Clinical Rehabilitation 2000; 14: 497505

Balance function and fall-related efcacy in patients with newly operated hip fracture
A Hellzn Ingemarsson Department of Physiotherapy, Mlndal, Sahlgrenska University Hospital, and Department of Geriatric Medicine, Gteborg University, K Frndin Department of Geriatric Medicine, Gteborg University, K Hellstrm Department of Neuroscience, Rehabilitation Medicine, Uppsala University, Uppsala and Rundgren Department of Geriatric Medicine, Gteborg University, Sweden Received 26th April 1999; returned for revisions 25th August 1999; revised manuscript accepted 12th March 2000.

Objective: To investigate the relation between fall-related efcacy in daily-life activities and functional as well as instrumental tests of balance in patients with hip fracture. Design: Analysis of different aspects of balance using the Falls Efcacy Scale, Swedish version FES(S), questions on fear of falling, Functional Reach (FR) and tests on a balance platform (Chattanooga). Subjects: Fifty-ve elderly inpatients (mean age 82.3) with newly operated hip fracture who were assessed during the last week in hospital before discharge. Results: The results showed a signicant relationship between the subjective ability measured with the FES(S) and the objectively measured balance in the Functional Reach test and also between fall-related efcacy measured with FES(S) and fear of falling. Very few signicant correlations were found between the results from balance tests on the force platform and those obtained with FES(S) and FR. Conclusions: Both the Falls Efcacy Scale, Swedish version, and the Functional Reach have been shown to be useful in analysing balance function in elderly patients newly operated on for hip fracture. The Falls Efcacy Scale also indicates which of the daily activities the patient perceives as troublesome and thus require further training.

Introduction With advancing age, the fragility of the skeleton increases as well as the tendency to fall. Osteoporosis with fragility fractures is a huge public health problem. The most serious fracture is the hip fracture, because it requires a relatively long
Address for correspondence: Annika Hellzn Ingemarsson, Banaliden 10, 436 45 Askim, Sweden. e-mail: annika. ingemarsson@sahlgrenska.se Arnold 2000

period of rehabilitation at a high cost to society.1,2 Impaired postural control and decreased muscle mass and muscle function in the lower extremities, hindering quick changes in body position, seem to be important factors for the occurrence of hip fractures.3 Postural instability increases with age4,5 but a comparison of physically active and physically inactive elderly persons has shown that the balance reactions of the active persons were similar to those of young people.6 When hip fracture
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AH Ingemarsson et al. previous falls had more balance problems than those who had not fallen. The purpose of this study was to investigate the relation between fall-related efcacy in daily-life activities and functional as well as instrumental tests of balance, and also to describe the relation between the different tests. Methods Subjects The study involved 55 inpatients (47 women, 8 men) newly operated on for hip fracture who were cared for postoperatively at the Geriatric Clinic stra, Vasa Hospital, Gteborg, Sweden. The sampling was done consecutively. The criteria for inclusion were as follows. Prospect of returning to their homes. This was evaluated by members of a geriatric team consisting of a doctor, a nurse, a physiotherapist, an occupational therapist and a social worker. Good cognitive function. All patients were asked some standard questions in order to detect cases with acute and chronic confusion. These questions included the patients name, date of birth and age, the name of the hospital as well as home address and month of year and season. If all questions were answered correctly, the patient was considered to have a good cognitive function.

patients and matched controls were compared, it was found that the hip fracture patients, when tested on a balance platform, had a more pronounced postural sway, especially sideways.7 Different laboratory methods have been used to study the maintenance of equilibrium, i.e. advanced force platforms such as EquiTest,8 AMTI7,9 and the Chattanooga Balance System,10,11 some of which can produce different kinds of perturbations. For the assessment of balance in clinical situations, simple tests such as one-leg stance, get-upand-go12 or walking in a gure of eight13 are needed. Another well-known functional test is Functional Reach,14 which measures the difference between the length of the arm and maximal forward reach in a standing position. In a study of 217 men living at home, Duncan et al.15 showed that those who could reach less than 15 cm had a four times greater risk of falling compared with those who could reach 25 cm, and twice the risk compared with those who could reach between 15 and 25 cm. Different scales have also been developed, for instance Bergs Balance Scale, which includes 14 items that are based on different daily-life activities.16 In addition, the Elderly Fall Screening Test (EFST), involving both a selfreported fall history and observations on gait patterns, has recently been presented.17 It has been shown to have good criterion and predictive validity and can be useful in community-based prevention programmes directed towards functionally independent elderly people. Fear of falling is common among elderly persons, both among those who have experienced a fall and among those who have not.18 Whether other factors of a psychological nature, such as self-efcacy, affect the risk of falling is less well known. Tinetti et al.19 have developed a scale which measures fear of falling and which can be helpful for the selection of rehabilitative as well as preventive strategies.18 Persons with low selfefcacy regarding the performance of certain activities have a tendency to avoid them,18,20 and such a change in ones activity pattern is usually not in proportion to the physical impairment level after a fall. This means that an elderly person who has experienced a fall tends to reduce his or her level of physical activity.21 Meldrum and Finn22 have shown that elderly people with

Assessment of balance The Falls Efcacy Scale (FES) was developed by Tinetti et al.19 It is based on the operational denition of fear expressed as low perceived self-efcacy at avoiding falls during essential, relatively nonhazardous activities of daily living and is a subjective evaluation of what the patient believes it is possible to do irrespective of ability. The scale runs from 0 to 10, where 0 means not condent at all and 10 completely condent, and subjects judge how condent they would be in performing certain everyday activities without falling. FES has been used in several studies and appears to be both reliable and valid.18,19,23 A translation into Swedish has been done by Hellstrm24 and is called Falls Efcacy Scale, Swedish version (FES(S)). The original 10

Balance function and fall-related efcacy activities of FES have been extended to 13 to include the activities get in/out of bed, get on/off toilet and personal grooming (Figure 1). The overall testretest reliability of the FES(S), tested on a group of 30 stroke patients, was high (intraclass correlation coefcient, ICC = 0.98). The ICC for the individual items ranged from 0.76 to 0.97.24 The patients were told to rate their ability in each of the 13 activities listed on a form in front of them. To assess fear of falling, patients were asked if they were afraid of falling and instructed to indicate their answers on a four-point ordinal scale with the alternatives: never (0), very seldom (1), sometimes (2) and often (3). In the statistical analysis the four alternatives were combined into two (0+1 versus 2+3). Functional Reach (FR) is a functional test of balance which has been shown to be reliable between raters and between trials, and to have predictive validity in community-dwelling elderly males.14,15,25 It has also been shown to be sensitive to clinical changes in balance.26 The test measures the ability to reach forward and is performed with the patient standing with his or her side to a wall. The patient is asked to lift one arm to a horizontal position, parallel to the wall and stretch the ngers out. A measuring tape glued along the wall is used to measure the difference in distance between the tips of the patients ngers when the patient is standing in an upright position and when reaching forward as far as possible without falling or taking a step. The patients are supposed to wear shoes and to stand with their feet one shoulder width apart. Protraction of the shoulder at the start is not allowed. In the present study, an initial instruction trial was performed, after which three tests were done and the highest value recorded. An instrumental test of balance was performed on a computerized force platform the Chattanooga Balance System (Chattanooga Group Inc., Hixon, TN, USA). The system measures the postural sway (posturography), which means the change of pressure of the foot in relation to a calculated centre centre of balance (COB). The variables measured in the present study were sway sideways left/right (L/R), sway forward/backward (F/B) and sway index (SI). SI is a numerical value of the standard deviation of

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the time and the distance the subject spent away from the COB.27 Byl and Sinott28 investigated the intratester and intertester reliability of the instrument and reported correlation coefcients of 0.92 and 0.90, respectively. Intertester reliability has also been investigated during single-leg static and dynamic testing, and an intraclass correlation coefcient ranging from 0.41 to 0.90 was reported.29 Measurements were performed with the patients standing on both legs. The patients were instructed to look xedly at a spot on the wall 1.5 metres away, to keep their hands behind the back and to maintain their balance. The footplates were adjusted individually according to the size of the feet and the distance between the feet according to shoulder width. The footplates were parallel. Five different tests were performed: Test 1: Platform stable, eyes open, 10 s Test 2: Platform stable, eyes closed, 10 s Test 3: Platform moving, toes up 4 and back to neutral, eyes open, 15 s Test 4: Platform moving, toes up 4, back past neutral and down 4, eyes open, 17 s Test 5: As test 4 but at twice the speed, 20 s Tests 3 and 4 were performed at a platform velocity of 1/s and test 5 at a velocity of 2/s. The recording frequency of the measurements was 100 Hz. If the patients lost their balance or grabbed the handrail in any of the tests, the test was excluded. Before each test a trial was done. Procedure All measurements were carried out one or two days prior to discharge. The number of days between surgery and assessment was on average 25.3 13.2, and the median value was 25 days with a range of 680 days. All tests were carried out by one of the authors (AHI). Statistics The data were analysed with the help of the SPSS statistical program. Descriptive statistics and Spearmans rank correlation as well as a multiple regression model were used. The number of patients in the different balance platform tests varies because some of them were unable to keep their balance and were thus excluded from that

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AH Ingemarsson et al. Results The mean values for age, body height and weight are shown in Table 1. The mean value for the scale FES(S) was 5.6 2.8, with the highest values regarding activities such as personal grooming, getting on and off the toilet, getting in and out of a chair and getting in and out of bed (Figure 1). To the question Are you afraid of falling, three patients answered never, 16 very seldom, 27 sometimes and nine often. The values for FR varied between 9 and 42 cm, with a mean value of 26.7 5.8 cm and a median value of 27 cm. The mean values from the ve different tests

particular test. The difference between dropouts and participants was tested with the two-sample t-test for interval-scaled variables and the Wilcoxon two-sample rank test for ordinal variables.

Table 1 Age, body height and weight in women, men and total (meanSD) Women (n = 47) Age (years) Height (cm) Weight (kg) 82.5 7,1 161.5 5.5 60.7 12.4 Men (n = 8) 81.1 4.8 174 4.1 70 10.9 Total (n = 55) 82.3 6.8 163.2 6.8 62 12.6

Figure 1

Results regarding the Falls Efcacy Scale, Swedish version (mean SD).

Balance function and fall-related efcacy on the balance platform for the variables sway sideways (L/R), sway forward/backward (F/B) and sway index (SI) are shown in Table 2. It can be seen that the amplitude of sway increased with test difculty. The differences between the tests were statistically signicant (p<0.001) with the exception of test 3 and test 4 for sway L/R, test 4 and test 5 for sway F/B and test 4 and test 5 for SI. As some of the patients were unable to perform all tests properly, the corresponding results have not been presented. Two patients failed in test 1, four in test 2, four in test 3, ve in test 4 and six patients failed in test 5. Most of the patients who fell in test 5 had fallen in earlier test(s). There was a signicant difference between dropouts (n = 6 in test 5) and participants (n = 49) regarding age, FES(S) and FR. The dropouts were signicantly older than the participants (p = 0.028), had lower values on FES(S) (p = 0.047) and performed worse in FR (p = 0.04). A few results in each test except test 1 had to be omitted due to technical problems, and the rst nine patients were not exposed to test 5. One patient was unable to take part in the platform tests due to sudden discharge. The analysis demonstrated a signicant relationship between fall-related efcacy (FES(S)) and ability to reach forward (FR) (Table 3). Patients with high self-efcacy could reach further than those who had low self-efcacy (Figure 2). Fear of falling also correlated signicantly with FES(S) (Table 3). The less fear a patient felt, the higher the fall-related efcacy in different activities. Patients who were never or seldom afraid of falling had on average a 40% higher score on FES(S) (p<0.001) than patients who reported that they were sometimes or often afraid of falling. To examine if the bivariate correlation between FES(S) and fear of falling and FR would

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be affected by age, sex, height and weight, a multivariate regression model, with FES(S) as dependent variable, was used. This did not change the strength of the correlation. Correlations between the various variables measured on the platform for each of the ve tests and FES(S), fear of falling and FR are shown in Table 4. Signicant correlations only occurred for test 1 (nonmoving footplate and eyes open) between SI, on the one hand, and FES(S), fear of falling and FR, on the other. Discussion The present study showed that patients with a high fall-related efcacy performed better than others in FR and were less afraid of falling. Another nding is that the measures of balance performance on the balance platform correlated only to an extremely small extent with the patients assessment of their condence in different daily activities, with their fear of falling or the functional test of balance. FES(S) and the question about fear of falling can be said to measure different aspects of the same phenomenon. In the rst case, there is a positive approach, with questions such as How sure are you that you can use the toilet without falling? and in the other case, the question is negative Are you afraid of falling? The fact that the instruments, in spite of this, show a fairly
Table 3 Correlations between Falls Efcacy Scale, Swedish version (FES(S)), Fear of falling (Fear) and Functional Reach (FR) FR FES(S) Fear ***p<0.001. 0.53*** 0.20 ns FES(S) 0.44 ***

Table 2 Means and standard deviations regarding sway sideways (L/R), forward/backward (F/B) and sway index (SI) for the ve different tests on the balance platform Test 1 (n = 50) L/R F/B SI 1.9 0.9 2.4 1.1 8.8 3.1 Test 2 (n = 49) 2.9 1.5 3.4 1.8 12.7 5.9 Test 3 (n = 48) 3.4 1.5 6.8 1.7 22.9 5.4 Test 4 (n = 47) 3.4 1.5 8.6 1.7 30.3 7.9 Test 5 (n = 39) 4.2 2.3 9.1 2.0 30.7 9.1

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Figure 2

Scatterplot showing individual results in both FES(S) and FR (n = 54).

Table 4 Correlations between the variables sway sideways (L/R), forward/backward (F/B) and sway index (SI) in Tests 15 on the balance platform and Falls Efcacy Scale, Swedish version (FES(S)), Fear of falling (Fear) and Functional Reach (FR) Correlations L/R FES(S) F/B FES(S) SI FES(S) L/R Fear F/B Fear SI Fear L/R FR F/B FR SI FR **p<0.01. Test 1 0.19 ns 0.22 ns 0.42** 0.21 ns 0.19 ns 0.34** 0.24 ns 0.21 ns 0.38** Test 2 0.03 0.03 0.03 0.22 0.18 0.28 0.09 0.07 0.05 ns ns ns ns ns ns ns ns ns Test 3 0.03 0.07 0.12 0.11 0.11 0.15 0.10 0.18 0.00 ns ns ns ns ns ns ns ns ns Test 4 0.02 0.04 0.07 0.02 0.07 0.05 0.23 0.08 0.08 ns ns ns ns ns ns ns ns ns Test 5 0.14 0.08 0.05 0.22 0.16 0.17 0.09 0.10 0.02 ns ns ns ns ns ns ns ns ns

good correlation supports their validity. Myers et al.30 have shown that dichotomous questions about fear of falling had the least relevance compared with other scales concerning condence in balance capacity in relation to physical ability and daily-life activities. In the present study, the question about fear of falling was used as an introduction. Myers et al.30 agree that this type of

question could be used for screening. There was no correlation between results in fear of falling and FR. The question about fear of falling probably has limited specicity and, as the question was posed when they were seated, the patients might have associated it with a less difcult situation than reaching forward when standing.

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Clinical messages Evaluating balance in elderly patients newly operated on for hip fracture is of importance. The Falls Efcacy Scale, Swedish version, and the Functional Reach test are useful measurements. Elderly patients newly operated on for hip fracture have reduced fall-related efcacy. Although the FR test may be a good screening tool for severe balance problems and fragility, the test has lately been shown not to be sensitive to balance problems for a group of patients from a balance and dizziness disorders clinic.31 The authors caution therapists to interpret the FR only for the population for which it was developed community-dwelling elderly people. The assessment scale FES(S) is easy to use as it is relatively short, easy to administer and not time-consuming. On the other hand, the patient must have a good cognitive function in order to understand the questions, and this limits its use. It is difcult to tell whether a patients answer refers to the actual behaviour in an activity or to the degree of self-condence regarding the activity, a problem that has also been stressed by Mendes de Leon et al.23 The original Falls Efcacy Scale, which measures fear of falling mainly regarding indoor activities, has recently been expanded by Hill et al.20 to include more outdoor activities. The Swedish revised version24 and the Australian version20 are similar concerning the number of activities (13 and 14 respectively), but the Australian version is more advanced in many activities, as it includes condence in using public transportation, crossing streets and doing not too strenuous gardening. The Swedish version focuses on more basic activities of daily living, which makes the scale suitable for subjects with moderate to low functional ability. In the present study, shopping, cleaning, taking a bath/shower and reaching into a cabinet had the strongest association with fear of falling, which is comparable to previously reported research ndings.19,20,32 However, a difference was noted for hurry to answer the telephone,

which turned out to be the activity that was most strongly associated with fear of falling in the present study. One possible reason might be different interpretations of the word hurry. Cooking was not associated with fear of falling in any of the studies. The reason why activities like personal grooming, toileting, getting in and out of a chair were considered to be relatively safe might be that the patients were used to performing these activities in hospital. The results from the balance platform (Chattanooga Balance System) showed very few signicant relationships with other assessments, and only in the rst test standing on a stable platform with eyes open. It is possible that this situation was most familiar to the patients and thus correlated with the daily-activity situations of the Falls Efcacy Scale, while the other tests were experienced as unfamiliar. As expected, the postural sway increased as the test situation became more and more difcult. Tests of postural stability are considered to be able to identify persons with a high risk of falling and, as a consequence, a high risk of fractures. Colledge et al.33 found that posturographic measurements on a balance platform predicted the risk of falling in elderly persons better than activity-based screening, and that posturography may be a simple way of identifying high-risk individuals. In the present study, many of the patients seemed to be afraid of the test situation, and thus did not move their centre of balance as much as could be expected. This has been conrmed by Duncan et al.,14 who state that the limit value for stability is within a smaller area in elderly persons than in young persons. This might reect a compensatory mechanism for decreasing postural control, implying that some of the results of measurements of sway might be misleading. There was no correlation between the results in FR and the instrumental test of balance, but the two test situations make different demands on performance. In FR the patients moved forward themselves, but in most of the tests on the balance platform the surface was moving. Ringsberg et al.10 states that there is no relationship between results on a moveable platform and results from simple clinical balance tests such as standing on one leg and walking speed. It is of great importance to develop predictors

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7 Jarnlo G-B, Thorngren KG. Standing balance in hip fracture patients. 20 middle-aged patients compared with 20 healthy subjects Acta Orthop Scand 1991; 62: 42734. 8 Ledin T, Kronhed A-C, Mller C, Mller M, dkvist LM, Olsson B. Effects of balance training in elderly evaluated by clinical tests and dynamic posturography. J Vestib Res 1991; 1: 12938. 9 Frndin K, Sonn U, Svantesson U, Grimby G. Functional balance tests in 76-year-olds in relation to performance, activities of daily living and platform tests. Scand J Rehabil Med 1995; 27: 23141. 10 Ringsberg K, Gerdhem P, Johansson J, Obrandt KJ. Is there a relationship between balance, gait performance and muscular strength in 75-year-old women? Age Ageing 1999; 28: 28993. 11 Wolf SL, Barnhart HX, Ellison GL, Coogler CE. The effect of tai chi quan and computerized balance training on postural stability in older subjects. Phys Ther 1997; 77: 37184. 12 Mathias S, Nayak USL, Isaacs B. Balance in elderly patients: The get-up and go test. Arch Phys Med Rehabil 1986; 67: 38789. 13 Johansson G, Jarnlo G-B. Balance training in 70-year-old women. Physiother Theory Pract 1991; 7: 12125. 14 Duncan PW, Weiner DK, Chandler J, Studenski S. Functional Reach: a new clinical measure of balance. J Gerontol 1990; 45: M19297. 15 Duncan PW, Studenski S, Chandler J, Prescott B. Functional Reach: predictive validity in a sample of elderly male veterans. J Gerontol 1992; 47: M9398. 16 Berg K, Wood-Dauphine S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can 1989; 41: 30411. 17 Cwikel JG, Fried AV, Biderman A, Galinsky D. Validation of a fall-risk screening test, the Elderly Fall Screening Test (EFST), for communitydwelling elderly. Disabil Rehabil 1998; 20: 16167. 18 Tinetti ME, Powell L. Fear of falling and low selfefcacy: A cause of dependence in elderly persons. J Gerontol 1993; 48: 3538. 19 Tinetti ME. Richman D, Powell L. Falls efcacy as a measure of fear of falling. J Gerontol 1990; 45: 23943. 20 Hill KD, Schwarz JA, Kalogeropoulos AJ, Gibson SJ. Fear of falling revisited. Arch Phys Med Rehabil 1996; 77: 102529. 21 Prudham D, Grimley Evans J. Factors associated with falls in the elderly: a community study. Age Ageing 1981; 10: 14146. 22 Meldrum D, Finn AM. An investigation of balance function in elderly subjects who have and have not fallen. Physiotherapy 1993; 79: 83942. 23 Mendes de Leon CF, Seeman TE, Baker DI, Richardsson ED, Tinetti ME. Self-efcacy, physical

that can identify people at risk of falling in time. If their self-efcacy can be inuenced and increased at an early stage, a great deal can be gained regarding safety in the performance of daily-life activities. A strong independent association between self-efcacy and function has been demonstrated by Tinetti et al.,34 and it is therefore suggested that rehabilitation should attempt to improve physical skills and condence simultaneously. It is important to take the activity level into account, as it has recently been demonstrated that elderly persons who were physically active were less afraid of falling, had a better balance function, and also greater self-efcacy than persons who were less active.35 Conclusions Both the Falls Efcacy Scale, Swedish version and Functional Reach have been shown to be useful for analysing balance function in elderly patients newly operated on for hip fracture. The Falls Efcacy Scale also indicates which of the daily activities the patient perceives as troublesome and thus require further training. Acknowledgement This study was supported by grants from the Hjalmar Svensson Foundation. We would like to express our gratitude to Franois Ct, Lena Nordholm and Valter Sundh for valuable help with the statistical calculations. References
1 Zetterberg C, Elmersson S, Andersson GBJ. Epidemiology of hip fractures in Gteborg, Sweden 1940-1983. Clin Orthop 1984; 191: 4352. 2 Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporosis Int 1997; 7: 40713. 3 Jarnlo G-B, Thorngren K-G. Background factors in hip fracture patients. Clin Orthop 1993; 287: 4149. 4 Sackley CM, Lincoln NB. Weight distribution and postural sway in healthy adults. Clin Rehabil 1991; 5: 18186. 5 Baloh RW, Fife TD, Zwerling L et al. Comparison of static and dynamic posturography in young and older people. J Am Geriatr Soc 1994; 42: 40212. 6 Patla A, Frank J, Winter D. Assessment of balance control in the elderly: Major issues. Physiother Can 1990; 42: 8997.

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decline, and change in functioning in community-living elders: a prospective study. J Gerontol 1996; 51: 18390. Hellstrm K, Lindmark B. Fear of falling in patients with stroke: a reliability study. Clin Rehabil 1999; 13: 50917. Weiner DK, Duncan PW, Chandler J, Studenski SA. Functional Reach: a marker of physical frailty. JAm Geriatr Soc 1992; 40: 203207. Weiner DK, Bongiorni DR, Studenski SA, Duncan PW. Kochersberger GG. Does Functional Reach improve with rehabilitation? Arch Phys Med Rehabil 1993; 70: 796800. Shaw LM. Falls in the elderly. Thesis, Glasgow Caledonian University, Scotland, 1994. Byl NN, Sinott PL. Variations in balance and body sway in middle-aged adults. Spine 1991; 16: 32530. Mattacola C, Perrin DH. Intertester reliability of assessing postural sway using the Chattecx Balance System. J Athl Train 1995; 30: 23741. Myers AM, Powell LE, Maki BE, Holliday PJ,

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Brawley LR, Sherk W. Psychological indicators of balance condence: relationship to actual and perceived abilities. J Gerontol 1996; 51: M3743. Light KE, Rose DK, Purser JL. The Functional Reach test for balance: strategies of elderly subjects with and without disequilibrium. Phys Occup Ther Geriatr 1996; 14: 3952. Powell L, Myers AM. The Activities Specic Balance Condence (ABC) Scale. J Gerontol 1995; 50A: M2834. Colledge NR, Cantley P, Peaston I, Brash H, Lewis S, Wilson JA. Ageing and balance: the measurement of spontaneous sway by posturography. Gerontology 1994; 40: 27378. Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related efcacy in relationship to functioning among community-living elders. J Gerontol 1994; 29: M14047. McAuley E, Mihalko SL, Rosengren K. Self-efcacy and balance correlates of fear of falling in the elderly. J Aging Phys Activity 1997; 5: 32940.

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