Validation of a new patient-reported outcome measure of balance recovery confidence (BRC) for community-dwelling older adults: a study protocol

Figures & data

Figure 1. The conceptual framework of the PROM that measures balance recovery confidence (BRC). The BRFES's conceptual framework has been developed and refined based on the literature from Bandura's self-efficacy concept, Maki's change-in-support paradigm, the definition of a near fall and the systematic review conducted (Bandura, 1977; Maidan et al., 2014; Maki & McIlroy, 1997; Soh, Lane, Xu, Gleeson, et al., 2020).

Figure 2. Example items from the PROM that measures balance recovery confidence (BRC).

Table 1. Hypotheses for construct validity.

Hypotheses to patient-reported outcome measures
1	A moderate positive correlation (0.30–0.59) was expected between the BRC and ABC, a measure of balance confidence. While BC and balance recovery confidence are unique, they are relatable constructs of balance control with ABC focuses on perceived ability to stay balanced during activity performance and BRC focuses on perceived balance recovery performance.
2	A moderate negative correlation (0.30–0.59) was expected between BRC and FES-I, which measures fear of falling. Balance recovery confidence and fear of falling, while conceptually different, are relatable, given that low balance confidence may have a high fear of falling.
3	A moderate positive correlation (0.30–0.59) was expected between the BRC and LLFDI. Both instruments measure perceived physical performance of an individual. LLFDI focuses on perceived ability to do specific activities, and BRC focuses on perceived balance recovery performance.
Hypotheses to performance measures
1	A strong positive correlation (≥0.60) was expected between BRC and JHSD. JHSD measures handgrip strength. Handgrip strength is necessary for reach-to-grasp maneuvers to recover balance.
2	A strong positive correlation (≥0.60) was expected between BRC and CST. CST measures lower limb strength. Lower limb strength is necessary for compensatory stepping maneuvers to recover balance.
3	A strong positive correlation (≥0.60) was expected between BRC and MBT. MBT measures the anticipatory and reactive ability for balance and balance recovery. MBT and BRC measure related constructs of balance control.

PROMs: Patient-reported outcome measures; BRC: Scale of balance recovery confidence; ABC: Activities-specific Balance Confidence Scale; BC: Balance Confidence; FES-I: Falls Efficacy Scale – International; LLFDI: Late-Life Function and Disability Instrument-Function component; JHSD: Jamar hand strength dynamometer; CST: 30-second chair stand test; MBT: Mini BESTest.

Figure 3. CONSORT flow diagram.

Table 2. Study eligibility criteria for recruitment of participants.

Eligibility criteria for community-dwelling older adults
Inclusion criteria	Exclusion criteria
65-year-old and above	Requiring any physical assistance from another person to walk within home
Have an adequate understanding of the English language	Presenting with clinical observable severe cognitive impairment
Living independently in the community with or without the use of a walking aid	Unable to provide written consent to participate in the study

Table 3. List of outcome measures used in the study.

Patient-reported instrument
BRC scale of balance recovery confidence	The BRC aims to measure the balance recovery confidence in community-dwelling older adults. A list of situations that a loss of balance, trip or slip which can be experienced by older adults are presented to determine how certain the respondent can recover their balance to prevent a fall by recording a number from 0 to 10 with 10 indicating ‘Highly certain can do’ and 0 refers to ‘Cannot do at all’.
Activities-specific Balance Confidence Scale (ABC) (Powell, 1998)	The ABC scale assesses older adults' confidence that they will not fall or lose their balance when performing several progressively challenging balance and mobility tasks. This scale provides a broad continuum of activity difficulty and contains situation-specific questions to determine the level of confidence in completing a task without falling or losing balance. The ABC Scale has 16 items, with answers ranging from 0% (no confidence) to 100% (complete confidence)
Falls Efficacy Scale – International (FES-I) (Yardley, 2005)	FES-I is a 16-item scale which measures fear of falling or ‘concerns about falling’ relating to basic and more demanding activities both physical and social. Each question is answered with a four-graded scale (1-4); not at all concerned, somewhat concerned, fairly concerned and very concerned. A total score is calculated and ranges from 16 to 64, an ordinal scale.
Late-Life Function and Disability Instrument-Function component (LLFDI) (Jette, 2002)	The Late-Life Function and Disability Instrument assess function and disability in older adults. The Functional component of the instrument evaluates self-reported difficulty a person has in performing activities of daily living tasks. Factors that may influence the difficulty in task performance include pain, fatigue, fear, weakness, soreness, ailment, health conditions, and disabilities. There are 32 items with response options of ‘none’, ‘a little’, ‘some’, ‘quite a lot’, and ‘cannot do’. An additional eight items will be completed by those who use canes or walkers.
Global Perceived Effect (GPE) scale (Kamper, 2010)	Participants will rate their upper limb and lower limb functioning, compared to a week ago. Response options will be: (1) much better than a week ago, (2) somewhat better than a week ago, (3) about the same as a week ago, (4) somewhat worse than a week ago, and (5) much worse than a week ago. For responses not reflecting ‘about the same as a week ago’, they will be regarded as a reflection of an ‘unstable’ status and will be excluded from reliability analyses.
Performance measure
Jamar hand strength dynamometer (JHSD) (NIHR, 2016)	The handheld dynamometer provides a quantitative measure of isometric grip strength of the hand by determining the amount of static force that the hand can squeeze around a dynamometer (Paltamaa, 2005). The test will be administered, adopting standardized instructions and positioning recommended by the NIHR Southampton Biomedical Research Centre.
30-second chair stand test (CDC, 2017)	A quantitative measure used as test functional lower extremity strength and to obtain an indicator of functional independence. The task details the repeated performance of sit to stand from a chair within 30 s. The test will be administered adopting standardized instructions and positioning recommended by the Stopping Elderly Accidents, Deaths and Injuries (STEADI).
Mini BESTest (Franchignoni et al., 2010)	The 14 items in the four sections are detailed as (1) sit to stand, rise to toes, stand on one leg (3 items for ‘Anticipatory Postural Adjustments’, (2) taking a compensatory step in 4 different directions (3 items for ‘Reactive Postural Responses’), (3) stance-eyes open, foam surface-eyes closed, incline-eye closed (3 items for ‘Sensory Orientation’), (4) gait during change speed, head turns, pivot turns, obstacles; cognitive ‘Get Up and Go’ with dual-task (5 items for ‘Balance during Gait’). Each item is scored on a 3-point scale (0 representing worse performance and 3 representing the best performance) with a total score of 28 points. Instructions and procedures will be executed as recommended by the Mini BESTest scoring form.