Occupational exoskeletons are designed to reduce workplace injury risk by decreasing work demands. Due to their relatively recent development, there has been limited research into potential unintended and undesirable consequences of wearing them. The goal of this thesis was to investigate the effects of exoskeleton use on reactive balance in response to simulated slips and trips. Five representative exoskeletons were investigated including leg-, back, and shoulder-support exoskeletons. This thesis consists of two studies: a smaller study investigating one exoskeleton and a larger one investigating multiple exoskeletons. Participants stood on a specialized treadmill, then abruptly and unexpectedly changing treadmill belt speed to simulate trip-like forward losses of balance or slip-like backward losses of balance. The results of the first study showed that a passive leg-support exoskeleton adversely reactive balance for both slips and trips. The results of the second study showed that back-support exoskeletons had a greater adverse effect on reactive balance compared to shoulder-support exoskeletons for both slips and trips. These exoskeletons affected reactive balance due to their interaction with stepping kinematics and movement constraints. This thesis provides important information that can be used to warn users of potential increased fall risks and inform exoskeleton manufacturers who may be able to modify designs to reduce any additional fall risk. / Master of Science / Occupational exoskeletons reduce muscle workload for workers during manual tasks. However, because of their additional weight and how they restrict movement, they can increase the risk of falling after a slip or a trip. The goal of this thesis was to see how exoskeletons affect balance after simulated slips and trips. Five exoskeletons were studied; These exoskeletons supported the legs, back, and shoulders. This thesis includes two studies: a smaller study with one exoskeleton and a larger one with multiple exoskeletons. In order to simulate a slip and trip, participants stood on a treadmill and then the treads would unexpectedly accelerate to a speed to make them lose their balance. The results of the first study showed that an exoskeleton that supported the legs negatively affected balance for both slips and trips. The results of the second study showed that exoskeletons that supported the back negatively affected balance more than those that supported the shoulders for both slips and trips. These exoskeletons affected balance due to them interacting with the legs and affected stepping. This thesis provides important information that can be used to warn workers of potential increased fall risks and inform exoskeleton manufacturers who may be able to help reduce any fall risk.

Problem Statement: Stepping is a common strategy after a perturbation. Stroke survivors display a predilection for stepping with non-paretic leg. Insight into induced stepping between stroke survivors and age-matched control may guide our understanding for reactive postural control training post stroke. Purpose: To investigate the difference in perturbation-induced stepping between chronic stroke survivors and age-matched controls at three phases of the stepping response: preparation, execution, and landing and association with clinical outcome measures. Procedure: Twenty-one community-dwelling chronic stroke survivors (mean age 59y/o ±13yrs) and 17 age- and gender-matched controls (mean age 54.4y/o ±17yrs) completed this study. Clinical measures of gait, balance, range, sensation, and motor control were assessed. A mechanical weight drop of 10% body weight (BW) was used to create the anterior waist pull perturbation during three stance symmetry positions: equal stance (EQ) and two asymmetrical stance (70% BW on dominant leg and 70% BW on nondominant leg). Ten perturbation trials plus two catch trials at 2% BW were given in a standard randomly order at the three stance positions. Kinematic and kinetic data was collected for perturbation steps. Results: The asymmetrical trials resulted in two types of stepping response, steps with the leg bearing 70% BW (loaded steps – LS) and steps with the leg that had 30% BW (unloaded steps – ULS). All subjects initiated steps more often with their unloaded leg (ULS) in the asymmetrical stance trials. In the stroke group the ULS increased paretic leg stepping compared to EQ (p=0.001) and LS (p=0.001). The stroke group had significantly earlier APA onset with both non-paretic leg (p=0.003) and paretic leg (p=0.028), took significantly more steps with paretic (p=0.01) and non-paretic (p=0.07), shorter step length (paretic, p=0.025 and non-paretic p=0.003), and less change in momentum at landing with paretic leg (p=0.01) compared to controls. Conclusion: Reacting to a perturbation is more challenging for chronic stroke survivors than age- and gender-matched control subjects in the preparation, execution, and landing phase of the stepping response regardless of the leg used. Perturbation training should include stepping with both non-paretic and paretic leg.

Trip-induced falls are a leading cause of injuries among adults aged 65 years or older. Perturbation-based balance training (PBT) has emerged as an exercise-based fall prevention intervention and shown efficacy in reducing the risk of trip-induced falls. The broad goal of my PhD research was to advance the application of this so-called trip training through three studies designed to address existing knowledge gaps. First, trip training is commonly conducted with the aid of costly specialized treadmills to induce trip-like perturbations. An alternative version of trip training that eliminates the need for a treadmill would enhance training feasibility and enable wider adoption. The goal of the first study was to compare the effects of non-treadmill training (NT), treadmill training (TT), and a control (i.e., no training) on reactive balance after laboratory-induced trips among community-dwelling older adults. After three weeks of the assigned intervention, participants were exposed to two laboratory-induced trips while walking. Results showed different beneficial effects of NT and TT. For example, NT may be more beneficial in improving recovery step kinematics, while TT may be more beneficial in improving trunk kinematics, compared to the control. While the first study showed the effects of PBT on laboratory-induced trips, little is known about how such training affects responses to real-world trips. Responses to real-world trips may be captured using wearable inertial measurement units (IMUs), yet IMUs have not been adequately validated for this use. Therefore, the goal of the second study was to investigate the concurrent validity of IMU-based trunk kinematics against the gold standard optical motion capture (OMC)-based trunk kinematics after overground trips among community-dwelling older adults. During two laboratory-induced trips, participants wore two IMUs placed on the sternum and shoulder, and OMC markers placed at anatomical landmarks of the trunk segment. Results showed that IMU-based trunk kinematics differed between falls and recoveries after overground trips, and exhibited at least good correlation (Pearson's correlation coefficient, r > 0.5) with the gold standard OMC-based trunk kinematics. The goal of the third study was then to explore differences in tripping kinematics between the laboratory and real world using wearable IMUs among community-dwelling older adults. Participants were asked to wear three IMUs (for sternum and both feet) and a voice recorder to capture their responses to real-world losses of balance (LOBs) during their daily activities for three weeks. Results showed a higher variance in laboratory-induced trips than real-world trips, and the study demonstrated the feasibility of using IMUs and a voice recorder to understand the underlying mechanisms and context of real-world LOBs. Overall, this work was innovative by evaluating a non-treadmill version of trip training, establishing the validity of IMUs in capturing kinematic responses after overground trips, and applying IMUs and a voice recorder to assess tripping kinematics in the real world. The results from this work will advance the use of PBT to reduce the prevalence of trip-induced falls and to investigate the real-world effects of such trip training in future studies. / Doctor of Philosophy / Trips and falls are a major health problem especially among older adults who are aged 65 years or older. Researchers have developed an innovative exercise-based fall prevention training program, which has shown to be helpful in reducing trips and falls. The broad goal of my PhD research was to advance the use of this so-called trip training through three new research studies. First, specialized treadmills are commonly used for trip training to simulate trip-induced falls. An alternative version of trip training without a treadmill would allow more people to receive benefits from this training. The goal of the first study was to compare the effects of non-treadmill training (NT), treadmill training (TT), and no training on balance recovery after tripping in the laboratory. Older adults living in the local community were recruited as research participants and completed NT, TT, or no training over three weeks. After that, they attended a laboratory session where they were tripped twice while walking on a walkway. Results showed that NT helped to take a longer and faster recovery step, while TT helped to limit trunk forward bending during tripping, both of which are important movements to prevent falling after tripping. While the first study showed benefits of trip training in the laboratory, not much is known about the benefits of trip training in the real world. Wearable sensors called inertial measurement units can record body movements without laboratory motion capture cameras, but their ability to record dynamic body movements during tripping needs to be tested. The goal of the second study was to evaluate the capabilities of these wearable sensors on recording trunk movements during tripping and compare them to those recorded by laboratory motion capture cameras. Participants were tripped twice in the laboratory, and their trunk movements were recorded by several wearable sensors and laboratory motion capture cameras. Results showed that these wearable sensors can distinguish between fallers and non-fallers after tripping, and that the trunk movements recorded by the wearable sensors were associated with those recorded by the laboratory motion capture cameras. With this confirmation, the third study was designed to compare balance recovery after tripping between the laboratory and real world using wearable sensors. Participants were asked to wear three wearable sensors and a voice recorder during their daily activities for three weeks. The wearable sensors recorded their trunk and feet movements, while the voice recorder was used for participants to provide detailed explanations of balance losses they experienced. Results showed a higher variability in balance recovery from the laboratory trips compared to the real-world trips. In addition, this study demonstrated that wearable sensors and a voice recorder can be used to study how people reacted to a balance loss and what they did to recover (or fall) from it. Overall, my PhD research work suggested a new version of trip training that does not require a treadmill, proved that wearable sensors can be used to record important body movements during tripping, and demonstrated the method to study balance recovery responses in the real world using wearable sensors. The results from the three studies will promote the use of trip training and provide guidelines for evaluating benefits of trip training in the real world.

Slips, trips, and falls are a serious public health concern, particularly among older adults and within occupational settings, given that falls contribute to a large number of injuries and associate with high medical costs. To reduce the number of falls, there is a need to better understand risk factors contributing to falls, and to develop and evaluate improved balance training interventions to prevent falls. To address these needs, this work has two primary goals: first, to better understand risk factors contributing to falls, including fatigue and balance reactions after a large postural perturbation, and, second, to develop and evaluate improved reactive balance training (RBT) interventions to reduce risk of falls due to slipping and tripping. The first study investigated the effects of performing occupationally-relevant fatigue-inducing physical work on trip and fall risk. Healthy young adults performed a simulated manual material handling (MMH) task, using either heavy or light boxes, for two hours. Gait measures related to risk of tripping and slipping were assessed before and after the task. Reactive balance during one laboratory-induced trip was also assessed after the task. Results showed that performing the heavy MMH task did not affect risk of tripping or slipping, or reactive balance after tripping. These results may have resulted from insufficient fatigue due to the MMH task. The second study investigated the relationship between feet kinematics upon slipping while walking, and the outcome of the slip. Seventy-one laboratory-induced slips were analyzed, which included recoveries, feet-split falls, feet-forward falls, and lateral falls. Feet kinematics differed between these four slip outcomes, and a discriminant model including six measures of feet kinematics correctly predicted 87% of slip outcomes. Two potentially modifiable characteristics of feet kinematics upon slipping that can improve the likelihood of successfully averting a fall were identified: (1) quickly arresting the motion of the slipping foot; and (2) a recovery step that places the trailing toe approximately 0-10% body height anterior to the sacrum. This information may be used to guide the development of improved RBT interventions to reduce risk of slip-induced falls. The third study evaluated the efficacy of two low-cost, low-tech RBT methods for improving reactive balance after slipping. The two methods were: unexpected slip training (UST), which involved repeated unexpected slips while walking and volitional slip-recovery training (VST), which involved practicing balance reactions after volitionally inducing a slip-like perturbation. Young adults completed one session of an assigned intervention (UST, VST, or control), followed by one unexpected, laboratory-induced slip while walking. Compared to controls, UST and VST resulted in a higher proportion of successful balance recoveries from the laboratory-induced slips. UST improved both proactive control and reactive stepping after slipping, while VST primarily improved the ability to arrest slipping foot motion. These results support the use of UST and VST as practical, low-tech methods of slip training. The fourth study evaluated the efficacy of RBT that targets both slipping and tripping. Community-dwelling, healthy older adults (61-75 years) completed four sessions of either RBT (treadmill-based trip-recovery training and VST) or control training (general strength and balance exercises). Reactive balance during unexpected laboratory-induced slips and trips was assessed before and after RBT, and compared between subjects at baseline (before the intervention), after control training, and after RBT. The incidence of slip-induced falls differed between groups in that 80% fell at baseline, 60% fell after control training, and 18% fell after RBT. Post-RBT subjects also exhibited less severe slips, compared to baseline and post-control subjects. The incidence of trip-induced falls did not differ between groups, but margin of stability after tripping was greater for post-RBT subjects, compared to post-control subjects. These results show promise for the use of RBT applied to both slipping and tripping to reduce fall risk among older adults. / Doctor of Philosophy / Slips, trips, and falls are a serious public health concern, given that falls contribute to a large number of injuries and deaths. Falls are particularly concerning among older adults, who are reported to fall more frequently, and within occupational settings, where falls cause a larger number of injuries and a significant economic burden. To reduce the number of falls, there is a need to better understand risk factors contributing to falls, and to develop and evaluate improved balance training interventions to prevent falls. Four studies were conducted to address these needs: two studies aimed to better understand risk factors contributing to falls, including fatigue and balance reactions after slipping, and two studies aimed to develop and evaluate improved balance training interventions to reduce risk of falls due to slipping and tripping. This work focused on slipping and tripping, because slips and trips are reported to cause a large number of injuries and falls among both workers and older adults. The first study investigated the effect of performing occupationally-relevant fatigue-inducing physical work on trip and fall risk among healthy young adults, and results showed that performing a simulated manual material handling task (i.e. moving and stacking boxes using a two-wheeled dolly) did not affect risk of tripping and falling. The second study investigated the relationship between balance reactions after slipping and the outcome of the slip. Results showed that balance reactions of the feet predicted the outcome of the slip (i.e. recovering balance or one of three types of slip-induced falls) with 87% accuracy. We also identified characteristics of balance reactions that can improve the likelihood of successfully averting a fall. The third study evaluated the efficacy of two low-tech reactive balance training (RBT) methods for reducing slip-induced fall risk among young adults. These methods involved practicing balance reactions after slip-like perturbations, induced either unexpectedly or volitionally. Results showed that both RBT methods improved reactive balance after slipping, but through different mechanisms. The fourth study evaluated the efficacy of a RBT intervention targeting both slipping and tripping among older adults. Results showed that RBT improved reactive balance during both slipping and tripping, and reduced the incidence of slip-induced falls. In conclusion, these results help to better understand risk factors contributing to falls, and support the use of practical reactive balance training interventions targeting both slipping and tripping to reduce fall risk.

Falls are a major concern for the health and safety of older adults worldwide. This dissertation consists of three primary studies that focus on fall prevention through tailored interventions based on optimal physical activity (PA) recommendations, the incongruence between physiological fall risk and fear of falling (FOF), and the development of a balance perturbation device for reactive balance assessment and training in older adults. The first study investigated the combined effects of PA and sedentary behavior (SB) on fall risk and body composition in older adults. Results showed that low sedentary status was associated with reduced fall risk and better body composition profile, even in those not meeting PA guidelines. These findings highlight the need to identify the optimal ratio of SB, light-intensity PA (LPA), and moderate-to-vigorous PA (MVPA) that can help reduce fall risk among older adults. The second study examined how the discrepancy between physiological fall risk and FOF in older adults is associated with their habitual PA levels. Results showed that FOF is a significant barrier for older adults to engage in high-intensity PA, regardless of balance and strength. These findings emphasize the need for tailored intervention strategies to promote PA based on an individual's FOF and physiological fall risk. The third study developed a cable-driven ankle perturbation system for studying reactive balance responses in older adults. Reactive balance is distinct from static and dynamic balance abilities and can provide more task-specificity in recovering balance stability following unexpected walking perturbations, such as slips or trips. Preliminary results from one healthy young subject demonstrated that the system could deliver random, unanticipated slip and trip perturbations of varying intensities at specific points in the gait cycle. Further investigation is necessary to validate its effectiveness as an assessment and training tool for improving reactive balance responses in older adults.

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