Preprint has been submitted for publication in journal
Preprint / Version 1

Strength in Arms

Empowering Older Adults Against the Risk of Slipping and Falling




aging, training, strength, falls, physical therapy, prevention


Background: Slips and falls are a serious health concern, particularly among older adults. Current physical therapy protocols strengthen the legs to improve balance. However, arm movements help maintain balance during a slip incident. Understanding how arm movements improve balance may help clinicians develop more comprehensive fall-prevention protocols to improve patient outcomes.

Clinical Question: What limitations exist in current physical therapy interventions for preventing falls in older adults during slip incidents, and what new strategies can enhance these outcomes?

Key Results: Slip incidents often result in a sideways loss of balance, leading to hip fractures in older adults. During a slip, the legs do not produce sideways motion and are less effective in regaining balance in this direction. Contrary, the arms produce 100+ degrees of abduction and this motion reduces falls by 200%+ during a slip incident. Notably, older adults exhibit slower arm abduction responses compared to younger adults. This delay may be attributed to age-related decreases in type II fibers of the deltoid. High-velocity and ballistic training have been shown to improve the proportion and size of type II fibers.

Clinical Application: Therefore, I propose incorporating arm abductor training, alongside leg exercises, as a cost-effective and low-risk intervention to enhance the slip responses in older adults. Given its low risk and high potential benefits, why not start training the arm abductors in older adults now?



Metrics Loading ...


Pitchai P, Dedhia HB, Bhandari N, Krishnan D, D’Souza NRJ, Bellara JM. Prevalence, risk factors, circumstances for falls and level of functional independence among geriatric population-A descriptive study. Indian J Public Health. 2019;63(1):21.

Dieleman JL, Baral R, Birger M, et al. US Spending on Personal Health Care and Public Health, 1996-2013. J Am Med Assoc. 2016;316(24):2627.

Leem SH, Kim JH, Lee BH. Effects of Otago exercise combined with action observation training on balance and gait in the old people. J Exerc Rehabil. 2019;15(6):848.

Chiu HL, Yeh TT, Lo YT, Liang PJ, Lee SC. The effects of the Otago Exercise Programme on actual and perceived balance in older adults: A meta-analysis. PLoS One. 2021;16(8):e0255780.

Lee-Confer JS, Kulig K, Powers CM. Constraining the arms during a slip perturbation results in a higher fall frequency in young adults. Hum Mov Sci. 2022;86:103016.

Allin LJ, Nussbaum MA, Madigan ML. Feet kinematics upon slipping discriminate between recoveries and three types of slip-induced falls. Ergonomics. 2018;61(6):866-876.

Rasmussen CM, Hunt NH. Unconstrained slip mechanics and stepping reactions depend on slip onset timing. J Biomech. 2021;125:110572.

Troy KL, Grabiner MD. Recovery responses to surrogate slipping tasks differ from responses to actual slips. Gait Posture. 2006;24(4):441-447.

Lee-Confer JS. Overground walking slip perturbations induce frontal plane motion of the trunk indicating that slips are not just a backwards but also a sideways loss of balance. bioRxiv. Published online 2023:2011-2023.

Wang S, Liu X, Lee A, Pai Y-C. Can recovery foot placement affect older adults’ slip-fall severity? Ann Biomed Eng. 2017;45(8):1941-1948.

Marigold DS, Patla AE. Strategies for dynamic stability during locomotion on a slippery surface: effects of prior experience and knowledge. J Neurophysiol. 2002;88(1):339-353.

Beschorner K, Cham R. Impact of joint torques on heel acceleration at heel contact, a contributor to slips and falls. Ergonomics. 2008;51(12):1799-1813.

Cham R, Redfern MS. Lower extremity corrective reactions to slip events. J Biomech. 2001;34(11):1439-1445.

Qu X, Hu X, Lew FL. Differences in lower extremity muscular responses between successful and failed balance recovery after slips. Int J Ind Ergon. 2012;42(5):499-504.

Parijat P, Lockhart TE. Effects of lower extremity muscle fatigue on the outcomes of slip-induced falls. Ergonomics. 2008;51(12):1873-1884.

Greenspan SL, Myers ER, Kiel DP, Parker RA, Hayes WC, Resnick NM. Fall direction, bone mineral density, and function: Risk factors for hip fracture in frail nursing home elderly. Am J Med. 1998;104(6):539-545.

Robinovitch SN, Inkster L, Maurer J, Warnick B. Strategies for avoiding hip impact during sideways falls. J bone Miner Res. 2003;18(7):1267-1273.

Nasiri Sarvi M, Luo Y. Sideways fall-induced impact force and its effect on hip fracture risk: a review. Osteoporos Int. 2017;28:2759-2780.

Kleiven S. Hip fracture risk functions for elderly men and women in sideways falls. J Biomech. 2020;105:109771.

Liu-Ambrose T, Davis JC, Best JR, et al. Effect of a home-based exercise program on subsequent falls among community-dwelling high-risk older adults after a fall: a randomized clinical trial. Jama. 2019;321(21):2092-2100.

Chittrakul J, Siviroj P, Sungkarat S, Sapbamrer R. Multi-system physical exercise intervention for fall prevention and quality of life in pre-frail older adults: a randomized controlled trial. Int J Environ Res Public Health. 2020;17(9):3102.

Papalia GF, Papalia R, Diaz Balzani LA, et al. The effects of physical exercise on balance and prevention of falls in older people: A systematic review and meta-analysis. J Clin Med. 2020;9(8):2595.

Beato M, Dawson N, Svien L, Wharton T. Examining the effects of an Otago-based home exercise program on falls and fall risks in an assisted living facility. J Geriatr Phys Ther. 2019;42(4):224-229.

Kadir MI, Hardiyanty N, Adliah F. A pilot study of the effect of Otago exercise program on fall risk and quality of life of older women. Phys Ther J Indones. 2021;2(1):1-4.

Cham R, Redfern MS. Lower extremity corrective reactions to slip events. J Biomech. 2001;34(11):1439-1445.

Wang S, Bhatt T, Liu X, Pai Y-C. The role of recovery lower limb segments in post-slip determination of falls due to instability or limb collapse. Ann Biomed Eng. 2020;48(1):192-202.

Karinkanta S, Piirtola M, Sievanen H, Uusi-Rasi K, Kannus P. Physical therapy approaches to reduce fall and fracture risk among older adults. Nat Rev Endocrinol. 2010;6(7):396-407.

Chevillotte CJ, Ali MH, Trousdale RT, Pagnano MW. Variability in hip range of motion on clinical examination. J Arthroplasty. 2009;24(5):693-697.

Barnes CJ, Van Steyn SJ, Fischer RA. The effects of age, sex, and shoulder dominance on range of motion of the shoulder. J Shoulder Elb Surg. 2001;10(3):242-246.

Sabari JS, Maltzev I, Lubarsky D, Liszkay E, Homel P. Goniometric assessment of shoulder range of motion: comparison of testing in supine and sitting positions. Arch Phys Med Rehabil. 1998;79(6):647-651.

Winter DA. Biomechanics and Motor Control of Human Movement. John Wiley & Sons; 2009.

Lee-Confer J, Bradley N, Powers C. Quantification of Reactive Arm Responses to a Slip Perturbation. J Biomech. 2022;133:110967.

Lee-Confer JS, Finley JM, Kulig K, Powers CM. Reactive Responses of the Arms Increase the Margins of Stability During a Slip Perturbation. J Biomech. 2023;157:111737.

Lee-Confer J, Lo M, Troy K. Young adults accelerate their arms significantly faster and earlier than old adults resulting in improved center of mass dynamics during an overground slip perturbation. bioRxiv. 2023; 2023-12

Merrill Z, Chambers AJ, Cham R. Arm reactions in response to an unexpected slip — Impact of aging. J Biomech. 2017;58:21-26.

Fayet G, Rouche A, Hogrel J-Y, Tomé FMS, Fardeau M. Age-related morphological changes of the deltoid muscle from 50 to 79 years of age. Acta Neuropathol. 2001;101:358-366.

Brunner F, Schmid A, Sheikhzadeh A, Nordin M, Yoon J, Frankel V. Effects of aging on Type II muscle fibers: a systematic review of the literature. J Aging Phys Act. 2007;15(3):336-348.

Wilson JM, Loenneke JP, Jo E, Wilson GJ, Zourdos MC, Kim J-S. The effects of endurance, strength, and power training on muscle fiber type shifting. J Strength Cond Res. 2012;26(6):1724-1729.

Arnold CM, Lanovaz J, Farthing JP, Legg H, Weimer M, Kim S. Fall arrest strategy training improves upper body response time compared to standard fall prevention exercise in older women: A randomized trial. Clin Rehabil. Published online 2022:02692155221087963.

Kanekar N, Aruin AS. Aging and balance control in response to external perturbations: Role of anticipatory and compensatory postural mechanisms. Age (Omaha). 2014;36:1067-1077.

Pai YC, Bhatt T, Yang F, Wang E. Perturbation training can reduce community-dwelling older adults’ annual fall risk: A randomized controlled trial. Journals Gerontol - Ser A Biol Sci Med Sci. 2014;69(12):1586-1594.

Karamanidis K, Epro G, McCrum C, König M. Improving trip-and slip-resisting skills in older people: perturbation dose matters. Exerc Sport Sci Rev. 2020;48(1):40-47.

Parijat P, Lockhart TE. Effects of moveable platform training in preventing slip-induced falls in older adults. Ann Biomed Eng. 2012;40(5):1111-1121.

Liu X, Bhatt T, Wang Y, Wang S, Lee A, Pai Y-C. The retention of fall-resisting behavior derived from treadmill slip-perturbation training in community-dwelling older adults. Geroscience. 2021;43:913-926.

Allin LJ, Brolinson PG, Beach BM, et al. Perturbation-based balance training targeting both slip-and trip-induced falls among older adults: a randomized controlled trial. BMC Geriatr. 2020;20(1):1-13.

Marzuca-Nassr GN, Alegría-Molina A, SanMartín-Calísto Y, et al. Muscle Mass and Strength Gains Following Resistance Exercise Training in Older Adults 65–75 Years and Older Adults Above 85 Years. Int J Sport Nutr Exerc Metab. 2023;1(aop):1-9.

Junata M, Cheng KC-C, Man HS, Lai CW-K, Soo YO-Y, Tong RK-Y. Kinect-based rapid movement training to improve balance recovery for stroke fall prevention: A randomized controlled trial. J Neuroeng Rehabil. 2021;18:1-12.