Osteoporosis International

, Volume 19, Issue 7, pp 919–927 | Cite as

Fall-related self-efficacy, not balance and mobility performance, is related to accidental falls in chronic stroke survivors with low bone mineral density

  • M. Y. C. Pang
  • J. J. Eng
Original Article



Chronic stroke survivors with low hip bone density are particularly prone to fractures. This study shows that fear of falling is independently associated with falls in this population. Thus, fear of falling should not be overlooked in the prevention of fragility fractures in these patients.


Chronic stroke survivors with low bone mineral density (BMD) are particularly prone to fragility fractures. The purpose of this study was to identify the determinants of balance, mobility and falls in this sub-group of stroke patients.


Thirty-nine chronic stroke survivors with low hip BMD (T-score <−1.0) were studied. Each subject was evaluated for the following: balance, mobility, leg muscle strength, spasticity, and fall-related self-efficacy. Any falls in the past 12 months were also recorded. Multiple regression analysis was used to identify the determinants of balance and mobility performance, whereas logistic regression was used to identify the determinants of falls.


Multiple regression analysis revealed that after adjusting for basic demographics, fall-related self-efficacy remained independently associated with balance/mobility performance (R2 = 0.494, P < 0.001). Logistic regression showed that fall-related self-efficacy, but not balance and mobility performance, was a significant determinant of falls (odds ratio: 0.18, P = 0.04).


Fall-related self-efficacy, but not mobility and balance performance, was the most important determinant of accidental falls. This psychological factor should not be overlooked in the prevention of fragility fractures among chronic stroke survivors with low hip BMD.


Bone density Cerebrovascular accident Falls Fractures Rehabilitation Self-efficacy 



M.Y.C.P. was supported by a post-doctoral fellowship from Natural Sciences and Engineering Research Council of Canada. This study was supported by a grant-in-aid from the Heart Stroke Foundation of British Columbia and Yukon (J.J.E.) and from career scientist awards from Canadian Institute of Health Research (J.J.E) and the Michael Smith Foundation for Health Research (J.J.E.).

Conflicts of interest



  1. 1.
    Jorgensen L, Engstad T, Jacobsen BK (2002) Higher incidence of falls in long-term stroke survivors than in population controls. Depressive symptoms predict falls after stroke. Stroke 33:542–547PubMedCrossRefGoogle Scholar
  2. 2.
    Tutuarima JA, van der Meulen JHP, de Haan RJ et al (1997) Risk factors for falls of hospitalized stroke patients. Stroke 28:297–301PubMedGoogle Scholar
  3. 3.
    Nyberg L, Gustafson Y (1995) Patient falls in stroke rehabilitation: a challenge to rehabilitation strategies. Stroke 26:838–842PubMedGoogle Scholar
  4. 4.
    Lamb SE, Ferrucci L, Volapto S et al (2003) Risk factors for falling in home-dwelling older women with stroke. The women’s health and aging study. Stroke 34:494–501PubMedCrossRefGoogle Scholar
  5. 5.
    Hyndman D, Ashburn A, Stack E et al (2002) Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers. Arch Phys Med Rehabil 83:165–170PubMedCrossRefGoogle Scholar
  6. 6.
    Hyndman D, Ashburn A (2003) People with stroke living in the community: attention deficits, balance, ADL ability, and falls. Disabil Rehabil 25:817–822PubMedCrossRefGoogle Scholar
  7. 7.
    Eng JJ, Chu KS, Dawson AS et al (2002) Functional walk tests in individuals with stroke. Relation to perceived exertion and myocardial exertion. Stroke 33:756–761PubMedCrossRefGoogle Scholar
  8. 8.
    Ng SS, Hui Chan CW (2005) The Timed Up & Go test: its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Arch Phys Med Rehabil 86:1641–1647PubMedCrossRefGoogle Scholar
  9. 9.
    Tinetti ME, Speechley M, Gineter SF et al (1988) Risk factors for falls among elderly persons living in the community. N Engl J Med 319:1701–1707PubMedCrossRefGoogle Scholar
  10. 10.
    Belgen B, Beninato M, Sullivan PE et al (2006) The association of balance capacity and falls self-efficacy with history of falling in community-dwelling people with chronic stroke. Arch Phys Med Rehabil 87:554–561PubMedCrossRefGoogle Scholar
  11. 11.
    Rosen E, Sunnerhagen KS, Kreuter M et al (2005) Fear of falling, balance, and gait velocity in patients with stroke. Physiother Theory Pract 21:113–120PubMedCrossRefGoogle Scholar
  12. 12.
    Powell LE, Myers AM (1995) The Activities-Specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci 50A:M28–M34PubMedGoogle Scholar
  13. 13.
    Myers AM, Fletcher PC, Myers AH et al (1998) Discriminative and evaluative properties of the Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci 53:M287–294PubMedGoogle Scholar
  14. 14.
    Fletcher PC, Hirdes JP (2004) Restriction in activity associated with fear of falling among community-based seniors using home care services. Age Ageing 33:273–279PubMedCrossRefGoogle Scholar
  15. 15.
    Tinetti ME, Mendes de Leon CF, Doucette JT et al (1994) Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol 49:M140–M147PubMedGoogle Scholar
  16. 16.
    Maki BE, Holliday PJ, Topper AK et al (1991) Fear of falling and postural performance in the elderly. J Gerontol Med Sci 46:M123–M131Google Scholar
  17. 17.
    Liu-Ambrose T, Khan KM, Donaldson MG et al (2006) Fall-related self-efficacy is independently associated with balance and mobility in older women with low bone mass. J Gerontol Med Sci A 8:832–838Google Scholar
  18. 18.
    Hellstrom K, Lindmark B, Wahlberg B et al (2003) Self-efficacy in relation to impairments and activities of daily living disability in elderly patients with stroke: a prospective investigation. J Rehabil Med 35:2002–2007Google Scholar
  19. 19.
    Ramnemark A, Nyberg L, Borssen B et al (1998) Fractures after stroke. Osteoporos Int 8:92–95PubMedCrossRefGoogle Scholar
  20. 20.
    Farahmand BY, Michaelsson K, Ahlbom A et al (2005) Swedish Hip Fracture Study Group. Survival after hip fracture. Osteoporos Int 16:1583–1590PubMedCrossRefGoogle Scholar
  21. 21.
    Ramnemark A, Nilsson M, Borssen B et al (2000) Stroke, a major and increasing risk factor for femoral neck fracture. Stroke 31:1572–1577PubMedGoogle Scholar
  22. 22.
    Di Monaco M, Vallero F, Di Monaco R et al (2003) Functional recovery and length of stay after hip fracture in patients with neurologic impairment. Am J Phys Med Rehabil. 82:143–148PubMedCrossRefGoogle Scholar
  23. 23.
    Eng JJ, Pang MYC, Ashe MA. Role of exercise in reducing the risk of fracture after stroke. J Rehabil Res Dev. In press.Google Scholar
  24. 24.
    Braithwaite RS, Col NF, Wong JB et al (2003) Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc 51:364–370PubMedCrossRefGoogle Scholar
  25. 25.
    Folstein MF, Folstein, SE, McHugh PR et al (1975) Mini-Mental State: A practical method for grading the state of patients for the clinician. J Psychiatr Res 12:189–198PubMedCrossRefGoogle Scholar
  26. 26.
    Washburn RA, Zhu W, McAuley E et al (2002) The physical activity scale for individuals with physical disabilities: development and evaluation. Arch Phys Med Rehabil 83:193–200PubMedCrossRefGoogle Scholar
  27. 27.
    Berg KO, Wood-Dauphinee SL, Williams JI et al (1992) Measuring balance in the elderly: Validation of an instrument. Physiother Can 41:304–311Google Scholar
  28. 28.
    Podsiadlo D, Richardson S (1991) The timed “Up & Go”: a test of basic functional mobility for frail elderly. J Am Geriatr Soc 39:142–148PubMedGoogle Scholar
  29. 29.
    Kim CM, Eng JJ (2003) The relationship of lower-extremity muscle torque to locomotor performance in people with stroke. Phys Ther 83:49–57PubMedGoogle Scholar
  30. 30.
    Bohannon RW (1997) Measurement and nature of muscle strength in patients with stroke. J Neuro Rehabil 11:115–125Google Scholar
  31. 31.
    Bohannon RW, Smith MB (1987) Interrater reliability of a Modified Ashworth Scale of muscle spasticity. Phys Ther 67:206–207PubMedGoogle Scholar
  32. 32.
    Botner EM, Miller WC, Eng JJ (2005) Measurement properties of the Activities-specific Balance Confidence Scale among individuals with stroke. Disabil Rehabil 27:156–163PubMedCrossRefGoogle Scholar
  33. 33.
    Tabachnick B, Fidell L (eds) (2001) Using multivariate statistics. 4th edition. Allyn and Bacon, BostonGoogle Scholar
  34. 34.
    Bogle Thorbahn LD, Newton RA (1996) Use of the Berg Balance Test to predict falls in elderly persons. Phys Ther 76:576–582PubMedGoogle Scholar
  35. 35.
    Shumway-Cook A, Baldwin M, Polissar NL et al (1997) Predicting the probability of falls in community-dwelling older adults. Phys Ther 77:812–819PubMedGoogle Scholar
  36. 36.
    Steffen TM, Hacker TA, Mollinger L (2002) Age- and gender-related test performance in community-dwelling elderly people: six-minute walk test, Berg balance sale, timed up & go test, and gait speeds. Phys Ther 82:128–137PubMedGoogle Scholar
  37. 37.
    Friedman SM, Munox B, West SK et al (2002) Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. J Am Geriatr Soc 50:1329–1335PubMedCrossRefGoogle Scholar
  38. 38.
    Salbach NM, Mayo NE, Robichaud-Ekstrand S et al (2006) Balance self-efficacy and its relevance to physical function and perceived health status after stroke. Arch Phys Med Rehabil 87:364–370PubMedCrossRefGoogle Scholar
  39. 39.
    Harris JE, Eng JJ, Marigold DS et al (2005) Relationship of balance and mobility to fall incidence in people with chronic stroke. Phys Ther 85:150–158PubMedGoogle Scholar
  40. 40.
    Melton III LJ, Brown Sr RD, Achenbach SJ et al (2001) Long-term fracture risk following ischemic stroke: a population study. Osteoporos Int 12:980–986PubMedCrossRefGoogle Scholar
  41. 41.
    Bandura A (1977) Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 84:240–245CrossRefGoogle Scholar
  42. 42.
    Howland J, Tennstedt S, Lachman M et al (1998) A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. J Gerontol Psychol Sci 53B:P384–392Google Scholar
  43. 43.
    Nevitt MC, Cummings SR, Kidd S et al (1989) Risk factors for recurrent nonsyncopal falls. JAMA 261:2663–2668PubMedCrossRefGoogle Scholar
  44. 44.
    Salbach NM, Mayo NE, Robichaud-Ekstrand S et al (2005) The effect of a task-oriented walking intervention on improving balance self-efficacy poststroke: a randomized, controlled trial. J Am Geriatr Soc 53:576–582PubMedCrossRefGoogle Scholar
  45. 45.
    Jorgensen HS, Nakayama H, Raaschou HO et al (1999) Stroke: Neurologic and functional recovery. The Copenhagen Study. Phys Med Rehabil Clin N Am 10:887–906PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2007

Authors and Affiliations

  1. 1.Department of Rehabilitation SciencesHong Kong Polytechnic UniversityHung HomChina
  2. 2.Department of Physical Therapy and Graduate Program in Rehabilitation SciencesUniversity of British ColumbiaVancouverCanada
  3. 3.Rehabilitation Research LaboratoryGF Strong CentreVancouverCanada

Personalised recommendations