belt conditions: 0%, 2%, 4%, 6%, and 8% of body weight. Outcome measures included reaction time, movement velocity, endpoint excursion, maximum excursion, and directional control in 4 cardinal moving directions. Results: None of our outcome variables were associated with a weight belt (p > 0.075), but all of them were associated with moving direction (p < 0.01). On average, movement velocity of the COM and maximum excursion were 31% and 18% greater, respectively, in mediolateral than anteroposterior direction (5.4°/s vs. 4.1°/s; 97.5% vs. 82.6%). Conclusion: Our results suggest that postural stability was not affected by the weightinduced lowered COM, informing the development and improvement of balance training strategies.

Background: Fall-related injuries in older adults are a major health problem, and the risks and mechanisms of these injuries should be affected by race, culture, living environment, and/or economic status. Objects: Research articles have been systematically reviewed to understand fall-related injuries in older adults in South Korea. Methods: 128 published research papers have been found through the Korea Citation Index and the Korean Studies Information Service System, and reviewed in various perspectives, including incidents, fall death rates, medical costs, causes, injury sites and types, locations where falls occurred, prevention strategies, scholarly fields interested in fall injuries, and the role of physical therapy. Results: Fall-related injuries were found to be more common in women than in men, and the number of incidents increased with age, with the highest rate found in individuals over 85 years old. Risk of fall injury was associated with education level, comorbidities, and fear of falling. Common places where falls occurred included the bathroom, living room, stairs, and hallway. Common types of injury included bruises, fractures, and sprains in the lower extremities. Intervention strategies included exercise programs, education, and protective clothing. Scholarly fields interested in fall-related injuries in older adults included medicine, nursing, physical therapy, occupational therapy, physical education, pharmacology, oriental medicine, biomedical engineering, design, clothing, and textiles. Physical therapy intervention using proprioceptive neuromuscular facilitation has been used to improve one’s balance. Conclusion: Any movement during the activities of daily living can lead to a fall. Physical therapists are highly educated to analyze human movements and should be involved in more research and practices to solve fall-related injuries in older adults.