Criteria for evaluation of measurement properties of clinical balance measures for use in fall prevention studies. Fall risk assessment: a prospective investigation of nurses' clinical judgement and risk assessment tools in predicting patient falls. Utility of Disease-Specific Measures and Clinical Balance Tests in Prediction of Falls in Persons With Multiple Sclerosis Clinical history and biologic age predicted falls better than objective functional tests. Fall Risk Assessment in Geriatric-Psychiatric Inpatients to Lower Events (FRAGILE). A multifactorial approach to understanding fall risk in older people. Posturography and Risk of Recurrent Falls in Healthy Non-Institutionalized Persons Aged Over 65 Diagnosis of Fall Risk in Parkinson Disease: An Analysis of Individual and Collective Clinical Balance Test Interpretation Use of the Berg Balance Scale for Predicting Multiple Falls in Community-Dwelling Elderly People: A Prospective Study External validation of a simple clinical tool used to predict falls in people with Parkinson disease. Identification of high risk fallers among older people living in residential care facilities: a simple screen based on easily collectable measures. Clinical and posturographic correlates of falling in Parkinson's disease. Objective Assessment of Fall Risk in Parkinson's Disease Using a Body-Fixed Sensor Worn for 3 Days The value of assessing falls in an elderly population. A randomized clinical trial. Evaluation of the fall prevention program in an acute care setting. Multifactorial Intervention with Balance Training as a Core Component Among Fall‐prone Older Adults A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients.
Work Package 3 of the Prevention of Falls Network Europe has evaluated measurement properties of clinical balance measures to be used to : ( 1 ) select participants for interventions with the goal to prevent falls in older people , and ( 2 ) assess the results of such intervention on balance function . Inclusion in a fall prevention study may be based on measures identifying subjects who have impaired balance or increased risk of future falls . We propose that an appropriate statistical method to analyse discriminative ability of a balance measure is discriminant analysis or logistic regression analysis . The optimal cut-off score is best determined by plotting a receiver-operating-characteristic curve for different cut-off values . The evaluation of predictors for risk of future falls should be based on a study design with a prospect i ve data collection of falls . Sensitivity to change is a measurement property needed to evaluate the outcome of an intervention . The st and ardized response mean is frequently encountered in the literature and is recommended as a statistical measure of sensitivity to change in the context of an intervention study . Adequate reliability is a prerequisite for consistent measurement . Relative reliability may be reported as an intraclass correlation coefficient and absolute reliability as the within-subject st and ard deviation ( s(w ) ) , also called st and ard error of measurement . When measurement error is proportional to the score , calculation of a coefficient of variation can be considered . In a second paper , the authors will evaluate  clinical balance measures  for use in fall prevention studies based upon criteria recommended in this report A prospect i ve cohort study was used to determine the reliability and validity of two fall risk assessment tools and  nurses ' clinical judgement in predicting patient falls .  The study wards comprised two aged care and rehabilitation wards within a 570 bed acute care tertiary teaching hospital in Western Australia . Instrument testing included test-retest reliability and calculations of sensitivity , specificity , positive predictive value , negative predictive value and accuracy . The test retest reliability of all methods was good . In this setting , the three methods of assessing fall risk showed good sensitivity but poor specificity . Also , all methods had limited accuracy , and overall , exhibited an inability to adequately discriminate between patient population s at risk of falling and those not at risk of falling . Consequently , neither nurses ' clinical judgement nor the fall risk assessment tools could be recommended for assessing fall risk in this clinical setting Background and Purpose : The sensory and motor deficits associated with multiple sclerosis ( MS ) contribute to falls with the majority of persons with MS falling at least once annually . To appropriately direct treatment , accurate fall prediction measures are needed . In this study of community-dwelling individuals with MS followed for 12 months , we sought to determine frequency of falls , utility of clinical balance tests to predict falls , and accuracy of participants ' retrospective recall of fall events . Methods : Independently ambulatory persons with MS underwent 5 clinical balance tests including Activities-specific Balance Confidence , Berg Balance Scale , Functional Reach , Timed Up and Go , and Dynamic Gait Index , and one disease-specific measure of disability  ( Exp and ed Disability Status Scale ) and then were followed for 1 year . Participants were queried monthly by phone to determine the number of fall events that had occurred . Accuracy of fall prediction was determined by receiver operating characteristic curve analysis and comparison of balance test performance between fallers and nonfallers . Results : Sixty-one percent of the 38 participants were classified as fallers at 12-month follow-up . Only the Berg Balance Scale , Dynamic Gait Index , and the Activities-specific Balance Confidence demonstrated clinical ly useful levels of accuracy . In addition , participants were generally poor in their accurate recall of fall events relative to their monthly fall reports . Discussion and Conclusions : The majority of participants fell during a 1-year prospect i ve follow-up . Only 2 balance performance measures and 1 balance confidence measure accurately distinguished between fallers and nonfallers as well as possessed clinical ly useful levels of sensitivity and specificity . These results also emphasized the inaccuracy of retrospective fall history in an MS sample . Video Abstract available ( see Supplemental Digital Content 1 , http://links.lww.com/JNPT/A55 ) for more insights from the author OBJECTIVE Fall risk assessment is important because the consequences , such as a fracture , may be devastating . The objective of this study was to find the test or tests that best predicted falls in a population -based sample of elderly women . STUDY DESIGN AND SETTING The fall-predictive ability of a question naire , a subjective estimate of biologic age and objective functional tests ( gait , balance [ Romberg and sway test ] , thigh muscle strength , and visual acuity ) were compared in 984 r and omly selected women , all 75 years of age . RESULTS A recalled fall was the most important predictor for future falls . Only recalled falls and intake of  psycho-active drugs  independently predicted future falls . Women with at least five of the most important fall predictors ( previous falls , conditions affecting the balance , tendency to fall , intake of psychoactive medication , inability to st and on one leg , high biologic age ) had an odds ratio of 11.27 ( 95 % confidence interval 4.61 - 27.60 ) for a fall ( sensitivity 70 % , specificity 79 % ) . CONCLUSION The more time-consuming objective functional tests were of limited importance for fall prediction . A simple clinical history , the inability to st and on one leg , and a subjective estimate of biologic age were more important as part of the fall risk assessment The objectives of this retrospective case-control study were to identify risk factors of falls in geriatric-psychiatric in patients and develop a screening tool to accurately predict falls . The study sample consisted of 225 geriatric-psychiatric in patients at a Midwestern referral facility . The sample included 136 in patients who fell and a r and om stratified sample of 89 in patients who did not fall . Data collected included age , gender , activities of daily living , and nursing parameters such as bathing assistance , bed height , use of bed rails , one-on-one observation , fall warning system , Conley Scale fall risk assessment , medical diagnosis , and medications . History of falls , impaired judgment , impaired gait , dizziness , delusions , delirium , chronic use of sedative or antipsychotic agents , and anticholinergic urinary bladder medications significantly increased fall risk . Alzheimer 's disease , acute use of sedative or anti-psychotic agents , and depression reduced fall risk . A falls risk tool , Fall Risk Assessment in Geriatric-psychiatric In patients to Lower Events ( FRAGILE ) , was developed for assessment and risk stratification with new diagnoses or medications OBJECTIVE To identify the interrelationships and discriminatory value of a broad range of objective ly measured explanatory risk factors for falls . DESIGN Prospect i ve cohort study with 12-month follow-up period . SETTING Community sample . PARTICIPANTS Five hundred community-dwelling people aged 70 to 90 . MEASUREMENTS All participants underwent assessment s on medical , disability , physical , cognitive , and psychological measures .  Fallers were defined as people who had at least one injurious fall or at least two noninjurious falls during a 12-month follow-up period . RESULTS Univariate regression analyses identified the following fall risk factors : disability , poor performance on physical tests , depressive symptoms , poor executive function , concern about falling , and previous falls . Classification and regression tree analysis revealed that balance-related impairments were critical predictors of falls . In those with good balance , disability and exercise levels influenced future fall risk-people in the lowest and the highest exercise tertiles were at greater risk . In those with impaired balance , different risk factors predicted greater fall risk-poor executive function , poor dynamic balance , and low exercise levels . Absolute risks for falls ranged from 11 % in those with no risk factors to 54 % in the highest-risk group . CONCLUSIONS A classification and regression tree approach highlighted interrelationships and discriminatory value of important explanatory fall risk factors . The information may prove useful in clinical setting s to assist in tailoring interventions to maximize the potential benefit of falls prevention strategies Background : A poor postural stability in older people is associated with an increased risk of falling . The posturographic tool has widely been used to assess balance control ; however , its value in predicting falls remains unclear . Objective : The purpose of this prospect i ve study was to determine the predictive value of posturography in the estimation of the risk of recurrent falls , including a comparison with st and ard clinical balance tests , in healthy non-institutionalized persons aged over 65 . Methods : Two hundred and six healthy non-institutionalized volunteers aged over 65 were tested .  Postural control  was evaluated by posturographic tests , performed on static , dynamic and dynamized platforms ( static test , slow dynamic test and Sensory Organization Test [ SOT ] ) and clinical balance tests ( Timed ‘ Up & Go ’ test , One-Leg Balance , Sit-to-St and -test ) .  Subsequent falls were monitored prospect ively with self- question naire sent every 4 months for a period of 16 months after the balance testing . Subjects were classified prospect ively in three groups of Non-Fallers ( 0 fall ) , Single-Fallers ( 1 fall ) and Multi-Fallers ( more than 2 falls ) . Results : Loss of balance during the last trial of the SOT sensory conflicting condition , when visual and somatosensory inputs were distorted , was the best factor to predict the risk of recurrent falls ( OR = 3.6 , 95 % CI = 1.3–10.11 ) . Multi-Fallers showed no postural adaptation during the repetitive trials of this sensory condition , contrary to Non-Fallers and Single-Fallers . The Multi-Fallers showed significantly more sway when visual inputs were occluded . The clinical balance tests , the static test and the slow dynamic test revealed no significant differences between the groups . Conclusion : In a sample of non-institutionalized older persons aged over 65 , posturographic evaluation by the SOT , especially with repetition of the same task in sensory conflicting condition , compared to the clinical tests and the static and dynamic posturographic test , appears to be a more sensitive tool to identify those at high-risk of recurrent falls Background and Purpose : Parkinson disease ( PD ) results in an increased frequency of falls relative to the frequency in neurologically healthy people . The purpose of this study was to compare the accuracy of PD fall risk diagnosis based on one test with that based on the collective interpretation of multiple tests . Participants : Seventy people with PD ( mean age=73.91 years ) participated in this study . Method : Clinical balance tests were conducted during the initial examinations of people with PD .  Validity indices were calculated for individual tests and compared with validity indices calculated for a combination of multiple tests . Results : Thirty-six participants reported a fall history . Analysis of individual tests revealed broad variations in validity indices , whereas the collective interpretation of multiple tests improved sensitivity and negative likelihood ratios . Discussion and Conclusion : Collective interpretation of clinical balance tests result ed in fewer false-negative results and more substantial adjustments to the posttest probability of being a “ faller ” than the interpretation of one test alone . These results should be confirmed in a prospect i ve examination of fall risk in PD Background and Purpose : Falls are a significant public health concern for older adults ; early identification of people at high risk for falling facilitates the provision of rehabilitation treatment to reduce future fall risk . The objective of this prospect i ve cohort study was to examine the predictive validity of the  Berg Balance Scale ( BBS  ) for 3 types of outcomes —any fall ( ≥1 fall ) , multiple falls ( ≥2 falls ) , and injurious falls — by use of sensitivity , specificity , receiver operating characteristic ( ROC ) curves , area under the curve , and likelihood ratios . Subjects and Methods : A sample of 210 community-dwelling older adults received a comprehensive geriatric assessment at baseline , which included the BBS to measure balance . Data on prospect i ve falls were collected monthly for a year . The predictive validity of the BBS for the identification of future fall risk was evaluated . Results : The BBS had good discriminative ability to predict multiple falls when ROC analysis was used . However , the use of the BBS as a dichotomous scale , with a threshold of ≤45 , was inadequate for the identification of the majority of people at risk for falling in the future , with sensitivities of 25 % and 45 % for any fall and for multiple falls , respectively . The use of likelihood ratios , maintaining the BBS as a multilevel scale , demonstrated a gradient of risk across scores , with fall risk increasing as scores decreased . Discussion and Conclusion : The use of the BBS as a dichotomous scale to identify people at high risk for falling should be discouraged because it fails to identify the majority of such people . The predictive validity of this scale for multiple falls is superior to that for other types of falls , and the use of likelihood ratios preserves the gradient of risk across the whole range of scores BACKGROUND Assessment of fall risk in an individual with Parkinson disease ( PD ) is a critical yet often time consuming component of patient care . Recently a simple clinical prediction tool based only on fall history in the previous year , freezing of gait in the past month , and gait velocity < 1.1 m/s was developed and accurately predicted future falls in a sample of individuals with PD . METHODS We sought to externally vali date the utility of the tool by administering it to a different cohort of 171 individuals with PD .  Falls were monitored prospect ively for 6 months following predictor assessment . RESULTS The tool accurately discriminated future fallers from non-fallers ( area under the curve [ AUC ] = 0.83 ; 95 % CI 0.76 - 0.89 ) , comparable to the developmental study . CONCLUSION The results vali date d the utility of the tool for allowing clinicians to quickly and accurately identify an individual 's risk of an impending fall PURPOSE To develop a simple screen based on easily collectable measures to identify older people living in residential care facilities at high risk of falls . METHODS This prospect i ve study was conducted in seven residential care facilities in the U.K. Residents aged>60 years who were not bedbound or terminally ill participated .  Demographics , medical history , medication use , cognition ( mini mental state examination ( MMSE ) ) , function ( Barthel , balance and sit-to-st and ability ) and behavior ( neuro-psychiatric inventory ( NPI ) and impulsivity ) were recorded at baseline . Falls and injuries were prospect ively recorded over 6 months . Data were analyzed for differences between fallers and non-fallers and significant variables entered into logistic regression analysis . RESULTS Two hundred and forty residents completed the study . In the follow-up period , 50 % fell ≥1 times . Fallers had worse function , cognition , behavior and balance and took more medications . Falling in the past year , walking frame and hypnotic/anxiolytic and anti-depressant medication use were also associated with increased likelihood of falling . Logistic regression identified MMSE<17 , impulsivity score ≥ 2 , st and ing balance score<6 , requiring a walking frame , falling in the previous year and use of antidepressants and hypnotics/anxiolytics as independent and significant predictors of falls . The area under the receiver operating curve ( ROC ) for this model was 0.79 ( 95 % CI 0.73 - 0.84 ) . CONCLUSIONS This tool comprising multi-factorial measures provides a simple way of quantifying the probability with which a care home resident will fall over a 6-month period . The tool may also assist in guiding the development and targeting of interventions to prevent falls in this group Various clinical tests and balance scales have been used to assess postural stability and the risk of falling in patients with idiopathic Parkinson 's disease ( IPD ) .  Quantitative posturography allows a more objective assessment but the findings in previous studies have been inconsistent and few studies have investigated which posturographic measures correlate best with a history of falling . The purpose of this study was to determine the efficacy of clinical tests , balance scales , and  stable-platform posturography  in detecting postural instability and discriminating between fallers and non-fallers in a home-dwelling PD cohort . Forty-eight PD subjects ( Hoehn & Yahr stage 1 - 3 ) and 17 age-matched controls had the following assessment s : Activities-specific Balance Confidence scale , Berg Balance Scale , Unified Parkinson 's Disease Rating Scale ( UPDRS ) ( motor ) , pull-test , timed up- and -go , static posturography , and dynamic posturography to assess multidirectional leaning balance . Of the clinical assessment s , all but the pull-test were closely correlated with a history of falling .  Static posturography  discriminated between PD fallers and controls but not between PD fallers and non-fallers , whereas  dynamic posturography ( reaction time , velocity , and target hit-time ) also discriminated between fallers and non-fallers . Our findings suggest that this combination of clinical and posturographic measures would be useful in the prospect i ve assessment of falls risk in PD patients . A further prospect i ve study is now required to assess their predictive value . © 2013 Movement Disorder Society Background Patients with Parkinson 's disease ( PD ) suffer from a high fall risk . Previous approaches for evaluating fall risk are based on self-report or testing at a given time point and may , therefore , be insufficient to optimally capture fall risk . We tested , for the first time , whether metrics derived from 3 day continuous recordings are associated with fall risk in PD . Methods and Material s 107 patients ( Hoehn & Yahr Stage : 2.6±0.7 ) wore a small , body-fixed sensor ( 3D accelerometer ) on lower back for 3 days .  Walking quantity ( e.g. , steps per 3-days ) and quality ( e.g. , frequency-derived measures of gait variability ) were determined . Subjects were classified as fallers or non-fallers based on fall history . Subjects were also followed for one year to evaluate predictors of the transition from non-faller to faller . Results The 3 day acceleration derived measures were significantly different in fallers and non-fallers and were significantly correlated with previously vali date d measures of fall risk . Walking quantity was similar in the two groups . In contrast , the fallers walked with higher step-to-step variability , e.g. , anterior-posterior width of the dominant frequency was larger ( p = 0.012 ) in the fallers ( 0.78±0.17 Hz ) compared to the non-fallers ( 0.71±0.07 Hz ) . Among subjects who reported no falls in the year prior to testing , sensor-derived measures predicted the time to first fall ( p = 0.0034 ) , whereas many traditional measures did not . Cox regression analysis showed that anterior-posterior width was significantly ( p = 0.0039 ) associated with time to fall during the follow-up period , even after adjusting for traditional measures . Conclusions / Significance These findings indicate that a body-fixed sensor worn continuously can evaluate fall risk in PD . This sensor-based approach was able to identify transition from non-faller to faller , whereas many traditional metrics were not successful . This approach may facilitate earlier detection of fall risk and may in the future , help reduce high costs associated with falls OBJECTIVE To measure the effects of a specialized postfall assessment intended to detect causes and underlying risk factors for falls , and to recommend preventive and therapeutic interventions . DESIGN R and omized , controlled trial . SETTING A long-term residential care facility for elderly persons . SUBJECTS Within 7 days of a fall , 160 ambulatory subjects ( mean age , 87 years ) were r and omly assigned to receive either a comprehensive postfall assessment ( intervention group , n = 79 ) or usual care ( control group , n = 81 ) . INTERVENTION The postfall assessment included a  detailed physical examination and environmental assessment by a nurse practitioner ; laboratory tests ; electrocardiogram ; and 24-hour Holter monitoring .  Probable cause or causes for the fall , identified risk factors , and therapeutic recommendations were given to the patient 's primary physician . MEASUREMENTS AND MAIN RESULTS Through use of the assessment , many remediable problems ( for example , weakness , environmental hazards , orthostatic hypotension , drug side effects , gait dysfunction ) were detected . At the end of the 2-year follow-up period , the intervention group had 26 % fewer hospitalizations ( P less than 0.05 ) and a 52 % reduction in hospital days ( P less than 0.01 ) compared with controls . Patients in the intervention group had 9 % fewer falls and 17 % fewer deaths than controls by 2 years , but these trends were not statistically significant . CONCLUSIONS Our study suggests that falls are a marker of underlying disorders easily identifiable by a careful postfall assessment , which in turn can reduce disability and costs PURPOSE To evaluate the effectiveness of a Falls Prevention Program ( FPP ) in reducing  patient fall rate  and to examine predictors of falls . SAMPLE A nonr and om , stratified convenience sample of 292 subjects was selected from medical-surgical/critical care patients at a large community hospital system . The sample included 101 patients who fell prior to the FPP , 98 patients who fell after FPP , and 93 patients who did not fall after FPP . METHODS A retrospective , preimplementation/long-term , postimplementation , comparative , descriptive design was used to address differences in patients who fell before and after FPP . Prediction factors associated with incidence of falls were assessed using a sample that included patients who fell and patients who did not fall in 1995 . Data were collected about the patients and the fall incidents via a retrospective chart and incident report review . FINDINGS No decrease in patient fall rate was found between patients who fell before and after implementation of the FPP . Patients tended to fall attempting to get out of the bed , suffering no injury . Model testing of the linear results of patients who fell and patients who did not fall after the implementation of the FPP demonstrated that fall prediction factors included age 60 or over , impaired memory , muscle weakness , and need of ambulatory assistance ( Log linear chi-square : 6.048 , df 4 , p = 0.811 ( p > .05 ) . CONCLUSION Identification of patients who exhibit characteristics of the fall prediction model may be useful in reducing falls in medical-surgical/critical care patients . Further testing of the four-factor model with subsequent inclusion of focused interventions may impact the incidence of falls ABSTRACT Purpose : The purpose of this r and omized controlled trial was to measure the effectiveness of A Matter of Balance , a small‐group based balance program , on muscle strength , gait , balance , and fall risk among older community‐dwelling adults at risk for falls . A secondary aim was to measure the effects of the program on actual fall rates over the 3‐month study . Methods : Twenty‐three older adults were r and omly assigned to either an experimental group that participated in a 12‐week small‐group based balance program or a control group . Subjects were assessed at baseline and following an intervention using the following outcome measures : lower extremity manual muscle testing ( MMT ) and range of motion ; gait analysis on the GAITRite ® system ; balance parameters on the SMART EquiTest ® , the Timed Up and Go test , the Berg Balance Scale , and incidence of falls . Results : A repeated measures ANOVA revealed that there was a significant interaction between groups over time in the Berg Balance Scale scores , P ≤.05 . The experimental group improved over time ( 48.1 to 52.9/56 , respectively ) , whereas the control group decreased in performance ( 49.1 to 47.8/56 , respectively ) , P ≤ .05 . The mean number of falls was significantly less in the experimental group during the intervention compared with the control group ( 0.09 and 0.50 , respectively ) , P ≤ .05 . Conclusions : A community‐based multifactorial intervention including individualized fall risk assessment , exercise , and home assessment appears to safely and effectively reduce the number of falls , result ing in significant improvements in functional balance ability and decreased fall risk OBJECTIVES To test the hypothesis that scores on 4 falls risk measures  will differ significantly in patients reporting recurrent falls compared with those who do not ; and to explore the validity of each measure to predict such falls status . DESIGN A convenience sample was tested to establish the sensitivity and specificity of the  Functional Reach Test , Timed Up & Go test , one-leg stance test ( OLST )  , and  balance subsection of the Performance Oriented Mobility Assessment ( B-POMA ) . A 12-month retrospective falls history was used to identify recurrent fallers . SETTING A day hospital for the elderly . PARTICIPANTS Convenience sample of 30 day hospital patients . The inclusion criteria were : ability to rise from a chair and walk 6 m ; no severe cognitive impairment or blindness ; age 65 years or older . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Scores on the 4 tests and retrospective falls histories . RESULTS Scores on the B-POMA and OLST showed significant differences between fallers and nonfallers ( P<.05 ) . An  OLST time of 1.02 seconds or less ( odds ratio [OR]=15.2 ; 95 % confidence interval [ CI ] , 1.72 - 133.95 ) and B-POMA score of 11 or less ( OR=18.5 ; 95 % CI , 2.05 - 167.79 ) were predictive of day hospital patients having a history of recurrent falls . CONCLUSIONS OLST and B-POMA both have potential as screening tools for risk of falls , but this observation requires confirmation in a prospect i ve study
Meta- analysis demonstrated fallers perform significantly worse than non-fallers on all measures analysed except the Timed Up and Go Cognitive ( p < 0.05 ) , but discriminative ability of the measures is commonly not reported .
Of those reported , the Activities-specific Balance Confidence Scale had the highest area under the receiver operating characteristic curve value ( 0.92 ) , but without reporting corresponding measures of clinical utility .
Conclusion : Clinical measures of balance differ significantly between fallers and non-fallers but have poor predictive ability for falls risk in people with multiple sclerosis
Objective : To determine the ability of clinical measures of balance to distinguish fallers from non-fallers and to determine their predictive validity in identifying those at risk of falls .