|UFDC Home||myUFDC Home | Help|
This item has the following downloads:
IMPACT OF POST-STROKE MOBILITY ON ACTIVITY AND PARTICIPATION
ARLENE ANN SCHMID
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
Arlene Ann Schmid
This dissertation is dedicated in the memory of my father, Albert R. Schmid.
Many people have gotten me to this phase of my life. I thank my parents and sister
for unending support and love, for always telling me that I could be successful. I thank
my mother for teaching me that I could always be more, and do more.
I thank Dr. Pamela Duncan for reminding me that I could always be more and do
more everyday. I would never be here without her support and dedication to my future.
I also thank Dr. Maude Rittman for continuous encouragement and assistance, and
wonderful everyday conversation that got me through this process. The rest of my
committee, Dr. Lorie Richards and Michael Marsiske, have provided wonderful guidance
for many of the years that I have been pursuing my graduate degree, but have been
outstanding as a dissertation committee.
Friendship has been a wonderful requirement of graduate school, I think we would
not survive without each other. I am honored to have known so many extraordinary
people who will do so many great things. I am especially grateful for the friendship of
Jessica, Roxanna, Rick, Ellen, Diane, Cesar, Jordan (thanks for the dog sitting too!!) and
my neighbors, Nate and Gretchen. Michelle deserves her own sentence. She has been a
great support, and always seemed to know what to do, plus those car rides to Buffalo
created some type of weird bond (and I knew she would complain if she did not have
your own line!!!). Megan (Meggy !!) has been an outstanding friend, and has provided
great information regarding the Midwest!! And Marieke! My IL! She is the "strangest
person I ever met". She is a great friend and has been so good to me. I thank her for being
fabulous! Thank you all for everything, I am glad we have crossed paths...
The 'boys', the 'PhDemons', how will I ever get through this new phase of my life
without them? From day one we have depended on each other, and have grown to
become something we never knew was possible. Michael and Dennis have provided
wonderful friendship and have made this time of life so much better. Thanks to the two of
them, I have many more happy memories and have had much more fun (as measured by
the fun-o'meter) than most on their way out of graduate school. But more importantly,
they have both provided guidance, and I hope I have also assisted them along this long
And finally to 'BZ', we have made it through this. I now have no question that we
can do anything, as long as we do it together. He is the sweetest and most wonderful
person and I am very lucky to be spending the rest of my life with him, Kalo, and Maile. I
thank him for always reminding me that I was capable of taking on the world.
TABLE OF CONTENTS
A C K N O W L E D G M E N T S ................................................................................................. iv
LIST OF TABLES ................................ ......... .. .. .. .......... ....... ix
LIST OF FIGURES ......... ......................... ...... ........ ............ xi
ABSTRACT ........ .............. ............. .. ...... .......... .......... xii
1 IN TR OD U CTION ............................................... .. ......................... ..
Theoretical M models ............................................... ...... ........................ ........ .3
The World Health Organization Model: International Classification of
Functioning, Disability, and Health .............. ............................................ 3
Theoretical Fram ew ork ............................................................................. 6
R research Q uestions........... .................................................................... ........ .... 7
2 REVIEW OF THE LITERATURE ........................................ ......................... 9
Introduction ................................................................. ...............
Mobility in the Community Dwelling Elderly...........................................................10
G ait V velocity ................................................................. .. ......................... 11
Gait velocity as an outcome measure.................................... ..................11
Gait velocity and other aspects of mobility...............................................12
F a lls ........................................ ...... .......... ............ ................ 1 2
Incidence and consequences of falls in the community dwelling elderly ....12
M ultifactorial risk factors................................... .............................. ...... 13
N um ber of risk factors...................... .................... ......... .......... ............... 14
Fear of falling as a risk factor and consequence of falls ............................15
F ear of F allin g ......................................... ....... ..... .. ........ ............... 15
Incidence of fear of falling in the community dwelling elderly.................. 16
Fear of falling risk factors ...........................................................17
M ability in the Post-Stroke Population ........................................... .....................18
Stroke and Mobility Impairment .................. ..................... ...............18
Stroke .................. ...... .. ......... ...... ..................... ....... 18
G ait V elocity A after Stroke........................................................ ............... 19
Falls A after Stroke ........................................ .. .. .... ........ ..... .... 22
Stroke as a risk factor for falls .......................................... ............... 23
P ost-stroke hip fractures...................................... ........................... ........ 24
Fear of Falling A after Stroke ........................................ .......................... 24
Post-stroke balance confidence ...................................................... 24
Post-stroke fear of falling assessments.................................................25
Post-stroke fear of falling ............................. ........... .................. 26
A activity and P participation ................................................................ ............... ...26
Restriction of Activity and Participation............... ...... ......................... 26
Gait Speed, Activity, and Participation .................................... ............... 27
Falls, Activity, and Participation ................................ ...............29
Fear of Falling, Activity, and Participation.......................... ............... 30
C areg iv ers ...................... .. .. ......... .. .. .................................................3 1
Stroke and Caregiving ................... ...... ........ .. .. .... ..... .. ........ .... 31
Mobility Disability and Caregiving.................... ............. ..............32
C aregiver D expression ............................................. ................ ............. 33
Caregiver Burden ....................... ....... ............................... .33
Sum m ary of the Literature Review .............. ................................... ................34
3 THE IMPACT OF POST-STROKE GAIT VELOCITY CHANGES ON
ACTIVITY AND PARTICIATION .................................................. .................. 35
Introdu action ...................................... ................................................. 3 5
M eth o d s ...................................................................3 7
D design ...................................................................................................... ....... 37
P articip an ts ................................................................ 3 8
O utcom e M measures .................................. ............. ...... ......... 39
G ait v elo city ................................................. ................ 3 9
Activity and participation..................... ...... ........................... 40
Statistical A analysis .......................................... .. .. .... .... ..... ..... .. 4 1
R e su lts ...........................................................................................4 1
D isc u ssio n ............................................................................................................. 4 4
4 FEAR OF FALLING AFTER STROKE ..................................................48
In tro du ctio n ...................................... ................................................ 4 8
M eth o d s ..................................................................5 0
D e sig n .......................................................................................5 0
Sam ple .............................................................................................................50
D ata Collection ................................................................ .. ... ............ 51
O utcom e M measures ...........................................................53
Functional status................................................... 54
Cognitive status ................................................................ .. .............54
D expression ............................... ........ .......................................... 54
Caregiver demographics, burden, and coping ...........................................55
A analysis of Q uantitative D ata ....................................................... 55
R e su lts ...............................................................................................5 6
D description of Sam ple ................................................................................... 56
Relationships Between Fear of falling, Functional Status, and Depression........56
The Experience of Fear of Falling Post-Stroke ....................................... 60
Onset of falling with the stroke event ............. ........................................61
Experiencing the changed body ....................................... ............... 62
A pervasive fear of the unpredictable .......................................................64
Falls as an everyday life experience.................................. ............... 66
Strategies for managing fear of falling ............. .......................................66
D iscu ssion ............................................................................................................ 7 0
Characterization of Fear of Falling.................................. ........................ 71
L im itatio n s ..................................................................................................... 7 4
Future R research ................................................... .. .......... .............. .. 74
5 C O N C L U SIO N ......... ......................................................................... ........ .. ..... .. 77
EVIDENCE BASED TABLE FOR FEAR OF FALLING AND ACTIVITY
R E ST R IC T IO N ................... .................... ................................... .......... .. .... 1
L IST O F R E FE R E N C E S ....................................................................... ... ...................85
BIOGRAPHICAL SKETCH ............................................................. ............... 105
LIST OF TABLES
2-1. M ultifactorial risk factors for falls ........................................ ....................... 14
2-2. Six am bulation categories ............................................... ............................. 20
2-3. G ait Speed C lassification .............................................................. .....................20
2-4 C om m unity am bulation ......................................... .............................................22
3-1. Community ambulation and gait speed...........................................................36
3-2. Baseline characteristics for participation with initial gait speed < 0.8 m/s
(success = advancing to a higher ambulation classification) .................................42
3-3. Proportions of success/fail for transitioning to next ambulation classification
between baseline and 3 m months ........ ............................................. ............... 43
3-4. Three month outcomes for entire sample...... ....................... ...........43
3-5. Three month outcomes stratified by gait speed.............. ..... .................44
4-1. Coding structure for qualitative interviews ............... .............. .....................53
4-2. Baseline data for those with and without fear of falling (FoF) ..............................56
4-3. Baseline/discharge data for those discussing fear of falling at one and six months 57
4-4. Baseline/discharge data and outcome measures for those with and without fear
of falling ......... ..... ............. ..................................... ............................58
4-5. Scoring of FAI and FIM items for those with and without fear of falling ..............59
4-6. Frequency counts of fear of falling at one and six months .................................59
4-7. Proportions of those with and without fear of falling and chi square ...................59
4-8. Comparison of caregivers for participants with and without fear of falling ............60
4-9. Content analysis frequencies (derived from 55 qualitative interviews) .................61
A-1. Fear of falling and activity restriction .................................... ......... ............... 82
LIST OF FIGURES
1-1. The ICIDH-2 M odel of Disablement ........ .............................. .. ............... 4
1-2. Conceptual M odel ...................... .... ............................................. ....
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
IMPACT OF POST-STROKE MOBILITY ON ACTIVITY AND
Arlene Ann Schmid
Chair: Pamela W. Duncan
Major Department: Rehabilitation Science
Post-stroke individuals often experience residual mobility impairments, reflected in
decreased gait speed, increased falls, and the possible development of fear of falling. This
research utilized two secondary analyses to explore the impact of post-stroke gait velocity
and fear of falling on activity and participation.
The first study examined clinically meaningful changes in gait velocity in 64 post-
stroke individuals. Velocity was measured at baseline and three months and was placed
into a three tier ambulation classification. T-tests determined a difference in functional
ability (activities of daily living (ADLs), instrumental activities of daily living (IADLs),
mobility, and social participation) between those who did and did not successfully
advance to the next ambulation classification. After stratifying by baseline gait velocity
and controlling for age, those most severely impaired at baseline, and who advanced
classifications, demonstrated significant differences in all measured functional abilities.
In comparison, those moderately impaired only demonstrated significant differences in
social participation. Thus, clinically meaningful changes in gait speed were related to
highly significant changes in all domains, particularly for participation.
The secondary objective was to characterize post-stroke fear of falling. Review of
qualitative interviews identified those with fear of falling. T-tests compared ADLs,
IADLs, and depression measures between those with and without fear. No significant
differences were found for the outcome measures; however, those with detected fear
exhibited slightly worse scores on all measures. Content analysis of the interviews
revealed five elements used to characterize post-stroke fear of falling: (1) onset of falling
with stroke event, (2) experiencing the changed body, (3) a pervasive fear of the
unpredictable, (4) falls as an everyday life experience, and (5) the strategies for managing
fear of falling. Such experiences and strategies became very individualized and imply the
need for future research regarding assessment and intervention of post-stroke fear of
Collectively, these results indicate that many post-stoke individuals live in the
community, but still demonstrate residual mobility deficits. Decreased gait velocity and
developed fear of falling were related to activity restriction and modification, possibly
leading to further losses of independence, placing individuals at risk for decreased quality
of life and life satisfaction.
The American Heart Association reports stroke to be a common diagnosis
occurring in 700,000 people annually. Stroke is the primary cause of disability and the
third leading cause of death for those over 65 [1-4]. Stroke is also classified as the most
disabling chronic disease and the cumulative consequences are often staggering for
individuals, families, and society [5, 6]. Residual motor, sensory, and visual post-stroke
deficits make mobility impairments common. Changes in gait velocity, falls, and fear of
falling are common post-stroke mobility impairments. All may contribute to decreased
performance of activities of daily living (ADLs), instrumental activities of daily living
(IADLs), social participation, and overall declines in quality of life.
The purpose of this dissertation is to report findings from two studies. Both studies
are secondary analyses of larger studies. The goal of the first study was to evaluate a
clinically meaningful change in post-stroke gait speed and its impact on activity and
participation levels post-stroke. A clinically meaningful change is important to determine
as it is related to patient-valued benefits. Barrett et al. discusses the need to merge
patient-oriented and evidence-based frameworks together by observing an "important
difference" . Such clinical significance can be seen by examining the sufficiently
important difference (SID), the smallest amount of patient-valued benefit required from
an intervention to justify associated costs, risks, and other harms. We observed data on
post-stroke gait speed changes and the existing relationship with ADLs, IADLs, and
social participation to examine a clinically meaningful change in gait velocity.
Data for this aspect of the study were derived from a prospective, randomized,
controlled, single-blind, clinical intervention trial . An analysis of three-month post-
stroke data related to gait speed was completed. Participants were stratified by changes in
gait speed. Comparisons were completed to determine significant differences in ADL,
IADL, and social participation scores between those who succeeded and those who failed
to increase gait speed at three months post-stroke. Literature supports an association
between gait speed and mobility [9, 10]. However, limited research currently exists to
support the relationship between changes in gait speed and the resultant difference in
performance of ADLs, IADLs, and social participation.
The second study was completed to identify and describe the characterizations of
fear of falling as reported by participants who have been discharged home following a
stroke. We used qualitative and quantitative data from a longitudinal multi-site cohort
study exploring stroke recovery and caregiving at one and six months post discharge
following acute stroke [11 ]. We examined the relationship between fear of falling and
demographic variables, depression, and the ability to perform ADLs and IADLs.
Additionally, caregiver depression and burden associated with fear of falling was
explored. Qualitative interviews were semi-structured around issues related to the post-
stroke experience but did not specifically ask about fear of falling. Therefore, the
interviews were examined to identify participants who discussed characteristics related to
fear of falling. The data specific to those with an identified fear were re-coded in QSR N-
6 (qualitative data computer software). Content analysis was used to analyze the
qualitative data and define characterizations of fear of falling across 6 months after
discharge home post acute stroke. Currently, there is a paucity of information related to
the development of fear of falling after stroke. This study provides initial exploration into
this complex syndrome and will supply preliminary data for future research regarding
post-stroke fear of falling and the residual influence it has on activities and participation.
Cumulatively, these research projects provide researchers and clinicians with
valuable information regarding performance of ADLs, IADLs, and social participation
related to both gait speed and fear of falling after stroke. The impact of post-stroke gait
speed on ADLs and IADLs is not well researched and this study contributes critical
information. This research is the first study to examine fear of falling in a stroke
population with longitudinal data that are both quantitative and qualitative. Results from
the study indicates the need for development of a future index related to fear of falling in
the population, and, more importantly, interventions to reduce both falls and manage fear
of falling in the post-stroke population. These studies provide a foundation for future
research related to post-stroke mobility and activities and participation.
Two theoretical models have guided this research. The International Classification
of Functioning, Disability, and Health was used to explain the fundamental relationships
between post-stroke mobility and ADLs, IADLs, and participation (see Figure 1-1). An
additional conceptual model was specifically proposed for these research study questions.
It was developed after a review and synthesis of the literature specific to gait velocity and
fear of falling (see Figure 1-2).
The World Health Organization Model: International Classification of Functioning,
Disability, and Health
Various models of disablement have been developed and explored over the years.
Because rehabilitation strives to reverse what was previously known as the "disabling"
process, proactive alterations have occurred in the theoretical models. Therefore they are
now termed "enablement models", and represent models of health and ability. The
International Classification of Functioning, Disability, and Health (ICF) is the model
most frequently used in rehabilitation sciences and was proposed by the World Health
Organization (WHO) [12, 13].
The ICF has recently undergone revisions to better incorporate the concepts of
health and ability and to replace terms such as impairment, disability, and handicap to
allow for a more positive framework and classification system . The ICF provides a
framework for the analysis of health conditions, body structure, body functions, activity
and participation, and environmental and personal factors . There are two parts of the
ICF; the first deals with functioning and disability and is derived of the components of
body structure, body functions, activity, and participation. The second part includes the
components of contextual factors and includes environmental and personal factors. See
Body Structure & Body
Functions Activities Participation
Environmental Factors Personal Factors
Figure 1-1. The ICIDH-2 Model of Disablement
Body structures are the anatomical parts of the body and include organs, limbs, and
their components. Body functions are the physiological or psychological functions of
body systems. Body function and structure impairments are related to significant
deviation or loss.
The activities and participation component collectively covers the complete range
of individual and societal functioning and disability. The model captures the major
actions of all people, regardless of culture or lifespan. Activity is the execution of a task
or action that is completed by an individual in a uniform environment. Activity
limitations are difficulties a person may have in executing activities. Activity includes
self-care, mobility, learning and applying new knowledge, general tasks and demands,
and communication. Participation is the involvement in a life situation in an individual's
current environment. Restrictions in participation are problems a person may experience
in involvement in life situations. Participation includes domestic life, interpersonal
interactions and involvement in relationships, major life areas, and community, social,
and civic life. Activities and participation have two qualifiers within the model. Capacity
is the completion of an item in a neutral or standard environment and focuses on how an
individual actually completes the task. Performance is related to completing the same
item during daily life, at home and in the environment. Capacity limitations indicate the
discordance between capacities of people with and without health related condition.
Performance limitations indicate a need for intervention at the environmental level.
Environmental and personal factors include external features of the physical, social,
and attitudinal environment in which people live and conduct their lives. Products and
technology, natural environments, human-made changes to the environment, support and
relationships, attitudes, and services, systems, and policies are all aspects of
environmental and personal factors.
Substantive reviews of the literature were completed. The literature pertaining to
post-stroke mobility, gait speed, falls, and fear of falling were incorporated into the ICF
model (see Figure 1-2). It was used to guide the research questions and analyses for these
In this study, the general health condition was "stroke." The type of stroke and
severity of stroke are important aspects that may impact post-stroke mobility. Stroke
related body function and body structure included sensory, cognitive, and motor
impairments. Environmental factors included caregiver depression, burden, and coping.
Personal factors included age, race, and cognition. These stroke related impairments and
personal factors might be related to activity limitations; such as difficulties completing
ADLs and IADLs, including walking, stair climbing, dressing, bathing, toileting, etc.
Mobility is a construct of ADLs and is therefore considered an aspect of activity. Gait
speed and fear of falling are each aspects of post-stroke mobility, and are therefore
considered as activity. It is thought that losses in gait speed and the development of fear
of falling adversely impact ADLs, IADLs, and social participation. Body function and
structure impairments and especially activity limitations may restrict participation in
society, thereby limiting role fulfillment at home, work, and within the social
environment. All of these post-stroke changes may also influence caregiver burden,
The current study was developed to specifically address the relationships between
changes in gait speed and the development of fear of falling with ADLs, IADLs,
participation, and depression. All aspects of the model may be affected by post-stroke
mobility. Activity, participation, and environmental/personal factors must therefore be
addressed. Importantly, all are related to the greater aspect of quality of life and life
*Type of Stroke
Body Structure & ADLs and IADLs Participation
Body Functions (including mobility, gait speed Social participation
Stroke related and fear f fallmg)
Environmental Factors Personal Factors
Figure 1-2. Conceptual Model
The following research questions are derived from the relationships depicted in
Figure 1-2. The conceptual model was the guiding focus of this study. We used both
qualitative and quantitative data in this study.
We explored the post-stroke relationship between clinically meaningful changes in
gait velocity and performance of ADLs, IADLs, and social participation.
1. Does a change in gait velocity classification impact the ability to perform ADLs,
IADLs, functional mobility, and social participation after stroke?
We also explored post-stroke fear of falling using qualitative and quantitative data.
Our research question related to examination of the fear of falling qualitative data
2. How do the participants report and characterize fear of falling in the home or
To complement the study, we examined the relationship between fear of falling and
3. How is post-stroke fear of falling related to performance in ADLs and IADLs?
4. How does caring for an individual with post-stroke fear of falling impact caregiver
burden and depression?
5. Is there a difference in the proportion of stroke survivors with fear of falling at 1
and 6 months post stroke?
REVIEW OF THE LITERATURE
Stroke is a common problem and the leading cause of adult disability in the United
States. There are many residual motor, sensory, and visual post-stroke deficits making
mobility impairments common. Common post-stroke mobility impairments include
decreased gait velocity, falls, and the development of fear of falling. All may negatively
impact performance of activities of daily living (ADLs), instrumental activities of daily
living (IADLs), and social participation. Such restriction in activity and participation has
been associated with declines in life satisfaction and quality of life.
The following review of the literature is based on the International Classification of
Functioning, Disability, and Health (ICF)  and the conceptual framework found in
Chapter 1 (Figure 1-1 and 1-2). As stated in Chapter 1, stroke related sensory, cognitive,
and motor impairments negatively influence post-stoke mobility, as demonstrated in
decreased gait speed and increased falls and fear of falling. These changes in post-stroke
mobility may impact activity and participation. Activity and participation limitations may
also negatively influence caregiver burden and depression.
In this review of the literature, there will be an overview of mobility concerns of
the community dwelling elderly. Specifically, gait speed, falls, and fear of falling will be
addressed. The limited existing literature specific to post-stroke gait speed, falls, and fear
of falling will also be presented. Additional literature is presented on the impact of
mobility on activity and participation; some is specific to the post-stroke population, but
much is generalized to the community dwelling elderly. Caregiver burden and depression
are also explored in this review as care needs change for those with decreased activity
and participation. Increased caregiver burden and depression are associated with a
patient's history of strokes, falls, and decreased independence.
The objective of this research was to determine the impact of post-stroke mobility
on activity and participation. Specifically, the relationships between changes in gait speed
and the impact on activity and participation were explored. Additionally, the
characterization of fear of falling by a post-stroke population was described. Performance
of ADLs, IADL, and depression for those with fear was also examined. This research will
provide foundational data for future studies examining the impact of post-stroke mobility
on activity and participation.
Mobility in the Community Dwelling Elderly
Mobility has been defined as the "ability to move from one place to another
without assistance" . It is a component of ADLs and is critical for the maintenance of
independence and a sustained quality of life [14, 15]. Mobility disability is defined by the
inability of individuals to "move effectively in their surroundings" . It is a strong
predictor of physical disability and often the first area in which older adults demonstrate
disabilities [16-18]. The prevalence of mobility disability increases from 7.7% of those
over the age of 65 to 35% for those over 80 years .
Disability is a risk factor for loss of independence, admission into care facilities,
increased need for caregiving, and health care utilization [20-24]. Those who demonstrate
mobility limitations are at risk for increased disability, dependence, morbidity, and
mortality [17, 25-32]. Mobility limitations have been utilized in predicating disability
Changes in gait velocity, increased number of falls, and the development of fear of
falling are three important aspects of mobility. All are common issues for the community
dwelling elderly population. Disability may occur due to any or all of these mobility
Mobility and mobility disability are commonly demonstrated by changes in gait
velocities. Gait velocities often decrease with age and have been associated with severity
of walking difficulties . Cress et al. found that walking speed was the strongest
indicator of self-perceived physical functioning . Gait velocity has therefore become
a frequently measured outcome and goal of rehabilitation.
Gait velocity as an outcome measure
Numerous elderly specific research studies have utilized gait velocity as a primary
outcome measure to assess mobility impairment . Velocity has been deemed useful in
rehabilitation medicine and research as it correlates well to many gait parameters . It
has been related to discharge placement following hospitalization in the elderly
population [37, 38].
Gait speed is an important measure of stroke recovery as it is simple to measure
and has been demonstrated as reliable and sensitive to the stage of recovery post stroke
[9, 35, 39]. Gait speed has been associated with discrimination of stroke effects and is
related to rehabilitation prognosis . Studenski and colleagues demonstrated gait speed
measures of less than 0.6 meters/second (m/s) as a predictor of future health care
utilization and declines in health status . In their study, 69% of the elderly with a
walking velocity of less than 0.6 m/s developed new personal care difficulty as compared
to 12% of those walking faster than 1.0 m/s.
Gait velocity and other aspects of mobility
Decreased gait speed has been related to falls and fear of falling [42-44]. Hausdorff
et al. reported a relationship between falls and factors such as gait speed and functional
status . Maki demonstrated a relationship between decreased gait speed and increased
falls and fear of falling in the community dwelling elderly population .
A fall has been defined as "an event which results in a person coming to rest
unintentionally on the ground or other lower level, not as a result of a major intrinsic
event (such as stroke) or overwhelming hazard" [46, 47] or as "falling all the way down
to the floor or ground, or falling and hitting an object like a chair or stair" . Falls are
significant mobility issues addressed in the literature for the community dwelling elderly.
Incidence and consequences of falls in the community dwelling elderly
Falls are the leading cause of injurious death for those over 65 in the United States
. At least 30% of those over 65 and residing in the community fall annually; 10-20%
fall two or more times . After age 80, annual fall rates increase to 50% [46, 51]. The
elderly who fall are likely to sustain more fall related trauma and serious injury and
demonstrated increased health care utilization compared to young fallers . Fall related
trauma is more likely to be the cause of death in older fallers 
In 2001, more than 1.6 million emergency room visits and 15,000 deaths were
attributable to falls . Severe consequences related to falls include hip fractures and
head trauma, increased health care utilization, declines in ADLs and IADLs, decreased
socialization, increased admissions to long-term care facilities, premature disability, and
death [53, 55]. Additionally, King and Tinetti determined that morbidity, physical injury,
restriction of mobility, reduction of activity and participation, and generalized decreases
in independence were fall related consequences .
Long-term care admissions. Donald and Bulpitt completed a longitudinal
prospective cohort study to assess fall related deaths and long-term care admissions .
Risk of death increased at both one and three years for recurrent fallers. However, all
who fell demonstrated loss of function and independence, consequently increasing long-
term care facility admissions. Tinetti et al. reported 40% of all nursing home admissions
as being fall related .
Fractures as a consequence of falls. Approximately 360,000 adults suffer a fall
related hip fracture each year . Half of those who suffer a hip fracture will never
regain their prior level of functioning. Hip fractures are a significant concern as they are
related to more deaths, disability, and medical costs than all other osteoporotic fractures
Falls are an independent risk factor and contribute to 90% of all hip fractures [59,
60]. Minor injuries such as bruises and abrasions occur after 30%-55% of falls [48, 51,
61] and about 4%-6% of falls end in a fracture, often of the hip [46, 48, 61, 62]. Death is
uncommon following a fall; however, fall related hip fractures are the leading cause of
death for those over the age of 65 [63, 64].
Multifactorial risk factors
A review of the literature indicates fall risks are considered multi-factorial [46, 51,
52, 65-75]. Meta-analyses and predictive models have been used to determine many of
the evidence based risk factors. An epidemiological study determined that over 400 fall
risk factors exist . Factors may differ between community dwelling individuals and
those residing in long term care facilities . Table 2-1 provides a list of common falls
risk factors. Each factor is supported in the literature and by recent meta-analyses [46, 49,
51, 52, 66, 68-71, 77].
Table 2-1. Multifactorial risk factors for falls
Disease & Disability
disease/blood pressure issues
Balance and gait deficit
Decreased gait speed/gait
Fear of falling
Medications and polypharmacy
Vision and hearing
Use of assistive device
[49, 61, 77, 87-89]
[49, 66, 77, 90, 91]
[49, 52, 77, 92-94]
[49, 52, 66, 77]
[52, 56, 95, 96]
[46, 52, 66, 97-100]
[42-46, 66, 69, 78, 90, 95, 97, 101]
[46, 52, 61, 66, 71, 74, 90, 95, 97, 99, 102-109]
[46, 66, 110, 111]
[46, 66, 90, 116, 117]
[46, 52, 66, 90, 118-122]
[48, 52, 66, 90, 97, 123]
[52, 66, 90, 107, 124]
[46, 100, 125-130]
[46, 74, 126, 131-133]
[66, 69, 74, 134, 135]
Number of risk factors
The risk of falling is exacerbated when the actual number of existing risk factors is
increased [46, 70]. Tinetti and colleagues completed a community based study examining
those with and without fall risk factors . At one year, 27% of individuals with one or
no risk factors fell compared to 78% of those with four or more factors. Nevitt and
colleagues indicated falls increased from 10% to 69% as the number of risk factors
increased from one to four or more . Robbins et al. compared one-year fall rates for
those with and without three identified risk factors: hip weakness, unstable balance, more
than four medications . One hundred percent of those with all three risk factors fell
compared to 12% who had none of the risk factors. Furthermore, Tinetti et al. ascertained
that falls increased from 0% in those with 0-3 risk factors to 100% for those with seven
or more factors .
Fear of falling as a risk factor and consequence of falls
Fear of falling has been established as both a risk factor and consequence of falls
[96, 112, 113]. Fear of falling may develop post-fall, or a fall may occur due to severe
issues related to fear of falling . Psychological trauma related to a fall may be related
to concern of suffering another fall or a result of changes in function and pain related to a
previous fall. Additionally, being stranded on the ground after a fall is a common fear.
Friedman et al. determined fear of falling as a significant risk factor for future falls,
and also demonstrated falls as a risk factor for the development of fear of falling .
Delbaere and colleagues examined the "vicious" cycle that exists between falls and fear
of falling . The authors concluded fear of falling is both a risk factor and serious
consequence of falls.
Fear of Falling
Fear of falling was first identified and termed "postfall syndrome"  or
ptophobia in 1982 , and then simply "fear of falling" in the later 1980's [138, 139].
Fear of falling has been defined as a "disabling symptom of impaired mobility among
frail older people that is significantly associated with depression, diminished performance
in gait, and restricted IADL"  and "as a lasting concern about falling that leads to an
individual's avoiding activities that he/she remains capable of performing" . Others
have considered fear of falling as a loss of confidence balance abilities [141, 142]. It has
also been defined as a general concept that describes low confidence (efficacy) for
avoiding falls and simply being afraid to fall .
Incidence of fear of falling in the community dwelling elderly
Fear of falling is a common difficulty faced by the elderly and is one of the greatest
fears experience by the elderly . Walker and Howland compared fear of falling to
the fear of robbery, fear of forgetting an important appointment, fear of financial
difficulties, and fear of losing a cherished item. Twenty-five percent of the 115
community based participants determined fear of falling as their greatest fear.
Great variability exists surrounding the incidence of fear of falling and incidence
may or may not be related to a previous fall. Researchers have indicated fear of falling in
29%-92% of those recently sustaining a fall and 12%-65% of those without a recent fall
[46, 70, 113, 115, 144-152]. Fear may develop simply due to knowing someone who had
sustained a serious fall or fall related injury .
Myers et al. examined fear of falling in community dwelling elders . Fear of
falling was assessed by asking "are you afraid of falling?"; 56% of those with a previous
fall and 58% without a fall reported being fearful. Further analysis with the Falls Efficacy
Scale determined similar results. The authors expressed that fear of falling may be
underestimated in the elderly due to a fear of institutionalization and a resultant refusal to
participate in such research.
Arfken completed a study to better determine the prevalence and the correlates of
fear of falling . Fear of falling was determined to be more prevalent among the older
participants. Dependent on age, 10%-16% of men reported to be moderately fearful and
0%-5% were very fearful. Comparatively, 15%-34% of women were moderately fearful
and 6%-12% were very fearful. More recently, Stolze et al. completed a prospective
study to investigate the prevalence of falls in differing neurological diseases . Prior
falls were significantly correlated with fear of falling; 57% of the fallers reported fear of
falling compared to 24% of the nonfallers.
Fear of falling risk factors
Like falls, fear of falling is considered to have multifactorial risk factors. Other
than a previous fall, risk factors correlated to the development of fear of falling include:
increased age [43, 144, 148], female gender [43, 144, 148, 155, 156], hospitalization
, and dizziness . Murphy et al. completed a study to identify predisposing risk
factors for the development of fear of falling in an all female community dwelling
population . Predisposing factors for fear development included: age over 80, visual
impairments, sedentary lifestyle, and lack of available emotional support.
Mobility [42, 155] and prior falls [96, 112, 113] are significant risk factors for the
development of future fear of falling. Maki and colleagues completed a cross-sectional
study to investigate the relationship between fear of falling and postural balance and
control . The researchers discussed significantly decreased scoring on balance
assessments for those with fear of falling. Additionally, Maki et al. demonstrated an
association between fear of falling and changes in mobility, such as decreased stride
length, decreased speed, increased double stance time, decreased clinical gait scores, and
increased stride . Vellas et al. demonstrated those with a reported fear of falling
experienced greater balance and gait disorders compared to those without fear of falling
. Ultimately, participants with fear of falling endured decreases in mobility.
Friedman et al. examined the temporal relationship and the shared predictors of
falls and fear of falling . Falls and fear of falling data were collected at both baseline
and 20 months. If participants were assessed as fearful of falling, they were asked about
fear related activity restriction. During the initial assessment, 27.8% participants reported
a fall, 20.8% expressed fear of falling, and 46.2% of those with fear of falling had
curtailed activities. At follow-up, nonfallers with fear were more likely to report falls
than those without fear (32.6% vs 17.9%). Fallers with no fear of falling at baseline were
twice as likely than nonfallers to report fear at follow-up (20.6% vs. 11.6%). Regardless
of fall status, all who expressed fear of falling at baseline were very likely to express fear
again at 20 months.
Researchers have discussed "evidence of a spiraling effect of increasing falls, fear,
and functional decline" . They stated fear of falling is not only an acute outcome
secondary to falls, but "more likely recognition of being at risk, both of falling and of the
adverse outcomes that can result from falls". Additionally it was concluded that once fear
develops, it is likely to persist and influence activities and future fall rates.
Mobility in the Post-Stroke Population
Stroke and Mobility Impairment
Post-stroke residual deficits may exacerbate the mobility issues of the community
dwelling elderly population. Such mobility impairments may negatively gait speed, falls,
and fear of falling after a stroke.
Stroke is the primary cause of disability and is the third leading cause of death for
those over the age of 65 [1-4]. The American Heart Association reports stroke as a
common neurological event occurring in 700,000 people annually; over 4 million are
living with residual deficits . O'Sullivan has defined a stroke, or cerebrovascular
accident (CVA), as "an acute onset of neurological dysfunction due to an abnormality in
cerebral circulation with resultant signs and symptoms that correspond to involvement of
focal areas of the brain" . It has been classified as the most disabling chronic disease
with deleterious consequences for individuals, families, and society [5, 6].
Because age is a known risk factor for stroke, stroke incidence is expected to
increase as the population ages. Stroke prevalence is expected to increases as stroke
survival rates continue to increase [161, 162]. The majority of stroke survivors will be
discharged from the acute care setting and will return home with mild or moderate
physical, cognitive, or emotional deficits . For example, in the Department of
Veterans' Affairs, 72% of all stroke survivors were discharged home into the community
in 1999 .
Gait Velocity After Stroke
Mobility impairment, such as decreased gait velocity has been related to stroke
related outcomes. Perry and colleagues assessed the relationship between gait speed and
mobility in participants 3 months post-stroke . Six ambulation categories were
developed, each was related to post-stroke mobility and ambulation in and out of the
home (borrowed from Hoffer et al. who utilized a four step walking handicap scale for
children ). See Table 2-2 for the six ambulation categories.
Perry et al. used five clinical measures to place post-stroke participants into one of
the six categories. The measures included: a walking ability questionnaire, stride
characteristics including gait speed, upright motor control testing, and proprioception.
Many analyses were completed, and the difference in gait velocity demonstrated the
greatest statistical significance between categories. Discriminate analyses were
completed and identified gait velocity as the only clinical measure to significantly predict
placement into the categories. Those considered as physiological walkers had a mean
velocity of 0.1 .03 m/s compared to community walkers with a gait velocity of 0.8 +
Table 2-2. Six ambulation categories
Limited household walker
Walks only for exercise or in therapy
Requires assist for some walking activities, does walk
during some home activities
Able to walk for all household activities, has difficulty with
stairs and uneven terrain, not able to enter and leave the
Able to enter and leave their home independently, is able to
ascend and descend curbs, able to manage stairs but with
assistance, independent in at least one community activity,
but needs assistance with others
Independent in stairs, all moderate community activities,
and in local stores and uncrowded shopping centers
Independent in all home and community activities, can walk
with crowds and on uneven terrain, and able to be
independent in shopping centers
The classification system was condensed to depict three distinct gait velocity based
classifications (see Table 2-3). This was necessary due to the similarities in gait speed
between the household walkers. A walking speed of less than 0.4 m/s was determined
equivalent to severe gait impairments and the household ambulation category. Limited
community ambulation equals moderate gait impairments and speeds between 0.4 m/s
and 0.8 m/s. Those in the community ambulation category walk over 0.8 m/s and are
considered to have mild or limited post-stroke gait impairment. The normal healthy older
population has been documented to walk at a gait velocity of 1.33 m/s .
Table 2-3. Gait Speed Classification
Speed, m/s Impairment Ambulation Ability
< 0.4 Severe Household ambulation
0.4-0.8 Moderate Limited Community Ambulation
> 0.8 Mild Community Ambulation
1.33 None Normal, Healthy Elderly Population
Lord and colleagues extended this work and evaluated the relationships between
post-stroke gait speed and community ambulation . Community ambulation was
defined as "locomotion outdoors to encompass activities such as visits to the
supermarket, shopping malls, and back; social outings; vacations; and pursuit of leisure
activities". All 130 post-stroke participants lived at home, 115 participants received
physical therapy for mobility impairments and 15 did not require therapy. Mobility
outcome measures assessed gait velocity, indoor and outdoor walking ability, functional
mobility, and gait endurance. An additional self-report questionnaire assessed community
ambulation according to unsupervised mobility. Participants were placed into one of four
ambulation categories (see Table 2-4.), 1) not ambulating outside of the home, 2)
ambulating as far as the letterbox, 3) ambulating within the immediate environment, 4)
ambulating in a shopping center and/or other places of interest.
Those not requiring physical therapy post-stroke demonstrated the fastest gait
velocity. Gait speed was within normal limits for this group and significantly higher than
the overall mean, 1.36 m/s compared to .94 m/s. Gait speed differed between the four
categories and increased as community ambulation increased (Table 2-4). The self-report
questionnaire indicated 14.6% of the participants were unable to leave their home
unsupervised, 16.9% were able to walk to the letterbox, 7.6% were limited to ambulating
in their immediate environment, and 60.7% were able to ambulate within a shopping
center and/or other place of interest. The authors concluded gait velocity was important to
community ambulation and demonstrated that nearly one third of the sample was not able
to ambulate independently within the community after a stroke.
The relationship between gait speed and mobility has been supported in the
literature. However the relationship between changes in post-stroke gait velocity and the
ability to perform ADLs, IADLs, and social participation has never been explored.
Table 2-4. Community ambulation
Group Community Ambulation Level % of Sample Speed (m/s)
1 Unable to leave home 14.6% 0.515 m/s
2 Able to walk to letter box 16.9% 0.66 m/s
3 Limited to immediate environment 7.6% 0.82 m/s
4 Ambulate in shopping center 60.7% 1.14 m/s
Falls After Stroke
Falls are considered the most common medical complication after stroke . Fall
rates increase significantly post-stroke due to motor and sensory impairments and
residual functional, cognitive, and emotional deficits. These deficits are often related to
mobility impairments and losses in ADLs, IADLs, social participation, and overall
quality of life. Falls may contribute to post-stroke residual impairments and further
decreased abilities to complete ADLs and IADLs.
Researchers have shown 22-39% of the acute stroke population falling before
hospital discharge [166-168]. Those who fall while in the hospital are twice as likely to
fall after discharge. Existing research indicates falls remain an issue at discharge [78, 79]
and still at 10 years post-stroke [82, 169]. Forster and Young examined falls incidence
and consequence and reported 73% of the participants fell in the first six-months post-
stroke . Importantly, only 21% of those who fell during the study had fallen prior to
their stroke. The "fallers", those with two or more falls, walked with a slower gait speed,
were engaged in less social activity, and were more likely to be depressed.
Stroke as a risk factor for falls
Stroke is one of the most commonly cited risk factor for falls . Hyndman et al.
determined stroke as a risk factor for falls in a cross-sectional, observational study .
Half of the 41 community dwelling stroke survivors sustained a post-stroke fall and 10
had fallen more than once. Additional risk factors for those deemed "repeated fallers"
included: post-stroke mobility deficits, upper extremity ability, and declines in ADLs and
IADLs. Byers and colleagues studied acute stroke survivors and concluded post-stroke
fall risk factors included a history of falls, impaired decision making ability, restlessness,
generalized weakness, and abnormal hematocrit levels . Jorgensen et al. determined
the risk of falling was at least twice as high for those post-stroke in a case-control study
. Forster and Young found those post-stroke who fell in the hospital were twice as
likely to fall after being discharged home .
Yates and colleagues indicated that those post-stroke are at increased risk for
falling . They investigated the effect of accumulated impairments on the risk of
falling in community-dwelling stroke survivors. Of 280 participants, 51% sustained a fall
between 1 and 6 months post-stroke. Accumulated post-stroke impairments were
characterized as motor, motor and sensory, or motor and sensory and visual. Fall rates for
those with accumulated deficits were compared to those without any of the impairments.
Results from a multiple logistic regression indicated that the risk of falling increased with
motor impairment and motor and sensory impairments. Interestingly, those with motor
and sensory and visual impairments had decreased falls risk. This was most likely due to
increased severity of the stroke, decreased balance, and therefore overall decreased
mobility. The authors concluded that the community-dwelling post-stroke population
demonstrate a higher risk of falling.
Post-stroke hip fractures
Those post-stroke are at risk for both falls and the development of osteoporosis of
the hemiparietic limb, consequently, increasing risk for hip fractures . Ramnemark
and colleagues observed hip fracture incidence in 1139 post-stroke individuals . One
hundred and twenty participants sustained 154 fractures, 84% of all fractures were
secondary to an accidental fall. Hip fractures accounted for 70 (45%) of all recorded
fractures and most affected the paretic side. A four-fold increase of hip fracture was
demonstrated in this post-stroke population.
Ramnemark, et al. completed an additional study examining those sustaining a
femoral neck fracture . Short-term outcomes and mortality were compared for those
with and without a history of stroke. In total, 27.4% participants had sustained a stroke
prior to the hip fracture. Additionally, the majority of hip fractures occurred to the
hemiparietic limb and survival rates were reduced for these patients.
Fear of Falling After Stroke
Post-stroke balance confidence
Currently, there is little research regarding the prevalence of fear of falling
development in the post-stroke population. At this time, the only work related to post-
stroke fear of falling has been completed to validate fear of falling assessments for the
post-stroke population [173-175]. The researchers have indicated that those who have
sustained a stroke are likely to exhibit lower falls confidence while performing activities,
thus demonstrated increased fear of falling.
Decreased falls confidence, or falls efficacy, is based on Bandura's theory of self-
efficacy . Those with low self-efficacy for a particular activity will tend to avoid
that activity. In contrast, those with high self-efficacy will initiate the activity with
enhanced confidence. The self-efficacy theory suggests a reciprocal relationship between
efficacy and function; efficacy may influence function, but the ability to complete
functional activities also influences efficacy. Fear of falling assessments are often based
on self-efficacy and assess whether a person feels confident in their ability to complete
activities with out sustaining a fall [112, 147, 174].
Post-stroke fear of falling assessments
Hellstrom and Lindmark completed a test-retest reliability study of the expanded
Falls Efficacy Scale (Swedish Version) (FES(S)) and compared group differences in
scores on the assessment . The FES was developed by Tinetti et al. and measures
self-perceived fear of falling during the performance of 10 common activities . The
FES(S) includes an additional three items, getting in and out of bed, grooming, and
toileting. These three items were added due to the reduced independence often sustained
by the post-stroke population. Thirty post-stroke participants were included, overall-test-
retest-reliability was high and the FES(S) was indicated as a reliable assessment of falls
efficacy in the post-stroke population. Hellstrom and colleagues completed additional
reliability assessments to determine the ability of the of the FES(S) to assess clinically
meaningful changes over time in the post-stroke population . The changes as
measured by the FES were compared to changes evident using the Berg Balance Scale
and the Fugl-Meyer balance and motor function subscale. The assessments were
completed at admission and discharge from rehabilitation and 10 months later. The
analyses of responsiveness determined individuals post-stroke demonstrated decreased
fall related self-efficacy compared to elderly participants in other fall studies.
A very recent study examined the reliability and validity of the Activities-specific
Balance Confidence (ABC) Scale for those post-stroke . The ABC is a previously
validated and reliable measure of balance confidence that measures confidence in
performing various tasks without falling [150, 177, 178]. All participants were
community dwelling ambulatory older adults who had sustained a stroke at least one year
prior to the study. Significant correlation existed between the ABC and gait speed and
balance assessments (Berg Balance). The authors concluded the ABC reliable and valid
for the post-stroke population.
Post-stroke fear of falling
While there is profuse research related to fear of falling in the community dwelling
elderly, there is a paucity of information specific to the development of fear of falling
after stroke. It can be construed that as fall rates increase  and mobility decreases
after stroke, an increase of fear of falling will be demonstrated. Motor function, balance,
mobility, emotional well-being, and attention may all be diminished following a stroke.
All may influence falls incidence and the development of fear of falling [78, 79].
Increased fear of falling may too be related to a realization of physical and cognitive
declines developed post-stroke.
Fear of falling has been demonstrated as both a risk factor for falls and as a serious
consequence resulting from falls [96, 112, 113]. With post-stroke falls incidence as high
as 73% , it is likely that the rate of fear of falling is equally exacerbated after a stroke.
However, there is little evidence-based literature to support this relationship.
Activity and Participation
Restriction of Activity and Participation
Restriction of activity has been related to the development of disability in the
elderly population. Health and functional status, health care utilization, decreased
independence, increased social isolation, and overall quality of life and life satisfaction
are all impacted by activity curtailment [179, 180]. It is related to decreased
independence and increases in caregiver burden. Restriction of activity has been used as
an outcome measure in geriatric intervention trials attempting to reduce disability [181-
183]. Thus activity restriction is an important consideration for the community dwelling
Gill et al. attempted to identify health and non-health related problems associated
with activity restriction . Within the 15-month study period, 76.6% of the elderly
sample restricted activity during at least one month and 39.3% for two consecutive
months. Health care utilization was elevated during months of activity restriction. Gill
and colleagues also evaluated the relationship between restricted activity and disability
development . The authors concluded that activity restriction was significantly
related to disability development for the community dwelling older population.
Guralnik et al. explored mobility disability and found that limitations in mobility
can lead to decreased performance of ADLs . Such limitations in ADLs and IADLs
have been related to disability and increased health care utilization. It therefore is
essential to explore the impact of mobility, such as gait speed, falls, and fear of falling, on
activity and participation.
Gait Speed, Activity, and Participation
Gait speed has been associated with community mobility [9, 10]. Those with
declines in gait speed may demonstrate decreases in activity and participation and
experience decreased opportunities to return to societal and personal roles .
Consequently, perceived quality of life and life satisfaction are at risk.
Potter and colleagues completed a study to determine a relationship between gait
speed and ADL performance in the elderly population . All participants were older
than 65 and independently mobile. Participants were all admitted to inpatient or
outpatient care, but not hospitalized due to a specific diagnosis. All participants had
nonsurgical hospitalizations, were medically stable, and were appropriate for
rehabilitation. Participants with differing diagnoses and a range of functional abilities
were eligible for inclusion, therefore, those with acute infectious illnesses, strokes, acute
relapses of chronic neurological disease (Parkinson's disease, multiple sclerosis), falls,
and cardiovascular pathologies were included. Gait speed, ADLs, and mental status were
assessed. Gait speed ranged from 0.05 m/s to greater than 0.55 m/s and was placed into
one of six categories.
The authors concluded that an association between decreased gait speed and ADL
ability levels was evident. Those with a gait speed of less than 0.25 m/s were more likely
dependent in one or more ADL; only 36% of those with gait speed less than 0.25 m/s
were considered independent in all ADL functioning. In contrast, 72.1% of those with
gait speed between 0.35 m/s and 0.55 m/s were independent in all ADLs.
Studenski et al. completed a prospective cohort study to determine whether gait
speed could be used as a "clinical vital sign" in a community dwelling elderly population
. Outcome measures included demographics, health and functional status, and
physical performance. Those with a gait speed of less than 0.6 m/s were categorized as
slow walkers and demonstrated a 69% incidence of new personal care difficulty.
Comparatively, 28% of those with a gait speed of 0.6 to 1.0 m/s and 12% with gait speed
greater than 1.0 m/s demonstrated new care needs. The researchers concluded that a
slowing of gait speed has negative effects on overall mobility and the ability to complete
ADLs and IADLs.
Falls, Activity, and Participation
Restriction of mobility and declines in ability to complete ADLs and IADLs are
severe consequences associated with falls [56, 138, 170]. All are negatively related to
decreased independence and quality of life. Stel and colleagues examined fall related
declines in functional status and physical activity . Functional status was measured
with stair climbing, dressing, standing from a chair, cutting toenails, walking outside and
transportation. Physical activity changes were measured with walking, bicycling,
gardening, sport activities, and light and heavy household activities. Post-fall declines in
functional status were reported by 35.3% of their sample and 15.2% reported declines in
physical activity. Vellas et al. determined that those who fell in a prospective study
demonstrated restricted activity and decreased independence at 6 months .
Tinetti and Williams completed a study to determine the impact of falls and fall
related injuries on ADLs, IADLs, social activity, and advanced physical activities in a
community dwelling elderly population . At one and three years, falling was
associated with declines in ADLs, IADLs, and social participation. Those with multiple
falls experienced greater declines in activity and participation and those with injurious
falls also demonstrated declines in advanced physical activity. An association between
declines in activity and falls incidence and/or severity of injury was demonstrated, thus
indicating a "dose response" relationship between falls and functional losses.
Yardley and Smith examined the most commonly held beliefs regarding falls and
activity curtailment . The Consequences of Falling (CoF) Scale was developed and
validated by the authors. It assessed types of fear related to falls, such as fear of physical
injury, fear of long-term functional incapacity, fear of subjective anxiety, and fear of
social discomfort. Demographics, mobility level, use of a walking aide, falls history and
incidence, falls related safety, and fear of falling were also assessed. Nearly half of the
participation reported a fall in the previous year. Long term functional disability and loss
of independence were cited as the most common fears. Social discomfort and a loss of
confidence and personal identity were also indicated as common fears. Activity
restriction was correlated with anticipated damage to personal identity and loss of
independence. Social participation was avoided to decrease the risk of social
embarrassment secondary to a fall. The CoF was correlated to activity avoidance, but
importantly, it also predicted increased avoidance of activity performance at follow up.
Fear of Falling, Activity, and Participation
Activity restriction has been demonstrated in 20% to 55% of those reporting fear of
falling [46, 93, 148, 187]. Activity limitations and decreased social participation may be
due to fear of falling or due to the injury or pain experienced from a previous fall [46, 48,
188]. Overall decreased independence, quality of life, and life satisfaction are at risk due
to fear of falling related changes in activity and participation.
Fear of falling has been related to declined performance of ADLs and IADLs,
social participation, and community integration [43, 137, 143, 149, 151, 152, 189-192].
Additionally fear of falling is related to decreased mobility, stair climbing, vision, general
health, depressed mood, decreased social and physical activities, and poor life satisfaction
[10, 56, 113, 140, 147, 186]. Fear of falling is associated with deteriorated health status
[143, 144, 148, 149, 152] and therefore negatively influences physical and functional
well-being . All lead to further functional declines, decreased quality of life, and
increased caregiver burden .
Li et al. summarized a relationship regarding fear of falling and concluded that fear
negatively influences falls related self-efficacy . This subsequently impacts balance,
physical ability, and mobility impairments. This cycle accelerates declines of physical
health, activity, and participation; possibly increasing the incidence of falls. Delbaere et
al. emphasized the "vicious cycle" of frailty regarding fear related avoidance of activity.
They concluded an association between fear of falling with new physical declines such as
increased frailty, decreased postural control, and decreased muscle strength, and an
overall increase of falls risk, thus leading to increased fear of falling .
The literature regarding the impact of fear of falling on activity and participation is
profuse. It has been identified, reviewed, and synthesized into an evidenced based table
found in Appendix a. It is evident from this review of the literature that those with
developed fear of falling are at great risk for decreased performance in ADLs, IADLs,
and social participation, and are therefore at significant risk for declines in quality of life
and life satisfaction.
Stroke and Caregiving
As demonstrated in the conceptual model, post-stroke mobility disability may
negatively impact activity, participation, and depression, thereby increasing dependence
and possibly increasing caregiver depression and burden. A review of the literature
reveals abundant caregiving research, however, there is a paucity of research specifically
related to caregiving after a stroke or specifically regarding the burden and stress
experienced by informal caregivers .
Those participating in post-stroke caregiving may provide assistance in many life
domains including mobility, self-care, and communication. However, stroke related
complications such as cognitive impairment, depression, and personality changes may
require increased provision of caregiving and assistance [4, 195]. A post-stroke reduction
in ADL and IADL performance frequently results in reduced levels of functional
independence and subsequently increases the necessity of additional care in the home.
Often, those post-stroke are dependent on caregivers to maintain community living and
stave off facility or institution admission. The review of the literature indicated more
research is necessary, specifically in the areas of caregiver physical health, ethnicity, and
Mobility Disability and Caregiving
Researchers have demonstrated relationships between mobility disability and
limitations in activity and participation and consequential losses of independence, and
increased need for care, health utilization, and admission into care facilities [14, 15, 20-
24]. Specifically, caregiving after falls has been explored. The resulting complications of
a fall can be severe and include death, fractures, and further losses of independence. It is
therefore expected that falls are negatively associated with caregiver burden and
depression. Forster and Young demonstrated negative effects for the caregiver when post-
fall declines in ADL performance were evident . The caregivers taking care of
"fallers" were more stressed, and one-third of all caregivers stated that concern for a fall
limited their own social activity. Stolze et al. also indicated increased burden for those
caring for the post-fall population . Howland and colleagues also demonstrated a
relationship between caregiver support and fear of falling related activity curtailment
There has been no research completed specifically examining caregiving after fear
of falling development or changes in gait speed. However it is expected that caregiving
needs will increase due to mobility related declines in performance of activities.
Researchers have indicated high levels of depression associated with stroke
survivor caregivers compared to non-caregivers . The prevalence of depression in the
caregiving population ranges from 34% to as high as 52% [196-199]. Spousal and female
caregivers have demonstrated increased depression which tends to persist over long
periods of time .
A Japanese study demonstrated depression in 52% of 100 stroke caregivers, this
was double the depression rate for the control group (23%) . Hartke and King found
that depressed caregivers were more likely to have difficulty with caregiving, report more
problems with the care recipient, experience financial concerns, and report a decrease in
social involvement . Researchers have found a relationship between increased
stroke caregiver depression and increased stroke severity [203, 204]. Kotila et al
compared the incidence and severity of depression at 3 and 12 months post-stroke .
Both stroke survivors and their caregivers demonstrated increased levels of depression
which were maintained at the one-year follow up.
Morimoto and colleagues found that the strongest predictor of declining quality of
life for stroke caregivers was a high level of caregiver burden . Burden is caused by
feelings of large responsibility, uncertainty about the care needs of the stroke survivor,
decreased social interaction, and being the sole provider of care . Bugge and
colleagues (1999) studied caregivers at 1, 3, and 6 months post-stroke. The amount of
time spent helping a patient, the amount of time spent with the patient, and the
caregiver's health were determined as the most influential factors of caregiver strain
. Caregivers providing greater levels of care (e.g. toileting, bathing) experienced
greater emotional distress and greater caregiver burden [208, 209].
Summary of the Literature Review
This review of literature demonstrates that post-stroke motor, sensory, and
cognitive impairments influence mobility. Falls, fear of falling, and gait speed are all
impacted aspects of post-stroke mobility and all may be related to restriction of activity
and participation. Activity curtailment has been related to decreases in quality of life and
There is no research specific to the development of fear of falling post-stroke. This
research was completed as an initial exploration of fear of falling in the post-stroke
population. Fear of falling was characterized for the post-stroke population, and activity
restriction was explored. Similarly, the relationship between post-stroke gait speed
changes and its impact on activity and participation were evaluated. This research will
provide a foundation for exploring the impact of post-stroke mobility on activity and
THE IMPACT OF POST-STROKE GAIT VELOCITY CHANGES ON
ACTIVITY AND PARTICIPATION
The American Heart Association reports that 700,000 people sustain a stroke
annually ; it is the primary cause of adult disability [2-4]. Stroke related deficits
include motor, sensory, and cognitive impairments that negatively influence mobility.
Losses in mobility are often reflected by declines in gait velocity [40, 210]. Mobility
impairments and changes in gait velocity are related to losses of independence and
decreased ability to reengage in the community .
Gait speed is an important clinical and research outcome measure. It is a common
measure of mobility and a reliable, valid, and sensitive measure of post-stroke locomotor
recovery [9, 39]. It discriminates the effects of stroke and is related to the potential for
rehabilitation recovery . Gait velocity is a predictor of health status and health care
utilization in the elderly . It is associated with performance of activities of daily
living (ADLs) and community ambulation [9, 10, 184].
Potter et al. determined a relationship between gait speed and ADL performance in
the community dwelling elderly . Participants with multiple diagnoses were
included and those with decreased gait speed demonstrated decreased independence. A
gait speed less than 0.25 meters per second (m/s) was associated with dependence in one
or more ADL; only 36% of those with gait speed less than 0.25 m/s were considered
independent in all ADLs. In contrast, 72.1% of those with gait speed between 0.35 m/s
and 0.55 m/s were independent in all ADLs.
Perry et al. examined the association between post-stroke gait velocity and
ambulation . The authors developed an ambulation classification related to necessary
gait speed for home and community ambulation. Household ambulation was equal to
severe gait impairment and velocity less than 0.4 m/s. Limited community ambulation
was equivalent to moderate gait impairments and walking between 0.4 m/s and 0.8 m/s.
Community ambulation indicated mild impairment and speed over 0.8 m/s. Increases in
gait velocity were related to improved home and community ambulation.
The relationship between post-stroke gait speed and community ambulation was
further explored by Lord and colleagues . Participants included 115 individuals who
received physical therapy for mobility impairments and 15 not requiring such therapy.
Mobility outcome measures assessed gait speed, indoor and outdoor walking ability, and
gait endurance. An additional self-report questionnaire assessed unsupervised mobility.
Participants were categorized by community ambulation levels as seen in Table 3-1. Gait
velocity differed between the categories and increased from 0.52 m/s for those unable to
leave home to 1.14 m/s for those able to ambulate in a shopping center. One third of the
sample was not able to ambulate independently within the community after a stroke.
Table 3-1. Community ambulation and gait speed
Group Community Ambulation Level % of Sample Speed (m/s)
1 Unable to leave home 14.6% 0.52
2 Able to walk to letter box 16.9% 0.66
3 Limited to immediate environment 7.6% 0.82
4 Ambulate in shopping center 60.7% 1.14
In summary, the relationships between gait speed and ADL performance in the
community dwelling elderly and between gait speed and post-stroke ambulation are well
established [9, 10, 184]. However, it is not known whether a change in post-stroke gait
velocity is "clinically meaningful", as reflected by improved functional abilities such as
activity and participation. A clinically meaningful change is important to determine as it
is related to patient-valued benefits. Barrett et al. discussed the need to observe a
clinically "important difference" by merging patient-oriented and evidence-based
frameworks together . Such clinical meaningfulness can be seen by examining the
sufficiently important difference (SID), the smallest amount of patient-valued benefit
required from an intervention to justify associated costs, risks, and other harms. Lord and
Rochester recently stated a need for a conceptual framework related to post-stroke
mobility and that there is "no guarantee that increases in gait velocity will denote a
meaningful improvement in performance" . The objective of this study was to
determine whether a change in gait speed over three months was clinically meaningful as
reflected by the impact on ADLs (including mobility), instrumental activities of daily
living (IADLs), and social participation after stroke.
Data in this study are derived from a parent study; a prospective, randomized,
controlled, single-blind, clinical intervention trial . The trial was completed to
determine the effects of a therapist-supervised 12-14 week home-based, structured, and
progressive exercise intervention on participants post-stroke. The intervention focused on
upper and lower-limb strength, balance, endurance, and increased use of the affected
extremities. The intervention group was compared to a usual care group who received
rehabilitation as prescribed by their physician and bi-weekly visits from research staff
Informed consent was received from all participants through methods approved by the
Institutional Review Board of the university and each participating facility. All
participants were recruited from an ongoing stroke registry. This secondary analysis was
approved by the University of Florida Health Science Center Institutional Review Board.
This analysis did not examine differences between intervention and usual care
groups. Rather we examined the differences in ADLs, IADLs, and social participation
between those who did and did not successfully advance to the next ambulation
classification as portrayed by Perry et al. . For example, the participants considered
successful, transitioned from an initial gait velocity of less than 0.4 m/s to 0.4 to 0.8 m/s
or faster or they advanced from an initial gait velocity between 0.4 to 0.8 m/s to greater
than 0.8 m/s. Gait velocity was measured at baseline and repeated at 3 months.
All participants were selected from one of 17 medical facilities, all of which were
partaking in an ongoing Kansas City Stroke Registry. All those registered gave informed
consent and permission to be screened for eligibility for future research studies. Those
eligible for the registry had a confirmed diagnosis of a stroke within 3-28 days, were over
age 50, and lived within a 50-mile radius. Registry exclusion criteria included the
following: subarachonoid hemorrhage, being lethargic, obtunded, or comatose,
uncontrolled blood pressure, hepatic or renal failure, NYHA III/IV heart failure, known
limited life expectancy, or pre-stroke disability in self care; or previously lived in a
nursing home prior to the stroke.
Those in the registry were eligible to be screened for this randomized clinical trial.
Inclusion for the parent clinical trial included: (1) stroke within 30-150 days, (2) ability to
ambulate 25 feet independently, (3) mild to moderate stroke deficits defined by a Fugl-
Meyer score of 29 to 90 for upper and lower extremities, an Orpington Prognostic Scale
score of 2.0 to 5.2, and palpable wrist extension on the involved side; and (4) Folstein
Mini-Mental Status examination score greater than 16. Exclusion criterion included: (1)
serious cardiac conditions (hospitalization for heart disease within 3 months, active
angina, serious cardiac arrhythmias, hypertrophic cardiomyopathy, severe aortic stenosis,
pulmonary embolus, or infarction), (2) oxygen dependence, (3) severe weight-bearing
pain, (4) other serious organ system disease, and (5) life expectancy of < 1 year. All
participants signed an informed consent to partake in the trial and all had approval from a
primary care physician . Ninety-two individuals completed the clinical trial, 44 in the
intervention arm and 48 in the usual care arm. Specifically, only 64 of the 92 participants
were included in this three-month analysis because those walking > 0.8 m/s at baseline
were excluded. This report does not compare the intervention to the usual care groups,
but combines all participants walking < 0.8 m/s at baseline to allow for examination of
clinically meaningful changes in post-stroke gait speed.
The parent clinical trial included the Orpington Prognostic Scale to measures stroke
severity . Disability outcomes measures included the Functional Independence
Measure (FIM) , the Barthel , the Lawton and Brody IADLs assessment ,
and gait speed thresholds for community ambulation . Quality of life measures
included subscales of the Stroke Impact Scale  and the Medical Outcomes Study SF
36 . Results for outcome measures are found elsewhere . Gait speed, activity, and
participation were the specific outcome measures used for this secondary analysis.
Gait velocity was measured by the 10-Meter Walk, a valid and reliable measure for
gait velocity assessment in the elderly post-stroke population . The 10-Meter Walk
consisted of two completed walks without rests in between and collected in
Specifically, the main outcome for this analysis was the proportion of participants
who demonstrated "success" by transitioning from one ambulation classification to the
next. Both baseline and final outcome measures were placed into the ambulation
classification previously developed by Perry et al.: < 0.4 = household ambulation, 0.4 -
0.8 = limited community ambulation, and > 0.8 = community ambulation . Changes in
gait velocity were considered as successful walking recovery when participants shifted
from < 0.4 m/s to 0.4 0.8 m/s (household to limited community ambulation) or 0.4 0.8
m/s to > 0.8 m/s (limited community to community ambulation) . A dichotomous
variable of "success" or "fail" was utilized for the analysis.
Activity and participation
Activity and participation were assessed with the Stroke Impact Scale (SIS), a
comprehensive and psychometrically robust stroke-specific outcome measure [216, 219].
The SIS was developed from the perspective of patients, caregivers, and health
professionals with stroke expertise. It has been demonstrated to be reliable, valid, and
sensitive to change related to stroke recovery. There are eight domains and 59 items in
version 3.0, specifically, the SIS ADL/IADL, mobility, participation, and SIS-16 physical
functioning components were used for this analysis . Items such as food preparation,
bathing, toileting, shopping, and household tasks were assessed with the ADL/IADL
component. Mobility was assessed with items regarding loss of balance, transferring,
walking, and stair climbing. Participation items included work, social activities, quiet
recreation, family and friend roles, religious and spiritual activities, and helping others.
The SIS-16 is a validated short instrument used to assess physical functioning with ADL
and mobility items .
All analyses were completed using SAS statistical software. Simple descriptive
statistics were used to describe demographics and outcomes scores for the entire sample.
Additional descriptive data delineated by success or failure of increasing to the next
walking classification was examined. Baseline characteristics of the 64 people who
completed the study with initial gait speed of < 0.8 m/s included demographics, stroke
characteristics, and baseline outcome measures. T-tests were utilized to determine
significant differences in activity and participation (SIS) between those who succeeded
and who failed to increase to the next walking classification at three months post-stroke.
Baseline demographics for the 64 participants are presented in Table 3-2. The
average age of the sample was 71.03 (10.64). Those successful in increasing to the next
ambulation classification were significantly younger than those who failed (p = .0023).
The entire sample included 54.69% males and 78.13% were white. All other
demographic characteristics and data related to participation and retention of participants
specific to the Kansas City Stroke Registry are reported elsewhere .
Mean baseline gait speed was 0.50 (0.16) m/s for the entire sample, 0.51 (0.17) m/s
for those who succeeded and 0.49 (0.16) m/s for those who failed to increase to the next
ambulation classification (p = 0.689). At three-months, gait speed for the entire group
was 0.68 (0.24) m/s. As anticipated, a significant difference was detected for three month
gait velocity scores between those who succeeded (0.82 (0.25) m/s) and failed (0.56
(0.16) m/s) to proceed to the next ambulation classification (p < 0.0001).
Table 3-2. Baseline characteristics for participation with initial gait speed < 0.8 m/s
(success = advancing to a higher ambulation classification)
Male Sex, n (%)
Race (White), n (%)
Orpington Prognostic Score
NIH Stroke Score
Right Hemisphere (%)
Left Hemisphere (%)
Brain Stem/Other (%)
Stroke Type, Ischemic (%)
Geriatric Depression Scale
10 Meter-Walk, m/s at
Values are mean (SD) when appropriate
The proportion of participants who succeeded or failed to transition from one
ambulation classification to the next is documented in Table 3-3. The highest proportion
of participants who transitioned to the next classification had initial gait speed of less
than 0.4 m/s; 63% of the household ambulators increased to the limited community
ambulator classification. In contrast, only 38% of those initially considered a limited
community ambulator (0.4 0.8 m/s) advanced to the community ambulation
classification. In all, 45% of the sample was successful and 55% failed to increase to the
next ambulation classification at three months.
Three-month outcomes associated with gait velocity are presented for the entire
sample in Table 3-4. Age was significantly different between those who were successful
and who failed to transition to the next ambulation classification. Therefore age was
controlled for at the < 0.100 level, as it is common that adjustment variables are retained
in the model at a lower significance level than that of the main factors. Equal variance
was established for all values except for the SIS-16 measure for the entire group.
Therefore t-tests were deemed appropriate and equal (pooled) p-values were used except
for the SIS-16 with the Satteerthwaite unequal variance p-value used. After controlling
for age, there were significant differences in SIS measured mobility and participation
between those who succeeded and failed to advance to the next ambulation classification
(p < 0.05). SIS ADL/IADL approached significance at 0.0524. When controlling for age
and stratifying by baseline gait speed, those with initial gait velocity of < 0.4 m/s
demonstrated significant differences in SIS ADL/IADL, mobility, social participation,
and SIS-16 measures between those who succeeded and failed (p < 0.05) (Table 3-5). In
contrast, when age was controlled for and initial gait speed was between 0.4 m/s and 0.8
m/s, only participation scores were significantly different between those who succeeded
and those who failed to progress to the next ambulation classification.
Table 3-3. Proportions of success/fail for transitioning to next ambulation classification
between baseline and 3 months
Initial Gait Velocity in m/s All
Total n (%) < 0.4 (Household) 12 (63%) 7(37%)
0.4-0.8 (Limited Community) 17 (38%) 28 (62%)
_Total 29 (45%) 35 (55%)
Table 3-4. Three month outcomes for entire sample
Success Failure p value p value^
Sample Size 29 35
SIS ADL/IADL 77.8 (14.1) 69.6 (19.0) 0.0589 N/A
SIS Mobility 77.6 (2.2) 65.5 (16.1) 0.0015 0.0359A
SIS Participation 68.2 (8.6) 52.9 (20.6) 0.0031 N/A
SIS 16 81.3 (11.2) 71.6(16.5) 0.0076 0.0844A
^p-value after adjusting for age when age is significantly different at the < 0.100 level
Table 3-5. Three month outcomes stratified by gait speed
Success Failure p value p value^
< 0.4 m/s at Baseline
Sample Size 12 7
SIS ADL/IADL 75.5 (15.2) 51.4(12.5) .0026 N/A
SIS Mobility 77.1 (11.4) 50.5(10.9) <.0001 N/A
SIS Participation 66.1 (15.2) 42.9 (19.6) .0100 N/A
SIS 16 67.2 (12.5) 46.7 (9.8) <.0001 N/A
0.4 0.8 m/s at Baseline
Sample Size 17 28
SIS ADL/IADL 79.6 (13.5) 74.2 (17.7) .2891 N/A
SIS Mobility 77.9 (13.1) 69.3 (14.9) 0.0565 .2215^
SIS Participation 69.7 (21.0) 55.5 (20.5) .0308 N/A
SIS 16 81.8 (12.7) 67.6 (13.7) .1756 .0718^
^p-value after adjusting for age when age is significantly different at the < 0.100 level
Gait speed is a valid and reliable assessment used frequently in elderly and post-
stroke research [9, 39, 40]. In the hopes of determining what is a clinically meaningful
change in gait speed, researchers have attempted to determine relationships between gait
speed and functional abilities [9, 10, 184]. Perry et al. and Lord et al. have previously
examined gait velocity classifications dependent on home and community ambulation in
the post-stroke population [9, 10]. Potter and colleagues demonstrated a relationship
between ADL performance and gait speed in an elderly population with various
This secondary analysis is the first study to examine the association between actual
changes in post-stroke gait velocity and the reciprocal impact on performance of ADLs
and IADLs and social participation as measured by the SIS. Our results validate
ambulation classification in both research and clinical rehabilitation settings, and
specifically validates the prior classification developed by Perry et al. . Additionally,
our results show that a clinically meaningful change in gait speed, as represented by an
increase to the next ambulation classification, was significantly associated with increased
activity and participation scoring, particularly for those with the slowest baseline gait
Those who successfully transitioned to the next ambulation classification were
significantly younger then those who did not (p = 0.0023). When age was controlled for,
those with baseline gait speeds of < 0.4 m/s demonstrated the greatest gains in activity
and participation. Among those who walked less than 0.4 m/s, there were significant
differences in SIS ADL/IADL, mobility, participation, and SIS-16 scores found between
those who were successful and who failed to advance to the next ambulation
classification. This may be attributable to the fact that those with greater deficits had
more opportunity for improvement and there were less ceiling effects in the measures.
After age was controlled for in the less impaired walking group, there was
significant difference in participation, between those who did and did not successfully
progress to the next classification. SIS participation items include higher level home and
community activities. Increased gait velocity was clearly attributable to increased
abilities to complete higher level tasks at home and in the community. A significant
difference in age contributed to mobility and SIS-16 scores. After controlling for age, the
SIS-16 approached significance, but likely was related to the assessment of higher level
ADLs and mobility. The lack of other significant findings is probably due to the
participants' high degree of independence at baseline and subsequent ceiling effects of
Stratifying by gait speed decreased the sample size, possibly decreasing the
detected differences between groups. Other post-stroke changes may have also impacted
ability to complete ADLs, IADLs, mobility, and social participation. The severity of
residual deficits is an additional component of post-stroke gait speed and activity and
participation; side of the lesion, medical complications, rehabilitation days, assistive
devices, caregiving, and overall support all play a role in performance of post-stroke
ADLs (including mobility) and IADLs and social participation.
Research competed by Potter et al. may provide some rationale for our specific
findings . The authors noted that some participants demonstrated greater gait speed
but not greater ADL performance. They concluded that some had difficulties specific to
upper extremity ADL and IADL activities that were not reliant on gait. Therefore no
relationship between ADLs and gait speed existed. Additionally, all of their study
participants walking between 0.35 m/s and 0.55 m/s were independent in all ADLs. Our
average baseline gait velocity was 0.50 (0.16) m/s for the entire sample, therefore,
independence in ADLs would be expected for our participants, particularly for those
walking initially walking greater than 0.4 m/s.
An important strength of this study is that the included participants are derived
from a large parent study of community living stroke survivors. This is a clinically
significant group because even though they have returned home, they still have limited
ambulation and other stroke related deficits. Additionally, the assessors were blinded
regarding intervention or control placement and all assessments were standardized. There
are also limitations. Duncan et al. reports study limitations related to the intervention and
possible bias in self-report because the control group participants knew their treatment
assignment . In future studies, we will assess the impact of post-stroke gait speed
changes using a continuous measure rather than ambulation classification.
Clinically meaningful changes in gait speed are important in rehabilitation clinics
and research. Rehabilitation goals often include increases in gait speed and endurance.
The results of this study indicate a significant impact of gait velocity on performance of
ADLs, IADLs, mobility, social participation, and SIS-16 scores making increased gait
speed an appropriate goal. These results are very relevant as they validate the ambulation
classification previously portrayed by Perry et al.  and represent a clinically
meaningful change in gait speed; encouraging the use of ambulation classification for
goal setting as it is related to overall increases in activity and participation. We have
demonstrated that a clinically meaningful change in gait speed is related to highly
significant improvement in all domains, particularly for social participation. Such
clinically meaningful gait speed changes may have a profound impact on overall quality
of life and life satisfaction as both have been negatively associated to restriction of
activity and participation [179, 180].
FEAR OF FALLING AFTER STROKE
Stroke is the primary cause of disability in the United States and is the third leading
cause of death in the country for those over 65 [2-4]. The American Heart Association
reports that stroke is a common neurological event occurring in 700,000 people a year
. Those surviving a stroke are often left with sensory, cognitive, motor, and balance
impairments which negatively influence mobility and other activities of daily living
(ADLs) and instrumental activities of daily living (IADLs) [222-224]. Fall rates increase
due to post-stroke mobility deficits  and are considered the most common medical
complication after stroke . The annual 30%  incidence of falls in the community
dwelling elderly population rises to 73% within the first six months post-stroke .
Those who fall post-stroke may be prone to developing fear of falling. The development
of fear of falling, with the cascading consequences of further mobility disability and
declines in activity and participation may be related to an overall decrease of
independence and quality of life [56, 170].
There is currently an abundance of research regarding falls after stroke and fear of
falling in the community dwelling elderly, but there is little specific to how people
describe the experience of fear of falling after stroke or how fear of falling develops
among this population. Fear of falling has been operationally defined for this study as "a
developed and lasting concern about falling related to a loss of confidence in balance
abilities and mobility and is often related to an avoidance of activities that he/she remains
capable of performing" [113, 140-143]. The incidence of fear of falling is still unclear
with researchers reporting fear of falling in the community dwelling elderly ranging from
29%-92% for those recently sustaining a fall and 12%-65% for those without a recent fall
[46, 70, 113, 115, 144-152]. Fear of falling incidence may rise after stroke due to
increased fall rates and declines in physical ability and mobility.
Fear of falling has been associated with declines in performance of ADLs and
IADLs, decreased participation, and community integration [43, 137, 143, 149, 151, 152,
189-192]. It has also been related to declines in mobility, stair climbing, vision, general
health status, depression, and poor life satisfaction, [10, 56, 113, 140, 147, 186], all
negatively influencing general well-being and life satisfaction . In addition, 20% to
55% of those with fear of falling have reported activity restriction [42, 43, 113, 114, 143,
148, 186, 187, 225-230]. Activity restriction has been independently related to increased
health care utilization, social isolation, depression, and caregiver burden and decreases in
health, functional status, and independence; resulting in overall decline in quality of life
and life satisfaction [10, 43, 56, 113, 140, 143, 147, 149, 151, 152, 179, 180, 186, 189].
Activity restrictions related to functional deficits, falls, and fear of falling may result in
reduced levels of independence and increasing need for additional care in the home .
Such decreases in abilities may be associated with increased caregiver burden, strain, and
depression [4, 79, 154]. Informal caregivers of people who have fallen report decreased
social activity, increased stress, and increased burden [79, 154].
This study is a secondary analysis of existing qualitative and quantitative data
obtained from a larger study . The objectives of this study were (1) characterize post-
stroke fear of falling as described by participants during the first six months following
discharge home; (2) explore the relationships between fear of falling and performance of
ADLs, IADLs, and depression; and (3) examine the relationship between fear of falling
and caregiver depression, burden, and coping.
This study used both qualitative and quantitative methods to evaluate fear of falling
in a population of veterans discharged home post-stroke. Participants who discussed fear
of falling were identified in the sample enrolled in the larger study. Content analysis was
used to identify descriptors that characterize fear of falling across six months after
discharge home post acute stroke. Patton describes content analysis as the process of
identification, coding, and categorization of the primary patterns in qualitative data .
Quantitative data were obtained from standardized outcome measures collected from
stroke survivors and their caregivers at one and six months.
All veterans and caregivers included in this study met the inclusion criteria to
participate in the larger study. The larger study included a total of 132 participants, 42
(32%) of these participants were identified with fear of falling at one or six months and
were included in the sub-study. The inclusion criteria for veterans to be involved in the
larger study were: (1) member of one of three ethnic groups (Caucasian, African
American, or Puerto Rican Hispanic), (2) discharged directly home from an acute care
unit following a stroke, (3) a Mini Mental Status Exam (MMSE) of 18 or higher and able
to verbally communicate at discharge, (4) have a caregiver willing to participate, and (5)
sign a consent form or have the consent form signed by a proxy. Inclusion criteria for the
informal caregivers were: (1) family or friend who the stroke survivor identified as a
primary caregiver, (2) able to communicate verbally, (3) willing to participate and sign a
consent form. Exclusion criteria for both veterans and caregivers was the inability to
communicate or unwillingness to participate. Inclusion criteria for this sub study were:
(1) male; (2) described some aspect of fear of falling during the interviews at one or six
months after discharge home. Each participant gave informed consent prior to
participation in the larger study through methods approved by the University of Florida
(UF) Health Science Center Intuitional Review Board (IRB) and the Veterans' Affairs
Subcommittee on Clinical Investigations (VA SCI). This secondary analysis was
approved by the UF IRB and VA SCI as an exempt study using existing data.
Data for the larger study were obtained to develop stroke recovery trajectories for
stroke survivors and their caregivers after discharge home following acute stroke for
three ethnic groups: African American, White, and Puerto Rican Hispanic. The larger
study is a longitudinal multi-site cohort study that includes qualitative and quantitative
data derived from participant interviews and responses to questionnaires. Demographics
were collected and baseline assessments were completed at the time of discharge. The
study was designed so that each stroke survivor was interviewed for approximately 50
minutes. Qualitative data were obtained during at home, in-depth, semi-structured
interviews with the stroke survivors at one and six months. Interviews were completed
with the stroke survivor first; probing questions were presented to capture stroke related
disability and recovery. Interviews were tape recorded, transcribed verbatim, verified,
and entered into QSR N6, a software application designed to assist with qualitative data
Fear of falling was not part of the formal assessments. Participants instead
spontaneously talked about fear of falling as an important part of managing their daily
lives and their experiences post stroke. Transcriptions of all interviews at one and six
months for all 132 participants in the larger study were transferred into a word processing
document to enable identification of those who discussed fear of falling and concerns
about falls, balance, and stability.
Identification of participants with a fear of falling was conducted via a semantic
content analysis of the qualitative interviews. During reviews of interviews, the following
word list was developed from the text. These words were then used to search all word
documents: fall, fell, balance, trip, stumble, wobble, wabbly, slip, dizzy, dizziness, walk,
walking, walker, cane, crutches, crutch, fear, fearful, afraid, scared, worry, worried.
Participants were identified for inclusion in this sub study when they specifically
stated they were fearful or used statements/words regarding concern, confidence, or fear
related to falling, balance, or mobility. A qualitative research specialist validated this
review of qualitative data and selection of participants with fear of falling. A second
dataset was created that included all one and six-month interviews for participants
identified as fearful. This dataset of interviews was coded to identify themes related to
the experience of fear of falling.
The interviews for those identified as fearful of falling were coded in N-6 to
identify themes derived from the interviews. All coding was validated by a rehabilitation
health care professional. Characterizations, quotes from participants, and recorded
observations were used to identify three main recurrent themes that were refined during
analyses. The three initial coding themes were "physical", "psychosocial", and
"strategies for managing fear of falling". Each code included sub-codes that have been
listed in the coding structure found in Table 4-1. Content analysis was completed to
identify phrases and sentences under this coding structure. A phrase or sentence could be
coded under more than one primary or secondary theme.
Table 4-1. Coding structure for qualitative interviews
Primary Theme Secondary Themes
Falls as a Physical Paralysis/hemiplegia
Event Fell at time of stroke
Injury (such as hip fracture or head injury)
Talk about falls (stumble, trip, wabble, etc)
Fearing Falls Fear, afraid, concern
Caregiver afraid will fall
Afraid of injury
Strategies for Walker/cane/WC/wall/other
Managing Fear of Relies on others
Falling Being careful
In addition to the qualitative interviews, stroke survivors completed standardized
measures to assess activity performance of ADLs and IADLs and depression. Caregivers
also completed standardized measures of depression and caregiver burden. Most often,
caregivers and stroke survivors were not interviewed with each other in the room.
Demographic data were collected at baseline for each stroke survivor and caregiver
included in the qualitative and quantitative analyses. Stroke survivor demographic data
included age, gender, race/ethnicity, employment status, income, and comorbidities
recorded in their medical records. Baseline standardized assessments included the
Functional Independence Measure (FIM) to assess functional status and the Mini Mental
Status Exam (MMSE) [233, 234] to measure cognitive status.
The FIM was utilized to measure functional status at baseline and was repeated at
one and six months. The FIM is the most widely used method of assessing functional
ability in persons with disability. Reliability and validity of the FIM have been
established [235, 236]. The FIM consists of 18-items and responses are scored on a 7-
level ordinal scale with six subscales: self-care, sphincter control, transfer capability,
locomotion, communication, and social cognition . The FIM was utilized as a
measure of severity of disability and functional status change over time.
The Frenchay Activities Index (FAI) was used to measure IADLs. The FAI is a
valid and reliable measure used to better assess normal living activities that occur among
community dwelling adults . The FAI is composed of 15 items and three major
subscales: domestic chores, leisure/work, and outdoor activities. Scores range from 0
(inactive) to 45 (very active). Wilkinson et al.  defined intact IADL function with an
FAI score of over 15.
The MMSE, a standardized test used to evaluate basic cognitive abilities, assessed
mild to moderate cognitive impairment for the stroke survivors [233, 234].
Stroke survivor and caregiver depression was assessed using the Geriatric
Depression Scale (GDS). The GDS has been used with the elderly population and those
who are cognitively impaired. It is a 30-item scale with dichotomous variables (yes, no).
Reliability, internal consistency, test-retest validity, and concurrent validity have all been
established for the GDS . Higher scores indicate increased levels of depression.
Caregiver demographics, burden, and coping
Demographic data on caregivers included age, gender, race/ethnicity, education,
and relationship to patient. Caregiver burden was measured using the Sense of
Competence Questionnaire (SCQ). The SCQ contains 27 items with three different
subscales: satisfaction with the care recipient, satisfaction with one's own performance as
a caregiver, and consequences of involvement in care for the personal life of the
caregiver. Each item is scored using a four point Likert type scale; burden is determined
by summing the three scales. Higher scoring indicates higher levels of burden
experienced by the caregiver. The three subscales and the aggregate burden score have all
been demonstrated to be both valid and reliable for use with stroke survivors.
The Sense of Coherence (SOC) questionnaire is a global measure of the ability to
mobilize adaptive coping resources and is used as a measure of coping ability. The SOC
is a 13-item, self-report scale which has been utilized in over 20 countries [239, 240].
The items on the scale are on a Likert-type scale, and possible scores on the SOC range
from 13-91, with higher scores indicating better ability to cope. This scale has
demonstrated strong internal validity, reliability, and test-retest correlations. Specifically,
Cronbach's alpha (internal consistency) has ranged from 0.74 to 0.91 and the test-retest
correlations for 12-month follow-ups ranged between 0.54 and 0.78.
Analysis of Quantitative Data
Quantitative data were used to describe the sample and to explore outcome
measures. Descriptive statistics were used to describe participant demographic
characteristics and performance of ADLs and IADLs, depression, and cognition for those
who did and did not discuss fear of falling. A chi-square was completed to examine the
proportions of participants who reported fear of falling at one month and six months post-
stroke. Additional descriptive statistics for caregivers delineated by stroke survivor fear
of falling status are included.
Description of Sample
The larger study enrolled 132 participants. Overall, 42 (32%) participants discussed
fear of falling at either one or six months and 90 (68%) did not. See Table 4-2 for
demographics of those with and without fear of falling.
Table 4-2. Baseline data for those with and without fear of falling (FoF)
Measures No FoF During 6 Months FoF During 6 Months
n 90 42
Age 65.62 (9.68) 67.50 (11.93)
White 29 (32%) 19 (45%)
AA 34(38%) 16(38%)
PR Hispanic 27 (30%) 7 (17%)
Values are mean (SD) when appropriate
A total of 33 (25%) participants were identified as fearful at one month. Nine
additional individuals described fear of falling at month six (7%). Thirteen participants
(10%) discussed fear of falling at both one and six months. Therefore, 20 participants
(61%) who reported fear of falling at one month did not discuss fearful at six months. In
total, 22 participants (17%) described fear of falling at month six (13 were fearful at one
and six months plus 9 new participants discussed fear at six months). See Table 4-3 for
demographics and baseline data for participants with fear at one and six months.
Relationships Between Fear of falling, Functional Status, and Depression
To explore the relationship between fear of falling, functional status, and
depression, we used descriptive statistics to provide a profile for stroke survivors with
fear of falling using data on ADLs, IADLs, depression, and cognition. See Table 4-4 for
the mean scores and standard deviations of the FIM, FAI, MMSE, and GDS scores for
the 42 unique individuals with fear of falling and the 90 who did not discuss fear.
Participants demonstrated consistent increases in FIM and FAI scores from baseline and
one month to six months scores regardless of fear of falling status. T-tests were
completed to assess differences between those with and without fear of falling. There
were no statistical differences for any assessment scores between those who did and did
not discuss fear of falling. The participants with fear of falling are slightly older and
demonstrate a somewhat lower functional status. Depression and cognition scores for
those who did and did not discuss fear of falling did not appear to differ.
Table 4-3. Baseline/discharge data for those discussing fear of falling at one and six
Month 1 FoF Month 6 FoF
33 FoF at 9 New FoF at 6 13 FoF at 1 and 22 Total FoF at 6
Month 1 Months 6 Months Months (9 + 13)
n 33 (25%) 9(7%) 13 (10%) 22(17%)
Age 64.58 (10.42) 78.22 (11.45) 68.08 (8.34) 72.23 (10.76)
White 15(45%) 4 (44%) 6 (46%) 10(45%)
AA 11(33%) 5 (56%) 3 (23%) 8 (36%)
PR Hispanic 7 (21%) 0 (0%) 4 (31%) 4 (18%)
MMSE 26.52 (2.40) 25.44 (3.97) 26.92 (2.90) 26.65 (3.20)
FIM Motor 73.10 (11.89) 74.56 (11.26) 74.69 (12.04) 74.63 (11.45)
FIM Cog 31.18(3.25) 31.22 (3.47) 31.84(3.34) 31.59(3.32)
FIM Total 104.27 (14.20) 105.78 (11.64) 106.54 (2.9) 106.23 (13.17)
(AA = African American, PR = Puerto Rican)
In addition, we examined scoring of individual FAI and FIM items specific to
activities that may be directly affected by fear of falling. Specifically we reported scoring
for "social occasions" and "walking outside for > 15 minutes" on the FAI and the
"walk/wheelchair" and "stairs" items from the FIM. See Table 4-5 for specific FAI and
FIM items for those who did and did not discuss fear of falling. Findings indicate that
those with fear of falling scored somewhat lower on all FIM and FAI individual items at
all assessment times. T-tests compared differences and only the FIM "stairs" item was
statistically significant different between those with and without fear of falling. Such a
result would not be uncommon in an elderly population, and those post-stroke would be
assumed to have increased difficulty with stair climbing. Changes in IADLs were
reflected in the qualitative interviews. Some participants talked about falls at home, often
in the bathroom, while performing basic ADLs. However, more often participants
commented on falls and fear of falling during higher-level activities, such as walking
around a store, community outings such as church or social gatherings, and physical
activities such as stair climbing. Thus IADLs and stair climbing were more likely
impacted by fear of falling in this higher functioning post-stroke group of participants.
These patterns of decreased performance in ADLs and IADLs for those with post-stroke
fear of falling warrant future research to better understand the impact on activity,
participation, and general quality of life.
Table 4-4. Baseline/discharge data and outcome measures for those with and without fear
Measures No FoF FoF During 6 months
n 90 42
Age 65.62 (9.68) 67.50 (11.93)
FIM motor 75.71 (17.40) 73.40 (11.64)
FIM cognition 31.14 (4.18) 31.19 (3.26)
FIM total 106.86 (20.47) 104.60 (13.57)
MMSE 26.76 (3.35) 26.29 (2.79)
FIM motor 80.46 (15.59) 78.86 (11.75)
FIM cognition 32.27 (3.47) 31.19 (3.85)
FIM total 112.73 (17.66) 110.05 (13.54)
FAI 30.54 (10.44) 27.26 (10.58)
MMSE 26.60 (3.05) 26.76 (2.54)
GDS 8.84 (6.59) 9.33 (6.76)
FIM motor 82.84 (13.54) 82.69 (8.31)
FIM cognition 32.45 (3.72) 32.33 (2.95)
FIM total 115.30 (15.59) 115.03 (9.83)
FAI 33.13 (11.29) 31.50(11.40)
Table 4-4. Continued table
No FoF FoF During 6 months
MMSE 27.17 (3.82) 26.53 (3.18)
GDS 8.76 (6.92) 9.03 (5.98)
Of the 33 participants who discussed fear of falling at month one, 13 (39%)
continued to demonstrate fear of falling at month six. See Table 4-6 for frequency counts.
A chi-square test was calculated examining the proportions of participants who were
identified as fearful of falling at month 1 and who continued to be fearful at month 6. A
significant interaction was found (X2, p< .05), and those with fear of falling at month one
were likely to demonstrate fear of falling at month six, see Table 4-7.
Table 4-5. Scoring of FAI and FIM items for those with and without fear of falling
Measures No FoF FoF During 6 months
n 90 42
FIM, walk/wheelchair 5.78 (1.44) 5.48 (1.40)
FIM, stairs 4.41 (2.34) 3.74 (2.30)
FAI, social occasions 2.50 (1.32) 2.26 (1.27)
FAI, walking outside 2.90 (1.38) 2.60 (1.38)
FIM, walk/wheelchair 6.17 (1.30) 5.76 (1.19)
FIM, stairs 5.50 (1.87) 4.64 (2.08) *
FAI, social occasions 2.84 (1.28) 2.78 (1.20)
FAI, walking outside 2.97 (1.31) 2.61 (1.44)
FIM, walk/wheelchair 6.39 (1.16) 6.08 (1.16)
FIM, stairs 5.88 (1.75) 4.97 (1.95) *
* Statistically significant at the < 0.05 level
Table 4-6. Frequency counts of fear of falling at one and six months
FoF at 6 Months Total
No FoF FoF Missing
FoF at Month 1 No FoF 90 9 99
FoF 16 13 4 33
Total 106 22 4 132
Table 4-7. Proportions of those with and without fear of falling and chi square
Month 1 Month 6 X2
Fear of Falling 25% 17%
No Fear of Falling 75% 83%
We also examined the relationship between fear of falling and caregiver depression,
burden, and coping, see Table 4-8. Caregiver results are delineated by stroke survivor
fear of falling status. There were no significant differences in caregiver scoring in
depression, burden or coping skills between those providing care for those with and
without fear of falling (p > 0.05). However, in the interviews, it was common for
caregivers to comment on fears related to stroke survivor falls and injury. Additionally,
many stroke survivors indicated dependence on caregivers as a strategy to prevent falls.
Table 4-8. Comparison of caregivers for participants with and without fear of falling
Measures No FoF FoF During 6 months
n 90 42
Caregiver Age 59.80 (14.10) 59.38 (11.83)
GDS 6.62 (6.17) 6.97 (5.65)
SCQ 51.64 (10.02) 50.08 (12.57)
SOC 71.42 (13.37) 71.13 (16.65)
GDS 5.99 (5.57) 6.38 (5.63)
SCQ 51.89 (11.76) 52.44 (11.99)
SOC 70.54 (13.40) 71.53 (13.69)
The Experience of Fear of Falling Post-Stroke
Qualitative findings are described in this section. Initially, three major theme
headings of "physical", "psychosocial", and "strategy" were used for the coding of the
qualitative interviews. However, after a review of the qualitative interview data and
content analysis, it became evident that the development of fear of falling is a process,
one that often impacts everyday life. Therefore, we present the characterization of fear of
falling as the process that reflects the way stroke survivors experience fear of falling in
their everyday lives. Data indicated that the beginning of the process was often the first
sustained fall that usually occurred at the time of the stroke. Participants discussed
themes related to: bodily changes that influenced falls and fear of falling, experiences
related to a pervasive fear of fall and injury, and the impact of fear of falling on activity
and everyday life. The unpredictability of falls and the resultant general acceptance of
fear became evident, making strategies to manage falls and fear of falling necessary.
Each of these themes are described below. See Table 4-9 for original content analysis
frequencies derived from 33 month one interviews and 22 from month 6 interviews.
Table 4-9. Content analysis frequencies (derived from 55 qualitative interviews)
Primary theme Secondary Themes Frequency
Falls as a Paralysis/hemiplegia 15 27%
Physical Event Fell at time of stroke 22 40%
Balance/stability 21 38%
Dizziness 17 31%
Decreased participation 14 25%
Injury (such as hip fracture or head injury) 6 11%
Talk about falls (stumble, trip, wabble, etc) 45 82%
Total from 55 interviews 140 occurrences
Fearing Falls Fear, afraid, concern 32 58%
Caregiver afraid will fall 16 29%
Afraid of injury 6 11%
Total from 55 interviews 108 occurrences
Strategies for Walker/cane/WC/wall/other 35 63%
Managing Fear Relies on others 9 17%
of Falling Being careful 27 49%
Total from 55 interviews 152 occurrences
Onset of falling with the stroke event
Falling at the time of a stroke is a common experience and maybe a harbinger of
development of fear of falling. For some, having a fall signaled a possible second stroke,
thus fear of falling and fear of another stroke became intertwined. Others discussed the
fall at the time of the stroke and the experience of laying on the floor without someone to
help them. Fear associated with a possible fall continued as individuals were concerned
about falling in the future and being left on the floor for substantial periods of time. One
participant stated "Yes, I fell. It was horrible; I lost control of my left arm, and my hand,
my left foot. They failed me and that's why I fell." Others said "When I had the stroke, I
was, I couldn't walk. I had to crawl and if I tried to stand up at all my legs and things, just
like that (unintelligible), sit down quick or you would fall over" and "Well, when I fell, I
knew I had a stroke and I was in such a bad shape. I was sweatin', the worst kind of
sweat and I asked the Lord."
Some stroke survivors who fell at the time of their stroke were living with the fear
of another stroke and of future falls. One participant commented, "I was scared of falling,
you know, uh it's sorta like it was the other stroke, you know?" These participants
equated the two and feared both. They realized a future stroke may further limit their
abilities and independence. However, the fear they live with daily may limit activity
performance and in itself cause increased dependence. These early experiences of falling
with stroke onset represent the early stages of development of fear of falling.
Experiencing the changed body
Another part of the process of developing fear of falling is related to experiencing
the changed body. The residual motor deficits related to mobility were of great concern to
many participants. Changes in movement and ability of the lower extremities were
frequently described. Individuals discussed not being able to move the same as before the
stroke, and how this negatively impacts mobility, adding to the fear of falling. For
example, participants made several statements about fearing their legs would no longer
function properly. Some said, "My legs give out real fast", "I fear, I fear a little that my
legs don't fail me", and "No, that's what I, I mean, well, as I told you before, you always
worry about a leg failure or that, right?" Others stated, "Oh, am I tired. I'm tired. Legs
just bow, buckle underneath me", "I'll be walking and all of a sudden I'm making love to
the pavement", and "Let's see, after I walk so long (long pause) the feeling that any time
now, the hip and leg are gonna give out and I'm gonna fall, so I watch where I walk so
that if I would fall, I wouldn't fall into something too expensive (laughs)."
Bodily changes were also related to the loss of balance, stability, and strength. For
example, one man stated, "Uh, the only problems I can think of I'm having now is
balance... around me I have to hold onto things, so it's a balance problem and I'm,
sometime I'm tipping and leaning and, prone to fall down." Many talked freely about
paralysis and hemiplegia, or general changes to their body, most often impacting balance
and strength. Another commented, "Well, weak in the knees still weak, have to walk
more slowly and seems like sometimes I get a little wobbly cause I'm so weak and I
haven't got all my strength back yet." Interestingly, some participants discussed concerns
related to their balance, but did not specifically discuss falls or fear of falling. For
instance, one man stated, "The only thing that concerns me is my balance, sometimes I
lose my balance a little bit, that's about it, nothing else because the balance, it isn't all
right." This may be important when utilizing fear of falling assessments, as participants
may worry about balance, but not connect the concern to fear of future falls.
Participants also discussed dizziness as a common aspect of the changed body. For
many, dizziness became a part of everyday life, making falls and fear of falling very
common. When feeling dizzy, participants would discuss the need to curb walking or
other activities and their need for assistance to maintain their balance and prevent a fall.
As an example, one man stated "I get dizzy and I start falling down", and others stated "I
am insecure when I walk around the house, because I get dizzy, and I start falling face
down. My nervous system doesn't help me ... and it's not the same" or "Helped my wife
in a lot of things ... but now I can't, because now ... now I get dizzy and I start falling
face down, I can't I'm not stable, I don't feel self-secured."
The participants who experienced post-stroke bodily changes often developed
unpredictable episodes of imbalance, instability, and dizziness. These changes were often
related to hemiplegia, paralysis, and other post-stroke bodily changes and were reflected
in their discussions of insecurity in mobility and subsequent falls and fear of falling.
A pervasive fear of the unpredictable
Participants often described a pervasive sense of fear of falling. Some specifically
talked about being afraid of a fall in the future. When the interviewer asked "What are
your greatest concerns about your body now?" a participant stated "Fear of falling ... I
think that's most concern of everybody is falls." Others commented that "My greatest
concern, that I don't fall, that I don't have another stroke" and "That is my fear, well, that
I could fall. That is what, what they look for, that I don't fall. Because in order to get up
afterwards is hell." Another stated "I fear a little that my legs ... that my legs don't fail
me" and a different man said "One feels afraid of falling and even dying because I can
get hit by something. I fell and almost hit my head, and thank God, I hit my butt instead."
Some participants avoided the use the words 'afraid' or 'fearful' in relation to falls.
Instead, individuals often talked about having a concern about falls, balance, or safety.
One standard interview question asked participants about their concerns post-stroke,
many discussed issues related to balance, stability, dizziness, falls, safety, and walking.
Some stated, "Trouble with balance, but I'm not about to fall" or "The only thing that
concerns me is the balance, sometimes I lose my balance a little bit but that's about it,
Still others talked about fear of falling and not feeling safe. Safety therefore became
an issue for participants while at home and in the community. One man said, "I don't feel
safe because the people there run around. And I don't feel safe because I sit in a corer,
and I tell you, they can trip you over." and another stated "I didn't feel safe 'cause I
didn't know if I was goin' to fall or what."
Participants characterizing fear of falling often talked about the fear of sustaining
future fall related injuries. Some made the following comments: "Ummm ... I worry
because there have been times where I have tripped and nailed myself" and "I'm afraid
to. I'll lose my balance. That's a long ways down. The fall wouldn't hurt you, it's just the
sudden stop (laughs) ... That ground's hard. Like I say that fall ain't gonna hurt ya."
Of most concern were hip fractures and head injuries. For example, some stated,
"Cause once you fall, could break a hip" and "I think it's falling like it it's it's falling, all
the time that's your worst fear, it's falling and you might hurt or break a leg, or or or or
you might uhh break a hip or something, I think you're more conscious of it yeah."
Participants described genuine concern about being hurt after sustaining a fall and the
subsequent impact on function, one commented, "Uh huh, it worries me; I can fall and
hurt myself bad, or hit my head and make it worse than it is."
Those who discussed a fear of falling tended to discuss fears and concerns related
to falls, future falls, and safety issues. While many participants specifically and openly
discussed fear of falling, many others only admitted to concerns about balance and
stability, not addressing actual fear. Those who communicated fears about future falls
were also likely to discuss fear of future injuries. For these individuals, the fear of falling,
and the prevention of falls often became a part of everyday life.
Falls as an everyday life experience
Participants discussed how falls became a frequent event and a common concern,
often part of every day life. For example, one man said, "Sometimes I fall down, but I'm
used to that now" For some, it seems that falls and fear of falling became all consuming.
Regardless of the frequency of falls, fear of falling became a constant worry for some.
Falls as a common occurrence were expressed in the following statements: "I always fall
on the stairs" and "I'd make about four steps and I fall down" or "I worried about those
steps out there every time I fall it's been on those steps"
Some participants were concerned they would fall while out in the community and
they addressed the embarrassment of a public fall. One individual commented, "Yeah. Uh
huh. Do something that I find difficult to do, is not be embarrassed when you stumble and
watch when you're going somewhere." They were also concerned about how they looked
while walking around and seemed to be worried about the stigma related to falls and
decreased mobility. One man discussed the following situation: "What worries me is that
I had the experience that I fell down, I fell down on a street, someone called 911 and they
picked me up because when I fell I had lost my conscience, because I have unbalance in
my legs, I fall down."
Strategies for managing fear of falling
Because fear of falling became an all consuming issue for some participants, talk
about strategies for the prevention of future falls and management of fear of falling was
common. Many participants discussed limiting everyday life activities, such as ADLs and
IADLs at home and out in the community. One participant said, "You know, I was, I, I'm
generally, well, no I wasn't a real religious fella or anything like that but I did go to
church occasionally with my wife on Sunday, y'know. But uh, I, in fact the last time I
went to church with her I lost my complete balance as we were walking' out o'church,
because of the fall problem I have, and I almost knocked an old lady down. So that was a
concern for me and I wouldn't go back to church. Y'know, since the stroke I've lost
confidence" Another man commented, "Well, well, like I tell you, I stutter, I stutter
more, I wobble and uh that's why I don't, I don't get out in the streets to much, I could, I
have enough energy to go walk and more but I don't" Others discussed limiting higher
level skills, for example, "Well, now I can't (laughing), now it's impossible for me to
climb a ladder. Now I can't do it because I can't get up the ladder (unintelligible), I fall."
Participants also discussed the use of assistive devices such as walkers, canes, and
wheel chairs to reduce falls and feel secure in their environment. As an example, one man
said, "Yeah, I use a cane ... ahhh ... just to ... for protection like in, so I don't fall.
Because, you know, somewhere along the line there was times when my leg felt like it
was going to give out, but it didn't." and another stated, "I keep my cane because I
never know whether one of my legs is gonna decide to give out, so I keep my cane with
me." Other individuals expressed their use of assistive devices with the following
quotations, "Like that cane. Once I, I got it set right by the door over there, 'cause I go
out that door, I'll grab that cane, keep my balance ... And when I get out the door I got
things I can hang onto but once I get away from it I can't. I gotta have that cane. So I
gotta have that cane handy" or "Mainly the only reason I use the walker is for balance."
Interestingly, some even used the furniture or walls as an alternative to assistive devices.
One participant stated, "I feel safe, like I say, the only thing that I am, ahh, really
concerned about in here is after I walk so long that my hip starts giving away and then I
might fall into somebody of up against something and break something, so I watch that.
If I have a banister, I feel, great, hold on to the banister," and an interviewer commented,
"At times, it was noted that he was unsteady on his feet and often used the furniture for
Participants also discussed where they used assistive device. Some commented on
using a device at the store or out in the community, but not at home. For example, "Yeah,
when I go in stores I carry my cane, and if I didn't I'd probably fall" and another, "I got a
walker in there that I use whenever I go up the hospital. Here in the house I really don't, I
use a cane occasionally, but you have the wall here, everything's close, see, y'know."
Others indicated reliance on others as an additional strategy utilized to reduce falls
and manage fear of falling. One man stated, "I was setting' there goin' to the left like that,
kept slidin' to the left, cause the left side's gone. It was in these here foldin' chairs. She
pulls hers right up side of me, leans up there before so I can lean against her, instead of
falling' out of the chair ... Yeah, she's sitting' on the left and she slid her chair right up
against mine, put her shoulder there where I can lean against her, keep me a slidin' out,
falling' out of this chair." Many discussed dependence on their caregivers or others for the
maintenance of balance and the prevention of falls. A participant referred to his caregiver
and said, "Oh, sure, grabbin' my hand, helping' me help straight up and down, keeping' me
from falling she'll walk along side of me every now and then, and, when I need her, you
can tell you know why I'm a little more off balance." Others commented, "Well my
beliefs are that I never will walk alone, I can't be alone at any time", "I'm afraid of
falling when she's not here. I may hurt myself ... Yeah, it makes a difference when she
is here, I walk around and all that." and "Well, yes, he helps me get ready to go to the
bathroom, because sometimes I fall." One stated, ... I want someone beside me to tell
me things and ... At least to prevent me from falling because the last time I fell."
Some caregivers were in the room during the interview and interjected information
about falls and their fear of the stroke survivor falling in the future. Caregivers made the
following comments, "I'm afraid he's going to fall again", "We don't want him to fall",
and "Cause I'm afraid he'll fall and wouldn't be able to get up." Stroke survivors were
aware of their caregiver's surveillance of possible falls and attempts to decrease falls
incidence. For instance, one stroke survivor commented, "My wife keeps attention when
I walk, if I fall or something", and another said, "She was watching me, to see if I was
gonna fall." Still others stated, "Well, they help me to stand up and walk, right? And they
fear that I might fall, right?" Another said, "During the day my wife is here with me in
the house, here .. paying attention to everything I do, too. If go walk over there she's
paying attention that I don't fall or anything."
A general tool for the management of fear of falling and a reduction of future falls
was simply to "be careful" or "cautious". For example, one man said, "I don't know how
to describe it but I think that you, uhh, are more cautious and more careful like, uhh,
umm, in you, when you in bathrooms, if you're in the shower and, uhh, you have to use,
sit down in the chair so that you won't fall." Being "careful" while performing specific
mobility and other everyday activities was commonly addressed. Being cautious was
expressed in the following excerpts: "It's about the same, only thing you do is um, make
sure you don't trip over nothing' an' try your best to sit some place where you don't fall
off of nothing and "I walk slower. I take my time now ... but I, uh, try my best to avoid
tripping. I just slow down." Another said, "Yeah, I, uh, had to be very careful 'cause, uh,
I first come home, home from the hospital, I'd try to get outta' my chair and I fell a
couple a' times." One man said, "I have to be careful when I walk. I might fall."
Many different strategies were utilized for the prevention of falls and the
management of the complexity of fear of falling. Participants discussed use of assistive
devices, reliance on others, and simply being cognizant of their own personal fall risks.
To summarize, quantitative and qualitative data were analyzed to explore the
characterization of fear of falling post-stroke. The main themes derived from the data
conceptualize the process of developing fear of falling, often beginning at the time of the
stroke or initial fall and continuing as individuals live with fear of falling as part of their
daily lives and learn to manage their new bodies and strategize against future falls and
fear of falling.
To our knowledge, this is the first study examining the development of fear of
falling in the post-stroke population. It is also the first qualitative studies on fear of
falling in the elderly. Characterization of post-stroke fear of falling has been derived from
analyses of the qualitative interviews and descriptions of participants using standardized
assessment scores. It is evident that falls and fear of falling are difficulties faced by many
of those who have sustained a stroke, often on a daily basis. Our findings are based on
secondary analyses and indicate that further study of the development of post-stroke fear
of falling and its management at home and in the community is warranted.
Many of the participants discussed falls and fear of falling during the first one to
six months post stroke. The experience of falls is supported by research completed by
Forster and Young who reported a 73% incidence of falls in the first six months post-
stroke . Our reports of fear of falling were less than expected when compared to the
community elderly population. Researchers have indicated fear of falling in 29%-92% of
those recently sustaining a fall and 12%-65% of those without a recent fall [46, 70, 113,
115, 144-152]. In our study, 25% of participants (33 of 133) in month one and 32%
(42/132) of all participants described fear during the first six months post stroke.
The lower fear of falling incidence may be related to the high functioning of our
participants. At discharge, the mean FIM motor score for all participants, regardless of
fear of falling, was 74.98 (15.79) with a range of 13 to 91, and 46% of all participants
scored over 80 (maximum score is 91). This increased to 69% at month one and 74% at
month six, indicating a high functioning group of post-stroke participants.
Incidence may have been impacted by an all male veteran sample. Women are
more likely to report a fear of falling [43, 144, 148, 155, 156] and men may underreport
fear due to a perceived negative stigma related to their fears. Fear of falling may be
underreported because those with the greatest fear may not partake in research [155, 241]
and others may fear institutionalization [143, 150].
Characterization of Fear of Falling
Participants discussed the characterization of fear of falling. Through review and
analysis of the interviews and exploration of post-stroke fear of falling functional status,
we have determined five important factors to include in the characterization:
(1) The time of the initial fall: participants often discussed a first fall coinciding
with their stroke. Participants realized they were at risk for both future falls and strokes
and indicated fear of decreased abilities and subsequent dependence on others. This
provides a preliminary exploration of the timing and development of fear of falling after
stroke. Timing may be related to the impact fear has on everyday life and important when
evaluating assessments and the efficacy of interventions to reduce future falls and
management of fear of falling. In preparation for discharge, clinicians need to talk with
patients about fear of falling and how they will manage safely at home.
(2) Post-stroke related changes in the body: resultant declines in balance, stability,
strength, and dizziness due to hemiplegia and paralysis were commonly discussed. Yates
and colleagues previously determined increased fall risks related to post-stroke motor
impairments . This sample of post-stroke participants discussed decreased mobility
due to the stroke and how it related to increased risk of future falls and fear of falling.
Rehabilitation clinicians and researchers need to develop interventions to support
mobility and safety among those patients with post-stroke fear of falling.
(3) Pervasive fear of future falls: many naturally discussed fear of falling, falls, and
balance issues when discussing post-stroke concerns and barriers. In contrast, others
discussed concern or trouble regarding balance, stability, strength, or their "legs giving
out" but did not admit to actual fear. Perhaps the stigma of "being afraid" was
overwhelming, especially for an all male veteran population. Researchers have
demonstrated increased likelihood of female fear of falling, perhaps our all male veteran
population were embarrassed to admit such fears [43, 144, 148, 155, 156]. The difference
in levels of fear may impact future research when assessing fear of falling evaluations
and preventative interventions. Participants not admitting to being fearful may require
different interventions to manage issues related to fear of falling and future falls.
(4) Every day fear of falling: it became evident that different levels of fear of
falling existed within this population. There is an apparent continuum of fear of falling in
this post-stroke population. It ranges from a healthy sense of fear to an overwhelming, all
encompassing, everyday, obtrusive fear that is reflected in a "constant awareness" of falls
risks and reported changes in activity and participation. The development of fear of
falling may have great impact on every day life, for some, it becomes all-consuming.
Assessing fear of falling and openly discussing it with patients and their caregivers may
help them manage more efficiently after discharge.
(5) Strategies for the management of fear of falling: participants discussed
individual techniques to manage falls and fear of falling. Many discussed restricting or
modifying performance of ADLs, IADLs, and social participation due to fear. Activity
restriction is common in those with fear of falling in the community dwelling elderly [43,
113, 114, 143, 148, 186, 187, 225-230]. Those with fear of falling related activity
restrictions may become increasingly dependent on caregivers. This may impact stroke
caregiver burden and depression. The use of assistive devices such as walkers, canes, and
wheel chairs was also common. Others discussed being careful or cautious to manage
falls and fear of falling. Overall, the development of strategies indicate that a certain,
normal, healthy fear may reduce future falls. Because fall risks are multidimensional [52,
65-67], the independent use of multiple strategies represents the need for
multidimensional and individualized interventions.
In summary, the process of fear of falling may begin at the time of the fall, often
coinciding with the stroke, possibly making the time of the development of fear an
important issue. We found that mobility issues related to changes in the body greatly
impact falls and fear of falling, and that the actual fear or concern may differ dependent
on individuals, ability levels, and possible fear of stigma or embarrassment. Interestingly,
participants naturally developed strategies to manage fear of falling and their fall risks.
Perhaps this was necessary because for some, fear of falling became an all consuming
aspect of life, impacting activity and participation.
There are several limitations to this study. Our study primarily used qualitative data
derived from a larger study. We were restricted to a convenience sample. Common to all
qualitative studies, generalization is not possible, although findings may be informative
across similar populations.
This study was a secondary analysis of naturally occurring data. There was not a
specific interview question related to falls, fear of falling, or post-stroke mobility, and we
did not include a standardized fear of falling or falls incidence assessment. We were
dependent on the use of natural conversation elicited from questions regarding changes
since stroke, concerns about bodily changes, and barriers to everyday life to determine
those who would be considered fearful of falling. Although this naturalistic approach
derives significant amounts of information, all of those with fear of falling may have not
been considered in the qualitative and quantitative analyses, thus possibly reducing
detection of fear of falling incidence.
Because falls and fear of falling are unpredictable, it is of great concern to those
managing life post-stroke. This preliminary research provides insight into the
development of fear of falling after discharge home post-stroke and the impact it has on
activity and participation. It is evident that some people develop a fear that promotes safe
completion of activities. However, others are likely to engage in a cycle of restricted
activities and then experience further functional losses. This plays into the "vicious
circle" portrayed by Delbaere and colleagues who suggested a pattern between reduced
activities and decreased muscle strength and balance, leading to further declines in ADLs,
increased falls incidence and fear of falling, and completing the circle with additional
declines in activities . Li et al. discussed the existing relationship between fear of
falling and falls efficacy, the effect on balance and physical disability, continuations in
deteriorated health, and future falls and development of fear of falling .
Clearly, more interventions are needed to assist stroke survivors and their
caregivers to effectively manage this cycle. It is important to acknowledge the number of
individuals who return home with significant residual mobility losses. This was a
relatively high functioning post-stroke population, and still many discussed fear of falling
and the necessity to manage it with assistive devices, activity restriction, and decreased
Future studies are needed to better define the natural history and experience of the
development of post-stroke fear of falling in the home and community. The utilization of
standardized fear of falling assessments, such as the Falls Efficacy Scale or the
Activities-Specific Balance Confidence Scale, both recently found valid and reliable for
the post-stroke population, [173-175] combined with qualitative data will provide more
complete explanations to better understand fear of falling development. This dual
qualitative and quantitative research study provided preliminary information to justify
future research. Addressing the impact of fear on quality of life and life satisfaction will
be an important step in determining the impact of fear on post-stroke management.
Important future research will include the advent of a fear of falling intervention specific
for the post-stroke population. Likely, interventions to manage fear of falling and reduce
fall rates will require individual treatment plans and will need to address the very issues
described by these participants.
The objective of this dissertation was to utilize secondary data from two larger
studies to examine the impact of post-stroke gait velocity and fear of falling on activity
and participation [8, 11]. In Chapter One, we presented a conceptual framework as the
foundation for this research (Figure 1-2). The framework indicates that those who sustain
a stroke are likely to demonstrate sensory, cognitive, and motor impairments. These
impairments are reflected by mobility disability, specifically changes in gait speed and
fear of falling. Through reviews of the literature, we speculated that change in gait speed
or the development of fear of falling would be associated with change in stroke survivor
performance of activities of daily living (ADLs) (including mobility), instrumental
activities of daily living (IADLs), social participation. Additionally we believed that such
changes in activity and participation, and therefore independence, would impact caregiver
depression, burden, and coping.
Our findings indicate that mobility disability was demonstrated in both of our post-
stroke populations. The first study examined clinically meaningful changes in gait speed
and the second study explored fear of falling. In support of our model, we observed that
those who portrayed a clinically meaningful increase in gait speed demonstrated
improved performance in ADLs, IADLs, mobility, and social participation. We also
described how a post-stroke veteran population characterizes fear of falling in the first six
months after discharge. In addition we examined post-stroke activity, participation, and
depression in those discussing fear of falling.
In the fist study, we measured the proportions of participants who successfully
advanced to a higher ambulation classification, demonstrating a clinically meaningful
change in gait velocity. Forty-five percent of our total sample transitioned to a higher
classification; however, after baseline gait speed stratification, 63% of those walking
slower than 0.4 meters/second (m/s) and 38% walking between 0.4 and 0.8 m/s advanced
to the next ambulation classification. This indicates that those with the slowest speed, and
possibly the most severe mobility deficits, have the greatest potential for gains in gait
We also compared the differences in Stroke Impact Scale (SIS) measured
ADLs/IADLs, mobility, social participation, and physical functioning (SIS-16) dependent
on success or failure of advancement to a higher ambulation classification. After
controlling for a significant difference in age, all SIS scores for those with baseline gait
velocity less than 0.4 m/s were statistically different. In contrast, only the participation
score was significantly different for those with baseline gait velocity between 0.4 and 0.8
m/s. This suggests that a transition to the next ambulation classification is a clinically
meaningful change because it is related to increased function, particularly for the initially
more impaired stroke survivors. This is important as it validates the previous ambulation
classification developed by Perry and colleagues . More importantly, it confirms the
use of ambulation classification in clinical and rehabilitation research settings. It indicates
that using ambulation classification is appropriate for goal setting and that increased gait
velocity is associated with highly significant increases in performance of activity and
In the second study, we used qualitative and quantitative data to examine how post-
stroke veteran populations characterize fear of falling and the relationship between fear
and ADLs, IADLs, and depression. Additional exploration of caregiver burden, coping,
and depression for those caring for post-stroke individuals with fear of falling was
completed. It is evident that those with fear demonstrated slightly lower scores for almost
all Functional Independence Measure (FIM), Frenchay Activity Index (FAI), and
depression scores. This trend was also established for individual FIM and FAI items and
caregiver burden, depression, and coping.
Content analysis and review of the qualitative interviews verified that many
participants naturally discussed post-stroke falls and fear of falling. We discovered that
participants characterize post-stroke fear of falling with five main factors, including: (1)
the importance of the time of the initial fall, (2) how post-stroke related changes in the
body were associated with falls and fear of falling, (3) the pervasive fear and concern of
future falls, (4) a continuum of everyday and unpredictable fear of falling, and (5) the
natural strategies utilized and discussed by participants for the management of fear of
falling and the prevention of falls.
These qualitative findings can be related to the examination of data retrieved from
the standardized assessments. Participants discussed concern regarding falls during
performance of both ADLs and IADLs, but it seems that participants were more likely to
discuss fear of falling in regard to the performance of higher level activity at home and in
the community. A small difference in FAI scores between those with and without fear of
falling is apparent. This implies that fear of falling had a bigger impact on higher level
IADLs in this relatively high functioning post-stroke population. Of additional
importance, participants naturally developed strategies to prevent falls and manage fear
of falling. This may impact future interventions to decrease falls and fear of falling in this
population. Programs may need to be individualized dependent on the need and abilities
of the post-stroke individual. This exploration warrants future research of post-stroke fear
In conclusion, we studied two post-stroke community dwelling populations, and
although all participants lived at home, we established that many continued to
demonstrate mobility impairments. The present studies provide support of the negative
impact of post-stroke mobility changes on activity and participation. Further study of gait
speed change and its influence on activity and participation is warranted. Natural
recovery may play an important role in improvement, but further evidence is needed to
determine appropriate interventions and timing of intervention to best enhance gait
velocity and consequently improve activity, participation, and quality of life. Future
research is necessary to better understand the true trajectory of the development of fear of
falling after stroke. It is evident that fear of falling development was very individualized
and our results provide preliminary data demonstrating that prevention strategies also
need to be individualized. This preliminary research provides foundational data to
continue investigation into post-stroke gait velocity and fear of falling, its impact on
everyday life, and future interventions. Collectively, this research will promote our
understanding of post-stroke mobility and its impact on functional independence.
EVIDENCE BASED TABLE FOR FEAR OF FALLING AND ACTIVITY
Table A-1. Fear of falling and activity restriction
Article I Design I Sample I Fear of falling assessment Functional Activity Measures Results
Arfken, et al., Cross- 890 "At the present time, are you very Mobility activities 29% reported some FoF
1994) sectional fearful, somewhat fearful, or not Social activities Of those very FoF
 analysis of fearful that you may fall (again)?" Depression o 48%not satisfied with life
data from a Life satisfaction o 25% depression
prospective Frailty measure o decreased mobility and social activities
study 1 year o 91% reported at least one characteristic of
follow up frailty
o 85% exhibited diminished balance
o 22% were delayed in getting up after
sustaining a fall
o 85% impaired balance
Brouwer, et al., Cross- 50 Activity-specific Balance Human Activity Profile Those with FoF had lower ABC scores,
2004 sectional 25 with FoF Confidence decreased balance, slower gait speed, lower
 study and activity limb weakness, and decreased physical
curtailment and health.
25 without FoF Similar activity profiles
Bruce, et al., Cross- 1500 females "Are you afraid to fall?" "Do you participate in any sports 34% afraid of falls
2002 sectional "Do you limit any household recreation or regular physical More FoF in sedentary woman (45.2%)
 analysis of activities because you are exercise?" FoF was independent risk factor for
baseline data frightened you may fall?" "Please list any sports recreation nonparticipation in physical activity
from a Do you limit any outside activities or regular physical activity, Analysis suggests FoF affected activity levels
longitudinal because you are frightened you including walking, that you at a predisability stage in those with mildly
study may fall?" undertook in the last 3 months" impaired mobility
(duration / frequency)
Chandler, et al., Secondary 149 male "Would you say that you are Mobility performance 43% of the high risk participants were very
1996 analysis of veterans somewhat afraid, not afraid, or very PADL and IADL afraid of falling
 data from a afraid of falling?" Change in inside and outside 55% had prior fall
prospective activity Walk time and life space reduced in nonfallers
observational who were very afraid of falling
study of falls Increased depression in those very afraid of
Decreased functional reach and activity for
those very afraid of falling
Decreased walk time, mobility skills,
functional reach, IADL, PADL, lifespace,
and activity levels if a faller AND very
afraid to fall
Walk time and IADL were independent
contributors to FoF
Table A-1. Continued
Article Design Sample Fear of falling assessment Functional Activity Measures Results
Cumming, et al., Secondary 418 at baseline Falls Efficacy Scale ADLs Those with lowest confidence in balance had
2000 data form a and 307 at 12 "Are you afraid of falling?" Use of community services increased risk of falls, poorer health,
 prospective months significant declines in ADLs, lowest QoL
Delbaere, et al., Cross- 225 (and 221 Survey of Activities and Fear of Survey of Activities and Fear of Frequent fallers more likely to avoid FoF
2004 sectional for longitudinal Falling in the Elderly (SAFFE) Falling in the Elderly (SAFFE) related activities
 study and portion) Scale Scale Mobility tasks avoided the most by those with
longitudinal Physical Performance Test FoF
study 1. i i i. .i FoF activity restriction was correlated with
physical performance, forward excursion of
the center of pressure and muscle strength
FoF and activity restriction predicted falls at
the one year follow up
Stated FoF is a "vicious circle of frailty"
where individuals cease activities, but
become more fearful and continue to reduce
activity, decreasing mobility levels, and
becoming more fearful
Fletcher and Cross- 2,304, all "Limited going outdoors due to fear Minimum Data Set for Home 41.2% restricted activity de to FoF
Hirdes, 2004 sectional receiving home of falling (e.g., stopped using bus, Care 27% sustained previous fall
 study care services goes out only with others) Clinical Assessment Protocols Predictive factors of activity limitation
IADLs o Female
o Need for informal support for IADLs and
o Being alone for long periods of the day
o Impaired gait
Howland, et al., Sample 266 "Are you afraid of falling?" Falls history 55% with FoF
1998 survey Social support 56% of those with FoF restricted activity
 Fear related to function and social support
Those with restricted activity:
o Did not communicate about falls
o Less social support
o Knew someone who had fallen
Kressign, et al., Base-line 287 Falls Efficacy Scale CESD About 12 of participants demonstrated fear of
2001 cross- Activity-specific Balance 360 turn falling
 sectional Confidence Functional reach Those fearful were more depressed and used a
study 10-meter walk walking aid
Single limb stands FoF was correlated to all functional measures
Picking up and object Depression, walking-aid, slow gait speed,
Chair stands being African American related to being
Table A-1. Continued
Li, et al., 2003 Cross- 256 Assessed with the Survey of Assessed with the Survey of FoF varied across differing activities of the
 sectional Activities and Fear of Falling in the Activities and Fear of Falling in SAFFE
study Elderly (SAFFE) Scale the Elderly (SAFFE) Scale 18% reported "high fear"
Berg Balance Those with high fear more likely to report fear
Functional Reach Test with activities of the SAFFE
Dynamic Gait Index for Fallers had a higher SAFFE score
functional mobility Difference in balance, functional mobility,
IADLs IADLs, and QoL between those with high
Quality of Life via SF-12 and low fear
Those with higher fear engaged in fewer
Murphy, et al., Cross- 1064 "Afraid of falling?" ADLs 24% reported FoF
2002 sectional Those with FoF were asked "did IADLs 19% reported FoF and activity restriction
 study the fear cause them to cut down on CESD Highest activity restriction seen in those over
activities?" 80, female, white, poor health status,
dizziness, 5 or more medications, visual
impairment, two or more diseases
Those with FoF and activity restriction were
more likely to be 80 and over, female, 2 or
more disease, slow timed physical
performance, ADL disability, prior injurious
fall, anxiety, and depressive symptoms
Suzuki, et al., Cross- 135 "At the present time are you very Short Form 36 Health Survey Females more likely to express FoF
2002 sectional fearful, somewhat fearful, or not measured health related quality Older participants more likely to express FoF
 study fearful that you may fall?" of life and perceived changes in 63.7% were moderately or very fearful of
health status falling
Females: walking and bathing had significant
relationship with FoF
Majority of those who required assist with
ADLs answered "moderately" or "very
Those with increased FoF demonstrated
decreased scoring on SF-36 subscales
o Physical problems
o Social functions
o Physical function
o General health perceptions
Yardley and Convenience 224 at baseline "In general, are you afraid of falling Consequence of Falling Scale Nearly half had fallen in previous year
Smith, 2002 sample form and 166 at 6 over?" (CoF) (validated by authors) 57% reported FoF
 a pragmatic months Answered: not at all, a little, quite a o Assesses fall related fears of o 46% a little afraid
double-blind bit, very much physical injury, long term o 11% more severe fear
randomized functional incapacity, FoF related activity avoidance increased with
controlled subjective anxiety, and age, female gender, and number of falls in
trial social discomfort. the last year.
Modified Survey of Activities and Each increase of reported FoF was associated
Fear of Falling in the Elderly with an increased in activity avoidance and
(SAFFE) Scale perceived negative falls consequences
LIST OF REFERENCES
1 Stineman MG, Maislin G, Fiedler RC, Granger CV: A prediction model for
functional recovery in stroke. Stroke 1997; 28: 550-556.
2 O'Sullivan SB: Stroke; in O'Sullivan SB, Schmitz TJ (eds): Physical
rehabilitation: Assessment and treatment; ed 4th. Philadelphia, F.A. Davis
Company, 2001, pp 519-582.
3 AHCPR: Clinical practice guidelines: Post-stroke rehabilitation, U.S. Department
of Health and Human Services, 1995.
4 Han B, Haley WE: Family caregiving for patients with stroke. Review and
analysis. Stroke 1999; 30: 1478-1485.
5 Lyons RA, Lo SV, Littlepage BN: Comparative health status of patients with 11
common illnesses in Wales. J Epidemiol Community Health 1994; 48: 388-390.
6 Fried LP, Ettinger WH, Lind B, Newman AB, Gardin J: Physical disability in
older adults: a physiological approach. Cardiovascular Health Study Research
Group. J Clin Epidemiol 1994; 47: 747-760.
7 Barrett B, Brown D, Mundt M, Brown R: Sufficiently important difference:
expanding the framework of clinical significance. Med Decis Making 2005; 25:
8 Duncan P, Studenski S, Richards L, Gollub S, Lai SM, Reker D, Perera S, Yates
J, Koch V, Rigler S, Johnson D: Randomized Clinical Trial of Therapeutic
Exercise in Subacute Stroke. Stroke 2003; 34: 2173-2180.
9 Perry J, Garrett M, Gronley JK, Mulroy SJ: Classification of walking handicap in
the stroke population. Stroke 1995; 26: 982-989.
10 Lord SE, McPherson K, McNaughton HK, Rochester L, Weatherall M:
Community ambulation after stroke: How important and obtainable is it and what
measures appear predictive? Arch Phys Med Rehabil 2004; 85: 234-239.
11 Rittman M, Vogel B, Spring HJ, Boylstein C, Faircloth C, Chumbler NR:
Culturally sensitive models of stroke recovery and caregiving after discharge
home, in HSR&D, Nursing Research Initiative. North Florida/South Georgia
Veterans Health System: Rehabilitation Outcomes Research Center: Gainesville,
12 Jette AM: Physical disablement concepts for physical therapy research and
practice. Phys Ther 1994; 74: 380-386.
13 ICF Introduction, 2003, July 4, 2004
14 Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ,
Roth EA, Shekelle PG: Interventions for the prevention of falls in older adults:
systematic review and meta-analysis of randomised clinical trials. BMJ 2004;
15 Patla AE, Shumway-Cook A: Dimensions of mobility: defining the complexity
and difficulty associated with community mobility. J Aging Phys Activity 1999;
7: 7 19.
16 Fried LP, Bandeen-Roche K, Chaves PH, Johnson BA: Preclinical mobility
disability predicts incident mobility disability in older women. J Gerontol A Biol
Sci Med Sci 2000; 55: M43-52.
17 Guralnik JM, LaCroix AZ, Abbott RD, Berkman LF, Satterfield S, Evans DA,
Wallace RB: Maintaining mobility in late life. I. Demographic characteristics and
chronic conditions. Am J Epidemiol 1993; 137: 845-857.
18 Hirvensalo M, Rantanen T, Heikkinen E: Mobility difficulties and physical
activity as predictors of mortality and loss of independence in the community-
living older population. J Am Geriatr Soc 2000; 48: 493-498.
19 Daley MJ, Spinks WL: Exercise, mobility and aging. Sports Med 2000; 29: 1-12.
20 Katz S, Branch LG, Branson MH, Papsidero JA, Beck JC, Greer DS: Active life
expectancy. N Engl J Med 1983; 309: 1218-1224.
21 Lennartsson C, Silverstein M: Does engagement with life enhance survival of
elderly people in Sweden? The role of social and leisure activities. J Gerontol B
Psychol Sci Soc Sci 2001; 56: S335-342.
22 Fried LP, Guralnik JM: Disability in older adults: evidence regarding
significance, etiology, and risk. J Am Geriatr Soc 1997; 45: 92-100.
23 Spector WD, Katz S, Murphy JB, Fulton JP: The hierarchical relationship
between activities of daily living and instrumental activities of daily living. J
Chronic Dis 1987; 40: 481-489.
24 Kemper P: The use of formal and informal home care by the disabled elderly.
Health Serv Res 1992; 27: 421-451.
25 Hellstrom Y, Hallberg IR: Perspectives of elderly people receiving home help on
health, care and quality of life. Health Soc Care Community 2001; 9: 61-71.
26 Melzer D, Lan T-Y, Tom BDM, Deeg DJH, Guralnik JM: Variation in Thresholds
for Reporting Mobility Disability Between National Population Subgroups and
Studies. J Gerontol A Biol Sci Med Sci 2004; 59: 1295-1303.
27 Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG,
Scherr PA, Wallace RB: A short physical performance battery assessing lower
extremity function: association with self-reported disability and prediction of
mortality and nursing home admission. J Gerontol 1994; 49: M85-94.
28 Ensrud KE, Nevitt MC, Yunis C, Cauley JA, Seeley DG, Fox KM, Cummings
SR: Correlates of impaired function in older women. J Am Geriatr Soc 1994; 42:
29 Gill TM, Williams CS, Tinetti ME: Assessing risk for the onset of functional
dependence among older adults: the role of physical performance. J Am Geriatr
Soc 1995; 43: 603-609.
30 Jette AM, Branch LG: The Framingham Disability Study: II. Physical disability
among the aging. Am J Public Health 1981; 71: 1211-1216.
31 Guralnik JM, Ferrucci L, Pieper CF, Leveille SG, Markides KS, Ostir GV,
Studenski S, Berkman LF, Wallace RB: Lower extremity function and subsequent
disability: consistency across studies, predictive models, and value of gait speed
alone compared with the short physical performance battery. J Gerontol A Biol
Sci Med Sci 2000; 55. M221-231.
32 Manton KG: A longitudinal study of functional change and mortality in the
United States. J Gerontol 1988; 43: S153-161.
33 Jylha M, Guralnik JM, Balfour J, Fried LP: Walking difficulty, walking speed,
and age as predictors of self-rated health: The women's health and aging study. J
Gerontol A Biol Sci Med Sci 2001; 56: M609-617.
34 Cress ME, Schechtman KB, Mulrow CD, Fiatarone MA, Gerety MB, Buchner
DM: Relationship between physical performance and self-perceived physical
function. J Am Geriatr Soc 1995; 43: 93-101.