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CONTENT ID=4127649&chk=YwGemZ, 2006.

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Received 24 January 2006; accepted in revised form 6 October
2006

Age and Ageing 2007; 36: 78–83

 The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society.

doi:10.1093/ageing/afl147

All rights reserved. For Permissions, please email: [e-mail]

Published electronically 15 December 2006

A comparison of different balance tests in the
prediction of falls in older women with vertebral
fractures: a cohort study

R

OB

M

ORRIS

1

, R

OWAN

H. H

ARWOOD

1

, R

OS

B

AKER

1

, O

PINDER

S

AHOTA

2

, S

ARAH

A

RMSTRONG

3

, T

AHIR

M

ASUD

1,4

1

Nottingham City Hospital, UK

2

Queen’s Medical Centre, Nottingham, UK

3

Trent Research and Development Support Unit, University of Nottingham, UK

4

University of Derby, UK

Address correspondence to: R. Morris. Tel: [phone]. Fax: [phone].
Email: [e-mail]; [e-mail]

Abstract

Background:

people with vertebral fractures are at high risk of developing hip fractures. Falls risk is important in the

pathogenesis of hip fractures.
Aim:

to investigate if balance tests, in conjunction with a falls history, can predict falls in older women with vertebral fractures.

Methods:

a cohort study of community-dwelling women aged over 60 years, with vertebral fractures. Balance tests investigated

were: 5 m-timed-up-and-go-test (5 m-TUG), timed 10 m walk, TURN180 test (number of steps to turn 180

◦

), tandem walk,

ability to stand from chair with arms folded. Leg extensor power was also measured.
Outcome Measure:

fallers (at least one fall in a 12 month follow-up period) versus non-fallers.

Results:

one hundred and four women aged 63-91 years [mean = 78

± 7], were recruited. Eighty-six (83%) completed the

study. Four variables were significantly associated with fallers: previous recurrent faller (2+ falls) [OR = 6.52; 95% CI =
1.69 –25.22], 5 m-TUG test [OR = 1.03; 1.00 –1.06], timed 10 m walk [OR = 1.07; 1.01 –1.13] and the TURN180 test [OR =
1.22; 1.00 –1.49] [P<0.05]. Multi-variable analysis showed that only two variables, previous recurrent faller [OR = 5.60;
1.40 –22.45] and the 5 m-TUG test [OR = 1.04; 1.00 –1.08], were independently significantly associated with fallers. The
optimal cut-off time for performing the 5 m-TUG test in predicting fallers was 30 s (area under ROC = 60%). Combining
previous recurrent faller with the 5 m-TUG improved prediction of fallers [OR = 16.79, specificity = 100%, sensitivity = 13%].
Conclusions:

a previous history of recurrent falls and the inability to perform the 5 m-TUG test within 30 s predicted falls

in older women with vertebral fractures. Combining these two measures can predict fallers with a high degree of specificity
(although a low sensitivity), allowing the identification of a group of patients suitable for fall and fracture prevention measures.

Keywords: accidental falls, compression fractures, musculoskeletal equilibrium, elderly

78

Balance tests for predicting falls

Introduction

Vertebral fractures are common consequences of osteo-
porosis. In the presence of vertebral fractures, the risk of hip
fracture increases by between 2.3- and 4.5-fold [1 –3]. These
patients are therefore an ideal group in which to consider hip
fracture prevention. In current clinical practice, most clini-
cians dealing with established vertebral osteoporosis focus
their attentions on bone mineral density and rarely con-
sider fall prediction or prevention. Targeting fall prevention
strategies in this group of patients may reduce the risk of
further fractures.

Someone with a history of previous falls has a two-thirds

chance of having a fall in the subsequent year [4]. In addition,
a number of balance tests have been shown to predict future
falls in older people. These include the following simple tests,
which may be used in a busy clinical setting: the ‘Chair Stand
test’ (ability to rise from a chair with the arms folded) [5],
The ‘Timed Up and Go’ (TUG) test (time taken to rise from
a chair, walk a set distance e.g. 3, 5 or 10 m, turn around,
walk back and sit down) [6], the ‘Tandem Walk test’ (walking
heel-to-toe in a straight line) [7], ‘The Timed 10 m Walk’ [8],
the ‘TURN180 test’ (number of steps needed to turn through
180

◦

) [9]. Slightly more complex tests, which can be used in

a day hospital setting include: leg extensor power [10], the
‘Berg Balance scale’ [11], ‘Functional Reach’ test [12], and
‘Body Sway’ as a measure of postural stability [13].

The aim of this study was to investigate if the use of

simple balance tests, in conjunction with a falls history, can
predict the likelihood of falling in older women with vertebral
fractures. We included the ‘Chair Stand’, ‘5 m-TUG’ (5 m-
TUG), ‘Tandem Walk’, ‘Timed 10 m Walk’ and the ‘TURN
180’ tests. The ‘leg extensor power’ was also included as this
can be measured using a dynamometer, which can be kept in
the clinic.

Methods

The design was a cohort study with the outcome being fallers
(at least one fall in a 12 month follow-up period) versus non-
fallers. Study participants were community-dwelling women
aged 60 years or over, with at least one vertebral fracture, who
were referred by general practitioners to the osteoporosis
clinic. Consecutively, referred patients were approached for
recruitment, to minimise selection bias. A ‘vertebral fracture’
was defined as ‘a

25% reduction in vertebral height on

lateral radiographic imaging’.

A ‘fall’ was defined as ‘an unexpected event where a

person comes to rest on the ground from an upper level or
the same level’ [14]. A ‘faller’ was defined as someone who fell
once or more during the follow-up period. A ‘previous faller’
was someone who fell once or more in the preceding year,
and a ‘previous recurrent faller’ was someone who fell twice
or more in the preceding year. ‘Previous recurrent fallers’
were a subgroup of ‘previous fallers’. Power calculations
(using Egret/Siz DOS package) showed that investigating
100 subjects and assuming falls to occur in a third of subjects,

the study would have 80% power to detect an odds ratio (OR)
of 3.5 for an effect of a risk factor, which occurs in a third of
the population. The study was approved by the Nottingham
City Hospital, Local Research Ethics Committee and all
patients gave written, informed consent.

Baseline data included patient demographics (age, height,

weight, smoking and alcohol history, mobility aid use)
and the number of falls recalled during the previous year.
The researcher then performed the five balance tests and
measured leg extensor power, in a standardised manner.

Follow-up was by telephone interviews conducted at 1, 2,

3, 6, 9 and 12 months. The number of falls, since the last tele-
phone call (or since recruitment for the first telephone call)
were ascertained. Each participant was categorised as a ‘non-
faller’ or a ‘faller’. Data analysis was performed using SPSS
version 10. Logistic regression analysis was used to exam-
ine the relation between balance tests and risk of falling.
Firstly, univariate logistic regression, using ‘faller/non-faller’
as the dependent variable, was employed to investigate the
relationship of the test variables. The ORs were calculated
for each explanatory variable. Some variables were treated
as categorical and others, where appropriate, were dealt with
as continuous. The following variables were included in a
categorical, dichotomous manner: current smoking, alcohol
consumption in excess of 14 units per week, use of any
mobility aid, ability to perform a Tandem Walk test, ability
to complete a Chair Stand test, previous falls and previous
recurrent falls (Table 2). Then multivariate logistic regres-
sion using stepwise-automated methods was performed to
investigate the independent effects of the appropriate tests
in predicting fallers. Sensitivities, specificities, positive and
negative predictive values of different cut-off times were
calculated for any non-categorical variable shown to have an
independent effect on predicting fallers.

Results

One hundred and ten women with vertebral fractures were
asked to participate in the study. Of these, 104 (95%) agreed
to take part. The six women who declined did so because
they did not like the idea of having to perform balance tests.
Baseline socio-demographic, falls history and balance test
data are shown in Table 1.

Eighty-six (82.7%) women completed the study at

12 months. Seven died, four were not traceable and seven
refused further involvement beyond the initial interview.
The non-completers were significantly older [mean 4.7 years
(95% CI 1.5 –7.9)], but there were no other significant
differences between the completers and non-completers.

Thirty-nine (45.3%) women had fallen by first year.

In the univariate analysis, four variables were significantly
associated with the risk of falling in the next year: previous
recurrent faller, ‘5 m-TUG Test’, ‘Timed 10 m Walk’ and
‘TURN180 test’ (Table 2). Previous recurrent fallers had 6.5
times increased risk. Each second longer it took to perform
the ‘5 m-TUG’ test was associated with a 3% increase,
each extra second to perform the ‘Timed 10 m walk’ was

79

R. Morris et al.

Table 1. Baseline demographic, previous falls
history and balance tests data

Mean age [years] (SD)

77.9 (6.5)

Age range [years]

63– 91

Mean BMI

a

[kg/m

2

] (SD)

25.07 (3.82)

BMI<20 [n] (%)

9 (8.7%)

Current smokers [n] (%)

16 (15.4%)

Alcohol >14 units/week [n] (%)

7 (6.7)

Use of mobility aid [n] (%)

None

49 (47.1%)

Stick

43 (41.3%)

Frame

10 (9.6%)

Wheel chair

2 (1.9%)

Housebound [n] (%)

23 (22.1%)

Previous fallers

b

[n] (%)

51 (49%)

Previous recurrent fallers

c

[n] (%)

35 (33.7%)

Inability to perform ‘Chair Stand test’ [n] (%)

23 (22.1%)

‘5 m-TUG test’

d

[median seconds]

18.7 (13.7– 29.8)

(IQ range) [range]

[7.9– 90.0]

Unable to perform ‘Tandem Walk’ [n] (%)

45 (43.3%)

‘Timed 10 m Walk’ [median seconds]

10.3 (8.0– 16.4)

(IQ range) [range]

[3.7– 65.0]

‘TURN180 test’ [median no. of steps]

4.5 (36) [213]

(IQ range) [range]
Leg Extensor Power [mean watts] (SD)

48.2 (24.7)

a

Body mass index.

b

At least one fall in the previous year.

c

At least two falls in the previous year.

d

Timed up and go test. At baseline, approximately a quarter of subjects

took over 30 s to perform the ‘TUG’ test.

associated with a 7% increase, and each extra step it took
to perform the ‘TURN 180’ test was associated with a 22%
increase in risk of becoming a faller.

Multi-variable logistic regression, using the four variables

found to be significantly associated in univariate analysis, was
performed using a model employing the forward stepwise
procedure. Two variables, previous recurrent faller [adjusted

Table 2. Univariate logistic regression with fallers at first
year as the dependent variable

OR

95%CI for OR

P

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Age (per year)

b

1.03

0.96– 1.11

0.35

Body mass index (per kg/m

2

)

b

0.96

0.86– 1.08

0.53

Current smoker

a

2.77

0.77– 10.04

0.12

Alcohol intake (>14 units/week)

a

0.97

0.90– 1.05

0.44

Use of any mobility aid

a,c

1.12

0.48– 2.62

0.80

Previous faller

a

1.33

0.57– 3.11

0.52

Previous recurrent faller

a

6.52

1.69 – 25.22

0.007

Leg Extensor Power (per watts)

b

1.00

0.98– 1.02

0.82

5 m-TUG test (per second)

b

1.03

1.001 – 1.063

0.045

Timed 10 m walk (per second)

b

1.07

1.01 – 1.13

0.03

TURN180 (per number of steps)

b

1.22

1.003 – 1.49

0.047

Unable to Tandem Walk

a

1.66

0.69– 3.97

0.25

Unable to Chair Stand

a

1.68

0.59– 4.78

0.33

TUG = ‘Timed Up and Go’ test.

a

Categorical dichotomous variable.

b

Continuous variable.

c

Reference = no mobility aid.

OR 5.60 (95% CI 1.40 –22.45; P

= 0.02)] and the ‘5 m-TUG’

test [adjusted OR 1.04 (95% CI 1.00 –1.08; P

= 0.04)]

remained in the final model, suggesting that these two
variables are independent predictors. Adjusted OR for the
‘5 m-TUG’ test showed that every second longer it took
to perform the test was associated with a 4% increased
chance of being a faller. We checked the multivariate logistic
regression analysis using the ‘methods = enter’ methodology
and the results were similar, with no other variable having an
independent significant effect in predicting fallers.

A cut-off of 10 s for the 5 m-TUG test gives 95%

sensitivity, but low specificity (11%). A 40 s cut-off gives
94% specificity but the sensitivity is considerably reduced
(20%) (Table 3). Someone with a time of more than 40 s is
almost certain to fall, whereas someone with a time less than
10 s is very unlikely to fall.

The receiver operator characteristic curve for the ‘5 m-

TUG’ test in predicting fallers estimated the optimum cut-off
as 30 s (area under the curve 60%). Using this cut-off, the
OR (95% CIs) for the inability to complete the ‘5 m-TUG’
test within 30 s for predicting fallers at 1 year was 2.86
(1.01 –8.11) [P

= 0.049].

With both explanatory variables in a logistic regression

model, the adjusted OR for previous recurrent fallers and
the inability to perform the ‘5 m-TUG’ test within 30 s were
6.24 (1.58 –24.60) [P<0.01] and 2.69 (0.90 –8.02) [P

= 0.07],

respectively. These are very similar to the univariate ORs,
indicating that they act essentially independently of each
other. The OR for the combination of previous recurrent
fallers and the inability to perform the ‘TUG’ test within 30
s was 16.79.

Only 5 of the 86 subjects who completed the study had

both a history of recurrent falling and were unable able to
complete the ‘5 m-TUG’test within 30 s. All five subjects
had at least one fall at first year (positive predictive value
and specificity of 100%). Sensitivity was only 13%, however,
implying 87% of fallers are missed.

Thirty subjects either had previous recurrent falls or

inability to perform the ‘5 m-TUG’ test within 30 s. Of these,
20 subjects were fallers at first year (sensitivity 51%, specificity
79%, ORs 3.90 (1.52 –9.96) [P<0.01]). The either/or test
thus correctly predicts half of future fallers, and falsely
predicts that 21% of non-fallers will fall.

Discussion

The results of this study suggest that, out of the various
performance-based balance tests investigated, the 5 m-TUG
test performed the best in predicting falls in older women
with vertebral fractures. The ‘Up and Go test’ (not timed)
was originally described as a 5-point subjective rating scale
and was assessed to be a satisfactory clinical measure of
balance in a group of 40 older people [15]. Subsequently, the
test was modified into a timed, 3 m version as a method
of assessing and quantifying locomotor performance [6].
The TUG test has been shown to have good re-test
reliability in different settings [16, 17], is an independent

80

Balance tests for predicting falls

Table 3. Sensitivities, specificities, positive predictive values, negative predictive
values, odds ratios (

±95% CIs) [P] of different cut-offs for the timed up and go

(TUG)test in predicting fallers

Predicting fallers

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cut-offs (s)

Sensitivity (%)

Specificity (%)

PPV (%)

NPV (%)

OR

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

94.9

10.6

46.8

71.4

2.2 (0.4– 2.0) [P

= 0.36]

15

71.8

42.6

50.9

64.5

1.9 (0.8– 4.7) P

= 0.17]

20

51.3

63.8

54.1

61.2

1.9 (0.8– 4.4) [P

= 0.16]

25

38.5

76.6

57.7

60.0

2.0 (0.8– 5.2) [P

= 0.13]

30

33.3

85.1

65.0

60.6

2.9 (1.0– 8.1) [P

= 0.049]

40

20.5

93.6

72.7

58.7

3.8 (0.9– 15.4) [P

= 0.06]

50

12.8

97.9

83.3

57.5

6.8 (0.8– 60.6) [P

= 0.09]

PPV, positive predictive value; NPV, negative predictive value; OR, odds ratio.

predictor of nursing home placement [18], and is sensitive
enough to show improvement in balance in patients with
rheumatoid arthritis undergoing knee extensor and flexor
muscle training [19]. Its usefulness in cognitively impaired
people has been questioned [20] and the height and type of
chair used (armrests or not) can affect performance [21].

Cross-sectional and case-controlled studies have shown

that the TUG test is associated with an increased risk of falls
[22 –25]. This study is the first prospective study of predictors
of falling in women with vertebral fractures. The 5 m-TUG
and a history of previous recurrent falling were independent
risk factors for falling. The chance of being a faller in the
next year increases by 4% for every additional second it takes
to complete the 5 m-TUG test, after adjustment for previous
recurrent fallers. Failing to complete the 5 m-TUG in 30 s
is associated with a 3-fold increase in risk of being a future
faller. However, with this cut-off, the sensitivity is only 33%,
and specificity 85%, implying that it will fail to predict falls
in two-third of future fallers, but will falsely predict falls in
only 15% of non-fallers.

A better predictor, than the TUG, of future fallers was

previous recurrent fallers. Thus, those subjects with two or
more falls in the previous year were 5.6 times more likely to
have at least one fall in the follow-up year, after adjustment
for the 5 m-TUG. Single previous falls were not significantly
associated with future risk although some, but not all, other
data suggest that a previous faller is at a higher risk [4, 26].

Combining the independent predictors improved fall

prediction to a clinically useful level. The inability to complete
the 5 m-TUG within 30 s combined with a previous history of
recurrent falls gave a specificity of 100% (i.e. all fell and should
therefore be considered for fall and fracture prevention
measures). The sensitivities of this combination in predicting
fallers at first year, however, was low (13%), implying that
the combination fails to predict most falls. These sensitivities
can be improved to 51% by using the ‘either or’ combination
method. Intervening on these patients would represent
reasonable targeting as only 21% of people ‘screened in’
as at high risk would not have subsequently fallen.

Univariate analysis showed that some of the other

performance-based tests also had some value in predicting

falls, although they were inferior to the TUG test. A previous
study showed that an increase in the number of steps while
turning 180

◦

is a marker of turning difficulty, which in itself

is associated with fall-risk [27], and another recent study has
shown that the number of steps taken to turn has a high sen-
sitivity for identifying multiple fallers [28]. Two studies have
shown that poor tandem walk ability was a predictor of falls
[4, 29]. A French-longitudinal study of 7,575 women aged
75 years and over, showed that, after adjustment for bone
density, poor tandem walk ability, as well as slow gait speed
and poor vision, were independent predictors of hip fracture
[7]. In our study the Chair Stand test was unable to predict
falls in contrast to other studies showing that the inability to
perform this test can predict fall and hip fracture risk [4, 5].

The TUG test includes elements of the other

performance-based tests studied, including getting up from a
chair, walking and turning. A high degree of correlation and
co-linearity therefore would be expected between these tests,
which is why on multi-variable analysis, most of the tests that
showed a significant association with fall-risk were no longer
independent predictors. We chose to test the 5 m version of
the TUG test in contrast to the 3 m version that has been
studied by most previous investigators. The 5 m version is
more in line with what clinicians ask their patients to do
routinely in clinics and on the wards to make a gait assess-
ment. Observing a gait for only 3 ms may not be enough to
make a proper qualitative gait assessment. The only situation
we believe the 3 m version has an advantage is when there
may be a limitation of space in a small clinic room. A recent
study by Bischoff et al., in 413 community-dwelling and 78
institutionalised women aged 65 –85 years, defined a cut-off
of 12 s for the 3 m version of the TUG, although this cut-off
was suggested as a screening tool to make a further in-depth
mobility assessment rather than as a predictor of falls [30].

The study was slightly underpowered to detect a significant

effect of some risk factors. Numbers recruited were based
on power calculations for detecting an odds ratio of 3.5 for
an effect of a risk factor occurring in a third of a population.
Many of the risk factors studied may have had a prevalence
of less than a third, and also gave an odds ratio of 2 or more
(but less than 3.5) in predicting fallers and recurrent fallers. A

81

R. Morris et al.

larger study may have shown a significant positive association
between these risk factors and fallers. However, the aim of the
study was to find the most important predictors of falls, which
the clinician can use in a busy clinical scenario, whereas risk
factors, which only have a minor role in fall prediction would
be less relevant (unless used in combination as a risk score).

A further limitation is that we took no account of co-

morbidity and the effects of drugs. Drugs are a well-known
risk factor for falling, which clinicians are generally aware
of and usually try and rationalise in subjects at high risk of
falls. However, the TUG and falls history are ‘final common
pathways’ for a number of mechanisms that mark someone
out as at increased falls risk, and highlight the need for
intervention and perhaps the need to compromise on an
otherwise-indicated drug therapy.

In conclusion, we found that the combination of the falls

history and the 5 m-TUG test have potential to provide
a clinically useful degree of selection for falls prevention
intervention in this high-risk group of patients.

Key points

•

Older women with vertebral fractures are at an increased
risk of hip fractures.

•

A history of previous recurrent falling and the inability to
perform the 5 m-TUG test within 30 s (‘timed up and go’)
can independently predict fallers in women with known
vertebral fractures.

•

Combining these two parameters can improve fall
prediction further.

•

Identifying people at a high risk of falls should allow
targeting of fall and fracture prevention measures to a
high-risk group.

Acknowledgements

We thank the Clinic Staff at Nottingham City Hospital for
assisting with the study.

Conflicts of interest

None

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Received 22 February 2006; accepted in revised form 20 October
2006

Age and Ageing 2007; 36: 83–89

 The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society.

doi:10.1093/ageing/afl145

All rights reserved. For Permissions, please email: [e-mail]

Published electronically 15 December 2006

The CareFile Project: a feasibility study to
examine the effects of an individualised
information booklet on patients after stroke

D

EBBIE

B. L

OWE

1

, A

NIL

K. S

HARMA

2

, M

ICHAEL

J. L

EATHLEY

3

1

Department of Medicine for the Elderly, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral, CH49 5PE, UK

2

Department of Medicine for the Elderly, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK

3

Clinical Practice Research Unit, Department of Nursing, University of Central Lancashire, Preston, PR1 2HE, UK

Address correspondence to: D. B. Lowe. Tel: [phone] Ext 2936 Fax: [phone]. Email: [e-mail]

Abstract

Introduction:

patients have reported a lack of knowledge and understanding of stroke and its risk factors. Uncertainty

remains about the most appropriate and effective method of educating patients after stroke.
Objective:

to assess the impact of the CareFile, an individualized information booklet, on patients’ knowledge and satisfaction

level after stroke.
Design:

randomised pilot study for a controlled trial.

Setting:

a large teaching hospital in Liverpool, UK.

Methods:

consecutive stroke patients admitted over a 9-month period, who met the inclusion criteria and consented to

participate, were randomised into this study. All patients received the usual stroke information leaflets provided by the stroke
unit. In addition, the intervention group received the ‘CareFile’, a booklet containing general information and patient-specific
information on stroke. Patients in both groups completed a stroke knowledge questionnaire at baseline, and at three and six
months post-stroke.
Results:

of the 259 admissions, 100 were eligible to participate, and 50 were randomised to each group. There was no

significant difference in patient knowledge between the groups at baseline (P>0.05). However, at three (P<0.05) and six
(P<0.005) months post-stroke, the intervention group had significantly better knowledge of stroke. There were no differences
between the groups regarding satisfaction with the information received.
Conclusions:

a simple education package, in the form of an individualized information booklet, resulted in a significant

improvement in knowledge and recognition of risk factors for stroke. The CareFile should make a valuable contribution in
meeting the requirements of the National Sentinel Audit and National Service Framework regarding provision of information
to patients after stroke.

Keywords: stroke, information dissemination, booklet, elderly

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