Posterior single-stepping thresholds are prospectively related to falls in older women



Falls are a leading cause of injury in older women. Stepping thresholds quantify balance-reaction capabilities. It is unclear how such evaluations predict falls in comparison to, or as a complement to, other objective measures of gait, standing postural control, strength, and balance confidence.


The objective of this study was to determine if stepping thresholds are prospectively related to falls in older women.


For this prospective cohort study, 125 ambulatory, community-dwelling women, age ≥ 65 years were recruited. Using a treadmill to deliver perturbations to standing participants, we determined anteroposterior single- and multiple-stepping thresholds. Here, thresholds represent the minimum perturbation magnitudes that consistently evoke one step or multiple steps. In addition, gait kinematics, obstacle-crossing kinematics, standing sway measures, unipedal stance time, the functional reach, lower extremity isometric strength, grip strength, balance confidence, and fall history were evaluated. Falls were prospectively recorded for one year.


Seventy-four participants (59%) fell at least once. Posterior single-stepping thresholds were the only outcome that predicted future fall status (OR = 1.50, 95% CI 1.01–2.28; AUC = .62). A multivariate approach added postural sway with eyes closed as a second predictive variable, although predictive abilities were not meaningfully improved.


These results align with the previous evidence that reactive balance is a prospective indicator of fall risk. Unlike previous studies, strength scaled to body size did not contribute to fall prediction.


Posterior single-stepping thresholds held a significant relationship with future fall status. This relationship was independent of, and superior to that of, other measures of standing balance, gait, strength, and balance confidence.

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We thank Louise McCready, R.N. for study coordination and Diana Hansen for data collection and processing.


This work was supported by National Institutes of Health [grant numbers R01AR027065 to SK/SA, T32HD07447 to J. R. Basford, NIH UL1TR000135 to SK]. The NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Author information




Jeremy R. Crenshaw, Ph.D.: conceptualization, methodology, formal analysis, investigation, writing—original draft, and visualization. Kathie A. Bernhardt, B.S.: methodology, software, investigation, data curation, writing—review & editing, and project administration. Elizabeth J. Atkinson, M.S.: software, formal analysis, data curation, and writing—review & editing. Sara J. Achenbach, M.S.: software, formal analysis, data curation, and writing—review & editing. Sundeep Khosla, M.D.: conceptualization, resources, writing—review & editing, and funding acquisition. Shreyasee Amin, M.D. M.P.H.: conceptualization, methodology, resources, writing—review & editing, supervision, project administration, and funding acquisition. Kenton R. Kaufman, Ph.D. P.E.: conceptualization, methodology, resources, writing—review & editing, supervision, project administration, and funding acquisition.

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Correspondence to Kenton R. Kaufman.

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An 89-year-old participant undergoes assessments of single- and multiple-stepping thresholds. Electronic supplementary material 1 (MP4 23740 kb)

Appendix 1

Appendix 1

See Table 3.

Table 3 Univariate relationships between assessment measures (not scaled to body size) and prospective fall status

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Crenshaw, J.R., Bernhardt, K.A., Atkinson, E.J. et al. Posterior single-stepping thresholds are prospectively related to falls in older women. Aging Clin Exp Res 32, 2507–2515 (2020).

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  • Balance
  • Standing sway
  • Gait
  • Strength
  • Balance reactions