Safety Science 43 (2005) 455468 www.elsevier.

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Slip and fall risk among reghters in relation to balance, muscular capacities and age
Anne Punakallio
a

a,*

, Mikko Hirvonen b, Raoul Gro nqvist

Department of Physiology, Finnish Institute of Occupational Health, Topeliuksenkatu 41 a A, FIN-00250 Helsinki, Finland b Department of Physics, Finnish Institute of Occupational Health, Topeliuksenkatu 41 a A, FIN-00250 Helsinki, Finland Department of Occupational Safety, Finnish Institute of Occupational Health, Topeliuksenkatu 41 a A, FIN-00250 Helsinki, Finland

Abstract Inuencing the safety of reghters work environment is almost impossible. Therefore, good individual physical capacities and adequate protective equipment are important in preventing accidents due to slips and falls. This study investigated slip and fall risk in walking experiments with reghters wearing re-protective equipment and determined the associations of balance, muscular capacities and age with the risk of slipping. Professional male reghters aged 3338 and 4356 years (n = 14 and n = 15, respectively) participated in four slipping trials under dierent conditions on a straight path of 8 meters. Slip distances were measured in each trial. Postural balance and dynamic stability were tested on a force platform, and functional balance was measured during walking on a wooden plank. Muscular capacity of the legs and trunk were also measured. The average slip distances with glycerol were 9.7 9.1 cm (100 steps/min) and 15.6 18.2 cm (120 steps/min) in the 33-to-38-year age group and correspondingly 10.8 15.3 cm and 18.0 18.6 cm in the 4356-year age group. Though the older reghters tended to have longer and more serious slips than the younger ones, the dierences in slip distances were not statistically signicant. Half of the reghters, regardless of their age, experienced critical, over 5-cm long, foot slides, considered to increase the risk of an unavoidable fall. These reghters performed signicantly poorer in the dynamic stability test as well, whereas associations with muscular capacity and risk of slipping were not signicant. The results suggest that the ability to exploit visual feedback eciently in balance control may be associated with smaller risk of slipping. This kind of test may be useful in evaluations of balance

Corresponding author. Tel.: +358 30 474 2668; fax: +358 9 890 713. E-mail address: anne.punakallio@ttl. (A. Punakallio).

0925-7535/$ - see front matter 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ssci.2005.08.009

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ability. The ndings also support the importance of adding exercises which enhance balance ability to the exercise protocols of reghters. 2005 Elsevier Ltd. All rights reserved.
Keywords: Slip distance; Fall risk; Balance; Postural control; Aging

1. Introduction In reghting and rescue operations work conditions are unpredictable and rapidly changing. Surfaces can be slippery and passages narrow and smoky or totally dark. Fireghters work frequently on roofs and with ladders, and they smoke-dive (i.e., extinguish a re and rescue victims in environment where is smoke and combustion gases), which also requires good balance and muscular capacities (Lusa et al., 1994). Besides of smoke-diving, also the other work tasks of reghters often necessitate the use of re-protective equipment, including re-protective clothing and a self-contained breathing apparatus (SCBA). The SCBA increases strain on the postural control system by increasing postural sway, especially, when postural muscles are fatigued (Kincl et al., 2002). Furthermore, a large amount, about 30%, of work-related accidents among professional reghters in Finland are due to slips or falls at the same level (Statistics Finland, 19962001). The proportion of slips and falls at the same level is lower (23%) among the working population in Finland (Statistics Finland, 2002). Compared with younger workers, workers over 45 years of age were reported to have a greater proportion of slip-, trip- and fall-related injuries (Kemmlert and Lundholm, 2001; Statistics Finland, 2002). The heel contact phase in early stance and the push-o phase during late stance are considered the most critical phases in locomotion when a slip and fall may occur (Perkins, 1978; Redfern et al., 2001; Strandberg and Lanshammar, 1981). For measuring forward slipping after the heel contact, slip distances during walking are used as indicators of slipping and falling hazards or as a discriminating factor between a slip recovery and likely falling (Brady et al., 2000; Gro nqvist et al., 1993; Strandberg and Lanshammar, 1981). Longer slip distances are associated with an increased risk of falling (Brady et al., 2000; Gro nqvist et al., 1993; Strandberg and Lanshammar, 1981). The nature of slipping and falling events is complex. Therefore, dierent objective, subjective and combined approaches are needed and used for studying individual risks of slips and falls in a laboratory (Brady et al., 2000; Gro nqvist et al., 1993, 2001a,b; Hirvonen et al., 1994; Strandberg and Lanshammar, 1981; You et al., 2001). During the slipping event, however, the variable that, according to current knowledge, best describes the probable outcome of a foot slide is the slip distance (Brady et al., 2000). The critical slip distance between an avoidable and unavoidable fall is reported to be in the range 522 cm (Brady et al., 2000; Gro nqvist et al., 1993, 1999; Strandberg and Lanshammar, 1981). A slip distance less than a few centimeteres may not be perceived by a person as a slippery condition, while a slip distance over 5 cm may cause falling accidents (Gro nqvist, 1995). The risk exposure to slipping and falling depends primarily on poor friction between footwear and underfoot surfaces (Gro nqvist et al., 2001b; Hanson et al., 1999). The friction demand, in terms of the peak required friction coecient, has been reported to vary between 0.17 and 0.22 for normal walking on level surfaces (Redfern et al., 2001). The magnitude of a given risk exposure depends on several extrinsic and intrinsic factors,

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for example, lighting, an individuals perception and cognition of the hazards and the ability to regain balance (Gro nqvist et al., 2001b). Lockhart et al. (2000) showed that older people experience as many slips as middle-aged and younger people, but their horizontal heel velocities at heel contact are higher and the slip distances longer, resulting in a higher frequency of falls. The ability to recover successfully from a slip may be aected by a degradation of lower-legs muscle strength, sensory function and balance (Lockhart et al., 2000). In epidemiological studies, impaired balance and muscle strength are signicant risk factors for falling among older people (Lord and Clark, 1996; Stalenhoef et al., 2002). Although the importance of balance, muscular abilities and age in the risk of slipping and falling is recognized, still little is known about how these factors are associated with biomechanical parameters of slip and fall risk. The aim of this study was to investigate the slip and fall risk in walking experiments with reghters who wore re-protective equipment and to determine the associations of balance, muscular capacities and age with the risk of slipping. 2. Subjects and methods 2.1. Subjects The subjects were a subgroup (n = 29) of 69 male reghters who participated in a 3-year follow-up study on the health and physical and mental capacity of Finnish professional reghters (Punakallio et al., 1999). Altogether 36 of 69 reghters in three age groups (3338, 4348 and 5356 years) were asked to volunteer for this study. First 12 randomly selected subjects in each age group were asked to volunteer. Six reghters over 50 years of age were excluded because they had had low-back pain during the preceding year, acute low back pain or other musculoskeletal pain and disorders, which may be aggravated due to experiments performed on slippery surfaces. In addition, three subjects in the 4348-year group refused to participate. The two older groups were merged because there were not enough suitable volunteers for the 53-to-56 year old group. To keep the number of subjects equal between the age groups, three subjects more in the age group of 3338 years were asked to volunteer. After the selection process, one reghter in the younger group declined to participate, leaving a total of 14 younger reghters (3338 years) and 15 older reghters (4356 years). The age, height, weight and body mass index (BMI) (kg m2) of the subjects are registered and shown in Table 1.

Table 1 Characteristics of the subjects in two age groups Characteristics Age group (years) 3338 (n = 14) Mean SD Age (years) Height (cm) Weight (kg) BMI (kg m2) BMI = Body mass index. 35.6 1.7 179 5.0 82.8 11.4 25.8 2.5 4356 (n = 15) Mean SD 48.9 4.7 178 4.4 86.2 6.6 27.2 2.5

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The younger and older subjects were employed in reghting and rescue work for an average of 14 (range 718) years and 26 (range 2034) years, respectively. Over half of the subjects in the younger (55%) and older (60%) age groups were physically active three times or more a week, mainly in terms of strength training, jogging and cycling. The subjects had no specic background in balance or other motor skill training. Two of the subjects engaged occasionally in downhill skiing and one skateboarded. There were no signicant dierences in the frequency of physical exercise of the two groups. Together twelve subjects reported slipping (n = 10) accidents or falling (n = 2) accidents from upper to lower levels at work during the past 3 years. The number of accidents was equal for the younger and older subjects. The subjects passed a health examination, and they had no previous balance, hearing or ocular problems. The study was approved by the Ethics Committee of the Finnish Institute of Occupational Health, and it was performed according to the Helsinki Declaration. Each subject provided a written informed consent before participating in the study. 2.1.1. Fire-protective equipment and sportswear During the walking trials (slipping tests) the subjects wore re-protective clothing and equipment, which included a two-piece multilayer re-protective suit that fullled the

Fig. 1. Fireghter with re-protective equipment in the postural balance test.

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requirements of the European standard (EN 469) (Committee for Standardization, 1995), and Nordic-type middle and under clothing (long cotton underwear and a polyester eece sweat shirt and trousers), rubber safety boots, a helmet and a tool belt (Fig. 1). The safety boots were new, and the slipperiness of their soles was standardized with light grinding. The subjects carried Dra ger SCBA with one steel air container, and they wore a full-face mask. The total mass of the re-protective clothing and equipment was 25.9 kg, of which the SCBA accounted for 15.5 kg. The tests of the balance abilities and muscular capacity were performed in sportswear (shorts and t-shirt) and sports shoes, excluding the balance ability tests, which were performed barefooted. 2.2. Walking trials Walking trials were carried out on a straight 8-m long path. At one spot (400 600 mm) covered in stainless steel, water and detergent (0.5% by weight sodium lauryl sulfate solution) or glycerol (85% by weight) were spread on the path. The rst half of the track was covered with a rubber carpet to prevent slipping. The walking cadence was 100 or 120 steps/min. The walker wore a safety harness fastened onto a rail above the track in order to prevent possible injury from slipping. The length of each slip (i.e., horizontal slip distance of the foot in the walking direction in centimeters) was assessed with one HiSIS 2001 high-speed camera system capable of recording 278 frames/s. Video-recordings (JVC Super VHS) were used to estimate the seriousness of the slipping incidents. The slips were classied into the following four categories according to the eorts of the walkers to restore their balance by corrective movements (Hirvonen et al., 1994): (1) no observable slipping (the length of the slip was less than 5 cm or the subject made no corrective movement), (2) controlled slip (the walker swayed and made controlled corrective movements and would probably have regained his balance even without safety the harness), (3) vigorous slip (the subject slipped and staggered signicantly; the corrective movements were vigorous; without the harness a loss of balance would have been possible), and (4) extremely vigorous slip (the walker lost his balance and was suspended by the safety harness). The subjects were also asked to evaluate the slipperiness of the stainless steel plate according to the following categories: slip resistant, moderately slip-resistant, neutral, moderately slippery and slippery (Gro nqvist et al., 1993). Each subject performed one slipping test under the following conditions: (1) dry path, walking cadence 100 steps/min, (2) path spread with water and detergent, walking cadence 100 steps/min, (3) path spread with glycerol, walking cadence 100 steps/min, and (4) path spread with glycerol, walking cadence 120 steps/min. Walking cadences were dened by metronome. The tests were performed in the same order with every subject, but the subjects were not aware of the slipperiness of the path in advance. The subjects were asked to walk at a given walking speed as naturally as possible throughout the tests. For technical reasons, the results of four subjects walking at a cadence of 120 steps/min when the path was spread with glycerol were not available. 2.3. Balance abilities Balance abilities were measured using a functional dynamic balance test, postural balance tests and a dynamic stability test. Functional balance was measured by a test in which the subjects walked forwards and backwards on a 2.5-m long, 9-cm wide and 5-cm thick

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wooden plank (Punakallio, 2003, 2004). They began the test from footprints marked on the oor at one end of the plank and walked forward to the marked 0.5-m mid-area of the plank, where they turned 180 and walked backwards to the footprints at the opposite end of the plank. The task was then immediately repeated from the opposite end, with the subjects returning in reverse fashion to the starting point. The subjects were instructed to walk as quickly as possible without falling o the plank or touching the oor, as these movements were considered errors. It was also an error if they turned around before or after the mid-area of the plank or if they did not step on the footprints at the ends of the plank. The performance time and the number of errors were recorded. A sum variable including the time and the number of errors was calculated and used as an outcome variable. One error always increased the performance time by 1 s. The functional balance test has shown good reliability for trial-to-trial reproducibility and for testretest stability over time according to intraclass correlation coecients and limits of agreement (Punakallio, 2004). Postural balance and dynamic stability were assessed using the Good Balance measurement device of Metitur Ltd. (Metitur, 2001). The measurement system consisted of an equilateral triangular force platform connected to a computer through an electronic unit, which included a 3-channel amplier and an A/D-converter (Fig. 1). The measurements were based on the registration of vertical forces produced by a subject standing on a force platform. In the postural balance tests the subjects stood in a normal position for 40 s with their feet comfortably apart, eyes open and hands on hips, and their gaze was xed on the mark (cross on an opposite wall at a distance of 2 m) at eye level. Then the test was repeated with the eyes closed. The subjects were instructed to stand as quietly as possible. The velocity moment (mm2/s) was analyzed. It refers to rst moment of velocity calculated as the mean area covered by the movement of the COP during each second of the test (Era et al., 1996). The calculation of the velocity moment account both the distances from the geometric midpoint of the whole test and the speed of movement during the same period (Era et al., 1996). Product moment correlations have shown signicant linear associations between the two repeated trials in normal standing tests of postural balance (Sihvonen and Era, 1999). At the beginning of the dynamic stability test each subject stood barefoot on the force platform. The monitor for visual feedback was on the table directly in front of the subject. Eight boxes, which were the targets, were shown in a circle on the computer monitor. The idea of the measurement was to move the center of pressure (COP) through the targets. The subject started to move his COP backwards to the lowest target, then followed the circle by leaning to the right, forward and to the left to hit each successive target and nishing again in the backward position (Metitur, 2001). At the beginning of each trial, the physiotherapist in charge of the test checked that the subject stood symmetrically on both legs and did not lean backwards or forwards. If the location of the feet changed during the trial, the test was repeated. The subject was instructed to reach the targets as quickly and as accurately as possible and to avoid unnecessary and uneconomic movements. The performance time (s) (i.e., time used to complete the test) and the distance (in mm) (the extent of the path (mm) traveled by the COP during the test) were measured and were used as the result. The dynamic stability test has shown moderate reliability according to intraclass correlation coecients and limits of agreement (Punakallio, 2004). Postural balance parameters were scaled by body height. In the postural balance test the scaled values were derived from original values by dividing the parameter by the sub-

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jects body height and multiplying it by the reference height of 180 cm to avoid the possibility that taller subjects received poorer results (Metitur, 2001). In the dynamic stability test, on the contrary, the scaled values were derived from original values by dividing the parameter by the reference height of 180 cm and multiplying it by the subjects body height to avoid the possibility that taller subjects received better results (Metitur, 2001). After the demonstration of the tests, each subject was allowed to practice the functional balance test and the dynamic stability test once before the four trials. The last trial value was used as an outcome variable. The postural balance tests were performed once. 2.4. Muscular capacities The assessments of muscular capacity included muscular strength and endurance, exibility and reaction time. The muscular endurance of the legs was measured by the squatting test. In the test the subjects squatted as many times as possible with 45-kg weights on their shoulders so that their thighs reached a horizontal plane within the time period of 60 s. The endurance of the trunk exors was measured by the maximum number of full bent-knee sit-ups within 60 s (Lusa, 1994). The maximal isometric strength of the trunk and knee extension were measured by a dynamometer (Newtest Ltd., Oulu, Finland). Trunk extension was measured with the subjects in a standing position. The subjects were asked to push their back as forceful as possible against strain gauge situated in the level of subjects shoulder blades (Viitasalo et al., 1997). Knee extension was measured on the dominant side in a sitting position with the knee at an angle of 60 from full extension (Heikkinen et al., 1984). The best performance of three trials was accepted as the result of maximal isometric strength. Flexibility was evaluated in a sit-and-reach test (Pollock and Wilmore, 1990). 2.5. Statistical methods The results were described with means and standard deviations (SD). Students t-test was applied to show statistical signicance among age classied by slip distance (<5 cm versus P5 cm). Logistic regression analysis was used when the associations between the slip distance (<5 cm versus P5 cm) (outcome) and predictive variables (balance and muscular capacities) were examined. Age and the body mass index were used as covariates. Odds ratios and 95% condence intervals were calculated. A 5% level or p < 0.05 was considered statistically signicant. The statistical analyses were performed using the Statistical Analysis System, SAS Version 8.2 (SAS Institute, 1999). 3. Results When the path was spread with water and detergent, two subjects in the older age group slipped 4 cm, and the sliding movement and balance was well controlled. After the track was made slippery with glycerol, every subject slipped in the tests at both walking cadences. Half of the subjects slipped over 5 cm in the test (Table 2). The average values of the slip distances were 9.7 9.1 cm (100 steps/min) and 15.6 18.2 cm (120 steps/min) in the 33-to-38-year age group and 10.8 15.3 cm and 18.0 18.6 cm, respectively, in the 43-to-56-year age group. The dierence between the age groups was not statistically signicant.

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Table 2 Slip/fall categories for four dierent conditions (dry, water and detergent and glycerol at walking cadence of 100 steps/min and glycerol at walking cadence of 120 steps/min on a steel surface) Condition Slip/fall category (n) No slip 0 cm Dry 100 steps/min Water and detergent, 100 steps/min Glycerol, 100 steps/min Glycerol, 120 steps/min 29 27 0 0 Slip recovery >0 (<5 cm) 0 2 14 9 Potential fall 1 P5 (<10 cm) 0 0 5 5 Potential fall 2 P10 (<22 cm) 0 0 6 4 Potential fall 3 P22 cm 0 0 4 7 All 29 29 29 25

The values are the number of incidents in each category. Potential fall 13 (i.e., maximum tolerable criterion for slip distance) according to dierent studies: (1) Gro nqvist et al. (1999), (2) Strandberg and Lanshammar (1981), (3) Brady et al. (2000).

Table 3 Seriousness of the slipping incidents and the length of slips on glycerol in two age groups at walking cadences of 100 and 120 steps/min Seriousness of the slips Walking cadence (steps/min) 100 Age group (years) 3338 n (slip distance range, cm) No corrective movement Controlled slipa Vigorous slipb Extremely vigorous slipc 1 8 5 0 n (2) (114) (1320) total 14 1 7 2 1 n (2) (220) (2050) (50) total 11 4356 n (slip distance range, cm) 2 9 3 1 n (2) (211) (4050) (25) total 15 1 7 2 4 n (2) (38) (1540) (3050) total 14 120 100 120

The values are the number of subjects in each category. The ranges of the slip distances are in parentheses. a Balance could be regained also without the safety harness. b Loss of balance is possible without the safety harness. c Subject lost his balance and was suspended by the safety harness.

Most of the slip incidents (37/54) were well controlled or needed no corrective movement. Five subjects in the older age group and one in the younger age group slipped so vigorously that they lost their balance and were suspended by the safety harness (Table 3). The correlations between the slip distances and the magnitude of the protective responses during the slips for walking cadences 100 and 120 steps/min (glycerol) were r = 0.77 (p = 0.0001) and r = 0.86 (p = 0.0001), respectively. The subjects whose slip distance was over 5 cm also evaluated the walking track as slippery. The correlations between the slip distances and the evaluations of slipperiness for walking cadences 100 and 120 steps/min were r = 0.53 (p = 0.003) and r = 0.50 (p = 0.012), respectively. The mean values of balance and muscular capacity tests classied by slip distance (<5 cm versus P5 cm) are shown in Table 4. According to logistic regression analyses, the subjects whose slip distance with glycerol was P5 cm performed signicantly poorer in the dynamic stability test than those who slipped <5 cm when the walking cadence

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Table 4 Mean and (SD) balance and muscular capacities as classied by slip distance when the path was spread with glycerol and the walking cadence was 100 steps/min Characteristic Slip distance <5 cm (n = 14) Mean (SD) Balance Functional balance (s) Functional balance (s + errors) Dynamic stability (cm) Dynamic stability (s) Postural balance (EO) (mm2/s) Postural balance (EC) (mm2/s) Muscular capacities Sit and reach (cm) Squatting (repetitions/60 s) Sit-up (repetitions/60 s) Trunk extension strength (N) Knee extension strength (N) EO = eyes open, EC = eyes closed. 10.7 (2.2) 11.0 (2.2) 139.3 (37.9) 15.1 (2.3) 7.5 (3.1) 10.4 (3.9) 32.9 (8.9) 28.4 (5.8) 35.4 (7.7) 795 (143) 532 (122) P5 cm (n = 15) Mean (SD) 12.2 (7.7) 12.9 (7.7) 190.2 (56.5) 18.8 (4.3) 9.2 (4.0) 11.8 (5.9) 29.9 (10.7) 24.8 (8.9) 34.3 (6.7) 866 (149) 494 (128)

Table 5 Odds ratios (OR), 95% condence intervals (CI) and P-values (logistic regression) for the signicant balance and muscular capacity results in respect of the slip distance Predictor Slip distance OR Dynamic stability (cm) Dynamic stability (s) 1.02 1.46 CI 1.001.04 1.052.02 P-value 0.024 0.023

The models were adjusted for age and body mass index (n = 29).

was 100 steps/min. Dierences between slip distance groups among the other balance and muscular capacity parameters were not signicant (Table 5). The associations of the walking trials with the higher cadence (120 steps/min with glycerol) with respect to all physical factors were similar compared to trials in 100 steps/min, but the dierences between slip distance groups were not signicant. For example, mean values SD of the distance in the dynamic stability test were 1469 405 mm in those subjects who slipped <5 cm (n = 9) and 1776 592 mm in the group who slipped P5 cm (n = 16). The corresponding results in performance time of the dynamic stability test were 15.1 2.1 and 17.4 3.8, respectively. 4. Discussion The main ndings of this study were that fast and controlled performance in the dynamic stability test was related to smaller (slip distance <5 cm) risk of slipping and falling, but the associations between muscular capacities and the risk of slipping were not significant. These associations were the same for both age groups. The older reghters tended to have longer and more serious slips than the younger ones, but the dierence was not

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statistically signicant. Furthermore, half of the reghters, regardless of age, slid over 5 cm foot slides in the tests. Over 5-cm long slides are considered to increase the risk of unavoidable fall (Gro nqvist et al., 1993, 1999). The reghters in both age groups of our study had long professional careers, and they were well experienced in using re-protective equipment. The mean age of the younger group (36 years) was below the average age of Finnish reghters (39 years) (Statistics Finland, 2003), and, correspondingly, that of the older ones (49 years) was clearly above the average age. The studied reghters were all men because there are only two professional female reghters in Finland. The subjects of our study performed the balance and muscular capacity tests in a manner similar to that of a representative group of Finnish reghters (n = 158) selected by stratied sampling (Punakallio et al., 1999). In order to preserve the unexpected and surprising nature of slipping in the tests, we limited the number of trials as much as possible. The reghters did not know how many trials they would perform or how slippery or slip-resistant the path would be. An anticipation of slipping may, however, have decreased the slipping responses. A more cautious walking strategy seems to be adopted when a potential risk of slipping exists (Cham and Redfern, 2002; Marigold and Patla, 2002). The landing is done with a atter foot, which increase the foot contact area, and the center of the mass is kept closer to the contralateral limb, which is in contact with the stable surface (Marigold and Patla, 2002). The stance duration and loading speed of the supporting foot are smaller, and the stride length is shorter; thus, the strength requirements of walking are decreased (Cham and Redfern, 2002). In this study, however, even 50 cm long slip distances were detected. The criteria for slip distances that may result in either falls or possible recovery are controversial. According to previous reports, the recommended maximum tolerable criterion for slip distance ranges from 5 to 22 cm (Brady et al., 2000; Gro nqvist et al., 1999; Strandberg and Lanshammar, 1981). In our study, slip distances of 250 cm were detected. Most of the slips were, however, well controlled, even if their length was about 20 cm, and in some cases, balance could be regained without the safety harness. The muscular endurance of the lower extremities of the reghters who slipped <5 cm can be classied as excellent, and it was good for those who slipped P5 cm (Lusa, 1994). It can be assumed that the good muscular capacity of the reghters allowed long controlled slips because the postural activity of the leg and thigh muscles have been shown to be the key factor to reactive balance control in slips occurring at heel strike (Tang et al., 1998). It has also been suggested that the inability to recover successfully from a slip may be due to a reduction in lower-leg muscle strength, sensory function and balance (Lockhart et al., 2000). Because of anticipation, the slipping responses in the laboratory in our study may also dier from those in actual reghting situations, often including noise, poor lighting and psychological stress. Fire-protective equipment may aect slip distances as well. In our study the slip distances were longer for the three reghters (34, 44 and 55 years) wearing re-protective equipment and clothing than to the slip distances with sportswear (results not shown). It has also been shown recently that re-protective equipment negatively aects balance (Kincl et al., 2002; Punakallio et al., 2003). For example, SCBA aects postural control by shifting the center of gravity both upwards and backwards. In addition, the extra weight of the SCBA (15.5 kg) may put more strain on the postural control system. According to Leamon and Li (1991), the addition of a load increases slip distance. Furthermore, the safety boots worn in the trials were classied as very slip resistant with water and deter-

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gent in that the value of the dynamic coecient of friction (DCOF) was in the range of 0.340.39 when measured with the slip simulator (Gro nqvist, 1995) and unsure (DCOF range 0.140.15) with glycerol. The results of this study were properly in line with the apparatus-based friction values. The reghters whose slip distance (glycerol 100 steps/min) was critical (P5 cm) performed signicantly more slowly and their distance in the dynamic stability test was longer. There was also the same tendency for the other parameters of balance, but high inter-individual variation, especially among the reghters with long slip distances aected the statistical signicance. The same tendency between balance and other physical factors and slip risk was seen with the cadence of 120 steps/min, but no dierences were signicant due to the smaller number of studied reghters (because of technical reasons four reghters results were not available). The dynamic stability test is based on visual feedback on how the COP is moved through the targets shown in a circle on the computer monitor. Although the balance task is to move the COP actively, it never goes over the base of support in a successful test. For a forward slip during walking, a smaller movement and faster velocity of the bodys center of mass over the base of support plays a signicant role in slip recovery and fall termination from heel strike to contralateral toe o (You et al., 2001). Although the balance task diers from the dynamic stability test in maintaining balance during slipping, both situations emphasized strict control of COP over the base of support. Furthermore, the ecient exploitation of visual feedback in balance control may be important during the slipping event as well. The dynamic stability test primarily demands the use of ankle strategy, which is one protective response after the onset of a slip as well. The activity of the bilateral leg and thigh muscles, as well as the coordination between the lower extremities, has been shown to be important in reactive balance control in slips occurring at heel strike (Tang et al., 1998). Especially in actual work situations, however, ankle strategy may be insucient to prevent falling during a slip event. The ankle moment was shown to decrease with the severity of the slip, and knee exor and hip extensor moments were primarily responsible for corrective balance reactions (Cham and Redfern, 2001). According to Marigold and Patla (2002), reactive recovery responses to slipping consist of a rapid onset of exor synergy, a large arm elevation strategy, and a modied swing limb trajectory. In addition, grasping, arm swing and compensatory stepping are ecient for restoring balance (Redfern et al., 2001). The older and younger reghters of our study experienced as many slips in tests with glycerol. The older reghters tended, however, to have longer slip distances, especially in the tests with a faster (120 steps/min) walking speed. Five older and one younger reghter lost their balance totally and were suspended by the safety harness during the trials. The mean age of Finnish reghters is rapidly increasing because the retirement age of reghters was raised from 55 to 65 years. Balance abilities also decrease with aging (Punakallio, 2003; Matheson et al., 1999). These facts and our ndings support the importance of specic training of balance abilities among reghters. It is important to provide ample training opportunities also with re-protective equipment. For the prevention of slips and falls among reghters, in addition to sucient balance abilities, valid balance tests are needed in respect to the risk of slipping and falling. The results in visual feedback based dynamic stability test was associated with the slip distance in this study. In the future, balance abilities and the risk of falling among workers

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in physical jobs should be tested concurrently in order to provide validation of balance tests and to provide more understanding of individual balance abilities in respect to slip-related accidents. Slipping tests should also better reect actual work situations, for example, a track with curves, uphills, and downhills, and dierent kinds of obstacles would be closer to actual work situations than the straight path. In addition only one foot stepped on the slippery surface in this study. A larger slippery area would be nearer actual environmental conditions. 5. Conclusion The younger and older reghters of our study experienced as many slips, and half of both groups experienced over 5 cm foot slides considered to increase the risk of an unavoidable fall. Older reghters, however, tended to have longer slip distances than the younger ones at a faster walking speed in particular. The reghters whose slip distance was over 5 cm performed signicantly poorer in the dynamic stability test as well, whereas associations between muscular capacity and the risk of slipping were not signicant. In respect to safety aspects on slippery surfaces, methods based on visual feedback may provide useful information of balance control, and, therefore, this kind of test may be useful in evaluations of balance ability. Furthermore, the ndings support the importance of adding exercises enhancing balance ability to the exercise protocols of reghters. Acknowledgments The authors wish to thank Professor Veikko Louhevaara and docent Pertti Era for their valuable comments during the preparation of this manuscript. We also thank Dr. Ritva Luukkonen for her advice regarding the statistical methods. The Fire Protection Fund of Finland and the Finnish Work Environment Fund supported this study nancially. References
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