Full length ArticleRelationships between fear of falling, balance confidence, and control of balance, gait, and reactive stepping in individuals with sub-acute stroke
Introduction
Fall risk for individuals with stroke is over twice that of healthy older adults [1]. Falling is a common medical complication post-stroke [2], [3], with an especially high risk of occurrence during hospital stay [4] and after discharge home from in-patient rehabilitation [5]. Falls often contribute to fear of falling (FOF); alternatively, or FOF can develop in absence of a fall [6]. FOF is prevalent post-stroke, with up to 88% of individuals with stroke who experience a fall developing FOF [7]. Resulting activity avoidance may lead to restricted mobility and deconditioning, contributing to reduced functional capabilities, loss of functional independence, and further increases in fall risk and FOF [8], [9], [10]. FOF [11] and balance confidence [12] are both associated with falls in individuals with stroke, suggesting that these factors are influential in fall occurrence post-stroke.
FOF has been shown to influence balance and gait control in older adults. Compared to older adults with no FOF, those with FOF demonstrate greater centre of pressure (COP) amplitude during eyes-closed quiet standing [13]. Gait in older adults with FOF is characterized by decreased velocity and step length, and increased step width, double support time, and spatio-temporal variability [14], [15], [16], [17], [18], [19]. Similarly, quiet standing and walking measures have been linked to balance confidence in older adults [16], [20]. Rosen et al. [21] identified significant, positive correlations between falls self-efficacy and clinical measures of balance and gait capability in individuals with stroke. However, no previous study has examined relationships between balance and gait features, FOF, and balance confidence in individuals with stroke.
A better understanding of the relationships between FOF, balance confidence, and features of balance and gait may provide insight into the mechanism(s) by which FOF and balance confidence relate to fall risk in individuals with stroke, and inform rehabilitation strategies to minimize these changes and their impact on fall risk. This study determined whether features of quiet standing balance, gait, and reactive stepping (a) differed between individuals with stroke with and without FOF, and (b) were related to balance confidence. It was hypothesized that, compared to individuals without FOF, those with FOF would exhibit: increased COP amplitude and greater reliance on vision (quiet standing); reduced velocity, increased double support time, and increased variability (gait); and increased frequency of failed responses (reactive stepping). Furthermore, balance confidence was expected to be negatively related to these measures, with the exception of walking velocity (positive relationship).
Section snippets
Participants
Data from individuals with stroke who underwent in-patient stroke rehabilitation at a rehabilitation hospital between October 2009 and September 2012 were analyzed retrospectively. To be included in the analysis, participants must have undergone a clinical assessment with a physiotherapist (part of routine care) at admission to in-patient rehabilitation, and answered a self-report FOF question. They must have completed at least one of: quiet standing, self-paced walking across a
Differences between fear of falling groups
FOF was reported by 40% of participants (84/208). Sex was a covariate for walking velocity, double support time, and step time variability; these measures differed between men and women (t ≥ 2.96, p < 0.06) and sex differed between FOF groups (χ(1) = 14.96, p < 0.001). Fall history was different between FOF groups (χ(1) = 2.90, p = 0.089), and total AP COP amplitude and ρ0 of AP COP during eyes-open standing, AP Romberg quotient, double support time, and number of reactive steps also differed between
Discussion
This study identified relationships between balance confidence and specific features of balance, gait, and reactive stepping. No differences in any of the outcome measures were identified between FOF groups. The results supported the hypotheses for balance confidence, with negative relationships between balance confidence and AP COP amplitude during eyes-open quiet standing, double support time, and step time variability, and a positive relationship between balance confidence and walking
Conflict of interest statement
None.
Acknowledgements
Equipment and space have been funded with grants from the Canada Foundation for Innovation, Ontario Innovation Trust, and the Ministry of Research and Innovation. ASI is supported by a Trainee Award from the Heart and Stroke Foundation Canadian Partnership for Stroke Recovery. AM holds a New Investigator Award from the Canadian Institutes of Health Research (MSH-141983). The funding sources did not have any role in the experimental process or in the preparation of the manuscript, and the views
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