The Balance Recovery Confidence Scale
| Empowering individuals to prevent falls better |
How to use the scale
Introduction
The Balance Recovery Confidence (BRC) scale is an evaluative patient-reported outcome instrument that measures a specific domain of falls efficacy in community-dwelling older adults. Falls efficacy refers to the perceived ability of an individual to prevent and manage a potential fall. The BRC assesses one’s perceived ability to recover balance in response to a perturbation, such as a slip, a trip or a loss of balance that can occur in common, everyday activities.
There is an increasing expectation of empowering older adults to deal with falls. Falls are real issues to older adults, given natural causes such as age-related deterioration of neural, sensory or musculoskeletal systems. More so, for older people with or at-risk for chronic physical disabilities. According to the World Health Organisation, falls are the leading causes of injuries, hospitalisations and deaths in older adults. People aged 65 and older have the highest risk of falling. Half of the people older than 80 were reported to have experienced a fall at least once a year.
There are many causes and risks established for older people related to falls. A mismatched perceived self-efficacy of physical abilities with actual physical performance will pose a greater level of risk, given that older adults will undertake inappropriate risk-taking behaviours. Assessing perceived self-efficacy is critical in evaluating older persons in clinical and research settings. For many applications, using patient-reported outcome measures is the most cost-effective and valid method of obtaining information directly from individuals. This approach allows a significant opportunity for clinicians and researchers to understand the older person better. It provides an opportunity to work with them on the issues relating to falls and physical functioning.
Self-report measures of falls efficacy are a reliable and accurate methodology to obtain information on the individual’s perceived ability to prevent and manage issues of falls. Although numerous self-report assessments are available in the literature, two significant limitations have been noted with current measures.
• First, many existing falls efficacy PROMs have been conceptualised at the pre-fall stage, e.g., the perceived ability of older people to perform activities of daily living without falling or losing balance. No suitable validated PROM measures the perceived ability to arrest a fall, e.g., the perceived ability of older people to catch themselves while falling.
• Secondly, numerous falls efficacy PROMs did not involve community-dwelling older adults in the development and the content validation of the PROM. The absence of their participation raises questions about whether the PROM content remains relevant, comprehensive, or comprehensible to the population of interest.
The BRC scale has been designed to overcome these two major limitations.
The rich body of the self-efficacy theory lends itself towards understanding the conceptual framework in balance recovery confidence. Self-efficacy is defined as the ‘beliefs in one’s capability to organise and execute the courses of action required to produce given attainments’. In the context of balance recovery perceived self-efficacy, the BRC scale has been constructed as a unidimensional measure of perceived performance to arrest a fall in various scenarios depicting different perturbations. Respondents would evaluate their reactive ability to execute balance recovery strategies such as the grasp and compensatory stepping strategies to arrest a fall in response to various perturbations such as a slip, a trip or a loss of balance experienced in an indoor or outdoor environment. Balance recovery manoeuvres are commonly executed strategies to prevent a fall following postural perturbations. For respondents to judge their self-efficacy on specific reactive balance strategies is not possible, given the interplay of many different other strategies such as ankle, hip, suspensory, or straight knee-fixed toes strategy. Therefore, specific reactive balance recovery manoeuvres are not intentionally defined in the BRC scale. Instead, the type of balance recovery strategy is left open for the interpretation of the respondents, and they would rate their balance recovery confidence based on the certainty of recovering their balance and arresting a fall in the given scenario.
The conceptual clarity of self-efficacy and balance recovery have been fundamental toward developing this PROM with its conceptual framework, alongside understanding how important the various clinical facets relate to each other. Measuring perceived balance recovery self-efficacy using the theoretical framework has several advantages. First, it classifies the cognitive interpretation of the balance recovery physical performance. The perceived self-efficacy of managing a fall has often been used interchangeably with emotional constructs such as fear of falling. Second, it provides a means of understanding the impact of disease or pathology on balance recovery confidence. These relationships can be explored and understood better only if a measurement system allows a discussion between clinicians and patients based on the perspectives given by the patients on their abilities to prevent falls.
Two studies were conducted to justify the development of the BRC scale. One presented an absence of a suitable scale that measures reactive balance recovery confidence. The other reported that the balance recovery was a relatable and relevant concept for community-dwelling older adults. The focused content of the BRC scale was then constructed and validated with 22 older adults and 28 medical and healthcare professionals representing physiotherapy, occupational therapy, nursing, podiatry and medicine. The final version was then evaluated for its psychometric properties using two measurement theories: Classical Test Theory (CTT) and Rasch Measurement Theory (RMT). CTT is a descriptive approach that assess the items’ performance7. RMT is a prescriptive approach that complements CTT to evaluating items’ performance with a probabilistic model factoring in item difficulty level and the person traits level.
Administering
The BRC scale assesses the perceived self-efficacy of reactive balance recovery ability to arrest a fall in community-dwelling older adults. The instrument is applied in an interview setting, where the administrator explains the purpose of the questionnaire and gives the questionnaire for the respondents to complete. Pictorial diagrams of each item are designed to provide clarity and consistency for the respondents to understand the different scenarios.
On perceived self-efficacy
Perceived self-efficacy or confidence refers to the strength of belief. It relates to what the respondents think they can do and not will do. Perceived self-efficacy should also be distinguished from self-esteem, locus of control, and outcome expectancies. Perceived efficacy is a judgment of capability. In contrast, self-esteem is a judgement of self-worth; locus of control refers to the ability to control the outcome; and outcome expectancies are judgments about the outcomes that potentially occur from the performance.
On reactive balance recovery ability
Reactive balance recovery ability refers to reacting to destabilising perturbations that cause the individual to fall. It relates to whether the respondents could recover their balance upon losing equilibrium. If the balance recovery is unsuccessful, they will land on lower ground (i.e., experience a fall). Reactive balance recovery ability should be distinguished from proactive balance recovery ability. Reactive balance recovery ability is about executing manoeuvres such as grasping and compensatory stepping to stop falling. In contrast, proactive balance recovery is about performing daily living activities steadily.
Respondents may mention taking precautions to avoid various precarious fall scenarios. For example, I will hold on to the railing while climbing stairs. The interviewer must reiterate that the instrument measures the confidence of reactive balance recovery ability. The suggested reply for the example would be, “How certain are you that you can recover your balance if you did not hold on to the railing while climbing stairs and experience a loss of balance.” Falls are often incidental, and the instrument aims to play this crucial role of identifying the reactive balance recovery ability.
On certainty
Factors that may affect certainty include fear, weakness, fatigue, stiffness, pain, health conditions, and disabilities. Some older adults have reported differing levels of energy level within the day or across days. The rating of certainty is based on the recall period of now. The instruction is given to maintain consistency in replies and avoid recall bias.
Note: Use of assistive devices
Older adults who use assistive devices such as a walking stick for mobility are to complete the questionnaire according to their usual use of assistive devices. This allows the respondents to reflect on the scenario based on their current functioning. For example, if they use a walking stick to climb steps, then they would reflect the scenario using a walking stick.
Scoring
The BRC scale has rating scale options from 0 (Cannot do at all), through the intermediate degree of certainty, 5 (Moderately can do); to complete certainty, 10 (Highly certain can do). It is constructed to depict a unipolar scale from 0 to a maximum strength as required of a self-efficacy scale 10.
There are 19 items depicting different challenges for the respondents to evaluate their balance recovery confidence. Presently, there is not enough information on these items to distinguish the item difficulty levels based on environments, i.e., indoors or outdoors, types of perturbations, i.e., slip and trips, fall direction, i.e. forward or backwards or perceived balance recovery manoeuvres, i.e., use of upper limb and lower limb. Future work aims to distinguish the items to enhance the BRC scale’s clinical utility. To determine the balance recovery confidence level, the score should be taken as an average of the total score.
Interpreting the results
Scores approaching 10 signify a high level of confidence to recover balance, whereas scores approaching 0 signify a low level of confidence to recovery balance.
Efficacy beliefs can differ in generality. People may judge themselves efficacious across various activity domains or only in certain activities. Assessment linked to the environment, types of perturbation, fall direction, or perceived balance recovery manoeuvres can reveal the patterning and degree of generality of one’s belief in their efficacy. Future work attempts to provide greater insights to distinguishing variations and provide a deeper understanding of the role of balance recovery confidence in older adults. At present, it is recommended to use the BRC scale with other falls efficacy scales to have a more complete understanding of older adults’ fall-related psychological concerns.