Original article 167
Balance self-efficacy in older adults following inpatient rehabilitation Suzanne S. Kuysa,b, Jacquelin Donovanc, Sarah Mattind and Nancy L. Low Choyd Older adults discharging from inpatient rehabilitation were investigated to determine change in self-efficacy at 1 month after discharge, the relationship with discharge balance performance and physical function, and the influence of diagnosis. A prospective cohort of 101 adults older than 50 years of age, 43% men, average age 75.84 (SD 9.8) years, were recruited at discharge from inpatient rehabilitation. Balance self-efficacy was assessed using Activities-specific Balance Confidence (ABC) scale at discharge and 1 month following discharge. Balance and physical function were measured at discharge using the Functional Independence Measure, Balance Outcome Measure for Elder Rehabilitation, Modified Elderly Mobility Scale and gait speed. At discharge, balance self-efficacy was moderate (ABC score 62, SD 23) and did not change at follow-up. When grouped by discharge self-efficacy (ABC scores: low < 50; moderate 51–80; high > 80), significant betweengroup differences were found for balance (P = 0.005) and physical function (P = 0.035). At the 1-month follow-up, those with low discharge balance self-efficacy showed improvement (mean-change ABC score 12, 95% confidence interval 2–22) and those with high discharge balance selfefficacy had lower scores (mean-change ABC score 18,
95% confidence interval − 8 to − 28). Differences in ABC change scores were also found between diagnostic groups (F = 3.740, P = 0.03), with the orthopaedic group improving (ABC mean change = 8) and the general frailty group showing a decrease in confidence (ABC mean change = 10). The differences in balance self-efficacy change at 1 month following discharge were related to self-efficacy level at discharge and clinical group requiring rehabilitation. Clinicians need to be aware of these changes as patients are prepared for discharge. International Journal of Rehabilitation Research 38:167–172 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Introduction
efficacy is associated with balance and mobility performance in other older adult clinical populations such as following a fractured neck of the femur or joint replacement (Portegijs et al., 2012) and that level of balance selfefficacy may be able to discriminate functional ability (Myers et al., 1998) in community-dwelling older adults, but further investigation is required.
Self-efficacy is defined as an individual’s perception or judgement of his/her ability to organize and execute specific tasks or type of performance (Bandura, 1977; Salbach et al., 2005). It is believed that an individual’s willingness to engage in a certain behaviour is influenced by his/her perception of his/her abilities to safely complete the behaviour. This certainly has implications for the performance of everyday activities by older adults. For example, falls self-efficacy has been shown to be associated independently with balance performance and mobility in older women (Liu-Ambrose et al., 2006). Similar findings have been reported for patients with stroke, with falls self-efficacy associated independently with balance and mobility performance (Pang and Eng, 2008). In addition, self-efficacy has been shown to be predictive of a stroke survivor’s ability to complete activities of daily living (Hellstrom et al., 2003) and reintegrate back into the community (Pang et al., 2007) as well as their overall health status (Salbach et al., 2006). There is some evidence to suggest that balance selfPart of the information in this manuscript was presented at the Australian Physiotherapy Conference, Australia 2011. 0342-5282 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
International Journal of Rehabilitation Research 2015, 38:167–172 Keywords: balance, balance self-efficacy, inpatient rehabilitation, older adults a
Griffith Health Institute, Griffith University, Gold Coast, bAllied Health Research Collaborative, Metro North Hospital and Health Service, The Prince Charles Hospital, Chermside, cPrincess Alexandra Hospital and dSchool of Physiotherapy, Australian Catholic University, Brisbane, Queensland, Australia Correspondence to Suzanne S. Kuys, PhD, Allied Health Research Collaborative, Metro North Hospital and Health Service, The Prince Charles Hospital, Rode Road, Chermside, Queensland 4032, Australia Tel: + 61 7 31396319; fax: + 61 7 31396228; e-mail: [email protected] Received 15 September 2014 Accepted 8 December 2014
Balance retraining is a common intervention undertaken during geriatric inpatient rehabilitation. Certainly, improvements in gait and balance following inpatient rehabilitation are reported for older adults (Jones et al., 2002; Gosselin et al., 2008) and self-efficacy has been shown to influence participation in exercise following discharge from hospital (Hill et al., 2011). However, changes in balance self-efficacy following discharge from hospital rehabilitation have received little attention and the relationship between balance performance, physical function and balance self-efficacy is unclear. To be confident that rehabilitation programmes are addressing the activity limitation and activity avoidance related to balance and mobility in this population, therapists need to know whether the balance and physical function outcomes assessed at discharge from a rehabilitation unit can DOI: 10.1097/MRR.0000000000000106
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inform balance confidence and community participation in the immediate transition period to home following discharge and whether the reason for admission or level of balance self-efficacy influences this issue. A relatively new tool, the Balance Outcome Measure for Elder Rehabilitation (BOOMER) (Haines et al., 2007), a composite balance score comprising the Functional Reach, static balance, Step Test and Timed Up and Go test, has recently been found to have concurrent validity with the Berg Balance Scale (Kuys et al., 2011) and a moderate association with self-reported balance confidence (Kuys et al., 2014) in a group of older adults admitted to hospital following an acute illness. Although the Berg Balance Scale has been strongly correlated with self-efficacy (Lajoie and Gallagher, 2004), the BOOMER (faster to perform in a busy inpatient setting) has not been assessed for its relationship with balance selfefficacy in rehabilitation cohorts. Other commonly used inpatient rehabilitation measures of physical function such as the Functional Independence Measure (FIM) (Granger et al., 1993), Modified Elderly Mobility Scale (MEMS) (Kuys and Brauer, 2006) and gait speed should also be investigated in terms of their relationship with self-efficacy. The aim of this study was to investigate balance selfefficacy of older adults at discharge and 1 month after discharge from inpatient rehabilitation to determine whether self-efficacy changed after discharge from inpatient rehabilitation. The secondary aims were to examine the relationship between the level of balance self-efficacy and discharge physical function, balance performance and gait speed. In addition, the study investigated the influence of the diagnosis or the reason for admission on balance self-efficacy, change in balance self-efficacy or physical function. We hypothesized that self-efficacy would improve by 1 month after discharge from inpatient rehabilitation, that balance self-efficacy would be related to performance and the reason for inpatient rehabilitation admission or diagnosis would not influence self-efficacy.
Participants and methods Design
A prospective longitudinal cohort study of older adults discharging home from inpatient rehabilitation was carried out in a tertiary hospital in Queensland, Australia. A sample of convenience was collected over a 2-year period. Participants underwent a routine physiotherapy assessment on discharge from inpatient rehabilitation, with self-efficacy reported at both discharge and 1 month after discharge. The study was approved by the institutional Human Research Ethics Committees and conformed to the Helsinki Declaration.
Participants, therapists, centres
Older adults admitted for inpatient rehabilitation and who were being discharged to community dwellings were eligible for participation. Participants provided informed consent, with an FIM cognitive score of more than 25 indicating that basic cognition was intact (Rabadi et al., 2008). Participants also had sufficient comprehension of English and written skills to complete the questionnaires, were older than 50 years of age and had been inpatients for a minimum of 3 weeks. Patients discharging to a residential aged care facility were excluded from this study. The rehabilitation unit comprised 76 beds, and patients underwent an individualized rehabilitation programme prescribed by the multidisciplinary team of geriatricians, nursing and allied health professionals. Procedures
Up to 48 h before discharge, participants underwent a standard physiotherapy discharge assessment that was completed by their treating therapist. This included measures of physical function using the MEMS, balance and gait speed. In addition, the rehabilitation team completed the FIM (cognitive and motor subscale) at rehabilitation discharge. The researchers administered the Activities-specific Balance Confidence (ABC) scale (Powell and Myers, 1995) at discharge and consented for follow-up at 1 month after discharge. At 1 month after discharge, participants were contacted both by phone and by post to collect follow-up measures of their balance selfefficacy at that time point. Clinical and demographic information recorded at discharge included age, sex, diagnosis and reason for admission to hospital (neurological, orthopaedic or other geriatric condition), rehabilitation length of stay and planned postdischarge therapy and social services such as home assistance for housework. Outcome measures
Balance self-efficacy was measured using the ABC scale (Powell and Myers, 1995). Physical function was measured using the FIM-M (FIM motor subscale) (Granger et al., 1993) and MEMS (Kuys and Brauer, 2006). Balance performance was measured using the BOOMER (Haines et al., 2007) and gait speed was assessed using comfortable and fast pace 10-m walk tests (Wade et al., 1987; Bohannon, 1997). The ABC scale (Powell and Myers, 1995) is a 16-item survey in which participants rate their perceived confidence with everyday balance tasks on a 0–100% scale. Balance self-efficacy scores at discharge to home and follow-up were grouped as high (ABC scores > 80), moderate (ABC scores 51–80) and low (ABC scores < 50) balance self-efficacy (Myers et al., 1998). The FIM is an 18-item scale that measured the assistance required to complete a range of motor and cognitive activities. A motor (13 items, 0–91) and cognitive (five items, 0–35) subscale score as well as a total score are determined
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Balance self-efficacy in older adults Kuys et al. 169
(Granger et al., 1993). MEMS is a valid and reliable measure of activity limitation, comprising eight items including bed mobility, sit to stand, gait speed, functional reach and stair climbing with each task rated (0–3) with a total score ranging from 0 to23 (Kuys and Brauer, 2006). The BOOMER (Haines et al., 2007) is a multi-item balance measure comprising the Timed Up and Go test (Podsiadlo and Richardson, 1991), Functional Reach (Duncan et al., 1990), Step test (Hill et al., 1996) and static balance determined by feet together eyes closed (Anacker and Di Fabio, 1992; Cohen et al., 1993). Each test is scored on a five-point scale (0–4), with a maximum score of 16. Gait speed was measured using the 10-m walk test. Participants walked both at a comfortable and at a fast pace over a 14-m track using usual gait aids with the middle 10 m timed using a hand-held stopwatch (Wade et al., 1987; Bohannon 1997). Data management and analysis
Descriptive analyses were carried out for all measures. A paired t-test was used to examine change in balance selfefficacy (ABC scores) over time. One-way analysis of variance (ANOVA) analyses were used to investigate differences in discharge physical function, balance and mobility between the groups on the basis of balance self-efficacy. One-way ANOVA with Tukey’s post-hoc analyses or a nonparametric equivalent were used to determine whether the diagnosis or the reason for admission (neurological, orthopaedic or other geriatric condition) influenced balance self-efficacy, change in balance self-efficacy or physical function. SPSS v21 (IBM Corporation SPSS Statistics, IBM Pty Ltd, Armonk, New York, USA) was used for all analyses and a P-value of 0.05 was set for significance.
Results One hundred and one participants were recruited into this study. Table 1 outlines the demographic and clinical characteristics of the participants recruited. Participants were older (mean age 76 years, SD 10), mostly women and admitted for a variety of conditions including
Demographic and clinical characteristics of the participants
Table 1
Characteristics Sex, males [n (%)] Age [mean (SD)] (years) Diagnosis/reason for admission [n (%)] Neurological Orthopaedic Other geriatric condition Length of rehabilitation stay [mean (SD)] (days) Discharge residence [n (%)] Living alone Living with family Other Discharge support [n (%)] Received postdischarge therapy services Received social support (e.g. home assistance)
n = 101 43 (42.6) 75.84 (9.8) 30 39 32 47.4
(29.7) (38.6) (31.7) (43.4)
40 (39.6) 58 (57.4) 2 (2) 71 (70.3) 48 (47.5)
neurological, orthopaedic and other geriatric conditions (chronic disease, deconditioning after illness) to undertake rehabilitation. At the 1-month follow-up, 64 (63.36%) participants could be contacted to complete measures. There was no difference for those lost to follow-up for age, sex, length of stay, diagnosis, discharge physical function or discharge balance self-efficacy (P > 0.182). Balance self-efficacy and physical function, balance and gait speed at discharge at the 1-month follow-up for the total cohort and the balance self-efficacy subgroups
Table 2 outlines the ABC scores at discharge and the 1-month follow-up, and discharge physical function, balance and gait speed for all participants and for balance selfefficacy sub-groups. At discharge and at the 1-month followup, participants showed moderate balance self-efficacy. When participants were grouped according to discharge balance self-efficacy, one-way ANOVA analyses showed significant between-group differences for FIM-M scores (F = 5.275, P = 0.007) and fast gait speed (F = 3.516, P = 0.035). Kruskal–Wallis analyses showed a significant between-group difference for MEMS (χ2 = 7.569, P = 0.022) and BOOMER (χ2 = 10.765, P = 0.005) scores. Participants with high balance self-efficacy on discharge (ABC scores > 80) (n = 30) showed better functional performance, balance and fast pace gait speed compared with participants with low balance self-efficacy on discharge (ABC score < 50) (n = 33) with higher FIM-M scores [mean difference 9, 95% confidence interval (CI) 2–15] and fast pace gait speed (mean difference 4.2 s, 95% CI 0.1–8.2). The median MEMS and BOOMER scores were also higher for those with high balance self-efficacy compared with other groups at hospital discharge (Table 2). At the 1-month follow-up, balance self-efficacy of the total cohort did not change (t = 0.336, P = 0.738). Differences were found when examining balance selfefficacy at 1 month across the self-efficacy subgroups. One-way ANOVA indicated significant between-group differences for ABC change scores from discharge to the 1-month follow-up. At the 1-month follow-up, those participants with low balance self-efficacy on discharge (ABC score < 50) (n = 33) showed improvement (mean change ABC score 12, 95% CI 2–22). In contrast, participants with high balance self-efficacy at discharge had lower scores at the 1-month follow-up, mean change ABC score − 18 (95% CI − 8 to − 28). Influence of diagnosis
Table 3 outlines the characteristics, self-efficacy and physical function scores of the three diagnostic groups: neurological, orthopaedic and other geriatric conditions. Those participants receiving inpatient rehabilitation for a neurological condition were younger than those admitted following an orthopaedic or other geriatric condition (F = 13.348, P < 0.001), and those admitted for an orthopaedic condition were more likely to be women (χ2 = 16.418, P < 0.001).
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Balance self-efficacy, physical performance measures, balance and gait speed at discharge for the total cohort and balance selfefficacy subgroups
Table 2
Balance self-efficacy All (n = 101)
Measures BOOMER/16 [median (IQR)] Timed 10-m walk timed (s) [mean (SD)] Comfortable pace Fast pace MEMS/23 [median (IQR)] Total FIM (0–126) [mean (SD)] Motor FIM (0–91) Cognitive FIM (0–35) Discharge Activities Balance Confidence scale/100 [mean (SD)] 1-month Activities Balance Confidence scale/100 [mean (SD)]
Low (ABC < 50) (n = 33)
11 (8–13) 17.55 13.78 21 111 79 33 62
(7.8) (5.9) (19–22) (12) (9) (3) (23)
63 (23)
8 (4–12) 18.99 15.54 20 106 74 33 35.6
(7.4) (6.5) (16–22) (14) (11) (3) (13)
52.3 (21)
Moderate (ABC score 51–80) (n = 38) 11 (9–13) 17.98 14.54 21 112 79 32 65.4
(7.9) (4.8) (19–23) (13) (12) (3) (8)
66.1 (22)
High (ABC score > 80) (n = 30) 13 (10–14) 15.39 11.39 22 115 83 33 90
(8.0) (5.86) (20–23) (7) (6) (2) (6)
71.1 (22)
BOOMER, Balance Outcome Measure for Elder Rehabilitation; FIM, Functional Independence Measure; IQR, interquartile range; MEMS, Modified Elderly Mobility Scale.
Table 3
Characteristics, balance self-efficacy and discharge balance and physical performance measures for diagnostic subgroups Diagnosis
Characteristics/measures Sex males [n (%)] Age [mean (SD)] (years) Length of stay [mean (SD)] (days) BOOMER/16 [median (IQR)] Timed 10-m walk timed (s) Comfortable pace [mean (SD)] Fast pace [mean (SD)] MEMS/23 [median (IQR)] Total FIM (0–126) [mean (SD)] Motor FIM (0–91) Cognitive FIM (0–35) Discharge Activities Balance Confidence scale/100 [mean (SD)] 1-month Activities Balance Confidence scale/100 [mean (SD)]
Neurological (n = 30) 19 69 62.4 11
(63) (10.4) (58.2) (8–14)
15.54 12.02 21 111.6 79.9 31.7 66.4 65.1
(8) (5.9) (19–22) (14) (11.8) (4) (23) (21)
Orthopaedic (n = 39) 7 79.7 37.7 10 19.25 14.63 21 109.5 76.3 33.2 58.5 68.8
Other geriatric condition (n = 32)
(18) (8.5) (21.4) (8–13)
17 77.6 44.9 11
(53) (7.5) (45.1) (6–13)
(6.5) (5.7) (18–22) (13) (12) (3) (25) (24.4)
17.27 13.97 21 112.1 79.8 33.3 63.5 52.4
(8.9) (6.1) (19–23) (10) (7) (2) (22) (20)
BOOMER, Balance Outcome Measure for Elder Rehabilitation; FIM, Functional Independence Measure; IQR, interquartile range; MEMS, Modified Elderly Mobility Scale.
No significant difference was found for length of rehabilitation stay (F = 2.898, P = 0.60), although neurological patients tended to have a longer length of stay compared with the other groups. There was no difference at discharge between the groups for physical function, balance and gait speed (χ2 < 1.545, F < 1.827; P > 0.167). One-way ANOVA indicated no significant between-group (neurological, orthopaedic, other geriatric condition) difference for ABC scores at discharge (F = 0.972, P = 0.382). One-way ANOVA analyses showed significant betweengroup differences for ABC change scores from discharge to the 1-month follow-up (F = 3.740, P = 0.03). At the 1-month follow-up, the orthopaedic group (n = 39) showed improvement (mean change ABC score 8, 95% CI − 2 to 17) whereas participants admitted for other geriatric conditions had worse ABC scores, mean change − 10 (95% CI − 23 to 1), and neurological patients showed no change.
Discussion This study found that older adults being discharged from inpatient rehabilitation had moderate balance selfefficacy. Older adults with high balance self-efficacy
had better balance, physical function and gait speed compared with those with low self-efficacy. By 1 month after discharge, those with low balance self-efficacy showed an improvement in their balance self-efficacy, whereas those with high self-efficacy had lower scores. Differences in balance self-efficacy were found across diagnostic groups between discharge and 1 month after discharge. Patients admitted with an orthopaedic condition showed improved balance self-efficacy at 1 month after discharge from inpatient rehabilitation, neurological patients did not show any change and those admitted with other geriatric conditions showed decreased balance self-efficacy. Balance self-efficacy in older adults discharged from inpatient hospital-based rehabilitation stay has received little investigation. We have reported previously on the balance self-efficacy of older adults on discharge from the acute hospital setting (Kuys et al., 2014). Similar ABC scores were reported by both studies, suggesting that balance self-efficacy is at best moderate for older hospitalized adults whether managed in acute ward or rehabilitation settings. In contrast to our hypothesis, we found
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Balance self-efficacy in older adults Kuys et al. 171
that balance self-efficacy did not change at 1 month following inpatient rehabilitation discharge, remaining at a moderate level. Clinical populations appear to have consistently reported moderate levels of balance selfefficacy, including those with chronic obstructive airways disease (Beauchamp et al., 2009) or stroke (Botner et al., 2005; Combs et al., 2010). Certainly in the current study, similar ABC scores were found for all diagnostic groups (neurological, orthopaedic, other geriatric condition). Community-dwelling older adults have been reported in the literature to have good balance self-efficacy, with older women at risk of falling scoring under 80 on the ABC (Talley et al., 2008) and healthier older adults scoring higher (Asano et al., 2007). Scores less than 80 on the ABC scale have also been linked to falls when individuals are diagnosed with Parkinson’s disease (Mak and Pang, 2009) and stroke (Beninato et al., 2009). It is possible that changes in balance self-efficacy, balance performance, physical function and gait speed may be related to the level of balance self-efficacy at hospital discharge. It is reasonable to suggest, for example, that those with low levels of balance self-efficacy may have worse balance performance, functional ability and slower gait speeds, and may also be more likely to improve following hospital discharge compared with those with high levels of balance self-efficacy. Balance self-efficacy level has been previously shown to be a strong determinant of functional mobility (Myers et al., 1998), balance performance and falls risk in community-dwelling older adults (Hatch et al., 2003; Lajoie and Gallagher, 2004). This relationship appears to be similar for older adults discharged from inpatient rehabilitation. We found significant differences in physical function and balance performance measures for the balance self-efficacy subgroups. Although falls diaries would have been a useful measure to include, it appears that those with low balance self-efficacy in the current study performed worse on all physical function and balance measures and were therefore likely to have a high falls risk once discharged back to the community. Alternatively, the diagnosis may have also contributed towards the level of balance self-efficacy observed. However, we found no difference in balance self-efficacy – or for physical function, balance and gait speed measures – for the three diagnostic groups at inpatient rehabilitation discharge. This suggests that multidisciplinary rehabilitation teams at least in this setting are fairly consistent in the functional requirements for rehabilitation discharge, irrespective of diagnosis. It is unknown whether this is a conscious decision. Anecdotally, clinical decision making on discharge timeliness does appear to focus on achievement of independent mobility, at least for neurological patients (Korner-Bitensky et al., 1989). In this study, balance performance, physical function and gait speed were indicative of independent functioning.
By 1 month after discharge, however, balance selfefficacy had changed depending on the diagnostic group. It is unclear why patients admitted with an orthopaedic condition would show an improvement in their balance self-efficacy at 1 month after discharge whereas those admitted with other geriatric conditions worsened. It is likely that the underlying prognosis associated with admission diagnosis may partly explain this finding. Improvements in walking ability and activity levels (Ingemarsson et al., 2003) and high balance selfefficacy have been found for older adults following hip fracture living in the community (Portegijs et al., 2012). It is possible that patients admitted for rehabilitation with other geriatric conditions may have been frail or deconditioned following their acute hospital admission. Little follow-up of this group following inpatient rehabilitation has been carried out previously (Kortebein, 2009); thus, it is unclear whether the findings of the current study are typical.
Limitations
This study is not without its limitations. Only patients who could provide consent (cognition scores above 25 on the FIM cognitive subscale) were recruited into this study. In addition, this was a sample of convenience with patients recruited as able by the treating physiotherapists. Details were not recorded as to the reasons why patients were not recruited into this study; thus, it is possible that these findings are not generalizable to all older adults being discharged from inpatient rehabilitation. A number of participants (n = 39) were lost at the 1-month follow-up. Although this number is high, it highlights the potential frailty of this group (Hubbard et al., 2011) and the difficulties experienced in the first month following discharge from hospital (Nalder et al., 2012). Those lost to follow-up were not different with respect to age, sex, diagnosis/reason for hospital admission, length of stay, physical function, balance, gait speed or balance self-efficacy (P > 0.197). In summary, balance self-efficacy was moderate in this group of older adults discharged from inpatient rehabilitation, and did not change by 1 month after discharge. Discharge balance self-efficacy was related to physical function, balance performance and gait speed at discharge. Diagnosis appears to influence changes in balance self-efficacy, with those admitted for orthopaedic reasons improving in balance self-efficacy and those admitted following a geriatric condition experiencing worse balance self-efficacy in the first month after discharge.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
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Balance self-efficacy in older adults following inpatient rehabilitation Suzanne S. Kuysa,b, Jacquelin Donovanc, Sarah Mattind and Nancy L. Low Choyd Older adults discharging from inpatient rehabilitation were investigated to determine change in self-efficacy at 1 month after discharge, the relationship with discharge balance performance and physical function, and the influence of diagnosis. A prospective cohort of 101 adults older than 50 years of age, 43% men, average age 75.84 (SD 9.8) years, were recruited at discharge from inpatient rehabilitation. Balance self-efficacy was assessed using Activities-specific Balance Confidence (ABC) scale at discharge and 1 month following discharge. Balance and physical function were measured at discharge using the Functional Independence Measure, Balance Outcome Measure for Elder Rehabilitation, Modified Elderly Mobility Scale and gait speed. At discharge, balance self-efficacy was moderate (ABC score 62, SD 23) and did not change at follow-up. When grouped by discharge self-efficacy (ABC scores: low < 50; moderate 51–80; high > 80), significant betweengroup differences were found for balance (P = 0.005) and physical function (P = 0.035). At the 1-month follow-up, those with low discharge balance self-efficacy showed improvement (mean-change ABC score 12, 95% confidence interval 2–22) and those with high discharge balance selfefficacy had lower scores (mean-change ABC score 18,
95% confidence interval − 8 to − 28). Differences in ABC change scores were also found between diagnostic groups (F = 3.740, P = 0.03), with the orthopaedic group improving (ABC mean change = 8) and the general frailty group showing a decrease in confidence (ABC mean change = 10). The differences in balance self-efficacy change at 1 month following discharge were related to self-efficacy level at discharge and clinical group requiring rehabilitation. Clinicians need to be aware of these changes as patients are prepared for discharge. International Journal of Rehabilitation Research 38:167–172 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Introduction
efficacy is associated with balance and mobility performance in other older adult clinical populations such as following a fractured neck of the femur or joint replacement (Portegijs et al., 2012) and that level of balance selfefficacy may be able to discriminate functional ability (Myers et al., 1998) in community-dwelling older adults, but further investigation is required.
Self-efficacy is defined as an individual’s perception or judgement of his/her ability to organize and execute specific tasks or type of performance (Bandura, 1977; Salbach et al., 2005). It is believed that an individual’s willingness to engage in a certain behaviour is influenced by his/her perception of his/her abilities to safely complete the behaviour. This certainly has implications for the performance of everyday activities by older adults. For example, falls self-efficacy has been shown to be associated independently with balance performance and mobility in older women (Liu-Ambrose et al., 2006). Similar findings have been reported for patients with stroke, with falls self-efficacy associated independently with balance and mobility performance (Pang and Eng, 2008). In addition, self-efficacy has been shown to be predictive of a stroke survivor’s ability to complete activities of daily living (Hellstrom et al., 2003) and reintegrate back into the community (Pang et al., 2007) as well as their overall health status (Salbach et al., 2006). There is some evidence to suggest that balance selfPart of the information in this manuscript was presented at the Australian Physiotherapy Conference, Australia 2011. 0342-5282 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
International Journal of Rehabilitation Research 2015, 38:167–172 Keywords: balance, balance self-efficacy, inpatient rehabilitation, older adults a
Griffith Health Institute, Griffith University, Gold Coast, bAllied Health Research Collaborative, Metro North Hospital and Health Service, The Prince Charles Hospital, Chermside, cPrincess Alexandra Hospital and dSchool of Physiotherapy, Australian Catholic University, Brisbane, Queensland, Australia Correspondence to Suzanne S. Kuys, PhD, Allied Health Research Collaborative, Metro North Hospital and Health Service, The Prince Charles Hospital, Rode Road, Chermside, Queensland 4032, Australia Tel: + 61 7 31396319; fax: + 61 7 31396228; e-mail: [email protected] Received 15 September 2014 Accepted 8 December 2014
Balance retraining is a common intervention undertaken during geriatric inpatient rehabilitation. Certainly, improvements in gait and balance following inpatient rehabilitation are reported for older adults (Jones et al., 2002; Gosselin et al., 2008) and self-efficacy has been shown to influence participation in exercise following discharge from hospital (Hill et al., 2011). However, changes in balance self-efficacy following discharge from hospital rehabilitation have received little attention and the relationship between balance performance, physical function and balance self-efficacy is unclear. To be confident that rehabilitation programmes are addressing the activity limitation and activity avoidance related to balance and mobility in this population, therapists need to know whether the balance and physical function outcomes assessed at discharge from a rehabilitation unit can DOI: 10.1097/MRR.0000000000000106
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inform balance confidence and community participation in the immediate transition period to home following discharge and whether the reason for admission or level of balance self-efficacy influences this issue. A relatively new tool, the Balance Outcome Measure for Elder Rehabilitation (BOOMER) (Haines et al., 2007), a composite balance score comprising the Functional Reach, static balance, Step Test and Timed Up and Go test, has recently been found to have concurrent validity with the Berg Balance Scale (Kuys et al., 2011) and a moderate association with self-reported balance confidence (Kuys et al., 2014) in a group of older adults admitted to hospital following an acute illness. Although the Berg Balance Scale has been strongly correlated with self-efficacy (Lajoie and Gallagher, 2004), the BOOMER (faster to perform in a busy inpatient setting) has not been assessed for its relationship with balance selfefficacy in rehabilitation cohorts. Other commonly used inpatient rehabilitation measures of physical function such as the Functional Independence Measure (FIM) (Granger et al., 1993), Modified Elderly Mobility Scale (MEMS) (Kuys and Brauer, 2006) and gait speed should also be investigated in terms of their relationship with self-efficacy. The aim of this study was to investigate balance selfefficacy of older adults at discharge and 1 month after discharge from inpatient rehabilitation to determine whether self-efficacy changed after discharge from inpatient rehabilitation. The secondary aims were to examine the relationship between the level of balance self-efficacy and discharge physical function, balance performance and gait speed. In addition, the study investigated the influence of the diagnosis or the reason for admission on balance self-efficacy, change in balance self-efficacy or physical function. We hypothesized that self-efficacy would improve by 1 month after discharge from inpatient rehabilitation, that balance self-efficacy would be related to performance and the reason for inpatient rehabilitation admission or diagnosis would not influence self-efficacy.
Participants and methods Design
A prospective longitudinal cohort study of older adults discharging home from inpatient rehabilitation was carried out in a tertiary hospital in Queensland, Australia. A sample of convenience was collected over a 2-year period. Participants underwent a routine physiotherapy assessment on discharge from inpatient rehabilitation, with self-efficacy reported at both discharge and 1 month after discharge. The study was approved by the institutional Human Research Ethics Committees and conformed to the Helsinki Declaration.
Participants, therapists, centres
Older adults admitted for inpatient rehabilitation and who were being discharged to community dwellings were eligible for participation. Participants provided informed consent, with an FIM cognitive score of more than 25 indicating that basic cognition was intact (Rabadi et al., 2008). Participants also had sufficient comprehension of English and written skills to complete the questionnaires, were older than 50 years of age and had been inpatients for a minimum of 3 weeks. Patients discharging to a residential aged care facility were excluded from this study. The rehabilitation unit comprised 76 beds, and patients underwent an individualized rehabilitation programme prescribed by the multidisciplinary team of geriatricians, nursing and allied health professionals. Procedures
Up to 48 h before discharge, participants underwent a standard physiotherapy discharge assessment that was completed by their treating therapist. This included measures of physical function using the MEMS, balance and gait speed. In addition, the rehabilitation team completed the FIM (cognitive and motor subscale) at rehabilitation discharge. The researchers administered the Activities-specific Balance Confidence (ABC) scale (Powell and Myers, 1995) at discharge and consented for follow-up at 1 month after discharge. At 1 month after discharge, participants were contacted both by phone and by post to collect follow-up measures of their balance selfefficacy at that time point. Clinical and demographic information recorded at discharge included age, sex, diagnosis and reason for admission to hospital (neurological, orthopaedic or other geriatric condition), rehabilitation length of stay and planned postdischarge therapy and social services such as home assistance for housework. Outcome measures
Balance self-efficacy was measured using the ABC scale (Powell and Myers, 1995). Physical function was measured using the FIM-M (FIM motor subscale) (Granger et al., 1993) and MEMS (Kuys and Brauer, 2006). Balance performance was measured using the BOOMER (Haines et al., 2007) and gait speed was assessed using comfortable and fast pace 10-m walk tests (Wade et al., 1987; Bohannon, 1997). The ABC scale (Powell and Myers, 1995) is a 16-item survey in which participants rate their perceived confidence with everyday balance tasks on a 0–100% scale. Balance self-efficacy scores at discharge to home and follow-up were grouped as high (ABC scores > 80), moderate (ABC scores 51–80) and low (ABC scores < 50) balance self-efficacy (Myers et al., 1998). The FIM is an 18-item scale that measured the assistance required to complete a range of motor and cognitive activities. A motor (13 items, 0–91) and cognitive (five items, 0–35) subscale score as well as a total score are determined
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Balance self-efficacy in older adults Kuys et al. 169
(Granger et al., 1993). MEMS is a valid and reliable measure of activity limitation, comprising eight items including bed mobility, sit to stand, gait speed, functional reach and stair climbing with each task rated (0–3) with a total score ranging from 0 to23 (Kuys and Brauer, 2006). The BOOMER (Haines et al., 2007) is a multi-item balance measure comprising the Timed Up and Go test (Podsiadlo and Richardson, 1991), Functional Reach (Duncan et al., 1990), Step test (Hill et al., 1996) and static balance determined by feet together eyes closed (Anacker and Di Fabio, 1992; Cohen et al., 1993). Each test is scored on a five-point scale (0–4), with a maximum score of 16. Gait speed was measured using the 10-m walk test. Participants walked both at a comfortable and at a fast pace over a 14-m track using usual gait aids with the middle 10 m timed using a hand-held stopwatch (Wade et al., 1987; Bohannon 1997). Data management and analysis
Descriptive analyses were carried out for all measures. A paired t-test was used to examine change in balance selfefficacy (ABC scores) over time. One-way analysis of variance (ANOVA) analyses were used to investigate differences in discharge physical function, balance and mobility between the groups on the basis of balance self-efficacy. One-way ANOVA with Tukey’s post-hoc analyses or a nonparametric equivalent were used to determine whether the diagnosis or the reason for admission (neurological, orthopaedic or other geriatric condition) influenced balance self-efficacy, change in balance self-efficacy or physical function. SPSS v21 (IBM Corporation SPSS Statistics, IBM Pty Ltd, Armonk, New York, USA) was used for all analyses and a P-value of 0.05 was set for significance.
Results One hundred and one participants were recruited into this study. Table 1 outlines the demographic and clinical characteristics of the participants recruited. Participants were older (mean age 76 years, SD 10), mostly women and admitted for a variety of conditions including
Demographic and clinical characteristics of the participants
Table 1
Characteristics Sex, males [n (%)] Age [mean (SD)] (years) Diagnosis/reason for admission [n (%)] Neurological Orthopaedic Other geriatric condition Length of rehabilitation stay [mean (SD)] (days) Discharge residence [n (%)] Living alone Living with family Other Discharge support [n (%)] Received postdischarge therapy services Received social support (e.g. home assistance)
n = 101 43 (42.6) 75.84 (9.8) 30 39 32 47.4
(29.7) (38.6) (31.7) (43.4)
40 (39.6) 58 (57.4) 2 (2) 71 (70.3) 48 (47.5)
neurological, orthopaedic and other geriatric conditions (chronic disease, deconditioning after illness) to undertake rehabilitation. At the 1-month follow-up, 64 (63.36%) participants could be contacted to complete measures. There was no difference for those lost to follow-up for age, sex, length of stay, diagnosis, discharge physical function or discharge balance self-efficacy (P > 0.182). Balance self-efficacy and physical function, balance and gait speed at discharge at the 1-month follow-up for the total cohort and the balance self-efficacy subgroups
Table 2 outlines the ABC scores at discharge and the 1-month follow-up, and discharge physical function, balance and gait speed for all participants and for balance selfefficacy sub-groups. At discharge and at the 1-month followup, participants showed moderate balance self-efficacy. When participants were grouped according to discharge balance self-efficacy, one-way ANOVA analyses showed significant between-group differences for FIM-M scores (F = 5.275, P = 0.007) and fast gait speed (F = 3.516, P = 0.035). Kruskal–Wallis analyses showed a significant between-group difference for MEMS (χ2 = 7.569, P = 0.022) and BOOMER (χ2 = 10.765, P = 0.005) scores. Participants with high balance self-efficacy on discharge (ABC scores > 80) (n = 30) showed better functional performance, balance and fast pace gait speed compared with participants with low balance self-efficacy on discharge (ABC score < 50) (n = 33) with higher FIM-M scores [mean difference 9, 95% confidence interval (CI) 2–15] and fast pace gait speed (mean difference 4.2 s, 95% CI 0.1–8.2). The median MEMS and BOOMER scores were also higher for those with high balance self-efficacy compared with other groups at hospital discharge (Table 2). At the 1-month follow-up, balance self-efficacy of the total cohort did not change (t = 0.336, P = 0.738). Differences were found when examining balance selfefficacy at 1 month across the self-efficacy subgroups. One-way ANOVA indicated significant between-group differences for ABC change scores from discharge to the 1-month follow-up. At the 1-month follow-up, those participants with low balance self-efficacy on discharge (ABC score < 50) (n = 33) showed improvement (mean change ABC score 12, 95% CI 2–22). In contrast, participants with high balance self-efficacy at discharge had lower scores at the 1-month follow-up, mean change ABC score − 18 (95% CI − 8 to − 28). Influence of diagnosis
Table 3 outlines the characteristics, self-efficacy and physical function scores of the three diagnostic groups: neurological, orthopaedic and other geriatric conditions. Those participants receiving inpatient rehabilitation for a neurological condition were younger than those admitted following an orthopaedic or other geriatric condition (F = 13.348, P < 0.001), and those admitted for an orthopaedic condition were more likely to be women (χ2 = 16.418, P < 0.001).
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Balance self-efficacy, physical performance measures, balance and gait speed at discharge for the total cohort and balance selfefficacy subgroups
Table 2
Balance self-efficacy All (n = 101)
Measures BOOMER/16 [median (IQR)] Timed 10-m walk timed (s) [mean (SD)] Comfortable pace Fast pace MEMS/23 [median (IQR)] Total FIM (0–126) [mean (SD)] Motor FIM (0–91) Cognitive FIM (0–35) Discharge Activities Balance Confidence scale/100 [mean (SD)] 1-month Activities Balance Confidence scale/100 [mean (SD)]
Low (ABC < 50) (n = 33)
11 (8–13) 17.55 13.78 21 111 79 33 62
(7.8) (5.9) (19–22) (12) (9) (3) (23)
63 (23)
8 (4–12) 18.99 15.54 20 106 74 33 35.6
(7.4) (6.5) (16–22) (14) (11) (3) (13)
52.3 (21)
Moderate (ABC score 51–80) (n = 38) 11 (9–13) 17.98 14.54 21 112 79 32 65.4
(7.9) (4.8) (19–23) (13) (12) (3) (8)
66.1 (22)
High (ABC score > 80) (n = 30) 13 (10–14) 15.39 11.39 22 115 83 33 90
(8.0) (5.86) (20–23) (7) (6) (2) (6)
71.1 (22)
BOOMER, Balance Outcome Measure for Elder Rehabilitation; FIM, Functional Independence Measure; IQR, interquartile range; MEMS, Modified Elderly Mobility Scale.
Table 3
Characteristics, balance self-efficacy and discharge balance and physical performance measures for diagnostic subgroups Diagnosis
Characteristics/measures Sex males [n (%)] Age [mean (SD)] (years) Length of stay [mean (SD)] (days) BOOMER/16 [median (IQR)] Timed 10-m walk timed (s) Comfortable pace [mean (SD)] Fast pace [mean (SD)] MEMS/23 [median (IQR)] Total FIM (0–126) [mean (SD)] Motor FIM (0–91) Cognitive FIM (0–35) Discharge Activities Balance Confidence scale/100 [mean (SD)] 1-month Activities Balance Confidence scale/100 [mean (SD)]
Neurological (n = 30) 19 69 62.4 11
(63) (10.4) (58.2) (8–14)
15.54 12.02 21 111.6 79.9 31.7 66.4 65.1
(8) (5.9) (19–22) (14) (11.8) (4) (23) (21)
Orthopaedic (n = 39) 7 79.7 37.7 10 19.25 14.63 21 109.5 76.3 33.2 58.5 68.8
Other geriatric condition (n = 32)
(18) (8.5) (21.4) (8–13)
17 77.6 44.9 11
(53) (7.5) (45.1) (6–13)
(6.5) (5.7) (18–22) (13) (12) (3) (25) (24.4)
17.27 13.97 21 112.1 79.8 33.3 63.5 52.4
(8.9) (6.1) (19–23) (10) (7) (2) (22) (20)
BOOMER, Balance Outcome Measure for Elder Rehabilitation; FIM, Functional Independence Measure; IQR, interquartile range; MEMS, Modified Elderly Mobility Scale.
No significant difference was found for length of rehabilitation stay (F = 2.898, P = 0.60), although neurological patients tended to have a longer length of stay compared with the other groups. There was no difference at discharge between the groups for physical function, balance and gait speed (χ2 < 1.545, F < 1.827; P > 0.167). One-way ANOVA indicated no significant between-group (neurological, orthopaedic, other geriatric condition) difference for ABC scores at discharge (F = 0.972, P = 0.382). One-way ANOVA analyses showed significant betweengroup differences for ABC change scores from discharge to the 1-month follow-up (F = 3.740, P = 0.03). At the 1-month follow-up, the orthopaedic group (n = 39) showed improvement (mean change ABC score 8, 95% CI − 2 to 17) whereas participants admitted for other geriatric conditions had worse ABC scores, mean change − 10 (95% CI − 23 to 1), and neurological patients showed no change.
Discussion This study found that older adults being discharged from inpatient rehabilitation had moderate balance selfefficacy. Older adults with high balance self-efficacy
had better balance, physical function and gait speed compared with those with low self-efficacy. By 1 month after discharge, those with low balance self-efficacy showed an improvement in their balance self-efficacy, whereas those with high self-efficacy had lower scores. Differences in balance self-efficacy were found across diagnostic groups between discharge and 1 month after discharge. Patients admitted with an orthopaedic condition showed improved balance self-efficacy at 1 month after discharge from inpatient rehabilitation, neurological patients did not show any change and those admitted with other geriatric conditions showed decreased balance self-efficacy. Balance self-efficacy in older adults discharged from inpatient hospital-based rehabilitation stay has received little investigation. We have reported previously on the balance self-efficacy of older adults on discharge from the acute hospital setting (Kuys et al., 2014). Similar ABC scores were reported by both studies, suggesting that balance self-efficacy is at best moderate for older hospitalized adults whether managed in acute ward or rehabilitation settings. In contrast to our hypothesis, we found
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Balance self-efficacy in older adults Kuys et al. 171
that balance self-efficacy did not change at 1 month following inpatient rehabilitation discharge, remaining at a moderate level. Clinical populations appear to have consistently reported moderate levels of balance selfefficacy, including those with chronic obstructive airways disease (Beauchamp et al., 2009) or stroke (Botner et al., 2005; Combs et al., 2010). Certainly in the current study, similar ABC scores were found for all diagnostic groups (neurological, orthopaedic, other geriatric condition). Community-dwelling older adults have been reported in the literature to have good balance self-efficacy, with older women at risk of falling scoring under 80 on the ABC (Talley et al., 2008) and healthier older adults scoring higher (Asano et al., 2007). Scores less than 80 on the ABC scale have also been linked to falls when individuals are diagnosed with Parkinson’s disease (Mak and Pang, 2009) and stroke (Beninato et al., 2009). It is possible that changes in balance self-efficacy, balance performance, physical function and gait speed may be related to the level of balance self-efficacy at hospital discharge. It is reasonable to suggest, for example, that those with low levels of balance self-efficacy may have worse balance performance, functional ability and slower gait speeds, and may also be more likely to improve following hospital discharge compared with those with high levels of balance self-efficacy. Balance self-efficacy level has been previously shown to be a strong determinant of functional mobility (Myers et al., 1998), balance performance and falls risk in community-dwelling older adults (Hatch et al., 2003; Lajoie and Gallagher, 2004). This relationship appears to be similar for older adults discharged from inpatient rehabilitation. We found significant differences in physical function and balance performance measures for the balance self-efficacy subgroups. Although falls diaries would have been a useful measure to include, it appears that those with low balance self-efficacy in the current study performed worse on all physical function and balance measures and were therefore likely to have a high falls risk once discharged back to the community. Alternatively, the diagnosis may have also contributed towards the level of balance self-efficacy observed. However, we found no difference in balance self-efficacy – or for physical function, balance and gait speed measures – for the three diagnostic groups at inpatient rehabilitation discharge. This suggests that multidisciplinary rehabilitation teams at least in this setting are fairly consistent in the functional requirements for rehabilitation discharge, irrespective of diagnosis. It is unknown whether this is a conscious decision. Anecdotally, clinical decision making on discharge timeliness does appear to focus on achievement of independent mobility, at least for neurological patients (Korner-Bitensky et al., 1989). In this study, balance performance, physical function and gait speed were indicative of independent functioning.
By 1 month after discharge, however, balance selfefficacy had changed depending on the diagnostic group. It is unclear why patients admitted with an orthopaedic condition would show an improvement in their balance self-efficacy at 1 month after discharge whereas those admitted with other geriatric conditions worsened. It is likely that the underlying prognosis associated with admission diagnosis may partly explain this finding. Improvements in walking ability and activity levels (Ingemarsson et al., 2003) and high balance selfefficacy have been found for older adults following hip fracture living in the community (Portegijs et al., 2012). It is possible that patients admitted for rehabilitation with other geriatric conditions may have been frail or deconditioned following their acute hospital admission. Little follow-up of this group following inpatient rehabilitation has been carried out previously (Kortebein, 2009); thus, it is unclear whether the findings of the current study are typical.
Limitations
This study is not without its limitations. Only patients who could provide consent (cognition scores above 25 on the FIM cognitive subscale) were recruited into this study. In addition, this was a sample of convenience with patients recruited as able by the treating physiotherapists. Details were not recorded as to the reasons why patients were not recruited into this study; thus, it is possible that these findings are not generalizable to all older adults being discharged from inpatient rehabilitation. A number of participants (n = 39) were lost at the 1-month follow-up. Although this number is high, it highlights the potential frailty of this group (Hubbard et al., 2011) and the difficulties experienced in the first month following discharge from hospital (Nalder et al., 2012). Those lost to follow-up were not different with respect to age, sex, diagnosis/reason for hospital admission, length of stay, physical function, balance, gait speed or balance self-efficacy (P > 0.197). In summary, balance self-efficacy was moderate in this group of older adults discharged from inpatient rehabilitation, and did not change by 1 month after discharge. Discharge balance self-efficacy was related to physical function, balance performance and gait speed at discharge. Diagnosis appears to influence changes in balance self-efficacy, with those admitted for orthopaedic reasons improving in balance self-efficacy and those admitted following a geriatric condition experiencing worse balance self-efficacy in the first month after discharge.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
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International Journal of Rehabilitation Research 2015, Vol 38 No 2
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