Research Article|Articles in Press, 104607

Training reactive balance using trips and slips in people with multiple sclerosis: a blinded randomised controlled trial


      • Reactive balance training improved dynamic stability and trunk control following trips.
      • These led to reduced trip-induced falls in people with multiple sclerosis.
      • Some patients did not tolerate the intervention due to increased pain.
      • The training protocol should be optimised for better efficiency and feasibility.
      • Further research is needed to assess long term effects and improve tolerability.



      This study examined the feasibility and efficacy of reactive balance training for improving stepping performance and reducing laboratory-induced falls in people with multiple sclerosis (MS).


      Thirty people diagnosed with MS (18-70 years) participated in a blinded randomized controlled trial (ACTRN12618001436268). The intervention group (n = 14) underwent two 50-minute sessions (total 100 minutes) that exposed them to a total of 24 trips and 24 slips in mixed order, over one week. The control group (n = 16) received sham training (stepping over foam obstacles) with equivalent dosage. The primary outcome was falls into the harness (defined as >30% body weight) when exposed to trips and slips that were unpredictable in timing, location and type at post-assessment. Physical and psychological measures were also assessed at baseline and post assessments.


      The intervention and control groups completed 86% and 95% of the training protocols respectively. Incidence rate ratios (95% confidence intervals) of the intervention group relative to the control group were 0.57 (0.25, 1.26) for all falls, 0.80 (0.30, 2.11) for slip falls and 0.20 (0.04, 0.96) for trip falls in the laboratory. Kinematic analyses indicated the intervention participants improved dynamic stability, with higher centre of mass position and reduced trunk sway during recovery steps following a trip, compared to control. There were no significant differences between the intervention and control participants at post-assessment for other secondary outcome measures.


      Reactive balance training improved trip-induced dynamic stability, limb support, trunk control and reduced falls in people with MS. More research is required to optimise the training protocol and determine whether the beneficial effects of reactive balance training can be retained long term and generalize to fewer daily-life falls.


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        • Allin L.J.
        • Nussbaum M.A.
        • Madigan M.L.
        Two Novel Slip Training Methods Improve the Likelihood of Recovering Balance After a Laboratory-Induced Slip.
        J Appl Biomech. 2018; : 1-31
        • Bohm S.
        • Mademli L.
        • Mersmann F.
        • Arampatzis A.
        Predictive and Reactive Locomotor Adaptability in Healthy Elderly: A Systematic Review and Meta-Analysis.
        Sports medicine (Auckland, N.Z.). 2015; 45: 1759-1777
        • Brodie M.
        • Okubo Y.
        • Sturnieks D.
        • Lord S.
        Optimizing successful balance recovery from unexpected trips and slips.
        Journal of Biomechanical Science and Engineering. 2018; 13: 1-10
        • Cameron M.H.
        • Horak F.B.
        • Herndon R.R.
        • Bourdette D.
        Imbalance in multiple sclerosis: a result of slowed spinal somatosensory conduction.
        Somatosens Mot Res. 2008; 25: 113-122
        • Cameron M.H.
        • Lord S.
        Postural control in multiple sclerosis: implications for fall prevention.
        Current neurology and neuroscience reports. 2010; 10: 407-412
        • Eng J.J.
        • Winter D.A.
        • Patla A.E.
        Strategies for recovery from a trip in early and late swing during human walking.
        Exp Brain Res. 1994; 102: 339-349
        • Finlayson M.L.
        • Peterson E.W.
        • Cho C.C.
        Risk factors for falling among people aged 45 to 90 years with multiple sclerosis.
        Arch Phys Med Rehabil. 2006; 87 (quiz 1287): 1274-1279
        • Fritz N.E.
        • Eloyan A.
        • Baynes M.
        • Newsome S.D.
        • Calabresi P.A.
        • Zackowski K.M.
        Distinguishing among multiple sclerosis fallers, near-fallers and non-fallers.
        Mult Scler Relat Disord. 2018; 19: 99-104
        • Gera G.
        • Fling B.W.
        • Van Ooteghem K.
        • Cameron M.
        • Frank J.S.
        • Horak F.B.
        Postural Motor Learning Deficits in People With MS in Spatial but Not Temporal Control of Center of Mass.
        Neurorehabil Neural Repair. 2016; 30: 722-730
        • Gianni C.
        • Prosperini L.
        • Jonsdottir J.
        • Cattaneo D.
        A systematic review of factors associated with accidental falls in people with multiple sclerosis: a meta-analytic approach.
        Clin Rehabil. 2014; 28: 704-716
        • Global Burden of Disease Neurological Disorders Collaborator Group
        Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
        Lancet Neurol. 2017; 16: 877-897
        • Hebb D.O.
        The Organization of Behavior - A Neuropsychological Theory.
        John Wiley & Sons, Inc., New York1949
      1. Ho, C., Huang, T., Cheung, D., Hicks, C., Treacy, D., Lord, S.R., Okubo, Y., In preparation. Clinician ratings of the feasibility of the ReacStep reactive balance training program for fall prevention.

        • Hof A.L.
        • Gazendam M.G.
        • Sinke W.E.
        The condition for dynamic stability.
        J Biomech. 2005; 38: 1-8
        • Kasser S.L.
        • Jacobs J.V.
        • Foley J.T.
        • Cardinal B.J.
        • Maddalozzo G.F.
        A prospective evaluation of balance, gait, and strength to predict falling in women with multiple sclerosis.
        Arch Phys Med Rehabil. 2011; 92: 1840-1846
        • Krupp L.B.
        • Alvarez L.A.
        • LaRocca N.G.
        • Scheinberg L.C.
        Fatigue in multiple sclerosis.
        Arch Neurol. 1988; 45: 435-437
        • Liu J.
        • Lockhart T.E.
        Trunk angular kinematics during slip-induced backward falls and activities of daily living.
        J Biomech Eng. 2014; 136101005
        • Lord S.R.
        • Clark R.D.
        • Webster I.W.
        Postural stability and associated physiological factors in a population of aged persons.
        J Gerontol. 1991; 46: M69-M76
        • Lord S.R.
        • Fitzpatrick R.C.
        Choice stepping reaction time: a composite measure of falls risk in older people.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M627-M632
        • Mansfield A.
        • Wong J.S.
        • Bryce J.
        • Knorr S.
        • Patterson K.K.
        Does perturbation-based balance training prevent falls? Systematic review and meta-analysis of preliminary randomized controlled trials.
        Physical therapy. 2015; 95: 700-709
        • Matsuda P.N.
        • Shumway-Cook A.
        • Bamer A.M.
        • Johnson S.L.
        • Amtmann D.
        • Kraft G.H.
        Falls in multiple sclerosis.
        PM R. 2011; 3 (quiz 632): 624-632
        • Mohamed Suhaimy M.S.B.
        • Lord S.R.
        • Hoang P.D.
        • Nieto A.
        • Sturnieks D.L.
        • Okubo Y.
        Reactive balance responses to a trip and slip during gait in people with multiple sclerosis.
        Clin Biomech (Bristol, Avon). 2021; 90105511
        • Mohamed Suhaimy M.S.B.
        • Okubo Y.
        • Hoang P.D.
        • Lord S.R.
        Reactive Balance Adaptability and Retention in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis.
        Neurorehabilitation and Neural Repair. 2020; 01545968320929681
        • Nilsagard Y.
        • Denison E.
        • Gunnarsson L.G.
        • Bostrom K.
        Factors perceived as being related to accidental falls by persons with multiple sclerosis.
        Disabil Rehabil. 2009; 31: 1301-1310
        • Nilsagard Y.
        • Gunn H.
        • Freeman J.
        • Hoang P.
        • Lord S.
        • Mazumder R.
        • Cameron M.
        Falls in people with MS–an individual data meta-analysis from studies from Australia, Sweden, United Kingdom and the United States.
        Mult Scler. 2015; 21: 92-100
        • Okubo Y.
        • Brodie M.
        • Sturnieks D.
        • Hicks C.
        • Lord S.
        A pilot study of reactive balance training using trips and slips with increasing unpredictability in young and older adults: Biomechanical mechanisms, falls and clinical feasibility.
        Clin Biomech. 2019; 67: 171-179
        • Okubo Y.
        • Brodie M.A.
        • Sturnieks D.L.
        • Hicks C.
        • Carter H.
        • Toson B.
        • Lord S.R.
        Exposure to trips and slips with increasing unpredictability while walking can improve balance recovery responses with minimum predictive gait alterations.
        PloS one. 2018; 13e0202913
        • Okubo Y.
        • Brodie M.A.
        • Sturnieks D.L.
        • Hicks C.
        • Carter H.
        • Toson B.
        • Lord S.R.
        Exposure to trips and slips with increasing unpredictability while walking improves balance recovery responses with minimal predictive gait alterations.
        PloS one. 2018; 13e0202913
        • Okubo Y.
        • Brodie M.A.
        • Sturnieks D.L.
        • Hicks C.
        • Lord S.R.
        A pilot study of reactive balance training using trips and slips with increasing unpredictability in young and older adults: Biomechanical mechanisms, falls and clinical feasibility.
        Clin Biomech (Bristol, Avon). 2019; 67: 171-179
        • Okubo Y.
        • Duran L.
        • Delbaere K.
        • Sturnieks D.L.
        • Richardson J.K.
        • Pijnappels M.
        • Lord S.R.
        Rapid Inhibition Accuracy and Leg Strength Are Required for Community-Dwelling Older People to Recover Balance From Induced Trips and Slips: An Experimental Prospective Study.
        J Geriatr Phys Ther. 2021;
        • Okubo Y.
        • Schoene D.
        • Lord S.R.
        Step training improves reaction time, gait and balance and reduces falls in older people: a systematic review and meta-analysis.
        British journal of sports medicine. 2017; 51: 586-593
        • Okubo Y.
        • Sturnieks D.L.
        Volitional and reactive step training.
        (Eds.)in: Lord S.R. Sherrington C. Naganathan V. Falls in older people: Risk factors, strategies for prevention and implications for practice. 2021
        • Okubo Y.
        • Sturnieks D.L.
        • Brodie M.A.
        • Duran L.
        • Lord S.R.
        Effect of reactive balance training involving repeated slips and trips on balance recovery among older adults: A blinded randomized controlled trial.
        J Gerontol A Biol Sci Med Sci. 2019; 74: 1489-1496
        • Pascual-Leone A.
        • Amedi A.
        • Fregni F.
        • Merabet L.B.
        The plastic human brain cortex.
        Annu Rev Neurosci. 2005; 28: 377-401
        • Peterson D.S.
        • Huisinga J.M.
        • Spain R.I.
        • Horak F.B.
        Characterization of Compensatory Stepping in People With Multiple Sclerosis.
        Arch Phys Med Rehabil. 2016; 97: 513-521
        • Reich D.S.
        • Lucchinetti C.F.
        • Calabresi P.A.
        Multiple Sclerosis.
        New England Journal of Medicine. 2018; 378: 169-180
        • Sandroff B.M.
        • Motl R.W.
        • Reed W.R.
        • Barbey A.K.
        • Benedict R.H.B.
        • DeLuca J.
        Integrative CNS Plasticity With Exercise in MS: The PRIMERS (PRocessing, Integration of Multisensory Exercise-Related Stimuli) Conceptual Framework.
        Neurorehabil Neural Repair. 2018; 32: 847-862
      2. Song, P.S., D. L., Davis, M., Lord, S.R., Okubo, Y., 2021. Perturbation-based balance training using repeated trips on a walkway versus a treadmill: A cross-over randomised controlled trial in community-dwelling older adults. Front Sports Act Living in press.

        • Stelmach G.E.
        • Worringham C.J.
        Sensorimotor deficits related to postural stability. Implications for falling in the elderly.
        Clin Geriatr Med. 1985; 1: 679-694
        • Van Liew C.
        • Dibble L.E.
        • Hunt G.R.
        • Foreman K.B.
        • Peterson D.S.
        Protective stepping in multiple sclerosis: Impacts of a single session of in-place perturbation practice.
        Mult Scler Relat Disord. 2019; 30: 17-24
        • van Vliet R.
        • Hoang P.
        • Lord S.
        • Gandevia S.
        • Delbaere K.
        Falls efficacy scale-international: a cross-sectional validation in people with multiple sclerosis.
        Arch Phys Med Rehabil. 2013; 94: 883-889
        • Vicon Motion Systems
        Plug-in Gait Reference Guide [Online].
        2017 (Available:) ([Accessed 22/02/2022])
        • Yang F.
        • Pai Y.C.
        Automatic recognition of falls in gait-slip training: Harness load cell based criteria.
        J Biomech. 2011; 44: 2243-2249
        • Yang F.
        • Su X.
        • Wen P.S.
        • Lazarus J.
        Adaptation to repeated gait-slip perturbations among individuals with multiple sclerosis.
        Mult Scler Relat Disord. 2019; 35: 135-141
        • Yardley L.
        • Beyer N.
        • Hauer K.
        • Kempen G.
        • Piot-Ziegler C.
        • Todd C.
        Development and initial validation of the Falls Efficacy Scale-International (FES-I).
        Age Ageing. 2005; 34: 614-619