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August/September 2003

By William C. Miller, PhD, OT

William C. Miller, PhD, OT, assists a client, Helen, in an ABC Scale activity, reaching for an object on tiptoes. Achieving repeated success in activities such as this leads to increased confidence.

Overcoming fear of falling plays an important role in treating individuals with lower-limb amputations.

It is commonly accepted that in order to get ahead in life you need to take risks. While some people throw caution to the wind and try, others never get started because they fear failure. When learning a new skill or relearning a formerly familiar skill, many individuals begin with trepidation until confidence grows. Simply put, having the physical ability does not imply that it will be used. You’ve got to believe.

Successful rehabilitation of an acute or chronic impairment extends beyond the acquisition of endurance, strength and range of motion, or learning about a new strategy. A major frustration experienced by therapists who work with individuals who are learning to use a prosthetic leg after amputation is that many patients do not achieve their potential. Failure to achieve occurs despite the technological advances in the fabrication of ultralight, durable, and microchip “smart” prosthetic limbs designed to improve the efficiency and quality of gait.

Given the cost, estimated to be $56,000,1 from time of amputation to 1 year postrehabilitation, careful consideration must be given not only in determining the most appropriate candidates for rehabilitation, but also in deciding who may require additional intervention to facilitate success. With 40,000 to 50,000 major lower limb amputations (at the ankle or higher) that require prosthetic rehabilitation each year,2 the cost is indeed considerable. Consequently, many studies have been conducted to identify indicators of successful outcomes in this population. Most of the indicators studied to date have focused on obvious factors such as age, comorbidity, cause, and level of amputation. A common observation made at our clinic was that many patients appeared to be afraid of losing their balance. Fear of falling and/or a lack of balance confidence when performing activities while using a prosthesis are modifiable factors that can be addressed by rehabilitation professionals.

Fear of Falling
Fear of falling can be linked to previous falls, although a person does not need to have fallen to experience the associated fear. Both falling and fear of falling are significant health problems that are of interest to health professionals and researchers because they suggest a decline in function that is potentially modifiable.3 Falling and fear of falling have interesting implications for the rehabilitation of the prosthetic amputee population because they are at considerable risk for falling and fear of falling given their specific impairments, which can including altered gait pattern associated with their use of a prosthesis, increased energy expenditure, and the loss of sensory feedback associated with the loss of a lower limb. Moreover, because people with lower-limb amputations are most often elderly people with multiple comorbidities,4 the loss of a lower limb brings an additional challenge. Consequently, the prevalence for falls and fear of falling among people with lower-limb amputations appears to be very high.5

While the annual incidence rate of falls among community living elderly (65 years and older) is approximately 30%,6 52% of a sample of people with unilateral transfemoral (TF) and transtibial (TT)amputations reported that they experienced at least one fall in a year.5 Falls are associated with functional disability and are likely indicative of declines in independence, decreased mobility, and self-imposed restrictions in activity.3 Aside from the potential for physical injury associated with falling,7,8 the psychological sequelae, often consisting of fear of falling, may be an even greater concern.

Fear of falling among the general population of elderly ranges from 20% to 46%,9,10 and has been reported to be as high as 49% in the amputee population.5 Although one does not have to fall to experience a fear of falling, fear appeared to be more of a problem among the fallers (55%) compared to nonfallers (43%).5 A major outcome of fear of falling is activity restriction. In fact, 76% of those individuals who had a fear of falling reported that they avoided many activities as a result of loss of confidence. Ultimately, such self-imposed restriction can lead to deterioration in balance,9 muscle endurance, strength, flexibility, and coordination11 and therefore, a cycle between dehabilitation and psychological sequelae likely exists.

From Fear To Confidence
There are a number of potential external indicators that identify individuals who are unsteady on their feet. These may act as proxies for clinicians to determine whether a person is afraid of falling. Some of these proxies include use of walk aids, such as a cane or walker; walk tests such as the Timed “Up and Go”; or balance tests such as the Berg Balance Scale. These performance-oriented measures provide a relatively objective indication of fear; however, they do not directly provide insight into an individual’s fear of falling.

Ultimately, the best way is to ask the individual. Historically, investigators have relied on a simple one-sentence question to assess fear related to falling. Several limitations exist with such an approach, and as a result Tinetti3 and others expanded on Albert Bandura’s Social Learning Theory and began investigating fear of falling using the construct of fall-related self-efficacy or balance confidence. In general, self-efficacy is defined as an individual’s perceived ability or self-confidence, where confidence is defined as the belief that the individual has the capability to perform an activity or action.13

Defining fear of falling as balance confidence during activities overcomes several limitations associated with the more general measure of fear.14 First, phrasing questions using confidence of performance reduces stigma associated with psychological conditions such as fears or phobias. Essentially, it is less threatening to ask about the degree of confidence in performing an activity especially among men who may associate admission of fear as a sign of weakness.9,14

Second, instead of relying on a yes/no response indicating the presence or absence of fear, measures of balance confidence capture data along a continuum (0-10) ranging from “no confidence” to “100% confident.” This development permits a more responsive measure that distinguishes between different levels of confidence and better enables researchers and clinicians to capture when change has occurred as a result of an intervention or treatment.

Finally, studies reveal that measures of confidence are strongly linked with independence in daily and social activities while global measures of traits such as absence or presence of fear are relatively poor predictors of behavior.3,7 Given that the ultimate goal of rehabilitation is a return to participation in social activities among individuals with impairments and disabilities, and that low self-efficacy has been shown to lead to avoidance of activities,13 the scale may provide useful clinical information about patients.

Measuring Fear
There are two prominent measures of balance confidence: the Falls Efficacy Scale (FES)3 and the Activities-specific Balance Confidence Scale (ABC).15 The ABC is the only scale that has been used in studies of the amputee population. The ABC Scale is a 16-item questionnaire (see Table 1, page 40) that asks about situation-specific activities that require varying amounts of balance to provide an estimate of the degree of fear of falling.

This scale, which takes about 5 minutes to complete, has recently received increasing attention from clinicians and researchers. The reliability and validity of the ABC in the amputee population have been demonstrated to be excellent for both research and clinical use. Findings suggest a change in score of ± 6 points would indicate that real change has occurred.7 Ongoing study of the ABC to identify change is currently under way.

Table 1. List of actions measured by the Activities-specific Balance Confidence (ABC) Scale.

In a descriptive study designed to examine balance confidence among people with transtibial or transfemoral lower-limb amputations, mean ABC scores of 63.8/100 were recorded; however, 35% of the sample scored 80 or better.17 To provide some context, Myers et al reported that healthy, physically active elderly achieved confidence scores of > 88 on the ABC.17 Both the vascular groups (amputation due to diseases such as diabetes that lead to damage of the arteries serving the lower limb) and nonvascular groups (amputation due to reasons related to cancer, trauma, or congenital causes) had lower mean scores (mean = 54.1 and 74.7, respectively) than highly functioning elderly. Intervention, in the form of education, balance training, and activity, has been advocated for individuals who score below 80,17 which equates to about 81% of the vascular and 46% of the nonvascular amputees.

Differences in balance confidence based on amputation cause were expected because individuals with vascular disease tend to be older, have more comorbidity, and use more medications. Studies also suggest that traumatic amputees perform better than vascular amputees in balance and postural sway.18-20

Interestingly, the difference in ABC Scale scores between individuals with TF and TT amputations was only about 4.01 points and not considered statistically important. This was a surprise because clinically, we would expect those with a TF amputation to display behaviors consistent with lower confidence, and would tend to have poorer performance related to mobility and activity. One would predict that the loss of stability from removal of both an ankle and a knee joint would result in substantially lower balance confidence given that prosthetic joints do not provide proprioceptive or kinesthetic sensation.

As logical as it is to expect differences in balance confidence between individuals with and without knee joints, it may simply be that behavioral adaptation, such as use of a mobility device and concentrating while walking, takes place regardless of amputation level.

Lower confidence scores were recorded for women, and for individuals who were older, had a lower level of education, and used more medications, all of which is consistent with findings from other populations where balance confidence has been studied.

Why Does Confidence Matter?
Balance confidence has been found to be important to a broad range of functioning. Specifically, in the amputee population, individuals who had a reduced balance confidence tended to also have a reduced prosthetic mobility capability (tasks people think they can do related to their mobility), reduced mobility performance (things people have done related to mobility), and limited participation in social activity.

Essentially, this supports the notion that balance confidence is indicative of performance. The link between confidence and performance is one of the primary tenets of Bandura’s Social Learning Theory of self-efficacy,13 which states that behavior is the result of having the skill, motivation, and confidence to engage in the activity. Self-efficacy, which is the basis for balance confidence, as measured by the ABC, is believed to be more predictive of future function than measures of performance among different treatment groups.

Diminished balance confidence is a condition that is thought to be remediable13 through graduated trials and practice of the activities in their actual environment. In a recent report, Pandian and Kowalske22 suggest amputee rehabilitation activities be conducted from a simple to complex continuum, starting in the rehabilitation setting and evolving to the home. The authors suggest that an advanced activity program will improve strength, balance, and coordination; however, it is possible that graduated task-specific intervention will also improve confidence. Randomized controlled intervention trials designed to counter the effects of reduced balance confidence among the elderly report improvement in activity performance and confidence.21

Thus, enhancement of balance confidence may improve prosthetic mobility and social activity among the amputee population and is worthy of further consideration by clinicians. Clinical trials are required to determine the efficacy of this form of treatment for amputees.

Getting The Message Out
Fear of falling or balance confidence is a major concern among the population of individuals who have had a lower limb amputation. The degree and influence of balance confidence on rehabilitation outcomes have gone largely unnoticed. Clinicians should consider adding a measure of balance confidence to identify and monitor for the presence of low balance confidence. With appropriate treatment, this remediable condition may be improved and the quality of life related to functional limitation and social activity of the patients under their care may improve. Moreover, balance confidence may be a good indicator to determine outcome at discharge from rehabilitation.

Bandura suggests that there are several approaches to improving confidence. The most powerful approach is to provide opportunities to master the activity in the natural environment. When applied to balance confidence, grading activities in a manner that provides the right level of challenge to permit repeated successes will promote confidence.

Providing exposure to others who are succeeding in similar situations can influence confidence because people also get their information through vicarious experiences and verbal persuasion. This can occur in formal settings such as the treatment area or informal settings such as the waiting room during follow-up visits or the patient’s home. Some programs outside amputee rehabilitation have successfully used support groups or “patient partners” to facilitate adaptive learning. Exposure to role models with lived experience provides proof that success is possible.

Verbal persuasion or encouragement or discouragement is another technique that can influence confidence. Often individuals are encouraged not to perform an activity for a variety of reasons such as safety. Well-meaning comments, such as “you shouldn’t go out right now because the sidewalks are wet and icy,” may inadvertently reinforce decreased confidence. This powerful message can be interpreted by the recipient that others may question the recipient’s ability. Those who do not believe they can perform certain activities are more likely to avoid them and therefore are less likely to fall.

Ultimately, the individual’s appraisal may change from being adaptive and avoiding hazardous activities, such as climbing on a chair to reach for something, to becoming maladaptive. In the latter case, the clients’ fears prevent them from doing activities within their capabilities, thus resulting in further health problems and increased likelihood of falls due to inactivity. Well-timed positive persuasion can be the boost that individuals need in order to achieve.

Finally, individuals who question their ability have strong visceral responses to the high arousal that accompanies performance. Assisting individuals to identify their cues and providing strategies to overcome their responses is another technique that may prove useful.

These techniques have not yet been fully assessed among individuals who have amputations. However, if the treatment assumptions and conditions of Social Learning Theory are generalized, the techniques described here could provide useful approaches to introduce and emphasize in amputee rehabilitation.

References

Calle-Pascual AL, Redondo MJ, Ballesteros M, et al. Nontraumatic lower extremity amputations in diabetic and non-diabetic subjects in Madrid, Spain. Diabetes Metab. 1997;23(6):519-23.
Malone JM. Complication of lower extremity amputation. In: Moore WS, Malone JM, eds. Lower Extremity Amputation. Philadelphia: WB Saunders; 1989:208.
Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol. 1984;49:M140-7.
De Frang RD, Taylor L, Porter JM. Basic data related to amputations. Ann Vasc Surg. 1991;5:202-207.
Miller WC, Deathe AB, Speechley M. The prevalence and risk factors of falling and fear of falling among individuals with lower extremity amputation. Arch Phys Med Rehabil. 2001;82:1031-1037.
Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med. 1989;320:1055-1059.
Miller WC, Speechley M, Deathe AB, Koval J. The influence of falling, fear of falling, and balance confidence on prosthetic mobility and social activity among individuals with a lower extremity amputation. Arch Phys Med Rehabil. 2001; 82:1238-1244.
Tinetti ME. Factors associated with serious injury during falls by ambulatory nursing home residents. J Am Geriat Soc. 1987;35:644-48.
Maki BE, Holliday PJ, Topper AK. Fear of falling and postural performance in the elderly. J Gerontol. 1991;46:M123-31.
Walker JE, Howland J. Falls and fear of falling among elderly persons living in the community: occupational therapy interventions. Am J Occup Ther. 1991; 45:119-22.
Myers A, Gonda G. Research on physical activity in the elderly: practical implications for program planning. Can J Aging. 1991;5:175-87.
Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med. 1989;320:1055-1059.
Bandura A. Self-efficacy mechanism human agency. Am Psychol. 1982;37:122-147.
Tinetti ME, Richman D, Powell LE. Falls efficacy as a measure of fear of falling. J Gerontol. 1990;45:P239-P243.
Myers AM, Powell LE, Maki BE, Holliday PJ, Brawley LR, Sherk W. Psychological indicators of balance confidence: relationship to actual and perceived abilities. J Gerontol. 1996;51A: M37-43.
Miller WC, Speechley M, Deathe AB. Balance confidence among people with lower-limb amputations. Phys Ther. 2002;82:856-65.
Myers AM, Fletcher PC, Myers AH, Sherk W. Discriminative and evaluative properties of the Activities-specific Balance Confidence (ABC) scale. J Gerontol. 1998;53:M287-94.
Fernie GR, Holliday PJ. Postural sway in amputees and normal subjects. J Bone Joint Surg Am. 1978;60:895-8.
Hermodsson Y, Ekadahl C, Persson BM, Roxendal G. Standing balance in trans-tibial amputees following vascular disease or trauma: a comparative study. Prosthet Orthot Int. 1994;18:150-8.
Isakov E, Mizrahi J, Ring H, Susak Z, Hakim N. Standing sway and weight-bearing distribution in people with below-knee amputations. Arch Phys Med Rehabil. 1992;73:174-8.
Tennstedt S, Howland J, Lachman M, Peterson E, Kasten L, Jette A. A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. J Gerontol B Psychol Sci Soc Sci. 1998; 53(6):P384-92.
Pandian G, Kowalske K. Daily functioning of patients with an amputated lower extremity. Clin Orthop. 1999;361: 91-97.

William C. Miller, PhD, OT, is a scientist with the Centre for Clinical Epidemiology and Evaluation at the Vancouver Coastal Health Authority and assistant professor for the University of British Columbia School of Rehabilitation Sciences, Vancouver, BC, Canada.

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