Open Access
Research Article  |   March 2012
Relationship Between Fall-Related Efficacy and Activity Engagement in Community-Dwelling Older Adults: A Meta-Analytic Review
Author Affiliations
  • Stacey Schepens, PhD, OTR, is Postdoctoral Fellow, Department of Physical Medicine and Rehabilitation, Institute of Gerontology, University of Michigan, 300 North Ingalls Street, 9th Floor, Ann Arbor, MI 48109-2007; schepens@umich.edu
  • Ananda Sen, PhD, is Research Associate Professor, Department of Family Medicine and Biostatistics, University of Michigan, Ann Arbor
  • Jane A. Painter, EdD, OTR/L, FAOTA, is Professor, Occupational Therapy Department, East Carolina University, Greenville, NC
  • Susan L. Murphy, ScD, OTR/L, is Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan, and Research Health Science Specialist, Geriatric Research Education and Clinical Center, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI
Article Information
Geriatrics/Productive Aging / Special Issue on Occupational Therapy Opportunities in Fall Prevention
Research Article   |   March 2012
Relationship Between Fall-Related Efficacy and Activity Engagement in Community-Dwelling Older Adults: A Meta-Analytic Review
American Journal of Occupational Therapy, March/April 2012, Vol. 66, 137-148. doi:10.5014/ajot.2012.001156
American Journal of Occupational Therapy, March/April 2012, Vol. 66, 137-148. doi:10.5014/ajot.2012.001156
Abstract

OBJECTIVE. Fear of falling can lead to restricted activity, but little is known about how this fear affects different aspects of people’s lives. This study examined the relationship between fall-related efficacy (i.e., confidence or belief in one’s ability to perform activities without losing balance or falling) and activity and participation.

METHOD. We conducted a meta-analysis of studies comparing community-dwelling older adults’ fall-related efficacy to measures of activity or participation.

RESULTS. An examination of 20 cross-sectional and prospective studies found a strong positive relationship between fall-related efficacy and activity (r = .53; 95% CI [.47, .58]). An insufficient number of studies examining fall-related efficacy and participation were available for analysis.

CONCLUSION. Low fall-related efficacy may be an important barrier to occupational engagement for many older adults and warrants careful consideration by occupational therapists. Future research should explore interventions that target fall-related efficacy and examine their effects on activity performance and engagement.

Falls in older adults are a major public health concern; nearly 3.5 million community-dwelling older adults reported at least one fall in a 3-mo time frame (Boyd & Stevens, 2009). Falls can have devastating physical consequences, including injury, hospitalization, and even death (Bergland & Wyller, 2004; Masud & Morris, 2001; Rubenstein, 2006). To treat and prevent falls, occupational therapists often focus on physical factors and attempt to increase safety in clients’ environments to enable them to more fully engage in daily activities.
Falls also have psychological consequences. Fear of falling, defined as concern about falling that leads to activity avoidance or reduction (Tinetti & Powell, 1993), has been reported to occur in 35% to 55% of older adults (Boyd & Stevens, 2009; Fletcher, Guthrie, Berg, & Hirdes, 2010; Friedman, Munoz, West, Rubin, & Fried, 2002; Zijlstra et al., 2007). Whereas some level of fear of falling may bring about increased caution during activity performance, which in turn may be protective against falls, this fear may also lead to excessive restriction of activity, which could be debilitating (Cumming, Salkeld, Thomas, & Szonyi, 2000; Deshpande, Metter, Lauretani, et al., 2008; Li et al., 2002; Steultjens, Dekker, & Bijlsma, 2001). Indeed, the link between fear of falling and activity restriction has been well established (Curcio, Gomez, & Reyes-Ortiz, 2009; Deshpande, Metter, Bandinelli, et al., 2008; Deshpande, Metter, Lauretani, et al., 2008; Fletcher et al., 2010; Lachman et al., 1998; Murphy, Williams, & Gill, 2002). Among adults who are fearful of falling, 13% to 50% have reported restricting their activity (Fletcher & Hirdes, 2004; Friedman et al., 2002; Murphy et al., 2002; Wilson et al., 2005; Zijlstra et al., 2007), and instruments have been developed to measure activity-related fear of falling (Lachman et al., 1998).
In addition to direct measures of fear of falling (Friedman et al., 2002; Howland et al., 1998; Kempen, van Haastregt, McKee, Delbaere, & Zijlstra, 2009), fear of falling is often operationalized by two related but separate constructs: (1) falls self-efficacy and (2) balance confidence (Jørstad, Hauer, Becker, & Lamb, 2005; Moore & Ellis, 2008). Both constructs are relevant to rehabilitation practice and provide important outcomes for clinical trials of fall prevention (Jørstad et al., 2005). The constructs are based on Bandura’s (1986, 1997)  self-efficacy theory, which postulates that a person’s perceived self-efficacy affects his or her activity performance. Self-efficacy is situation specific in that a person’s belief in his or her ability to execute a course of action is particular to the given situation. Instruments used to measure self-efficacy often include a variety of activities (Bandura, 1997) and tend to ask “how confident” or “how certain” a person is that he or she can achieve a behavior or physiological state within a specific set of conditions (Lorig & Holman, 2003).
Falls self-efficacy has been defined as “perceived self-confidence at avoiding falls during essential, relatively non-hazardous activities” (Tinetti & Powell, 1993, p. 36). This concept was originally introduced as a measure of fear of falling, but since then it has been recognized as a distinct construct that measures the psychological sequelae of falls and perceived fall risk. Falls self-efficacy has received a great deal of attention in research, as evidenced by several tools developed to measure the construct (Jørstad et al., 2005) and the recent international focus of the Prevention of Falls Network Europe (ProFaNE) group on falls self-efficacy (Skelton et al., 2004; Yardley et al., 2005).
Although not as widely researched as falls self-efficacy, balance confidence has been a focus of attention as a psychological aspect related to falling. Balance confidence addresses a person’s confidence or efficacy in maintaining balance and has specifically been defined as one’s degree of belief in one’s ability to avoid a loss of balance during activities of daily living (ADLs; Powell & Myers, 1995). For the purposes of this article, falls self-efficacy and balance confidence are referred to collectively as fall-related efficacy—that is, confidence in one’s ability to perform activities without losing balance or falling. Low falls self-efficacy and balance confidence have been associated with both physical and psychological adverse outcomes such as poor balance performance (Schepens, Goldberg, & Wallace, 2010), reduced lower-extremity strength (Maki, Holliday, & Topper, 1991), depression (Chou, Yeung, & Wong, 2005), anxiety (Gagnon, Flint, Naglie, & Devins, 2005), and decreased quality of life (Kato et al., 2008; Lachman et al., 1998).
The relationship between self-efficacy and performance has been demonstrated in a wide range of research areas such as health behaviors (Grembowski et al., 1993), physical functioning (Li et al., 2001), work performance (Stajkovic & Luthans, 1998), and educational achievement (Lent, Brown, & Larkin, 1984). One’s personal sense of ability and control influences one’s motivation to engage in valued activities and occupations (Kielhofner, 2008; Peterson et al., 1999; Peterson, Kielhofner, Tham, & von Koch, 2010). Because self-efficacy theory directly links self-efficacy to participation in and performance of activity, addressing low fall-related efficacy may indeed enhance occupational engagement and provide an important adjunct to occupational therapy treatment that is in need of further investigation.
The research described in this article aimed to answer two questions:
  1. 1.What are the relationships between fall-related efficacy and measures of activity and participation in community-dwelling older adults?
  2. 2.Does the strength of these relationships vary depending on the type of fall-related efficacy scale and type of activity assessed?
Method
Our meta-analysis included a review of published articles that addressed both fall-related efficacy and measures of activity and participation. Between December 2009 and June 2010, we conducted a computerized search of the following databases: CINAHL, Cochrane Library and Best Evidence, ISI Web of Science, MEDLINE, and PubMed. We identified the MeSH subject terms and key words pertaining to fall-related efficacy, activity, and participation before initiating the search. Fall-related efficacy terms were balance confidence, concern for falling, efficacy, fall-related efficacy, falls self-efficacy, and self-efficacy. In addition, we used fear of falling as a search term because fear of falling and fall-related efficacy terms are often used interchangeably (Jørstad et al., 2005). Key words we used for activity and participation were activities of daily living, activity, activity avoidance, activity engagement, activity restriction, balance, exercise, leisure, mobility, occupation, occupational performance, participation, performance, physical activity, social role, and tasks. In addition to computerized searches, we conducted manual searches of the reference sections of extracted articles and pertinent review articles.
Extraction Procedures
Three reviewers (Stacey Schepens, Susan L. Murphy, and Jane A. Painter) took part in article identification and data extraction. Schepens conducted the database search and the manual search of references to identify potentially relevant articles. Schepens also reviewed titles and abstracts, excluded articles not meeting the selection criteria, and retrieved full-text documents of the remaining articles for additional screening. Schepens and Murphy reviewed these articles to confirm that selection criteria were met. When we disagreed, all three reviewers discussed the discrepancy until we reached consensus. Finally, Painter extracted pertinent information from the remaining articles (e.g., research design, sample size, measures used, effect sizes) and confirmed that all studies met the selection criteria.
Selection Criteria
To be included, studies had to be written in English and published between 1990 and 2010. This 20-yr time span was deemed satisfactory to capture the salient research on fall-related efficacy, because this was a new research focus in the early 1990s. Study samples were required to include older adults with a mean age of ≥60 yr who lived in the community and were not designated as belonging to a specific disease group (e.g., Parkinson’s disease, multiple sclerosis). Whereas some studies selected older adults on the basis of fall history, we did not consider fall status of the sample for inclusion in our study. With regard to the research design, we included nonintervention studies (e.g., cross-sectional, prospective) but excluded case reports and qualitative studies. Additionally, we required that each study report statistical information necessary to perform the meta-analysis, including means, standard deviations, sample size, and r or partial r values.
We excluded studies reporting only adjusted r or R2 values because the absence of the other data would hinder our ability to pool the data. Finally, studies had to assess fall-related efficacy using the Falls Efficacy Scale (FES; Tinetti, Richman, & Powell, 1990) or the Activities-specific Balance Confidence (ABC) scale (Powell & Myers, 1995), along with a measure of activity or participation functioning or performance, as defined in Table 1.
Table 1.
Operationally Defined Terms Used as Selection Criteria
Operationally Defined Terms Used as Selection Criteria×
TermDefinitionMeasures Included
Fall-related efficacyCollective term that includes the concepts of falls efficacy and balance confidence; confidence or belief in one’s ability to perform activities without losing balance or fallingFES and ABC
Falls self-efficacyPerceived self-confidence in avoiding falls during essential, relatively nonhazardous activities (Tinetti & Powell, 1993)FES
Balance confidenceDegree of confidence in one’s ability to avoid a loss of balance while performing ADLs (Powell & Myers, 1995)ABC
ActivityExecution of a task or action by an individual (World Health Organization, 2002)Measures addressing learning and applying knowledge, general tasks and demands, communication, mobility, self-care, and domestic life
Occupation-based activitiesActivities with occupation as the core focusADL or IADL measures; occupation-based measures
Performance skillsSkills clients demonstrate in the actions they perform (American Occupational Therapy Association, 2008) and that underlie activity performancePerformance-based measures addressing motor or motor planning skills
ParticipationInvolvement in life situationsMeasures addressing interpersonal interactions and relationships, major life areas, and community, social, and civic life
Table Footer NoteNote. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living.
Note. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living.×
Table 1.
Operationally Defined Terms Used as Selection Criteria
Operationally Defined Terms Used as Selection Criteria×
TermDefinitionMeasures Included
Fall-related efficacyCollective term that includes the concepts of falls efficacy and balance confidence; confidence or belief in one’s ability to perform activities without losing balance or fallingFES and ABC
Falls self-efficacyPerceived self-confidence in avoiding falls during essential, relatively nonhazardous activities (Tinetti & Powell, 1993)FES
Balance confidenceDegree of confidence in one’s ability to avoid a loss of balance while performing ADLs (Powell & Myers, 1995)ABC
ActivityExecution of a task or action by an individual (World Health Organization, 2002)Measures addressing learning and applying knowledge, general tasks and demands, communication, mobility, self-care, and domestic life
Occupation-based activitiesActivities with occupation as the core focusADL or IADL measures; occupation-based measures
Performance skillsSkills clients demonstrate in the actions they perform (American Occupational Therapy Association, 2008) and that underlie activity performancePerformance-based measures addressing motor or motor planning skills
ParticipationInvolvement in life situationsMeasures addressing interpersonal interactions and relationships, major life areas, and community, social, and civic life
Table Footer NoteNote. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living.
Note. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living.×
×
Operationalized Terms
Fall-related efficacy included two psychological constructs: falls self-efficacy and balance confidence (see Table 1). To avoid comparing dissimilar studies, which is a common threat to validity (Sharpe, 1997), we included only studies using original measures of these concepts—that is, the FES and the ABC scale. These two scales are valid and reliable measures of falls self-efficacy and balance confidence (Hotchkiss et al., 2004; Powell & Myers, 1995; Talley, Wyman, & Gross, 2008; Tinetti et al., 1990). We considered analysis of the separate relationships of the FES and ABC scale with activity and participation measures to be appropriate because (1) the scales measure slightly different constructs (Jørstad et al., 2005) and (2) the FES has been suggested as appropriate for frail older adults because of its focus on basic ADLs, whereas the ABC scale has been suggested as appropriate for active older adults because of its focus on high-level balancing and walking abilities (Myers et al., 1996; Powell & Myers, 1995).
We defined activity and participation using specific classifications suggested by Whiteneck and Dijkers (2009)  from the International Classification of Functioning, Disability and Health (World Health Organization, 2002). Activity items include learning and applying knowledge, general tasks and demands, communication, mobility, self-care, and domestic life. Participation items include interpersonal interactions and relationships, major life areas, and community, social, and civic life (Whiteneck & Dijkers, 2009). Because activity is such a broad category, it was subcategorized by type: occupation-based activity or performance skill (see Table 1 for definitions).
Data Analysis
We carried out a meta-analysis of the linear association between fall-related efficacy and measures of activity and participation using the Pearson correlation coefficient r as the unit of analysis. For prospective studies, only the r values collected at baseline were analyzed. Before performing the meta-analysis on the correlation values r, Fisher’s Z transformation was performed on the correlation (Equation 1). The transformation is expressed as
and provides a unit of measurement that has variability that depends only on the sample size (Fisher, 1915). This transformation is widely used and recommended in meta-analysis involving correlation (Hedges & Olkin, 1985). We used a homogeneity test using Cochran’s Q statistic to examine between-study variation. If the Q statistic was significant (p ≤ .05), we used a random effects model using a study-specific random intercept to pool the correlation values. The random effect also accounts for any clustering effects across measurements obtained from the same study. The study-specific Z measures were weighted by the reciprocal of the variance, 1/(N − 3), where N is the sample size for the study. We calculated the pooled estimate of Z and back-transformed the Z value to an r unit using the following formula (Equation 2):
Moreover, We then calculated a 95% confidence interval (CI) for the pooled estimate, first in the Z scale and then in the r scale, by applying Equation 2 to the end points.
We conducted two subanalyses, pooling the r value and the CIs separately for each fall-related efficacy scale (FES vs. ABC scale) and activity type (occupation-based activity vs. performance skill). A meta-regression was run to determine whether activity type or fall-related efficacy scale had a significant differential effect. The strength of all resultant effect sizes was described as weak, moderate, or strong and corresponded to the size classifications by Cohen (1988) : small = .10 ≥ r ≥ .29, medium = .30 ≥ r ≥ .49, and large = r ≥ .50. Finally, we investigated the existence of publication bias by means of tests by Begg and Mazumdar (1994)  and Egger, Davey Smith, Schneider, and Minder (1997) .
Results
We obtained a total of 1,118 references from the initial database searches, and from those we selected 82 studies for detailed evaluation. The selection process is depicted in Figure 1. Because only two studies met criteria and reported correlations between fall-related efficacy and measures of participation, we could not perform an analysis of participation. With regard to activity, we found 20 studies yielding 67 correlations between fall-related efficacy scales and activity type (see Table 2 for details).
Figure 1.
Selection process of studies considered for and included in the meta-analysis.
Note. ABC = Activities-specific Balance Confidence scale; FES = Falls Efficacy Scale.
Figure 1.
Selection process of studies considered for and included in the meta-analysis.
Note. ABC = Activities-specific Balance Confidence scale; FES = Falls Efficacy Scale.
×
Table 2.
Characteristics of Included Studies and Correlations Between the Fall-Related Efficacy and Activity Measures
Characteristics of Included Studies and Correlations Between the Fall-Related Efficacy and Activity Measures×
StudyDesignNMean AgeEfficacy ScaleActivity TypeActivity Measurerp
Anaby, Miller, Eng, Jarus, & Noreau (2009) Cross-sectional20075ABCADLTotal LIFE–H.46.01
Ashe, Eng, Miller, & Soon (2007) Cross-sectional20074ABCPerformance6-min walk.52≤.001
ABCPerformancePedometer—mean daily steps.32≤.001
Binda, Culham, & Brouwer (2003) Cross-sectional40Control group = 72.5; fear of falling group = 77.1ABCPerformanceAnterior–posterior COP.65<.001
ABCPerformanceRight–left COP.39<.017
ABCPerformanceKnee flexor strength.38<.04
ABCPerformanceKnee extensor strength.39<.04
ABCPerformanceAnkle plantar flexor strength.34<.04
Brouwer, Musselman, & Culham (2004) Cross-sectional2576.4ABCADL PerformanceSF–36 physical component sum.698NR
ABCHip flexor torque.504NR
Cho, Scarpace, & Alexander (2004) Cross-sectional16778ABCPerformanceMaximum step length.661<.01
ABCPerformanceRapid step test−.321<.01
ABCPerformanceTimed tandem stance.592<.01
ABCPerformanceTimed unipedal stance.586<.01
ABCPerformanceTimed tandem walk−.52<.01
ABCPerformanceTimed Up & Go test−.606<.01
ABCPerformance6-min walk.631<.01
ABCPerformancePerformance Oriented Mobility Assessment.637<.01
ABCADLEPESE physical function battery−.644<.01
Giladi, Herman, Reider-Groswasser, Gurevich, & Hausdorff (2005) Cross-sectional2578.4ABCADL PerformanceBarthel ADL Index.48<.015
ABCGait speed.61<.002
Hatch, Gill-Body, & Portney (2003) Cross-sectional5081.7ABCPerformanceBerg Balance Scale.752<.01
ABCPerformanceTimed Up & Go test.698<.01
Herman, Inbar-Borovsky, Brozgol, Giladi, & Hausdorff (2009) Prospective27876.3ABCPerformanceDynamic Gait Index.49<.001
Inderjeeth et al. (2007) Cross-sectional99/10579.5FESPerformanceLeft leg extension peak torque.368<.001
FESPerformanceLeft leg extensor maximum power.307.003
FESPerformanceLeft leg flexion peak torque.325.002
FESPerformanceLeft leg flexor maximum power.212.046
Lachman et al. (1998) Cross-sectional27076.16FESADLSF–36 physical functioning.67<.001
FESADLSAFE no. of activities.69NR
Liu-Ambrose, Katarynych, Ashe, Nagamatsu, & Hsu (2009) Cross-sectional14069.6ABCPerformanceSimple walking while talking−.55≤.001
ABCPerformanceComplex walking while talking−.54≤.001
McAuley et al. (2006) Prospective24968.12ABCPerformance8-ft Up & Go test−.41<.01
ABCADLFunction & Disability Inventory: Basic lower-extremity function.53<.01
ABCPerformanceStair ascent−.46<.01
ABCPerformance7-min walk−.35<.01
ABCADLPhysical Activity Scale for the Elderly.31<.01
ABCADLCommunity Healthy Activity Model Program for Seniors.22<.01
ABCPerformanceStair descent−.53<.01
ABCADLFunction & Disability Inventory: Advanced lower-extremity function.58<.01
McAuley, Mihalko, & Rosengren (1997) Cross-sectional5871.72FESPerformanceBerg Balance Scale.49<.01
McKee et al. (2002) Cross-sectional8280.2FESADLPrefall activity problems−.70<.001
FESADLFunctional limitations profile−.37.005
Medell & Alexander (2000) Cross-sectional34Young = 21; unimpaired older = 69; impaired older = 77ABCPerformanceMaximum step length.75<.002
ABCPerformanceRapid step test time−.54<.002
Myers et al. (1996) Cross-sectional6074.6ABCPerformance30-m walking speed.56<.01
FESPerformance30-m walking speed−.25>.05
ABCADLFloor sweeping frequency.70<.001
ABCADLShopping frequency.54<.001
ABCADLActivity avoidance ratings of ABC items−.92<.001
ABCADLPerceived difficulty ratings of ABC items−.89<.001
Rosengren, McAuley, & Mihalko (1998) Cross-sectional5571.1FESADLPhysical activity.21>.05
FESPerformanceBerg Balance Scale.48<.01
FESPerformanceGait speed—No obstacle.43<.01
FESPerformanceGait speed—2.5 cm obstacle.35<.01
FESPerformanceGait speed—5.05 cm obstacle.30<.01
FESPerformanceGait speed—10.0 cm obstacle.32<.01
FESPerformanceGait speed—20.0 cm obstacle.31<.05
FESPerformanceGait speed—40.0 cm obstacle.28<.05
Schepens, Goldberg, & Wallace (2010) Cross-sectional3572.86ABCPerformanceUnipedal stance time.46≤.01
ABCPerformanceMaximum step length.69≤.001
ABCPerformanceFunctional Reach.33≤.05
ABCPerformanceTimed Up & Go test−.65≤.001
Sihvonen et al. (2009) Cross-sectional7974.4ABCPerformanceBerg Balance Scale: Hip fracture group.74NR
31ABCPerformanceBerg Balance Scale: Nonfracture group.384NR
Tinetti, Mendes de Leon, Doucette, & Baker (1994) Cross-sectional1,10379.6FESADLADL and IADL function.55NR
FESADLYale Physical Activity Survey–modified.49NR
Table Footer NoteNote. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; COP = center of pressure; EPESE = Epidemiological Study of the Elderly; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living; LIFE–H = Assessment of Life Habits; NR = not reported; SAFE = Survey of Activities and Fear of Falling in the Elderly; SF–36 = Short Form–36 Health Survey.
Note. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; COP = center of pressure; EPESE = Epidemiological Study of the Elderly; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living; LIFE–H = Assessment of Life Habits; NR = not reported; SAFE = Survey of Activities and Fear of Falling in the Elderly; SF–36 = Short Form–36 Health Survey.×
Table 2.
Characteristics of Included Studies and Correlations Between the Fall-Related Efficacy and Activity Measures
Characteristics of Included Studies and Correlations Between the Fall-Related Efficacy and Activity Measures×
StudyDesignNMean AgeEfficacy ScaleActivity TypeActivity Measurerp
Anaby, Miller, Eng, Jarus, & Noreau (2009) Cross-sectional20075ABCADLTotal LIFE–H.46.01
Ashe, Eng, Miller, & Soon (2007) Cross-sectional20074ABCPerformance6-min walk.52≤.001
ABCPerformancePedometer—mean daily steps.32≤.001
Binda, Culham, & Brouwer (2003) Cross-sectional40Control group = 72.5; fear of falling group = 77.1ABCPerformanceAnterior–posterior COP.65<.001
ABCPerformanceRight–left COP.39<.017
ABCPerformanceKnee flexor strength.38<.04
ABCPerformanceKnee extensor strength.39<.04
ABCPerformanceAnkle plantar flexor strength.34<.04
Brouwer, Musselman, & Culham (2004) Cross-sectional2576.4ABCADL PerformanceSF–36 physical component sum.698NR
ABCHip flexor torque.504NR
Cho, Scarpace, & Alexander (2004) Cross-sectional16778ABCPerformanceMaximum step length.661<.01
ABCPerformanceRapid step test−.321<.01
ABCPerformanceTimed tandem stance.592<.01
ABCPerformanceTimed unipedal stance.586<.01
ABCPerformanceTimed tandem walk−.52<.01
ABCPerformanceTimed Up & Go test−.606<.01
ABCPerformance6-min walk.631<.01
ABCPerformancePerformance Oriented Mobility Assessment.637<.01
ABCADLEPESE physical function battery−.644<.01
Giladi, Herman, Reider-Groswasser, Gurevich, & Hausdorff (2005) Cross-sectional2578.4ABCADL PerformanceBarthel ADL Index.48<.015
ABCGait speed.61<.002
Hatch, Gill-Body, & Portney (2003) Cross-sectional5081.7ABCPerformanceBerg Balance Scale.752<.01
ABCPerformanceTimed Up & Go test.698<.01
Herman, Inbar-Borovsky, Brozgol, Giladi, & Hausdorff (2009) Prospective27876.3ABCPerformanceDynamic Gait Index.49<.001
Inderjeeth et al. (2007) Cross-sectional99/10579.5FESPerformanceLeft leg extension peak torque.368<.001
FESPerformanceLeft leg extensor maximum power.307.003
FESPerformanceLeft leg flexion peak torque.325.002
FESPerformanceLeft leg flexor maximum power.212.046
Lachman et al. (1998) Cross-sectional27076.16FESADLSF–36 physical functioning.67<.001
FESADLSAFE no. of activities.69NR
Liu-Ambrose, Katarynych, Ashe, Nagamatsu, & Hsu (2009) Cross-sectional14069.6ABCPerformanceSimple walking while talking−.55≤.001
ABCPerformanceComplex walking while talking−.54≤.001
McAuley et al. (2006) Prospective24968.12ABCPerformance8-ft Up & Go test−.41<.01
ABCADLFunction & Disability Inventory: Basic lower-extremity function.53<.01
ABCPerformanceStair ascent−.46<.01
ABCPerformance7-min walk−.35<.01
ABCADLPhysical Activity Scale for the Elderly.31<.01
ABCADLCommunity Healthy Activity Model Program for Seniors.22<.01
ABCPerformanceStair descent−.53<.01
ABCADLFunction & Disability Inventory: Advanced lower-extremity function.58<.01
McAuley, Mihalko, & Rosengren (1997) Cross-sectional5871.72FESPerformanceBerg Balance Scale.49<.01
McKee et al. (2002) Cross-sectional8280.2FESADLPrefall activity problems−.70<.001
FESADLFunctional limitations profile−.37.005
Medell & Alexander (2000) Cross-sectional34Young = 21; unimpaired older = 69; impaired older = 77ABCPerformanceMaximum step length.75<.002
ABCPerformanceRapid step test time−.54<.002
Myers et al. (1996) Cross-sectional6074.6ABCPerformance30-m walking speed.56<.01
FESPerformance30-m walking speed−.25>.05
ABCADLFloor sweeping frequency.70<.001
ABCADLShopping frequency.54<.001
ABCADLActivity avoidance ratings of ABC items−.92<.001
ABCADLPerceived difficulty ratings of ABC items−.89<.001
Rosengren, McAuley, & Mihalko (1998) Cross-sectional5571.1FESADLPhysical activity.21>.05
FESPerformanceBerg Balance Scale.48<.01
FESPerformanceGait speed—No obstacle.43<.01
FESPerformanceGait speed—2.5 cm obstacle.35<.01
FESPerformanceGait speed—5.05 cm obstacle.30<.01
FESPerformanceGait speed—10.0 cm obstacle.32<.01
FESPerformanceGait speed—20.0 cm obstacle.31<.05
FESPerformanceGait speed—40.0 cm obstacle.28<.05
Schepens, Goldberg, & Wallace (2010) Cross-sectional3572.86ABCPerformanceUnipedal stance time.46≤.01
ABCPerformanceMaximum step length.69≤.001
ABCPerformanceFunctional Reach.33≤.05
ABCPerformanceTimed Up & Go test−.65≤.001
Sihvonen et al. (2009) Cross-sectional7974.4ABCPerformanceBerg Balance Scale: Hip fracture group.74NR
31ABCPerformanceBerg Balance Scale: Nonfracture group.384NR
Tinetti, Mendes de Leon, Doucette, & Baker (1994) Cross-sectional1,10379.6FESADLADL and IADL function.55NR
FESADLYale Physical Activity Survey–modified.49NR
Table Footer NoteNote. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; COP = center of pressure; EPESE = Epidemiological Study of the Elderly; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living; LIFE–H = Assessment of Life Habits; NR = not reported; SAFE = Survey of Activities and Fear of Falling in the Elderly; SF–36 = Short Form–36 Health Survey.
Note. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; COP = center of pressure; EPESE = Epidemiological Study of the Elderly; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living; LIFE–H = Assessment of Life Habits; NR = not reported; SAFE = Survey of Activities and Fear of Falling in the Elderly; SF–36 = Short Form–36 Health Survey.×
×
The homogeneity test using Cochran’s (1954) Q statistic was significant (p < .001), thereby indicating substantial between-study variation. As a result, we performed the random effects analysis. The pooled estimate of Z equaled .59 (95% CI [.51, .67]). After back-transformation to an r unit, the pooled estimate was large (r = .53; 95% CI [.47, .58]). A forest plot showing individual and pooled r values with 95% CIs is provided in Figure 2. The plot is presented with a single (average) correlation per study.
Figure 2.
Forest plot depicting the average r value and associated 95% confidence interval from 20 distinct studies, as well as the pooled r value.
Figure 2.
Forest plot depicting the average r value and associated 95% confidence interval from 20 distinct studies, as well as the pooled r value.
×
The subgroup analysis for fall-related efficacy on the basis of type of scale yielded pooled correlation coefficients for the FES and ABC scales of .47 (95% CI [.34, .58]) and .55 (95% CI [.48, .62]), respectively. For activity type, pooled correlation coefficients for occupation-based activity and performance skill were .55 (95% CI [.44, .65]) and .51 (95% CI [.44, .56]), respectively. The meta-regression analysis of the r values indicated a lack of differential effect resulting from either fall-related efficacy scale (p = .10) or activity type (p = .27). However, a trend toward significance was noted for efficacy scale type. Overall, the pooled correlation estimates for the main and subgroup analyses were .47–.55, with a range showing medium to large effect sizes and little variability in correlations. Tests for publication bias yielded highly nonsignificant p values, establishing lack of bias.
Discussion
The results of our meta-analysis suggest a strong positive relationship between fall-related efficacy and activity. Higher fall-related efficacy in performing certain daily tasks without losing balance or falling is associated with higher levels of activity function and performance. This finding is consistent with the significant correlations reported in nearly all of the articles reviewed.
Further investigation into the relationship between fall-related efficacy and activity showed that both FES and ABC scale scores were strongly related to activity. Additionally, a trend was found toward a differential effect between the two scales; the ABC scale showed a stronger relationship with activity than did the FES. This finding suggests that a meaningful distinction may exist between these two constructs of fall-related efficacy, an idea supported in previous research (Moore & Ellis, 2008), and that assessing both balance confidence and falls self-efficacy as they relate to activity may be important. The difference found between the scales may be a result of the type and complexity of activities measured within the individual studies. The ABC scale was designed to address a wider continuum of ADL difficulty than was the FES (Powell & Myers, 1995). If activities included in each study were more frequently tapping high-level balance- and mobility-related activities, then this trend toward the ABC scale having a stronger relationship with such activities is reasonable. Although the difference was not statistically significant, a true difference between the two efficacy scales and their relationship to activity may be revealed with a larger sample of studies of similar focus. This finding provides justification for further investigation into measures of balance confidence because the current focus in fall-related efficacy research is largely on falls self-efficacy measures. Moreover, research into the FES–International—a scale designed in part to address the ceiling effect of the original FES (Yardley et al., 2005)—is warranted and may show a similar trend in stronger significance to activity performance than the FES.
We also explored the relationship between fall-related efficacy and activity by dividing activity into two types: occupation-based activities and performance skills. Although both activity types were strongly correlated with fall-related efficacy, no significant differential effect existed between the two. Thus, fall-related efficacy affects not only the more complex activities categorized under occupation-based activities (e.g., ADL performance) but also the more basic performance skills that underlie activity performance and are necessary to engage in ADLs (e.g., muscle strength). The lack of a differential effect between activity types is somewhat surprising because both measures of fall-related efficacy are designed to specifically address occupation-based activities (e.g., standing on a chair to change a light bulb) as opposed to individual performance skills. Consequently, these results emphasize that occupational therapists should consider all levels of occupational performance when working with older adults, including both occupation-based performance and the more basic performance skills necessary to carry out ADLs.
Limitations
This study has some limitations. We examined the relationship of fall-related efficacy and activity at one point in time; therefore, causality cannot be determined. In addition, we found insufficient evidence to form conclusions about the relationship of fall-related efficacy to participation, in part because of the lack of participation measures and the difficulty of distinguishing participation from activity in current instruments. It will be important to examine the relationship between fall-related efficacy and participation when more targeted measures are developed. Regarding study selection, published studies with significant results may have been overrepresented; however, this bias appears unlikely on the basis of the tests for publication bias we conducted (Begg & Mazumdar, 1994; Egger et al., 1997). Our meta-analysis included a limited number of smaller studies, which affects generalizability. In addition, although we made efforts to reduce the heterogeneity of our activity measures by classifying them by type, a wide variety of activity measures were used across studies. The unique differences of specific activity measures within each of our classification types (occupation-based activities and performance skills) cannot be disentangled in this analysis.
Implications for Occupational Therapy Practice
Our findings have important clinical implications for occupational therapists who work with community-dwelling older adults. Given the strong relationships we found between fall-related efficacy and activity, occupational therapists clearly have an important role in assessing older adults’ fall-related efficacy issues. A client-centered approach in occupational therapy must include not only objective, physically based outcomes but also subjective information that may influence occupational performance (American Occupational Therapy Association, 2008), such as that which is gathered from measures of fall-related efficacy. Further analysis of the relationship between fall-related efficacy and activity showed a trend toward a differential effect of falls self-efficacy versus balance confidence. This finding indicates a potential need for occupational therapists to assess the two constructs separately when working with older adults.
In terms of intervention, research has shown that general self-efficacy is modifiable and can be influenced using strategies such as providing mastery experiences and modeling the activity (Bandura, 1982). More specifically, evidence suggests that fall-related efficacy can also be influenced through interventions (Zijlstra et al., 2007) such as the cognitive–behavioral approach taken by Tennstedt and colleagues (1998), whose intervention successfully altered falls self-efficacy by targeting beliefs about falls and fall risk, stressing safe behaviors, and including action planning.
With interventions, it is important to keep in mind the appropriateness of an older adult’s fall-related efficacy relative to his or her personal fall risk (Delbaere, Close, Brodaty, Sachdev, & Lord, 2010). It is not practical, for instance, to automatically conclude that an older adult with low fall-related efficacy is in need of intervention if this fear is rational and results in caution when engaging in activity. However, low fall-related efficacy is an issue worth addressing if it is associated with reduced activity performance and functioning that could affect occupational engagement. Therefore, interventions aimed at improving the appropriateness of fall-related efficacy may indeed result in improved activity performance and occupational engagement. Interventions addressing balance confidence and falls self-efficacy separately may also prove beneficial, according to the findings from this study, and may require different strategies to effectively address either aspect of fall-related efficacy. Remaining active is a critical component of successful aging (Berkman et al., 1993; Fisher, 1995), and addressing fall-related efficacy may be one avenue toward helping older adults maintain health and wellness.
In summary,
  • The strong relationships found between fall-related efficacy and activity mean that occupational therapists have an important role in assessing older adults’ fall-related efficacy issues.

  • The finding of a differential effect of falls self-efficacy versus balance confidence indicates a potential need for occupational therapists to assess the two constructs separately in older adults.

  • Interventions addressing balance confidence and falls self-efficacy separately may prove beneficial and may require different strategies.

Conclusion
Our meta-analysis found fall-related efficacy to be strongly related to measures of activity and performance in community-dwelling older adults. These findings highlight the potential need to address fall-related efficacy when promoting occupational engagement in this population. Future research should address the relationship of participation to fall-related efficacy and interventions targeting fall-related efficacy.
Acknowledgments
Stacey Schepens was supported by Award No. T32HD007422 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
References
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process. (2nd ed.). American Journal of Occupational Therapy, 62, 625–683. http://dx.doi.org/10.5014/ajot.62.6.625 [Article] [PubMed]
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process. (2nd ed.). American Journal of Occupational Therapy, 62, 625–683. http://dx.doi.org/10.5014/ajot.62.6.625 [Article] [PubMed]×
*Anaby, D., Miller, W. C., Eng, J. J., Jarus, T., & Noreau, L.; PACC Research Group., (2009). Can personal and environmental factors explain participation of older adults. Disability and Rehabilitation, 31, 1275–1282. http://dx.doi.org/10.1080/09638280802572940 [Article] [PubMed]
*Anaby, D., Miller, W. C., Eng, J. J., Jarus, T., & Noreau, L.; PACC Research Group., (2009). Can personal and environmental factors explain participation of older adults. Disability and Rehabilitation, 31, 1275–1282. http://dx.doi.org/10.1080/09638280802572940 [Article] [PubMed]×
*Ashe, M. C., Eng, J. J., Miller, W. C., & Soon, J. A. (2007). Disparity between physical capacity and participation in seniors with chronic disease. Medicine and Science in Sports and Exercise, 39, 1139–1146. http://dx.doi.org/10.1249/mss.0b013e31804d2417 [Article] [PubMed]
*Ashe, M. C., Eng, J. J., Miller, W. C., & Soon, J. A. (2007). Disparity between physical capacity and participation in seniors with chronic disease. Medicine and Science in Sports and Exercise, 39, 1139–1146. http://dx.doi.org/10.1249/mss.0b013e31804d2417 [Article] [PubMed]×
Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122–147. http://dx.doi.org/10.1037/0003-066X.37.2.122 [Article]
Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122–147. http://dx.doi.org/10.1037/0003-066X.37.2.122 [Article]×
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.×
Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W. H. Freeman.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W. H. Freeman.×
Begg, C. B., & Mazumdar, M. (1994). Operating characteristics of a rank correlation test for publication bias. Biometrics, 50, 1088–1101. http://dx.doi.org/10.2307/2533446 [Article] [PubMed]
Begg, C. B., & Mazumdar, M. (1994). Operating characteristics of a rank correlation test for publication bias. Biometrics, 50, 1088–1101. http://dx.doi.org/10.2307/2533446 [Article] [PubMed]×
Bergland, A., & Wyller, T. B. (2004). Risk factors for serious fall related injury in elderly women living at home. Injury Prevention, 10, 308–313. http://dx.doi.org/10.1136/ip.2003.004721 [Article] [PubMed]
Bergland, A., & Wyller, T. B. (2004). Risk factors for serious fall related injury in elderly women living at home. Injury Prevention, 10, 308–313. http://dx.doi.org/10.1136/ip.2003.004721 [Article] [PubMed]×
Berkman, L. F., Seeman, T. E., Albert, M., Blazer, D., Kahn, R., Mohs, R., et al. (1993). High, usual, and impaired functioning in community-dwelling older men and women: Findings from the MacArthur Foundation Research Network on Successful Aging. Journal of Clinical Epidemiology, 46, 1129–1140. http://dx.doi.org/10.1016/0895-4356(93)90112-E [Article] [PubMed]
Berkman, L. F., Seeman, T. E., Albert, M., Blazer, D., Kahn, R., Mohs, R., et al. (1993). High, usual, and impaired functioning in community-dwelling older men and women: Findings from the MacArthur Foundation Research Network on Successful Aging. Journal of Clinical Epidemiology, 46, 1129–1140. http://dx.doi.org/10.1016/0895-4356(93)90112-E [Article] [PubMed]×
*Binda, S. M., Culham, E. G., & Brouwer, B. (2003). Balance, muscle strength, and fear of falling in older adults. Experimental Aging Research, 29, 205–219. http://dx.doi.org/10.1080/03610730303711 [Article] [PubMed]
*Binda, S. M., Culham, E. G., & Brouwer, B. (2003). Balance, muscle strength, and fear of falling in older adults. Experimental Aging Research, 29, 205–219. http://dx.doi.org/10.1080/03610730303711 [Article] [PubMed]×
Boyd, R., & Stevens, J. A. (2009). Falls and fear of falling: Burden, beliefs and behaviours. Age and Ageing, 38, 423–428. http://dx.doi.org/10.1093/ageing/afp053 [Article] [PubMed]
Boyd, R., & Stevens, J. A. (2009). Falls and fear of falling: Burden, beliefs and behaviours. Age and Ageing, 38, 423–428. http://dx.doi.org/10.1093/ageing/afp053 [Article] [PubMed]×
*Brouwer, B., Musselman, K., & Culham, E. (2004). Physical function and health status among seniors with and without a fear of falling. Gerontology, 50, 135–141. http://dx.doi.org/10.1159/000076771 [Article] [PubMed]
*Brouwer, B., Musselman, K., & Culham, E. (2004). Physical function and health status among seniors with and without a fear of falling. Gerontology, 50, 135–141. http://dx.doi.org/10.1159/000076771 [Article] [PubMed]×
*Cho, B. L., Scarpace, D., & Alexander, N. B. (2004). Tests of stepping as indicators of mobility, balance, and fall risk in balance-impaired older adults. Journal of the American Geriatrics Society, 52, 1168–1173. http://dx.doi.org/10.1111/j.1532-5415.2004.52317.x [Article] [PubMed]
*Cho, B. L., Scarpace, D., & Alexander, N. B. (2004). Tests of stepping as indicators of mobility, balance, and fall risk in balance-impaired older adults. Journal of the American Geriatrics Society, 52, 1168–1173. http://dx.doi.org/10.1111/j.1532-5415.2004.52317.x [Article] [PubMed]×
Chou, K. L., Yeung, F. K., & Wong, E. C. (2005). Fear of falling and depressive symptoms in Chinese elderly living in nursing homes: Fall efficacy and activity level as mediator or moderator. Aging and Mental Health, 9, 255–261. http://dx.doi.org/10.1080/13607860500114035 [Article] [PubMed]
Chou, K. L., Yeung, F. K., & Wong, E. C. (2005). Fear of falling and depressive symptoms in Chinese elderly living in nursing homes: Fall efficacy and activity level as mediator or moderator. Aging and Mental Health, 9, 255–261. http://dx.doi.org/10.1080/13607860500114035 [Article] [PubMed]×
Cochran, W. G. (1954). The combination of estimates from different experiments. Biometrics, 10, 101–129. [Article]
Cochran, W. G. (1954). The combination of estimates from different experiments. Biometrics, 10, 101–129. [Article]×
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). New York: Erlbaum.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). New York: Erlbaum.×
Cumming, R. G., Salkeld, G., Thomas, M., & Szonyi, G. (2000). Prospective study of the impact of fear of falling on activities of daily living, SF–36 scores, and nursing home admission. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 55A, 299–305. http://dx.doi.org/10.1093/gerona/55.5.M299 [Article]
Cumming, R. G., Salkeld, G., Thomas, M., & Szonyi, G. (2000). Prospective study of the impact of fear of falling on activities of daily living, SF–36 scores, and nursing home admission. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 55A, 299–305. http://dx.doi.org/10.1093/gerona/55.5.M299 [Article]×
Curcio, C. L., Gomez, F., & Reyes-Ortiz, C. A. (2009). Activity restriction related to fear of falling among older people in the Colombian Andes mountains: Are functional or psychosocial risk factors more important. Journal of Aging and Health, 21, 460–479. http://dx.doi.org/10.1177/0898264308329024 [Article] [PubMed]
Curcio, C. L., Gomez, F., & Reyes-Ortiz, C. A. (2009). Activity restriction related to fear of falling among older people in the Colombian Andes mountains: Are functional or psychosocial risk factors more important. Journal of Aging and Health, 21, 460–479. http://dx.doi.org/10.1177/0898264308329024 [Article] [PubMed]×
Delbaere, K., Close, J. C., Brodaty, H., Sachdev, P., & Lord, S. R. (2010). Determinants of disparities between perceived and physiological risk of falling among elderly people: Cohort study. British Medical Journal, 341, c4165. [Article] [PubMed]
Delbaere, K., Close, J. C., Brodaty, H., Sachdev, P., & Lord, S. R. (2010). Determinants of disparities between perceived and physiological risk of falling among elderly people: Cohort study. British Medical Journal, 341, c4165. [Article] [PubMed]×
Deshpande, N., Metter, E. J., Bandinelli, S., Lauretani, F., Windham, B. G., & Ferrucci, L. (2008). Psychological, physical, and sensory correlates of fear of falling and consequent activity restriction in the elderly: The InCHIANTI study. American Journal of Physical Medicine and Rehabilitation, 87, 354–362. http://dx.doi.org/10.1097/PHM.0b013e31815e6e9b [Article] [PubMed]
Deshpande, N., Metter, E. J., Bandinelli, S., Lauretani, F., Windham, B. G., & Ferrucci, L. (2008). Psychological, physical, and sensory correlates of fear of falling and consequent activity restriction in the elderly: The InCHIANTI study. American Journal of Physical Medicine and Rehabilitation, 87, 354–362. http://dx.doi.org/10.1097/PHM.0b013e31815e6e9b [Article] [PubMed]×
Deshpande, N., Metter, E. J., Lauretani, F., Bandinelli, S., Guralnik, J., & Ferrucci, L. (2008). Activity restriction induced by fear of falling and objective and subjective measures of physical function: A prospective cohort study. Journal of the American Geriatrics Society, 56, 615–620. http://dx.doi.org/10.1111/j.1532-5415.2007.01639.x [Article] [PubMed]
Deshpande, N., Metter, E. J., Lauretani, F., Bandinelli, S., Guralnik, J., & Ferrucci, L. (2008). Activity restriction induced by fear of falling and objective and subjective measures of physical function: A prospective cohort study. Journal of the American Geriatrics Society, 56, 615–620. http://dx.doi.org/10.1111/j.1532-5415.2007.01639.x [Article] [PubMed]×
Egger, M., Davey Smith, G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315, 629–634. [Article] [PubMed]
Egger, M., Davey Smith, G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315, 629–634. [Article] [PubMed]×
Fisher, B. J. (1995). Successful aging, life satisfaction, and generativity in later life. International Journal of Aging and Human Development, 41, 239–250. http://dx.doi.org/10.2190/HA9X-H48D-9GYB-85XW [Article] [PubMed]
Fisher, B. J. (1995). Successful aging, life satisfaction, and generativity in later life. International Journal of Aging and Human Development, 41, 239–250. http://dx.doi.org/10.2190/HA9X-H48D-9GYB-85XW [Article] [PubMed]×
Fisher, R. A. (1915). Frequency distribution of the values of the correlation coefficient in samples of an indefinitely large population. Biometrika, 10, 507–521.
Fisher, R. A. (1915). Frequency distribution of the values of the correlation coefficient in samples of an indefinitely large population. Biometrika, 10, 507–521.×
Fletcher, P. C., Guthrie, D. M., Berg, K., & Hirdes, J. P. (2010). Risk factors for restriction in activity associated with fear of falling among seniors within the community. Journal of Patient Safety, 6, 187–191. [Article] [PubMed]
Fletcher, P. C., Guthrie, D. M., Berg, K., & Hirdes, J. P. (2010). Risk factors for restriction in activity associated with fear of falling among seniors within the community. Journal of Patient Safety, 6, 187–191. [Article] [PubMed]×
Fletcher, P. C., & Hirdes, J. P. (2004). Restriction in activity associated with fear of falling among community-based seniors using home care services. Age and Ageing, 33, 273–279. http://dx.doi.org/10.1093/ageing/afh077 [Article] [PubMed]
Fletcher, P. C., & Hirdes, J. P. (2004). Restriction in activity associated with fear of falling among community-based seniors using home care services. Age and Ageing, 33, 273–279. http://dx.doi.org/10.1093/ageing/afh077 [Article] [PubMed]×
Friedman, S. M., Munoz, B., West, S. K., Rubin, G. S., & Fried, L. P. (2002). Falls and fear of falling: Which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. Journal of the American Geriatrics Society, 50, 1329–1335. http://dx.doi.org/10.1046/j.1532-5415.2002.50352.x [Article] [PubMed]
Friedman, S. M., Munoz, B., West, S. K., Rubin, G. S., & Fried, L. P. (2002). Falls and fear of falling: Which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. Journal of the American Geriatrics Society, 50, 1329–1335. http://dx.doi.org/10.1046/j.1532-5415.2002.50352.x [Article] [PubMed]×
Gagnon, N., Flint, A. J., Naglie, G., & Devins, G. M. (2005). Affective correlates of fear of falling in elderly persons. American Journal of Geriatric Psychiatry, 13, 7–14. [Article] [PubMed]
Gagnon, N., Flint, A. J., Naglie, G., & Devins, G. M. (2005). Affective correlates of fear of falling in elderly persons. American Journal of Geriatric Psychiatry, 13, 7–14. [Article] [PubMed]×
*Giladi, N., Herman, T., Reider-Groswasser, I. I., Gurevich, T., & Hausdorff, J. M. (2005). Clinical characteristics of elderly patients with a cautious gait of unknown origin. Journal of Neurology, 252, 300–306. http://dx.doi.org/10.1007/s00415-005-0641-2 [Article] [PubMed]
*Giladi, N., Herman, T., Reider-Groswasser, I. I., Gurevich, T., & Hausdorff, J. M. (2005). Clinical characteristics of elderly patients with a cautious gait of unknown origin. Journal of Neurology, 252, 300–306. http://dx.doi.org/10.1007/s00415-005-0641-2 [Article] [PubMed]×
Grembowski, D., Patrick, D., Diehr, P., Durham, M., Beresford, S., Kay, E., et al. (1993). Self-efficacy and health behavior among older adults. Journal of Health and Social Behavior, 34, 89–104. http://dx.doi.org/10.2307/2137237 [Article] [PubMed]
Grembowski, D., Patrick, D., Diehr, P., Durham, M., Beresford, S., Kay, E., et al. (1993). Self-efficacy and health behavior among older adults. Journal of Health and Social Behavior, 34, 89–104. http://dx.doi.org/10.2307/2137237 [Article] [PubMed]×
*Hatch, J., Gill-Body, K. M., & Portney, L. G. (2003). Determinants of balance confidence in community-dwelling elderly people. Physical Therapy, 83, 1072–1079. [PubMed]
*Hatch, J., Gill-Body, K. M., & Portney, L. G. (2003). Determinants of balance confidence in community-dwelling elderly people. Physical Therapy, 83, 1072–1079. [PubMed]×
Hedges, L. V., & Olkin, I. (1985). Statistical methods for meta-analysis. Orlando, FL: Academic Press.
Hedges, L. V., & Olkin, I. (1985). Statistical methods for meta-analysis. Orlando, FL: Academic Press.×
*Herman, T., Inbar-Borovsky, N., Brozgol, M., Giladi, N., & Hausdorff, J. M. (2009). The Dynamic Gait Index in healthy older adults: The role of stair climbing, fear of falling and gender. Gait and Posture, 29, 237–241. http://dx.doi.org/10.1016/j.gaitpost.2008.08.013 [Article] [PubMed]
*Herman, T., Inbar-Borovsky, N., Brozgol, M., Giladi, N., & Hausdorff, J. M. (2009). The Dynamic Gait Index in healthy older adults: The role of stair climbing, fear of falling and gender. Gait and Posture, 29, 237–241. http://dx.doi.org/10.1016/j.gaitpost.2008.08.013 [Article] [PubMed]×
*Hotchkiss, A., Fisher, A., Robertson, R., Ruttencutter, A., Schuffert, J., & Barker, D. B. (2004). Convergent and predictive validity of three scales related to falls in the elderly. American Journal of Occupational Therapy, 58, 100–103. http://dx.doi.org/10.5014/ajot.58.1.100 [Article] [PubMed]
*Hotchkiss, A., Fisher, A., Robertson, R., Ruttencutter, A., Schuffert, J., & Barker, D. B. (2004). Convergent and predictive validity of three scales related to falls in the elderly. American Journal of Occupational Therapy, 58, 100–103. http://dx.doi.org/10.5014/ajot.58.1.100 [Article] [PubMed]×
Howland, J., Lachman, M. E., Peterson, E. W., Cote, J., Kasten, L., & Jette, A. (1998). Covariates of fear of falling and associated activity curtailment. Gerontologist, 38, 549–555. http://dx.doi.org/10.1093/geront/38.5.549 [Article] [PubMed]
Howland, J., Lachman, M. E., Peterson, E. W., Cote, J., Kasten, L., & Jette, A. (1998). Covariates of fear of falling and associated activity curtailment. Gerontologist, 38, 549–555. http://dx.doi.org/10.1093/geront/38.5.549 [Article] [PubMed]×
*Inderjeeth, C. A., Glennon, D., Petta, A., Soderstrom, J., Boyatzis, I., & Tapper, J. (2007). Vitamin D and muscle strength in patients with previous fractures. New Zealand Medical Journal, 120, U2730. [PubMed]
*Inderjeeth, C. A., Glennon, D., Petta, A., Soderstrom, J., Boyatzis, I., & Tapper, J. (2007). Vitamin D and muscle strength in patients with previous fractures. New Zealand Medical Journal, 120, U2730. [PubMed]×
Jørstad, E. C., Hauer, K., Becker, C., & Lamb, S. E.; ProFaNE Group., (2005). Measuring the psychological outcomes of falling: A systematic review. Journal of the American Geriatrics Society, 53, 501–510. http://dx.doi.org/10.1111/j.1532-5415.2005.53172.x [Article] [PubMed]
Jørstad, E. C., Hauer, K., Becker, C., & Lamb, S. E.; ProFaNE Group., (2005). Measuring the psychological outcomes of falling: A systematic review. Journal of the American Geriatrics Society, 53, 501–510. http://dx.doi.org/10.1111/j.1532-5415.2005.53172.x [Article] [PubMed]×
Kato, C., Ida, K., Kawamura, M., Nagaya, M., Tokuda, H., Tamakoshi, A., et al. (2008). Relation of Falls Efficacy Scale (FES) to quality of life among nursing home female residents with comparatively intact cognitive function in Japan. Nagoya Journal of Medical Science, 70, 19–27. [PubMed]
Kato, C., Ida, K., Kawamura, M., Nagaya, M., Tokuda, H., Tamakoshi, A., et al. (2008). Relation of Falls Efficacy Scale (FES) to quality of life among nursing home female residents with comparatively intact cognitive function in Japan. Nagoya Journal of Medical Science, 70, 19–27. [PubMed]×
Kempen, G. I., van Haastregt, J. C., McKee, K. J., Delbaere, K., & Zijlstra, G. A. (2009). Socio-demographic, health-related and psychosocial correlates of fear of falling and avoidance of activity in community-living older persons who avoid activity due to fear of falling. BMC Public Health, 9, 170. http://dx.doi.org/10.1186/1471-2458-9-170 [Article] [PubMed]
Kempen, G. I., van Haastregt, J. C., McKee, K. J., Delbaere, K., & Zijlstra, G. A. (2009). Socio-demographic, health-related and psychosocial correlates of fear of falling and avoidance of activity in community-living older persons who avoid activity due to fear of falling. BMC Public Health, 9, 170. http://dx.doi.org/10.1186/1471-2458-9-170 [Article] [PubMed]×
Kielhofner, G. (2008). A model of human occupation: Theory and application (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
Kielhofner, G. (2008). A model of human occupation: Theory and application (4th ed.). Philadelphia: Lippincott Williams & Wilkins.×
*Lachman, M. E., Howland, J., Tennstedt, S., Jette, A., Assmann, S., & Peterson, E. W. (1998). Fear of falling and activity restriction: The Survey of Activities and Fear of Falling in the Elderly (SAFE). Journals of Gerontology, Series B: Psychological Sciences, 53B, 43–50. http://dx.doi.org/10.1093/geronb/53B.1.P43 [Article]
*Lachman, M. E., Howland, J., Tennstedt, S., Jette, A., Assmann, S., & Peterson, E. W. (1998). Fear of falling and activity restriction: The Survey of Activities and Fear of Falling in the Elderly (SAFE). Journals of Gerontology, Series B: Psychological Sciences, 53B, 43–50. http://dx.doi.org/10.1093/geronb/53B.1.P43 [Article]×
Lent, R. W., Brown, S. D., & Larkin, K. C. (1984). Relation of self-efficacy expectations to academic achievement and persistence. Journal of Counseling Psychology, 31, 356–362. http://dx.doi.org/10.1037/0022-0167.31.3.356 [Article]
Lent, R. W., Brown, S. D., & Larkin, K. C. (1984). Relation of self-efficacy expectations to academic achievement and persistence. Journal of Counseling Psychology, 31, 356–362. http://dx.doi.org/10.1037/0022-0167.31.3.356 [Article]×
Li, F., Harmer, P., McAuley, E., Fisher, K. J., Duncan, T. E., & Duncan, S. C. (2001). Tai chi, self-efficacy, and physical function in the elderly. Prevention Science, 2, 229–239. http://dx.doi.org/10.1023/A:1013614200329 [Article] [PubMed]
Li, F., Harmer, P., McAuley, E., Fisher, K. J., Duncan, T. E., & Duncan, S. C. (2001). Tai chi, self-efficacy, and physical function in the elderly. Prevention Science, 2, 229–239. http://dx.doi.org/10.1023/A:1013614200329 [Article] [PubMed]×
Li, F., McAuley, E., Fisher, K. J., Harmer, P., Chaumeton, N., & Wilson, N. L. (2002). Self-efficacy as a mediator between fear of falling and functional ability in the elderly. Journal of Aging and Health, 14, 452–466. http://dx.doi.org/10.1177/089826402237178 [Article] [PubMed]
Li, F., McAuley, E., Fisher, K. J., Harmer, P., Chaumeton, N., & Wilson, N. L. (2002). Self-efficacy as a mediator between fear of falling and functional ability in the elderly. Journal of Aging and Health, 14, 452–466. http://dx.doi.org/10.1177/089826402237178 [Article] [PubMed]×
*Liu-Ambrose, T., Katarynych, L. A., Ashe, M. C., Nagamatsu, L. S., & Hsu, C. L. (2009). Dual-task gait performance among community-dwelling senior women: The role of balance confidence and executive functions. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 64A, 975–982. http://dx.doi.org/10.1093/gerona/glp063 [Article]
*Liu-Ambrose, T., Katarynych, L. A., Ashe, M. C., Nagamatsu, L. S., & Hsu, C. L. (2009). Dual-task gait performance among community-dwelling senior women: The role of balance confidence and executive functions. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 64A, 975–982. http://dx.doi.org/10.1093/gerona/glp063 [Article]×
Lorig, K. R., & Holman, H. (2003). Self-management education: History, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26, 1–7. http://dx.doi.org/10.1207/S15324796ABM2601_01 [Article] [PubMed]
Lorig, K. R., & Holman, H. (2003). Self-management education: History, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26, 1–7. http://dx.doi.org/10.1207/S15324796ABM2601_01 [Article] [PubMed]×
Maki, B. E., Holliday, P. J., & Topper, A. K. (1991). Fear of falling and postural performance in the elderly. Journal of Gerontology, Series B: Biological Sciences and Medical Sciences, 46B, 123–131.
Maki, B. E., Holliday, P. J., & Topper, A. K. (1991). Fear of falling and postural performance in the elderly. Journal of Gerontology, Series B: Biological Sciences and Medical Sciences, 46B, 123–131.×
Masud, T., & Morris, R. O. (2001). Epidemiology of falls. Age and Ageing, 30(Suppl. 4), 3–7. http://dx.doi.org/10.1093/ageing/30.suppl_4.3 [Article] [PubMed]
Masud, T., & Morris, R. O. (2001). Epidemiology of falls. Age and Ageing, 30(Suppl. 4), 3–7. http://dx.doi.org/10.1093/ageing/30.suppl_4.3 [Article] [PubMed]×
*McAuley, E., Konopack, J. F., Morris, K. S., Motl, R. W., Hu, L., Doerksen, S. E., et al. (2006). Physical activity and functional limitations in older women: Influence of self-efficacy. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 61B, 270–277. [Article]
*McAuley, E., Konopack, J. F., Morris, K. S., Motl, R. W., Hu, L., Doerksen, S. E., et al. (2006). Physical activity and functional limitations in older women: Influence of self-efficacy. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 61B, 270–277. [Article]×
*McAuley, E., Mihalko, S., & Rosengren, K. (1997). Self-efficacy and balance correlates of fear of falling in the elderly. Journal of Aging and Physical Activity, 5, 329–340.
*McAuley, E., Mihalko, S., & Rosengren, K. (1997). Self-efficacy and balance correlates of fear of falling in the elderly. Journal of Aging and Physical Activity, 5, 329–340.×
*McKee, K. J., Orbell, S., Austin, C. A., Bettridge, R., Liddle, B. J., Morgan, K., et al. (2002). Fear of falling, falls efficacy, and health outcomes in older people following hip fracture. Disability and Rehabilitation, 24, 327–333. http://dx.doi.org/10.1080/09638280110093686 [Article] [PubMed]
*McKee, K. J., Orbell, S., Austin, C. A., Bettridge, R., Liddle, B. J., Morgan, K., et al. (2002). Fear of falling, falls efficacy, and health outcomes in older people following hip fracture. Disability and Rehabilitation, 24, 327–333. http://dx.doi.org/10.1080/09638280110093686 [Article] [PubMed]×
*Medell, J. L., & Alexander, N. B. (2000). A clinical measure of maximal and rapid stepping in older women. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 55A, 429–433. http://dx.doi.org/10.1093/gerona/55.8.M429 [Article]
*Medell, J. L., & Alexander, N. B. (2000). A clinical measure of maximal and rapid stepping in older women. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 55A, 429–433. http://dx.doi.org/10.1093/gerona/55.8.M429 [Article]×
Moore, D. S., & Ellis, R. (2008). Measurement of fall-related psychological constructs among independent-living older adults: A review of the research literature. Aging and Mental Health, 12, 684–699. http://dx.doi.org/10.1080/13607860802148855 [Article] [PubMed]
Moore, D. S., & Ellis, R. (2008). Measurement of fall-related psychological constructs among independent-living older adults: A review of the research literature. Aging and Mental Health, 12, 684–699. http://dx.doi.org/10.1080/13607860802148855 [Article] [PubMed]×
Murphy, S. L., Williams, C. S., & Gill, T. M. (2002). Characteristics associated with fear of falling and activity restriction in community-living older persons. Journal of the American Geriatrics Society, 50, 516–520. http://dx.doi.org/10.1046/j.1532-5415.2002.50119.x [Article] [PubMed]
Murphy, S. L., Williams, C. S., & Gill, T. M. (2002). Characteristics associated with fear of falling and activity restriction in community-living older persons. Journal of the American Geriatrics Society, 50, 516–520. http://dx.doi.org/10.1046/j.1532-5415.2002.50119.x [Article] [PubMed]×
*Myers, A. M., Powell, L. E., Maki, B. E., Holliday, P. J., Brawley, L. R., & Sherk, W. (1996). Psychological indicators of balance confidence: Relationship to actual and perceived abilities. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 51A, 37–43. http://dx.doi.org/10.1093/gerona/51A.1.M37 [Article]
*Myers, A. M., Powell, L. E., Maki, B. E., Holliday, P. J., Brawley, L. R., & Sherk, W. (1996). Psychological indicators of balance confidence: Relationship to actual and perceived abilities. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 51A, 37–43. http://dx.doi.org/10.1093/gerona/51A.1.M37 [Article]×
Peterson, E., Howland, J., Kielhofner, G., Lachman, M. E., Assmann, S., Cote, J., et al. (1999). Falls self-efficacy and occupational adaptation among elders. Physical and Occupational Therapy in Geriatrics, 16, 1–16.
Peterson, E., Howland, J., Kielhofner, G., Lachman, M. E., Assmann, S., Cote, J., et al. (1999). Falls self-efficacy and occupational adaptation among elders. Physical and Occupational Therapy in Geriatrics, 16, 1–16.×
Peterson, E., Kielhofner, G., Tham, K., & von Koch, L. (2010). Falls self-efficacy among adults with MS: A phenomenological study. OTJR: Occupation, Participation and Health, 30, 148–157. http://dx.doi.org/10.3928/15394492-20091123-02 [Article]
Peterson, E., Kielhofner, G., Tham, K., & von Koch, L. (2010). Falls self-efficacy among adults with MS: A phenomenological study. OTJR: Occupation, Participation and Health, 30, 148–157. http://dx.doi.org/10.3928/15394492-20091123-02 [Article]×
Powell, L. E., & Myers, A. M. (1995). The Activities-specific Balance Confidence (ABC) scale. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 50A, 28–34. http://dx.doi.org/10.1093/gerona/50A.1.M28 [Article]
Powell, L. E., & Myers, A. M. (1995). The Activities-specific Balance Confidence (ABC) scale. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 50A, 28–34. http://dx.doi.org/10.1093/gerona/50A.1.M28 [Article]×
*Rosengren, K. S., McAuley, E., & Mihalko, S. L. (1998). Gait adjustments in older adults: Activity and efficacy influences. Psychology and Aging, 13, 375–386. http://dx.doi.org/10.1037/0882-7974.13.3.375 [Article] [PubMed]
*Rosengren, K. S., McAuley, E., & Mihalko, S. L. (1998). Gait adjustments in older adults: Activity and efficacy influences. Psychology and Aging, 13, 375–386. http://dx.doi.org/10.1037/0882-7974.13.3.375 [Article] [PubMed]×
Rubenstein, L. Z. (2006). Falls in older people: Epidemiology, risk factors and strategies for prevention. Age and Ageing, 35(Suppl. 2), ii37–ii41. http://dx.doi.org/10.1093/ageing/afl084 [Article] [PubMed]
Rubenstein, L. Z. (2006). Falls in older people: Epidemiology, risk factors and strategies for prevention. Age and Ageing, 35(Suppl. 2), ii37–ii41. http://dx.doi.org/10.1093/ageing/afl084 [Article] [PubMed]×
*Schepens, S., Goldberg, A., & Wallace, M. (2010). The short version of the Activities-specific Balance Confidence (ABC) scale: Its validity, reliability, and relationship to balance impairment and falls in older adults. Archives of Gerontology and Geriatrics, 51, 9–12. http://dx.doi.org/10.1016/j.archger.2009.06.003 [Article] [PubMed]
*Schepens, S., Goldberg, A., & Wallace, M. (2010). The short version of the Activities-specific Balance Confidence (ABC) scale: Its validity, reliability, and relationship to balance impairment and falls in older adults. Archives of Gerontology and Geriatrics, 51, 9–12. http://dx.doi.org/10.1016/j.archger.2009.06.003 [Article] [PubMed]×
Sharpe, D. (1997). Of apples and oranges, file drawers and garbage: Why validity issues in meta-analysis will not go away. Clinical Psychology Review, 17, 881–901. http://dx.doi.org/10.1016/S0272-7358(97)00056-1 [Article] [PubMed]
Sharpe, D. (1997). Of apples and oranges, file drawers and garbage: Why validity issues in meta-analysis will not go away. Clinical Psychology Review, 17, 881–901. http://dx.doi.org/10.1016/S0272-7358(97)00056-1 [Article] [PubMed]×
*Sihvonen, S., Kulmala, J., Kallinen, M., Alén, M., Kiviranta, I., & Sipila, S. (2009). Postural balance and self-reported balance confidence in older adults with a hip fracture history. Gerontology, 55, 630–636. http://dx.doi.org/10.1159/000240016 [Article] [PubMed]
*Sihvonen, S., Kulmala, J., Kallinen, M., Alén, M., Kiviranta, I., & Sipila, S. (2009). Postural balance and self-reported balance confidence in older adults with a hip fracture history. Gerontology, 55, 630–636. http://dx.doi.org/10.1159/000240016 [Article] [PubMed]×
Skelton, D. A., Becker, C., Lamb, S. E., Close, J., Zijlstra, W., Yardley, L., et al. (2004). Prevention of Falls Network Europe: A thematic network aimed at introducing good practice in effective falls prevention across Europe. European Journal of Ageing, 1, 89–94. http://dx.doi.org/10.1007/s10433-004-0008-z [Article]
Skelton, D. A., Becker, C., Lamb, S. E., Close, J., Zijlstra, W., Yardley, L., et al. (2004). Prevention of Falls Network Europe: A thematic network aimed at introducing good practice in effective falls prevention across Europe. European Journal of Ageing, 1, 89–94. http://dx.doi.org/10.1007/s10433-004-0008-z [Article]×
Stajkovic, A. D., & Luthans, F. (1998). Self-efficacy and work-related performance: A meta-analysis. Psychological Bulletin, 124, 240–261. http://dx.doi.org/10.1037/0033-2909.124.2.240 [Article]
Stajkovic, A. D., & Luthans, F. (1998). Self-efficacy and work-related performance: A meta-analysis. Psychological Bulletin, 124, 240–261. http://dx.doi.org/10.1037/0033-2909.124.2.240 [Article]×
Steultjens, M. P., Dekker, J., & Bijlsma, J. W. (2001). Coping, pain, and disability in osteoarthritis: A longitudinal study. Journal of Rheumatology, 28, 1068–1072. [PubMed]
Steultjens, M. P., Dekker, J., & Bijlsma, J. W. (2001). Coping, pain, and disability in osteoarthritis: A longitudinal study. Journal of Rheumatology, 28, 1068–1072. [PubMed]×
Talley, K. M., Wyman, J. F., & Gross, C. R. (2008). Psychometric properties of the Activities-specific Balance Confidence scale and the Survey of Activities and Fear of Falling in Older Women. Journal of the American Geriatrics Society, 56, 328–333. http://dx.doi.org/10.1111/j.1532-5415.2007.01550.x [Article] [PubMed]
Talley, K. M., Wyman, J. F., & Gross, C. R. (2008). Psychometric properties of the Activities-specific Balance Confidence scale and the Survey of Activities and Fear of Falling in Older Women. Journal of the American Geriatrics Society, 56, 328–333. http://dx.doi.org/10.1111/j.1532-5415.2007.01550.x [Article] [PubMed]×
Tennstedt, S., Howland, J., Lachman, M., Peterson, E., Kasten, L., & Jette, A. (1998). A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. Journal of Gerontology, Series B: Psychological Sciences and Social Sciences, 53B, 384–392. [Article]
Tennstedt, S., Howland, J., Lachman, M., Peterson, E., Kasten, L., & Jette, A. (1998). A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. Journal of Gerontology, Series B: Psychological Sciences and Social Sciences, 53B, 384–392. [Article]×
*Tinetti, M. E., Mendes de Leon, C. F., Doucette, J. T., & Baker, D. I. (1994). Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. Journal of Gerontology, 49, M140–M147. [Article] [PubMed]
*Tinetti, M. E., Mendes de Leon, C. F., Doucette, J. T., & Baker, D. I. (1994). Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. Journal of Gerontology, 49, M140–M147. [Article] [PubMed]×
Tinetti, M. E., & Powell, L. (1993). Fear of falling and low self-efficacy: A case of dependence in elderly persons. Journal of Gerontology, 48, 35–38. [Article] [PubMed]
Tinetti, M. E., & Powell, L. (1993). Fear of falling and low self-efficacy: A case of dependence in elderly persons. Journal of Gerontology, 48, 35–38. [Article] [PubMed]×
Tinetti, M. E., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology, 45, 239–243. [Article]
Tinetti, M. E., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of fear of falling. Journal of Gerontology, 45, 239–243. [Article]×
Whiteneck, G., & Dijkers, M. P. (2009). Difficult to measure constructs: Conceptual and methodological issues concerning participation and environmental factors. Archives of Physical Medicine and Rehabilitation, 90(Suppl.), S22–S35. http://dx.doi.org/10.1016/j.apmr.2009.06.009 [Article] [PubMed]
Whiteneck, G., & Dijkers, M. P. (2009). Difficult to measure constructs: Conceptual and methodological issues concerning participation and environmental factors. Archives of Physical Medicine and Rehabilitation, 90(Suppl.), S22–S35. http://dx.doi.org/10.1016/j.apmr.2009.06.009 [Article] [PubMed]×
Wilson, M. M., Miller, D. K., Andresen, E. M., Malmstrom, T. K., Miller, J. P., & Wolinsky, F. D. (2005). Fear of falling and related activity restriction among middle-aged African Americans. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 60A, 355–360. http://dx.doi.org/10.1093/gerona/60.3.355 [Article]
Wilson, M. M., Miller, D. K., Andresen, E. M., Malmstrom, T. K., Miller, J. P., & Wolinsky, F. D. (2005). Fear of falling and related activity restriction among middle-aged African Americans. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 60A, 355–360. http://dx.doi.org/10.1093/gerona/60.3.355 [Article]×
World Health Organization. (2002). Towards a common language for functioning, disability, and health. Retrieved October 18, 2010, from www.who.int.proxy.lib.umich.edu/classifications/icf/training/icfbeginnersguide.pdf
World Health Organization. (2002). Towards a common language for functioning, disability, and health. Retrieved October 18, 2010, from www.who.int.proxy.lib.umich.edu/classifications/icf/training/icfbeginnersguide.pdf×
Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., & Todd, C. (2005). Development and initial validation of the Falls Efficacy Scale–International (FES–I). Age and Ageing, 34, 614–619. http://dx.doi.org/10.1093/ageing/afi196 [Article] [PubMed]
Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., & Todd, C. (2005). Development and initial validation of the Falls Efficacy Scale–International (FES–I). Age and Ageing, 34, 614–619. http://dx.doi.org/10.1093/ageing/afi196 [Article] [PubMed]×
Zijlstra, G. A., van Haastregt, J. C., van Eijk, J. T., van Rossum, E., Stalenhoef, P. A., & Kempen, G. I. (2007). Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. Age and Ageing, 36, 304–309. http://dx.doi.org/10.1093/ageing/afm021 [Article] [PubMed]
Zijlstra, G. A., van Haastregt, J. C., van Eijk, J. T., van Rossum, E., Stalenhoef, P. A., & Kempen, G. I. (2007). Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. Age and Ageing, 36, 304–309. http://dx.doi.org/10.1093/ageing/afm021 [Article] [PubMed]×
*Indicates studies that were included in the meta-analysis.
*Indicates studies that were included in the meta-analysis.×
Figure 1.
Selection process of studies considered for and included in the meta-analysis.
Note. ABC = Activities-specific Balance Confidence scale; FES = Falls Efficacy Scale.
Figure 1.
Selection process of studies considered for and included in the meta-analysis.
Note. ABC = Activities-specific Balance Confidence scale; FES = Falls Efficacy Scale.
×
Figure 2.
Forest plot depicting the average r value and associated 95% confidence interval from 20 distinct studies, as well as the pooled r value.
Figure 2.
Forest plot depicting the average r value and associated 95% confidence interval from 20 distinct studies, as well as the pooled r value.
×
Table 1.
Operationally Defined Terms Used as Selection Criteria
Operationally Defined Terms Used as Selection Criteria×
TermDefinitionMeasures Included
Fall-related efficacyCollective term that includes the concepts of falls efficacy and balance confidence; confidence or belief in one’s ability to perform activities without losing balance or fallingFES and ABC
Falls self-efficacyPerceived self-confidence in avoiding falls during essential, relatively nonhazardous activities (Tinetti & Powell, 1993)FES
Balance confidenceDegree of confidence in one’s ability to avoid a loss of balance while performing ADLs (Powell & Myers, 1995)ABC
ActivityExecution of a task or action by an individual (World Health Organization, 2002)Measures addressing learning and applying knowledge, general tasks and demands, communication, mobility, self-care, and domestic life
Occupation-based activitiesActivities with occupation as the core focusADL or IADL measures; occupation-based measures
Performance skillsSkills clients demonstrate in the actions they perform (American Occupational Therapy Association, 2008) and that underlie activity performancePerformance-based measures addressing motor or motor planning skills
ParticipationInvolvement in life situationsMeasures addressing interpersonal interactions and relationships, major life areas, and community, social, and civic life
Table Footer NoteNote. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living.
Note. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living.×
Table 1.
Operationally Defined Terms Used as Selection Criteria
Operationally Defined Terms Used as Selection Criteria×
TermDefinitionMeasures Included
Fall-related efficacyCollective term that includes the concepts of falls efficacy and balance confidence; confidence or belief in one’s ability to perform activities without losing balance or fallingFES and ABC
Falls self-efficacyPerceived self-confidence in avoiding falls during essential, relatively nonhazardous activities (Tinetti & Powell, 1993)FES
Balance confidenceDegree of confidence in one’s ability to avoid a loss of balance while performing ADLs (Powell & Myers, 1995)ABC
ActivityExecution of a task or action by an individual (World Health Organization, 2002)Measures addressing learning and applying knowledge, general tasks and demands, communication, mobility, self-care, and domestic life
Occupation-based activitiesActivities with occupation as the core focusADL or IADL measures; occupation-based measures
Performance skillsSkills clients demonstrate in the actions they perform (American Occupational Therapy Association, 2008) and that underlie activity performancePerformance-based measures addressing motor or motor planning skills
ParticipationInvolvement in life situationsMeasures addressing interpersonal interactions and relationships, major life areas, and community, social, and civic life
Table Footer NoteNote. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living.
Note. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living.×
×
Table 2.
Characteristics of Included Studies and Correlations Between the Fall-Related Efficacy and Activity Measures
Characteristics of Included Studies and Correlations Between the Fall-Related Efficacy and Activity Measures×
StudyDesignNMean AgeEfficacy ScaleActivity TypeActivity Measurerp
Anaby, Miller, Eng, Jarus, & Noreau (2009) Cross-sectional20075ABCADLTotal LIFE–H.46.01
Ashe, Eng, Miller, & Soon (2007) Cross-sectional20074ABCPerformance6-min walk.52≤.001
ABCPerformancePedometer—mean daily steps.32≤.001
Binda, Culham, & Brouwer (2003) Cross-sectional40Control group = 72.5; fear of falling group = 77.1ABCPerformanceAnterior–posterior COP.65<.001
ABCPerformanceRight–left COP.39<.017
ABCPerformanceKnee flexor strength.38<.04
ABCPerformanceKnee extensor strength.39<.04
ABCPerformanceAnkle plantar flexor strength.34<.04
Brouwer, Musselman, & Culham (2004) Cross-sectional2576.4ABCADL PerformanceSF–36 physical component sum.698NR
ABCHip flexor torque.504NR
Cho, Scarpace, & Alexander (2004) Cross-sectional16778ABCPerformanceMaximum step length.661<.01
ABCPerformanceRapid step test−.321<.01
ABCPerformanceTimed tandem stance.592<.01
ABCPerformanceTimed unipedal stance.586<.01
ABCPerformanceTimed tandem walk−.52<.01
ABCPerformanceTimed Up & Go test−.606<.01
ABCPerformance6-min walk.631<.01
ABCPerformancePerformance Oriented Mobility Assessment.637<.01
ABCADLEPESE physical function battery−.644<.01
Giladi, Herman, Reider-Groswasser, Gurevich, & Hausdorff (2005) Cross-sectional2578.4ABCADL PerformanceBarthel ADL Index.48<.015
ABCGait speed.61<.002
Hatch, Gill-Body, & Portney (2003) Cross-sectional5081.7ABCPerformanceBerg Balance Scale.752<.01
ABCPerformanceTimed Up & Go test.698<.01
Herman, Inbar-Borovsky, Brozgol, Giladi, & Hausdorff (2009) Prospective27876.3ABCPerformanceDynamic Gait Index.49<.001
Inderjeeth et al. (2007) Cross-sectional99/10579.5FESPerformanceLeft leg extension peak torque.368<.001
FESPerformanceLeft leg extensor maximum power.307.003
FESPerformanceLeft leg flexion peak torque.325.002
FESPerformanceLeft leg flexor maximum power.212.046
Lachman et al. (1998) Cross-sectional27076.16FESADLSF–36 physical functioning.67<.001
FESADLSAFE no. of activities.69NR
Liu-Ambrose, Katarynych, Ashe, Nagamatsu, & Hsu (2009) Cross-sectional14069.6ABCPerformanceSimple walking while talking−.55≤.001
ABCPerformanceComplex walking while talking−.54≤.001
McAuley et al. (2006) Prospective24968.12ABCPerformance8-ft Up & Go test−.41<.01
ABCADLFunction & Disability Inventory: Basic lower-extremity function.53<.01
ABCPerformanceStair ascent−.46<.01
ABCPerformance7-min walk−.35<.01
ABCADLPhysical Activity Scale for the Elderly.31<.01
ABCADLCommunity Healthy Activity Model Program for Seniors.22<.01
ABCPerformanceStair descent−.53<.01
ABCADLFunction & Disability Inventory: Advanced lower-extremity function.58<.01
McAuley, Mihalko, & Rosengren (1997) Cross-sectional5871.72FESPerformanceBerg Balance Scale.49<.01
McKee et al. (2002) Cross-sectional8280.2FESADLPrefall activity problems−.70<.001
FESADLFunctional limitations profile−.37.005
Medell & Alexander (2000) Cross-sectional34Young = 21; unimpaired older = 69; impaired older = 77ABCPerformanceMaximum step length.75<.002
ABCPerformanceRapid step test time−.54<.002
Myers et al. (1996) Cross-sectional6074.6ABCPerformance30-m walking speed.56<.01
FESPerformance30-m walking speed−.25>.05
ABCADLFloor sweeping frequency.70<.001
ABCADLShopping frequency.54<.001
ABCADLActivity avoidance ratings of ABC items−.92<.001
ABCADLPerceived difficulty ratings of ABC items−.89<.001
Rosengren, McAuley, & Mihalko (1998) Cross-sectional5571.1FESADLPhysical activity.21>.05
FESPerformanceBerg Balance Scale.48<.01
FESPerformanceGait speed—No obstacle.43<.01
FESPerformanceGait speed—2.5 cm obstacle.35<.01
FESPerformanceGait speed—5.05 cm obstacle.30<.01
FESPerformanceGait speed—10.0 cm obstacle.32<.01
FESPerformanceGait speed—20.0 cm obstacle.31<.05
FESPerformanceGait speed—40.0 cm obstacle.28<.05
Schepens, Goldberg, & Wallace (2010) Cross-sectional3572.86ABCPerformanceUnipedal stance time.46≤.01
ABCPerformanceMaximum step length.69≤.001
ABCPerformanceFunctional Reach.33≤.05
ABCPerformanceTimed Up & Go test−.65≤.001
Sihvonen et al. (2009) Cross-sectional7974.4ABCPerformanceBerg Balance Scale: Hip fracture group.74NR
31ABCPerformanceBerg Balance Scale: Nonfracture group.384NR
Tinetti, Mendes de Leon, Doucette, & Baker (1994) Cross-sectional1,10379.6FESADLADL and IADL function.55NR
FESADLYale Physical Activity Survey–modified.49NR
Table Footer NoteNote. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; COP = center of pressure; EPESE = Epidemiological Study of the Elderly; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living; LIFE–H = Assessment of Life Habits; NR = not reported; SAFE = Survey of Activities and Fear of Falling in the Elderly; SF–36 = Short Form–36 Health Survey.
Note. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; COP = center of pressure; EPESE = Epidemiological Study of the Elderly; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living; LIFE–H = Assessment of Life Habits; NR = not reported; SAFE = Survey of Activities and Fear of Falling in the Elderly; SF–36 = Short Form–36 Health Survey.×
Table 2.
Characteristics of Included Studies and Correlations Between the Fall-Related Efficacy and Activity Measures
Characteristics of Included Studies and Correlations Between the Fall-Related Efficacy and Activity Measures×
StudyDesignNMean AgeEfficacy ScaleActivity TypeActivity Measurerp
Anaby, Miller, Eng, Jarus, & Noreau (2009) Cross-sectional20075ABCADLTotal LIFE–H.46.01
Ashe, Eng, Miller, & Soon (2007) Cross-sectional20074ABCPerformance6-min walk.52≤.001
ABCPerformancePedometer—mean daily steps.32≤.001
Binda, Culham, & Brouwer (2003) Cross-sectional40Control group = 72.5; fear of falling group = 77.1ABCPerformanceAnterior–posterior COP.65<.001
ABCPerformanceRight–left COP.39<.017
ABCPerformanceKnee flexor strength.38<.04
ABCPerformanceKnee extensor strength.39<.04
ABCPerformanceAnkle plantar flexor strength.34<.04
Brouwer, Musselman, & Culham (2004) Cross-sectional2576.4ABCADL PerformanceSF–36 physical component sum.698NR
ABCHip flexor torque.504NR
Cho, Scarpace, & Alexander (2004) Cross-sectional16778ABCPerformanceMaximum step length.661<.01
ABCPerformanceRapid step test−.321<.01
ABCPerformanceTimed tandem stance.592<.01
ABCPerformanceTimed unipedal stance.586<.01
ABCPerformanceTimed tandem walk−.52<.01
ABCPerformanceTimed Up & Go test−.606<.01
ABCPerformance6-min walk.631<.01
ABCPerformancePerformance Oriented Mobility Assessment.637<.01
ABCADLEPESE physical function battery−.644<.01
Giladi, Herman, Reider-Groswasser, Gurevich, & Hausdorff (2005) Cross-sectional2578.4ABCADL PerformanceBarthel ADL Index.48<.015
ABCGait speed.61<.002
Hatch, Gill-Body, & Portney (2003) Cross-sectional5081.7ABCPerformanceBerg Balance Scale.752<.01
ABCPerformanceTimed Up & Go test.698<.01
Herman, Inbar-Borovsky, Brozgol, Giladi, & Hausdorff (2009) Prospective27876.3ABCPerformanceDynamic Gait Index.49<.001
Inderjeeth et al. (2007) Cross-sectional99/10579.5FESPerformanceLeft leg extension peak torque.368<.001
FESPerformanceLeft leg extensor maximum power.307.003
FESPerformanceLeft leg flexion peak torque.325.002
FESPerformanceLeft leg flexor maximum power.212.046
Lachman et al. (1998) Cross-sectional27076.16FESADLSF–36 physical functioning.67<.001
FESADLSAFE no. of activities.69NR
Liu-Ambrose, Katarynych, Ashe, Nagamatsu, & Hsu (2009) Cross-sectional14069.6ABCPerformanceSimple walking while talking−.55≤.001
ABCPerformanceComplex walking while talking−.54≤.001
McAuley et al. (2006) Prospective24968.12ABCPerformance8-ft Up & Go test−.41<.01
ABCADLFunction & Disability Inventory: Basic lower-extremity function.53<.01
ABCPerformanceStair ascent−.46<.01
ABCPerformance7-min walk−.35<.01
ABCADLPhysical Activity Scale for the Elderly.31<.01
ABCADLCommunity Healthy Activity Model Program for Seniors.22<.01
ABCPerformanceStair descent−.53<.01
ABCADLFunction & Disability Inventory: Advanced lower-extremity function.58<.01
McAuley, Mihalko, & Rosengren (1997) Cross-sectional5871.72FESPerformanceBerg Balance Scale.49<.01
McKee et al. (2002) Cross-sectional8280.2FESADLPrefall activity problems−.70<.001
FESADLFunctional limitations profile−.37.005
Medell & Alexander (2000) Cross-sectional34Young = 21; unimpaired older = 69; impaired older = 77ABCPerformanceMaximum step length.75<.002
ABCPerformanceRapid step test time−.54<.002
Myers et al. (1996) Cross-sectional6074.6ABCPerformance30-m walking speed.56<.01
FESPerformance30-m walking speed−.25>.05
ABCADLFloor sweeping frequency.70<.001
ABCADLShopping frequency.54<.001
ABCADLActivity avoidance ratings of ABC items−.92<.001
ABCADLPerceived difficulty ratings of ABC items−.89<.001
Rosengren, McAuley, & Mihalko (1998) Cross-sectional5571.1FESADLPhysical activity.21>.05
FESPerformanceBerg Balance Scale.48<.01
FESPerformanceGait speed—No obstacle.43<.01
FESPerformanceGait speed—2.5 cm obstacle.35<.01
FESPerformanceGait speed—5.05 cm obstacle.30<.01
FESPerformanceGait speed—10.0 cm obstacle.32<.01
FESPerformanceGait speed—20.0 cm obstacle.31<.05
FESPerformanceGait speed—40.0 cm obstacle.28<.05
Schepens, Goldberg, & Wallace (2010) Cross-sectional3572.86ABCPerformanceUnipedal stance time.46≤.01
ABCPerformanceMaximum step length.69≤.001
ABCPerformanceFunctional Reach.33≤.05
ABCPerformanceTimed Up & Go test−.65≤.001
Sihvonen et al. (2009) Cross-sectional7974.4ABCPerformanceBerg Balance Scale: Hip fracture group.74NR
31ABCPerformanceBerg Balance Scale: Nonfracture group.384NR
Tinetti, Mendes de Leon, Doucette, & Baker (1994) Cross-sectional1,10379.6FESADLADL and IADL function.55NR
FESADLYale Physical Activity Survey–modified.49NR
Table Footer NoteNote. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; COP = center of pressure; EPESE = Epidemiological Study of the Elderly; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living; LIFE–H = Assessment of Life Habits; NR = not reported; SAFE = Survey of Activities and Fear of Falling in the Elderly; SF–36 = Short Form–36 Health Survey.
Note. ABC = Activities-specific Balance Confidence scale; ADL = activity of daily living; COP = center of pressure; EPESE = Epidemiological Study of the Elderly; FES = Falls Efficacy Scale; IADL = instrumental activity of daily living; LIFE–H = Assessment of Life Habits; NR = not reported; SAFE = Survey of Activities and Fear of Falling in the Elderly; SF–36 = Short Form–36 Health Survey.×
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