INTRODUCTION
Fall prevention is critical for preserving the health and independence of an older adult.1 Standardized assessment tools are commonly used both to identify those at risk of falling and to guide interventions.2 The Functional Gait Assessment (FGA) is one such tool, designed to quantify postural stability during a variety of walking tasks. The test was developed to reduce the ceiling effect on the Dynamic Gait Index3 and is used in both clinical and research settings. It is a reliable test of postural stability in community-dwelling older adults4 and has been shown to be a better predictor of falls than other available assessment tools.5
Editor's Note: See, however, Lusardi et al, Determining risk of falls in community dwelling older adults: A systematic review and meta-analysis using posttest probability. J Geriatr Phys Ther. 2017;40(1):1-36.
Because the FGA is used to assess fall risk in older adults, a patient could fall while being tested. For this reason, some clinicians may provide hands-on guarding when administering the FGA. Others feel that placing a hand on a patient may influence performance, thus altering the test results. Many medical facilities have policies and procedures that require the use of a gait belt during transfer and gait activities as part of standard patient care and risk management procedures.6 Functional Gait Assessment instructions do not specify how to guard, though inclusion criteria for a prior validity and reliability study on individuals with vestibular disorders required that participants be able to walk 20 ft without human assistance.3
Previous studies have investigated the effects of external contact on postural control. Active fingertip light contact on a stationary object during quiet stance,7 in response to an unexpected perturbation,8 and while walking9 has been shown to reduce body sway for both healthy and unsteady individuals. While active light contact on a stationary object improves stability, the same contact on a moving object does not appear to provide any additional support.9
Other studies have measured the effect of passive light contact on balance.10,11 Johannsen et al11 found that deliberately light interpersonal touch could facilitate balance control in individuals with neurologic deficits. No studies to date have measured the effect of passive light interpersonal touch when the intent is not to facilitate balance control but rather to prevent a fall to the ground. This type of light touch would occur when providing hands-on, or contact guarding (CG), during a standardized fall risk assessment. The purpose of this study was to determine the effect of hands-on guarding on performance during the FGA in community-dwelling older adults. On the basis of the intent of the guarding PT, we hypothesized that (1) there would not be a significant difference in FGA scores when comparing CG with standby guarding (SG), and (2) participants would not perceive a difference between the 2 guarding methods.
METHODS
Participants
Twenty-three community-dwelling aging and older adults were recruited from participants in annual Fall Prevention Awareness Day activities at a local community center between September 2016 and February 2017. All participants met the following inclusion criteria: (1) age 55 years or older; (2) no reported history of neurologic disorders affecting the central nervous system, such as stroke, traumatic brain injury, or spinal cord injury; and (3) well-controlled chronic medical conditions such as diabetes and hypertension. Exclusion criteria included (1) use of medications that might affect balance, (2) inability to follow directions and perform test procedures, (3) inability to stand independently for 20 minutes with or without an assistive device, and (4) a history of an orthopedic injury, surgery, or fracture in the past 6 months. After meeting these criteria, participants received oral and written information about the study from the researchers, but were blinded to the purpose of this study. Participants gave informed consent before testing. This study was approved by the Missouri State University institutional review board. The rights of human participants in this study have, and will continue to be protected.
Participants performed 2 trials of the FGA with a 2-minute seated rest period between trials. A single trial for each guarding method was deemed appropriate due to excellent FGA test-retest reliability described in studies by Lin et al12 (intraclass correlation coefficient [ICC] = 0.95; 95% CI, 0.91-0.97) and Leddy et al13 (ICC = 0.91; 95% CI, 0.80-0.96). Participants wore self-selected comfortable walking shoes during test procedures. The FGA was completed in a secluded area near a flight of stairs with a 20-ft walkway marked off as indicated in FGA instructions.3,5 The FGA assesses balance or postural stability during various walking tasks, including gait on level surface, change in gait speed, gait with horizontal head turns, gait with vertical head turns, gait with pivot turn, step over obstacle, gait with eyes closed, gait with narrow base of support, ambulating backward, and ascending and descending steps. Tasks are scored on an ordinal scale from 0 to 3, with 0 = severe impairment, 1 = moderate impairment, 2 = mild impairment, and 3 = normal ambulation. When used with community-dwelling older adults, scores of 22/30 or less were found to be predictive of falls.5
Testing instructions for each item were read to participants, as outlined in the FGA. A physical therapist (PT) with 19 years of clinical experience guarded all participants during both trials, one trial with SG and a second trial with hands-on or CG. The order of testing, with either SG or CG, was alternated for each consecutive participant. All variables remained constant under both FGA trials for this within-subjects design, except for guarding methods.
For both SG and CG conditions, a gait belt was placed around the participant's waist. However, only during the CG condition did the guarding PT touch the participant, by holding the underside of the gait belt with the forearm supinated and fingers in contact with the participant's lumbar region. When providing SG, the PT's hand was positioned near the lumbar region but not in contact with the participant or gait belt. The guarding PT's other hand was positioned anterior to, but not in contact with, the pectoral/shoulder region for both guarding conditions. These guarding techniques were selected because they follow descriptions provided in textbooks commonly used in PT education programs.14,15 If the guarding PT determined that the participant would not recover from a loss of balance and would subsequently fall to the ground, then hands-on assistance was immediately given to prevent a fall, regardless of the testing condition.
All trials were video recorded for scoring by 2 PT raters, each with more than 5 years of clinical experience. Neither received formal FGA training; however, both used the test in clinical practice. The PT raters were blinded to the purpose of the study and to each other. The recording view (Figure) was standardized for all participants using a direct anterior view for all items on the FGA, with exception of item 5 (gait and pivot turn) and item 10 (steps). For item 5, an anterior view became a posterior view at the end of the pivot turn. For item 10, a posterior view was recorded as the participant ascended stairs, resulting in an anterior view when descending the stairs. These views were chosen for clarity in judging gait deviations relative to marked lines on the floor, as outlined in the FGA, and to conceal the difference in guarding methods between the 2 conditions. In other words, from an anterior or posterior view alone, it would be difficult to discern whether the guarding PT's hand was in contact with, or simply near, the participant. Before scoring the recorded trials, PT raters were given the instruction that a raised hand by the guarding PT indicated that physical assistance to prevent a fall had been given. To further minimize potential rater bias between the 2 testing conditions, the order for viewing the recorded trials was edited such that trials of the same participant were not consecutively presented to the PT raters.
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Figure.: Functional Gait Assessment recording view.
Data Analyses
Data analyses were conducted using IBM SPSS for Macintosh, version 24.16 Data were de-identified and entered electronically into a spreadsheet. Data screening was used to identify accuracy, missing data, outliers, linearity, and heteroscedasticity. No violations of the data assumptions were found. Descriptive statistics were calculated; nominal data were reported as frequencies and percentages, and continuous data were reported as means and standard deviations. Normality of the data was assessed using the Shapiro-Wilk test. Bivariate comparisons were conducted on participant demographic variables to look for differences between CG and SG conditions. Intraclass correlation coefficients were used to determine interrater reliability. In accordance with Portney and Watkins,17 an ICC of 0.75 was considered a minimum for good reliability and an ICC of greater than 0.90 indicated excellent reliability with reasonable validity. A paired-samples t test was used to compare the sum of CG FGA scores with the sum of SG FGA scores (based on average scores of 2 raters that were summed to create totals). Finally, nominal data were compared using a Fisher's exact test.
RESULTS
Among the 23 participants, 16 were women and 7 were men. The mean age was 73.6 (SD = 6.2) years, with a minimum of 63 years and a maximum of 87 years. Participant scores for the FGA, under different guarding conditions, as scored by each PT rater, are shown in the Table.
Table. -
Functional Gait Assessment Scores by Guarding Methods (N = 23)
| Measurement |
Mean (SD) |
| Rater 1 FGA CG |
20.7 (5.4) |
| Rater 2 FGA CG |
19.8 (6.4) |
| Rater 1 FGA SG |
20.4 (4.7) |
| Rater 2 FGA SG |
19.9 (6.0) |
Abbreviations: FGA CG, Functional Gait Assessment with contact guarding; FGA SG, Functional Gait Assessment with standby guarding.
Dependent variables were assessed for normality using the Shapiro-Wilk test. Neither the CG (W23 = 0.941, P = .186) nor SG (W23 = 0.964, P = .544) distributions differed from normality. The ICC indicated high internal agreement between the raters for both CG and SG conditions (CG: ICC = 0.949; SG: ICC = 0.935). Further comparative analysis was conducted by averaging scores categorized within similar ranges. No significant differences were found between the scores of PT rater 1 and PT rater 2 on either guarding condition. The paired-samples t test comparing the sum of CG FGA scores with the sum of SG FGA scores did not indicate a significant difference between the 2 guarding methods (t22 = 0.15, P = .882, corrected d = 0.02; 95% CI, −1.11 to 1.29).
Participants were asked whether they felt they performed better on one trial than on the other. Fifteen of 23 participants (65%) felt that they performed better on the second trial, with 3 of those participants (13%) stating that they felt more confident and knew what to expect. Three participants (13%) felt they performed worse on the second trial because they were tired, whereas the remaining 5 participants (22%) felt they performed the same on both trials. In addition, when asked whether they noticed any difference between the trials, 18 of 23 participants (78%) perceived no difference in the trials. The remaining 5 participants (22%) noticed only a difference in their performance. None of the participants reported a difference in guarding methods during the 2 trials. All participants meeting the inclusion and exclusion criteria completed both trials of the FGA. No falls to the ground occurred during testing, and there were no reported injuries.
DISCUSSION
The purpose of this study was to compare the effects of SG with CG on performance during the FGA with community-dwelling older adults. Very high interrater reliability for FGA total scores was found under both SG and CG conditions. Our results for SG (ICC = 0.935) and CG (ICC = 0.949) are similar to those found by Walker et al4 (ICC = 0.93), who tested community-dwelling older adults using SG, and slightly higher than those found by Wrisley et al3 (ICC = 0.86), who tested individuals with vestibular deficits under a no guarding condition.
An accurate fall risk assessment using the FGA has widespread clinical and research implications. As a predictor of fall risk,5 FGA scores may provide justification for intervention. In the case of chronic stroke, FGA scores may direct clinicians toward more targeted interventions, including guidance with recommendations related to independent living.18 As a reliable measure of postural stability in community-dwelling older adults,4 researchers may use FGA scores as outcome measures that may lead to clinical practice guidelines. However, the desire for accuracy in testing should not compromise participant safety.
It has been our experience that efforts to reduce the risk of a fall during a standardized fall risk assessment are usually through SG or CG methods. While the FGA does not specify how to guard, previous studies have used an SG or no guarding design.3,4 Walker et al4 used a gait belt around the waist of all participants in determining FGA group reference data, though all participants received SG. A possible advantage of SG is the participant may feel unconstrained or unassisted, more closely representing “real-world” performance. A possible disadvantage is the added time to make contact with the participant, potentially coming too late. On the contrary, a perceived need to react sooner than later may cause the SG PT to overreact to a minor loss of balance for which a participant might have recovered unassisted.
In contrast, CG could aid in more accurate testing, as the guarding PT may allow for greater loss of balance with potential for recovery, knowing a hand is prepositioned to assist. This may be especially important when the participant's center of mass moves downward or away from the guarding PT. Under these circumstances, a preemptive CG position, grasping a securely fastened gait belt, may be less perturbing to balance than reactive hands-on assistance when using SG, though the results of this study do not indicate that this occurred.
On the contrary, CG could inadvertently perturb balance in ways that are helpful or a hindrance. Johannsen et al11 were able to reduce sway using deliberately light interpersonal touch applied to sites on the posterior torso and elbow of individuals with Parkinson's disease and chronic stroke. The authors did not quantify the deliberately light interpersonal force applied via 4 fingers, though it was estimated to be about 1 N. In addition, Johannsen et al11 replicated previous findings that higher contact points were more helpful at reducing sway than lower points,10 and 2 points of simultaneous contact were more effective than one.10,19 During CG in the current study, the PT's hand was in constant contact with the participant's lumbar region, ready to directly assist at the point of contact or indirectly through the gait belt. Based on results from Johannsen et al,11 the CG effect on sway in the current study may have been reduced because of using a single low point of contact on the lumbar region, though the effect on sway is potentially broader when exerting a force through the gait belt.
Another difference between the current study and the Johannsen et al11 design is the purpose for the contact. Deliberately light interpersonal touch is intended to aid balance before sway requires a notable corrective mechanical force. This was evidenced by the use of a second person to guard the participant in the event of a fall.11 In contrast, the intent with CG in the current study was to avoid assistance, unless required to prevent a fall to the ground. Furthermore, testing conditions on the FGA likely allow for more sway than the Johannsen et al design, as the participant is allowed to move the base of support.
In addition to sensorimotor and biomechanical effects of guarding, psychological factors should be considered. Balash et al20 found reduced fear of falling in older adults with a high-level gait disorder via handholding assistance or by walking alongside the participant. Although fear was reduced, neither condition improved gait performance when compared with walking alone. Similarly, the current study results do not indicate that performance was affected by potential differences in confidence between guarding methods.
Also, of significance from the current study was the qualitative finding that not a single participant mentioned the guarding method when asked about possible differences between the 2 trials. This may indicate that the CG was subtle and inconsequential, as supported by the results. Another possible explanation may be an increased cognitive demand with the multistep instructions on the FGA, which may have diverted attention from the actions of the guarding PT. In previous studies regarding the effect of light touch on sway, comparatively simple instructions were given.7–11
A final potential cause for lack of perceived difference in guarding methods may relate to the frequency of required assistance. While nearly half of the participants in the current study scored within the at-risk-to-fall range,5 all were community-dwelling older adults. Perhaps, perceived differences in guarding methods would be more apparent with individuals who are more dependent on the guarding PT to prevent a fall.
In addition to fall risk assessment, the results of this study may be relevant to guarding methods for treatment, as postural perturbations are necessary for both conditions. Both require the guarding PT to skillfully act as a “safety net,” while minimizing interference with a patient's natural postural adjustments.
This study is the first published comparison of guarding methods on a standardized fall risk assessment. The results support our hypotheses that there would not be a significant difference in performance on the FGA when comparing CG with SG, and participants would not perceive a difference in guarding methods.
Study Limitations
The same PT guarded all participants, thus controlling for variability in how the guarding methods were applied between the 2 testing conditions and across the sample. However, individual characteristics of the guarding PT, such as proficiency that comes with experience in guarding, may have allowed for similar participant performance under each guarding condition. A second limiting factor is that participants in this study were all community-dwelling older adults. Participants with greater impairment and dependence on guarding assistance to prevent a fall may have been more influenced by the guarding method.
CONCLUSIONS
The results of this study indicate that hands-on guarding does not significantly influence performance on the FGA when guarding is provided by an experienced PT and the participant is a community-dwelling older adult. These findings should provide clinicians and researchers with greater assurance that, under these conditions, participant safety can be maintained at a higher level without compromising results. Future studies should investigate whether individual characteristics of the guarding PT, such as experience, influence FGA performance and whether low-functioning participants are more influenced by the guarding method. Such studies should also compare CG with SG on other standardized fall risk assessments, especially those where the cognitive demand is lower and less likely to divert attention from the actions of the guarding PT. A final recommended area for future investigation is to determine whether treatment interventions that require guarding to prevent a fall are influenced by the type of guarding.
Clinical Relevance
An experienced PT may use hands-on guarding when administering the FGA on a community-dwelling older adult without significantly affecting the FGA score.
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