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1.  Relationship Between Fall-Related Efficacy and Activity Engagement in Community-Dwelling Older Adults: A Meta-Analytic Review 
OBJECTIVE
Fear of falling can lead to restricted activity, but little is known about how this fear affects different aspects of people’s lives. This study examined the relationship between fall-related efficacy (i.e., confidence or belief in one’s ability to perform activities without losing balance or falling) and activity and participation.
METHOD
We conducted a meta-analysis of studies comparing community-dwelling older adults’ fall-related efficacy to measures of activity or participation.
RESULTS
An examination of 20 cross-sectional and prospective studies found a strong positive relationship between fall-related efficacy and activity (r = .53; 95% CI [.47, .58]). An insufficient number of studies examining fall-related efficacy and participation were available for analysis.
CONCLUSION
Low fall-related efficacy may be an important barrier to occupational engagement for many older adults and warrants careful consideration by occupational therapists. Future research should explore interventions that target fall-related efficacy and examine their effects on activity performance and engagement.
doi:10.5014/ajot.2012.001156
PMCID: PMC3324848  PMID: 22394523
accidental falls; activities of daily living; fear; self efficacy
2.  Characteristics Associated with Fear of Falling and Activity Restriction in Community-Living Older Persons 
OBJECTIVES
To identify the characteristics associated with restricting activity because of fear of falling (activity restriction) and to determine which characteristics distinguish older persons who restrict activity from those who have fear of falling but do not restrict their activities (fear of falling alone).
DESIGN
Population-based cross-sectional study.
SETTING
General community.
PARTICIPANTS
One thousand sixty-four community-living persons aged 72 and older.
MEASUREMENTS
Candidate predictors were identified from the following domains: demographic, health status, physical, psychosocial, and fall-related. The outcome measure was the report of no fear of falling, fear of falling alone, or activity restriction.
RESULTS
Fifty-seven percent of the cohort reported no fear of falling, 24% reported fear of falling alone, and 19% reported restricting activity. The proportion of participants with poor health status, slow timed physical performance, activities of daily living disability, and poor psychosocial function was highest in those with activity restriction, intermediate in those with fear of falling alone, and lowest in those with no fear of falling. Of participants with fear of falling, characteristics independently associated with activity restriction were history of an injurious fall, slow timed physical performance, two or more chronic conditions, and depressive symptoms.
CONCLUSION
Older persons who restrict activity are more physically frail and have a greater burden of chronic conditions and depressive symptoms than those who have fear of falling alone. These differences between persons with fear of falling may guide the refinement of clinical interventions and preventative programs.
PMCID: PMC3046411  PMID: 11943049
activity restriction; fear of falling; falling; older population
3.  Disparity in the Fear of Falling Between Urban and Rural Residents in Relation With Socio-economic Variables, Health Issues, and Functional Independency 
Annals of Rehabilitation Medicine  2013;37(6):848-861.
Objective
To investigate disparities in the fear of falling between urban and rural communities in relation to socio-demographics, health status, and functional level.
Methods
A total of 974 subjects aged 40 years or older participated in this study (335 urban residents and 639 rural). They completed a questionnaire about socio-demographics, health-related variables, and experience with falls. We employed both direct questioning and the Korean version of Falls Efficacy Scale-International (KFES-I) to investigate fear of falling in terms of perceptive fear and higher level of concern over falling during daily activities. The Korean version of Instrumental Activities of Daily Living was used to assess functional independency.
Results
Aging, female gender, fall history, and the presence of chronic medical problems were independently associated with higher prevalence for the fear of falling. Both perceptive fear of falling and a higher level of concern over falling were more prevalent in the rural senior population compared with those in the urban population when they had the following characteristics: lower income or educational background, physical laborer or unemployed, no chronic medical morbidity, or functional independency in daily activities.
Conclusion
The disparity in the fear of falling between the two areas is thought to be related to age structure, and it may also exist in healthy or functionally independent senior populations under the influence of socio-environmental factors. A senior population with lower socio-economic status residing in a rural area might be related with a greater vulnerability to the fear of falling. We should consider regional characteristics when we design fall-related studies or develop fall-prevention programs at the community level.
doi:10.5535/arm.2013.37.6.848
PMCID: PMC3895525  PMID: 24466520
Accidental falls; Geriatric assessment; Activities of daily living
4.  Feasibility of a cognitive behavioural group intervention to reduce fear of falling and associated avoidance of activity in community-living older people: a process evaluation 
Background
Fear of falling and associated avoidance of activity are common among older people and may have negative consequences in terms of functional decline, quality of life and institutionalisation. We evaluated the effects of a cognitive behavioural group intervention to reduce fear of falling and associated avoidance of activity among older persons. This intervention showed favourable effects on fear of falling, avoidance of activity, daily activity, and several secondary outcomes. The aim of the present study is to assess the feasibility of this cognitive behavioural group intervention for participants and facilitators.
Methods
The intervention consisted of eight weekly group sessions lasting two hours each and a booster session after six months. Self-administered questionnaires, registration forms and interviews were used to collect data from participants (n = 168) and facilitators (n = 6) on the extent to which the intervention was performed according to protocol, participant attendance, participant adherence, and participants' and facilitators' opinion of the intervention. Quantitative data from the questionnaires and registration forms were analysed by means of descriptive statistics. Qualitative data were categorised based on matching contents of the answers.
Results
Facilitators reported no major protocol deviations. Twenty-six percent of the participants withdrew before the start of the programme. Of the persons who started the programme, 84% actually completed it. The participants reported their adherence as good, but facilitators had a less favourable opinion of this. The majority of participants still reported substantial benefits from the programme after six and twelve months of follow-up (71% and 61% respectively). Both participants and facilitators provided suggestions for improvement of the intervention.
Conclusion
Results of this study show that the current cognitive behavioural group intervention is feasible for both participants and facilitators and fits in well with regular care. Minor refinement of the intervention, however, is warranted to further improve intervention effectiveness and efficiency. Based on these positive findings, we recommend implementing a refined version of this effective and feasible intervention in regular care.
Trial registration
ISRCTN43792817
doi:10.1186/1472-6963-7-156
PMCID: PMC2194766  PMID: 17900336
5.  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.
Background
Fear of falling and avoidance of activity are common in old age and are suggested to be (public) health problems of equal importance to falls. Earlier studies of correlates of fear of falling and avoidance of activity did hardly differentiate between severe and mild levels of fear of falling and avoidance of activity which may be relevant from clinical point of view. Furthermore, most studies focused only on socio-demographics and/or health-related variables and hardly incorporated an extensive range of potential correlates of fear of falling including psychosocial variables. This study analyzes the univariate and multivariate associations between five socio-demographic, seven health-related and six psychosocial variables and levels of fear of falling and avoidance of activity in older persons who avoid activity due to fear of falling.
Methods
Cross-sectional study in 540 community-living older people aged ≥ 70 years with at least mild fear of falling and avoidance of activity. Chi-squares, t-tests and logistics regression analyses were performed to study the associations between the selected correlates and both outcomes.
Results
Old age, female sex, limitations in activity of daily living, impaired vision, poor perceived health, chronic morbidity, falls, low general self-efficacy, low mastery, loneliness, feelings of anxiety and symptoms of depression were identified as univariate correlates of severe fear of falling and avoidance of activity. Female sex, limitations in activity of daily living and one or more falls in the previous six months correlated independently with severe fear of falling. Higher age and limitations in activity of daily living correlated independently with severe avoidance of activity.
Conclusion
Psychosocial variables did not contribute independently to the difference between mild and severe fear of falling and to the difference between mild and severe avoidance of activity due to fear of falling. Although knowledge about the unique associations of specific variables with levels of severe fear of falling and avoidance of activity is of interest for theoretical reasons, knowledge of univariate association may also help to specify the concepts for developing interventions and programmes to reduce fear of falling and avoidance of activity in old age, particularly in their early stages of development.
doi:10.1186/1471-2458-9-170
PMCID: PMC2698855  PMID: 19490640
6.  Relationship between location and activity in injurious falls: an exploratory study 
BMC Geriatrics  2010;10:40.
Background
Knowledge about the circumstances under which injurious falls occur could provide healthcare workers with better tools to prevent falls and fall-related injuries. Therefore, we assessed whether older persons who sustain an injurious fall can be classified into specific fall types, based on a combination of fall location and activity up to the moment of the fall. In addition, we assessed whether specific injurious fall types are related to causes of the fall, consequences of the fall, socio-demographic characteristics, and health-related characteristics.
Methods
An exploratory, cross-sectional study design was used to identify injurious fall types. The study population comprised 333 community-dwelling Dutch elderly people aged 65 years or over who attended an accident and emergency department after a fall. All participants received a self-administered questionnaire after being discharged home. The questionnaire comprised items concerning circumstances of the injurious fall, causes of the fall, consequences of the fall, socio-demographic characteristics and health-related characteristics. Injurious fall types were distinguished by analyzing data by means of HOMALS (homogeneity analysis by means of alternating least squares).
Results
We identified 4 injurious fall types: 1) Indoor falls related to lavatory visits (hall and bathroom); 2) Indoor falls during other activities of daily living; 3) Outdoor falls near the home during instrumental activities of daily living; 4) Outdoor falls away from home, occurring during walking, cycling, and shopping for groceries. These injurious fall types were significantly related to age, cause of the fall, activity avoidance and daily functioning.
Conclusion
The face validity of the injurious fall typology is obvious. However, we found no relationship between the injurious fall types and severity of the consequences of the fall. Nevertheless, there appears to be a difference between the prevalence of fractures and the cause of the fall between the injurious fall types. Our data suggests that with regard to prevention of serious injuries, we should pay special attention to outdoor fallers and indoor fallers during lavatory visits. In addition, we should have special attention for causes of the fall. However, the conclusions reached in this exploratory analysis are tentative and need to be validated in a separate dataset.
doi:10.1186/1471-2318-10-40
PMCID: PMC2902483  PMID: 20565871
7.  Recurrent Falls in Parkinson's Disease: A Systematic Review 
Parkinson's Disease  2013;2013:906274.
Most people with Parkinson's disease (PD) fall and many experience recurrent falls. The aim of this review was to examine the scope of recurrent falls and to identify factors associated with recurrent fallers. A database search for journal articles which reported prospectively collected information concerning recurrent falls in people with PD identified 22 studies. In these studies, 60.5% (range 35 to 90%) of participants reported at least one fall, with 39% (range 18 to 65%) reporting recurrent falls. Recurrent fallers reported an average of 4.7 to 67.6 falls per person per year (overall average 20.8 falls). Factors associated with recurrent falls include: a positive fall history, increased disease severity and duration, increased motor impairment, treatment with dopamine agonists, increased levodopa dosage, cognitive impairment, fear of falling, freezing of gait, impaired mobility and reduced physical activity. The wide range in the frequency of recurrent falls experienced by people with PD suggests that it would be beneficial to classify recurrent fallers into sub-groups based on fall frequency. Given that there are several factors particularly associated with recurrent falls, fall management and prevention strategies specifically targeting recurrent fallers require urgent evaluation in order to inform clinical practice.
doi:10.1155/2013/906274
PMCID: PMC3606768  PMID: 23533953
8.  Falls among community-residing stroke survivors following inpatient rehabilitation: a descriptive analysis of longitudinal data 
BMC Geriatrics  2009;9:46.
Background
Stroke victims are at relatively high risk for injurious falls. The purpose of this study was to document longitudinal fall patterns following inpatient rehabilitation for first-time stroke survivors.
Methods
Participants (n = 231) were recruited at the end of their rehab stay and interviewed monthly via telephone for 1 to 32 months regarding fall incidents. Analyses were conducted on: total reports of falls by month over time for first-time and repeat fallers, the incidence of falling in any given month; and factors differing between fallers and non fallers.
Results
The largest percentage of participants (14%) reported falling in the first month post-discharge. After month five, less than 10% of the sample reported falling, bar months 15 (10.4%) and 23 (13.2%). From months one to nine, the percentage of those reporting one fall with and without a prior fall were similar. After month nine, the number of individuals who reported a single fall with a fall history was twice as high compared to those without a prior fall who reported falling. In both cases the percentages were small. A very small subset of the population emerged who fell multiple times each month, most of whom had a prior fall history. At least a third of the sample reported a loss of balance each month. Few factors differed significantly between fallers and non-fallers in months one to six.
Conclusion
Longitudinal data suggest that falls most likely linked to first time strokes occur in the first six months post discharge, particularly month one. Data routinely available at discharge does not distinguish fallers from non-fallers. Once a fall incident has occurred however, preventive intervention is warranted.
doi:10.1186/1471-2318-9-46
PMCID: PMC2771071  PMID: 19828029
9.  Slow Down and Concentrate: Time for a Paradigm Shift in Fall Prevention among People with Parkinson's Disease? 
Parkinson's Disease  2013;2013:704237.
Introduction. We know little about how environmental challenges beyond home exacerbate difficulty moving, leading to falls among people with Parkinson's (PwP). Aims. To survey falls beyond home, identifying challenges amenable to behaviour change. Methods. We distributed 380 questionnaires to PwP in Southern England, asking participants to count and describe falls beyond home in the previous 12 months. Results. Among 255 responses, 136 PwP (diagnosed a median 8 years) reported falling beyond home. They described 249 falls in detail, commonly falling forward after tripping in streets. Single fallers (one fall in 12 months) commonly missed their footing, walking, or changing position and recovered to standing alone or with unfamiliar help. Repeat fallers (median falls, two) commonly felt shaken or embarrassed and sought medical advice. Very frequent fallers (falling at least monthly; median falls beyond home, six) commonly fell backward, in shops and after collapse but often recovered to standing alone. Conclusion. Even independently active PwP who do not fall at home may fall beyond home, often after tripping. Falling beyond home may result in psychological and/or physical trauma (embarrassment if observed by strangers and/or injury if falling backwards onto a hard surface). Prevention requires vigilance and preparedness: slowing down and concentrating on a single task might effectively prevent falling.
doi:10.1155/2013/704237
PMCID: PMC3596919  PMID: 23533952
10.  Evaluation of the Frails' Fall Efficacy by Comparing Treatments (EFFECT) on reducing fall and fear of fall in moderately frail older adults: study protocol for a randomised control trial 
Trials  2011;12:155.
Background
Falls are common in frail older adults and often result in injuries and hospitalisation. The Nintendo® Wii™ is an easily available exercise modality in the community which has been shown to improve lower limb strength and balance. However, not much is known on the effectiveness of the Nintendo® Wii™ to improve fall efficacy and reduce falls in a moderately frail older adult. Fall efficacy is the measure of fear of falling in performing various daily activities. Fear contributes to avoidance of activities and functional decline.
Methods
This randomised active-control trial is a comparison between the Nintendo WiiActive programme against standard gym-based rehabilitation of the older population. Eighty subjects aged above 60, fallers and non-fallers, will be recruited from the hospital outpatient clinic. The primary outcome measure is the Modified Falls Efficacy Scale and the secondary outcome measures are self-reported falls, quadriceps strength, walking agility, dynamic balance and quality of life assessments.
Discussions
The study is the first randomised control trial using the Nintendo Wii as a rehabilitation modality investigating a change in fall efficacy and self-reported falls. Longitudinally, the study will investigate if the interventions can successfully reduce falls and analyse the cost-effectiveness of the programme.
Trial registration
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000576022
doi:10.1186/1745-6215-12-155
PMCID: PMC3141531  PMID: 21682909
11.  Evaluating an intervention to reduce fear of falling and associated activity restriction in elderly persons: design of a randomised controlled trial [ISRCTN43792817] 
BMC Public Health  2005;5:26.
Background
Fear of falling and associated activity restriction is common in older persons living in the community. Adverse consequences of fear of falling and associated activity restriction, like functional decline and falls, may have a major impact on physical, mental and social functioning of these persons. This paper presents the design of a trial evaluating a cognitive behavioural group intervention to reduce fear of falling and associated activity restriction in older persons living in the community.
Methods/design
A two-group randomised controlled trial was developed to evaluate the intervention. Persons 70 years of age or over and still living in the community were eligible for study if they experienced at least some fear of falling and associated activity restriction. A random community sample of elderly people was screened for eligibility; those eligible for study were measured at baseline and were subsequently allocated to the intervention or control group. Follow-up measurements were carried out directly after the intervention period, and then at six months and 12 months after the intervention. People allocated to the intervention group were invited to participate in eight weekly sessions of two hours each and a booster session. This booster session was conducted before the follow-up measurement at six months after the intervention. People allocated to the control group received no intervention as a result of this trial.
Both an effect evaluation and a process evaluation were performed. The primary outcome measures of the effect evaluation are fear of falling, avoidance of activity due to fear of falling, and daily activity. The secondary outcome measures are perceived general health, self-rated life satisfaction, activities of daily life, feelings of anxiety, symptoms of depression, social support interactions, feelings of loneliness, falls, perceived consequences of falling, and perceived risk of falling. The outcomes of the process evaluation comprise the performance of the intervention according to protocol, the attendance and adherence of participants, and the participants' and facilitators' opinion about the intervention. Data of the effect evaluation will be analysed according the intention-to-treat and on-treatment principle. Data of the process evaluation will be analysed using descriptive techniques.
doi:10.1186/1471-2458-5-26
PMCID: PMC1084249  PMID: 15780139
12.  It Is Always on Your Mind: Experiences and Perceptions of Falling of Older People and Their Carers and the Potential of a Mobile Falls Detection Device 
Background. Falls and fear of falling present a major risk to older people as both can affect their quality of life and independence. Mobile assistive technologies (AT) fall detection devices may maximise the potential for older people to live independently for as long as possible within their own homes by facilitating early detection of falls. Aims. To explore the experiences and perceptions of older people and their carers as to the potential of a mobile falls detection AT device. Methods. Nine focus groups with 47 participants including both older people with a range of health conditions and their carers. Interviews were audio recorded, transcribed verbatim, and thematically analysed. Results. Four key themes were identified relating to participants' experiences and perceptions of falling and the potential impact of a mobile falls detector: cause of falling, falling as everyday vulnerability, the environmental context of falling, and regaining confidence and independence by having a mobile falls detector. Conclusion. The perceived benefits of a mobile falls detector may differ between older people and their carers. The experience of falling has to be taken into account when designing mobile assistive technology devices as these may influence perceptions of such devices and how older people utilise them.
doi:10.1155/2013/295073
PMCID: PMC3885192  PMID: 24454358
13.  Balance Confidence Improves with Resistance or Agility training: Increase is not Correlated with Objective Changes in Fall Risk and Physical Abilities 
Gerontology  2004;50(6):373-382.
Background
While the fear of falling is a common psychological consequence of falling, older adults who have not fallen also frequently report this fear. Fear of falling can lead to activity restriction that is self-imposed rather than due to actual physical impairments. Evidence suggests that exercise can significantly improve balance confidence, as measured by falls-related self-efficacy scales. However, there are no prospective reports that correlate change in balance confidence with changes in fall risk and physical abilities as induced by participating in a group-based exercise program.
Objective
The primary purpose of this prospective study was to examine the relationship between the change in balance confidence and the changes in fall risk and physical abilities in older women with confirmed low bone mass after 13 weeks of exercise participation. The secondary purpose of this study was to examine the relationship between the change in balance confidence and the change in physical activity level.
Methods
The sample comprised 98 women aged 75 to 85 years old women with low bone mass. Participants were randomly assigned to one of three groups: Resistance Training (n=32), Agility Training (n=34), and Stretching (sham) exercises (n=32). The 50-minute exercise classes for each study arm were held twice weekly at a local YMCA community centre.
Results
Both resistance training and agility training significantly improved balance confidence by 6% from baseline after 13 weeks. However, the change in balance confidence was only weakly correlated with improved general physical function and not significantly correlated with the changes in fall risk score, postural stability, gait speed, or physical activity level. As well, we observed balance confidence enhancement in the presence of increased fall risk or deterioration in physical abilities.
Conclusions
Two different types of exercise training improved balance confidence in older women with low bone mass. This change in balance confidence was significantly correlated with change in general physical function. Because of the observation of discordance between balance confidence change and changes in fall risk and physical abilities, those who design group-based exercise programs for community-dwelling older adults may wish to consider including an education component on factors that influence fear of falling. Objective changes in fall risk factors cannot be assumed to mirror change of fear of falling and physical abilities in older adults in the short-term.
doi:10.1159/000080175
PMCID: PMC3383061  PMID: 15477698 CAMSID: cams2199
Balance confidence; fall risk; exercise; older women; low bone mass
14.  Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care 
BMC Geriatrics  2014;14:40.
Background
Falls are the most common cause of injuries and hospital admissions in the elderly. The Swedish National Board of Health and Welfare has created a list of drugs considered to increase the fall risk (FRIDs) and drugs that might cause/worsen orthostatism (ODs). This cross-sectional study was aimed to assess FRIDs and their correlation with falls in a sample of 369 community-dwelling and nursing home patients aged ≥75 years and who were using a multi-dose drug dispensing system.
Methods
Data were collected from the patients’ electronic medication lists. Retrospective data on reported falls during the previous three months and severe falls during the previous 12 months were collected. Primary outcome measures were incidence of falls as well as numbers of FRIDs and ODs in fallers and non-fallers.
Results
The studied sample had a high incidence of both reported falls (29%) and severe falls (17%). Patients were dispensed a mean of 2.2 (SD 1.5) FRIDs and 2.0 (SD 1.6) ODs. Fallers used on average more FRIDs. Severe falls were more common in nursing homes patients. More women than men experienced severe falls. There were positive associations between number of FRIDs and the total number of drugs (p < 0.01), severe falls (p < 0.01) and female sex (p = 0.03). There were also associations between number of ODs and both total number of drugs (p < 0.01) and being community dwelling (p = 0.02). No association was found between number of ODs and severe falls. Antidepressants and anxiolytics were the most frequently dispensed FRIDs.
Conclusions
Fallers had a higher number of FRIDs. Numbers of FRIDs and ODs were correlated with the total number of drugs dispensed. Interventions to reduce falls in the elderly by focusing on reducing the total number of drugs and withdrawal of psychotropic medications might improve the quality and safety of drug treatment in primary care.
doi:10.1186/1471-2318-14-40
PMCID: PMC3986685  PMID: 24674152
Elderly; Falls; Prevention; Drug therapy; Fall risk-increasing drugs
15.  Determinants of disparities between perceived and physiological risk of falling among elderly people: cohort study 
Objectives To gain an understanding of elderly people’s fear of falling by exploring the prevalence and determinants of perceived and physiological fall risk and to understand the role of disparities in perceived and physiological risk in the cause of falls.
Design Prospective cohort study.
Setting Community sample drawn from eastern Sydney, Australia.
Participants 500 men and women aged 70–90 years.
Main outcome measures Baseline assessment of medical, physiological, and neuropsychological measures, with physiological fall risk estimated with the physiological profile assessment, and perceived fall risk estimated with the falls efficacy scale international. Participants were followed up monthly for falls over one year.
Results Multivariate logistic regression analyses showed that perceived and physiological fall risk were both independent predictors of future falls. Classification tree analysis was used to split the sample into four groups (vigorous, anxious, stoic, and aware) based on the disparity between physiological and perceived risk of falling. Perceived fall risk was congruent with physiological fall risk in the vigorous (144 (29%)) and aware (202 (40%)) groups. The anxious group (54 (11%)) had a low physiological risk but high perceived fall risk, which was related to depressive symptoms (P=0.029), neurotic personality traits (P=0.026), and decreased executive functioning (P=0.010). The stoic group (100 (20%)) had a high physiological risk but low perceived fall risk, which was protective for falling and mediated through a positive outlook on life (P=0.001) and maintained physical activity and community participation (P=0.048).
Conclusion Many elderly people underestimated or overestimated their risk of falling. Such disparities between perceived and physiological fall risk were primarily associated with psychological measures and strongly influenced the probability of falling. Measures of both physiological and perceived fall risk should be included in fall risk assessments to allow tailoring of interventions for preventing falls in elderly people.
doi:10.1136/bmj.c4165
PMCID: PMC2930273  PMID: 20724399
16.  Overall reductions in functional brain activation are associated with falls in older adults: an fMRI study 
Falls are a common geriatric condition, and while impaired cognitive function has been identified as a key risk factor, the neural correlates that contribute to reduced executive functioning and falls currently remain unknown. In this study, community-dwelling adults aged 65–75 years were divided into two groups based on their recent history of falls (fallers versus non-fallers). All participants completed the Flanker task during functional magnetic resonance imaging (fMRI). We examined the hemodynamic response of congruent and incongruent trials separately in order to separate the relative contribution of each trial type as a function of falls history. We found that fallers exhibited a smaller difference in functional activation between congruent and incongruent trials relative to non-fallers, as well as an overall reduction in level of blood-oxygen-level dependent response. Of particular note, the medial frontal gyrus – a region implicated in motor planning – demonstrated hypo-activation in fallers, providing evidence that the prefrontal cortex might play a central role in falls risk in older adults.
doi:10.3389/fnagi.2013.00091
PMCID: PMC3867665  PMID: 24391584
falls; older adults; fMRI; executive cognitive functions; Flanker task; medial frontal gyrus
17.  Fear-avoidance beliefs and parental responses to pain in adolescents with chronic pain 
BACKGROUND:
The fear-avoidance model of chronic pain posits that fear of pain is associated with fear and avoidance of activity, which can lead to deconditioning and persistence of pain and disability. Despite being well supported in adults, little is known about the role of fear-avoidance beliefs regarding physical activity in children. Research has shown that parental protectiveness contributes to activity limitations in children; however, no studies have examined relationships between protectiveness, and fear and avoidance.
OBJECTIVES:
To conduct a cross-sectional study to provide additional information regarding the reliability and validity of the Fear-Avoidance Beliefs Questionnaire physical activity subscale among adolescents with chronic pain; examine fear-avoidance beliefs and depressive symptoms as concurrent predictors of physical activity limitations; and test competing models using fear-avoidance beliefs as mediators and moderators of the association between parental protectiveness and activity limitations.
METHODS:
Adolescents (n=42) 11 to 17 years of age with chronic pain completed questionnaires assessing pain intensity, fear-avoidance beliefs, depressive symptoms and physical activity limitations. Their parents completed questionnaires regarding protectiveness and adolescent activity limitations.
RESULTS:
The Fear-Avoidance Beliefs Questionnaire physical activity subscale was useful for assessing fear-avoidance beliefs in the present population. In support of hypotheses, greater fear-avoidance beliefs were associated with greater activity limitations, above pain intensity and depressive symptoms. Support was found for fear-avoidance beliefs as mediators of the association between parental protectiveness and activity limitations. Tests of moderation were not significant.
CONCLUSIONS:
Fear-avoidance beliefs may be an important target for interventions focused on decreasing activity limitations in youth with chronic pain. Future research should investigate these associations longitudinally.
PMCID: PMC3198113  PMID: 21766067
Chronic pain; Disability; Fear avoidance; Pediatric; Physical activity
18.  Falls and the use of health services in community-living elderly people. 
Falls are common and often preventable in older people. This short report describes substantial unmet need in relation to falls. Although falling, nearly falling, fear of falling, and activity restriction are common, many people do not seek assistance from healthcare professionals. Only 2% of those who had attended their general practioner (GP), a casualty department, or had been admitted to hospital after a fall were taking drugs to protect against osteoporosis. People who have fallen or are at a risk of falling need to be identified, and local policies and information regarding treatment for osteoporosis are needed.
PMCID: PMC1314445  PMID: 12434962
19.  Gait disturbances as specific predictive markers of the first fall onset in elderly people: a two-year prospective observational study 
Falls are common in the elderly, and potentially result in injury and disability. Thus, preventing falls as soon as possible in older adults is a public health priority, yet there is no specific marker that is predictive of the first fall onset. We hypothesized that gait features should be the most relevant variables for predicting the first fall. Clinical baseline characteristics (e.g., gender, cognitive function) were assessed in 259 home-dwelling people aged 66 to 75 that had never fallen. Likewise, global kinetic behavior of gait was recorded from 22 variables in 1036 walking tests with an accelerometric gait analysis system. Afterward, monthly telephone monitoring reported the date of the first fall over 24 months. A principal components analysis was used to assess the relationship between gait variables and fall status in four groups: non-fallers, fallers from 0 to 6 months, fallers from 6 to 12 months and fallers from 12 to 24 months. The association of significant principal components (PC) with an increased risk of first fall was then evaluated using the area under the Receiver Operator Characteristic Curve (ROC). No effect of clinical confounding variables was shown as a function of groups. An eigenvalue decomposition of the correlation matrix identified a large statistical PC1 (termed “Global kinetics of gait pattern”), which accounted for 36.7% of total variance. Principal component loadings also revealed a PC2 (12.6% of total variance), related to the “Global gait regularity.” Subsequent ANOVAs showed that only PC1 discriminated the fall status during the first 6 months, while PC2 discriminated the first fall onset between 6 and 12 months. After one year, any PC was associated with falls. These results were bolstered by the ROC analyses, showing good predictive models of the first fall during the first six months or from 6 to 12 months. Overall, these findings suggest that the performance of a standardized walking test at least once a year is essential for fall prevention.
doi:10.3389/fnagi.2014.00022
PMCID: PMC3933787  PMID: 24611048
risk of fall; gait analysis; gait variability; gait speed; accelerometric device; fall-related injuries; home-dwelling people; principal components analysis
20.  Falls in people with chronic obstructive pulmonary disease: an observational cohort study 
Respiratory Medicine  2011;105(3):461-469.
SUMMARY
Study objective
To investigate incidence, risk factors and impact of falls on health related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD).
Design
Observational cohort study
Methods
Patients completed these questionnaires at baseline and at 6-months: Medical Outcomes Study Short Form 36 (SF-36), Chronic Respiratory Questionnaire (CRQ), Activities Balance Confidence (ABC) Scale and a form to record demographic data, medications, co-morbidities, oxygen use, acute exacerbations, fall history and assistive device use. Physical activity was measured with the Physical Activity Scale for the Elderly (PASE) only at baseline. Fall incidence was monitored through monthly fall diaries. Patients were categorized as non-fallers (0 falls) or fallers (≥1 falls).
Results
Data from 101 patients with a forced expiratory volume in one second of 46.4±21.6% predicted were analyzed. Thirty-two patients (31.7%) reported at least one fall during the 6-months. Fall incidence rate was 0.1 (95% CI:0.06 to 0.14) falls per person-month. Fallers tended to be older (p=0.04), female (p=0.04) and oxygen dependent (p=0.02), have a history of previous falls (p<0.001), more co-morbidities (p=0.007) and take more medications (p=0.001). Previous falls (OR=7.36; 95% CI:2.39 to 22.69) and diagnosis of coronary heart disease (OR=7.07; 95% CI:2.14 to 23.36) were the most important predictors of falls. The Dyspnea Domain of the CRQ declined significantly more (p=0.02) in the fallers group at 6-months.
Conclusions
Patients with COPD have a high susceptibility to falls, which is associated with a worsening of dyspnea perception as related to HRQoL. Fall prevention programs in COPD are recommended.
doi:10.1016/j.rmed.2010.08.015
PMCID: PMC3350813  PMID: 20869227 CAMSID: cams2186
21.  Re-evaluating the Implications of Recurrent Falls in Older Adults: Location Changes the Inference 
OBJECTIVE
To compare characteristics of indoor and outdoor recurrent fallers and explore some implications for clinical practice, in which a fall risk assessment for all recurrent fallers has been recommended.
DESIGN
Prospective cohort study.
SETTING
MOBILIZE Boston, a study of falls etiology among community-dwelling older individuals from randomly sampled households in the Boston MA area.
PARTICIPANTS
713 women and men, mainly of age 70 years and older, with at least one year of follow-up.
MEASUREMENTS
Data at baseline and an 18-month follow-up examination were collected by questionnaire and comprehensive clinic examination. During follow-up participants recorded falls on daily calendars. A telephone interview queried location and circumstances of each fall.
RESULTS
145 participants reported recurrent falls (≥ 2 falls) during the first year. Those who had fallen only outdoors had good health characteristics, whereas those who had fallen only indoors were generally in poor health. For instance, 25.5% of indoor-only recurrent fallers had gait speeds < 0.6 meters/second compared to 2.9% among outdoor-only recurrent fallers; the respective percentages were 44.7% and 8.8% for Berg balance score < 48. Recurrent indoor fallers generally had poor health characteristics regardless of their activity at the time of their falls, whereas recurrent outdoor fallers who fell during vigorous activity or walking were especially healthy. A report of any recurrent falls in the first year did not predict number of positive findings on either a comprehensive or abbreviated fall risk assessment at the 18-month follow-up examination.
CONCLUSION
Characteristics of community-dwelling older people with recurrent indoor and outdoor falls are very different. If confirmed, these results suggest that different types of fall risk assessment are needed for specific categories of recurrent fallers.
doi:10.1111/j.1532-5415.2011.03834.x
PMCID: PMC3302971  PMID: 22283236
recurrent falls; risk factors; aging research; fall risk assessment
22.  The harmonic ratio of trunk acceleration predicts falling among older people: results of a 1-year prospective study 
Background
Gait variables derived from trunk accelerometry may predict the risk of falls; however, their associations with falls are not fully understood. The purpose of the study was to determine which gait variables derived from upper and lower trunk accelerometry are associated with the incidence of falls, and to compare the discriminative ability of gait variables and physical performance.
Methods
This study was a 1-year prospective study. Older people (n = 73) walked normally while wearing accelerometers attached to the upper and lower trunk. Participants were classified as fallers (n = 16) or non-fallers (n = 57) based on the incidence of falls over 1 year. The harmonic ratio (HR) of the upper and lower trunk was measured. Physical performance was measured in five chair stands and in the timed up and go test.
Results
The HR of the upper and lower trunk were consistently lower in fallers than non-fallers (P < 0.05). Upper trunk HR, was independently associated with the incidence of falls (P < 0.05) after adjusting for confounding factors including physical performances. Consequently, upper trunk HR showed high discrimination for the risk of falls (AUC = 0.81).
Conclusions
HR derived from upper trunk accelerometry may predict the risk of falls, independently of physical performance. The discriminative ability of HR for the risk of falls may have some validity, and further studies are needed to confirm the clinical relevance of trunk HR.
doi:10.1186/1743-0003-10-7
PMCID: PMC3562223  PMID: 23356576
Trunk; Gait; Acceleration; Falls
23.  Fear Avoidance Beliefs Predict Disability in Older Adults with Chronic Low Back Pain 
Objectives
To determine whether fear avoidance beliefs (FAB) in older adults with chronic low back pain (CLBP) is significantly associated with gait speed and/or self-report (Roland Morris Questionnaire, RMQ)
Design
Cross-sectional analysis
Setting
Academic Medical Center (single site)
Participants
Two-hundred English-speaking participants aged 65 and older with CLBP every day or almost every day of ≥ moderate intensity for ≥3 months.
Measurements
The physical activity portion of the FAB questionnaire assessed fear avoidance beliefs. Disability was measured with gait speed and the RMQ. Covariates measured included age, gender, BMI, chronic disease (Cumulative Illness Rating Scale-CIRS), depression (Geriatric Depression Scale-GDS), and pain (McGill Pain Questionnaire short form-MPQ.)
Results
Fear avoidance beliefs were significantly associated with the RMQ (p<.0001) and gait speed (p=.002) after controlling for all covariates.
Conclusion
Fear avoidance beliefs related to physical activity in older adults with CLBP were significantly associated with both self-reported and performance-based disability after controlling for known confounders. Previous studies have reported similar associations between self-reported measures of disabling back pain and fear avoidance beliefs. Ours is the first study to examine the relationship between FAB and gait speed, a powerful predictor of morbidity and mortality. Future work should examine whether targeting fear avoidance in addition to other psychosocial measures in older adults with CLBP improves gait speed and functional independence.
doi:10.1016/j.pmrj.2012.01.017
PMCID: PMC3917604  PMID: 22516436
24.  EXercising with Computers in Later Life (EXCELL) - pilot and feasibility study of the acceptability of the Nintendo® WiiFit in community-dwelling fallers 
BMC Research Notes  2010;3:238.
Background
Falls management programmes have been instituted to attempt to reduce falls. This pilot study was undertaken to determine whether the Nintendo® WiiFit was a feasible and acceptable intervention in community-dwelling older fallers.
Findings
Community-dwelling fallers over 70 years were recruited and attended for computer-based exercises (n = 15) or standard care (n = 6). Balance and fear of falling were assessed at weeks 0, 4 and 12. Participants were interviewed on completion of the study to determine whether the intervention was acceptable.
Eighty percent of participants attended 75% or more of the exercise sessions. An improvement in Berg Score was seen at four weeks (p = 0.02) and in Wii Age at 12 weeks (p = 0.03) in the intervention group. There was no improvement in balance scores in the standard care group.
Conclusion
WiiFit exercise is acceptable in self-referred older people with a history of falls. The WiiFit has the potential to improve balance but further work is required.
Trial Registration
ClinicalTrials.gov - NCT01082042
doi:10.1186/1756-0500-3-238
PMCID: PMC2945358  PMID: 20831836
25.  Fear of Falling and Visual Field Loss from Glaucoma 
Ophthalmology  2012;119(7):1352-1358.
Objective
To determine if visual field (VF) loss from glaucoma is associated with greater fear of falling.
Design
Prospective observational study.
Participants
Fear of falling was compared between 83 glaucoma subjects with bilateral VF loss, and 60 control subjects with good visual acuity and without significant VF loss recruited from patients followed for suspicion of glaucoma.
Methods
Participants completed the University of Illinois at Chicago Fear of Falling Questionnaire. The extent of fear of falling was assessed using Rasch analysis.
Main Outcome Measures
Subject ability to perform tasks without fear of falling was expressed in logits, with lower scores implying less ability and greater fear of falling.
Results
Glaucoma subjects had greater VF loss than control subjects (median better-eye mean deviation (MD) of −8.0 decibels [dB] vs. +0.2 dB, p<0.001), but did not differ with regards to age, race, gender, employment status, the presence of other adults in the home, body mass index (BMI), grip strength, cognitive ability, mood, or comorbid illness (p≥0.1 for all).
In multivariable models, glaucoma subjects reported greater fear of falling as compared to controls (β= −1.20 logits; 95% Confidence Interval [CI] = −1.87 to −0.53; p=0.001), and fear of falling increased with greater VF loss severity (β= −0.52 logits per 5 dB decrement in the better eye VF MD; 95% CI = −0.72 to −0.33; p<0.001). Other variables predicting greater fear of falling included female gender (β= −0.55 logits; 95% CI = −1.03 to −0.06; p=0.03), higher BMI (β= −0.07 logits per 1 unit increase in BMI; 95% CI = −0.13 to −0.01; p=0.02), living with another adult (β= −1.16 logits; 95% CI = −0.34 to −1.99 logits; p=0.006), and greater comorbid illness (β= −0.53 logits/1 additional illness; 95% CI = −0.74 to −0.32; p<0.001).
Conclusions
Bilateral VF loss from glaucoma is associated with greater fear of falling, with an impact that exceeds numerous other risk factors. Given the physical and psychological repercussions associated with fear of falling, significant quality of life improvements may be achievable in patients with VF loss by screening for, and developing interventions to minimize, fear of falling.
doi:10.1016/j.ophtha.2012.01.037
PMCID: PMC3389306  PMID: 22480738

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