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Participation Restriction, Not Fear of Falling, Predicts Actual Balance and Mobility Abilities in Rural Community-Dwelling Older Adults

Allison, Leslie K. PT, PhD; Painter, Jane A. EdD, OTR/L, FAOTA; Emory, Amanda DPT; Whitehurst, Patricia DPT; Raby, Amanda DPT

Journal of Geriatric Physical Therapy: January/March 2013 - Volume 36 - Issue 1 - p 13–23
doi: 10.1519/JPT.0b013e3182493d20
Research Reports

Background and Purpose: Fear of falling (FOF) has been correlated with an increased risk for falls, self-restriction of physical activity, and subsequent decrease in quality of life in older adults. The relationship between perceived FOF, participation restriction, and balance and mobility abilities is unclear, as results from prior studies are inconsistent. Few studies have used the Survey of Activities and Fear of Falling in the Elderly (SAFE) as a standard measure of FOF, although this survey provides both a measure of FOF and participation restriction. Only one study has explored the relationship of individual items from the SAFE with balance and mobility tests that predict fall risk. The primary purpose of this study was to investigate the relationships between FOF and participation restriction as measured by the SAFE and actual balance and mobility abilities in a diverse group of older adults.

Participants: Eighty-two community-dwelling older adults (17 men) with a mean age of 74 (SD = 8.8; range = 55–91) participated in this study. The sample comprised 45% African Americans and 54% whites.

Methods: Fear of falling and participation restriction were assessed using the SAFE, a self-assessment survey. The SAFE assesses information about participation in 11 functional activities as well as the extent to which fear is a source of participation restriction. Balance and functional mobility were measured using the Berg Balance Scale (BBS) and Timed Get Up & Go Test (TUG), respectively. Participants were categorized as low (N = 36), mixed (N = 19), or high (N = 24) risk for future falls based on their past fall history and results on the BBS and the TUG. Data analysis included χ2 and Spearman correlation and 2 regression analyses.

Results: Both SAFE FOF and participation restriction scores were significantly correlated with BBS and TUG scores. However, SAFE participation restriction scores, but not SAFE FOF scores, predicted BBS and TUG scores. SAFE FOF scores could discriminate older adults at high risk for falls from those at mixed and low risk but could not discriminate between the mixed- and low-risk groups.

Discussion/Conclusion: The relationship between self-reported participation restriction and objectively measured balance and mobility abilities is stronger than the relationship between self-reported FOF and objectively measured balance and mobility abilities. These findings lend support to the argument that participation restriction may be the critical mediating factor between FOF, balance and mobility limitations, and fall risk. Evaluation of and intervention for FOF and fall risk without direct and specific attention to participation restriction may not yield optimal results. Older adults whose goals include both reduction in fall risk and increase in participation level may need combined treatment approaches.

1Physical Therapy Department, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina.

2Occupational Therapy Department, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina.

Address correspondence to: Leslie K. Allison, PT, PhD, Physical Therapy Department, College of Allied Health Sciences, East Carolina University, 3305 F Health Sciences Bldg, Greenville, NC 27858 (

Preliminary results from this study were presented as a poster at the APTA Combined Sections Meeting in Las Vegas, Nevada, February 11, 2009.

This study was supported in part by Pitt Partners for Health, Older Adult Health Subcommittee, funded through Pitt Memorial Hospital Foundation.

The authors declare no conflict of interest.

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Thirty percent of community-dwelling persons 65 years and older have 1 or more accidental falls each year.1,2 The annual incidence of falls increases to nearly 50% of seniors older than 80 years, and it is estimated that half of all participants with a history of falls fall repeatedly. The consequences of falls include serious injuries such as fractures and traumatic brain injuries.3 Falls are the leading cause of accidental death in older adults.4 Even when falls do not result in injury, they can provoke a fear of falling (FOF) that may set in motion a downward spiral of progressive participation restriction. This increased inactivity leads to impairments such as decreased strength, balance, agility, and endurance. These accumulated impairments result in frailty, a loss of independence, and, ironically, an increased risk of falls.5

Estimates of the prevalence of FOF vary widely, from 12% to 65% of older adults who have no history of falls to 29% to 92% of those who have fallen.6,7 By itself, fear is not necessarily damaging unless it leads to sedentary behavior or participation restriction, interferes with judgment, or becomes obsessive.8 However, FOF should be recognized as a health care concern in older adults, independent of fall history. Fear of falling has consistently been correlated with numerous negative consequences. These negative consequences include decreased health status, balance skills, walking abilities, mobility, activity level, social engagement, quality of life, increased fall risk, self-restriction of physical activity, frailty, institutionalization, and mortality.6,7911

Fear of falling is strongly associated with participation restriction in both participants with a history of falls and participants with no history of falls.1215 The reported prevalence of fear-related participation restriction varies widely depending on the characteristics of study populations.1618 Fear-related participation restriction is higher in those who are older, female, those who are inactive, and those who have reduced functional performance, poorer health, decreased leg strength, decreased balance, impaired vision, anxiety, depression, social isolation, low self-efficacy, and a history of falls.1922 Importantly, in a sample of more than 650 community-dwelling older adults, fear-related participation restriction was found to be an independent predictor of declines in lower extremity and functional performance, and increased disability, over a 3-year period.23

While some relationship between self-perceived FOF and actual balance and mobility abilities is strongly supported,6,92427 the nature and relative importance of that relationship is unclear.2831 A lack of standardization in terminology and measurement may contribute to discrepant findings.32,33 There are 3 primary fall-related psychological terms: FOF,34 falls efficacy,35,36 and balance confidence.36,37 Although each of these terms is defined differently, they are frequently used interchangeably in research and practice.38,39Fear of falling is defined as “a lasting concern about falling that leads an individual to avoid activities that he/she remains capable of performing.”34(p36)Falls efficacy is defined as “low perceived self-efficacy at avoiding falls during essential, non-hazardous activities of daily living.35(p239)Balance confidence is defined as “the belief that the individual has the capability to perform an activity or action.”40(p257) Falls efficacy and balance confidence are similar to each other in that they are both based on the self-efficacy construct. However, in contrast to FOF, neither falls efficacy nor balance confidence includes activity avoidance in its definition.35,36 Note that the term participation used in this study is consistent with the current terminology of the International Classification of Functioning, Disability and Health41 and can be considered comparable with the term activity used in the prior version of this classification system.

These fall-related psychological constructs are also measured differently, for example, the Survey of Activities and Fear of Falling in the Elderly (SAFE),8 which includes questions about both FOF and participation restriction, the Falls Efficacy Scale (FES),35 and the Activities-specific Balance Confidence (ABC) scale.36 Although the FES and the ABC scale do not include any measure of participation restriction, they are often used as measurement tools in studies of FOF, which by definition involves participation restriction.42 These measurement differences may have significant consequences. There are different views on whether participation restriction is a critical mediating factor between FOF and a patient's actual balance and mobility abilities.13,4347 Studies that used FOF measures that more directly captured participation restriction might have demonstrated a stronger relationship between participation restriction and balance/mobility abilities, lending support for participation restriction as a critical mediating factor. Studies that used FOF measures that did not explicitly include participation restriction would not have found such a relationship, potentially leading to conclusions excluding participation restriction as a critical mediating factor.

Early studies of FOF often employed the single question “Are you afraid of falling?” with responses being either yes/no or graded along an ordinal rating scale.39,48 Subsequently, researchers investigating the behavioral consequences of FOF considered this single-question approach inadequate, as it was not associated with physical performance and a poor predictor of future behavior.37 More recent research typically includes one of the standardized surveys used to rate FOF (SAFE, FES, and ABC scale) related to specific activities.

Neither the FES nor the ABC scale contains questions inquiring about exercise or social activity, although the ABC scale does ask about walking in a mall and using an escalator. This may be problematic because it is likely that the consequences of FOF in community-dwelling older adults would first be seen in more advanced activities and challenging situations.49 Importantly, neither the FES nor the ABC scale examines participation restriction; they look solely at efficacy/confidence during activity. Because the definition of FOF includes the pivotal component of participation restriction, in this study, we chose an FOF measure that does ask about activity avoidance, the SAFE.

The SAFE is a measure that examines FOF as it relates to participation restriction.8 The SAFE response options capture the possible combinations of active or not, and fearful or not. An older adult may engage in an activity and may be fearful or not fearful while doing so. Another older adult may avoid that activity, perhaps due to fear or for some completely different reason or perhaps due to a combination of fear and other factors. The SAFE acknowledges that there are many reasons why older adults may continue to engage in or curtail their activities.

Given these advantages, relative to other FOF measures, the SAFE is understudied. Few studies have used the SAFE as a standard measure of FOF. Only 3 studies have explored the relationship between SAFE and performance measures of balance and mobility that are known to be associated with fall risk.5052 Two of these 3 studies considered FOF separately from participation restriction,50,51 None of the 3 studies investigated the relationship between the several individual SAFE parts, which distinguish between FOF and participation restriction, and the performance measures.

The purpose of this study was to investigate the relationship between perceived FOF and participation restriction as measured by the SAFE and observed balance and mobility abilities as measured by the Berg Balance Scale (BBS)53,54 and Timed Get Up & Go Test (TUG)55 in a diverse group of community-dwelling older adults. The BBS and the TUG are widely used measures of balance and mobility in research and clinical practice, respectively. Three specific questions were addressed:

  1. Is the SAFE FOF component measure correlated with BBS and TUG scores?
  2. Do each of the component measures of the SAFE predict BBS and TUG scores?
  3. Does the SAFE FOF component measure discriminate between low, moderate, and high fall risk groups?
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Eighty-two community-dwelling older adults (17 men) from a rural county volunteered for and completed this study. The sample was 45% African American and 54% white, with a mean age of 74.3 years (SD = 8.8; range = 55–91 years). The minimum eligibility age of 55 was selected on the basis of the results of a prior needs survey that indicated that falls and fall-related injuries were occurring in local older adults in the 55- to 65-year age group.56 Participants included older adults with and without a history of falls. Subjects were recruited using posters, flyers, and announcements and were drawn from senior centers, senior housing complexes, and senior community organizations. Inclusion criteria included age 55 years or older and the ability to walk 20 ft independently with or without an assistive device. The study was approved by the university institutional review board. Informed consent was obtained from each participant prior to data collection.

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For this study, we defined a fall as unintentionally coming to rest on the ground or some lower surface when you did not intend to be there, unrelated to a sudden medical condition, or an overwhelming external force.57 We defined FOF as an ongoing concern about falling that ultimately limits the performance of daily activities.34

Testing occurred at various sites convenient to the participants (eg, in their retirement community, at their senior center). Two separate testing sessions were completed. The first session included consent procedures and survey data collection, which were performed by an experienced occupational therapist or trained occupational therapist graduate students under direct supervision. Sociodemographic data and self-reported fall histories were collected using a written questionnaire; an interviewer was present to assist with reading, if necessary, and to address any questions or concerns about questionnaire completion. Fall history was documented as the number of falls the individual recalled having in the past year. Participants received verbal and written definition of a fall as unintentionally coming to rest on the ground or some lower surface when you did not intend to be there. Fall history is highly predictive of the likelihood of future falls.58

This survey also included the question “Are you afraid of falling in the future?” Response options were “yes,” “no,” or “uncertain.” During this first session, 3 other surveys were also completed in the following order: the Survey of Activities and Fear of Falling in the Elderly (SAFE),8 the Geriatric Depression Scale,59 and the Hamilton Anxiety Scale.60 Results related to relationships between outcomes from the SAFE, the Geriatric Depression Scale, and the Hamilton Anxiety Scale are reported elsewhere.61 The first session (session 1) lasted approximately 90 minutes.

Fear of falling and participation restriction were assessed using the SAFE.8 The SAFE is a self-rating of FOF during the performance of 11 functional activities. The range of activities includes activities of daily living, mobility, and social engagement. Information is gathered about participation in these activities, participation restriction, and the extent to which fear is a factor in participation restriction. The SAFE has an internal consistency of 0.70 to 0.91.8,18 Test-retest reliability of the SAFE in persons with Parkinson disease over a 6- to 10-day time frame is high (ICC = 0.92 [95% confidence interval = 0.86–0.95]).62 Test-retest reliability of the modified SAFE in community-dwelling older adults over an extended 6-month time frame is moderate (ρ = 0.75).15

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SAFE Administration

The SAFE was administered using a standardized interview protocol. Subjects responded to a series of 5 questions for each SAFE activity:

  • Question A: Do you currently do the activity? (Yes/no)
  • Question B: If respondents answered yes to part A, the follow-up question was: When you do this activity, how worried are you that you might fall? (Response options: very worried, somewhat worried, a little worried, and not at all worried, recorded as 3, 2, 1, and 0, respectively.)
  • Question C: If respondents answered no to question A, the follow-up question was “Do you not do this activity because you are worried you might fall?” (Response options: very worried, somewhat worried, a little worried, and not at all worried, recorded as 3, 2, 1, and 0, respectively.)
  • Question D: If the response to question C indicated any degree of worry, the follow-up questions was “Are there other reasons you do not do the activity?” Participant specified any reasons in addition to fear that contributed to their participation restriction.
  • Question E: If the answer to part C indicated no worry, the follow-up question was “What are the reasons that you do not do the activity?” Participants specified any reasons they avoided the activity unrelated to FOF.
  • Question F: The final question was “Compared with 5 years ago, how often do you do this activity?” (Response options: more than you used to, about the same, or less than you used to.)
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SAFE Scoring

We scored the SAFE as recommended by the developers of the instrument8 and developed 1 additional index on the basis of responses to SAFE questions.

  • Part A: Number of SAFE activities being done: sum of affirmative responses to the first question (maximum 11).
  • Parts B: Fear of falling during activity performance; calculated as the sum of worry ratings from question B (maximum 33) divided by total number of activities performed in part A. High scores indicate a greater FOF.
  • Part C-1: Activities not done unrelated to FOF; calculated as the sum of all the “not at all worried” responses to part C for each of the 11 activities.
  • Part C-2: Participation restriction due to FOF (among other reasons); calculated as the sum of worry scores from question part C, divided by the number of activities the respondent reported doing (part A). High part C-2 scores indicate that fear played a greater role in participation restriction, whereas low scores indicate that reasons other than fear were responsible.
  • Part D: The number of activities not done because of other reasons in addition to FOF.
  • Part E: The number of activities not done for reasons other than FOF.
  • Part F: Activity restriction; calculated by counting the number of “less than” responses.

During the second testing session, balance and mobility abilities were assessed using 2 physical performance measures, the BBS53,54 and the TUG.55 These tests were administered in random order by an experienced physical therapist or trained physical therapist graduate students under direct supervision. These individuals were blind to all survey results obtained during the first testing session. During testing, each participant wore a gait belt and was guarded by the tester to reduce fall risk. Participants were encouraged to take rest periods as needed.

The BBS is a standardized balance assessment that may also be used to predict fall risk.6365 It includes 14 balance challenge tasks performed in order from easiest to most difficult. Each task is scored using a 5-point ordinal rating scale measuring levels of ability from 0 (cannot perform) to 4 (normal performance). The highest possible score is 56. Subjects with a score of 45 or less qualified as at risk for falls 63 The BBS has high intra- and interrater reliability (ICC = 0.99; ICC = 0.98, respectively) and good internal consistency (Cronbach α = 0.96).66 For fall prediction, with a cutoff score of 45, the BBS has fair to moderate sensitivity (53%-64%) and high specificity (90%-96%).67 The positive predictive value of the BBS is 72% and the negative predictive value is 85%; it is better at detecting participants with no history of falls than participants with a history of falls.67 Test administration for this study permitted 2 attempts on any task that did not receive a score of 4 on the first attempt, typically the more difficult tasks such as tandem stance or single leg stance. We chose this “2-attempt” method of administration in an effort to ensure that we were scoring the participant's true ability to perform the task versus any difficulty understanding the task demands and any initial learning effect. If different, the higher of the 2 scores was recorded. If the participant declined to attempt an activity, that task received a score of 0.

The TUG is a standardized mobility screening tool that may also be used to indicate fall risk.68,69 The time taken for the older adult to stand up from a chair, walk 3 m, turn around a bright orange cone, walk back to the chair, and sit down was recorded in seconds with a stopwatch. The TUG has high intra- and interrater reliability with trained raters (ICC = 0.99; ICC = 0.87–0.99).55,70 A TUG time of less than 9 seconds indicates low risk, 10 to 13 seconds indicates moderate risk, and 14 seconds or more indicates high risk of future falls.68 On the basis of a cutoff score of 14 seconds, the TUG has good sensitivity (75%-87%) and specificity (67%-87%) in community-dwelling older adults.68,69 Test administration for this study included 1 practice trial (score not recorded) and 3 scored trials. The mean of the 3 scored trials was used in subsequent analysis. Participants were permitted to use the arms of the chair to push to stand if necessary.71,72 Those participants who used an assistive device for community ambulation were tested using that device.73,74 Verbal instructions to “walk as quickly as you safely can” were carefully explained. Trials in which participants did not follow instructions, for example, running, or unsafe behavior, were stopped and repeated following review of instructions.

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Data Analyses

We measured FOF in 2 ways, with the single question “Are you afraid of falling in the future?” and with the SAFE part B FOF score. The relationships between these 2 measures of FOF versus actual balance and mobility abilities (as measured by the BBS and the TUG, respectively) were examined using χ2 (dichotomous data) tests and Spearman (nonparametric data) correlations.

Two separate multiple linear regression analyses were then performed, one with the BBS and the other with the TUG as the dependent variable. Fall history (number of falls in the last year) and 5 parts of the SAFE tool (parts B, C-1, C-2, D, and F) were the independent variables entered into the regression equation in an “all variables entered” manner that permits the statistical software to order the variables in the regression equation to maximize prediction. Both the BBS and the SAFE are ordinal rating scales; however, the data from these 2 measures have been used as ratio-level data for the purpose of this regression analysis.

Participants were categorized into low, mixed, and high risk for falls groups on the basis of fall history, BBS scores, and TUG scores (Figure 1). We included the BBS and TUG scores in addition to the number of falls in the past year for 2 reasons. First, self-report of prior falls is unverifiable and may reflect changing risk status over the prior year whereas the BBS and TUG performance measures are directly observable and current. Second, most falls occur due to the interaction of intrinsic risk factors (eg, weakness, imbalance) and extrinsic risk factors (hazards in the environment, such as slippery or cluttered surface).75 The degree of exposure to extrinsic risk factors in participants' lives was not controllable or measured; hence, 2 participants might have equivalent intrinsic risk level but different fall histories due to differences in extrinsic risk exposure. By including the BBS and TUG scores in the risk classification, we capture within-participant intrinsic risk levels and between-participant commonalities that would otherwise remain obscure.

Figure 1

Figure 1

After classification, we had 36 in the low-risk group, 19 in the mixed-risk group, and 24 in the high-risk group. The mean BBS score and TUG times for each group were compared using t tests to determine whether our classification schema produced 3 distinct groups. The same procedure was then applied to the total SAFE part B FOF scores to determine whether the SAFE offered similar discrimination. All analyses were performed using SPSS v.15 (SPSS Inc, an IBM Company, Chicago, Illinois.)

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A majority of the participants (65%) reported no falls in the previous year; 35% reported a single fall, and 18% had fallen more than once (range, 2–7 falls) Nearly two-thirds of the participants (64%) lived alone. Only 12% of participants used an assistive device for ambulation. Test results for the SAFE, the BBS, and the TUG are given in Table 1. The mean BBS score for the sample (52.07) was well above the established fall risk cutoff score of 45. The mean TUG time for the sample (10.1 seconds) was below the established fall risk cutoff score of 13.5 seconds.

Table 1

Table 1

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Relationship Between Fear of Falling and Actual Balance and Mobility Abilities

The SAFE part B FOF score was significantly correlated with actual balance and mobility abilities as measured by the BBS and the TUG (rSAFE_B-BBS = −0.348, P = .003; rSAFE_B-TUG = 0.411, P < .001). Fear of falling, represented by the single question “Are you afraid of future falls” was not significantly correlated with actual balance and mobility abilities as measured by the BBS and the TUG (χ2BBS = 19.44, df = 18, P = .37; χ2TUG = 79.0, df = 77, P = .42). Scores from the BBS and TUG were significantly correlated with each other (rBBS-TUG = −0.86, P < .001).

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Prediction of Actual Balance and Mobility Abilities by Fall History and SAFE Parts

Tables 2 and 3 provide the multivariate results using SAFE and fall history to predict BBS score and TUG times. Table 4 provides univariate results for the prediction of BBS analysis, and Table 5 provides those for prediction of TUG scores. Both the BBS and TUG scores were predicted by fall history and SAFE part F degree of activity restriction values. The BBS score was also predicted by the SAFE part C-1 no fear of falling and SAFE part C-2 FOF participation restriction scores (Table 4). The TUG scores were also predicted by the SAFE part D Activity restriction (Table 5).

Table 2

Table 2

Table 3

Table 3

Table 4

Table 4

Table 5

Table 5

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Discrimination of Low, Mixed, and High Risk by the Total SAFE Fear of Falling Score

Table 6 provides scores across risk groups (low, mixed, and high) for factors discriminating risk group. The BBS and the TUG scores for the 3 risk groups displayed in Table 6 were all significantly different from each other (Figure 2). The total SAFE part B FOF scores were significantly different between the low-risk and high-risk groups and between the mixed-risk and high-risk groups. There was no significant difference in total SAFE part B FOF scores between the low-risk and mixed-risk groups.

Figure 2

Figure 2

Table 6

Table 6

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Although not selected randomly, our subject sample had fall characteristics very similar to those reported in the literature, with 35% reporting at least 1 fall and just over half of that group reporting multiple falls. Because the majority of the sample was participants with no history of falls, the relatively high mean scores on the balance and mobility measures (BBS and TUG) were not surprising. Furthermore, the inclusion of adults in the less frail 55- to 65-year age range may have resulted in a more active and able sample than is typical in studies with a minimum age of 65 years.

We measured FOF in 2 ways, using the single question “Are you afraid of falling?” with a yes/no/uncertain response option, and the SAFE part B FOF score. Fear of falling as measured by the SAFE part B FOF score was clearly related to balance and mobility abilities as measured by the BBS and the TUG, whereas FOF as measured by the “Are you afraid” question was not. These results reflect the conflicting results found between earlier studies (for reviews, see Scheffer et al33 and Legters76) and imply that measurement method may explain a great deal of the discrepancy. Although clinicians, who are pressed for time, may be tempted to just to ask the quick question, current results indicate this single-question measure with few response options is of little value.

Fall history predicted both BBS and TUG scores. This finding is not surprising, as all 3 variables are predictive of future fall58,6365,68,69; hence, a strong relationship might be suspected. Furthermore, balance and gait deficits, as reflected here by BBS and TUG scores, are known to be primary risk factors for falls,75 reflected here by the fall history. Participants with more prior falls would likely have more balance and gait deficits, thus poorer performance on the BBS and the TUG. This result implies that a positive fall history (≥2 falls in the last year) is a “red flag” for probable balance and gait deficits.

The only SAFE part score that predicted both BBS and TUG scores was part F, a measure of participation restriction, not FOF. If participation restriction is the mediating mechanism between FOF and physical performance abilities,4345 this significant relationship is not surprising. The finding that FOF (part B) did not predict either BBS or TUG scores was unexpected, given the significant correlation discussed earlier, as well as prior studies that reported significant correlations between fear and physical performance.50,77,78 If FOF is measured/analyzed and participation restriction is not, as in any prior study using the FES and the ABC scale that did not also include a more direct measure of participation restriction, then the apparent relationship between FOF and physical performance may be confounded by the “invisible” participation restriction variable. When we placed both FOF and participation restriction in the analysis, we found that participation restriction plays a much larger role than FOF in explaining balance and mobility abilities. These results are in agreement with others studies that have found that activity limitation is more strongly associated with decreased physical performance and functional ability than FOF.4345 There is by no means a consensus on this point, however, as other investigators argue for the primacy of FOF versus participation restriction in the explanation of falls and function in older adults.13,46,47

Scores from SAFE parts C-1 and C-2, which we consider to reflect FOF in addition to part B, also predicted the BBS scores. Several of the BBS tasks, such as sit-to-stand, transfers, pick up slipper from floor, are relatively easy as well as familiar to participants and are unlikely to generate fear. However, other BBS tasks, such as timed toe touches on stool, tandem stance, single leg stance, are much more challenging as well as unfamiliar. These tasks may be perceived as “higher threat” and consequently increase fear.79 For example, although we did not measure refusal to perform tasks, there were some participants who felt sufficiently insecure even with a spotter and reassurance that they declined to attempt some of the more difficult BBS tasks. This may explain the relationship between the part C1 and C2 scores and the BBS scores, with more fearful participants having lower BBS scores.

Participation restriction as measured by SAFE part D also predicted the TUG scores. Performance on the TUG is strongly associated with balance and gait impairments.70,80 The presence of balance and gait impairments may be a mediating factor between participation restriction and mobility abilities.16,1820 Older adults may develop balance and gait impairments that lead to perceived fall/injury risk and/or make it difficult to be independently mobile in their community. These seniors may then restrict their activities as a compensatory strategy. Alternatively, older adults may first restrict their activities due to fear, for other reasons, or because of a combination of both fear and other contributing factors. The progressive inactivity of these seniors leads to the development of balance and gait impairments. In either case, balance and gait impairments and participation restriction are related and occur concurrently. Older adults in either category would likely earn higher (worse) scores on both part F and the TUG.

Our results agree with many prior studies that reported a relationship between FOF and objectively measured balance and mobility abilities.6,92427 However, our results indicate that participation restriction better reflects imbalance and mobility decline than does FOF. This finding is consistent with McKee et al,44 who demonstrated that when biomedical variables are controlled, FOF does not by itself explain variation in functional limitations. If participation restriction is more indicative of actual balance and mobility abilities than FOF, then clinicians should consider an increased focus on the measurement and management of participation restriction relative to fear.

Responses to the single question “Are you afraid of future falls?” were not related to BBS and TUG scores. This result provides further evidence that just asking this single question yields little useful information for clinicians. Given the finding that participation restriction better reflects imbalance and mobility decline than FOF, if a single question were to be used, a better question for community-dwelling older adults might be related to participation versus fear. One possible phrase, for example, could be “Is there anything you no longer do, or no longer will do by yourself, that you used to do a year ago?”

Lachman and colleagues8 designated SAFE part B scores as representative of FOF. We found that part B scores were able to discriminate between participants at low and mixed risks versus high risk for falls. This result is in agreement with Li et al,51 who demonstrated a relationship between FOF as measured by SAFE part B and fall risk. However, part B scores could not discriminate between low- and mixed-risk participants. Compared with balance and mobility measures, this FOF measure may not be as useful for early detection of older adults transitioning from a low-risk to a more moderate-risk category. As the BBS and TUG scores were used to define the risk groups in this study, their apparent ability to discriminate between all 3 groups is an artifact of this categorization method. However, prior research has established that the BBS6365 and the TUG68,69 do predict distinct fall risk groups.

In research and clinical practice, the FES and the ABC scale are used much more often than the SAFE, probably because they are simpler and take less time to administer. Yet, only the SAFE measures both FOF and participation restriction. We interpret our result that participation restriction predicts balance and mobility abilities whereas FOF does not to indicate that participation restriction is a better reflection of actual balance and mobility abilities than FOF. In addition, the SAFE responses provide valuable information about current participation levels and the multiple factors that influence the respondents' decisions regarding their participation level. This information would be very useful in planning an intervention strategy for an older adult at risk for falls and loss of mobility independence.

Clearly, participation restriction due to FOF despite the ability to continue performing the activities is a maladaptive behavior that leads to increased risk of falls and decreased function. We label this “primary” fear-related participation restriction. Alternatively, participation restriction related to FOF may be an appropriate adaptive reaction to accurately perceived balance and gait deficits in the short term. We label this “secondary” fear-related participation restriction. This is not an ideal long-term strategy if intervention to address imbalance and mobility loss could improve the existing deficits. To distinguish between primary versus secondary fear-related participation restriction, clinicians would need to perform both the SAFE and relevant physical performance measures. For older adults who unnecessarily self-limit their activities, intervention might focus on anxiety reduction, increasing the sense of control and choosing healthier behaviors. Examples of such evidence-based intervention programs are “A Matter of Balance” (National Council on Aging, Center for Healthy Aging, Washington, District of Columbia), and “Stepping On” (Freiberg Press Inc, Cedar Falls, Iowa), both a series of classes to provide fall prevention health education and promote positive health behaviors. Intervention for older adults who avoid activities to compensate for existing balance and mobility problems would target these physical impairments to reduce fall risk and improve safe mobility. Concurrent patient education regarding the need to increase activity level as performance capacity improves would also be included. Whether primary or secondary, fear-related participation restriction deserves the clinician's attention and emphasis if resumption of activities in the home and community is a goal.

We recognize several limitations to this study. We used a volunteer sample of convenience, which may lead to biased results. There are known problems with the self-report of fall history that may result in the underreporting of falls. Two of the 11 SAFE activities may not be pertinent to this region (rural south). For example, “Go out when it is slippery” may be more relevant in areas where snow and ice are common in the winter, and “Walk several blocks outside” is a difficult proposition when there are no “blocks,” no sidewalks, or in some instances, no paved roads adjacent to the homes. All measures were taken only once, so our results may be more affected by the state of the participant on that day than if the mean of repeated measures across different days were used. Finally, the manner in which we categorized participants into risk groups, while based on evidence from the literature, was our own convention and has not been independently validated.

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We investigated the relationship between perceived FOF and participation restriction and observed balance and mobility abilities. Despite the greater emphasis on FOF in research and clinical practice, degree of participation restriction, more than FOF, is related to performance on clinical measures of both balance and mobility. We propose that the use of FOF survey tools that do not measure participation restriction (eg, FES, ABC scale) results in a failure to capture highly relevant information that could negatively affect intervention plans and activity engagement outcomes. Although the SAFE requires somewhat more time and effort to administer and score, the fact that it yields information about both FOF and participation restriction enhances its relative value. For practical clinical use, the development of a short version of the SAFE that includes both FOF and participation restriction, or a different dual FOF/participation restriction survey tool that is faster and easier to use, would facilitate adoption.

Future research should explore directly whether the addition of new interventions to reduce FOF and participation restriction to existing interventions for balance and gait impairments leads to improved clinical outcomes and increased activity engagement in the home and community.

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activity restriction; balance; falls; fear of falling; mobility; participation restriction

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