Deficient limb support is a major contributor to age differences in falling

Older adults are more likely than young to fall upon a loss of balance, yet the factors responsible for this difference are not well understood. This study investigated whether age-related differences in movement stability, limb support, and protective stepping contribute to the greater likelihood of falling among older adults. Sixty young and 41 older, safety-harnessed, healthy adults were exposed to a novel and unexpected forward slip during a sit-to-stand task. More older than young adults fell (76% vs. 30%). Falls in both age groups were related to lesser stability and lower hip height at first step touchdown, with 97.1% of slip outcomes correctly classified based on these variables. Decreases in hip height at touchdown had over 20 times greater effect on the odds of falling than equivalent decreases in stability. Three age differences placed older adults at greater risk of falling: older adults had lower and more slowly rising hips at slip onset, they were less likely to respond to slipping with ample limb support, and they placed their stepping foot less posterior to their center of mass. The first two differences, each associated with deficient limb support, reduced hip ascent and increased hip descent. The third difference resulted in lesser stability at step touchdown. These results suggest that deficient limb support in normal movement patterns and in the reactive response to a perturbation is a major contributor to the high incidence of falls in older adults. Improving proactive and reactive limb support should be a focus of fall prevention efforts.     

Adaptive recovery responses to repeated forward loss of balance in older adults

Experiments designed to assess balance recovery in older adults often involve exposing participants to repeated loss of balance. The purpose of this study was to investigate the adaptive balance recovery response exhibited by older adults following repeated exposure to forward loss of balance induced by releasing participants from a static forward lean angle. Fifty-eight healthy, community-dwelling older adults, aged 65-80 years, participated in the study. Participants were instructed to attempt to recover with a single step and performed four trials at each of three lean angles. Adaptive recovery responses at four events (cable release, toe-off of the stepping foot, foot contact and maximum knee flexion angle following landing in the stepping leg) were quantified for trials performed at the intermediate lean angle using the concept of margin of stability. The antero-posterior and medio-lateral margin of stability were computed as the difference between the velocity-adjusted position of the whole body centre of mass and the corresponding anterior or lateral boundary of the base of support. Across repeated trials adaptations in reactive stepping responses were detected that resulted in improved antero-posterior stability at foot contact and maximum knee flexion angle. Improved antero-posterior stability following repeated trials was explained by more effective control of the whole body centre of mass during the reactive stepping response and not by adjustments in step timing or base of support. The observed adaptations occurred within a single testing session and need to be considered in the design of balance recovery experiments.     

Automatic recognition of falls in gait-slip training: Harness load cell based criteria

Over-head-harness systems, equipped with load cell sensors, are essential to the participants' safety and to the outcome assessment in perturbation training. The purpose of this study was to first develop an automatic outcome recognition criterion among young adults for gait-slip training and then verify such criterion among older adults. Each of 39 young and 71 older subjects, all protected by safety harness, experienced 8 unannounced, repeated slips, while walking on a 7m walkway. Each trial was monitored with a motion capture system, bilateral ground reaction force (GRF), harness force, and video recording. The fall trials were first unambiguously indentified with careful visual inspection of all video records. The recoveries without balance loss (in which subjects' trailing foot landed anteriorly to the slipping foot) were also first fully recognized from motion and GRF analyses. These analyses then set the gold standard for the outcome recognition with load cell measurements. Logistic regression analyses based on young subjects' data revealed that the peak load cell force was the best predictor of falls (with 100% accuracy) at the threshold of 30% body weight. On the other hand, the peak moving average force of load cell across 1s period, was the best predictor (with 100% accuracy) separating recoveries with backward balance loss (in which the recovery step landed posterior to slipping foot) from harness assistance at the threshold of 4.5% body weight. These threshold values were fully verified using the data from older adults (100% accuracy in recognizing falls). Because of the increasing popularity in the perturbation training coupling with the protective over-head-harness system, this new criterion could have far reaching implications in automatic outcome recognition during the movement therapy.     

Static versus dynamic predictions of protective stepping following waist–pull perturbations in young and older adults

The purposes of this study were: (1) to determine the frequency of protective stepping for balance recovery in subjects of different ages and fall-status, and (2) to compare predicted stepping based on a dynamic model (Pai and Patton, 1997. Journal of Biomechanics 30, 347–354) involving displacement and velocity combinations of the center of mass (COM) versus a static model based on displacement alone against experimentally induced stepping. Responses to three different magnitudes of forward waist pulls were recorded for 13 young, 18 older-non-fallers and 18 older-fallers. The COM phase plane trajectories derived from motion analysis were compared with the model-predicted threshold values for stepping. We found that the older fallers had the highest percentage of stepping trials (52%), followed by older-non-fallers (17.3%), and young (2.7%) at the lowest perturbation level. Younger subjects stepped less often than the elderly at the middle level. Everyone consistently stepped at the highest level of perturbation. Overall, the dynamic model showed better predictive capacity (65%) than the static model (5%) for estimating the initiation of stepping. Furthermore, the threshold for step initiation derived from the dynamic model could consistently predict when a step must occur. However, it was limited, especially among older fallers at the low perturbation level, in that it considered some steps ‘unnecessary’ that were presumably triggered by fear of falling or other factors.     

Mechanisms of limb collapse following a slip among young and older adults

Recovery from a large perturbation, such as a slip, can be successful when stability of movement can be reestablished with protective stepping. Nevertheless, one dilemma for executing a protective step is that its liftoff can weaken support against limb collapse. This study investigated whether failures in limb support leading to falls after a protective step result from insufficient joint moment generation, and whether such insufficiency is greater among older fallers. A novel, unexpected slip was induced immediately following seat-off during a sit-to-stand. Joint work and mechanical energy were calculated for 43 young (9 falls, 34 recoveries) and 22 older (13 falls, 9 recoveries) adults who responded with a protective step. Comparisons of the work produced at three joints of the bilateral lower limbs revealed that insufficient concentric knee and hip extensor work prior to step liftoff was a primary differentiating factor between falling and recovery, regardless of age. Also, during stepping, fallers regardless of age failed to limit the eccentric knee extensor work at their stance limb sufficiently to retard rapid knee flexion and the consequent potential energy loss. We concluded that young and older fallers had comparable weak limb support. The greater fall incidence among the older adults likely resulted from a greater proportion of subjects who responded to the slip with insufficient knee extensor support, possibly attributable to age-differences in chair-rising. One strategy to address this dilemma may rely on task-specific training to enhance feedforward control that improves movement stability, and thus lessens the reliance on protective stepping.     

Biomechanical influences on balance recovery by stepping.

Stepping represents a common means for balance recovery after a perturbation to upright posture. Yet little is known regarding the biomechanical factors which determine whether a step succeeds in preventing a fall. In the present study, we developed a simple pendulum-spring model of balance recovery by stepping, and used this to assess how step length and step contact time influence the effort (leg contact force) and feasibility of balance recovery by stepping. We then compared model predictions of step characteristics which minimize leg contact force to experimentally observed values over a range of perturbation strengths. At all perturbation levels, experimentally observed step execution times were higher than optimal, and step lengths were smaller than optimal. However, the predicted increase in leg contact force associated with these deviations was substantial only for large perturbations. Furthermore, increases in the strength of the perturbation caused subjects to take larger, quicker steps, which reduced their predicted leg contact force. We interpret these data to reflect young subjects' desire to minimize recovery effort, subject to neuromuscular constraints on step execution time and step length. Finally, our model predicts that successful balance recovery by stepping is governed by a coupling between step length, step execution time, and leg strength, so that the feasibility of balance recovery decreases unless declines in one capacity are offset by enhancements in the others. This suggests that one's risk for falls may be affected more by small but diffuse neuromuscular impairments than by larger impairment in a single motor capacity.     

Stepping boundary of external force-controlled perturbations of varying durations: Comparison of experimental data and model simulations

This study investigated the stepping boundary – the force that can be resisted without stepping – for force-controlled perturbations of different durations. Twenty-two healthy young adults (19–37 years old) were instructed to try not to step in response to 86 different force/time combinations of forward waist-pulls. The forces at which 50% of subjects stepped (F₅₀) were identified for each tested perturbation durations. Results showed that F₅₀ decreased hyperbolically when the perturbation’s duration increased and converged toward a constant value (about 10% BW) for longer perturbations (over 1500 ms). The effect of perturbation duration was critical for the shortest perturbations (less than 1 s).In parallel, a simple function was proposed to estimate this stepping boundary. Considering the dynamics of a linear inverted pendulum + foot model and simple balance recovery reactions, we could express the maximum pulling force that can be withstood without stepping as a simple function of the perturbation duration. When used with values of the main model parameters determined experimentally, this function replicated adequately the experimental results.This study demonstrates for the first time that perturbation duration has a major influence on the outcomes of compliant perturbations such as force-controlled pulls. The stepping boundary corresponds to a constant perturbation force-duration product and is largely explained by only two parameters: the reaction time and the displacement of the center of pressure within the functional base of support. Future work should investigate pathological populations and additional parameters characterizing the perturbation time-profile such as the time derivative of the perturbation.     

Muscle contributions to recovery from forward loss of balance by stepping

The purpose of this study was to determine the muscular contributions to the stepping phase of recovery from forward loss of balance in 5 young and 5 older adults that were able to recover balance in a single step, and 5 older adults that required multiple steps. Forward loss of balance was achieved by releasing participants from a static forward lean angle. All participants were instructed to attempt to recover balance by taking a rapid single step. A scalable anatomical model consisting of 36 degrees-of-freedom was used to compute kinematics and joint moments from motion capture and force plate data. Forces for 94 muscle actuators were computed using static optimisation and induced acceleration analysis was used to compute individual muscle contributions to net lumbar spine joint, and stepping side hip joint and knee joint accelerations during recovery. Older adults that required multiple recovery steps used a significantly shorter and faster initial recovery step and adopted significantly more trunk flexion throughout recovery compared to the older single steppers. Older multiple steppers also produced significantly more force in the stance side hamstrings, which resulted in significantly higher hamstring induced flexion accelerations at the lumbar spine and extension accelerations at the hip. However since the net joint lumbar spine and hip accelerations remained similar between older multiple steppers and older single steppers, we suggest that the recovery strategy adopted by older multiple steppers was less efficient as well as less effective than for older single steppers.     

Stepping threshold with platform-translation and shoulder-pull postural perturbation methods

The type of balance recovery, feet-in-place or stepping, is predicated on the perturbation intensity, often defined by the combination of applied force and displacement. Few studies examined the relationship between characteristics required to produce a stepping response with one of the postural perturbation methods. The purpose of this study was to investigate the relationship between perturbation characteristics (applied force and displacement) required to elicit a forward stepping response with platform-translation and shoulder-pull methods, and to establish whether a common set of perturbation characteristics existed across both perturbation methods. Fourteen young healthy males participated. Temporally unexpected platform translations and shoulder pulls were induced by release of free weights, which fell a controlled height exerting a pull on the platform or on the participant via a shoulder harness. Participants responded with either feet-in-place or stepping responses. The force and displacement were varied to investigate the range of force-displacement combinations required to elicit stepping responses. Force-displacement combinations that elicited stepping responses were recorded and normalized to the participant’s body weight (BW) and the base of support (BOS; participant’s foot length). The lowest force and associated displacement that elicited stepping responses showed an inverse linear relationship during both platform-translation and shoulder-pull trials. The lowest force-displacement combination common to both perturbation methods was found to be 8.75%BW and 105%BOS, which, in the future work, could enable a direct comparison of the neuromuscular and biomechanical responses to different perturbation methods in a manner that attempts to equilibrate the perturbation stimulus across the methods.     

Thresholds for step initiation induced by support-surface translation: a dynamic center-of-mass model provides much better prediction than a static model

The need to initiate a step in order to recover balance could, in theory, be predicted by a static model based solely on displacement of the center of mass (COM) with respect to the base of support (BOS), or by a dynamic model based on the interaction between COM displacement and velocity. The purpose of this study was to determine whether the dynamic model provides better prediction than the static model regarding the need to step in response to moving-platform perturbation. The COM phase plane trajectories were determined for 10 healthy young adults for trials where the supporting platform was translated at three different acceleration levels in anterior and posterior directions. These trajectories were compared with the thresholds for step initiation predicted by the static and dynamic COM models. A single-link-plus-foot biomechanical model was employed to mathematically simulate termination of the COM movement, without stepping, using the measured platform acceleration as the input. An optimization routine was used to determine the stability boundaries in COM state space so as to establish the dynamic thresholds where a compensatory step must be initiated in order to recover balance. In the static model, the threshold for step initiation was reached if the COM was displaced beyond the BOS limits. The dynamic model showed substantially better accuracy than the static model in predicting the need to step in order to recover balance: 71% of all stepping responses predicted correctly by the dynamic model versus only 11% by the static model. These results support the proposition that the central nervous system must react to and control dynamic effects, i.e. COM velocity, as well as COM displacement in order to maintain stability with respect to the existing BOS without stepping.     

Reducing hip fracture risk during sideways falls: evidence in young adults of the protective effects of impact to the hands and stepping

Hip fracture is rare in young adults, despite evidence that the energy available in a fall is sufficient to fracture the young proximal femur. This might be explained by protective responses that allow young individuals to avoid hip impact during sideways falls. To test this hypothesis, we conducted experiments with 44 individuals (31 women and 13 men) aged 19-26 years, who were instructed to try to maintain balance after a sudden unpredictable sideways translation was applied to the platform they stood upon. While the surface adjacent to the platform was formed of gymnasium mats, we provided no information on surface compliance, or the direction and speed of the perturbation. Ninety percent of participants fell and impacted the pelvis, and 98% of those cases involved direct impact to the hip region. Impact occurred to the hand in 98% of falls, and preceded impact to the pelvis by 50 ms on average (SD=40, range=-12-175 ms). The impact velocity of the pelvis decreased 3.6% for every 10 ms increase in the interval between hand and pelvis impact, and was reduced by 22% on average by stepping prior to impact. Our results suggest that the lack of hip fractures in young adults cannot be explained by avoidance of hip impact during sideways falls. Rather, it probably relates to use of the hands and stepping, and by simply possessing sufficient bone strength to withstand the direct blow to the greater trochanter that tends to accompany sideways falls.     

Force-Controlled Balance Perturbations Associated with Falls in Older People: A Prospective Cohort Study

Balance recovery from an unpredictable postural perturbation can be a challenging task for many older people and poor recovery could contribute to their risk of falls. This study examined associations between responses to unpredictable perturbations and fall risk in older people. 242 older adults (80.0±4.4 years) underwent assessments of stepping responses to multi-directional force-controlled waist-pull perturbations. Participants returned monthly falls calendars for the subsequent 12 months. Future falls were associated with lower force thresholds for stepping in the posterior and lateral but not anterior directions. Those with lower posterior force thresholds for stepping were 68% more likely to fall at home than those with higher force thresholds for stepping. These results suggest that amount of force that can be withstood following an unpredictable balance perturbation predicts future falls in community-dwelling older adults. Perturbations in the posterior direction best discriminated between future fallers and non-fallers.     

Effects of aging on hip abductor-adductor neuromuscular and mechanical performance during the weight transfer phase of lateral protective stepping

Aging brings about challenges in the ability to recover balance through protective stepping, especially in the lateral direction. Previous work has suggested that lateral protective stepping during weight transfer may be affected by impaired muscle composition and performance of the hip abductors (AB) in older adults. Hence, this study investigated the influence of hip abductor-adductor (AB-AD) neuromuscular performance on the weight transfer phase of lateral protective stepping in younger and older adults. Healthy younger (n = 15) and older adults (n = 15) performed hip AB-AD isometric maximal voluntary contractions (IMVC). Lateral balance perturbations were applied via motorized waist-pulls. Participants were instructed to recover their balance using a single lateral step. Kinetic, kinematic and electromyographic (EMG) data were analyzed during the weight transfer phase. In the hip IMVC task, older adults showed reduced peak AB-AD torque, AB rate of torque development and AB-AD rate of EMG neuromuscular activation (RActv). During the lateral balance perturbations, older individuals had a lower incidence of lateral steps, reduced hip AB-AD RActv and delayed weight transfer. However, several outcomes were larger in the older group, such as, center of mass momentum at step onset, step-side peak rate of vertical force development, hip AB net joint torque, and power. Although older adults had greater hip muscular output during the weight transfer phase, their lateral balance recovery was still impaired. The reduced maximal hip AB-AD capacity, especially RActv, may have been a greater contributor to this impairment, as it affects the ability to generate rapid force, crucial for balance recovery.     

Adaptive feedback potential in dynamic stability during disturbed walking in the elderly

After perturbation of the gait, feedback information may help regaining balance adequately, but it remains unknown whether adaptive feedback responses are possible after repetitive and unexpected perturbations during gait and if there are age-related differences. Prior experience may contribute to improved reactive behavior. Fourteen old (59-73 yrs) and fourteen young (22-31 yrs) males walked on a walkway which included one covered element. By exchanging this element participants either stepped on hard surface or unexpectedly on soft surface which caused a perturbation in gait. The gait protocol contained 5 unexpected soft trials to quantify the reactive adaptation. Each soft trial was followed by 4-8 hard trials to generate a wash-out effect. The dynamic stability was investigated by using the margin of stability (MoS), which was calculated as the difference between the anterior boundary of the base of support and the extrapolated position of the center of mass in the anterior-posterior direction. MoS at recovery leg touchdown were significantly lower in the unexpected soft trials compared to the baseline, indicating a less stable posture. However, MoS increased (p<0.05) in both groups within the disturbed trials, indicating feedback adaptive improvements. Young and old participants showed differences in the handling of the perturbation in the course of several trials. The magnitude of the reactive adaptation after the fifth unexpected perturbation was significantly different compared to the first unexpected perturbation (old: 49±30%; young: 77±40%), showing a tendency (p=0.065) for higher values in the young participants. Old individuals maintain the ability to adapt to feedback controlled perturbations. However, the locomotor behavior is more conservative compared to the young ones, leading to disadvantages in the reactive adaptation during disturbed walking.     

Effects of obesity on dynamic stability control during recovery from a treadmill-induced slip among young adults

This study sought to investigate the effects of obesity on falls and dynamic stability control in young adults when subject to a standardized treadmill-induced gait-slip. Forty-four young adults (21 normal-weight and 23 obese) participated in this study. After their muscle strength was assessed at the right knee under maximum voluntary isometric (flexion and extension) contractions, participants were moved to an ActiveStep treadmill. Following 5 normal walking trials on the treadmill, all participants encountered an identical and unexpected slip defined as a perturbation in the anterior direction with the magnitude of 24-cm slip distance and 2.4-m/s peak slip velocity. The trials were categorized as a fall or recovery based on the reliance of the subject on external support following the slip. Compared with the normal-weight group, the obese group demonstrated less relative muscle strength and fell more responding to the slip (78.3% vs. 40.0%, p=0.009). After adjusting the body height and gender, the results indicated that the obese group was 19.1-time (95% confidence interval: [2.06, 177.36]) more prone to a fall than the normal-weight group when experiencing the same treadmill-induced slip. The obese group showed significantly impaired dynamic stability after slip possibly due to the inability of controlling the trunk segment׳s backward lean movement. Obesity measurements explained more slip outcome variance than did the strength measurements (53.4% vs. 18.1%). This study indicates that obesity most likely influences the ability to recover from slip perturbations. It is important to develop interventions to improve the capability of balance recovery among individuals with obesity.     

Mechanisms of adaptation from a multiple to a single step recovery strategy following repeated exposure to forward loss of balance in older adults

When released from an initial, static, forward lean angle and instructed to recover with a single step, some older adults are able to meet the task requirements, whereas others either stumble or fall. The purpose of the present study was to use the concept of margin of stability (MoS) to investigate balance recovery responses in the anterior-posterior direction exhibited by older single steppers, multiple steppers and those that are able to adapt from multiple to single steps following exposure to repeated forward loss of balance. One hundred and fifty-one healthy, community dwelling, older adults, aged 65-80 years, participated in the study. Participants performed four trials of the balance recovery task from each of three initial lean angles. Balance recovery responses in the anterior-posterior direction were quantified at three events; cable release (CR), toe-off (TO) and foot contact (FC), for trials performed at the intermediate lean angle. MoS was computed as the anterior-posterior distance between the forward boundary of the Base of Support (BoS) and the vertical projection of the velocity adjusted centre of mass position (XCoM). Approximately one-third of participants adapted from a multiple to a single step recovery strategy following repeated exposure to the task. MoS at FC for the single and multiple step trials in the adaptation group were intermediate between the exclusively single step group and the exclusively multiple step group, with the single step trials having a significant, 3.7 times higher MoS at FC than the multiple step trials. Consistent with differences between single and multiple steppers, adaptation from multiple to single steps was attributed to an increased BoS at FC, a reduced XCoM at FC and an increased rate of BoS displacement from TO to FC. Adaptations occurred within a single test session and suggest older adults that are close to the threshold of successful recovery can rapidly improve dynamic stability following repeated exposure to a forward loss of balance.     

Effects of a single-session stance-slip perturbation training program on reducing risk of slip-related falls

The purpose of this pilot study was to establish the efficacy and feasibility of a single-session treadmill-based stance-slip perturbation program on preventing slip-related falls while walking over the ground among young adults. Two groups (training vs. control) of healthy young participants were respectively exposed to a treadmill-based stance-slip perturbation training protocol and a placebo training protocol. Post training, both groups experienced an unexpected overground gait-slip. Our results indicated that 28.6% of individuals in the training group and 55.0% of controls fell when responding to the overground slip. In comparison with the control group, the training group exhibited better control over the compensatory step and dynamic stability at the instant immediately prior to recovery touchdown. The improved dynamic stability control in the training group likely resulted from the enhanced capability of harnessing the slip kinematics of the base of support. Dynamic stability did not display any significant group-associated difference at slipping foot touchdown and recovery foot liftoff. This implies that a stance-slip perturbation training protocol with eight slips may not provide enough and very task-specific incentive to the Central Nervous System to form the capability of sufficiently modifying regular gait pattern after an unexpected gait slip. However, given its ease of use, stance-perturbation could be a practical option to train individuals in clinical settings as a simple push or pull could exert a perturbation to a standing individual. The findings from this study provide information for developing future studies based on large-scale samples.     

Age-related differences in muscle power during single-step balance recovery

The purpose of this study was to investigate age-related differences in muscle power during a surrogate task of trip recovery. Participants included 10 healthy young men (19-23 years old) and 10 healthy older men (65-83). The task involved releasing participants from a forward-leaning posture. After release, participants attempted to recover their balance using a single step of the right foot. Muscle power at the hip, knee, and ankle of the stepping limb were determined from the product of joint angular velocity and joint torque. Muscle powers during balance recovery followed a relatively consistent pattern in both young and older men, and showed effects of both lean and age. Interestingly, the effects of age did not always involve smaller peak power values in the older men as expected from the well-documented loss of muscle power with aging. Older men exhibited smaller peak muscle power at the knee and larger peak muscle power at the ankle and hip compared to young men. The increases in muscle power at the ankle and hip may result from a neuromuscular adaptation aimed at improving balance recovery ability by compensating for the age-related loss of muscle function.     

Arm reactions in response to an unexpected slip—Impact of aging

Slips and falls represent a serious public safety concern in older adults, with the segment of the United States population over the age of 65 accounting for about three quarters of all fall related deaths. The majority of falls in older adults are due to trips and slips. The objective of this study was to investigate how age affects arm reactions generated in response to unexpected slips. Thirty-three participants divided into two age groups (16 young, 17 old) participated in this study. Participants were exposed to two conditions: known dry walking (baseline) and an unexpected slip initiated when stepping onto a glycerol-contaminated floor. The upper extremity parameters of interest included the timing and amplitude of the shoulder flexion moment generated in response to the slip as well as the resulting angular kinematics (trajectories). The analysis of the kinetic data revealed a delayed shoulder flexion reaction to slips in older adults compared to their young counterparts, as well as a greater flexion moment magnitude. Knowledge of such upper body reaction mechanisms to unexpected slips may help to improve balance recovery training in older adults, as well as aid in the implementation of environmental modifications, e.g. handrails, to reduce falls-related injuries.     

Muscle activities used by young and old adults when stepping to regain balance during a forward fall

The current study was undertaken to determine if age-related differences in muscle activities might relate to older adults being significantly less able than young adults to recover balance during a forward fall. Fourteen young and twelve older healthy males were released from forward leans of various magnitudes and asked to regain standing balance by taking a single forward step. Myoelectric signals were recorded from 12 lower extremity muscles and processed to compare the muscle activation patterns of young and older adults. Young adults successfully recovered from significantly larger leans than older adults using a single step (32.2° vs. 23.5°). Muscular latency times, the time between release and activity onset, ranged from 73 to 114 ms with no significant age-related differences in the shortest muscular latency times. The overall response muscular activation patterns were similar for young and older adults. However older adults were slower to deactivate three stance leg muscles and also demonstrated delays in activating the step leg hip flexors and knee extensors prior to and during the swing phase. In the forward fall paradigm studied, age-differences in balance recovery performance do not seem due to slowness in response onset but may relate to differences in muscle activation timing during the stepping movement.