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��ࡱ�>��	�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������_	����bjbj���	7���9b��9bm�+���������zzzzz�������8�t:L��9��������g9i9i9i9i9i9i9$<��>L�9z������9zz����9'''��z�z�g9'�g9''�/6|�7�����c��������D ^�6S9�90�9�6�?� @?$�7?z�7���Ar'�\�����9�9�#:����9������������������������������������������������������������������������?����������B@:	Identification of Effective and Ineffective Reactive Movements when Attempting to Recover from a Slippery Perturbation
Aditya Jayadasa and James L. Smithb 
aDesign, Housing & Merchandising Dept., Oklahoma State Univ., Stillwater, OK, USA
bIndustrial Engineering Dept., Texas Tech Univ., Lubbock, TX, USA
*e-mail:  HYPERLINK "mailto:aditya.jayadas@okstate.edu" aditya.jayadas@okstate.edu
ABSTRACT
Slips and falls continue to be a growing problem in the elderly with the elderly population growing at a rapid rate.  One of the primary objectives for researchers is to understand why it is that elderly individuals slip and fall, and how this problem can be corrected. This paper aims to identify the frequency of use of effective and ineffective strategies used by young and older individuals under different arm restrictions. 

Twenty-eight individuals (14 young and 14 elderly) with equal number of males and females participated in the study.  Individuals were required to walk along a circular track and they were exposed to an �unknown� slippery floor condition under no-arm, two-arm and one-arm restriction).  

The results from the observations indicate that 10 strategies were used to aid in slip recoveries with the most important being the trunk twisting/leaning, followed by the sliding and the breaking strategy.  The arm extension/abduction strategy was also frequently used to aid in recovery.  For the no-arm restriction the arm extension/abduction was most commonly used while for the two-arm and one-arm restriction conditions the trunk twisting/leaning strategy was most commonly used.  Also, while the younger individuals favored the sliding strategy the older individuals used the trunk twisting/leaning strategy the most.  In terms of ineffective strategies, the use of a poor trunk strategy resulted in the most falls followed by an ineffective breaking strategy and next the poor placement of the non-sliding leg or inability to bring it to the floor to aid in recovery.

The identification of effective and ineffective reactive strategies under different arm restriction conditions might help better inform slip and fall/recovery research in the elderly.  A better understanding of these strategies might help practitioners in developing training programs that would help individuals better use effective strategies when encountering a slippery perturbation.  

Keywords: Slip, sliding, braking, abduction, extension, cross-over, twisting, leaning, 		        spring up, collapse






1.  Introduction

	Elderly individuals rely on walking to perform various activities of daily living (ADL).  The number of elderly individuals walking to perform their ADL is increasing day-by-day.  The current demographic trends indicate that there is a transition in the population structure towards an aging population.  Current projections estimate that there will be 70 million people over the age of 65 in the United States (U.S.) by the year 2030, which is double the figure of 35 million in 2003 (as cited in Lockhart, 2007).  In terms of injury, Anderson & Smith (2003) reported that the death rate in the US population from unintentional injury almost triples with age, from around 32 per 100,000 population for adults aged 25-64 to 93.3 per 100,000 population for individuals aged 65 and older.  Campbell et al. (1981) reported that 28% to 35% of all individuals aged 65 years or older experience a fall each year.  In addition, Downtown & Andrews (1991) reported that the fall incidence rate further increased in individuals aged 75 years or older with rate being 32% to 42%.  Masud & Morris (2001) reported that age-adjusted fall rates are increasing as time passes.  Thus, it could be inferred that as the number of elderly individuals increase, the problems associated with falls could also increase unless measures are taken to reduce the high incidence of falls in the elderly.  In terms of injury resulting from a fall, fracture was reported as the most frequent non-fatal injury in the elderly (Stevens et al., 2006).  Norton et al. (1997) reported that 66% of all fall-related fractures occurred on slippery surfaces.  Thus, slips and falls are one of the serious causes of injuries associated with disability, fracture and death in the elderly population.
The goal of most slip and fall studies is to understand why it is that elderly individuals slip and fall so much and to also provide suggestions that might help reduce slip and fall occurrences in the elderly.  Studies have looked at different gait variables to better understand slip and fall mechanisms.  You et al. (2001) suggested that smaller displacement and faster velocity of the whole body center of mass (WBCOM) with respect to the base of support (BOS) are noteworthy reactive response strategies to help individuals regain balance during the period of heel-strike to contralateral toe-off.  This suggests that moving the trunk forward quickly could aid in recovery.  Grabiner et al. (2008) have reported that trunk motion is crucial for recovery in elderly individuals.  The trunk motion often works in tandem with arm motion to aid in recovery.  Troy, Donovan & Grabiner (2009) reported that arm responses (abduction and extension) served to reduce trunk rotational velocity immediately following the slip while simultaneously repositioning the upper body center of mass (UBCOM) away from the rear support boundary.  Arm motion therefore may be crucial to aid in the recovery process.  Marigold, Bethune & Patla (2003) demonstrated that during unexpected slip incidents an elevated arm strategy could help reduce the likelihood of a fall.  In terms of lower extremity, Redfern & Cham (2002) reported that fast sliding velocities (greater than 0.8m/s) resulted in a fall.  Higher sliding velocities might be a result of higher heel contact velocities.  Lockhart et al. (2003) reported that heel contact velocity was higher for elderly individuals when encountering a slippery surface.  This could predispose them to more falls as a result of the higher sliding heel velocities.  Higher sliding velocities also could be indicative of ineffective braking or the use of a sliding strategy.   Marigold & Patla (2002) found that younger individuals decreased their braking impulse during slip trials.  Thus, younger individuals might be more comfortable using a sliding strategy.  Elderly individuals might be less confident in using a sliding strategy and opt for a braking strategy instead.  Decline in strength in the elderly could also affect the choice of their strategy to aid in recovery.  Whipple et al. (1987) reported that knee and ankle weakness could contribute to falls in the elderly.  In terms of knee weakness, Chambers & Cham (2007) suggested that slower knee extensor muscle activation led to a slower knee extension movement, which in turn prevented elderly individuals from recovering in a timely fashion.  Elderly individuals were not able to generate thigh and leg muscular activation responses as great as younger individuals to help them recover from a slip event.  The authors suggested that this could be due to lower peak strength and/or ability to generate a quick reactive response.  
It is evident that a significant body of research has explored the issue of slips and falls in the elderly (Chambers & Cham, 2007; Moyer, 2006; Lockhart, Smith & Woldstad, 2003; Cham & Redfern, 2002; Marigold & Patla, 2002; You et al., 2001) but none of the studies have attempted to identify successful strategies and unsuccessful reactive movements classified by arm restriction (no-arm, one-arm and two-arm restriction) and age when individuals attempt to recover from a slippery perturbation.  Therefore, the purpose of the study was to identify successful strategies and unsuccessful reactive movements used by individuals when attempting to recover from a slippery perturbation.  Identification and documentation of successful reactive strategies that individuals use to avoid slip-induced falls could help practitioners incorporate these strategies into training regimes to help improve balance and gait mechanics in the elderly.  On the other hand, the �risky� behavior of fall prone individuals could also be explored by identifying unsuccessful reactive movements in order to develop intervention strategies that could be used to reduce the likelihood of slips and falls in the elderly.


2.  Methods

Experiment location and approval

	The research study was conducted at the Ergonomics Laboratory in the Industrial Engineering Department at Texas Tech University (TTU).  All procedures for this study were conducted upon approval from the Texas Tech University Institutional Review Board for the protection of human subjects.
Subjects

	Twenty-eight individuals were recruited for the study.  Specifically, 14 young adult (7 male and 7 female) and 14 elderly (7 male and 7 female) individuals from the university and elderly community in Lubbock, Texas volunteered to participate in the study.  The 14 elderly subjects ranged as follows in age (65-80 yr), height (1.56-1.93 m) and mass (56.4-113.2 kg).  The 14 younger subjects ranged as follows in age (20-33 yr), height (1.63-1.88 m) and mass (44.7-101.6 kg).  All the individuals were in good health and passed the screening procedures required for participation.  Individuals were screened for heart problems, blood pressure, shortness of breath, dizziness, fatigue, discomfort in hip, knee and/or ankle joints, difficulty in walking, difficulty with cognition and history of prior falls.  Further, individuals were required to do a practice gait trial while wearing a whole body fall protection harness.  If individuals indicated difficulty in walking, they were not included in the study.  No monetary benefits were provided to the subjects for their participation in the study.  
Experimental set-up and protocol

	Gait trials were performed on a circular track equipped with a fall arrest rig system.  Subjects walked at their preferred walking speed and wore a full body harness which was connected to the fall arrest rig system to protect them in case they fell.  Motion data were captured using an 8-camera motion capture system from Motion Analysis Corporation (Santa Rosa, California, USA).  The sampling rate used for the motion capture of the 3-D (dimensional) position data using reflective markers was 120 Hz.  Marker coordinate data were smoothed using a 4th order zero lag Butterworth filter with a cut off frequency of  6 Hz.  Nineteen reflective markers were placed on each individual at various palpable locations.  The marker protocol previously used by Lockhart (2000) was modified and used in the study.  Markers were placed bilaterally on the ulnar styloid process, lateral epicondyle (estimating elbow axis), temporal bone (above the ear), acromial process (most lateral part), greater trochanter, lateral femoral condyle, lateral malleolus, head of second metatarsal, heel and on the sacrum.  The heel marker and the markers on the second metatarsal head were placed on the shoe.  A stick figure was created from the 19 markers to provide a visual model to better understand the recovery effort during a slippery perturbation.  The markers were placed over clothing and shoes, so slight movement of the clothing could have slightly altered the marker location.  This was minimized using double sticky tape and elastic bands to secure the clothing.
	Individuals were introduced to an �unknown� slippery perturbation under different arm restriction conditions (no-arm, two-arm and one-arm) for a total of 84 unknown slippery perturbations (28 subjects * 3 arm restriction conditions).  It is important to note that the different arm restriction conditions were tested across three different weeks (with a minimum of one week between testing sessions).  For the two-arm and one-arm restriction conditions individuals were required to carry a box.  The dimensions of the box were 0.29 m (length) x 0.23 m (breadth) x 0.05 m (thickness), and the mass of the box was 0.2 kg.  The box was held with the elbow bent at a 90-degree angle.  For the two-arm condition both hands were used to hold the load, for the one-arm restriction the load was always carried in the right hand. 
 Classification of the outcome of the unknown slippery trials
	The outcomes of the 84 �unknown� slippery perturbations were classified as �recovery� or �fall�.  A trial was classified as a �fall� if the resulting vertical load exceeded 100 N as detected by the fall-arrest-rig (FAR) system which would cause the machine to shut down and support the individual fully using the full-body-harness system attached to the FAR.  If individuals did not exert a vertical force greater than 100 N on the FAR the trial was classified as �recovery�.  Individuals who fell were classified as �fallers�, whereas individuals who recovered were classified as �non-fallers�.  The �fall� and �recovery� trials were also visually confirmed through observation of all the 84 gait trials.
Observation of effective and ineffective strategies used for recovery
	The recovery and fall trials were then observed carefully and strategies were identified based on what movements individuals used to aid in the recovery process and if the movement did help individuals recover it was classified as �effective�.  If a movement was used which was counter effective or not used but could have been used, it was classified as �ineffective�.
 Statistical Analysis
	Frequency was the only measure used to record the number of times a particular (effective or ineffective) strategy was used.  Not other statistical analyses were carried out. 
3.  Results
From the observation of the markers (video of the track files using the Cortex 2.1 Motion Analysis System), 10 strategies were identified as individuals attempted to recover. These 10 strategies were then classified as effective or ineffective for the 70 recovery and 14 fall trials.  Nine out of the 14 fall trials involved older individuals.  Strategies were classified by age and arm restriction, and are presented in (Table 1).  Some individuals used more than one strategy to recover.  For example, the trunk twisting strategy was used simultaneously with the cross-over step strategy.  
In terms of the effective strategies used to aid in recovery, regardless of arm restriction, the trunk twisting/leaning strategy was used the most (47 times), followed by the sliding strategy which was used 35 times, in turn followed by the braking strategy which was used 25 times.  If the arm abduction/extension is combined (for two-arm, and left or right), then this strategy was used 43 times suggesting that the use of arms was considered an important strategy to aid in recovery from a slippery perturbation.  In terms of the strategies as classified by arm restriction, the most used strategy for the no-arm restriction condition was extension-abduction of both arms.  This result was expected with both arms being free (without any arm restriction).  As for the two-arm restriction condition, the most used strategy was trunk twisting-leaning.  This use of this trunk strategy provided some insight into the use of the trunk as a compensation strategy when the arms were not readily available for use in the recovery process to avoid a fall.  The trunk strategy was also the most used strategy for the one-arm restriction condition.  Lastly, in terms of age, the sliding strategy was the most commonly used strategy by younger individuals whereas the trunk twisting/leaning strategy was used the most by the elderly individuals.  Each of the successful strategies used is discussed in more detail below.
<INSERT TABLE 1 HERE>
 The first strategy that will be described is the trunk twisting-leaning strategy was used in 47 out of the 84 slippery trials to help individuals recover; making it the most used strategy to aid in recovery.  This strategy was used 11 times for the no-arm restriction condition, 17 times for the two-arm restriction condition and 19 times for the one-arm restriction condition.  The elderly used this strategy 22 times when compared to 25 times by the younger individuals.  This strategy involves twisting or leaning of the trunk to prevent falling to one side.  It was sometimes used simultaneously with the cross-over step strategy.  The trunk twisting strategy is shown in (Figure 1).   This strategy is used as a compensation strategy when one or two-arms are restricted and the arms are not readily available for the shoulder extension-abduction strategy.  Thus, this strategy was used much more in the two-arm and one-arm restriction conditions.
<INSERT FIGURE 1 HERE>
Next, the sliding strategy was used in 35 out of the 84 slippery trials to help individuals recover.  This strategy was used 10 times for the no-arm, 12 times for the two-arm restriction conditions and 13 times for the one-arm restriction condition.  This strategy was used a lot by younger individuals (27 to eight when compared to older individuals).  This strategy involves going with the slip, in other words sliding through the slip while maintaining balance and safe placement of the non-sliding leg at the end of slip.  This strategy is shown in (Figure 2).   As you can see the slip distance is large.  As you can observe in the figure, the left leg begins slipping, and as it is slipping, the right leg is lifted up and moved while the upper body is fairly unperturbed (no sudden twisting or leaning of trunk involved) and the leg is then placed in a safe location at the end of slip.  
<INSERT FIGURE 2 HERE>
When compared to the sliding, the breaking strategy was used in 25 out of the 84 slippery trials to help individuals recover.  This strategy was used 10 times each for the no-arm and two-arm restriction conditions, and five times for the one-arm restriction condition.  In this case, the older individuals used this strategy 16 times compared to only nine (9) times for younger individuals.  This suggests that older individuals preferred a braking strategy over the sliding strategy.  This strategy involves arresting the slip immediately through deceleration of the sliding leg.  This strategy is shown in (Figure 3).   As you can observe the slip distance is very small.  
<INSERT FIGURE 3 HERE>
As you can observe in the figure, the left leg begins slipping, and as it is slipping, the right leg is lifted up, moved and placed in a safe location at the end of slip.  This strategy was used effectively to prevent hazardous slips (where the peak sliding velocity was greater than 1m/s).  
Next, the �both shoulders� extension-abduction strategy involved abducting and extending both the right and left shoulders in an attempt to recover from the slippery perturbation.  This strategy was used a lot to help individuals recover.  It was used in 24 out of the 84 slippery trials to help individuals recover.  This strategy was used 12 times for the no-arm restriction condition, seven times for two-arm restriction condition and five times for the one-arm restriction condition.  The older individuals used this strategy 11 times while the younger individuals use this strategy 13 times.  As expected, this strategy was used most for the no-arm condition, when both arms were free.  This strategy was used to help individuals regain or maintain balance to aid in the recovery process.  As the name suggests, this strategy involves extension and abduction of both the shoulders as shown in (Figure 4).   
<INSERT FIGURE 4 HERE>
Next, safe placement of the non-sliding leg involved placing the non-sliding leg in a safe location and not over the slippery floor surface.  This strategy was used in 15 out of the 84 slippery trials to help individuals recover.  This strategy was used five times each for the no-arm, two-arm and one-arm restriction conditions, but 10 times by the elderly individuals and only five times by the younger individuals.  This strategy involves safe placement of the non-sliding leg to prevent a fall.  This strategy is shown in (Figure 5).   Placement of the non-sliding leg in a spot where there was no contamination (oil) was pivotal in preventing multiple slips and a possible fall.  It must be pointed out that 25 of the 84 slip events resulted in a double slip.  In other words, on 25 occasions individuals did not place their non-sliding leg in a safe location which resulted in the double slip and in six (6) instances a fall.
<INSERT FIGURE 5 HERE>
In terms of the left shoulder extension-abduction strategy, it was used in 10 out of the 84 slippery trials to help individuals recover.  This strategy was used one time each for the no-arm and two-arm restriction conditions and eight times for the one-arm restriction condition.  The older and younger individuals each used this strategy five times.  This was expected as the left arm did not carry the load for the one-arm load carrying condition.  Thus this strategy was used for recovery mostly in the one-arm restriction condition.  As the name suggests, this strategy involves extension and abduction of the left shoulder as shown in (Figure 6).   
<INSERT FIGURE 6 HERE>
Next, the right arm extension-abduction strategy was used in nine out of the 84 slippery trials to help individuals recover.  This strategy was used six times for the no-arm restriction condition and three times for the one-arm restriction condition.  It was never used for the two-arm restriction condition.  In terms of age, the strategy was used five and four times respectively by the elderly and young.  It is important to note that the right arm always carried the load for the one-arm load carrying condition.  Though the right arm carried the light load (0.5lbs), it was used to aid in recovery for the one-arm restriction condition.  It might be interesting to see if this strategy would be used if the load were heavier, and if not, what other compensation strategy would be used to aid in the recovery from a slippery perturbation when carrying a heavier load using one-arm.  As the name suggests, this strategy involves extension and abduction of the right shoulder as shown in (Figure 7).   
<INSERT FIGURE 7 HERE>
Next, the leg up spring up strategy had to do with using one or two legs to spring out of the slip.  This strategy was used in six out of the 84 slippery trials to help individuals recover.  This strategy was used two times for the no-arm restriction condition and four times for the two-arm restriction condition.  It was used five times by younger individuals and only once by elderly individuals.  This strategy involves using one or two legs to spring out of the slip.  This is a good indicator of lower extremity strength to prevent lower limb collapse.  This strategy is shown in (Figure 8). 
<INSERT FIGURE 8 HERE>
Next, the cross-over step occurs when one foot is placed in front of the other foot.  For instance, when the left foot is sliding inward (to the left) as seen in (Figure 9), the right foot is placed to the right in order to counter the inward sliding motion of the left foot.  This strategy was used in four out of the 84 slippery trials to help individuals recover from a slippery perturbation.  It was used one time for the no-arm and two-arm restriction conditions, and two times for the one-arm restriction condition.  This strategy was used three times by the younger individuals and only once by the older individuals.
<INSERT FIGURE 9 HERE>
Lastly, the left arm tuck in strategy was used only twice out of the 84 slippery trials to help individuals recover.  This strategy was used only for the one-arm restriction condition and was used by one elderly and one younger individual.  This strategy involves tucking in of the left arm.  Thus this strategy is more of an �adduction� strategy as opposed to the arm extension-abduction strategy used by many individuals to aid in the recovery.  This strategy was perhaps also used as a protective strategy to maybe lower the height of the whole body center of mass to increase stability and avoid a fall.  This strategy is shown in (Figure 10).   
<INSERT FIGURE 10 HERE>
The unsuccessful reactive movements are discussed next.  Leaning to the left too much was reported at the highest unsuccessful reactive movement.  This could have resulted from all individuals being required to walk in a clockwise direction on a circular track with the left side of the body always facing the center tower which acted as the base for the beam housing the fall arrest system.   Poor placement of initial non-sliding leg was reported as the second highest unsuccessful reactive movement.  This resulted in multiple slips, which have not been reported previously and thus it appears that this needs further analysis.  Multiple slips are discussed in more detail later in this section of the report.  The third highest unsuccessful reactive movement involved collapse of the legs.  Collapse of the legs has to do with less strength in the lower extremity to help keep the body upright.   Each of the unsuccessful reactive movements is discussed in detail below.  A better understanding of these unsuccessful reactive movements and incorporation of training strategies to help minimize these reactive movements could help reduce slip induced fall incidences in the elderly.
Next, ineffective trunk leaning/twisting of the trunk was observed in all the 14 fall trials (in nine trials involving the elderly and five trials in the young).  Some of the trials had to do with leaning to the left.  This could have resulted from individuals walking over the circular direction in a clockwise direction.  In other words, the safety harness system (to protect individuals from a fall) which was suspended from a boom on a central tower was always to the left of individuals when they walked.  This fall is dangerous as it could result in an impact of the head of the greater trochanter resulting in a hip fracture.  The sideward (and backward) fall as a result of leaning to the left is shown in (Figure 11).
<INSERT FIGURE 11 HERE>
Next, arresting a slip is of primary importance in preventing a slip-induced fall.  When the sliding heel is accelerating at a high rate and deceleration cannot be successfully accomplished, then a higher slip distance could result.  The high acceleration of the heel and the higher slip distance and duration provides a higher challenge to maintain the whole body center of mass under the dynamically changing base of support, which could result in a fall.  The inability to break often results in slipping a farther distance (as indicated by the dashed arrow pointing to the right) which in turn increases the risk of falling.  A fall that resulted from less effective breaking as observed in seven (7) elderly and five (5) younger individual�s fall trials is shown in (Figure 12). 
<INSERT FIGURE 12 HERE>
Out of the 14 trials that resulted in a fall in this study, six were forward falls, with four involving younger individuals.  The forward fall resulted from poor placement of the non-sliding leg over the contaminated floor surface, thus resulting in a secondary slip and the upper body moving forward while the leg slid backwards.  This could thus be also classified as less effective braking from the secondary slip. Failure to arrest the forward momentum of the upper body caused the whole body center of mass to go out of the base of support in the anterior direction and thus resulted in the forward fall.  A forward fall is shown in (Figure 13).
<INSERT FIGURE 13 HERE>
A fall can also result from placing the initial non-sliding leg over the contaminated floor surface.  This could result in a multiple slip.  Twenty-five double slip trials were observed out of the 84 trials, but only six of them resulted in falls.  Often a short step length or step width resulted in the non-sliding leg being placed close to where the sliding leg was placed initially.  This resulted in a fall as shown in (Figure 14). 
<INSERT FIGURE 14 HERE>
When individuals begin to slip, they either try to arrest the slip by planting the non-sliding leg firmly to the ground or they try to use the non-sliding leg to move forward and place the non-sliding leg in a safe location and transfer the weight bearing to the non-sliding leg once again.  In attempting to place the non-sliding leg to the ground, at times the sliding leg keeps sliding and the whole body center of mass falls outside the small base of support of the sliding leg resulting in a fall.  In two instances, the non- sliding leg of elderly individuals could not be brought to the ground to aid in recovery.  This scenario is show in (Figure 15). 
<INSERT FIGURE 15 HERE>
Next, the arm extension-abduction strategy (using both arms and left or right arms) was used in 43 of the 84 trials to help individuals recover.  Failure to use this strategy (as shown in Figure 16) could result in a fall as observed in five fall trials all involving older individuals (three for both-arm extension/abduction and two times for the left-arm extension/abduction).  The left arm tuck in could also be classified under this category and one elderly individual had his arm tucked in and fell.  Sometimes individuals are �frozen� with the unexpected slip and they fall with less reactive movements to aid in the recovery process.  This needs further investigation.  It is unsure if individuals went with the fall thinking that the slip was too hazardous to attempt recovery.  The use of the safety harness could have influenced the choice of an individual not attempting a recovery strategy.  It is also possible that the slip happened too quickly and individuals did not have time to react.
<INSERT FIGURE 16 HERE>
The reactive movement which resulted in limb collapse and subsequent fall is shown in (Figure 17).  This was probably a result of poor lower extremity strength.   More specifically, weak knee extensors which prevent individuals from rising up or counteracting the downward fall with an upward push to raise the legs and thighs (and thus increase the vertical height of whole body center of mass) could be the underlying cause which resulted in the fall.  One elderly individual fell as a result of poor knee extensor strength.
<INSERT FIGURE 17 HERE>
4.  Discussion

The objective of this paper was to identify and report the frequency of effective and ineffective strategies used to aid recovery from a slippery perturbation.  Several biomechanics of slip and fall studies have reported successful strategies used based on discussion of variables calculated, for instance the use of rapid arms movements for recovery (Mariold and Patla, 2003).  However, documentation and reporting of frequencies of successful strategies used in recovery and unsuccessful reactive movements that resulted in a fall during a recovery effort under no-arm, two-arm and one-arm restriction conditions has not been done before.
While the use of rapid arm movements as observed in the study by elevating the arms forward and outward in attempt to stabilize the backward displacement of the WBCOM has been discussed in the past (Marigold et al., 2003), the use of a left arm tuck in strategy to possibly lower the whole-body-center-of-mass has not been reported.  The arm movement was found to be a crucial strategy to aid in recovery.  The trunk strategy as discussed by Troy, Donovan & Grabiner (2009) with the aid of the arms to move the UBCOM away from the rearward boundary was the most used in this study by both older and younger individuals.  The biggest difference in terms of age was the higher use of the sliding strategy by younger individuals and the braking strategy by the older individuals.  In terms of the sliding strategy, Lockhart et al. (2003) found that younger individuals could slip longer and faster and not fall when compared to older individuals through the use of a more effective sliding strategy.  The same was observed in the current study.  In terms of the braking strategy, Marigold & Patla (2002) found that younger individuals decreased their breaking impulse during slip trials.  Though braking impulse was not directly measured in the current study, a higher heel deceleration was observed in the younger individuals when compared to older individuals in the study, which suggests the use of an effective braking strategy.  In terms of the cross over step, Macki & Mcilroy (2005) reported that younger individuals often used a cross-over step with the trailing leg through the use of an effective foot trajectory to move the foot across the body while avoiding contact with the foot in contact with the floor.  The cross-over step was less likely to be used by older individuals as it involves careful placement of the trailing leg in front of the sliding leg.  This would require maintaining more time in single stance.  An additional problem could be that in attempting the cross-over step elderly individuals could end up colliding the trialing leg with the stance leg (sliding leg in the case of a slip) and thus possibly resulting in a fall (Macki, Edmonstone & Mcilroy, 2000).  Safe placement of the foot is vital in the recovery from a slippery perturbation.  Individuals could lose balance and fall if they do not take a sufficiently long recovery step (Baxter, 2009).  Thus taking a sufficiently large enough step to make sure that trailing leg did not land on the contaminated tile over the force plate to induce a multiple slip was crucial in avoiding a double slip and a possible fall. 
In terms of ineffective strategies, past literature (Yang et al., 2007; Lockhart et al., 2003; Cham & Redfern, 2002) has suggested that the dynamic balance of an individual is challenged when they encounter a slippery perturbation and a possible fall could result.  In relation to limb collapse that resulted in a fall in two elderly individuals in the study, which was probably a result of poor knee extensors, it is important to note that Whipple et al. (1987) reported that knee and ankle weakness contributed to falls in the elderly.  Less effective breaking also possibly resulted in falls.  Less effective breaking probably resulted in the higher peak sliding velocities (of greater than 1 m/s as reported by Moyer, 2006) and longer slip distances.  Less effective use of arms to aid in the recovery also probably contributed to falls.  As pointed out earlier, rapid arm movements are crucial for recovery (Marigold et al., 2003).  Poor placement of the trailing leg was another possible cause of falls.  Safe placement of the trailing leg was crucial in avoiding multiple slips and possible falls.  In the current study, 25 of the 84 slip trials resulted in poor placement of the trailing leg over the contaminated floor surface resulting in six (6) falls.  
The important question is how might identification of the effective and ineffective strategies help reduce slip and fall incidences in the elderly?  A few suggestions based on the identification of the strategies could include:
Strengthening not only the knee extensors to avoid limb collapse but also the core , torso and shoulder as they may help individuals better recover when they encounter a slippery perturbation
Improving shoulder mobility through stretching and yoga perhaps as it may be a vital component in a quick response to a slip when using the arms in attempting to recover
Teaching individuals to better coordinate upper and lower body movements through programs like Tai-chi
Helping individuals understand their limitations and also improve their capabilities through regular physical activity
Brisk walking might be one activity
Creating awareness of slip and falls and introduce individuals to different proactive strategies that they could use when walking over slippery surfaces
Proactive strategies do help reduce the incidence of slips and falls
Incorporate anticipation and feed-forward mechanisms 
Improving reactive times through training in tasks that involve eye-limb coordination
Having individuals do challenging dual tasks involving their hands as they walk
This could help familiarize individuals in multitasking and thus help individuals to better recover if they encounter a slippery surface when carrying an object
If elderly individuals are carrying something when they begin to slip, they should drop it if possible and use the arms to aid in the recovery process
Safe placement of legs to avoid double slips
It must be pointed out that the elderly individual who participated in this study were physically active individuals and thus the findings from this study should not be generalized for all elderly individuals.  Less active elderly individuals might have a different gait pattern and thus possibly use alternative strategies to aid in recovery.  Thus, identification and documentation of effective and ineffective strategies should be an ongoing process.
5.  Conclusion

	In conclusion, individuals use different strategies when they attempt to recover from a slippery perturbation, only some of which are effective.  Trunk and arm motion along with sliding (for the younger individuals) and braking (for the older individuals) strategies appear to be crucial when recovering with the trunk motion used more when the arms are restricted.  On the other hand, a sliding strategy (for the older individuals), too much lean trunk leaning to one side during the recovery effort and poor placement of the non-sliding leg are all possible strategies that individuals should try to avoid when attempting to recover from a slippery perturbation.  Identification and documentation of effective and ineffective strategies used by elderly individuals when attempting to recover from a slippery perturbation could make a meaningful contribution to better understanding slips and falls in the elderly.  Future studies should include diverse populations within the elderly community to better understand and address the issue of slips and falls.   
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