Effect of a pilot gait and balance training program: The importance of fear of falling.

Purpose: To determine the evolution of fear of falling, and its relationship with gait performance after a 10-week gait and balance training program. Population and methods: Participants (N=50) were community-dwelling elderly persons enrolled voluntarily in a 10-week, low intensity, gait and balance training program. At baseline, fear of falling was assessed using a previously validated version of Tinetti's Fall Efficacy Scale (FES, range 0-120, higher score indicating higher confidence), that assesses one's confidence in performing 12 activities of daily life without falling. Gait parameters were measured over a 20m walk at preferred gait speed, using the Physilog system (Aminian K, et al., J Biomechanics, 2002). This system uses 4 kinematics sensors attached to the lower limbs and a data logger carried by the subject. Follow-up data on fear of falling and gait were collected one week after completion of the program. Results: Overall, 43 (86%) of the participants completed the program. Mean age was 78.1 years, 79% were women. At baseline, mean FES score was 98.8 (range 58-120) and mean gait speed was 0.92 m/sec (range 0.43-1.47). At follow-up, participants modestly improved their FES score (98.8±17.0 vs 103.2±16.0, P=.04) and gait speed (0.92±0.27 vs 0.99±0.26 m/sec, P<.01). In secondary analyses stratified by subject's baseline FES, those with lower than average confidence (N=21) improved significantly both FES score (84.4±11.8 vs 94.5±17.9, P<.01) and gait speed (0.79±0.26 vs 0.90±0.28 m/sec, P<.01), while no similar improvement was observed in subjects (N=22) with higher baseline confidence (112.5±6.6 vs 111.5±7.5, P=.56 and 1.03±0.22 vs 1.07±0.21 m/sec, P=.41). After adjustment for age, gender and baseline gait speed, subjects with lower baseline confidence had higher odds than the others to improve their confidence (AdjOR=10.8, 95%CI 1.8- 64.8 P=.01) and gait speed (AdjOR=3.3, 95%CI 0.6-19.7, P=.19) at follow-up. Conclusions: This pilot program of low intensity exercise modestly improved participants' fear of falling and gait speed. Interestingly, subjects with higher baseline fear of falling seemed more likely to benefit. Despite methodological limitations (pre-post comparisons, small sample), these results suggest that measuring fear of falling might be useful to better target subjects most likely to benefit from similar programs.

Physical activity, bodyweight, health and fear of negative evaluation in primary school children.

Fear of negative evaluation (FNE) is regarded as being the core feature of social anxiety. The present study examined how FNE is associated with physical activity (PA), body mass index (BMI) and perceived physical health (PPH) in children. Data were collected in a sample of 502 primary school children in first and fifth grades taking part in a randomized-controlled trial ("Kinder-Sportstudie KISS") aimed at increasing PA and health. PA was assessed by accelerometry over 7 days, PPH by the Child Health Questionnaire and FNE by the Social Anxiety Scale for Children--Revised. BMI z-scores were calculated based on Swiss norms. Cross-sectional analyses indicated that children high in FNE exercised less, reported lower levels of PPH and had higher BMI z-scores (P&lt;0.01). Using mixed linear models, the school-based PA intervention did not manage to reduce FNE scores. Overweight children demonstrated a greater increase in FNE (P&lt;0.05) indicating that enhanced weight may be a risk factor for FNE. In conclusion, the associations among high FNE, low PA and increased BMI should be considered when promoting an active lifestyle in children.

What is the relationship between fear of falling and gait in well-functioning older persons aged 65 to 70 years?

OBJECTIVE: To investigate the association between fear of falling and gait performance in well-functioning older persons. DESIGN: Survey. SETTING: Community. PARTICIPANTS: Subjects (N=860, aged 65-70y) were a subsample of participants enrolled in a cohort study who underwent gait measurements. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Fear of falling and its severity were assessed by 2 questions about fear and related activity restriction. Gait performance, including gait variability, was measured using body-fixed sensors. RESULTS: Overall, 29.6% (210/860) of the participants reported fear of falling, with 5.2% (45/860) reporting activity restriction. Fear of falling was associated with reduced gait performance, including increased gait variability. A gradient in gait performance was observed from participants without fear to those reporting fear without activity restriction and those reporting both fear and activity restriction. For instance, stride velocity decreased from 1.15+/-.15 to 1.11+/-.17 to 1.00+/-.19 m/s (P<.001) in participants without fear, with fear but no activity restriction and with fear and activity restriction, respectively. In multivariate analysis, fear of falling with activity restriction remained associated with reduced gait performance, independent of sex, comorbidity, functional status, falls history, and depressive symptoms. CONCLUSIONS: In these well-functioning older people, those reporting fear of falling with activity restriction had reduced gait performance and increased gait variability, independent of health and functional status. These relationships suggest that early interventions targeting fear of falling might potentially help to prevent its adverse consequences on mobility and function in similar populations.

Quand la peur des dépenses incite au gaspillage humain et financier [When the fear of spending incites a human and financial waste!]

Dans les années 80, la crainte de la pléthore médicale imposait des mesures radicales. En 2002, c'est l'angoisse de l'envahisseur européen qui a justifié un moratoire sur l'ouverture de nouveaux cabinets. Aujourd'hui, alors que la Suisse recrute de plus en plus de médecins étrangers pour ses besoins, le Conseiller fédéral Couchepin brandit la menace d'une augmentation des coûts de la santé de 300 millions par an pour justifier une troisième prolongation du moratoire. Ces mesures ont été dictées par la peur d'une explosion des coûts au point de faire perdre de vue la globalité de la situation. Aujourd'hui pourtant, une gestion rationnelle des ressources impose de tout faire pour qu'un maximum de médecins puissent travailler, car la population en a besoin et a déjà beaucoup investi dans leur formation ! Pour y parvenir, la création de postes d'assistanat à temps partiel, l'adaptation urgente des structures d'accueil en garderie et le respect de conditions de travail raisonnables sont des éléments incontournables mais trop souvent négligés par les politiques et les médecins eux-mêmes !

The relationship between fear of falling and foot clearance in older people

Introduction : Fear of falling (FOF) is associated with falls and modifications in gait parameters. Foot clearance during walking is directly linked to tripping and falling. The relationship between FOF and foot Downloaded from http://gerontologist.oxfordjournals.org/ at Université & EPFL Lausanne on January 23, 2013 436 The Gerontological Society of America clearance has never been evaluated. Methods : Participants (N=568, aged 66 to 71 years, 57.2% women) underwent gait parameters measurements using footworn sensors. Specific foot clearance parameters evaluated included maximal and minimal heel and toe clearances and their variability. FOF was assessed using a single question. Results : Overall, 27.4% of the participants reported FOF. Compared to the others, participants with FOF had decreased maximal heel (28.9 vs 30.4 cm, p<.001) and toe clearance (12.5 vs 13.8 cm, p<.001), and decreased minimal toe clearance variability (SD 3.7 vs 4.0 cm, p<.001). Conclusion : These preliminary results suggest a relationship between FOF and foot clearance parameters. Multivariate analyses are underway.

Evaluating fear of falling among community-dwelling older people: A qualitative pattern model based on the experience of falls

This research was conducted in the context of the project IRIS 8A Health and Society (2002-2008) and financially supported by the University of Lausanne. It was aomed at developping a model based on the elder people's experience and allowed us to develop a "Portrait evaluation" of fear of falling using their examples and words. It is a very simple evaluation, which can be used by professionals, but by the elder people themselves. The "Portrait evaluation" and the user's guide are on free access, but we would very much approciate to know whether other people or scientists have used it and collect their comments. (contact: Chantal.Piot-Ziegler@unil.ch)The purpose of this study is to create a model grounded in the elderly people's experience allowing the development of an original instrument to evaluate FOF.In a previous study, 58 semi-structured interviews were conducted with community-dwelling elderly people. The qualitative thematic analysis showed that fear of falling was defined through the functional, social and psychological long-term consequences of falls (Piot-Ziegler et al., 2007).In order to reveal patterns in the expression of fear of falling, an original qualitative thematic pattern analysis (QUAlitative Pattern Analysis - QUAPA) is developed and applied on these interviews.The results of this analysis show an internal coherence across the three dimensions (functional, social and psychological). Four different patterns are found, corresponding to four degrees of fear of falling. They are formalized in a fear of falling intensity model.This model leads to a portrait-evaluation for fallers and non-fallers. The evaluation must be confronted to large samples of elderly people, living in different environments. It presents an original alternative to the concept of self-efficacy to evaluate fear of falling in older people.The model of FOF presented in this article is grounded on elderly people's experience. It gives an experiential description of the three dimensions constitutive of FOF and of their evolution as fear increases, and defines an evaluation tool using situations and wordings based on the elderly people's discourse.

Fear of Falling Appearing after Post-Acute Rehabilitation is Associated with Reduced Functional Status

Objective: To investigate the association between fear of falling appearing within one month after discharge from post-acute rehabilitation and functional status in elderly patients. Methods: Participants (N=180, mean age 81.37.1 years, 75.6% women) were patients consecutively admitted to rehabilitation over a 6-month period. Demographics, functional, cognitive and affective status were assessed upon admission; functional status was assessed at discharge; history of falls since discharge, functional and affective status were assessed by phone one month after discharge. Fear of falling was assessed using the question: "Are you afraid of falling?". Results: Among patients without fear of falling at discharge (N=95), 20.0% (N=19) reported new fear of falling one month after discharge. Living alone (adjOR=4.9, 95%CI 1.04-23.16, P=.045), functional status at discharge (adjOR=0.5, 95%CI 0.32-0.88, P=.014), and depressive symptoms (adjOR=5.4, 95%CI 1.20-24.32, P=.028) independently predicted fear of falling at one month. There was weak evidence that history of falls since discharge (adjOR=4.1, 95%CI 0.81-21.31, P=.088) was associated with new fear of falling. Developing fear of falling was also associated with reduced functional status at one month (mean basic ADL score: fearful 5.20.8; confident: 5.80.4,P<.001). This association remained after controlling for demographics, functional status at discharge, depressive symptoms, and history of falls since discharge (coef =-0.4, 95%CI -0.73 to -0.16, P=.003). Conclusion: Fear of falling appearing within one month after discharge from post-acute rehabilitation was associated with reduced functional status in elderly patients. Further studies should determine whether early interventions targeting specifically fear of falling in these patients would improve their functional status.

Extreme self-monitoring, fear of hypoglycemia and obsessive-compulsive disorder in type 1 diabetes mellitus: when less is better

Background: Pre-existing psychological factors can strongly influence coping with type 1 diabetes mellitus and interfere with self-monitoring. Psychiatric disorders seem to be positively associated with poor metabolic control. We present a case of extreme compulsive blood testing due to obsessive fear of hypoglycemia in an adolescent with type 1 diabetes mellitus. Case report: Type 1 diabetes mellitus (anti GAD-antibodies 2624 U/l, norm < 9.5) was diagnosed in a boy aged 14.3 years [170 cm (+ 0.93 SDS), weight 50.5 kg (+ 0.05 SDS)]. Laboratory work-up showed no evidence for other autoimmune disease. Family and past medical history were unremarkable. Growth and developmental milestones were normal. Insulin-analog based basal-bolus regime was initiated, associated to standard diabetic education. Routine psychological evaluation performed at the onset of diabetes revealed intermittent anxiety and obsessivecompulsive traits. Accordingly, a close psychiatric follow-up was initiated for the patient and his family. An adequate metabolic control (HbA1c drop from >14 to 8%) was achieved within 3 months, attributed to residual -cell function. In the following 6 months, HbA1c rose unexpectedly despite seemingly adequate adaptations of insulin doses. Obsessive fear of hypoglycemia leading to a severe compulsive behavior developed progressively with as many as 68 glycemia measurements per day (mean over 1 week). The patient reported that he could not bear leaving home with glycemia < 15 mmol/l, ending up with school eviction and severe intra-familial conflict. Despite intensive psychiatric outpatient support, HbA1c rose rapidly to >14% with glycemia-testing reaching peaks of 120 tests/day. The situation could only be discontinued through psychiatric hospitalization with intensive behavioral training. As a result, adequate metabolic balance was restored (HbA1c value: 7.1 %) with acceptable 10-15 daily glycemia measurements. Discussion: The association of overt psychiatric disorders to type 1 diabetes mellitus is very rare in the pediatric age group. It can lead to a pathological behavior with uncontrolled diabetes. Such exceptional situations require long-term admissions with specialized psychiatric care. Slow acceptation of a "less is better" principle in glycemia testing and amelioration of metabolic control are difficult to achieve.