February 2019, Volume 69, Issue 2

Short Reports

Common balance measures and fall risk scores among older adults in Pakistan: Normative values and correlation

Furqan Ahmed Siddiqi  ( Foundation University Institute of Rehabilitation Sciences )
Tahir Masood  ( Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Jouf University, Saudi Arabia. )
Muhammad Osama  ( Foundation University Institute of Rehabilitation Sciences )
Muhammad Ehab Azim  ( Foundation University Institute of Rehabilitation Sciences )
Muhammad Naveed Babur  ( Isra Institute of Rehabilitation Sciences, Islamabad, Pakistan )


The objective of this study was to assess the balance and fall risk among the community dwelling healthy older adults in Pakistan and to determine the correlation between balance measures and fall risk, for which a crosssectional correlation study was conducted at Foundation University Islamabad and Fauji Foundation Hospital from
March 2016 to February 2017. A total of 77 individuals over 50 years were included via convenience sampling. I n di vi d u al s w i t h he a r i ng /v is ua l an d c o gn it ive impairments, infections, and orthopaedic and severe comorbid conditions were excluded. Data collection tools included Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Functional Reach Test (FRT) and Fall Risk Score (FRS). Independent t-test and Bivariate Pearson Correlation (CI=95%, P<0.05) were used for analysis. Mean value of the BBS, FRS, TUG and FRT was 41.36±2.96, 3.40±1.47, 15.90±2.68 and 13.34±3.45 respectively. Age had a significant (p<0.05) positive correlation with FRS
and negative correlation with BBS. A significant correlation (P<0.05) was found only between FRT & TUG and TUG & BBS.
Keywords: Balance assessment, Berg Balance Scale, Dynamic Posturography, Fall Risk Score, Functional Reach Test, Geriatrics, Pakistan, Timed Up and Go test.


With advancement in health care, mor tality has decreased, resulting in a rise in geriatric population. A total of 12.13 million people in Pakistan are above the age of 60, which is expected to rise to 17.53 million by 2025.1 Falls is one of the major concerns in elderly, the worldwide prevalence of which ranges from 17.2-33.1%, and is likely to re-occur in 5.7-15.2% individuals.2 Literature shows that 1/3 elderly individuals suffer a fall every year, 6% of which results in fractures,3 and 0.42
million individuals worldwide die from falls every year, 80% of which are from middle and low income countries.2,4,5 Impaired gait and balance are one of the most important risk factors for falls in the elderly, which can be due to impairments in visual, sensorimotor or vestibular system.6-8 Age itself is also a risk factor for impaired balance with 30-50% of the individuals greater than 65 years experiencing difficulty in maintaining balance,6-8 perhaps due to physical and neurological deterioration resulting in impaired balance.9 For this reason a regular fall risk screening and balanceassessment is essential. Unfortunately, the normative balance measures\' scores for the elderly population in Pakistan are not established. Moreover balance is divided into static and dynamic balance, the association of which is also not well proven in literature. The purpose of the current study was to assess balance and fall risk scores in the healthy elderly population of Pakistan, so that normative values for these measures can be established, and to determine the correlation between common balance measures and fall risk in older adults.


A cross sectional analytical study was conducted at Foundation University Islamabad, and Fauji Foundation Hospital, Rawalpindi from March 2016 to February 2017. A total of 77 community dwelling elderly individuals aged 50 years and above were included via convenience sampling. Individuals with severe hearing and visual impairments, impaired cognition, orthopaedic conditions such as fractures, inflammatory conditions and active infectious diseases, and severe co-morbid conditions like stroke, cardiac failure, dementia and Alzheimer\'s etc were excluded from the study. Data collection tools included Berg Balance Scale(BBS) which is used for both static and dynamic balance assessment, Timed Up and Go( TUG) test which is used for dynamic balance assessment only, Functional Reach Test(FRT ) which is used for anticipatory balance assessment and Fall Risk Score (FRS) which was measured via computerized dynamic posturography using the Biodex Balance System SD (Figure I a+b).

Data was analyzed using SPSS v21.0. Independent t-test was used for gender based comparison and Bivariate Pearson Correlation was used to determine the association between age, BBS, TUG, FRT and FRS (CI=95%, P<0.05).


Of the total 77 participants, 26 were males and 51 were females. The mean age of the participants was 62.10±8.84 years, and the mean weight and height was 73.47±8.75kg and 162.19±7.23cm respectively. Mean value of the BBS was 41.36±2.96, FRS was 3.40±1.47, TUG was 15.90±2.68 and FRT was 13.34±3.45.A significant difference (P<0.05) was observed only in height, however no significant differences (P>0.05) were found in age, weight and balance outcomes in terms of gender (Table-I).

Increasing age had a significantly (p<0.05) positive correlation with FRS and a non-significant (P>0.05) positive correlation with TUG test scores (Table-2).

Increasing age had a significantly (p<0.05) negative correlation with BBS and
a non-significant (P>0.05) negative correlation with FRT scores (Table-2). A significant correlation (P<0.05) exists only between FRT & TUG and TUG & BBS (Table-2).


BBS, TUG and FRT are perhaps the most common balance measures performed not only in clinical but also in research settings. According to a systematic review
conducted by Langley FA, BBS and TUG test are the most vigorously tested balance measures and are found to have the greatest published validity and reliability with
community dwelling older adults among 17 commonly used functional balance tests.10 The mean score of BBS of 41.36±2.96 with a mean age of 62.10±8.84 years in the current study was in the low fall risk (41 to 56) category, however it is still lower than the overall mean score of 54.0±1.5 for age group of 60 to 69 years in a similar study conducted by Lusardi MM et al in the United States (US).11 Similarly a TUG score of 15.90±2.68 in the current study was higher than 7.9±0.9 in the study conducted by Lusardi MM.11 These findings in view of the existing literature suggest a comparatively poorer static and dynamic balance among the elderly in Pakistan as compared to those in the US.The findings of the current study show that a significantly negative correlation (P<0.05) exists between FRT and TUG scores showing that anticipatory balance and
dynamic balance have a positive association with each other as increase in functional reach (FRT) is associated with a decreased time during TUG. Moreover, even though the correlation between FRT and BBS was positive, it was not significant. Moreover, as BBS assesses both static and dynamic balance it can be suggested that even though anticipatory balance improves with an improvement in dynamic balance, association between anticipatory and static balance is not conclusive. However, a significantly negative correlation exists between BBS and TUG scores in the current study. Thi finding may suggest that both tools measure dynamic balance so they possess a significant correlation, or maybe there is an association between static and dynamic balance as BBS assesses both static and dynamic components of balance, and for this reason the relationship between static and dynamic balance needsto be further investigated. A similar study conducted by Drowatzky JN et al looked into the interrelationshi  between static and dynamic balance measures in which 6 different balance measures were used, out of which 3 were used to assess the static and 3 were used to assess the dynamic components of balance. However, only one
coefficient of correlation showed a p value of less than 0.05, for the measures of sideward leap and bass stepping stone, both of which were in fact measures of dynamic balance, thus showing no significant correlation between measures of static and dynamic balance.12 It is important to point out that the balance measures used in Drowatzky JN et al\'s study were not common clinical measures used in balance assessment, and secondly the study was conducted on grade 7 girls instead of older adults. Moreover, in the current study none of the balance measures show a significant correlation with FRS. This may suggest that static and dynamic balances alone are not the only predictors of fall risk, and perhaps there is a major contribution by other factors such as muscular performance, gait and anthropometric parameters.13-16 A study conducted by Greve J et al showed that more displacements are required to maintain postural balance as BMI is increased,15 which may increase risk of fall, emphasizing the contribution of anthropometric changes in postural balance and fall risk. Similarly a study
conducted by Hausdorff JM et al on older adults showed that stride time variability predicted falls (p<0.05).13 Another study conducted byVerghese J et al showed that slower gait speed, worse performance on swing, double support phase, swing time and stride length variability, all predict fall risk,14 emphasizing the contribution of gait in risk of fall. In terms of importance of muscle performance predicting fall risk it is shown that muscle strength especially of the lower extremity is an essential aspect that should not only be assessed but also treated in the elderly who are at risk for falls.16 Thus in view of the existing literature and findings of the current study, even though there is an increasing trend of balance assessment and training among the  rehabilitation professionals a significant correlation between common balance measures and fall risk does not exist, and it is imperative to point out other factors such as muscle performance, gait and anthropometric parameters are also important contributors and should also be assessed and treated accordingly in the elderly who are at risk of fall.


Our study suggest a low fall risk for the elderly population in Pakistan but still Pakistani older adults are found to have poorer balance in comparison to the West.Moreover, no significant correlation is observed between common balance measures and fall risk scores.

Limitations and Recommendations

The current study was a single centered study with a limited sample side. It is suggested that multi centered studies with statistically calculated samples should be conducted, and correlation of other factors such as anthropometric measures, gait and muscle performance etc with fall risk should also be explored.

Disclaimer: This manuscript is a part of PhD thesis in Rehabilitation Sciences.
Conflict of Interest: None.
Funding Sources: None
Ethical statement: This manuscript is a part of PhD in Rehabilitation Sciences, titled, "Effects of balance training on fall risk and mobility in the elderly" for which the ethical approval was acquired from Foundation University Medical College, Ethical Review Committee, Letter No. 217-1/FF/FUMC/ERC, dated 2nd June 2016.


1. PAKISTAN ECONOMIC SURVEY 2014-15, Population, Labor Force and Empowerment: Ministry of Finance, Government of Pakistan; 2014-2015. [Online] [Cited 2017 May 15]. Available from: URL: http://www.finance.gov.pk/survey_1415.html.
2. Chen SF, Huang SF, Lu LT, Wang MC, Liao JY, Guo JL. Patterns of perspectives on fall-prevention beliefs by community-dwelling older adults: a Q method investigation. BMC Geriatr 2016; 16: 132.
3. Das CP, Joseph S. Falls in elderly. J Indian Med Assoc 2005; 103: 136, 8, 40 passim.
4. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2009; 2: CD007146.
5. Zijlstra GA, Van Haastregt JC, Van Rossum E, Van Eijk J, Yardley L, Kempen GI. Interventions to reduce fear of falling in community?living older people: a systematic review. J Am Geriatr Soc 2007; 55: 603-15.
6. Sibley KM, Straus SE, Inness EL, Salbach NM, Jaglal SB. Balance assessment practices and use of standardized balance measure  among Ontario physical therapists. Phys Ther 2011; 91: 1583-91.
7. Mancini M, Horak FB. The relevance of clinical balance assessment tools to differentiate balance deficits. Eur J Phys Rehab Med 2010; 46: 239-48.
8. Bloem BR, Grimbergen YA, Cramer M, Willemsen M, Zwinderman AH. Prospective assessment of falls in Parkinson\'s disease. J Neurol 2001; 248: 950-8.
9. Liu Y, Chan JS, Yan JH. Neuropsychological mechanisms of falls in older adults. Front Aging Neurosci 2014; 6: 64.
10. Langley FA, Mackintosh SF. Functional balance assessment of older community dwelling adults: a systematic review of the literature. Int J All Health Sci Pract 2007; 5:13.
11. Lusardi MM, Pellecchia GL, Schulman M. Functional performance in community living older adults. J Geriatr Phys Ther 2003; 26: 14-22.
12. Drowatzky JN, Zuccato FC. Interrelationships between selected measures of static and dynamic balance. Research Quarterly American Association for Health, Physical Education and Recreation 1967; 38: 509-10.
13. Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehab 2001; 82: 1050-6.
14. Verghese J, Holtzer R, Lipton RB, Wang C. Quantitative gait markers and incident fall risk in older adults. J Gerontol A Biol Sci Med Sci
2009; 64: 896-901.
15. Greve J, Alonso A, Bordini AC, Camanho GL. Correlation between body mass index and postural balance. Clinics (Sao Paulo) 2007; 62: 717-20.
16. Moreland JD, Richardson JA, Goldsmith CH, Clase CM. Muscle weakness and falls in older adults: a systematic review and m et a ? a n a l y s i s . J Am G e r i a t r S o c 2 0 0 4 ; 5 2 : 1 1 2 1 - 9.


Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: