A CORRELATION BETWEEN
FEAR OF FALL, BALANCE CAPACITY AND WALKING ABILITY
IN COMMUNITY DWELLING ELDERLY INDIVIDUALS WITH RECENT HISTORY OF FALL
SUBMISSION OF SYNOPSIS FOR THE REGISTRATION OF THE DISSERTATION FOR MASTER OF PHYSIOTHERAPY
SUBMITTED TO
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGaLORE, KARNATAKA
SUBMITTED BY
PRANITEE.p.BHOSALE
NAVODAYA COLLEGE OF PHYSIOTHERAPY
P.B.No. 26, MANTRALAYAM ROAD, RAICHUR
KARNATAKA
APRIL2010
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGaLORE, KARNATAKA
ANNEXURE-II
PROFORMA FOR THE REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME OF THE CANDIDATEAND ADDRESS /
- PRANITEE.P.BHOSALE
- NAVODAYA COLLEGE OF PHYSIOTHERAPY,
- MANTRALAYAM ROAD, RAICHUR.
2 / NAME OF THE INSTITUTION / NAVODAYA COLLEGE OF PHYSIOTHERAPY,
MANTRALAYAM ROAD, RAICHUR, KARNATAKA.
3 / COURSE OF AND STUDY
SUBJECT /
- MASTER OF PHYSIOTHERAPY ( MPT )
4 /
- DATE OF ADMISSION TO THE COURSE
5 /
- TITLE OF THE TOPIC:
- “ A CORRELATION BETWEEN FEAR OF FALL, BALANCE CAPACITY AND WALKING ABILITY IN COMMUNITY DWELLING ELDERLY INDIVIDUALS WITH RECENT HISTORY OF FALL”
6. RESEARCH QUESTION:
Is there any correlation between fear of fall, balance capacity and walking ability in community dwelling elderly individuals with recent history of fall?
6.1 BRIEF RESUME OF THE INTENEDED WORK:
The number of person above age of 60yrs is fast growing1. According to WHO(World Health Organization) the number of this age group was estimated to be 688 million in 2006,projected to grow to almost 2 billion by 20502.In India which is second most populous country in the world has 76.6 million people over age of 60yrs.It constitute about 7.7% of total population1. It is expected about 127 million in 2025, 324 million in 2040 and will constitute 25% of total population by 20503.This rapid increase in number of elderly people in population also raises various social, economic and health issues.
Falls are one of the major health problems in elderly and defined as unintentionally coming to the ground or some lower level and other than as a consequences of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or on epileptic seizures4. Fall is important cause of morbidity and mortality in elderly1.
In western countries fall rate ranges between 29% to 34%5 whereas in India various studies show that it ranges between 14% to 51.3%1. It lead to various serious consequences like fracture, traumatic brain injury, fear of fall, hospitalization and immobilization5 .
The risk factors for falls are divided into intrinsic and extrinsic risk factors. Intrinsic factors includes demographic data (race, socioeconomic status), biological factors (age, sex, fear of fall, balance instability, gait instability, physical disability) and extrinsic factors includes environmental and behavioral factors5. Among these risk factors fear of fall, balance and gait instability are considered to be major risk factors. These factors has been shown to be important predictor of fall in elderly individuals and also increases the risk of future fall6,7,8,9,10.
FEAR OF FALL (FOF):
FOF is ongoing concern about the fall that ultimately limits the performance of daily living11 and it is defined as low perceived self efficacy at avoiding falls during essential, non hazardous activities of daily living12.
FOF has multifactorial etiology13,14. Factors contributing to FOF are numerous but exact cause remain unclear.FOF results from psychological trauma of fall so it may lead to reduced activity and subsequent loss in physical capacities15,16.FOF is associated with lower quality of life17,18, poor health status19 and functional decline18,20. The role of self efficacy becomes important in our society where older people are often stereotyped as lacking independence and capabilities and frequently offered aid when none is required. This may lead to decreased sense of self and in turn lead to reluctance to carry out normal activities even when skills are available.
FOF is quantified using standardized questionnaires. There are many instruments available to measure FOF like Fall Efficacy Scale (FES), modified fall efficacy scale, Shortened version of fall efficacy scale (SFES-I), survey of activities and fear of falling in elderly and activities –specific balance confidence scale. These scales directly inquire about FOF or about confidence in maintaining balance or preventing fall .Out of these scales SFES-I shows excellent test-retest reliability and appears to be good and feasible measures to assess FOF in elderly population21. It consist of 7 item questionnaires which is self administrated or administrated through interviewer, that ask respondent to rate their level of confidence in performing common activities. Maximum score is 28.
BALANCE INSTABILITY:
Balance instability is a marker of fall risk and frailty. The risk of fall underscores the importance of ability of adult to be able to receive and integrate sensory information and to take appropriate action to avoid falling. Many age related changes like decreasing sensitivity of sensory receptor, slowing of nervous system capabilities, muscle weakness affect balance gradually permitting older adult to compensate until they reach critical point that result in balance instability. Falls, balance instability and inability to remain mobile are major problem or factors for admission in nursing home and also constitute a series of problem in elderly people. FOF can create a cycle of inactivity, loss of confidence, social isolation and increased fall risk10.
Commonly used instruments in measuring balance in elderly are Berg Balance Scale (BBS), Performance Oriented Mobility Assessment subscale of Balance(POMA-B), Functional Reach Test(FRT), Time Up and Go Test. BBS is considered as the gold standard assessment of balance with good intra-rater and inter-rater reliability and good inter validity22. It is 14- item scale consists of activities like sitting to standing, standing unsupported etc. Total score is 56.
WALKING:
The potential for a loss of balance when performing simple task such as walking is considerable. Fear of fall may influence balance during walking in elderly people so dynamic walking balance play important role and directly related to fall23. Dynamic walking balance is achieved by integrating sensory input from visual, vestibular and proprioceptive system with adequate lower limb strength and free joint space24.
Numbers of studies shows old people who exhibit falls have increased variability in gait velocity and stride length25,26. and that there is changes in basic temporal-spatial gait parameters in persons with FOF27. These are significantly associated with physiological factors like decreased lower limb strength, slow reaction time and psychological factors like anxiety, depression, FOF. These changes may represent reluctance rather than an inability to walk. There is also stride to stride variation in gait cycle were significantly associated with FOF26 and suggest that it may actually lead to gait instability in elderly8. Elder people with FOF use to adapt their gait often described as “Caution gait or fearful gait” where the gait velocity is reduce which further reflect activities of daily living functions28.
In elderly, gait can be examined by Gait assessment rating scale, Tinetti gait scale, Time up and go test and Dynamic gait index(DGI). Among these dynamic gait index is used as clinical tool to assess gait, balance and fall risk. It appears to be an appropriate tool for assessing function in older adult as it is not only evaluate steady state walking but also walking during more challenging task29. It has shown to yield ratios of sub variability to total variability with excellent reliability and test-retest reliability30. It consist of 8 different tasks. Total score is 24.
In view of above discussion, it is demonstrated that fear of fall, balance and gait instability is a major risk factor leading significant risk of fall in elderly but the relation between these risk factor remains unclear especially among the rural elderly population of India. Therefore purpose of this study is to find correlation between fear of fall, balance capacity and walking ability in community dwelling elderly individuals with recent history of fall.
6.2 HYPOTHESIS
NULL HYPOTHESIS (H0)
There will be no correlation between fear of fall, balance capacity and walking ability in community dwelling elderly individuals with recent history of fall.
ALTERNATIVE HYPOTHESIS (H1)
There will be significant correlation between fear of fall, balance capacity and walking ability in community dwelling elderly individuals with recent history of fall.
6.3 REVIEW OF LITERATURE
1.Johnson J.R (2006)31 conducted study to examine the frequency and nature of falls and fall related injuries among older women in India. Study involved 82 community living and 63 institutionalized women of age 60 years and older. Study result found that 45% of community living participant suffered fall in previous year compared to 64% of those in long term care setting (p<0.05).Overall those who fell 74% reported injury as a result of fall.
2. Tinetti M.E., Speechly M.(1988)32 conducted a prospective study to investigate risk of falling using sample of 356 people at least age of 75 years. During 1st year 32% (108/356) at least once. They conclude that fall among older person living in community are common and that a simple assessment can identify the elderly person who are at greater risk of falling.
3.Vellas.B,Sharon.J. et al (1997)33 conducted a prospective study to identify the characteristics of elderly person who developed fear of fall after experience fall and to investigate association of this fear of fall with changes in health status. This result shows that 32% of subjects reported fear of fall; fallers who were afraid of falling again had a significantly more balance and gait disorder. This subjects experienced a greater increase in balance (p= 0.08) and gait disorder (JP >0.01) which lead to decrease mobility level.
4.Sheffer A.C., Schuurmans M.J. et al (2007)34 conducted study to measure fear of fall, to study prevalence of fear of fall among fallers and non fallers, to identify factors related to FOF and its possible consequences among community dwelling older person. This study suggest that main risk factor for developing fear of fall are at least 1 fall and main consequences were identified as decline in physical and mental performance, increased risk of falling and decreased quality of life.
5.Chu L-w,AliceY.Y Chiu. et al (2005)35 conducted a prospective cohort study on 1517 older adult. They used Barthel index, Tinetti balance and gait scale (POMA) and Instrumental ADL scale. It shows result that fallers particularly recurrent fallers experiences significantly greater decline in functional measures. Fall incidence have a significant negative impact on balance, gait and ADL in community dwelling older adult.
6.Kempen G.I.J.M,Yardley L. et al(2007)21 conducted study to develop and validate a shortened version of FES-I on 193 people of age between 70-92 years. This study result shows that the internal and 4 week test retest reliability of the short FES-I is excellent (cronbach’s alpha 0.92,intra-class coefficient 0.83)The correlation between the short FES-I and the FES-I is 0.97.The short FES-I is a good and feasible measures to assess fear of falling in elder people.
7.Johnson J.R, Neistdt M.E. et al (1998)36conducted study on 39 sample to see if fear of fall in elderly older person in sub acute rehabilitation is related to actual balance and gait abilities. They measures fear of fall by fall efficacy scale, balance and gait by POMA and found that there is no significant positive association between total scores on FES, balance and gait subtest scores indicate significant positive association between balance and gait scores and 4 activities like – climbing stairs, shopping, walking around neighborhood and running for telephone.
8.Tinetti M.,Mendos C.F. et al (1994)37conducted a cohort study to find out the relation of fear of fall and fall related efficacy with ADL and I-ADL and physical and social functioning. This study has found that 57% denied fear of fall,24% acknowledge fear of fall but denied effect on activity and 19% acknowledge avoiding activity because of fear of fall. Fall related efficacy proved potent independent correlate of ADL- IADL (partial correlation = .265, p < 0.001) physical ( partial correlation = .234, p < 0.001) and social ( partial correlation = .088, p < .01) so fear of fall was only marginally related (p=0.5) with ADL, I-ADL ,functioning and was not associated with social functioning and higher level functioning.
9.Howland J., Lachman M. et al (1998)38 conducted a study with a sample survey of 266 elderly adult to identify covariates of fear of fall among all subjects and to identify covariates of activity curtailment among subject who were afraid of falling. It gives result that 55% of respondent were afraid of falling and 56% of this had curtailed activity due to this fear. factors associated with fear of fall were being female, having had previous fall and having fewer social contact. Fall history appears an important contributor to fear of fall and where as the impact of this fear on activities appears more a function of social support.
10.Suraj Kumar, Venu Vendhan G. et al (2008)39 conducted study to find is there any relationship exist among fear of fall, balance impairment and functional mobility in community dwelling elderly(N=52)with age range 65 yrs to 90 yrs. Fear of fall was measured using Fall Efficacy scale, balance was measured using Berg Balance Scale and mobility was assessed using Timed Up and Go Test. This result shows that the correlation coefficient between fall efficacy and balance performance was -0.97(p=0.01) and correlation coefficient between fall efficacy and time up and test was 0.95(p=0.05) so this study conclude that there was a significant association between fall efficacy, the balance performance and functional mobility in elderly people.
11.Johnsons J.R.,Stwart D. (1986)40 conducted study to review, compare and construct 5 most frequently cites scale of balance [Performance Oriented Mobility Assessment(POMA), Get Up and Go Test (GUGT), Berg Balance Scale (BBS) Functional Reach Test (FRT) and Fall Efficacy Scale (FES)].This study gives result that GUGT and FES were identified as screening tool while BBS, POMA, FRT are suggested for more in depth evaluation.
12.Berg K, Wood D.S. et al (1995)22 conducted a study to assess the reliability of the balance scale. Study includes 113 elderly resident and 70 stroke patient. They evaluated patient at 2,4,6 and 12 weeks. The Cronbach’s alphas at each evaluation were greater than 0.83 and 0.97 for elderly resident and stroke patient respectively. This study shows the agreement between intra-rater and inter-rater was excellent (ICC=0.97), so this study support the use of balance scale.
13.Herman T, Giladio N. et al (2005)28 conducted study to better understand the caution gait in elderly.28-healthy control and 25-individual with gait and high level disorder. Gait variability significantly increases in HLGD subject(52+- 26 ms) compared to healthy (27+-9 ms).Among HLGD significantly associated with fear of fall(r=0.69,p=0.0001). It gives idea that gait changes in older adult who walk with fear may be appropriate response to unsteadiness.
14.Chamberlin M.E.,Fulwinder.B.D. et al (2004)27 conducted study to determine fear of fall in elderly was associated with changes in spatial-temporal gait parameters in 95 community dwelling adult of age 60-97years. Participant divided into fearful and fearless group with help of M-FES. This study shows result that fearful group had a significantly slower gait speed(p=0.05) so fear of fall influences gait parameter and this were found to be associated with pre-existing fear of fall.
15.Marchetti G, whitney S.L. et al (2008)41conducted cross sectional study to describe characteristics and reliability in people with balance or vestibular dysfunction. Study done on 47 subjects (26- control, 21- with vestibular dysfunction) of age range 24-90 years. Result of this study shows that reliability of most gait parameters during DGI performance were fair to excellent between trials. Evaluating person’s performance on items of DGI may be useful in identifying gait deviation and in evaluating gait improvement as result of intervention.
16.Hermana.T,Borovskya.N. et al (2008)29 conducted study to evaluate the DGI and it’s association with falls, FOF, depression, anxiety and other measures of balance and mobility in 278 healthy elderly individuals. Measures includes the DGI, Berg Balance Test(BBT), Timed Up and Go Test(TUAG), Mini Mental State Examination(MMSE) and Activities-specific Balance Confidence Scale(ABC).This study shows result that DGI was moderately correlated with BBT (r=0.53:p<0.001), TUAG (r=-0.42:p<0.001) , ABC(r=0.49:p< 0.001).Fallers performed worse on DG as compared to non-fallers(p=0.029).These findings suggest that DGI, although susceptible to ceiling effect but appears to be appropriate tool for assessing function.
6.4 OBJECTIVE OF THE STUDY.
To study the correlation between fear of fall, balance capacity and walking ability in community dwelling elderly individuals with recent history of fall.
7.MATERIALS
Chair
Cones
Stopwatch
Step or Stepstool
Ruler
7.1SOURCES OF DATA
The data will be obtained from the villages surrounding Raichur district.
A.RESEARCH DESIGN
A Correlation study.
B.SETTING OF THE STUDY
Villages surrounding Raichur district.
C. VARIABLE
Fear of fall
Balance capacity.
Walking ability.
D. SAMPLES
Total sample size consists of 100 subjects.
E. SAMPLE TECHNIQUE
convenient sampling.
F. INCLUSION CRITERIA
Age 60yrs & above.
Both female & male.
Fallers with history of greater than 1 fall within past 1 year.
Independent mobility skill in home without assistive device.
Competent enough to follow instruction.
G. EXCLUSION CRITERIA.
Dependant on assistive device.
Those judged to be incompetent.
Suffering from dizziness with changes in position.
Unable to compete all tasks of BBS, DGI and to give answer from SFES-I.
7.2 METHOD OF DATA COLLECTION.
The subjects will be recruited from the villages surrounding Raichur district based on inclusion & exclusion criteria.
100 subjects will be recruited for the study.
BBS, SFES-I and DGI will be performed consecutively in a day for each subject.
- PROCEDURE.
A brief explanation of the procedure will be given to prepare the subjects after obtaining the informed consent.
The subject will be made to complete SFES-I, BBS and DGI.
SFES-I consist of 7 questions based on activities of daily living like taking shower, stair climbing. With scoring (1)not at all concerned and (4)very concerned having max score 28.
BBS-consist of 14 different tasks with scores ranges from 0-4. (0) indicate lowest level of function and (4) indicate highest level of function. Total score is 56.