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Balance and healthy aging: a close relationship

November 2020
Revista Portuguesa de Clínica Geral 36(5):383-393

DOI:10.32385/rpmgf.v36i5.12753

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CC BY-NC 4.0

Authors:

Sara Almeida

University of Aveiro

Cátia Paixão

University of Aveiro

Alda Marques

University of Aveiro

Objectives: This study explored the: i) correlations between the Balance Evaluation Systems Test (BESTest) and its short-versions (Mini-BESTest and Brief-BESTest), with functional ability, gait speed, physical activity, and health-related quality of life; ii) ability of the Five Times Sit to Stand (5STS), 10 Meter Walk Test (10MWT), Brief Physical Activity Assessment Tool (BPAAT) and World Health Organization Quality of Life-Bref (WHOQoL-Bref) to identify the prior history of falls in community-dwelling older people. Methods: An exploratory cross-sectional study was conducted with healthy older people living in the community. Balance (BESTest and its short versions), functional ability (5STS), gait speed (10MWT), physical activity (BPAAT), and health-related quality of life (WHOQoL-Bref) were assessed. Spearman correlation coefficient and receiver operating characteristics analysis were calculated. Results: One hundred and eighteen individuals (76[69-83.3] years; n=79, 66.9% female) participated in this study. Correlations between balance and functional ability (-0.61< r < -0.51, p<0.001), gait speed (0.69 < r < 0.78, p<0.001), physical activity (0.39 < r < 0.42, p<0.001) and health-related quality of life (0.28 < r < 0.57, p≤0.002) were identified. The following cutoff points to differentiate between prior history of falls were established: 80.5 points for the BESTest, 16.5 points for the Mini-BESTest and 12.5 points for the Brief-BESTest, 13.5s for the 5STS, 1.2m/s for the 10MWT, 1.5 points for the BPAAT and 14.5/66; 14.5/66; 14/62.5; 15.5/72 points for domains I, II, III and IV, respectively, of the WHOQoL-Bref 0-20/100. Conclusion: The BESTest and its short versions correlated with functional ability, gait speed, physical activity, and health-related quality of life in older people. These outcomes can differentiate prior history of falls in community-dwelling older people.

Receiver operator characteristics of the (A) Balance Evaluation Systems Test, (B) Mini-Balance Evaluation System Test and (C) Brief-Balance Evaluation System Test to differentiate between self-reported prior history of non-fallers and multiple fallers. The points corresponding to cutoff points are indicated by arrows (n=118). Abbreviations: BESTest = Balance Evaluation Systems Test.

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Figure S1. Scatterplots showing the correlations between Balance Evaluation Systems Test, Mini-Balance Evaluation System Test and Brief-Balance Evaluation Systems Test and Five Times Sit to Stand test: A1-3, 10 Meter Walk Test: B1-3, Brief Physical Activity Assessment Tool: C1-3, and World Health Organization Quality of Life-Bref domain I: D1-3, domain II: E1-3, domain III: F1-3, domain IV: G1-3 (n=118). Legends: 5STS = Five Times Sit to Stand test; 10MWT = 10 Meter Walk Test; BESTest = Balance Evaluation Systems Test; BPAAT = Brief Physical Activity Assessment Tool; CI = Confidence interval; WHOQoL-Bref = World Health Organization Quality of Life-Bref.

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Figure S1. (continuação).

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1. Lab3R – Respiratory Research and Rehabilitation Laboratory (Lab3R), School of

Health Sciences, University of Aveiro, Aveiro, Portugal.

2. Institute for Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal

INTRODUCTION

Healthy aging is defined “as the process of de-

veloping and maintaining the functional

ability that allows well-being in older peo-

ple”.1Balance plays an important role in

functional ability and falls and, consequently, in the

daily life of older people,1-3 resulting in a potential im-

pact on healthy aging.3-4 Furthermore, associations be-

tween balance and recognized predictors of healthy

aging (e.g., functional ability,5gait speed,6self-repor-

ted physical activity [PA]7and health-related quality of

life [HRQoL])8have been reported.

Balance may be assessed in older people through a

number of outcome tools, such as the Berg Balance

Scale (BBS), the Timed Up and Go test (TUG), and the

Sara Almeida,1-2 Cátia Paixão,1-2 Alda Marques1-2

Balance and healthy aging: a

close relationship

RESUMO

Objectives: This study explored the: i) correlations between the Balance Evaluation Systems Test (BESTest) and its short-ver-

sions (Mini-BESTest and Brief-BESTest), with functional ability, gait speed, physical activity, and health-related quality of life; ii)

ability of the Five Times Sit to Stand (5STS), 10 Meter Walk Test (10MWT), Brief Physical Activity Assessment Tool (BPAAT) and

World Health Organization Quality of Life-Bref (WHOQoL-Bref) to identify the prior history of falls in community-dwelling ol-

der people.

Methods:An exploratory cross-sectional study was conducted with healthy older people living in the community. Balance (BES-

Test and its short versions), functional ability (5STS), gait speed (10MWT), physical activity (BPAAT), and health-related quali-

ty of life (WHOQoL-Bref) were assessed. Spearman correlation coefficient and receiver operating characteristics analysis were

calculated.

Results: One hundred and eighteen individuals (76[69-83.3] years; n=79, 66.9% female) participated in this study. Correlations

between balance and functional ability (-0.61< r< -0.51, p<0.001), gait speed (0.69 < r< 0.78, p<0.001), physical activity (0.39

< r< 0.42, p<0.001) and health-related quality of life (0.28 < r< 0.57, p≤0.002) were identified. The following cutoff points to

differentiate between prior history of falls were established: 80.5 points for the BESTest, 16.5 points for the Mini-BESTest and

12.5 points for the Brief-BESTest, 13.5s for the 5STS, 1.2m/s for the 10MWT, 1.5 points for the BPAAT and 14.5/66; 14.5/66;

14/62.5; 15.5/72 points for domains I, II, III and IV, respectively, of the WHOQoL-Bref 0-20/100.

Conclusion: The BESTest and its short versions correlated with functional ability, gait speed, physical activity, and health-rela-

ted quality of life in older people. These outcomes can differentiate prior history of falls in community-dwelling older people.

Keywords: Community-dwelling older people; Falls; Functional ability; Health-related quality of life; Self-reported physical

activity.

Functional Reach Test.9However, most of these balance

tools present ceiling effects in older people10 and none

identify the different balance systems. Thus, a clinical

comprehensive tool of balance, the Balance Evaluation

Systems Test (BESTest), and its short versions (e.g.,

Mini-BESTest and Brief-BESTest), were developed to

overcome these limitations.11-13 BESTest and its short

versions have been providing valuable information to

tailor interventions for improving balance in healthy

older people.2However, the correlation between the

BESTest and its short versions with tools of healthy ag-

ing in community-dwelling older people remains un-

known.

Additionally, falls affect healthy aging, as it is known

that these events result in loss of independence, dis-

ability, social isolation, institutionalization, morbidity,

and mortality.3Balance tools have been shown to be

able to identify fall status in older people,4,14 however the

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DOI: 10.32385/rpmgf.v36i5.12753

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384 estudosoriginais

etiology of falls is multifactorial.3 ,15 Thus, functional

ability, gait speed, self-reported PA, and HRQoL may

also play an important role in identifying people at risk

of falling who will benefit from a more comprehensive

assessment of balance and, if needed, a personalized

balance intervention. The Five Times Sit to Stand test

(5STS), the 10 Meter Walk Test (10MWT), and the World

Health Organization Quality of Life-Bref ( WHOQoL-

Bref) have been recognized as tools able to identify

healthy aging14,16-17 and falls in older people.18-20The Brief

PA assessment tool (BPAAT) has been poorly studied,

however, PA is strongly associated with healthy aging

and falls.21 Nevertheless, research on the ability of the

5STS, 10MWT, WHOQoL-Bref, and BPAAT tools to iden-

tify the history of falls in older people is scarce and it is

important to be conducted since those who have fall-

en are at higher risk to fall again.22

Therefore, this study aimed to explore the correlation

between BESTest and its short versions, and function-

al ability, gait speed, self-reported PA and HRQoL; and

to establish the ability of 5STS, 10MWT, BPAAT, and

WHOQoL-Bref to identify the history of falls in com-

munity-dwelling older people. We hypothesized that

higher balance scores will be positive and strongly cor-

related with better performances in functional ability,

gait speed, self-reported PA, and HRQoL and that these

tools will be able to identify a history of falls in com-

munity-dwelling older people.

METHODS

Study design and ethics

An exploratory cross-sectional study in community-

dwelling older people was conducted. Ethical approval

was first obtained (238/10-2014) followed by informed

consent.

Participants

Community-dwelling older people were recruited

from six day-care centers, two gymnasiums, and one se-

nior university. The manager of each institution iden-

tified and explained the study to eligible people. A meet-

ing was scheduled with interested people and the re-

searcher provided further information about the study.

Community-dwelling older people were eligible if

they: were ≥ 60 years old;23 understood the aims of the

study; were able to express their opinions; demon-

strated coherent discourse and spatiotemporal orien-

tation, and voluntarily accepted to participate. Exclu-

sion criteria involved any condition that could poten-

tially influence scores on balance measurements, such

as: hospitalization in the previous month; a history of

dizziness or fainting; medication that could cause dizzi-

ness or impaired balance; depressive disorders; signs of

cognitive impairment or psychiatric symptoms; signi-

ficant musculoskeletal, neurological or cardiorespira-

tory disorders; the need of physical assistance to walk;

and/or signs of substances abuses.

Data collection

Sociodemographic (age and gender) and anthropo-

metric (height, weight, body mass index [BMI], and per-

centage of fat-free mass [FFM]) data were first collec-

ted, through a structured questionnaire based on the

International Classification of Functioning, Disability

and Health (ICF–checklist). BMI (weight/height2) and

FFM (%) were assessed with a bioimpedance equip-

ment (Omron body fat monitor BF306). The self-re-

ported number of falls was assessed using two stand-

ardized questions (1. «Have you had any fall in the last

12 mon ths? / Teve alguma queda nos últimos 12

meses?» and, if yes, 2. «How many times did you fall

down in the last 12 months? / Quantas quedas teve nos

últimos 12 meses?»), after presenting to each partici-

pant a clear definition of falls (“an event when you find

yourself unintentionally on the ground, floor or lower

level”).3

Then performance-based tests (BESTest, 5STS, and

10MWT) were performed. First, tests’ instructions were

read by one researcher while a second researcher

demonstrated the task to the participant. One re-

searcher provided supervision to ensure the partici-

pant’s safety during physical tests. All tests were as-

sessed by the same assessor to ensure data reliability.

The balance was assessed with the BESTest and its

short-versions. The BESTest is a clinical comprehen-

sive balance assessment tool, with 36 items and cate-

gorized into six balance systems: biomechanical cons-

traints, stability limits/verticality, transitions/anticipa-

tory postural adjustments, reactive postural control,

sensory orientation, and stability in gait.12 Each task is

scored on an ordinal scale from zero(severe impair-

ment) to three (no impairment).12-13 The total score is

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estudosoriginais

108 points, with higher scores indicating better balance

performance.12-13 BESTest takes between 20-60 minutes

to administer,12-13 thus its use may not be doable in clini-

cal practice. Therefore, a short version, Mini-BESTest,

has been proposed to reduce the assessment time.11

The Mini-BESTest takes 10-15 minutes to apply and

includes 14 items from the original BESTest, based in

four balance systems: anticipatory postural adjust-

ments, reactive postural responses, sensory orienta-

tion, and stability in gait.11 The Mini-BESTest total score

is 32 points and each task is scored on a 3-point scale

(zero to two), with higher scores indicating better per-

formance.11 Nevertheless, as the Mini-BESTest does not

identify the six balance systems of the original BESTest,

the Brief-BESTest has been proposed.

The Brief-BESTest takes only 10 minutes to be ap-

plied and consists of six items of the original BESTest.13

Each task is scored on a four-point scale (zero to three),

with a total score of 24 points, with higher scores indi-

cating better balance performance.13

Functional ability was assessed with the 5STS,19 gait

speed with the 10MWT,24 PA with the BPAAT,25 and the

HRQoL with WHOQoL-Bref.16,26

The 5STS consists of standing up and sitting down

from a straight-backed armless chair with a hard seat

stabilized against a wall for five repetitions.19 Longer

time (seconds) to perform the test indicates worst func-

tional ability performance.19

The 10MWT consists of walking 10 meters distance

at a comfortable gait speed, whilst the velocity achieved

during the intermediate six meters is recorded.24 High-

er scores (m/s) indicate worst gait speed performance.24

The BPAAT consists of two questions (1. «How many

times a week do you usually do 20 minutes or more of

vigorous-intensity PA that makes you sweat or puff and

pant? (e.g., heavy lifting, digging, jogging, aerobics, or

fast bicycling)» [3 or more times a week, 1 to 2 times a

week, none] / «Quantas vezes por semana, costuma

realizar 20 minutos de atividade física intensa que o faz

suar ou ficar ofegante? (e.g., jogging, levantamento de

grandes pesos, cavar, aeróbica ou andar de bicicleta a

um ritmo rápido)» [3 ou mais vezes por semana, 1 a 2

vezes por semana, nenhuma]; 2. «How many times a

week do you usually do 30 minutes or more of mode-

rate-intensity PA or walking that increases your heart

rate or makes you breathe harder than normal? (e.g.,

carrying light loads, bicycling at a regular pace, or dou-

bles tennis)» [5 or more times a week, 3-4 times a week,

1-2 times a week, none] / «Quantas vezes por semana,

costuma realizar 30 minutos de atividade física mode-

rada ou caminhada que aumenta a sua frequência car-

díaca ou o faz respirar com mais dificuldade que o nor-

mal? (e.g., cortar a relva, transportar cargas leves, an-

dar de bicicleta a um ritmo regular, ou jogar ténis em

duplas)» [5 ou mais vezes por semana, 3 a 4 vezes por

semana, 1 a 2 vezes por semana, nenhuma]) assessing

the frequency and duration of intense and moderate PA,

undertaken in a usual week.25,27 A total score was calcu-

lated (range zero to eight), in which higher scores cor-

respond to higher PA levels (scores < 4 indicate that the

person is insufficiently active and scores ≥ 4 indicate

that the person is sufficiently active).25

The WHOQoL-Bref is a short version of the original

WHOQoL and assesses four domains of quality of life:

I-Physical, II-Psychological, III-Social relationships,

and IV-Environment.26 This scale is composed of 26

questions, scored on a Likert scale from one to five, with

higher scores indicating better quality of life.26

Data analysis

Statistical analyses were performed in IBM SPSS 24.0

(IBM Corp., Armonk, NY) and GraphPad Prism 5.01

(GraphPad Software, San Diego, CA). The level of sig-

nificance was set at 0.05.

Descriptive statistics were used to characterize the

sample. Participants were classified into two groups:

non-fallers (reported history of zero or one fall) and

multiple fallers (reported history of ≥ 2 falls). The nor-

mality of data distribution was tested with the Kol-

mogorov-Smirnov test and z-test with the skewness and

Kurtosis.28 Comparisons between groups were per-

formed with Mann-Whitney-U tests since most vari-

ables were not normally distributed. If significant dif-

ferences in the performance of the tests were found, ef-

fect sizes (ES) were computed with Cohen’s d(small d

≥ 0.2, medium d≥ 0.5 or large d≥ 0.8 effect).28 The skew-

ness of the distribution of scores was assessed for each

tool to verify the occurrence of floor and ceiling effects

(substantial floor effect: skewness > 1; substantial cei-

ling effect: skewness < -1).28

Correlations were assessed using Spearman rank cor-

relation and interpreted as negligible (0 – 0.30), low (0.30

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386 estudosoriginais

– 0.50), moderate (0.50 – 0.70), high (0.70 – 0.90) and

very high (0.90-1).28

Receiver operating characteristics (ROC) analysis

was used to assess the ability of the tools to significantly

differentiate between a self-reported prior history of

non-fallers and multiple fallers. The cutoff was chosen

as the value which simultaneously maximized the sen-

sitivity and specificity: (1-sensitivity)2+(1-specificity)2

for each tool.28 Area under the curves (AUC) and 95%

conf ide nce inte rval (95%CI) interpret ation wa s:

AUC=0.5 no discrimination; 0.7 ≤ AUC < 0.8 acceptable;

0.8 ≤ AUC < 0.9 excellent, and AUC ≥ 0.9 outstanding dis-

crimination.28 The positive and negative likelihood ra-

tios (LR+ and LR-) were computed.28

RESULTS

One hundred and eighteen community-dwelling

older people (mean ± standard deviation 76.2 ± 8.9; me-

dian [interquartile range] 76 [69 – 83.3] years old; n=79;

69.9% female) were enrolled in this study. On average

Non-fallers (0-1) Multiple fallers

Characteristics Overall (n=118) (n=98) (2 or more) (n=20) p-value

Age (years) 76 [69 - 83.3] 74 [68 - 82] 80.5 [71.5 - 87.5] 0.063

Gender (female n, %) 79, 66.9% 63, 64.3% 16, 80% 0.203

FFM (%) 34.9 ± 7.3 34.7 ± 7.5 35.9 ± 6.6 0.514

BMI (kg/m2) 26.2 [24 - 29] 26.2 [24 - 29.3] 27.1 [23.8 - 28.5] 0.917

Tools

BESTest (points) 87.5 [68.8 - 94.4] 87.9 [74.9 - 95.4] 61.7 [53.6 - 85.9] 0.001*

Mini-BESTest (points) 22.5 [14 - 29] 25 [17 - 30] 7.5 [5 - 19] < 0.001*

Brief-BESTest (points) 16 [9 - 20.3] 17 [12 - 21] 6.5 [3 - 11.8] < 0.001*

5STS (s) 12.1 [9.1 - 16.5] 11.5 [8.9 - 15.7] 17.5 [13 - 25.3] 0.002*

10MWT (m/s) 1.3 [1 - 2.1] 1.5 [1.1 - 2.2] 0.9 [0.6 - 1.2] 0.001*

BPAAT 1.5 [0 - 8] 2 [0 - 8] 0 [0 - 3] < 0.001*

Sufficiently active score ≥ 4 (n, %) 31, 26.3% 67, 68.4% --

Insufficiently active score 0-3 (n, %) 87, 73.7% 31, 31.6% 20, 100% -

WHOQoL-Bref 0-20 score (points)

I – Physical health 15 [13 - 17] 15.2 [13 - 17] 13 [11 - 14] < 0.001*

II – Psychological 15 [13 - 17] 15 [13 - 17] 13 [12 - 14.8] < 0.001*

III – Social relationships 15 [13 - 16] 15 [13 - 16] 13 [11 - 15.8] 0.019*

IV – Environment 16 [14 - 17] 16 [15 - 17] 14 [13 - 16] 0.002*

WHOQoL-Bref 0-100 score (points)

I – Physical health 69 [56 - 81] 69 [56 - 81] 56 [44 - 63] < 0.001*

II – Psychological 69 [56 - 81] 69 [56 - 81] 56 [50 - 67.5] < 0.001*

III – Social relationships 69 [56 - 75] 69 [56 - 75] 56 [44 - 73.5] 0.019*

IV – Environment 75 [63 - 81] 75 [69 - 81] 63 [56 - 75] 0.002*

TABLE 1. Participants’ characteristics (n=118)

Note: values are presented in median [interquartile range] and mean ± standard deviation unless otherwise stated.

Abbreviations: 5STS = Five Times Sit to Stand test; 10MWT = 10 Meter Walk Test; BESTest = Balance Evaluation Systems Test; BMI = Body Mass Index;

BPAAT = Brief Physical Activity Assessment Tool; FFM = Free-fat Mass Index; WHOQoL-Bref = World Health Organization Quality of Life–Bref. *p<0.05

significance.

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estudosoriginais

participants were overweight (mean ± standard devia-

tion 26.8 ± 4.2 median [interquartile range] 26.2 [24-29]

kg/m2) and presented high FFM (34.9 ± 7.3%). Most in-

dividuals (n=98; 83.1%) reported to have had zero or one

fall, and 16.9% (n=20) reported to have had two or more

falls in the previous year. Most participants were insuf-

ficiently active (n=87; 73.7%). More than 1/3 of non-

fallers were insufficiently active (n=31; 31.6%) and mul-

tiple fallers were all insufficiently active (n=20; 100%)

(Table 1).

All tools were able to significantly differentiate be-

tween a self-reported prior history of non-fallers and

multiple fallers (Table 1). Non-fallers performed sig-

nificantly better at the BESTest (ES=0.87), Mini-BESTest

(ES=1.15), Brief-BESTest (ES=1.11), 5STS (ES=0.76),

10MWT (ES=0.81), BPAAT (ES=0.97), and WHOQoL-Bref

domains 0-20 (ESDOM – I=1.12, ESDOM – II=1, ESDOM – III=0.43

and ESDOM – IV=0.90) and 0-100 (ESDOM – I=1.14, ESDOM –

II=0.81, ESDOM – III=0.62 and ESDOM – IV=0.87) than multiple

fallers.

The 5STS (skewness=1.31) and the BPAAT (skew-

ness=1) presented lower floor effects than the 10MWT

(skewness=1.62). The WHOQoL-Bref0 – 20&0-100 presented

ceiling effect, which was higher in domains II and III

(skewnessDOMII:0 – 20&0 – 100=-0.35; skewnessDOMIII:0 – 20=-0.31;

skewnessDOMI II:0 – 100=-0.32) than in domains I and IV

(skewnessDOMI:0 – 20=-0.11; skewnessDOMI:0 - 100=-0.10; skew-

nessDOMIV:0 – 20=-0.08; skewnessDOMIV:0 – 100=-0.07).

The BESTest and its short versions showed positive

correlations with the 10MWT, BPAAT and WHOQoL-

Bref and negative correlations with the 5STS. Correla-

tion values are presented in Table 2. Scatterplots show-

ing the correlations between BESTest, Mini-BESTest

and Brief-BESTest and 5STS, 10MWT, BPAAT, and WHO-

QoL-Bref domains can be found in Figure S1 (supple-

mentary material).

The AUC of the BESTest and its short versions, 5STS,

10MWT, BPAAT, and WHOQoL-Bref domains ranged

between 0.65–0.79, indicating that these tests were able

to significantly discriminate between older people with

and without a history of multiple falls. The short ver-

sions of the BESTest (Mini- [0.79] and Brief-BESTest

[0.7 8]) and the WHOQoL-Bref domains I and II

(AUC=0.77 for both), presented the higher AUCs. Table

3 shows the results of the ROC analysis.

To differentiate between a self-reported prior histo-

ry of non-fallers and multiple fallers, the following cut-

offs were identified: 80.5 points for BESTest, 16.5 points

for Mini-BESTest, 12.5 points for Brief-BESTest, 13.5

seconds for 5STS, 1.2m/s for 10MWT, 1.5 points for

BPAAT, 14.5/66; 14.5/66; 15/62.5; 15.5/72 for domains

I, II, III, and IV of the WHOQoL-Bref 0-20/0–100,

Variables BESTest pMini-BESTest pBrief-BESTest p

5STS - 0.51 < 0.001 - 0.59 < 0.001 - 0.61 < 0.001

10MWT 0.69 < 0.001 0.78 < 0.001 0.77 < 0.001

BPAAT 0.39 < 0.001 0.40 < 0.001 0.42 < 0.001

WHOQoL-Bref (0-20 and 0-100 scores)

I – Physical health 0.46 < 0.001 0.53 < 0.001 0.57 < 0.001

II – Psychological 0.47 < 0.001 0.53 < 0.001 0.52 < 0.001

III – Social relationships 0.32 0.002 0.28 < 0.001 0.36 0.002

IV – Environment 0.46 < 0.001 0.46 < 0.001 0.51 < 0.001

TABLE 2. Correlations between Balance Evaluation Systems Test, Mini-Balance Evaluation System Test and Brief-Balance

Evaluation Systems Test, and Five Times Sit to Stand Test, 10 Meter Walk Test, Brief Physical Activity Assessment Tool and

World Health Organization Quality of Life Bref (n=118)

Note: Spearman correlation coefficient are presented.

Abbreviations: 5STS = Five Times Sit to Stand Test; 10MWT = 10 Meter Walk Test; BESTest = Balance Evaluation Systems Test; BPAAT = Brief Physical

Activity Assessment Tool; WHOQoL-Bref = World Health Organization Quality of Life Bref. p<0.05 significance.

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388 estudosoriginais

respectively. The cutoff points for all tools are presen-

ted in Table 3 and Figures 1 and 2.

DISCUSSION

According to the authors’ best knowledge, this is the

first study demonstrating that the BESTest and its short

versions correlate significantly with functional ability,

gait speed, self-reported PA, and HRQoL in communi-

ty-dwelling older people and that these tools are able

to differentiate between a self-reported prior history of

non-fallers and multiple fallers in this population with

sensitivities and specificities above 50%.

Moderate to high correlations between balance and

i) functional ability in people with multiple sclerosis,5

ii) gait speed in healthy people (>40 years),6iii) self-re-

ported PA in older people,7and iv) HRQoL in older peo-

ple8have been previously demonstrated. However, the

balance tools used in these studies (BBS,5-6 TUG,5and

One Leg Stance test),7are unable to assess balance com-

prehensively. The BESTest distinguishes itself from

these other balance tools by allowing the identification

of specific balance domains that are preserved or im-

paired hence, guiding personalized interventions.12 The

correlations found between the BESTest and its short

versions with the functional ability, gait speed, self-re-

ported PA, and HRQoL strengthens the value of their use

routinely, especially the short versions which presen-

ted similar or even higher correlations than the BESTest.

This finding is of particular relevance for clinical prac-

tice since the short versions are simple, quicker and re-

quire less material to be applied.11,13

It is widely recognized that falls have a multifactori-

al etiology and numerous risk factors have been iden-

tified in community-dwelling older people, including

Tools AUC (SEM) 95% CI Cutoff %%Positive/Negative

Point Sensitivity Specificity Likelihood Ratios

BESTest (points) 0.73 (0.07) 0.59 - 0.87 80.5 75 68 2.34/0.37

Mini-BESTest (points) 0.79 (0.06) 0.68 - 0.91 16.5 75 80 3.75/0.31

Brief-BESTest (points) 0.78 (0.06) 0.66 - 0.90 12.5 80 75 3.20/0.27

5STS (s) 0.72 (0.07) 0.59 - 0.86 13.5 75 68 2.34/0.37

10MWT (m/s) 0.74 (0.06) 0.61 - 0.86 1.2 75 68 2.34/0.37

BPAAT (number) 0.65 (0.06) 0.53 - 0.76 1.5 70 54 1.52/0.56

WHOQoL-Bref 0-20 score (points)

I – Physical health 0.77 (0.05) 0.67 - 0.88 14.5 80 59 1.95/0.34

II – Psychological 0.76 (0.05) 0.66 - 0.86 14.5 75 65 2.14/0.38

III – Social relationships 0.66 (0.06) 0.54 - 0.79 14 55 65 1.57/0.69

IV – Environment 0.72 (0.06) 0.60 - 0.85 15.5 65 64 1.81/0.55

WHOQoL-Bref 0-100 score (points)

I – Physical health 0.77 (0.05) 0.67 - 0.88 66 80 59 1.95/0.34

II – Psychological 0.76 (0.05) 0.66 - 0.86 66 75 65 2.14/0.38

III – Social relationships 0.66 (0.06) 0.54 - 0.79 62.5 55 65 1.57/0.69

IV – Environment 0.72 (0.06) 0.60 - 0.85 72 65 64 1.81/0.55

TABLE 3. Ability to identify history of falls of the Balance Evaluation Systems Test, Brief-Balance Evaluation System Test

and Mini-Balance Evaluation Systems Test, Five Times Sit to Stand Test, 10 Meter Walk Test, Brief Physical Activity

Assessment Tool and World Health Organization Quality of Life Bref (n=118)

Abbreviations: BESTest = Balance Evaluation Systems Test; 5STS = Five Times Sit to Stand test; 10MWT = 10 Meter Walk Test; AUC = Area Under the

Curve; BPAAT = Brief Physical Activity Assessment Tool; CI = Confidence interval; WHOQoL-Bref = World Health Organization Quality of Life-Bref;

p<0.05.

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gait and/or balance impairments, social factors, and

quality of life.15 These and other risk factors can be easi-

ly evaluated with the BESTest and its short versions,14

5STS, 10MWT, BPAAT and WHOQoL-Bref.21,24,29-30

The ability of BESTest and its short versions to iden-

tify fallers and non-fallers was previously published.14

We have found similar results, however, the current

study adds information on the ability of these compre-

hensive balance tools to identify a self-reported prior

history of non-fallers and multiple fallers in communi-

ty-dwelling older people, establishing now specific cut-

offs for this purpose which can be especially useful for

clinical practice to identify those who are more likely to

fall again.

One previous study has determined a cutoff of 12s for

multiple fallers in the 5STS test.31 This result differs

slightly from the cutoff of 13.1s established in this study

however, our study differentiated non-fallers and mul-

tiple fallers based on the self-reported number of falls

while that study analyzed falls prospectively and

recorded with a monthly calendar.31 For the 10MWT, a

considerable variance between our cutoff (1.2m/s) and

the cutoff proposed in a study including community-

dwelling older indigenous Taiwanese (0.88m/s) was

found.32 However, in the Taiwanese study32 only wo-

men were included and assessments were taken in a 10

meters corridor with 10 (five+five) meters extra provid-

ed for acceleration/deceleration, whilst in our study

women and men participated and assessments were

taken from a six meters corridor, with four (two+two)

meters for acceleration/deceleration, as recommen-

ded.24 Different methodological approaches might con-

tribute to the different results found between the stu-

dies.

A cutoff for falls using a PA tool has been proposed

in the literature,33 however a different test (short form

of the International PA Questionnaire) to assess PA was

used, hindering comparisons with the present study.

Nevertheless, and similarly to our findings, fallers re-

ported less PA than non-fallers.33 Since PA plays an im-

portant role in the maintenance of the functional abi-

lity independence and decreases the risk of falls,3the es-

tablished cutoff of 1.5 points for the BPAAT might be

useful to quickly screen community-dwelling older

people and refer them for a comprehensive balance as-

sessment in case of need.

100

020 40 60 80 100

Sensitivity (%)

100% - Specificity%

BESTest

100

020 40 60 80 100

Sensitivity (%)

100% - Specificity%

Mini-BESTest

100

020 40 60 80 100

Sensitivity (%)

100% - Specificity%

Brief-BESTest

Figure 1. Receiver operator characteristics of the (A) Balance

Evaluation Systems Test, (B) Mini-Balance Evaluation System Test

and (C) Brief-Balance Evaluation System Test to differentiate bet-

ween self-reported prior history of non-fallers and multiple fallers.

The points corresponding to cutoff points are indicated by arrows

(n=118).

Abbreviations: BESTest = Balance Evaluation Systems Test.

Rev Port Med Geral Fam 2020;36:383-95

390

100

100% - Specificity%

Sensitivity (%)

10MWT

100

100% - Specificity%

Sensitivity (%)

I-Physical health

100

100% - Specificity%

Sensitivity (%)

5STS

10090

70605040

100

Sensitivity (%)

100% - Specificity%

BPAAT

100

060 80 100

100% - Specificity%

Sensitivity (%)

III-Social relationships

100

100% - Specificity%

Sensitivity (%)

II-Psychological

100

100% - Specificity%

Sensitivity (%)

IV-Environment

Figure 2.Receiver operator characteristics of the (A) Five Times Sit to Stand Test, (B) 10 Meter Walk Test, (C) Brief Physical Activity Assessment

Tool, (D) World Health Organization Quality of Life-Bref Physical health, (E) World Health Organization Quality of Life-Bref Psychological,

(F) World Health Organization Quality of Life-Bref Social relationships and (G) World Health Organization Quality of Life-Bref Environment

to differentiate between self-reported prior history of non-fallers and multiple fallers. The points corresponding to cutoff points are indica-

ted by arrows (n=118).

Abbreviations: 5STS = Five Times Sit to Stand Test; 10MWT = 10 Meter Walk Test; BPAAT = Brief Physical Activity Assessment Tool.

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estudosoriginais

Our findings showed that multiple-fallers presented

worse HRQoL than non-fallers, as corroborated by the

literature.8Although the impact of falls on the quality

of life is well established, the ability of the quality of life

to detect the risk of falls is poorly explored. According

to the authors’ best knowledge, this is the first study

providing a cutoff to distinguish the self-reported pri-

or history of non-fallers and multiple fallers using an

HRQoLtool. The established cutoffs for the different do-

mains of the WHOQoL-Bref might be useful to identify

those to whom a preventive and/or effective interven-

tion for falls might be a priority.

These values will enable professionals to interpret re-

sults with more confidence and take informed action

(e.g., referral for comprehensive balance assessments

and personalized interventions since those who have

fallen are more likely to fall again)22 based on the results

obtained, preventing disability and promoting healthy

aging in community-dwelling older people.

This study has several limitations that need to be ac-

knowledged. Due to the nature of this cross-sectional

study, the ability to identify a history of falls was ana-

lyzed retrospectively. Thus, future studies should con-

duct longitudinal studies to assess the ability of the tools

to identify multiple fallers prospectively. Moreover, falls

were based on individuals’ self-report, hence, some de-

gree of bias might have been present despite the im-

portant contribution to the understanding balance and

functional ability, gait speed, self-reported PA, and

HRQoL in community-dwelling older people. Mini-

BESTest and Brief-BESTest scores were derived from

the original BESTest, thus it is possible to have occurred

inter-item influences. In future studies, each test should

be performed separately.

CONCLUSIONS

In conclusion, this study showed significant correla-

tions between the BESTest and its short versions, with

functional ability, gait speed, self-reported PA, and

HRQoL in community-dwelling older people. Higher

associations were found with the short versions. Since

these comprehensive balance tools allow the identifi-

cation of domains where balance is preserved or im-

paired, their use in clinical practice offers great poten-

tial to personalize interventions and effectively pro-

mote healthy aging in community-older people.

BESTest and its short-versions and tools commonly

used to assess functional ability, gait speed, self-re-

ported PA and HRQoL in community-dwelling older

people were able to distinguish between the self-re-

ported prior history of non-fallers and multiple fallers.

Cutoff points were identified for BESTest, Mini-BESTest,

Brief-BESTest, 5STS, 10MWT, BPAAT, and WHOQoL-

Bref. Health professionals can now use these cutoffs to

identify those who might benefit from a more compre-

hensive balance assessment which will inform who to

prioritize for balance interventions. These findings are

of great importance since falls prevention is a main goal

in older populations that needs comprehensive and re-

alistic interventions to be implemented.

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CONFLICTS OF INTEREST AND SOURCE OF FUNDING

The authors have no conflict of interest to disclosure.

This work was funded by Programa Operacional de Competitividade e In-

ternacionalização – POCI, through Fundo Europeu de Desenvolvimento Re-

gional – FEDER (POCI-01-0145-FEDER-007628), Fundação para a Ciência

e a Tecnologia (PTDC/SAU-SER/28806/2017; SFRH/BD/1206958/2016;

SFRH/BD/148741/2019) and under iBiMED – Institute of Biomedicine

(UIDB/04501/2020).

CORRESPONDING AUTHOR

Alda Marques

E-mail: amarques@ua.pt

https://orcid.org/0000-0003-4980-6200

Recebido em 13-11-2019

Aceite para publicação em 07-05-2020

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estudosoriginais

ABSTRACT

BALANCE AND HEALTHY AGING: A CLOSE RELATIONSHIP