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According to the Canadian Institute for Health Information (2002), falls are the cause of 85% of injury hospitalizations among older adults in Canada, and with one of three adults older than age 65 falling annually (American Geriatrics Society, British Geriatrics Society, & American Academy of Orthopaedic Surgeons Panel on Falls Prevention, 2001), the cost to individuals and the health care system is a major public health concern. The incidence of falls may be higher in populations with chronic disease such as osteoarthritis (OA). In a review of 16 fall risk studies (American Geriatrics Society et al., 2001), presence of arthritis was identified as having a higher mean relative risk of predicting future falls than age or cognitive status.
OA, the most common kind of arthritis affecting more than one third of the adult population older than age 65, accounts for 55% of all arthritis-related hospital admissions and is one of the leading causes of disability among older adults (National Center for Chronic Disease Prevention and Health Promotion, 2008a). Hip OA, affecting approximately 5% of older adults, results in pain, limited mobility, and disability. With the rising trend of higher proportions of older adults in the population, the prevalence of hip OA and the associated health care costs are expected to rise substantially (National Center for Chronic Disease Prevention and Health Promotion, 2008b).
Lower limb weakness, slower gait, decreased mobility, and pain—all physical outcomes related to the presence of hip OA—are also established risk factors for falls (Leveille et al., 2002; Varela-Burstein & Miller, 2003). There is some evidence of increased fall risk as measured by balance, strength, and reaction time in older adults with hip and knee arthritis (Sturnieks et al., 2004); however, other studies have found decreased fall risk for women with more severe radiographic changes of hip OA (Arden et al., 1999) but increased risk for those with self-reported OA (Arden et al., 1999) or new episodes of hip pain (Nahit, Silman, & Macfarlane, 1998).
There has been little research evaluating the impact of other psychological factors, such as falls-efficacy, that may increase risk of falls in older adults with lower extremity OA. Falls-efficacy is based on Bandura’s theory of self-efficacy (Bandura, 1997) and is defined as individuals’ beliefs in their ability and skills to successfully perform a task and avoid a fall (Marks, 2001). There is controversy in the literature regarding the relationship of falls-efficacy with functional ability in older adults. Falls-efficacy has been correlated with performance on balance tests (Kressig et al., 2001; Myers et al., 1996), but no significant difference in balance was found between fearful older adults and a nonfearful cohort matched for age and gender (Brouwer, Musselman, & Culham, 2004). In a study of older women with osteoporosis (Liu-Ambrose et al., 2006), balance confidence (falls-efficacy) was found to be an independent predictor of balance and mobility even after other fall risk factors, such as age, vision, and activity level, were controlled.
The connection between fear of falls and risk of falling is not unidirectional. In a large prospective sample, fear of falls significantly predicted the risk of falling 20 months later, and a history of falls at baseline significantly predicted new onset of fear 20 months later (Friedman, Munoz, West, Rubin, & Fried, 2002). Fear and falls appear to have a spiraling relationship that can lead older adults down a path of progressive functional deterioration and worsening confidence in their ability to prevent falls, which leads them to a much greater risk of falling. Although the pathways of how this downward spiral occurs and the nature of the relationships are not completely clear, the impact of fear on fall risk could be substantial, particularly for certain populations at higher risk.
Fear of falls is significantly higher in populations with arthritis (Howland et al., 1993) and those with higher levels of pain (Jamison, Neuberger, & Miller, 2003). The presence of back, joint, or muscle pain increased the likelihood of reported fear of falling two to four times in adults diagnosed with rheumatoid arthritis (Howland et al., 1993). As fear results in lower levels of falls-efficacy, it is possible that the association of falls-efficacy with functional balance performance may be more prominent in older adults with lower extremity OA; no previous studies have examined this relationship. The objective of this study was to determine the association of falls-efficacy to balance performance in older adults with hip OA. The hypotheses were that higher levels of falls-efficacy would predict better performance of clinical balance and dual task function (ability to perform two tasks simultaneously) in the hip OA population.
This study describes baseline data from a larger study evaluating the efficacy of an exercise and education intervention on fall risk factors in this population. The recruitment and screening process has been described in detail previously (Arnold & Faulkner, 2007). Participants were recruited from the community using newspaper advertisements and posters. Inclusion criteria were age 65 or older, presence of hip pain for 6 months or longer, diagnosed with hip OA as determined by clinical diagnostic criteria (Altman et al., 1991), and having one fall risk factor, either a Timed Up and Go (TUG) test (Podsiadlo & Richardson, 1991) score of 10 seconds or longer or history of a fall in the past 12 months. The TUG test involves standing up from a chair, walking as quickly as possible for 3 meters, and then turning around and sitting back down. Healthy community-dwelling older adults typically score less than 10 seconds (Podsiadlo & Richardson, 1991). A fall was defined as any event in which the person inadvertently or unintentionally comes to rest on the ground or another lower level, such as a chair, toilet, or bed (Tideiksaar, 2002). Individuals with significant neurological or medical conditions affecting daily function and those currently involved in a regular group program incorporating balance exercise were excluded. In total, 191 men and women were screened, and 83 met eligibility criteria, 4 of the eligible participants dropped out prior to testing. Ethical approval was obtained from the institution’s ethical review board, and informed consent was given prior to the screening test.
The clinical tools for fall risk used in this study were chosen to measure the constructs of balance and dual task function. Balance incorporates a complex mix of both anticipatory and reactive movement strategies, as well as an interaction of the task to changes in the environment (Shumway-Cook & Woollacott, 2007). Dual task function involves performing a physical task simultaneously with a second task that may involve cognition or manipulation. Dual task function has been associated with increased fall risk in older adults (Shumway-Cook, Woollacott, Kerns, & Baldwin, 1997).
Falls-efficacy was measured using two questionnaires to measure confidence in related daily tasks known to affect fall risk. The impact of arthritis on daily function and physical activity level were tested via questionnaires. Testing was conducted by two physical therapists with experience assessing older adults and a research assistant. Participants first completed the falls-efficacy questionnaires; then within 2 hours of doing so, the clinical tests of balance and dual task function were performed. Other questionnaires were dispersed between the physical tests. The tests used are outlined below.
Balance. Three components of balance were measured: functional balance, sensory organization, and reaction time. Functional balance was measured with a modified version of the Berg Balance Scale (BBSm) (Berg, Wood-Dauphinee, Williams, & Gayton, 1989; Rose, 2003), consisting of the last nine tasks of the original BBS, rated on a scale of 1 to 4 using a standard protocol, for a maximum score of 36. This scale has excellent inter-rater and intrarater reliability (intra-class correlation coefficient [ICC] = 0.98 and 0.99) (Berg et al., 1989), is correlated with other functional and balance tests, and has been shown to predict falls in older adults (Lajoie & Gallagher, 2004).
The Modified Clinical Test of Sensory Interaction and Balance (MCTSIB) (Shumway-Cook & Horak, 1986) measures the impact of sensory information on balance under four conditions: eyes open and closed stable surface, eyes open and closed compliant surface, shoes on, and heels and forefoot touching. If the participant achieved 30 seconds without the foot lifting, arms uncrossing, eyes opening, or manual assistance required to prevent a fall, they completed that condition; if not, two additional trials are given with a mean score calculated. The total possible score for this test is 120 seconds. The MCTSIB has been correlated with other tests of balance and has demonstrated good reliability and validity (Wrisley & Whitney, 2004).
Lower extremity forward step reaction time in response to an auditory cue was measured using a digital timer. Two photo cells approximately 12 inches apart stopped the timer once the participant’s forefoot stepped between the cells. The distance from the start position to the photo cells was set at 60% of the participant’s maximal step length, which was measured just prior to the reaction time test (Medell & Alexander, 2000). Intrarater and interrater reliability for combined means for five trials of left and right step was confirmed in a sample of 18 older adults with and without lower extremity arthritis (ICC = 0.86 and 0.81) (Warkentin, Arnold, Chilibeck, Magnus, & Skarpinsky, 2007).
Dual Task Function. The TUG test was performed under three conditions: TUGstandard, TUGcog, and TUGman (Shumway-Cook, Brauer, & Woollacott, 2000). The TUGcog and TUGman add the challenge of a cognitive subtraction task and a manual carrying task while performing the standard test (a measure of dual function) and has been found to negatively affect balance (Shumway-Cook et al., 1997). The protocol for the standard TUG test is described elsewhere (Arnold & Faulkner, 2007). For the TUGcog, the dual task was counting backwards by twos, with total time recorded. For the TUGman, participants picked up a 10-cm-tall cup filled to 6.6 cm with water from a 70-cm-high stool, walked 3 meters, and returned to sitting, placing the cup back on the stool, with total time recorded.
Falls-Efficacy. The Activities-specific Balance Confidence (ABC) scale has excellent internal consistency (Cronbach’s alpha coefficient = 0.96) and test-retest reliability (r = 0.92) (Powell & Myers, 1995) and has been found to discriminate higher versus lower functional status (Myers, Fletcher, Myers, & Sherk, 1998). The 16 items in the ABC scale do not capture the diverse range of incidents and activities that older adults may fear in day-to-day living; therefore, a second questionnaire, the Falls-Efficacy Questionnaire (FEQ) was developed specifically for this study to measure efficacy related to: (a) dual task function (FEQdual), (b) recovering balance when displaced unexpectedly (FEQreaction), and (c) more complex functional tasks, such as getting up from the floor after a fall (FEQcomplex). The internal consistency of the FEQtotal (15 questions) was 0.98 (Cronbach’s alpha coefficient) and internal consistency ranged from 0.93 to 0.97 across categories.
Questionnaires. The Arthritis Impact Measurement Scale version 2 (AIMS-2) is a self-report questionnaire designed to measure the impact of arthritis on daily function and is recommended as a reliable and valid instrument for use in the population with arthritis (Swinkels, Dijkstra, & Bouter, 2005). The three-component model (physical, affect, and symptoms) was used in this study. The Physical Activity Scale for the Elderly (PASE) is a valid and reliable tool in elderly populations and can distinguish between different mobility levels and several environmental factors that may impact level of mobility (Chad et al., 2005). Additional demographic information was obtained via a self-report questionnaire.
Data cleaning was conducted using a standard protocol (Tabachnick & Fidell, 2007). Group means were substituted for missing values, or when possible, the case mean was used for variables where there were missing data points. Missing data were distributed equally across variables and accounted for less than 5%. For variables that significantly deviated from normalcy, transformations were performed, and then the distribution was reevaluated. If the transformation corrected the skewness or kurtosis to less than twice the value of the standard error, the transformation was retained. Extreme outliers, defined as greater than three interquartile ranges (IQR) from the outer boundaries of the box plot, were found for the BBSm (two cases), MCTSIB (one case), PASE (one case), and TUGman (one case). These deviant scores were converted to one unit above or below the next highest or lowest value in the distribution, thus reducing the impact of the outlier on the data distribution, while still conserving the placement in the distribution (Tabachnick & Fidell, 2007). The following variables were transformed: BBSm (reflect square root); MCTSIB (reflect square root); TUGstandard, TUGman, and TUGcog (log10); FEQdual (square root); and AIMS-2 (log10).
The hypothesis that falls-efficacy would predict outcome of balance and dual task function was tested with seven hierarchical linear regression equations to answer the following questions:
- Does FEQdual predict clinical scores of dual task function (TUGcog and TUGman)?
- Does FEQreaction predict scores of reaction time?
- Does FEQcomplex predict scores of functional balance (BBSm) and sensory organization (MCTSIB)?
- Does a total score of falls-efficacy (ABC and FEQtotal) predict scores of functional balance (BBSm)?
Other demographic factors with significant correlations to balance performance were first entered into the regression equation to determine the independent effect of falls-efficacy. SPSS version 14.0 was used for all statistical analyses with p < 0.05 used for determining statistical significance.
A total of 79 participants (71% women and 29% men) completed testing. Table 1 contains relevant demographic and fall risk data. Thirty-nine (49%) of the 79 participants reported a fall in the past year. Thirty-three (42%) reported use of a walking aid, and 26 (33%) had arthritis in at least one other joint. Thirty-one (39%) reported bilateral hip involvement. Age, use of a walking aid, number of prescription medications, and AIMS-2 and PASE scores were significantly correlated to the functional tests (Pearson r correlation values ranged from 0.23 to 0.41); thus, these variables were entered into the regression models used to answer the hypothesis that falls-efficacy would be a significant predictor of balance and dual task performance.
Table 1: Descriptive Demographic Data and Fall Risk Variables for Older Adults with Hip Osteoarthritis (N = 79)
Falls-efficacy of dual task performance and reaction time (FEQdual and FEQreaction) were not significant contributors to the models in predicting the TUGcog, TUGman, or reaction time, respectively. Age, based on the standardized beta values, accounted for most of the variance in the models for TUGcog (R2 = 0.29, p = 0.004), TUGman (R2 = 0.29, p = 0.004), and reaction time (R2 = 0.29, p = 0.004). However, falls-efficacy was a significant, independent predictor of balance performance, as measured by the BBSm and the MCTSIB. FEQcomplex and FEQtotal significantly improved the model and explained 11% and 10%, respectively, additional variance for the BBSm beyond that already accounted for by age, number of medications, use of a walking aid, and PASE and AIMS-2 scores. FEQcomplex explained approximately 7% additional variance for the MCTSIB and significantly improved the model. ABC scale scores, a second measure of falls-efficacy or balance confidence, also significantly improved the model, adding 5% additional variance (Table 2).
Table 2: Hierarchical Linear Regression Model for Predictors of Balance: Model 2a of the Regression Equation Entering Falls-Efficacy into the Model
In this study, we examined the relationship of falls-efficacy to functional balance performance in a sample of older community-dwelling men and women with hip OA. Results showed falls-efficacy independently predicted balance performance, even when age, health status, use of a walking aid, and physical activity level were controlled for. These results support the conjecture that falls-efficacy is an important contributor to fall risk for older adults with hip OA.
Because it was cross-sectional, this study was limited in its ability to predict future falling risk; however, our results provide new insight into the relationship of falls-efficacy to physical performance in older adults with higher fall risk because of arthritis and mobility limitations. Falls-efficacy, individuals’ beliefs in their ability and skills to successfully perform a task and avoid a fall, relates directly to self-efficacy theory (Marks, 2001), and self-efficacy has been found to be an important predictor of overall health status for individuals with arthritis (Marks, 2001). The spiraling effect of fear of falls predicting falls, and falls predicting further escalation of fear is well known (Friedman et al., 2002). For populations such as older adults with hip OA, the combination of lower falls-efficacy, physical impairments, and pain may accentuate this spiraling effect, resulting in further loss of mobility and function. Screening for falls-efficacy may be important to identify those at higher risk for falls and progression to frailty.
We included a sample of older adults with mobility restrictions due to hip OA who already had lower levels of falls-efficacy than samples in other studies of community-dwelling older adults. Mean scores for the ABC scale in this study were lower than mean scores found in samples of other populations with chronic conditions such as osteoporosis (Liu-Ambrose et al., 2006) and similar to mean scores found for fearful community-dwelling older adults (Myers et al., 1996). This could be due to the presence of a fall in the past year or because of the unique contribution of having hip pain and arthritis. Knowing that there is an association between falls-efficacy and physical fall risk factors for this higher risk population suggests that interventions need to be targeted to address both falls-efficacy and physical performance.
Falls-efficacy was an independent predictor of balance both in the BBSm and MCTSIB, measures that include functional balance tasks encountered in everyday experiences, as well as balance under sensory challenges such as eyes closed and standing on less stable surfaces. This relationship remained even after accounting for other factors associated with balance and falls. Considering that falls-efficacy is associated with lower mobility and functional status, an additional independent contribution beyond these factors is clinically relevant. Previous data support these findings; for example, Liu-Ambrose et al. (2006) found an independent effect of falls-efficacy as measured by the ABC scale on balance and gait speed in a sample of older women with low bone mass, with 18% and 11% of the variance explained by falls-efficacy after controlling for age, activity level, and other balance and visual impairment tests. Others have found relationships of falls-efficacy to balance and functional status, as measured by functional reach, self-paced walk, single leg stance, and a stepping test (Kressig et al., 2001). To our knowledge, our data are the first to evaluate falls-efficacy specific to dual task performance, stepping reactions, and balance under different environmental challenges.
Falls-efficacy of the ability to react quickly if pushed or bumped unexpectedly (FEQreaction) was not an independent predictor of reaction time, nor was falls-efficacy of dual task function (FEQdual) predictive of the TUGcog. Reaction time is a reflexive response to an unexpected perturbation, and individuals may not feel they have as much control over these movements as opposed to a self-initiated functional task. In addition, the TUGcog involved walking while counting backwards by twos, which is not a common dual task in day-to-day living; thus, falls-efficacy rating might be more reflective of the unknown, rather than lack of confidence. However, FEQcomplex, confidence in functional movements such as walking on rough ground, stepping up and down curbs, getting up and down from the floor, or walking to the bathroom at night, was independently associated with balance performance. These are common activities during which falls occur. If screening for falls-efficacy can identify individuals who physically have poorer balance in similar daily tasks, this could be a helpful tool for clinicians to use.
The relationship of falls-efficacy to the risk of future falls is still not clear, but the results of this study suggest that lower levels of falls-efficacy independently predict fall risk as measured by functional balance tests in older adults with hip OA. This has important implications for screening and intervention. Simple questions about falls-efficacy should be included in screening evaluations of older adults to identify those who may be at higher risk. Older adults with lower extremity arthritis may be at higher risk for falls due to both physical impairments and lower levels of falls-efficacy. Intervention programs should also consider the addition of confidence building or efficacy enhancement strategies related to day-to-day balance tasks.
Falls-efficacy is an important contributor to balance impairment in older adults with hip OA. This finding emphasizes the importance of including falls-efficacy in screening as well as fall prevention strategies for this population. Further study needs to determine the association of both physical and psychosocial risk factors to future falls, as well as the best interventions to prevent falls in this population with pain and mobility limitations.
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Descriptive Demographic Data and Fall Risk Variables for Older Adults with Hip Osteoarthritis (N = 79)
|Age (years)||74.4 (6.3)||65 to 88|
|Number of comorbidities||2.1 (1.3)||0 to 5|
|Duration of hip pain (years)||7.6 (8.8)||0.5 to 50|
|Number of current prescription medications||3 (2.6)||0 to 12|
| BBSma (of 36)||30.3 (4)||19 to 36|
| MCTSIBa (of 120 seconds)||95 (21)||23 to 120|
| Reaction time (seconds)||0.89 (0.18)||0.2 to 1.45|
| Dual (of 100)||64.9 (24.9)||0 to 100|
| Reaction (of 100)||50.9 (26)||0 to 100|
| Complex (of 100)||62.8 (26.1)||12.5 to 100|
| Total (of 100)||60.1 (24)||8.7 to 100|
| ABC scale (of 100)||68.4 (19.9)||15.6 to 99.4|
|TUGstandard (seconds)||11.9 (4.3)||7.5 to 28|
|TUGcog (counting backward by twos, seconds)||15 (7.2)||6.3 to 49.9|
|TUGman (carrying cup ¾ full of water, seconds)||12.1 (4.4)||6.8 to 28.2|
|AIMS-2 (three-component model, of 25)||10.5 (3.1)||5.6 to 22.7|
|PASE total score||101.6 (47.3)||25 to 215.7|
Hierarchical Linear Regression Model for Predictors of Balance: Model 2a of the Regression Equation Entering Falls-Efficacy into the Model
|Independent variable - - - Dependent variable||R2||R2Change||Standardized β||p Value|
|FEQcomplex - - - BBSm (reflect square root)|
| Model 2||0.44||0.11|
| Use of a walking aid||0.09||0.39|
| Number of current prescription medications||0.14||0.16|
|FEQcomplex - - - MCTSIB (reflect square root)|
| Model 2||0.31||0.07|
| Use of a walking aid||−0.13||0.28|
| Number of current prescription medications||0.25||0.03|
|FEQtotal - - - BBSm (reflect square root)|
| Model 2||0.43||0.10|
| Use of a walking aid||0.09||0.38|
| Number of current prescription medications||0.12||0.21|
|ABC - - - BBSm (reflect square root)|
| Model 2||0.37||0.05|
| Use of a walking aid||0.11||0.34|
| Number of current prescription medications||0.10||0.32|