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 fall58,63–65,68,69; 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,43–45 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.43–45 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.
Our results agree with many prior studies that reported a relationship between FOF and objectively measured balance and mobility abilities.6,924–27 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.
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.
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.
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.
1. Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil. 2001;82:1050–1056.
2. Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls
among community-dwelling older persons: results from a randomized trial. Gerontologist. 1994;34:16–23.
3. Sterling DA, O'Connor JA, Bonadies J. Geriatric falls
: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50:116–119.
5. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling
and restriction of mobility
in elderly fallers. Age Ageing. 1997;26:189–193.
6. Visschedijk J, Achterberg W, Van Balen R, Hertogh C. Fear of falling
after hip fracture: a systematic review of measurement instruments, prevalence, interventions, and related factors. J Am Geriatr Soc. 2010;58:1739–1748.
7. Evitt CP, Quigley PA. Fear of falling
in older adults: a guide to its prevalence, risk factors, and consequences. Rehabil Nurs. 2004;29:207–210.
8. Lachman ME, Howland J, Tennstedt S, Jette A, Assmann S, Peterson EW. Fear of falling
and activity restriction
: the Survey of Activities and Fear of Falling
in the Elderly (SAFE). J Gerontol B Psychol Sci Soc Sci. 1998;53:P43–P50.
9. Sharaf AY, Ibrahim HS. Physical and psychosocial correlates of fear of falling
: among older adults in assisted living facilities. J Gerontol Nurs. 2008;34:27–35.
10. Cumming RG, Salkeld G, Thomas M, Szonyi G. Prospective study of the impact of fear of falling
on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci. 2000;55:M299–M305.
11. Arfken CL, Lach HW, Birge SJ, Miller JP. The prevalence and correlates of fear of falling
in elderly persons living in the community. Am J Public Health. 1994;84:565–570.
12. Delbaere K, Crombez G, van Haastregt JC, Vlaeyen JW. Falls
and catastrophic thoughts about falls
restriction in community-dwelling older people: a structural equation modelling approach. Aging Ment Health. 2009;13:587–592.
13. Bertera EM, Bertera RL. Fear of falling
and activity avoidance in a national sample of older adults in the United States. Health Soc Work. 2008;33:54–62.
14. Zijlstra GA, van Haastregt JC, van Eijk JT, van Rossum E, Stalenhoef PA, Kempen GI. Prevalence and correlates of fear of falling
, and associated avoidance of activity in the general population of community-living older people. Age Ageing. 2007;36:304–309.
15. Yardley L, Smith H. A prospective study of the relationship between feared consequences of falling and avoidance of activity in community-living older people. Gerontologist. 2002;42:17–23.
16. Wilson MM, Miller DK, Andresen EM, Malmstrom TK, Miller JP, Wolinsky FD. Fear of falling
and related activity restriction
among middle-aged African Americans. J Gerontol A Biol Sci Med Sci. 2005;60:355–360.
17. Deshpande N, Metter EJ, Bandinelli S, Lauretani F, Windham BG, Ferrucci L. Psychological, physical, and sensory correlates of fear of falling
and consequent activity restriction
in the elderly: the In CHIANTI study. Am J Phys Med Rehabil. 2008;87:354–362.
18. Fletcher PC, Hirdes JP. Restriction in activity associated with fear of falling
among community-based seniors using home care services. Age Ageing. 2004;33:273–279.
19. Kempen GI, van Haastregt JC, McKee KJ, Delbaere K, Zijlstra GA. Socio-demographic, health-related and psychosocial correlates of fear of falling
and avoidance of activity in community-living older persons who avoid activity due to fear of falling
. BMC Public Health. 2009;9:170.
20. Delbaere K, Crombez G, Vanderstraeten G, Willems T, Cambier D. Fear-related avoidance of activities, falls
and physical frailty. A prospective community-based cohort study. Age Ageing. 2004;33:368–373.
21. Bruce DG, Devine A, Prince RL. Recreational physical activity levels in healthy older women: the importance of fear of falling
. J Am Geriatr Soc. 2002;50:84–89.
22. Fessel KD, Nevitt MC. Correlates of fear of falling
and activity limitation among persons with rheumatoid arthritis. Arthritis Care Res. 1997;10:222–228.
23. Deshpande N, Metter EJ, Lauretani F, Bandinelli S, Guralnik J, Ferrucci L. Activity restriction
induced by fear of falling
and objective and subjective measures of physical function: a prospective cohort study. J Am Geriatr Soc. 2008;56:615–620.
24. Arnold CM, Faulkner RA. Does falls
-efficacy predict balance
performance in older adults with hip osteoarthritis? J Gerontol Nurs. 2009;35:45–52.
25. Andresen EM, Wolinsky FD, Miller JP, Wilson MM, Malmstrom TK, Miller DK. Cross-sectional and longitudinal risk factors for falls
, fear of falling
, and falls
efficacy in a cohort of middle-aged African Americans. Gerontologist. 2006;46:249–257.
26. Liu-Ambrose T, Khan KM, Donaldson MG, Eng JJ, Lord SR, McKay HA. Falls
-related self-efficacy is independently associated with balance
in older women with low bone mass. J Gerontol A Biol Sci Med Sci. 2006;61:832–838.
27. Binda SM, Culham EG, Brouwer B. Balance
, muscle strength, and fear of falling
in older adults. Exp Aging Res. 2003;29:205–219.
28. Delbaere K, Close JC, Brodaty H, Sachdev P, Lord SR. Determinants of disparities between perceived and physiological risk of falling among elderly people: cohort study. BMJ. 2010;341:c4165.
29. Delbaere K, Crombez G, Van Den Noortgate N, Willems T, Cambier D. The risk of being fearful or fearless of falls
in older people: an empirical validation. Disabil Rehabil. 2006;28:751–756.
30. Ward-Griffin C, Hobson S, Melles P, Kloseck M, Vandervoort A, Crilly R. Falls
and fear of falling
among community-dwelling seniors: the dynamic tension between exercising precaution and striving for independence. Can J Aging. 2004;23:307–318.
31. Maki BE, Holliday PJ, Topper AK. Fear of falling
and postural performance in the elderly. J Gerontol. 1991;46:M123–M131.
32. Alarcon T, Gonzalez-Montalvo JI, Otero Puime A. [Assessing patients with fear of falling
. Does the method use change the results? A systematic review]. Aten Primaria. 2009;41:262–268.
33. Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, de Rooij SE. Fear of falling
: measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing. 2008;37:19–24.
34. Tinetti ME, Powell L. Fear of falling
and low self-efficacy: a case of dependence in elderly persons. J Gerontol. 1993;48(spec no.):35–38.
35. Tinetti ME, Richman D, Powell L. Falls
efficacy as a measure of fear of falling
. J Gerontol. 1990;45:P239–P243.
36. Powell LE, Myers AM. The Activities-specific Balance
Confidence (ABC) scale. J Gerontol A Biol Sci Med Sci. 1995;50A:M28–M34.
37. Myers AM, Powell LE, Maki BE, Holliday PJ, Brawley LR, Sherk W. Psychological indicators of balance
confidence: relationship to actual and perceived abilities. J Gerontol A Biol Sci Med Sci. 1996;51:M37–M43.
38. Godfrey JR, Studenski SA. Toward optimal health: preventing falls
and promoting mobility
in older women. J Womens Health (Larchmt). 2010;19:185–188.
39. Moore DS, Ellis R. Measurement of fall-related psychological constructs among independent-living older adults: a review of the research literature. Aging Ment Health. 2008;12:684–699.
40. Miller WC, Speechley M, Deathe AB. Balance
confidence among people with lower-limb amputations. Phys Ther. 2002;82:856–865.
42. Kressig RW, Wolf SL, Sattin RW, et al. Associations of demographic, functional, and behavioral characteristics with activity-related fear of falling
among older adults transitioning to frailty. J Am Geriatr Soc. 2001;49:1456–1462.
43. Martin FC, Hart D, Spector T, Doyle DV, Harari D. Fear of falling
limiting activity in young-old women is associated with reduced functional mobility
rather than psychological factors. Age Ageing. 2005;34:281–287.
44. McKee KJ, Orbell S, Austin CA, et al. Fear of falling
efficacy, and health outcomes in older people following hip fracture. Disabil Rehabil. 2002;24:327–333.
45. Murphy SL, Williams CS, Gill TM. Characteristics associated with fear of falling
and activity restriction
in community-living older persons. J Am Geriatr Soc. 2002;50:516–520.
46. Hadjistavropoulos T, Delbaere K, Fitzgerald TD. Reconceptualizing the role of fear of falling
confidence in fall risk. J Aging Health. 2011;23:3–23.
47. Hadjistavropoulos T, Martin RR, Sharpe D, Lints AC, McCreary DR, Asmundson GJ. A longitudinal investigation of fear of falling
, fear of pain, and activity avoidance in community-dwelling older adults. J Aging Health. 2007;19:965–984.
48. Jorstad EC, Hauer K, Becker C, Lamb SE; ProFaNE Group. Measuring the psychological outcomes of falling: a systematic review. J Am Geriatr Soc. 2005;53:501–510.
49. Deshpande N, Metter EJ, Lauretani F, Bandinelli S, Ferrucci L. Interpreting fear of falling
in the elderly: what do we need to consider? J Geriatr Phys Ther. 2009;32:91–96.
50. Talley KM, Wyman JF, Gross CR. Psychometric properties of the Activities-specific Balance
Confidence Scale and the Survey of Activities and Fear of Falling
in older women. J Am Geriatr Soc. 2008;56:328–333.
51. Li F, Fisher KJ, Harmer P, McAuley E, Wilson NL. Fear of falling
in elderly persons: association with falls
, functional ability, and quality of life. J Gerontol B Psychol Sci Soc Sci. 2003;58:P283–P290.
52. Fuzhong L, McAuley E, Fisher KJ, Harmer P, Chaumeton N, Wilson NL. Self-efficacy as a mediator between fear of falling
and functional ability in the elderly. J Aging Health. 2002;14:452–466.
53. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance
in the elderly: validation of an instrument. Can J Public Health. 1992;83(suppl 2):S7–S11.
54. Berg KO, Maki BE, Williams JI, Holliday PJ, Wood-Dauphinee SL. Clinical and laboratory measures of postural balance
in an elderly population. Arch Phys Med Rehabil. 1992;73:1073–1080.
55. Podsiadlo D, Richardson S. The Timed “Up & Go”: a test of basic functional mobility
for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148.
56. Painter JA, Elliott SJ, Hudson S. Falls
in community-dwelling adults aged 50 years and older: prevalence and contributing factors. J Allied Health. 2009;38:201–207.
57. Tinetti ME, Williams CS. Falls
, injuries due to falls
, and the risk of admission to a nursing home. N Engl J Med. 1997;337:1279–1284.
58. Stalenhoef PA, Diederiks JP, Knottnerus JA, Kester AD, Crebolder HF. A risk model for the prediction of recurrent falls
in community-dwelling elderly: a prospective cohort study. J Clin Epidemiol. 2002;55:1088–1094.
59. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982;17:37–49.
60. Maier W, Buller R, Philipp M, Heuser I. The Hamilton Anxiety Scale: reliability, validity and sensitivity to change in anxiety and depressive disorders. J Affect Disord. 1988;14:61–68.
61. Painter JA, Allison LK, Dhingha P, Daughtery J, Cogdill K. Fear of falling
and its relationship with anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66:1–9.
62. Nilsson MH, Drake AM, Hagell P. Assessment of fall-related self-efficacy and activity avoidance in people with Parkinson's disease. BMC Geriatr. 2010;10:78.
63. Bogle Thorbahn LD, Newton RA. Use of the Berg Balance
Test to predict falls
in elderly persons. Phys Ther. 1996;76:576–583; discussion 584–585.
64. Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the probability for falls
in community-dwelling older adults. Phys Ther. 1997;77:812–819.
65. Lajoie Y, Gallagher SP. Predicting falls
within the elderly community: comparison of postural sway, reaction time, the Berg Balance
Scale and the Activities-specific Balance
Confidence (ABC) scale for comparing fallers and non-fallers. Arch Gerontol Geriatr. 2004;38:11–26.
66. Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance
in the elderly: preliminary development of an instrument. Physiother Can. 1989;41:304.
67. Riddle DL, Stratford PW. Interpreting validity indexes for diagnostic tests: an illustration using the Berg Balance
Test. Phys Ther. 1999;79:939–948.
68. Trueblood PR, Hodson-Chennault N, McCubbin A, Youngclarke D. Performance and impairment-based assessment among community-dwelling elderly: sensitivity and specificity. Issues Aging. 2001;24:2–6.
69. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls
in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80:896–903.
70. Steffen TM, Hacker TA, Mollinger L. Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance
Scale, Timed Up & Go Test, and gait speeds. Phys Ther. 2002;82:128–137.
71. Siggeirsdottir K, Jonsson BY, Jonsson H Jr, Iwarsson S. The Timed “Up & Go” is dependent on chair type. Clin Rehabil. 2002;16:609–616.
72. Kalula SZ, Swingler GH, Sayer AA, Badri M, Ferreira M. Does chair type influence outcome in the Timed “Up and Go” Test in older persons? J Nutr Health Aging. 2010;14:319–323.
73. Ries JD, Echternach JL, Nof L, Gagnon Blodgett M. Test-retest reliability and minimal detectable change scores for the Timed “Up & Go” Test, the Six-Minute Walk Test, and gait speed in people with Alzheimer disease. Phys Ther. 2009;89:569–579.
74. Vogt L, Lucki K, Bach M, Banzer W. Rollator use and functional outcome of geriatric rehabilitation. J Rehabil Res Dev. 2010;47:151–156.
75. Speechley M. Unintentional falls
in older adults: a methodological historical review. Can J Aging. 2011:1–12.
76. Legters K. Fear of falling
. Phys Ther. 2002;82:264–272.
77. Brouwer B, Musselman K, Culham E. Physical function and health status among seniors with and without a fear of falling
. Gerontology. 2004;50:135–141.
78. Hatch J, Gill-Body KM, Portney LG. Determinants of balance
confidence in community-dwelling elderly people. Phys Ther. 2003;83:1072–1079.
79. Kornetti DL, Fritz SL, Chiu YP, Light KE, Velozo CA. Rating scale analysis of the Berg Balance
Scale. Arch Phys Med Rehabil. 2004;85:1128–1135.
80. Nordin E, Rosendahl E, Lundin-Olsson L. Timed “Up & Go” Test: reliability in older people dependent in activities of daily living—focus on cognitive state. Phys Ther. 2006;86:646–655.