Title: FALLS SELF‐EFFICACY AND GAIT PERFORMANCE AFTER GAIT AND BALANCE TRAINING IN OLDER PEOPLE
Abstract: To the Editor: Fear of falling is common in community-dwelling older people, with a prevalence as high as 70% in some studies.1 Several adverse consequences have been associated with fear of falling, such as functional decline, poorer quality of life, new falls, and impairment in gait and mobility, but the relationship between gait characteristics and fear of falling is complex and not completely understood.2,3 Several studies have found an association between fear of falling and altered gait performance, such as reduced gait speed, reduced stride length, and increased double support.4,5 Interventions in community-dwelling elderly people have been successful in reducing fear of falling and improving falls-related self-efficacy. They have also had positive effects on physical ability such as balance and strength,6,7 but the effect of such interventions on the interplay between gait and fear of falling in older people remains largely unknown. The aim of this pilot study was to determine the effect of a 10-week, low-intensity gait and balance training program on gait performance and to investigate whether this effect differed according to participants' falls efficacy. Participants were community-dwelling older people reporting balance and gait impairments and enrolled voluntarily in a 10-week, low-intensity, gait and balance training program in several cities of Switzerland. Fear of falling was measured using a French validated version of Tinetti's Falls Efficacy Scale (FES) that assesses confidence in performing 12 activities of daily living without falling.8 Gait was assessed over a 20-m walkway with participants wearing their regular shoes and walking at preferred pace. Gait parameters were measured using the Physilog system (BioAGM, Tour-de-Peilz, Switzerland), which has been previously validated for gait analysis in older persons.9 Falls efficacy and gait assessments were repeated under the same conditions 1 week after completion of the exercise program. The program included weekly 1-hour group training sessions for 10 weeks, with low-intensity exercises targeting balance, flexibility, coordination, and progressive lower limb strengthening. The program was standardized, but the progression in difficulty was adapted to each participant's ability. Ninety-four percent (47/50) of the participants (mean age 78.1±8.9, 82% women, 28% reporting a fall in the previous year) completed the program. Overall, participants slightly improved their gait speed after completion of the exercise program (0.98±0.24 vs 0.94±0.27 m/s, P=.03). To investigate the mediating role of falls efficacy, a secondary analysis was performed after stratifying the population according to baseline falls efficacy into fearful (n=23, baseline FES below median score (≤99)) and confident (n=24, baseline FES above median score (>99)). There was no difference in age, sex, history of falls and lower limb surgery or trauma between fearful and confident participants, but the former were more likely to report using hypnotic medications (10/20 vs 4/23 in fearful and confident group, respectively, P=.048). At baseline, fearful participants had slower gait speed (0.84±0.27 vs 1.04±0.23 m/s, P=.009) and shorter stride length (1.03±0.24 vs 1.22±0.18 m, P=.004) than confident subjects (Table 1). No significant change in FES and gait performance occurred in confident subjects after completion of the program. In contrast, fearful subjects significantly improved FES and most gait parameters (Table 1). Similarly, the proportion of subjects who improved gait performance at follow-up was greater in fearful than confident subjects for gait speed (18/23 vs 11/24, odds ratio (OR)=4.25, 95% confidence interval (CI)=1.19–15.23, P=.03) and stride length (17/23 vs 8/24, OR=5.67, 95% CI=1.61–19.97, P=.007). In multivariate analysis adjusted for baseline gait performance, fearful participants remained at higher odds of improving stride length (adjOR=4.06, 95% CI=1.07–15.47, P=.04). This pilot study shows that a 10-week low-intensity gait and balance training program resulted in small but significant improvements in gait performance and falls efficacy, particularly in subjects with low baseline falls efficacy. These results provide evidence for a link between falls efficacy and the probability of gait improvement after a training program. They further support the hypothesis of a reciprocal relationship between mobility performance and falls efficacy and suggest that measures of falls efficacy might be useful for better targeting individuals most likely to benefit from a similar training program.10 In addition, this study provides preliminary information about the magnitude of improvements in gait speed, stride length, and falls efficacy to expect in older individuals participating in similar training programs. In particular, improvement in falls efficacy in fearful subjects can be explicitly translated into a gain of almost one activity of daily living that a person can regain confidence in performing, useful information when trying to boost adherence to exercise programs in older persons. Finally, from a methodological perspective, this study provides original information about the sensitivity to change of the measures of falls efficacy used.8 We would like to thank the volunteers who participated in the study and the staff from Pro Senectute for providing time and logistical support. We are also grateful to Melanie Thomi, Valerie Besson, and Marie-Laure Bensassi who participated in data collection, Nadine Corbaz for secretarial assistance, and J.C. Beck and R.G. Cumming for comments on the manuscript. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this letter. Kamiar Aminian and Bijan Najafi developed the device (Physilog) used in the study to measure gait parameters and have a patent on the algorithm used to analyze these parameters. We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated. This study was partially supported by grants from the Swiss National Scientific Foundation 3252BO-100416) (Dr. Büla), and the Leenaards Foundation (Dr. Rochat). Author Contributions: Dr. Rochat had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Rochat, Martin, Piot-Ziegler, Aminian, and Büla. Acquisition of data: Rochat, Piot-Ziegler, Najafi, Aminian, and Büla. Analysis and interpretation of data: Rochat, Martin, Piot-Ziegler, Aminian, and Büla. Drafting of the manuscript: Rochat, Martin, and Büla. Critical revision of the manuscript for important intellectual content: Rochat, Martin, Piot-Ziegler, Aminian, and Büla. Statistical analysis: Martin, and Büla. Obtained funding: Rochat, and Büla. Administrative, technical, and material support: Rochat, Martin, Piot-Ziegler, Aminian, and Büla. Study supervision: Rochat, Piot-Ziegler, Aminian, and Büla. Patient recruitment: Rochat, Piot-Ziegler, and Büla. Sponsor's Role: The sponsors did not contribute to any part of the study or the preparation of the manuscript.