REDUCE FALLS RISK: TRAIN TO MOVE YOUR FEET

SUMMARY: Older adult (OA) falls risk is a perennial concern, so that’s why it’s “Falls Prevention Awareness Week 2025”. Falls risk is multifactorial, so a broad menu of risk factors should be considered, and subsequent interventions focused on the specific needs of the individual. When training falls-related physical capacities, there can be a gap between what’s required to reduce falls risk and what OAs often perform, with “balance” being a prime example. Often static balance is trained with drills performed while standing still. Although this approach may have some value, there’s a greater urgency for most OAs to develop dynamic balance, which requires an ability to move their feet readily & rapidly in response or anticipation of outside forces or environmental changes. Volitional step training can help with dynamic balance, and mobile phone apps like “Clock Yourself” can make this type of training more accessible; as can practicing controlled multi-directional “rescue steps”.  Concepts like enhancing OAs falls resiliency (lower their potential for injury) are also gaining support, with sufficiently challenging resistance exercise a key component here. Acknowledging that we’re never going to prevent all falls, an emerging falls risk reduction strategy is teaching OAs skills to fall more safely.

INTRO

Our topic is falls prevention since it’s “Falls Prevention Awareness Week”, and falls are a major threat to older adult’s (OAs) health & well-being. My previous post “Fear of Falling: Enhancing Your React-Ability”, is a recommended read, since it lays some groundwork for this post.

To train to enhance the physical capacities to reduce falls risk, the ideal is to have an individualized anti-fall program formulated by an OA-specialized trainer or physical therapist who does a personalized physical assessment to determine what functional performance factors & skills you most need to focus on.

THE WIDER VIEW OF FALLS RISK

OA fall risk is “multifactorial” (multifaceted or multidimensional) with risk factors in four broad categories (1), but often the major contributors to fall risk are the age-associated functional decline of all body systems, as well as multiple chronic diseases affecting OAs (2). Since falls risk is multifactorial, what’s most important for you to consider may not necessarily be relevant for another OA, but there will certainly be commonalities for all OAs.

Looking across the broad topic of falls risk reduction, let’s encourage you to pay attention to some basic things which are often overlooked or just flat-out ignored – details in footnote text:

1. Home Environment (3)
2. Polypharmacy (4) 
3. Unnecessary Risk-Taking (5)
4. Physical Inactivity (6)  
5. Alcohol intake (7)
6. Toes/Feet/Ankles (8)
7. Footwear (9)

YOUR BALANCE: MANAGING YOUR TIPPING POINT

Balance – the ability to maintain your center of mass (COM) over your base of support (feet) – is crucial for reducing falls risk. But the type of balance you need is not necessarily the type you improve with often-recommended drills like single leg standing (SLS) or reduced base-of-support exercises like in-line (toe-to-heel) stance. Those activities are expressions of static, or non-moving, balance (SB), yet most falls happen when we’re up and moving around in our environment. Balance while the body is moving is an expression of dynamic balance (DB), which is what’s actually required to prevent many, if not most, falls. DB is essentially the capability to move your feet readily & quickly in response and adjustment to your changing COM, so it requires MOVEMENT to train, not standing still, yet many OAs are unaware of this fact.

So why is feet movement skill so essential? Think of it this way: as soon as your COM moves outside your base of support, it’s accelerated by gravity toward the ground, (you’ve reached your tipping point and are starting to fall), so it literally becomes a race-against-time to move your feet back under your (falling) COM to create a new base of support to re-establish vertical equilibrium to prevent a fall.

So, DB skills are mostly about being able to move your feet in real time and at various speeds & positions whether you’re planning to or not. Said differently, DB is the capacity to constantly adjust your feet to match or react to where your center of mass (COM) goes whether you anticipate it (anticipatory balance) or you’re reacting to events or outside forces acting on your body (reactive balance). If your feet move under your constantly shifting COM, you stay on your feet, if they don’t you will fall…

TRAIN TO MOVE YOUR FEET

So why is training DB skills often overlooked? The short answer: to improve DB you literally need to be almost falling!

The longer answer: I think because training SB is accessible and easy to set up and perform in a safe manner, while DB training is, by its very nature, more uncontrolled and harder to do safely, especially if you’re more de-conditioned or physically limited (10). For example, when I train DB with clients, I often place a multi-handled belt around their waist and hold on to the handles to protect them from a violent fall. With this “guarding” they can go to the very limits of their DB capabilities (be in the physical state of “almost falling”), which is often what’s required to improve DB. But it’s hard for the typical OA to have this “guarding” protection if they want to train DB skills on their own. So, there’s a bit of a gap between what’s actually required to reduce falls risk (DB) and what’s often being discussed (SB).

And the DB conundrum is actually two-fold: 1) How to train DB safely on your own; and 2) OAs don’t like to move their feet much to begin with, and this movement hesitancy gets worse with age.

Regarding conundrum #2, I’ve trained and observed a lot of OAs, and they are often very parsimonious with feet movement and they don’t have great movement “literacy” – they tend to be uncomfortable with multi-directional steps/movements. I’ve observed OAs will “cut corners” to minimize foot movement or steps – if OAs can save taking a step, they often will, even if it’s potentially destabilizing – which makes it a form of risky behavior. More alarming still: when I train DB or associated skills like gait (walking) enhancement with my clients, if they stumble and lose their DB and start to fall, they will often freeze up and fall like a tree instead of moving their feet to try to recover balance and save themselves (remember I’m holding them up with the handled belt). This tendency to freeze when surprised by loss of DB stability & control is what desperately needs to be specifically trained with OAs – it’s potentially life-saving.  

So, in the physical realm of OA falls risk reduction training, it’s about becoming quicker, more agile and comfortable (automatic) moving your feet in multiple directions to adjust & react to changing circumstances. I tell my clients “If you’re ever in doubt, you need to move your feet”; that is, if you’re uncertain about your vertical stability because you’re potentially at your tipping point, it’s better to take too many adjustment steps, than one less than you need to prevent a fall.

FIRST STEPS (PUN INTENDED)

So how to train to become more comfortable moving your feet in multiple directions in a way that is safe and can be scaled for different physical capabilities? Physical therapists have a term, “volitional step training”, which involves different step drills performed with intention & purpose – stepping to targets or over lines on the floor or up & over obstacles, etc. For many OAs, ANY kind of volitional step training that can be safely performed can be quite helpful because it often leads to some improvement in DB and being more comfortable (safer) on your feet.

One tool I use for volitional step training is the Clock Yourself app ($2.99) – it’s fun and challenging (physically & mentally) – and, if you need the safety, you can often set yourself up in a place like a wall corner plus a chair in front that can prevent you from falling in several directions at once. With the Clock Yourself app, you are standing in the center of an imaginary clock face on the ground, and the Clock Yourself app directs the stepping drills, allows you to set the tempo (pace of stepping), and has six increasingly challenging categories of movements, the first of which is simple four-direction movement quadrants without clock numbers, and the second is a simple clock stepping to the numbers. Get the app and use it regularly!!

RESCUE STEPS

Rescue steps are a form of deliberate step training to help improve your ability to move your feet and also develop the capability to decelerate your body to potentially save yourself from a fall. Rescue steps involve taking one powerful, fast and solid step that decelerates your body’s (COM) momentum toward the ground. You practice these steps in multiple directions. The step direction, speed & stride length are scaled to what you are presently capable of doing safely and you can use a balance/stability aid as needed.

We could potentially step in any direction with rescue steps (you can fall in any direction after all), but initially we’d start with stepping to the front, side and backwards. What’s REALLY important is that with each step you are able to stop all movement of your body – you’re able to step and then freeze – you work on your speed of stepping (foot plant) and then your leg’s body-stopping ability (so it’s quick foot movement and then rock-solid leg strength and stability).

Forward Rescue Step Video

Backward Rescue Step Video (11).

Use caution with backward steps, please see footnote (11).

Side (lateral) Rescue Step Video

You would progress rescue steps with:

1. First speed

2. Then length of stride

3. Third, elevate up on toes (heel raise) before stepping

4. Next, (but only if you can stop & freeze your body with 1-3 above) push back immediately to the starting point, which turns it into a shallow lunge movement

5. It’s possible that more than one rescue step in a given direction will be necessary to prevent a fall, so practicing 2-3 quick steps in succession would be important if you can do this safely

6. With side steps, it’s possible in a fall situation a first or second step would need to be a crossover step (12), so having this skill is important as well. When learning, first step half-way, so your trailing foot is directly in front of the stationary leg – called a half-braided step (video below) – and then learn to keep that leg moving all the way across for a full side step.  

Crossover Step Video

Half-braided Step Video

FALLS RESILIENCY

Think of falls resiliency as your ability to withstand & bounce back from a fall without sustaining a major injury or worse – the “toughness” of your body, as well as the ability to evade the worst consequence of a fall, which would be head impact with the ground/object.

The concept of falls resiliency acknowledges that everyone falls, young & old, but OAs are more likely to be seriously injured. Indeed, this recent Canadian study found no difference in fall frequency between young and old, but OAs were more likely to be hospitalized. So how can we make OAs bodies more like younger adults?

There are two key aspects of falls resiliency: 1) physical training that helps your body to withstand the forces of a fall and 2) training that teaches you how to fall more safely, and particularly to avoid head, and secondarily, hip impact.

Physical training for falls resiliency:

Most important by far is regular performance of sufficiently challenging resistance exercise targeted to the whole body, but with special emphasis to the hips and, although almost always neglected, some static (isometric) multi-directional neck resistance training to help keep your head off the ground would be a bonus.

Second, train to be supple. You need enough joint-tissue range-of-motion (ROM) available so, in a fall, you’re not forced to go into a ROM your joints/tissues don’t have the capacity to withstand without tissue injury – focus on the shoulder’s ability to accommodate your arm going overhead from the front/side (abduction/overhead flexion) &  your wrist’s ability to bring the top of your hand toward your forearm (extension – like the pushup position).

Training to fall more safely:

I am not an expert, but this is an emerging area of science since the first clinical trial is underway. Avoiding impact or reducing speed of impact of head and hips would seem paramount – anything you can learn or practice to protect these vulnerable areas is advised.

1. Forward fall: you will likely need to “sacrifice” knees, elbows, and wrists to the greater good of avoiding head impact. If a forward fall is unavoidable, try to get to your knees first, and then elbows if possible (13). Turn your head if a face-plant seems inevitable and learning to roll onto the shoulder would probably be helpful.
2. Backward fall: you must try to get any other part of your body to contact the ground before your head. You should tuck your chin to your chest to allow the shoulders/upper back to contact the ground before your head.
3. Sideways fall: again, getting the knees to contact the ground first would be best, and anything you can do to avoid a direct side impact with your hip, like turning forward to get elbows on the ground.  

Footnotes:

(1) Risk factors include: Behavioral, Environmental, Biological, and Socioeconomic.

(2) Atherosclerotic cardiovascular disease (ASCVD), osteoarthritis, obesity, diabetes, neurodegenerative diseases, and dementia.

(3)  You’ve made your home and surroundings as safe as possible – this is a no-brainer, but it’s often neglected. Helpful resources here & here.

(4) You’ve worked with your doctors to thoroughly review all your medications for current need, correct (and perhaps reduced) dosage, possible interactions with other medications or supplements, and feasibility of safer alternative medications.

(5)  You don’t wear risky footwear like high heels, flip flops, strapless sandals, or loose-fitting shoes; you also don’t descend stairs without holding on to the handrail; or neglect to use a cane or other assistive device if you need it (especially in unfamiliar, dark or risky environments or when fatigued); or go without vision or hearing correction if you need it; and please take those extra steps to access objects or loads without excessive reaching.

(6)  The most important physical activity for OAs is sufficiently challenging resistance exercise, period & full stop. But regardless, you have a lifestyle where you’re up and about, moving & physically active most days of the week (whatever that means to you).

(7) OAs lose the ability to metabolize alcohol (as well as many other drugs) so one drink can act like two, etc., and of course alcohol reduces balance, stability, reaction time, attention and judgement; and alcohol can interact dangerously with many medications that OAs are commonly prescribed.

(8) Your feet are the neglected super heroes of physical function:  they’re where you interface with the ground and are your base-of-support (foundation) for all upright activities. Your feet can either enhance or detract from your stability, so, address any issues you might have that limit their functional ability. A particularly common notion is that feet need to be “supported”, however the more contemporary view is that feet need to be “conditioned” to improve function and load tolerance, just like any other part of the body – this is a sneakily important concept – studies here & here have linked falls with toe strength. Common with age is ankles which lack forward bendability – dorsiflexion – this affects balance, walking ability, overstresses toes, and puts you that much closer to falling. It’s really wise to have a regular foot hygiene program to stay in touch with the condition of your feet & toes in real time before anything gets serious and limits your ability to be on your feet.  

(9) One of our balance systems (somatosensory) relies on our sensory ability to “feel the ground” (proprioception); but we lose this sensory ability as we age. Soft, compliant surfaces increase this loss of “ground feel”, but perversely it’s increasingly common for OAs to wear built-up, big-as-a-boat footwear like Hoka’s that put you on a pillow-soft platform nearly two inches off the ground (Hoka’s Clifton 10: heel height 42 mm or 1.7 inches). It’s a disservice to OAs that shoes designed for running (with massive cushioning) are now the default shoes for walking. Toes also need room to “splay” apart to provide stability, but we often constrict them in narrow toe boxes – do consider toe spacers, which can help train toes to space apart more.  Shoes that have a rigid “rocker” forefoot eliminate the essential functions of our toes completely – they aren’t allowed to push off – and will become weaker as a result. Shoes that have a large heel-to-toe height difference (drop) reduce stability by tipping your stance forward and also increase knee stress (and the knee joint is one of the most commonly affected by osteoarthritis, a risk factor for falls). Consider adding a pair of minimalist shoes that you start wearing a little bit at a time and gradually build up time – good brands are Vivo Barefoot, Xero, and Feelgrounds – they provide great ground feel, a wide toe box so your toes can splay apart, are flexible so your toes can do their job and push off and get stronger, and will gradually increase the functional ability of your feet.

(10) I think there’s also the assumption that training static balance will transfer over and help improve dynamic balance; possibly true, but I can’t find a study that assesses dynamic balance before and after a single intervention of ONLY static balance training and then notes improvement (I didn’t do an exhaustive search).

(11) In the video, notice I try to contact the ground with my forefoot/toes first (as opposed to a flat foot) to start the deceleration; this forefoot-first strategy adds lower leg stopping power and gets part of your foot in contact with the ground sooner to start the deceleration process, BUT I’D USE CAUTION AND SEEK MEDICAL OPINION before practicing because this dynamic position – elevated heel with quick step back – has been implicated for Achilles tendon injuries, and OAs have less tendon force absorbing capacity unless they perform lower leg resistance exercise regularly, like lots of resisted heel raises, preferably elevated (deficit) heel raises, if you’ve worked up to it (which I do regularly).

(12) Also called a braided, carioche, or grapevine step.

(13) Having the capacity to perform a front plank from knees & elbows; feet & elbows; push up hand position & knees; and push up position & feet would be very helpful here. See my previous post here for photo (headline photo is a front plank), discussion, and You Tube video link regarding front planks (also called a front bridge).