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RehabMeasures Instrument

Tinetti Falls Efficacy Scale

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Purpose

Asseses perception of balance and stability during activities of daily living. Assesses fear of falling in the elderly population Has also been utilized in individuals diagnosed with Multiple Sclerosis (MS).

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Instrument Details

Acronym Tinetti FES

Area of Assessment

Activities of Daily Living
Balance – Non-vestibular
Functional Mobility
Life Participation
Self-efficacy

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Brain Injury
  • Multiple Sclerosis
  • Parkinson's Disease + Neurologic Rehabilitation
  • Spinal Cord Injury
  • Stroke Recovery

Key Descriptions

  • A 10-item questionnaire designed confidence in their ability to perform 10 daily tasks without falling as an indicator of how one's fear of falling impacts physical performance.

    Each item is rated from 1 ("very confident") to 10 ("not confident at all"), and the per item ratings are added to generate a summary.

    Total scores can range from 10 (best possible) to 100 (worst possible). Thus, lower scores indicate more confidence and higher scores indicate lack of confidence and greater fear of falling.

Number of Items

10

Equipment Required

  • Paper Survey

Time to Administer

10-15 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by the Rehabilitation Measures Team and Kathleen Brandfass, MS, PT and the MS EDGE Taskforce of the Neurology Section of the APTA in 8/2011; Updated by Phyllis Palma, PT, DPT, Christopher Newman, PT, MPT, NCS, and the SCI EDGE task force of the Neurology Section of the APTA in 2012; Updated by Sue Saliga, PT, MS, DHSc, and the TBI EDGE task force of the Neurology Section of the APTA in 2012; Updated by Erin Hussey, DPT, MS, NCS, and the PD EDGE task force of the Neurology Section of APTA in 2013.  

ICF Domain

Activity
Participation

Measurement Domain

Activities of Daily Living
Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post) 

(Vestibular < 6 months post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

LS

LS

LS

StrokEDGE

R

UR

UR

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

UR

UR

UR

UR

UR

StrokEDGE

UR

R

UR

UR

UR

TBI EDGE

NR

LS

NR

LS

LS

 

Recommendations based on SCI AIS Classification: 

 

AIS A/B

AIS C/D

SCI EDGE

LS

LS

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

UR

UR

UR

NR

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

No

No

No

Yes

SCI EDGE

No

No

No

Not reported

StrokEDGE

No

No

Yes

Not reported

TBI EDGE

No

No

No

Not reported

Considerations

  • A version of the FES in which “cabinets or closets” was changed to “cupboards” has been developed (Parry et al, 2001).
  • Basic, easily understandable tool to administer.
  • Wirz 2010 (SCI), interobserver reliability was excellent, but not able to distinguish between fallers and non-fallers.
  • Noted discrepancy in reversal of scoring that reverses whether 100 is indicative of low confidence (as described in this summary consistent with the original Tinetti) or high confidence (as in modified forms). Multiple modifications and scoring variations complicate any potential for comparisons or recommendation.
  • Several studies published using Swedish version of FES are not included because the FES-s is a 13-item measure, thus is not the same as the 10-item version identified for RMD review. Nillson et al, 2010 (lists all items), and 2012; Bergstrom et al, 2012.
  • Several studies published using the FES-International. This measure was developed to expand on the initial Tinetti FES scale (1990) in order to include social context, thus results are not directly comparable. Developed by members of the ProFANE study and the survey uses a 16-item scale and a 4-point Likert Scale (1 = not at all concerned; 4= very concerned). Items 1-10 are consistent with original Tinetti FES; items 11-16 are unique to FES-I. In general, strong psychometrics reported for internal consistency and test-retest reliability.

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Older Adults and Geriatric Care

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Cut-Off Scores

Geriatrics:

(Tinetti et al, 1990; n = 74 community dwelling elderly persons)

  • > 80 increased risk of falling
  • > 70 indicates a fear of falling

Normative Data

Geriatrics: 
(Harada 1995; n = 53; residents in two residential care facilities; mean age = 83.3 (7.7) years)
  • Mean = 18.3 (9.9) 
  • Median = 12 (range = 10 - 40)  

 

(Huang & Wang, 2009; n = 174 community-dwelling adults aged 60 and older; Taiwanese sample)

  • FES mean score was 91.85 (16.89); with scores ranging from 11 to 100
  • Baseline scores were found to skew toward confident (-2.71)
  • 57.1% of participants (n = 96) scored 100, indicating no fear of falling
  • At 8 weeks mean FES scores were 91.67 (17.42), again, scores tended to skew toward confident (-2.52)

Test/Retest Reliability

Geriatric:

(Tinetti et al, 1990)

  • Adequate test-retest reliability (r = 0.71)

Internal Consistency

Geriatric:

(Tinetti et al, 1990)

  • Excellent internal consistency (Cronbach’s alpha = 0.91)

Criterion Validity (Predictive/Concurrent)

Geriatric:

(Huang & Wang, 2009)

  • Adequate concurrent validity with the ABC Scale (r = -0.55)
  • Adequate concurrent validity with the Geriatric Fear of Falling Measurement (r = -0.57)

 

Geriatric: 

(Powell and Myers, 1995; n = 60 community dwelling seniors aged 65-95; self-classified as either high or low in mobility confidence)

  • Excellent correlation with the Activities Specific Balance Confidence Scale (ABC) (r = 0.84)

 

Geriatric: 

(Hotchkiss et al, 2004; n = 118 community dwelling individuals 60 years and older; mean age = 75.8(60-99) years)

  • Excellent correlation with Activities Specific Balance Scale (ABC) in individuals 60 years or older (r = 0.86)
  • Excellent correlation with Survey and Fear of Falling in the Elderly (SAFE) in individuals 60 years or older (= 0.67)
  • FES cannot identify individuals who restrict their activity
    • Scores on the FES explained 28% of the variance
  • FES cannot identify individuals with a history of falling
    • Scores on the FES explained 4% of the variance

Construct Validity

Geriatric:

(Huang &  Wang, 2009)

  • Poor correlation with age (r = -0.23)

  • Excellent correlation with balance (= 0.66)

  • Excellent correlation with gait  (= 0.67)

  • Excellent correlation with mobility (r = 0.71)

  • Adequate correlation with fall history (r = -0.47)

  • Poor correlation with medical conditions (r = -0.18)

  • Adequate correlation with self-rated health status (r = 0.36)

Responsiveness

Elderly: 

(Powell & Myers, 1995)

  • Large responsiveness between low and high mobility groups (Effect size = 1.20)

 

Elderly

(Harada et al, 1995; n = 53 individuals living in two residential care facilities for the elderly)

  • Sensitivity (59%)
  • Specificity (82%)

 

Geriatric Hip Fracture:

(Petrella et al, 2000; n = 56; enrolled in daily rehab (~80 min/session) for 3-6 weeks) 

  • Mean change in score over time: 14–72/365, Moderate effect size (0.78), SRM = 0.75.

Spinal Injuries

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Normative Data

SCI:

(Wirz et al, 2010; n = 42; mean age = 49.3 (11.5) years; ASIA A = 2, B = 2, C = 35, D = 3; injured within one year of assessment, Swiss sample)

  • Mean score = 30.7 (12.1)

Criterion Validity (Predictive/Concurrent)

Spinal Cord Injury:

(Wirz et al, 2010)

  • Excellent concurrent validity with the Berg Balance Scale and the 16-item FES-I (r = -0.81)

Parkinson's Disease

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Normative Data

Parkinson disease:

(Rahman et al, 2011. n =110 with PD – all completed questionnaire (out of 130 respondents); mean age 66.7 (8.52); mean duration of disease = 12.1 (7.94); mean self-rated HY stage 2.63 (1.19). Measured Fear of Falling using: FES, SAFFE activity avoidance, and perceived consequence of falling (CoF))

  • Mean Tinetti FES = 38.9% (24.8) 

 

(Thomas et al, 2010; Retrospective survey. n = 102 with idiopathic PD; mean age 70.8 (11.5); Disease duration 7.6 (8.2); MMSE mean 27.3 (2.4); H& Y median 2.5. Excluded 2 subjects as outliers for extremely high fall rate; 59% were non-fallers. Of the fallers, mean fall rate over 3 months was 1.22 (2.5) falls)

  • Mean Tinetti FES score: 24.96% (16.99)

Criterion Validity (Predictive/Concurrent)

Parkinson Disease:

(Rahman et al, 2011; Measured Fear of Falling using: FES, SAFFE activity avoidance, and perceived consequence of falling (CoF))

  • Fallers had greater fear than non-fallers (p < 0.05), longer disease duration (p = 0.001), higher HY stage (p < 0.05)
  • Tinetti FES variance (41.2%) explained by disability (HY stage), previous falls, and specific mobility indicators but only HY stage was significant predictor of FES (B = -0.41, t = -4.97, p < 0.0005)
  • Fear of falling measures collectively explained 65% of variance in PDQ-39 with FES and SAFFE the primary predictors (FES: B = 0.24, t = 2.51, p = 0.015). (SAFFE B = 0.399, t = 3.44, p = 0.001)

(Thomas et al, 2010) 

 

Correlation Tinetti FES with other measures

 

 

Measure

Correlation Strength

Correlation

MMSE (inverse)

Adequate

r = -0.41, p < 0.001

Freezing

Poor

Tau-B = 0.21, p = 0.01

Number of falls

Adequate

Rho = 0.32, p = 0.001

Use of gait assistive device

Adequate

Tau-B = 0.35, p = 0.001

 

Construct Validity

Parkinson's Disease:

(Cakit et al, 2007; n = 31 with diagnosis of idiopathic PD; mean age = 71.8 (6.4); duration of PD diagnosis = 5.58 (2.9) years; UPDRS motor subscale mean = 18.14 (9.32); MMSE > 20/30; tested in "on" state of medications. RCT with random assignment to treadmill walking or control group)

  • FES did not differentiate "fallers" and "non-fallers" at baseline nor after treadmill training

 

(Rahman et al, 2011)

  • FES demonstrated confidence was significantly lower in those with higher falls frequency (p > 0.01)
    • FES non-fallers = 30.8 (25.1) and FES fallers = 40.4 (23.4)

Floor/Ceiling Effects

Parkinson Disease:

(Thomas et al 2010)

  • In PD with some history of falls (from rare to very frequent) and representing HY stages 1-4, most reported ranges of scores for that did not demonstrate floor effect. The 2 subjects with very high falls frequency rated confidence higher than expected and could represent ceiling effect - median rating = 12.5% (0.71)

Responsiveness

Parkinson Disease:

(Cakit et al 2007)

  • FES scores improved significantly (p < 0.01) in treadmill group but not in control group. (Also significant score change for BBS and DGI). However, FES did not differentiate “fallers” and “non-fallers” at baseline nor after treadmill training

Stroke

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Test/Retest Reliability

Chronic Stroke:

(Hellstrom & Lindmark, 1999; n = 30; mean age =  65 (11) years; stroke onset between 5 and 84 months prior to assessment)

  • Excellent test-retest reliability (ICC = 0.97)

Multiple Sclerosis

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Criterion Validity (Predictive/Concurrent)

Multiple Sclerosis: 

(Cakt et al, 2010; n = 45 patients with multiple sclerosis; mean age = 37.9 (10.43) years)

  • Excellent correlation with 10 meter walk test (r = 0.826)
  • Excellent correlation with Dynamic Gait Index (r = -0.601)
  • Adequate correlation with Times Up and Go (r = 0.535)
  • Excellent correlation with Functional Reach (r = -0.612)
  • Excellent correlation with the Beck Depression Inventory (r = 0.811)

Brain Injury

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Construct Validity

Brain Injury (traumatic and anoxic):

(Medley et al., 2006; n = 26, mean = 41.9 (12.4); mean time since injury = 9 years (10); community-dwelling participants; 15 subjects did not use assistive device) 

Spearman Correlation Coefficients: 

 

FES Score 

Strength 

Age 

0.254 

poor 

Berg Balance Scale 

0.467* 

adequate 

Assistive Device 

-0.399* 

adequate 

Dynamic Gait Index score 

0.473* 

adequate 

P < 0.05

Responsiveness

Brain Injury (traumatic and anoxic brain injury): (Medley et al., 2006; n = 26, mean = 41.9 (12.4); mean time since injury = 9 years (10); community-dwelling participants; 15 subjects did not use assistive device) 

  • With cutoff score of 80: sensitivity was 54% and specificity was 92% (cut off score based on literature: Tinetti et al, 1990)

Bibliography

Cakt, B. D., Nacir, B., et al. (2010). "Cycling progressive resistance training for people with multiple sclerosis: a randomized controlled study." American Journal of Physical Medicine and Rehabilitation 89(6): 446-457. Find it on PubMed

Harada, N., Chiu, V., et al. (1995). "Screening for balance and mobility impairment in elderly individuals living in residential care facilities." Physical Therapy 75(6): 462. 

Hauer, K., Yardley, L., et al. (2010). "Validation of the Falls Efficacy Scale and Falls Efficacy Scale International in geriatric patients with and without cognitive impairment: results of self-report and interview-based questionnaires." Gerontology 56(2): 190-199. 

Hellstrom, K. and Lindmark, B. (1999). "Fear of falling in patients with stroke: a reliability study." Clinical rehabilitation 13(6): 509. Find it on PubMed

Hotchkiss, A., Fisher, A., et al. (2004). "Convergent and predictive validity of three scales related to falls in the elderly." American Journal of Occupational Therapy 58(1): 100-103. Find it on PubMed

Huang, T. T. and Wang, W. S. (2009). "Comparison of three established measures of fear of falling in community-dwelling older adults: psychometric testing." International Journal of Nursing Studies 46(10): 1313-1319. Find it on PubMed

Jørstad, E. C., Hauer, K., et al. (2005). "Measuring the psychological outcomes of falling: a systematic review." Journal of the American Geriatrics Society 53(3): 501-510. 

Jorstad, E. C., Hauer, K., et al. (2005). "Measuring the psychological outcomes of falling: a systematic review." Journal of the American Geriatrics Society 53(3): 501-510. Find it on PubMed

Kempen, G. I., Yardley, L., et al. (2008). "The Short FES-I: a shortened version of the falls efficacy scale-international to assess fear of falling." Age Ageing 37(1): 45-50. Find it on PubMed

Kempen, G. I. J. M., Yardley, L., et al. (2008). "The Short FES-I: a shortened version of the falls efficacy scale-international to assess fear of falling." Age and ageing 37(1): 45-50. 

Medley, A., Thompson, M., et al. (2006). "Predicting the probability of falls in community dwelling persons with brain injury: a pilot study." Brain Injury 20(13-14): 1403-1408.

Parry, S. W., Steen, N., et al. (2001). "Falls and confidence related quality of life outcome measures in an older British cohort." Postgraduate Medical Journal 77(904): 103-108. Find it on PubMed

Petrella, R. J., Payne, M., et al. (2000). "Physical function and fear of falling after hip fracture rehabilitation in the elderly." American Journal of Physical Medicine and Rehabilitation 79(2): 154-160. Find it on PubMed

Petrella, R. J., Payne, M., et al. (2000). "Physical function and fear of falling after hip fracture rehabilitation in the elderly." American journal of physical medicine & rehabilitation 79(2): 154-160. 

Powell, L. and Myers, A. (1995). "The activities-specific balance confidence (ABC) scale." The Journals of Gerontology: Series A 50(1): M28. Find it on PubMed

Tinetti, M., Richman, D., et al. (1990). "Falls efficacy as a measure of fear of falling." Journal of gerontology 45(6): P239. Find it on PubMed

Tinetti, M. E. (1990). "Falls Efficacy Scale Measure."

Wirz, M., Muller, R., et al. (2010). "Falls in persons with spinal cord injury: validity and reliability of the Berg Balance Scale." Neurorehabil Neural Repair 24(1): 70-77. Find it on PubMed

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