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Use of Clinical and Impairment-
Based Tests to Predict Falls by
Community-Dwelling Older Adults
5.64) were
tested.
Methods.
Subjects were tracked for falls over a 1-year period
following testing. Impairment-based tests, which are tests that attempt
to specifically identify which sensory systems are impaired or how
motor control is impaired (eg, speed, accuracy of movement), were the
Modified Clinical Tests of Sensory Interaction for Balance (Modified
CTSIB) and the 100% Limits of Stability Test, both of which were done
on the Balance Master 6.1. Performance-based tests, which are func-
tional tests that identify functional limitations without necessarily
identifying their causes, were the Berg Balance Scale, the Timed “Up
& Go” Test, and the Dynamic Gait Index. Demographic and health
data included age, sex, number of medications, physical activity level,
presence of dizziness, vision problems, and history of falls over the
previous year. Logistic regression was used to determine which com-
binations of data from balance tests, demographics, and health factors
were predictive of falls.
Results.
Two models—(1) the “standing on a
firm surface with eyes closed” (FEC) condition of the Modified CTSIB
and (2) the FEC combined with age and sex—were predictive of falls,
but predicted only 1 and 2 subjects who were at risk for falling,
respectively, out of 20 people who were at risk for falling.
Discussion
and Conclusion.
Five balance tests combined with health and demo-
graphic factors did not predict falls in a sample of community-dwelling
older adults who were active and independent. [Boulgarides LK,
McGinty SM, Willett JA, Barnes CW. Use of clinical and impairment-
based tests to predict falls by community-dwelling older adults.
Phys
Ther
. 2003;83:328 –339.]
74.02, SD
Key Words:
Balance tests, Fall prediction, Older adults.
Lois K Boulgarides, Susan M McGinty, Jayne A Willett, Carole W Barnes
328
Physical Therapy . Volume 83 . Number 4 . April 2003
Background and Purpose.
Few tests have been found to be strongly
predictive of falls in community-dwelling older adults. The purpose of
this study was to determine whether data from 5 balance tests—
combined with data regarding fall history, number of medications,
dizziness, visual problems, use of an assistive device, physical activity
level, sex, and age— could predict falls in community-dwelling older
adults who were independent.
Subjects.
Ninety-nine community-
dwelling older adults aged 65 to 90 years (X
years and older fall each year.
1– 4
The high
fall incidence in older adults is costly in terms
of both health care dollars and quality of life.
Most older adults hospitalized for falls are discharged to
long-term care facilities.
5
Fear of falling is an important
factor that affects the willingness of many older adults to
participate in physical activity and exercise.
6,7
Cessation
of physical activities, whether due to fear of falling or
due to declining mobility and balance, accelerates the
decline in muscle force production and function, fur-
ther increasing fall risk and further decreasing quality of
life.
6,7
Low fall-related self-efficacy has been associated
with decreased function, increased fall risk, and risk of
admission to assisted living or long-term care
institutions.
6,7
retirement facility, or community. Some researchers
11–14
have found multifaceted intervention programs that
include exercise to increase muscle force, flexibility, and
balance to be effective approaches.
A number of fall-risk screening tests have been used to
identify people at risk for falling (“fallers”) among
residents of nursing homes; however, these tests are less
predictive of falls in older adults who have fewer health
problems, live independently, and are more active.
15,16
The Berg Balance Scale (BBS),
17,18
the Tinetti
Performance-Oriented Mobility Assessment (POMA),
19
the Tinetti Balance Subscales,
19
and the Timed “Up &
Go” Test (TUGT)
20
were developed for, and validated
primarily on, residents of nursing homes.
A number of interventions to improve balance and
decrease fall risk have been found to be effective.
8 –10
Interventions may be performed in the hospital, clinic,
The usefulness of a test in predicting falls may vary
depending on the health status and level of function of
the older adults being tested. In a study of community-
dwelling older adults who were in good health, O’Brien
LK Boulgarides, PT, MS, is Lecturer, Kinesiology and Health Science Department, California State University, Sacramento, 6000 J St, Sacramento,
CA 95819-6073 (USA) (boulgarides@csus.edu), and Faculty Director, CSUS LIFE Center for Senior Fitness and Wellness. Address all
correspondence to Ms Boulgarides.
SM McGinty, PT, EdD, is Chair, Department of Physical Therapy, California State University, Sacramento.
JA Willett, PhD, ATC, is Associate Professor, Kinesiology and Health Science Department, California State University, Sacramento.
CW Barnes, PhD, is Professor, Department of Sociology, California State University, Sacramento, and Director, CSUS Institute for Social Research.
All authors provided concept/research design. Ms Boulgarides, Dr McGinty, and Dr Willett provided writing, data collection, project management,
fund procurement, and subjects. Ms Boulgarides, Dr McGinty, and Dr Barnes provided data analysis. Dr McGinty and Dr Willett provided
facilities/equipment and consultation (including review of manuscript before submission). Ms Boulgarides and Dr McGinty provided institutional
liaisons. Dr McGinty provided clerical/secretarial support. The authors thank Edward Barakatt for assistance with statistical analysis and Heather
Carling-Smith and Patricia A Harris for their contributions to data collection. The authors also thank the baccalaureate and post-baccalaureate
students from the Department of Kinesiology and Health Science and the Department of Physical Therapy, California State University,
Sacramento, for their assistance with subject recruitment and data collection.
This study was approved by the California State University, Sacramento, Committee for Protection of Human Subjects.
This study was supported by a grant from the California State University, Sacramento, Research and Creative Activity Committee.
This article was submitted May 8, 2002, and was accepted November 22, 2002.
Physical Therapy . Volume 83 . Number 4 . April 2003
Boulgarides et al . 329
A
n estimated 25% to 35% of adults aged 65
Table 1.
Subject Characteristics (N
99)
Method
n% X SD Median Range
Subjects
One hundred six community-dwelling
older adults (age range
Age (y)
74.02 5.64 74
65–90
65–90 years)
who were independent were recruited
from retirement communities, senior
centers, the 50-Plus Wellness Program,
and the general community in Sacra-
mento, Calif. Ninety-nine subjects (60
women and 39 men) completed the
study. One subject died, 1 subject
declined to continue the study, and 5
subjects could not be reached for con-
tinued follow-up.
No. of medications
2.74 2.26
2
0–10
Sex
Female
60 61
Male
39 39
Reported dizziness
No
43 43.4
Yes
56 56.6
Reported vision problems (corrected)
No
94 94.9
Yes
5
5.1
Use of assistive device
No
89 89.9
In order to participate in the study,
subjects must have been able to stand
for at least 5 minutes without an assis-
tive device and to walk a minimum of
12 m (40 ft) at a time with or without an
assistive device. Inclusion criteria were
communicated through recruiting
materials, confirmed by telephone
when appointments were scheduled,
and reconfirmed in the medical history
questionnaire at the time of testing.
People with cognitive deficits or medical or neurological
problems were excluded only if the condition prevented
them from meeting the inclusion criteria. No screening
for dementia was done, but all subjects were able to
follow directions, give appropriate responses to survey
questions, and participate in the interview process with-
out assistance. Subjects with conditions such as heart or
pulmonary problems, in which mild activity could cause
medical risk during the testing, were excluded from the
study. Before participating in the study, all subjects
signed an informed consent form that summarized the
purpose of the study, explained risks and discomforts,
indicated that all information gathered would remain
confidential, and assured subjects that they could with-
draw at any time.
Yes
10 10.1
History of falls
0
49 49.5
1–2
33 33.3
3 or more
17 17.2
Regular physical activity
No regular exercise
12 12.1
Regular exercise
87 87.9
et al
16
found the BBS was less sensitive in predicting falls
than did Berg et al
17
who studied residents of a nursing
home. Other researchers
21
studying community-
dwelling older adults found BBS scores to be predictive
of falls. The fallers, however, were only those who had a
history of recurrent falls, which, in our opinion, indi-
cates that the group was at greater fall risk. Thus, the
BBS may better identify older adults who have greater
impairments and who are at risk for falls than older
adults who are in good health and more active but who
also may be at risk for falls.
Many factors affect a person’s likelihood of falling. Age,
vision, muscle force, flexibility, sensation, balance, num-
ber and type of medications, cognitive impairment, and
concomitant medical problems have all been associated
with fall risk.
2– 4,19
The purpose of our study was to
determine whether data from a combination of 5 bal-
ance assessment tests— combined with data regarding
fall history, number of medications, dizziness, visual
problems, use of an assistive device, physical activity
level, sex, and age— could predict fall risk in a group of
community-dwelling older adults who were indepen-
dent. The balance tests that we used were the BBS,
17,18
the Dynamic Gait Index (DGI),
11,21
the TUGT,
20
the
100% Limits of Stability Test (100% LOS),
22
and the
Modified Clinical Test of Sensory Interaction for Bal-
ance (Modified CTSIB).
23,24
Table 1 summarizes the subjects’ demographic informa-
tion. Subjects had a mean age of 74.02 years (SD
5.64,
65–90). The number
o
f medications the subjects
took ranged from 0 to 10 (X
2.26). Fifty-six
subjects (56.6%) reported problems with dizziness, 5
subjects (5.1%) reported vision problems when using
corrective lenses, 10 subjects (10.1%) reported using an
assistive device, and 87 subjects (87.9%) reported being
involved in regular physical exercise. Seventeen subjects
(17.2%) recalled falling 3 or more times, 33 subjects
(33.3%) recalled falling 1 or 2 times, and 49 subjects
(49.5%) recalled no falls in the year prior to the study.
2.74, SD
330 . Boulgarides et al
Physical Therapy . Volume 83 . Number 4 . April 2003
range
Procedure
Subjects were tested one time for the study. They were
then followed for 12 months to track falls. Testing was
performed in the Kinesiology/Physical Therapy Labora-
tory at California State University, Sacramento, by phys-
ical therapy and kinesiology faculty and by graduate and
undergraduate students in physical therapy and
kinesiology.
identifying their causes. Impairment-based tests, which
were done using the Balance Master 6.1, are tests that
attempt to specifically identify which sensory systems are
impaired or how motor control is impaired (eg, speed,
direction of movement, accuracy of movement). Two
test administrators were present for each subject’s test-
ing. One tester administered the test, and the other
tester assisted primarily by standing by the subject to
prevent falls during testing. All subjects wore gait safety
belts throughout the balance testing.
Before administering the tests, students and faculty
completed 6 hours of training and practice in the
correct use of the NeuroCom Balance Master 6.1,*
administration and recording of all tests, and interview
techniques. All were tested for the reliability of their data
collection skills. We were concerned about the reliability
of the data collected by all testers because the BBS and
DGI require raters to make a judgment about movement
quality. Interrater reliability for these tests was estab-
lished by having all testers view videotapes of 3 subjects
and judge movement quality using the BBS and the DGI.
An 80% or better agreement between testers was
achieved before proceeding with subject testing. Reli-
ability was not assessed with the use of any statistics, such
as those that correct for chance agreement or are based
on probabilistic models.
Each subject was given a booklet at the end of the
balance test session. The booklet contained a calendar
for recording falls, the definition of a fall, and instruc-
tions for use of the calendar. Subjects were asked to
record daily whether a fall occurred. Details of any falls,
including time, location, and circumstances, were
recorded on a form provided on the back of each
month’s page.
Telephone Survey
Follow-up contact was made by telephone or e-mail every
2 to 4 weeks during the 12 months following the balance
assessment to track the subjects’ fall history. Subjects
referred to their fall calendars to report losses of bal-
ance. If a fall had occurred, the subjects were asked
whether they were injured and whether they sought
medical attention. Subjects were asked if they were using
the fall calendar on a daily basis and were encouraged to
continue daily recording of fall status.
Subjects were interviewed about their medical history,
history of falls, and physical activity. Medical history
included questions about vision (with and without cor-
rective lenses, in poor light), dizziness experienced in
the year before the study, number of medications,
cardiac and pulmonary problems, use of an assistive
device, and cancer. Fall history was determined by
self-report of the number of falls that the subject recalled
from the previous year, including the time of day,
location, conditions, and injuries. A
fall
was defined as
any disturbance of balance during routine activities that
resulted in a person’s trunk, knee, or hand unintention-
ally coming to rest on the ground, wall, table, chair, or
some other surface. Physical activity was determined by
self-report of the activity type and how often and how
regularly the activity was performed in the year before
the study. Subjects were classified as “active” if they
exercised regularly at least one time per week.
Balance Tests
The balance assessment consisted of 3 performance-
based balance tests (BBS, TUGT, and DGI) and 2
impairment-based tests (Modified CTSIB and 100%
LOS). Both impairment-based tests were conducted
using the NeuroCom Balance Master 6.1.
.97–.98).
18
Cri-
terion validity was established in a study of 31 subjects
with a mean age of 83 years. The BBS scores were
correlated to the Tinetti Balance Subscale and the
TUGT (
r
After the interview, 2 subjects were tested at a time.
Subjects’ heights were measured to the nearest half inch.
One subject was given performance-based tests (the BBS,
TUGT, and DGI) followed by impairment-based tests
(100% LOS and Modified CTSIB) on the NeuroCom
Balance Master 6.1. The other subject was given
impairment-based tests, followed by performance-based
tests. Performance-based tests are functional tests that we
believe identify functional limitations without necessarily
.76 –.91).
17
The BBS is designed to challenge
subjects to keep their balance with an increasingly
narrow base of support; the initial level is sitting, and the
final level is one-leg standing. Weight shifting, turning,
and reaching also are measured. Points for each item are
totaled. The highest possible score is 56 points. In a
clinical setting, the cutoff score to separate fallers from
people who are not at risk for falling (“nonfallers”)is
usually 45 points.
15
We used the BBS score for statistical
analysis, rather than as a cutoff value for distinguishing
fallers from nonfallers.
* NeuroCom International, 9570 SE Lawnfield Rd, Clackamas, OR 97015.
Physical Therapy . Volume 83 . Number 4 . April 2003
Boulgarides et al . 331
Berg Balance Scale.
Reliability of data obtained with
the BBS has been established in a previous study of 35
residents of nursing homes and 35 patients with stroke
(intraclass correlation coefficient [ICC]
Dynamic Gait Index.
The DGI uses 8 test items to
measure a person’s ability to accommodate to changes in
environment, speed, and head position during gait.
Tasks are rated on a 3-point scale from 0 (unable) to 3
(normal execution). The highest possible score is 24.
The rating is based on the person maintaining normal
gait pace (a person’s natural walking pace) and staying
within a 38.1-cm-wide (15-in) pathway without stumbling
or staggering during walking. This test is designed to
demand many of the adjustments to gait that should
occur when walking in the community or home, includ-
ing walking with horizontal and vertical head turns,
walking while speeding up and slowing down, walking
over and around objects, and ascending and descending
stairs. No studies measuring intrarater and interrater
reliability of data obtained with the DGI as a single test
have been found. We chose the DGI for our study
because we believed it to be the most challenging gait
mobility test available for older adults. For statistical
analysis, we used the DGI score rather than a cutoff value
to distinguish fallers from nonfallers.
with the Modified CTSIB on the Balance Master uses
dual force platforms to measure amplitude, direction,
and speed of movement of a person’ center of pressure.
Subjects stood straight and still on a force platform
during three 20-second trials in each of the 4 conditions.
For each condition, each subject’s feet were placed in
the standard position recommended by the manufac-
turer of the Balance Master.
26
Foot position was moni-
tored throughout the test. If foot placement changed,
the feet were again placed in the correct position. The
Modified CTSIB gives 2 sets of data collected by the
computer from the 4 conditions. Data include mean
center of pressure sway speed (which is measured in
degrees per second) and average center of pressure
position (which measures deviation of the center of
pressure in degrees over 20 seconds). We used center-
of-pressure speed for the 4 conditions and composite
sway for statistical analysis. In a study of 12 subjects from
24 to 68 years of age (X
.91 for FEO, ICC
Timed “Up & Go” Test.
The TUGT is measured with a
stopwatch. The subject is instructed to move from a
seated position in a chair to a standing position, walk 3 m
(10 ft) at a normal and safe pace, turn around, walk back
to the chair, and sit down. The subject is given a practice
trial followed by 2 timed trials. The 2 timed trials are
averaged for each subject’s score. Excellent intertester
and intratester reliability of data obtained with the
TUGT were established (ICC
.97 for FEC).
27
It should be noted, however, that
the sample studied was much younger than the sample
used in the present study.
.99 for both) in a study of
60 older adults who were frail and 10 older adults who
were in good health.
20
Trueblood et al
24
felt that a cutoff
time of 10 to 12 seconds separated fallers from nonfall-
ers in a group of community-dwelling older adults. A
20-second cutoff time had previously been used when
testing elderly people who were frail for independence
in functional mobility.
20
In another study in which
investigators chose a 14-second cutoff time, the TUGT
was found to have 87% sensitivity of correctly predicting
fallers and 87% specificity for correctly predicting non-
fallers.
25
In our study, we did not use a cutoff time, but
we used total time in the logistic regression equation.
100% Limits of Stability Test.
A theoretical 100% LOS is
established for each person by the Balance Master 6.1
software based on the person’s height. This theoretical
100% LOS is the maximum angle a person of a given
height should be able to sway the body over the feet
without losing balance and having to take a step. It is
measured by a person’s ability to shift his or her center
of pressure from a center point to 8 targets viewed on a
computer screen that are placed around the center of
pressure: front, sides, back, and 4 diagonal points. The
targets represent the maximum distance the person
should be able to sway the center of pressure in any
direction without losing balance and having to change
foot position.
The 100% LOS provides 5 sets of information as a
person shifts his or her center of pressure from the
center toward individual visual targets on the computer
screen.
Reaction time
, measured in milliseconds, is the
time from the computer’s command to move and the
initiation of movement.
Movement speed
, measured in
degrees per second, is the average speed of movement of
the center of pressure.
End-point excursion
is the greatest
distance reached by the center of pressure in the first
sustained attempt to reach the target and is expressed as
a percentage of a straight line from center to target.
Readjustments in position after the initial movement are
not calculated in end-point excursion.
Maximum excur-
sion
is the greatest distance reached by the center of
pressure toward the target during the target’s entire trial
Modified Clinical Test for Sensory Interaction on Balance.
The Modified CTSIB was conducted on the NeuroCom
Balance Master 6.1.
26
The Modified CTSIB examines
postural sway during the 4 conditions assessed for the
CTSIB: “standing on a firm surface with eyes open”
(FEO), “standing on a firm surface with eyes closed”
(FEC), “standing on a foam surface with eyes open”
(FOEO), and “standing on a foam surface with eyes
closed” (FOEC). Composite sway is the mean sway speed
averaged over the 4 conditions. Each condition is tested
3 times. Although visual examination of amplitude and
speed of sway is used as a measure in the CTSIB, testing
332 . Boulgarides et al
Physical Therapy . Volume 83 . Number 4 . April 2003
42.2), test-retest reliability for
the Modified CTSIB using only FEO and FEC conditions
was found to be high (ICC [3,4]
[3,4]
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