Validation of an Adapted Falls Efficacy Scale in Older Rehabilitation Patients

Article Outline

• Abstract
• Methods
  • Study Population and Setting
  • Data Collection
  • Assessment of Falls Efficacy
  • Statistical Analysis
• Results
  • Scale Reliability and Structure
  • Construct Validity
  • Predictive Validity
• Discussion
  • Study Limitations
• Conclusions
• References
• Copyright

Abstract 

Büla CJ, Martin E, Rochat S, Piot-Ziegler C. Validation of an adapted Falls Efficacy Scale in older rehabilitation patients.

Objective

To determine the psychometric properties of an adapted version of the Falls Efficacy Scale (FES) in older rehabilitation patients.

Design

Cross-sectional survey.

Setting

Postacute rehabilitation facility in Switzerland.

Participants

Seventy elderly persons aged 65 years and older receiving postacute, inpatient rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

FES questions asked about subject’s confidence (range, 0 [none]–10 [full]) in performing 12 activities of daily living (ADLs) without falling. Construct validity was assessed using correlation with measures of physical (basic ADLs [BADLs]), cognitive (Mini-Mental State Examination [MMSE]), affective (15-item Geriatric Depression Scale [GDS]), and mobility (Performance Oriented Mobility Assessment [POMA]) performance. Predictive validity was assessed using the length of rehabilitation stay as the outcome. To determine test-retest reliability, FES administration was repeated in a random subsample (n=20) within 72 hours.

Results

FES scores ranged from 10 to 120 (mean, 88.7±26.5). Internal consistency was optimal (Cronbach α=.90), and item-to-total correlations were all significant, ranging from .56 (toilet use) to .82 (reaching into closets). Test-retest reliability was high (intraclass correlation coefficient, .97; 95% confidence interval, .95−.99; P<.001). Subjects reporting a fall in the previous year had lower FES scores than nonfallers (85.0±25.2 vs 94.4±27.9, P=.054). The FES correlated with POMA (Spearman ρ=.40, P<.001), MMSE (ρ=.37, P=.001), BADL (ρ=.43, P<.001), and GDS (ρ=−.53, P<.001) scores. These relationships remained significant in multivariable analysis for BADLs and GDS, confirming FES construct validity. There was a significant inverse relationship between FES score and the length of rehabilitation stay, independent of sociodemographic, functional, cognitive, and fall status.

Conclusions

This adapted FES is reliable and valid in older patients undergoing postacute rehabilitation. The independent association between poor falls efficacy and increased length of stay has not been previously described and needs further investigations.

Key Words: Accidental falls, Fear, Rehabilitation

FEAR OF FALLING IS FREQUENT among community-dwelling elderly persons, with prevalence ranging from 25% up to 50%.¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹ In these persons, fear of falling has been associated with activity restriction, functional decline, decreased quality of life, and institutionalization,¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹ making it a potential target for specific intervention.

Several approaches have been used to investigate fear of falling, ranging from a single question asking about being afraid of falling to more complex scales inquiring about self-perceived confidence in performing various activities without falling.⁴, ¹², ¹³, ¹⁴, ¹⁵ Although both measures are highly correlated, measures of falls efficacy were found in some studies to have stronger association with functional status than a single question,⁷, ⁹ suggesting they might be different, albeit complementary measures. The Falls Efficacy Scale (FES) was developed by Tinetti et al⁴ to assess the confidence a person has in performing several activities of daily living (ADLs) without falling. Initially validated in a sample of community-dwelling elderly persons, this scale was shown to be reliable and to have construct as well as predictive validity in subsequent studies of similar populations.², ⁴, ⁹ Moreover, it was shown to be sensitive to change after interventions,¹⁶ making falls efficacy a potential important clinical endpoint for rehabilitation.

Surprisingly, none of the instruments developed to assess falls efficacy have been formally validated in older patients undergoing postacute rehabilitation,¹⁵ despite the high likelihood of these patients experiencing poor falls self-efficacy.¹⁷ It is therefore unclear whether these instruments will maintain their psychometric properties in this population. In addition, some authors¹², ¹⁸ mentioned their concern about a potential ceiling effect when using the FES to assess older persons with higher function. Older patients admitted to postacute rehabilitation have very heterogeneous levels of function. It is also unclear what is the best set of activities to include to avoid the ceiling or floor effect when assessing this population.

The aim of this study was to determine the psychometric properties of an adapted version of the FES in a sample of older patients admitted to postacute care rehabilitation. The specific objectives were to determine the internal consistency, intraobserver test-retest reliability, construct, and predictive validity of the FES. Construct validity was assessed by testing the hypotheses that the FES score would be lower in fallers compared with nonfallers; would be positively correlated with measures of functional, physical, and mobility performance; and would be negatively correlated with depressive symptoms. For predictive validity, the hypothesis was that the FES would be inversely correlated with the rehabilitation length of stay (LOS).

Back to Article Outline

Methods 

Study Population and Setting 

Participants were consecutive patients aged 65 years and over admitted to a postacute rehabilitation facility. Subjects were not eligible if they had significant cognitive impairment, defined as a score lower than 20 on the Mini-Mental State Examination (MMSE),¹⁹ or significant depressive symptoms, defined as a score of 6 or more on the 15-item Geriatric Depression Scale (GDS).²⁰ A sample size of 70 persons was selected to perform multivariate analysis with potential sociodemographic and functional covariates, but no formal sample-size calculation was performed. The study was approved by the institutional review board. Oral informed consent for participation was obtained from each participant.

Data Collection 

Data were collected through face-to-face interviews by a research assistant within 72 hours after admission. Data included demographics, living arrangement, previous falls within the last 6 months, self-reported performance in basic ADLs (BADLs), using Katz’s instrument,²¹ and instrumental ADLs (IADLs), using Lawton’s instrument.²² Observed performance in BADLs was collected from the nursing charts. For each activity, patients were considered dependent if unable to perform the task without assistance. Cognitive status and affective status were assessed using MMSE¹⁹ and 15-item GDS²⁰ scales, respectively. Gait and balance performance was assessed using the Performance Oriented Mobility Assessment (POMA) scale.²³

Assessment of Falls Efficacy 

A translated and adapted version of the FES⁴ was used to assess falls self-efficacy. A translation−back-translation process from English to French to English was performed, including cultural adaptation for some items (eg, walking around the house rather than around the block). The adapted version includes 12 ADLs (table 1) because 2 outdoor activities (walking around one’s house, simple shopping) were added to the original scale to include more demanding activities when investigating populations with a wider range of functional abilities. These 2 activities were selected from the list of activities initially considered when the FES was developed.⁴ As in the revised FES format,⁹ participants were asked to rank on a 0 (no confidence) to 10 (full confidence) scale their confidence in performing these activities without falling. The research assistant read the questions out to the participants who had the FES in written format in front of them. In case they were not able to perform the activity, participants were asked to indicate their level of confidence if performing the task. Participants were prompted to provide a hypothetical rating by asking them to estimate how much fear of a fall was responsible for not performing the task. Test-retest reliability was assessed in a random subsample of 20 elderly participants by repeating the FES within 72 hours of the first interview.

Table 1. Content of the FES in Order of Presentation and Item-to-Total Correlation Coefficients

Statistical Analysis 

Characteristics of subjects were described using descriptive statistics. Internal consistency of the FES was assessed using the Pearson coefficient from interitem and item-to-total correlation analyses. Internal reliability was assessed using Cronbach α coefficient. Test-retest reliability was assessed by intraclass correlation coefficient (ICC) between FES scores at test and retest 72 hours later, using analysis of variance.²⁴ Factor analysis was performed to study the structure of the scale, using principal component analysis with varimax rotation.

Construct validity was assessed using the Pearson coefficient from correlation analyses with continuous variables such as GDS, MMSE, POMA, and BADL scores. Stepwise multivariable linear regression analyses were performed to (1) identify participants’ characteristics that were independent predictors of FES score and (2) determine the association between FES score and rehabilitation LOS. To be included in the multivariable models, variables had to show a statistically significant association in bivariate analysis. Because some variables were highly correlated (eg, preadmission BADLs and IADLs, admission BADLs, MMSE), the a priori decision was to preferentially include in the initial model variables that resulted from objective rather than self-reported measures (eg, nurse-observed BADL performance on admission rather than self-reported BADL before hospitalization). Covariates included in the multivariate models were age, sex, BADL, GDS, MMSE, and POMA scores to predict FES score and age, living situation (living alone or not), BADL, MMSE, and fall status to predict LOS. The significance levels to enter and to remain in the models were set at 0.1 and 0.2, respectively. Compatibility with the regression assumptions was checked for both models. Stability of the models were further assessed using bootstrapping methods.²⁵ Statistical analyses were performed by using Stata.^a

Back to Article Outline

Results 

Characteristics of the study population are shown in table 2. Overall, participants had a wide range of age and functional and mobility performance. Almost two thirds reported a fall in the previous year, including 14% who were admitted after a hip fracture. FES administration took a median of 4 minutes 10 seconds (range, 1min 20s–11min 30s). Scores ranged from 10 to 120 (mean, 88.7±26.5; median, 93).

Table 2. Baseline Characteristics of the Total Population (N=70)

NOTE. Values are mean ± standard deviation (range) or percent.

Scale Reliability and Structure 

The scale’s internal consistency was optimal (Cronbach α=.90), with interitem correlations ranging from .19 to .80. Item-to-total correlations (see table 1) were all significant, ranging from .56 (toilet use) to .82 (reaching into closets), and test-retest reliability was high (ICC=.97; 95% confidence interval [CI], .95−.99; P<.001).

Factor analysis suggested a 2-factor solution, accounting for 63.7% of the sample variance. A first rotated factor explained 32.8% of the variance and loaded mostly on outdoor activities (eg, walking around the house, simple shopping), whereas the second factor (explaining 30.9% of the variance) loaded mostly on indoor activities related to BADLs (eg, transferring in or out of bed, getting on or off the toilet, getting dressed or undressed).

Construct Validity 

Comparisons of FES score between subjects reporting a fall in the previous 12-month period or not showed that the former tended to have lower self-efficacy than the latter (85.0±25.2 vs 94.4±27.9, P=.054). Of note, a difference in FES scores became clearly significant when excluding a patient who scored 10 on the FES and had significant cognitive impairment (MMSE score, 22/30) and balance impairment (POMA score, 22/28) but reported no previous fall.

Other analyses showed that the FES correlated significantly with measures of gait and balance (Spearman ρ=.40, P<.001), affective status (ρ=−.53, P<.001), and observed performance in BADLs at admission (ρ=.43, P<.001) (fig 1). Additional significant correlations were observed with cognitive performance (MMSE, ρ=.37, P=.001) and self-reported performance in IADLs before hospital admission (ρ=.32, P=.006). In multivariable linear regression analysis, the FES total score remained significantly associated (adjusted R²=.47) with affective status, observed BADL performance, age, and female sex (table 3).

• 
  • View Large Image
  • Download to PowerPoint

• Fig 1. 

  Relationships between FES scores (range, 0−120; higher scores indicate higher confidence) and (A) POMA scores (range, 0−28; higher scores indicate better gait and balance), (B) GDS scores (range, 0−15; higher scores indicate more depressive symptoms), and (C) performance in BADLs (range, 0−6; higher scores indicate higher independence). Shaded areas correspond to the 95% CIs around regression line.

Table 3. Results of the Multivariate Analysis Predicting FES Score

Characteristics	β	SE	95% CI	P
GDS score	−6.0	1.6	−9.2to−2.8	<.001
BADL score	7.2	1.8	3.7to10.8	<.001
Age	0.8	0.3	0.2to1.4	.006
Female sex	−10.7	5.0	−20.7to−0.8	.035

Abbreviation: SE, standard error.

Predictive Validity 

Finally, participants’ LOS in rehabilitation ranged from 2 to 49 days (median, 20d; mean, 21.4±9.1d) and correlated inversely with FES score (ρ=−.51, P<.001) (fig 2). This relationship remained significant in multivariable analysis that controlled for observed performance in BADLs, cognition, and fall status (adjusted R²=.42, β=–.09; 95% CI, –.17 to –.01; P=.032) (table 4).

• 
  • View Large Image
  • Download to PowerPoint

• Fig 2. 

  Relationship between FES scores (range, 0−120; higher scores indicate higher confidence) and rehabilitation LOS.

Table 4. Results of the Multivariate Analysis Predicting Rehabilitation LOS

Characteristics	β	SE	95% CI	P
FES score	−0.09	0.04	−0.17to−0.01	.032
BADL score	−1.80	0.70	−3.19to−0.39	.013
Faller	3.64	1.80	0.04to7.24	.047
MMSE score	−0.81	0.44	−1.69to0.06	.068

At the end of rehabilitation, only 5 patients (5/70 [7.1%]) did not return to their home and were transferred to the acute hospital (1 elective and 1 emergency transfer) and to nursing homes (2 short-term and 1 long-term admissions). They had lower FES scores than other participants (median 55 vs 97; Kruskall-Wallis rank-sum test, P=.011).

Back to Article Outline

Discussion 

This study shows that, among these older patients admitted to postacute rehabilitation, this adapted version of the FES has excellent psychometric properties, similar to the original version, in terms of internal consistency, test-retest reliability, and construct validity. In particular, results confirmed our hypotheses of significant associations with measures of function, mobility, and affect performance.

This study also increases the knowledge of potential adverse effects of fear of falling and poor falls self-efficacy in the independent association with the rehabilitation LOS. To our knowledge, this is the first study that specifically addresses this issue in patients undergoing postacute rehabilitation and links poor self-efficacy at admission with an increased LOS. Although a previous study¹⁷ in patients undergoing rehabilitation after a hip fracture mentions a correlation between change in falls self-efficacy and LOS, no multivariable analysis was performed to adjust for potential confounders. The observational design of the present study does not permit conclusions about causality, even though it is suggested by the chronology and the clear inverse dose-response relationship between falls efficacy and LOS shown in figure 2. Several hypotheses could be proposed to explain this finding. Most likely, poor falls self-efficacy might retard progress in walking rehabilitation. Measuring gait and balance performance both at baseline and before discharge could help clarify this issue. Unfortunately, this was not performed in the current study, making it impossible to adjust for gait performance to better isolate the independent effect of falls self-efficacy. This should be investigated in a future study. Similarly, poor falls efficacy might also interfere with rehabilitation in ADLs such as transferring, dressing, and going to the toilet. This association will also require further study. An alternative explanation could be that this association reflects poorer health and functional status in patients with poor falls efficacy. However, the relationship between the FES and LOS remained when controlling for functional, cognitive, and fall status, making it an unlikely explanation, even though residual confounding is still possible. Finally, it could also be hypothesized that an increased LOS in subjects with poor falls efficacy indirectly resulted from a difference in discharge destination because these persons were less likely to return home. However, only 5 participants did not return home. Moreover, results were similar when the analysis of LOS was repeated after excluding these subjects, as a sensitivity analysis. Disentangling this issue is certainly important because it will help in decisions as to whether interventions targeted at falls self-efficacy improvement should be added to the current panoply of interventions proposed for older patients admitted to postacute care rehabilitation. Improvements in falls efficacy have been documented in community-dwelling elderly persons using interventions ranging from simple exercise to multifaceted programs that included educational, psychologic, behavioral, environmental, and exercise components.¹⁸, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰ Whether similar interventions applied to older patients admitted to postacute rehabilitation will improve their functional abilities and mobility and decrease their LOS need to be further investigated.

This study also confirms findings from other studies², ³, ⁴, ⁷, ⁹ in which falls efficacy was highly correlated with measures of functional, affective, cognitive, and mobility performance. Interestingly, falls self-efficacy was more strongly correlated with the measure of depressive symptoms than with the measure of balance and gait, a finding that contrasts with results from some studies in younger populations,³¹ even though this study used a 1-item question about activity-limiting fear. Although counterintuitive, this result likely reflects the fact that psychologic characteristics are stronger determinants of FES than mobility performance in older rehabilitation patients, as found in a study that specifically investigated the affective correlates of fear of falling.³² This is also suggested by the disappearance of the significant relationship between fall status and FES score, after controlling for depressive symptoms in the multivariable analysis. Overall, these results emphasize the complex interplay between physical and mental determinants of falls self-efficacy in older patients.

Several specific comments could be added about FES use in this postacute care population. First, the addition of 2 outdoor activities (walking around the home, simple shopping) compared with the initial version of the scale proved useful to attenuate the ceiling effect observed in other, more functional populations. Nevertheless, the recently developed Falls Efficacy Scale International³³ that includes outdoor activities with higher fall risk such as walking on a slippery or on an uneven surface will certainly be more appropriate for a larger range of activity performance when assessing populations with more heterogeneous functional and mobility status. Second, as observed in previous studies, most subjects who did not perform an activity reported difficulties in providing a rating. Prompting them by asking to estimate the extent their concern about falling played in not performing the task, as used in another study,¹³ proved useful, but hypothetical rating is likely to remain an issue when using scales with standard items requiring high levels of functioning in populations with heterogeneous functional status. Finally, the use of a 0 to 10 rating scale for each item also proved difficult to comprehend for some participants. A 4-level response format that was adopted in other studies³³, ³⁴ is certainly a better option.

Study Limitations 

This study has several limitations. First, the study was conducted in a small convenience sample of subjects admitted for rehabilitation, most of whom reported 1 or more falls in the previous year. The scale might perform differently in other rehabilitation populations, especially those less directly concerned by falls experience. Second, subjects with significant depressive symptoms and those scoring lower than 20 at the MMSE were excluded. The FES performance in these subjects remains unknown but is likely to be substantially altered. Finally, we did not use a measure of comorbid conditions to adjust in the multivariable models, even though functional status likely grossly reflects health status in this population.

This study also has several strengths, including the wide range of age, functional status, and mobility performance of the participants. In addition, extensive information was gathered at the baseline interview over a large set of covariates, there were no missing data on LOS, and follow-up information on discharge destination was also complete.

Back to Article Outline

Conclusions 

These results confirm that this version of the FES is reliable and valid to assess falls self-efficacy in older patients admitted to postacute care rehabilitation. It might prove useful to document change in falls efficacy in this population at great risk for falls. These results also permit further work investigating the independent effect of falls efficacy on rehabilitation outcome. In particular, future studies should determine this scale’s sensitivity to change in similar older patients undergoing gait rehabilitation and investigate in detail the exact relationship between improvement in gait performance and falls self-efficacy evolution. This is a necessary step in deciding whether to invest effort in further improving current interventions targeting fear of falling in this frail population.

Supplier

Back to Article Outline

References 

1. Arfken CL, Lach HW, Birge SJ, Miller JP. The prevalence and correlates of fear of falling in elderly persons living in the community. Am J Public Health. 1994;84:565–570
   • View In Article
   • MEDLINE
   • CrossRef
2. Kressig RW, Wolf SL, Sattin RW, et al. Associations of demographic, functional, and behavioral characteristics with activity-related fear of falling among older adults transitioning to frailty. J Am Geriatr Soc. 2001;49:1456–1462
   • View In Article
   • MEDLINE
   • CrossRef
3. Murphy SL, Williams CS, Gill TM. Characteristics associated with fear of falling and activity restriction in community-living older persons. J Am Geriatr Soc. 2002;50:516–520
   • View In Article
   • MEDLINE
   • CrossRef
4. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol. 1990;45:P239–P243
   • View In Article
   • MEDLINE
5. Bruce DG, Devine A, Prince RL. Recreational physical activity levels in healthy older women: the importance of fear of falling. J Am Geriatr Soc. 2002;50:84–89
   • View In Article
   • MEDLINE
   • CrossRef
6. Delbaere K, Crombez G, Vanderstraeten G, Willems T, Cambier D. Fear-related avoidance of activities, falls and physical frailty (A prospective community-based cohort study). Age Ageing. 2004;33:368–373
   • View In Article
   • MEDLINE
   • CrossRef
7. Cumming RG, Salkeld G, Thomas M, Szonyi G. Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci. 2000;55:M299–M305
   • View In Article
   • MEDLINE
   • CrossRef
8. Mendes de Leon CF, Seeman TE, Baker DI, Richardson ED, Tinetti ME. Self-efficacy, physical decline, and change in functioning in community-living elders: a prospective study. J Gerontol Psychol Sci Soc Sci. 1996;51:S183–S190
   • View In Article
9. Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol. 1994;49:M140–M147
   • View In Article
   • MEDLINE
10. Li F, Fisher KJ, Harmer P, Wilson NL. Fear of falling in elderly persons: association with falls, functional ability, and quality of life. J Gerontol B Psychol Sci Soc Sci. 2003;58:P283–P290
    • View In Article
    • MEDLINE
    • CrossRef
11. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997;26:189–193
    • View In Article
    • MEDLINE
    • CrossRef
12. Powell LE, Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995;50:M28–M34
    • View In Article
13. Lachman ME, Howland J, Tennstedt S, Jette A, Assmann S, Peterson EW. Fear of falling and activity restriction: the survey of activities and fear of falling in the elderly (SAFE). J Gerontol Psychol Sci Soc Sci. 1998;53:P43–P50
    • View In Article
14. Hill KD, Schwarz JA, Kalogeropoulos AJ, Gibson SJ. Fear of falling revisited. Arch Phys Med Rehabil. 1996;77:1025–1029
    • View In Article
    • Abstract
    • Full-Text PDF (551 KB)
    • CrossRef
15. Jorstad EC, Hauer K, Becker C, Lamb SE ProFaNE Group. Measuring the psychological outcomes of falling: a systematic review. J Am Geriatr Soc. 2005;53:501–510
    • View In Article
    • MEDLINE
    • CrossRef
16. Cameron ID, Stafford B, Cumming R, et al. Hip protectors improve falls self-efficacy. Age Ageing. 2000;29:57–62
    • View In Article
    • MEDLINE
    • CrossRef
17. Petrella RJ, Payne M, Myers A, Overend T, Chesworth B. Physical function and fear of falling after hip fracture rehabilitation in the elderly. Am J Phys Med Rehabil. 2000;79:154–160
    • View In Article
    • MEDLINE
    • CrossRef
18. Arai T, Obuchi S, Inaba Y, et al. The effects of short-term exercise intervention on falls self-efficacy and the relationship between changes in physical function and falls self-efficacy in Japanese older people: a randomized controlled trial. Am J Phys Med Rehabil. 2007;86:133–141
    • View In Article
    • MEDLINE
    • CrossRef
19. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state” (A practical method for grading the cognitive state of patients for the clinician). J Psychiatr Res. 1975;12:189–198
    • View In Article
    • Full-Text PDF (635 KB)
    • CrossRef
20. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–173
    • View In Article
    • CrossRef
21. Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983;31:721–727
    • View In Article
    • MEDLINE
22. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179–186
    • View In Article
    • MEDLINE
    • CrossRef
23. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34:119–126
    • View In Article
    • MEDLINE
24. Shrout PE, Fleiss JL. Intraclass correlations: use in assessing rater reliability. Psychol Bull. 1979;86:420–428
    • View In Article
    • CrossRef
25. Hinkley DV, Davison AC. Bootstrap methods and their application. New York: Cambridge Univ Pr; 1997;
    • View In Article
26. Li F, Fisher KJ, Harmer P, McAuley E. Falls self-efficacy as a mediator of fear of falling in an exercise intervention for older adults. J Gerontol B Psychol Sci Soc Sci. 2005;60:P34–P40
    • View In Article
    • MEDLINE
    • CrossRef
27. Li F, Harmer P, Fisher KJ, et al. Tai Chi and fall reductions in older adults: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2005;60:187–194
    • View In Article
    • MEDLINE
    • CrossRef
28. Yates SM, Dunnagan TA. Evaluating the effectiveness of a home-based fall risk reduction program for rural community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2001;56:M226–M230
    • View In Article
    • MEDLINE
    • CrossRef
29. Brouwer BJ, Walker C, Rydahl SJ, Culham EG. Reducing fear of falling in seniors through education and activity programs: a randomized trial. J Am Geriatr Soc. 2003;51:829–834
    • View In Article
    • MEDLINE
    • CrossRef
30. Tennstedt S, Howland J, Lachman M, Peterson E, Kasten L, Jette A. A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. J Gerontol B Psychol Sci Soc Sci. 1998;53:P384–P392
    • View In Article
    • MEDLINE
31. Martin FC, Hart D, Spector T, Doyle DV, Harari D. Fear of falling limiting activity in young-old women is associated with reduced functional mobility rather than psychological factors. Age Ageing. 2005;34:281–287
    • View In Article
    • MEDLINE
    • CrossRef
32. Gagnon N, Flint AJ, Naglie G, Devins GM. Affective correlates of fear of falling in elderly persons. Am J Geriatr Psychiatry. 2005;13:7–14
    • View In Article
    • MEDLINE
    • CrossRef
33. Yardley L, Todd C, Beyer N, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale International (FES-I). Age Ageing. 2005;34:614–619
    • View In Article
    • MEDLINE
    • CrossRef
34. Buchner DM, Hornbrook MC, Kutner NG, et al. Development of the common data base for the FICSIT trials. J Am Geriatr Soc. 1993;41:297–308
    • View In Article
    • MEDLINE

• a Version 9.0; Stata Corp, 4905 Lakeway Dr, College Station, TX 77845.