Safety on Stairs

The majority of falls in the elderly occur during stair descent. Several functional parameters, including muscle strength, joint mobility and our sense of balance, may be involved, all of which deteriorate with age. The aim of this programme is to understand the role played in stepping performance by musculoskeletal and sensory functions and their deterioration with ageing and to find ways of improving the ability of older people to descend stairs.

The first approach will be to examine the design of stairs, specifically the combination of step-rise and step-going, since older people may lack the strength to cope with high steps or have difficulty landing safely on narrow steps. The results of this study could lead to alterations of the current building regulations relating to stair design. The second approach is to see to what extent “tailor-made” exercise training, for both strength and skill deficits identified in older people, can minimise the age-related deterioration of stepping ability. It is anticipated that this investigation will result in guidelines concerning the efficacy and cost effectiveness of training interventions.

Investigator(s)

Constantinos Maganaris, Manchester Metropolitan University

Team

Vasilios Baltzopoulos, Manchester Metropolitan Universtiy

Consultant

Mike Royce, British Research Establishment

Contact details

Constantinos Maganaris

Background

• Falls are a major problem in old age, and the majority of falls occur during stair descent. This is because the downward movement of the body has to be halted every time the foot hits the step and our ability to do this depends on many factors, including muscle strength, joint mobility and our sense of balance, all of which deteriorate with age.
• Older individuals may be unable to generate the muscle forces required to support the body on the upper step or to control the motion when landing on the lower step, especially if the step-rise is high. On the other hand, if the step-going is small (as is often the case in older homes), the ball of the foot of the lead leg will be placed towards the front edge of the step during descent, risking a slip. Motor control and balance deteriorations with old age could amplify the problem and a systematic study of stepping errors and how they vary in younger and older participants as the rise and going are changed is required.
• One other approach for minimising the risks of falls is to improve the competence and confidence of the individual so that they can cope better with the demands of the built environment. Muscle strength and joint flexibility can be significantly improved by specific training at all ages, as so can balance and motor skills. However, wide-scale training programmes may not translate into improvements in tasks such as stair descent and a more effective approach would be to design targeted training programmes based on individual specific needs.

Aims/objectives

The overall aim of this programme is to understand the role played in stepping performance by musculoskeletal and sensory functions and their deterioration with ageing and to find ways of improving the ability of older people to descend stairs. To achieve this, the specific objectives are:

1. To quantify the impact that factors such as deteriorating muscle strength, joint flexibility, balance and motor control have on the ability to safely descend stairs in old age.

2. To identify the optimum design of stairs for safe negotiation by elderly people.

3. To determine the extent to which the identified biomechanical and physiological constraints on stair descent can be minimised with “tailor-made” exercise interventions.

Design

Methods

• Three studies will address these points. Study 1 will identify the contribution that biomechanical factors such as muscle strength and range of motion make to safe stair descent. Study 2 will examine the design of stairs to see if changing the going and rise matches better the capabilities of elderly people and improves safety when they negotiate stairs. This study will also identify individuals who may have biomechanical limitations and those where motor control and coordination are the main problems. The final Study 3, will take subjects, identified in Study 2 as having either biomechanical limitations or problems with balance and coordination, and provide appropriate training to see how effective this is and to what extent it might be used on a larger scale.

• Fifty older participants (>65 y), including individuals with a history of falls, and fifty younger participants ( < 40 y) will be tested on a staircase with adjustable step-going and step-rise, previously used by our consultant at the BRE.

• For Study 1, the staircase will be implemented with force plates, and kinematic data will be recorded with an optoelectronic system. The measured joint angles and the calculated forces during the descent tasks will be compared with values of maximum force and maximum range of motion in isolated tests, so that indexes of muscle strength and joint mobility reserves can be quantified.

• In Study 2, the optimum combination of step-rise and step-going will be identified from analysis of the kinematic data, quantifying stepping errors such as missteps, hesitations, use of handrail and glances at feet. Fear of falling will be assessed from questionnaire scores.

• In Study 3, older individuals for whom an increased step-rise causes difficulties will be identified. They will be considered as having mainly musculoskeletal problems and they will undergo eight weeks of knee and ankle muscle strengthening and ankle joint flexibility. Older individuals with difficulties in reduced step-going values will be considered as having mainly motor control and balance problems and they will perform eight weeks of balance training and stair descents with corrective feedback and supervised practice. The two exercise groups will be re-tested on the BRE stairs after completion of their training using stair settings identified as “challenging” when first tested to see whether the “tailor-made” interventions were effective.

Outcomes

• At the end of this project we will be able to recommend the optimum combination of going to rise for older people. Such recommendations could become part of the general building regulations and have a significant impact on the physical safety and the confidence of older people.

• The outcome of Studies 1 and 2 will identify the relative importance of a range of biomechanical and physiological factors that adversely affect stepping performance. This information will inform the nature of the interventions outlined in Study 3.

• Study 3 will indicate the extent to which training for strength, flexibility, balance or motor skills can improve performance. This information is essential for any cost/benefit analysis of possible future large-scale population-based interventions.

Policy implications

Falls, and fear of falling, are major factors affecting the mobility and quality of life for the elderly, and it is descending steps and stairs in the home, gardens, public spaces and on public transport, where problems occur most frequently. The aim of our project is to find ways of improving the competence and confidence of older people when descending steps and stairs. Our programme of work meets the primary NDA objective to “develop practical policy and implementation guidance along with novel scientific, technological and design responses to help older people enjoy better quality lives.” We are addressing a major problem for older people. Our approach to this question is novel and multidisciplinary in that it touches on the perceptions and fears of falling, and examines the involvement of biomechanical and motor control factors, as well as stair-design aspects. Our findings may lead to the implementation of policy in the shape of new building regulations through our connections with British Research Establishment (BRE) and recommendations about the efficacy of training programmes.

Beneficiaries. The present project will be of direct benefit to:

1. The older people and their quality of life. The fear and actuality of falling, especially when descending steps and stairs, severely limits the mobility in the elderly and leads to social isolation and poor quality of life. Our proposal aims at improving the safety of people on stairs, finding ways of optimising the stair-design and enhancing the competence and confidence of older users.
2. The National Health Service (NHS). Most accidents of older people on stairs result in fractures, which often require surgical treatment and hospitalisation. The annual cost of fracture treatment to the NHS is ~ £1 billion. Reducing the incidence of accidents by improving the locomotory performance of the elderly on stairs will reduce the cost of fracture treatment and allow redirection of scarce resources to other critical areas of NHS treatment.
3. The academic community and science. The present project will enhance our understanding of the exact mechanisms underlying the high incidence of falls on stairs, providing knowledge on the causes of functional deterioration with ageing and the adaptability of the motor system to exercise training in old age.
4. Health professionals and clinicians dealing with older people, because they will be provided with specific information and advice for effective interventions aiming at improving the safety of individuals with mobility problems in old age.
5. Organisations and professionals concerned with stair design and building construction standard and policies, because they will be provided with specific recommendations for safer stair designs for vulnerable groups in buildings and public spaces.

To achieve the above targets, the results of the project will be disseminated to the scientific community through publications in peer-review academic journals and presentations in scientific meetings. Dissemination will also involve publication of articles in magazines and local newspapers and leaflets for the non-academic community, local community, GR surgeries and physiotherapy clinics, the University of Third Age (U3A) and relevant charitable organisations working with older people (e.g., Age Concern).