364
ORIGINAL ARTICLE
Balance Self-Efficacy and Its Relevance to Physical Function
and Perceived Health Status After Stroke
Nancy M. Salbach, PhD, Nancy E. Mayo, PhD, Sylvie Robichaud-Ekstrand, PhD, James A. Hanley, PhD,
Carol L. Richards, PhD, Sharon Wood-Dauphinee, PhD
ABSTRACT. Salbach NM, Mayo NE, Robichaud-Ekstrand
S, Hanley JA, Richards CL, Wood-Dauphinee S. Balance selfefficacy and its relevance to physical function and perceived
health status after stroke. Arch Phys Med Rehabil 2006;87:
364-70.
Objectives: To estimate the level of balance self-efficacy
among community-dwelling subjects with stroke and to determine the relative importance of balance self-efficacy compared
with functional walking capacity in predicting physical function and perceived health status.
Design: Secondary analysis of baseline, postintervention,
and 6-month follow-up data from a randomized trial.
Setting: General community.
Participants: Ninety-one subjects with a first or recurrent
stroke, discharged from rehabilitation therapy with a residual
walking deficit.
Interventions: Not applicable.
Main Outcome Measures: The Activities-Specific Balance
Confidence (ABC) Scale, Medical Outcomes Study 36-Item
Short-Form Health Survey physical function scale, and the
EQ-5D visual analog scale of perceived health status.
Results: Average balance self-efficacy was 59 out of 100
points on the ABC scale (95% confidence interval, 55– 64;
n⫽89). After adjusting for age and sex, functional walking
capacity explained 32% and 0% of the respective variability in
physical function and perceived health status scores obtained 6
months later. After adjustment for age, sex, and functional
walking capacity, balance self-efficacy explained 3% and 19%
of variation in 6-month physical function and perceived health
status scores, respectively.
Conclusions: Subjects living in the community after stroke
experience impaired balance self-efficacy. Enhancing balance
self-efficacy in addition to functional walking capacity may
lead to greater improvement, primarily in perceived health
From the Department of Epidemiology and Biostatistics (Salbach, Hanley, WoodDauphinee) and School of Physical and Occupational Therapy (Mayo, WoodDauphinee), Faculty of Medicine, McGill University, Montreal, QC; Division of
Clinical Epidemiology, Royal Victoria Hospital, Montreal, QC (Mayo, Hanley,
Wood-Dauphinee); Faculty of Nursing, University of Montreal, Montreal, QC
(Robichaud-Ekstrand); Rehabilitation Department, Laval University, Quebec City,
QC (Richards); and Interdisciplinary Research Centre for Rehabilitation and Social
Integration, Rehabilitation Institute of Quebec, Quebec City, QC (Richards), Canada.
Presented, in part, to the Canadian Physiotherapy Association Congress, May 28,
2005, Victoria, BC, Canada.
Supported by the Canadian Institutes of Health Research, the Quebec Réseau
Provincial de Recherche en Adaptation-Réadaptation, the Heart and Stroke Foundation of Canada, and the Canadian Stroke Network.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Correspondence to Nancy M. Salbach, PhD, Dept of Physical Therapy, University of Toronto, 160-500 University Ave, Toronto, ON M5G 1V7, Canada, e-mail:
nancy.salbach@utoronto.ca. Reprints are not available from the author.
0003-9993/06/8703-10230$32.00/0
doi:10.1016/j.apmr.2005.11.017
Arch Phys Med Rehabil Vol 87, March 2006
status, but also in physical function, than the enhancement of
functional walking capacity alone.
Key Words: Balance; Cerebrovascular accident; Health status; Rehabilitation; Self-efficacy.
© 2006 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
Rehabilitation
EHABILITATION EFFORTS FOR persons with stroke
focus primarily on enhancing physical function with less
R
attention paid to mental functions such as self-efficacy. Selfefficacy, defined as a judgment of one’s ability to organize and
execute given types of performances,1 is considered as important as physical ability in influencing decisions to engage in
various activities. Investigation of the role of self-efficacy in
motor recovery poststroke is preliminary and has been limited
to personal belief in the ability to undertake activities of daily
living (ADLs) without losing balance (balance self-efficacy2)
or falling (falls self-efficacy3-6). Improvement in falls selfefficacy, initially impaired after stroke, has been observed
during inpatient rehabilitation and is associated with gains in
balance, motor function,4,5 and walking capacity.5 Findings
from experimental studies have indicated that gait training
enhances falls7 and balance self-efficacy2,8 and that depression,
age, sex, comorbidity, time poststroke, and functional mobility
predict self-efficacy improvement.2 One study5 has shown that
self-efficacy is a stronger predictor than balance capacity of
performance of basic ADLs among people with stroke living in
the community. Demonstrating the contribution of balance
self-efficacy to more complex outcomes than basic ADL performance would help to justify targeting this construct as a
stroke rehabilitation outcome. Such investigation should be
based on current theories of disability that provide the advantage of a common language for describing and understanding
the impact of stroke on the individual.
In 2001, the World Health Organization adopted a new
system, the International Classification of Functioning, Disability and Health (ICF),9 for classifying health and healthrelated domains. The ICF applies the positive terms body
functions and structures, and activities and participation to
describe human functioning and the corresponding negative
terms impairments, activity limitations, and participation restrictions to describe health-related problems. The meaning of
the new term activities and participation are further enhanced
by such qualifiers as capacity, which refers to an individual’s
level of ability, and performance, which signifies what an
individual actually does in his/her environment.9 The ICF
recognizes the important influence of contextual factors on
levels of functioning and classifies them as either environmental (eg, physical barriers, culture, political climate) or personal
(eg, age, sex, education). The ICF was not designed to capture
broader constructs such as perceived health status. However,
factors such as physical, mental, social, and psychologic functioning, that in combination drive perceptions of health, are
considered as components of the ICF.10 Linking self-efficacy to
BALANCE SELF-EFFICACY POSTSTROKE, Salbach
perceived health status and its components would provide a
strong rationale for evaluating and targeting self-efficacy in
stroke rehabilitation.
Thus, the objectives of this study were to estimate: (1) the
level of balance self-efficacy in persons with stroke; (2) the
strength of associations between balance self-efficacy and sociodemographic and stroke characteristics, cognition, depression, balance, walking capacity, ADL performance, physical
function, physical health, and perceived health status; and (3)
the ability of balance self-efficacy to predict physical function,
physical health, and perceived health status after controlling for
functional walking capacity. Selection of potential correlates of
self-efficacy was based on previous research conducted in
the elderly,11-21 or among people with cardiac22-27 or pulmonary28,29 disease, stroke,2,5,30 or lower-limb amputation.31
METHODS
Overview
Data on balance self-efficacy were available from a randomized controlled trial2,32 of a task-oriented walking intervention
conducted among community-dwelling persons with stroke. In
this trial, 91 subjects were randomly assigned to a 6-week
intervention designed to enhance either walking or upperextremity function. Trained research personnel administered
measures of balance self-efficacy, cognition, depression, balance, walking capacity, performance in basic ADLs, and perceived health status in a hospital setting at baseline, on completion of the 6-week intervention, and 6 months later.
Participants
Recruitment was conducted in 9 hospitals and 2 rehabilitation centers in Montreal and Quebec City, QC. Eligibility was
determined by a clinical diagnosis of a first or recurrent stroke;
a residual walking deficit; mental competency verified using
the telephone version of the Mini-Mental State Examination
(MMSE),33 the capacity to walk a 10-m distance independently, using an aid or orthosis, with or without supervision;
the ability to comprehend testing procedures; residence in the
community; termination of physical rehabilitation services; and
a period of 1 year or less between the occurrence of the most
recent stroke and recruitment. People were excluded when the
neurologic deficit was caused by a metastatic disease, when
walking capacity was comparable to age- and sex-specific
norms34 on the 6-minute walk test (6MWT),35 if place of
residence was a permanent-care facility, or if other illnesses
prevented participation in walking or upper-extremity retraining.
Measurement
We assessed balance self-efficacy using the Activities-Specific
Balance Confidence (ABC) scale.11,12,36 To complete this questionnaire, subjects are instructed to rate their level of confidence on an 11-point scale that ranges from 0% (no confidence)
to 100% (complete confidence) in performing 16 different
activities without losing their balance or becoming unsteady.
Each activity involves position change or walking. A total
score out of 100 is computed by taking the average of the item
scores.
We evaluated cognition using the telephone version of the
MMSE.33 Scores below 17 indicate cognitive impairment
(range, 0 –22). Subjects scoring below 17 on this exam due to
the presence of dysphasia were admitted to the study if they
expressed an interest in participation and demonstrated a sufficient level of understanding, indicated by the ability to follow
multistep directives during baseline testing. Level of depres-
365
sive symptoms was evaluated using the Geriatric Depression
Scale (GDS),37 a 30-item questionnaire. The summary score
between 0 and 30 is used to classify the level of depressive
symptoms, with 0 to 9 points reflecting normal mood, 10 to 19
points indicating mild depressive symptoms, and 20 to 30
points signifying severe depressive symptoms.
We assessed balance using the Berg Balance Scale (BBS).38
The ability to maintain balance while performing each of 14
tasks required in everyday living is scored on a 5-point scale,
rendering a range of scores from 0 to 56. Higher scores reflect
a better level of balance ability.
Walking capacity was captured by multiple measures that
included the 6MWT,35 the 5-m walk (walking speed),39 the
Timed Up & Go40 (TUG) test, the Functional Ambulation
Classification (FAC),41 and the use of assistive devices.
The 6MWT is considered a measure of functional walking
capacity in persons with stroke. The maximum distance covered on a 20-m walkway in 6 minutes is recorded. Evaluators
provide standard encouragement,34 and subjects rest when necessary. We performed 2 trials with a 30-minute rest period in
between and the better distance was used in the analysis.
Walking speed was computed using the time taken to traverse
the middle 5m of a 9-m walkway. One trial was completed at
a comfortable pace, and a second trial at a maximal pace. In
administering the TUG, the time a subject takes to stand up
independently from an armchair, walk 3m, turn and return to
the seated position is recorded. No physical assistance is provided. The FAC is used to group subjects into 1 of 6 categories
(range, 0 –5) according to the level of human assistance required during walking.
We evaluated performance in basic ADLs using the Barthel
Index.42 Subjects are rated, using a 3-point scale, on their
ability to accomplish 10 ADLs including feeding, personal
hygiene, bathing, dressing, toilet transfers, bowel control, bladder control, chair to bed transfers, walking, and using stairs.
Scores range from 0 to 100 with higher scores indicating better
levels of functioning.
We measured function and physical health using the physical
function (PF) scale and the physical component summary (PCS),
respectively, of the Medical Outcomes Study 36-Item Short-Form
Health Survey (SF-36), a 36-item generic measure of perceived
health status.43 Scores on the 10-item PF scale reflect the
degree to which subjects feel limited in performing activities
that range in difficulty from running to bathing or dressing.
Scale scores vary from 0 to 100 with higher scores reflecting a
higher level of physical function. The PCS combines scores
from 4 scales of the SF-36: PF scale, role limitations due to
physical problems (role–physical), bodily pain, and general
health. Scores on the PCS are standardized to have a mean of
50 and a standard deviation (SD) of 10.
We measured perceived health status using the visual
analog scale (VAS) of the EQ-5D (EQ VAS).44-46 The EQ
VAS is a feeling thermometer, calibrated between 0 (worst
imaginable health state) and 100 (best imaginable health state),
on which subjects indicate the level of their current overall
health status.
Information on sociodemographic variables (age, sex, educational level, monthly income, number of comorbid conditions, cohabitation) and stroke characteristics (type of stroke,
number of strokes, side of hemiparesis) was obtained from the
medical chart.
Statistical Methods
The level of balance self-efficacy of persons living in the
community after stroke was expressed as the mean ABC score
of the study sample at baseline with the associated 95% conArch Phys Med Rehabil Vol 87, March 2006
366
BALANCE SELF-EFFICACY POSTSTROKE, Salbach
fidence interval (CI). The procedure for estimating associations
between balance self-efficacy and other variables depended on
the scale of measurement. For variables measured on an ordinal
scale, including age category, educational level, monthly income, number of comorbid conditions, cognition, level of
depressive symptoms, balance, walking capacity, ADL performance, physical function, physical health, and perceived health
status, associations were estimated using Spearman correlation
coefficients with associated 95% CIs. For nominal variables
with 2 categories, such as sex, type of stroke, history of stroke,
and side of hemiparesis, the difference in mean balance selfefficacy between categories was expressed with the associated
95% CI. For nominal variables with more than 2 categories,
such as cohabitation, a 1-way analysis of variance (ANOVA)
was conducted. Associations were estimated using baseline
data, because data collection was complete for 99% of the
sample at this time point.
The predictive relations between balance self-efficacy rated
postintervention and physical function (SF-36 PF scale), physical health (SF-36 PCS), and perceived health status (EQ VAS)
measured 6 months later were first estimated using Spearman
correlation coefficients with associated 95% CIs. Multiple linear regression was then performed to control for the effects of
age, sex, and functional walking capacity to determine the
contribution of self-efficacy to the outcomes over and above
basic demographics and walking capacity. An ␣ level of .05
defined significance in hypothesis testing. The analysis was
conducted using SAS.a
We conducted the study following approval by the institutional review board of McGill University and the Research
Ethics Committees in each hospital center. Voluntary, informed,
and written consent was obtained.
RESULTS
During the recruitment period of May 2000 to February
2003, 91 subjects consented to participate. Two subjects were
unable to complete the ABC scale at baseline due to language
and cognitive deficits, leading to a sample of 89 subjects with
self-efficacy data. At the postintervention evaluation, self-efficacy data were complete for 84 of the 91 subjects, because 4
Table 1: Characteristics of the Study Subjects (nⴝ89)
Characteristic
Values
Age (y)
Sex
Male
Female
Living with
Spouse
Other
Alone
Side of hemiparesis
Left
Right
Bilateral
Type of stroke
Ischemic
Hemorrhagic
No. of strokes
1
⬎1
Days poststroke
72⫾11 (38–91)
56 (63)
33 (37)
55 (62)
17 (19)
17 (19)
38 (43)
50 (56)
1 (1)
75 (84)
14 (16)
79 (89)
10 (11)
227⫾79 (57–386)
NOTE. Values are mean ⫾ SD (range) or n (%).
Arch Phys Med Rehabil Vol 87, March 2006
Table 2: Associations Between Balance Self-Efficacy and
Sociodemographic Characteristics at Baseline (nⴝ89)
Baseline ABC
Scores
Variable
Age (y)
⬍65
65–74
75–84
⬎84
Educational level
None–primary
Secondary
College–
university
Monthly income*
Insufficient
Adequate
Ample
No. of comorbid
conditions
0–1
2–3
4–9
No. (%)
Mean ⫾ SD
Range
18 (21)
35 (40)
25 (29)
11 (12)
54⫾23
63⫾21
65⫾17
44⫾18
19–96
24–99
38–91
23–85
26 (29)
33 (37)
57⫾22
62⫾22
25–98
19–93
30 (34)
58⫾19
23–99
15 (18)
23 (28)
44 (54)
52⫾20
59⫾22
63⫾20
19–93
29–99
21–98
23 (26)
35 (39)
31 (35)
59⫾24
61⫾20
58⫾19
21–96
23–98
19–99
Spearman ␳
(95% CI)
⫺.03 (⫺.24 to .18)
.00 (⫺.21 to .21)
.21 (⫺.01 to .41)
⫺.04 (⫺.25 to .17)
*Subjects indicated whether, at the end of each month, they had: not
enough money to make ends meet (insufficient), just enough to
make ends meet (adequate), or some money left over (ample). Data
were missing for 7 subjects who refused to answer the question.
subjects had withdrawn from the study and 3 persons had
difficulty understanding the scale. By the 6-month follow-up
evaluation, a total of 25 people were lost to follow-up and a
few subjects did not complete some of the questionnaires
leading to variable sample sizes for analyses of the PCS
(n⫽61), PF scale (n⫽62), and EQ VAS (n⫽64) scores. As
expected, subjects with missing 6-month follow-up data on the
PCS of the SF-36 (n⫽30) were more likely to have dysphasia
(Fisher exact test, P⫽.01) and right-sided hemiparesis (␹21
test⫽4.3, P⫽.04), compared with subjects with complete data
for all 3 evaluations (n⫽61); otherwise, these subjects did not
differ on any of the other variables measured at baseline based
on a conservative type I error level of .10.
Table 1 presents sociodemographic and stroke characteristics of the study sample with complete self-efficacy data at
baseline (n⫽89). Subjects were, on average ⫾ SD, 72⫾11
years of age (range, 38 –91y) and were between 57 and 386
days poststroke (mean, 227⫾79d). The average level of balance self-efficacy in this community-dwelling sample at study
entry was 59⫾21 out of 100 points on the ABC scale (95% CI,
55⫺64) with scores ranging from 19 to 99 points.
Table 2 presents correlations between sociodemographic
characteristics and balance self-efficacy. Based on Spearman
␳ values, balance self-efficacy was not significantly associated
with age category, educational level, monthly income, or the
number of comorbid conditions. Average balance self-efficacy
ratings among men and women were 64⫾21 and 51⫾19
points, respectively. On average, men rated their self-efficacy
significantly higher than women (mean difference, 13 points;
95% CI, 4⫺21). Average self-efficacy scores among subjects
living with a spouse, with a person who was not a spouse, or
alone were 61⫾20, 55⫾20, and 55⫾21 points, respectively.
No association was observed between balance self-efficacy and
cohabitation based on a 1-way ANOVA (F2,86⫽.61, P⫽.55).
367
BALANCE SELF-EFFICACY POSTSTROKE, Salbach
Table 3: Associations Between Cognition, Depressive Symptoms, and Independence in Walking and Balance Self-Efficacy at
Baseline (nⴝ89)
Baseline ABC Scores
Variable (measure)
Cognition (MMSE)
⬍17/22
ⱖ17/22
Depressive symptoms (GDS)*
Severe
Mild
None
Independence in walking (FAC)
Supportive manual contact
Light manual contact
Supervision
Independent on level surfaces
Independent on all surfaces
Walking aid
Walker
Cane
None
Spearman ␳ (95% CI)
No. (%)
Mean ⫾ SD
Range
23 (26)
66 (74)
54⫾19
61⫾21
23–88
19–99
12 (14)
40 (45)
36 (41)
44⫾20
56⫾20
68⫾19
19–79
21–98
29–99
2 (2)
5 (6)
18 (20)
31 (35)
33 (37)
39⫾24
46⫾21
47⫾19
57⫾18
72⫾18
23–56
21–66
24–83
19–88
38–99
8 (9)
40 (45)
41 (46)
46⫾21
54⫾18
67⫾21
23–80
21–91
19–99
.14 (⫺.07 to .34)
⫺.39 (⫺.55 to ⫺.19)
.48 (.30 to .63)
⫺.34 (⫺.51 to ⫺.14)
*Score was missing for 1 subject who was too emotional to complete the questionnaire.
Age did not appear to relate to balance self-efficacy in a
linear fashion, although a 1-way ANOVA revealed a significant difference in balance self-efficacy among age categories
(F3,85⫽3.40, P⫽.02). A lower average score on the 6MWT was
observed among subjects older than 84 years compared with
subjects in other age groups and a higher frequency of severe
depressive symptoms was observed in the youngest and oldest
age groups compared with persons aged 65 to 84 years.
Balance self-efficacy was unrelated to stroke characteristics,
such as the type or side of stroke and the number of strokes
sustained. Average ratings were 59 and 60 points on the ABC
scale in persons with ischemic and hemorrhagic stroke, respectively (mean difference, 1 point; 95% CI, ⫺12 to 13). In
persons with a first stroke compared with a recurrent stroke,
mean scores on the ABC scale were 59 and 60 points, respectively (mean difference, 1 point; 95% CI, ⫺13 to 15). Persons
with left- as opposed to right-sided hemiparesis scored an
average of 57 and 61 points, respectively, on the ABC scale
(mean difference, 4 points; 95% CI, ⫺5 to 13).
Table 3 presents estimates of the associations between balance self-efficacy and cognition, level of depressive symptoms,
the level of independence while walking (FAC category) as
well as the walking aid used. Ratings of balance self-efficacy
decreased with increasing depressive symptoms, decreasing
independence in walking and with increasing level of support
from assistive devices and these relations were statistically
significant. Balance self-efficacy was not significantly associated with cognitive ability. Further analysis revealed that subjects with cognitive impairment (telephone version MMSE
score, ⬍17/22) tended to walk more slowly and shorter distances than subjects without impairment. At the postintervention and 6-month evaluations, correlations between balance
self-efficacy and level of depressive symptoms and walking
independence were similar to those observed at baseline.
In table 4, baseline scores on measures of balance, walking
capacity, ADL performance, physical function, physical health,
and perceived health status are presented. Associations between balance self-efficacy and these variables are also provided in order of decreasing strength. Correlations were fair to
moderate47 ranging from .36 to .59 (n⫽89, P⬍.001). These
relations were upheld at the postintervention (␳ range, .44⫺.69;
P⬍.001) and 6-month evaluations (␳ range, .44⫺.63; P⬍.001).
In the prediction analysis, balance self-efficacy rated postintervention correlated moderately with 6-month physical function as measured by the PF scale (n⫽62; ␳⫽.56; 95% CI,
.36⫺.71), physical health captured by the PCS (n⫽61; ␳⫽.40;
95% CI, .16⫺.59), and perceived health status rated using the
EQ VAS (n⫽64; ␳⫽.40; 95% CI, .17⫺.59). For those subjects
with data at the 6-month evaluation, the average score on the
PF scale was 46⫾28 points (range, 0⫺95) that represents 61%
of the Canadian norm for persons aged 65 to 74 years.48 This
age range captured the largest proportion of study subjects
(45%). Subjects scored an average of 37⫾9 points (range,
15⫺57) on the PCS representing 78% of the expected mean
score in Canadians aged 65 to 74 years.48 Subjects rated their
Table 4: Associations Between Balance Self-Efficacy
and Measures of Balance, Walking Capacity, ADL
Performance, Physical Function/Health, and
Perceived Health Status at Baseline (nⴝ89)
Baseline Scores
Measure (unit or
maximum score)
Mean ⫾ SD
Range
Spearman ␳ (95% CI)
SF-36 PF scale* (/100)
41⫾24
0–90
.59 (.44⫺.71)
EQ VAS (/100)
65⫾21
0–100
.52 (.35⫺.66)
5-m walk, maximum
pace (m/s)
.81⫾.47 0.08–2.33
.49 (.31⫺.63)
5-m walk, comfortable
pace (m/s)
.63⫾.35 0.08–1.90
.46 (.28⫺.61)
BBS (/56)
41⫾12
5–56
.44 (.25⫺.59)
Barthel Index (/100)
87⫾13
55–100
.43 (.24⫺.59)
6MWT (m)*
216⫾125
31–594
.43 (.24⫺.59)
TUG test (s)
24.1⫾18.8 7.0–100.0 ⫺.43 (⫺.59 to ⫺.24)
SF-36 PCS*†
36⫾8
16–54
.36 (.16⫺.53)
*Data were missing for the SF-36 due to language impairment (n⫽1)
and for the 6MWT (n⫽3) due to failure on the medical screen for this
test.
†
Scores standardized to have a mean of 50 and an SD of 10.
Arch Phys Med Rehabil Vol 87, March 2006
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BALANCE SELF-EFFICACY POSTSTROKE, Salbach
Table 5: Modeling the Ability of Balance Self-Efficacy to Predict Physical Function/Health and Perceived Health Status 6 Months Later
Crude Effects
Order of Variables in the Model
SF-36 PF scale (n⫽62, R ⫽.56)
Age (y)
Sex (0⫽male)
6MWT (m)
ABC scale (/100)
SF-36 PCS (n⫽61, R2‡⫽.26)
Age (y)
Sex (0⫽male)
6MWT (m)
ABC scale (/100)
EQ VAS (n⫽64, R2‡⫽.24)
Age (y)
Sex (0⫽male)
6MWT (m)
ABC scale (/100)
Adjusted Effects
␤* (95% CI)
R2
␤* (95% CI)
R2†
⫺1.11 (⫺1.80 to ⫺0.41)
⫺9.86 (⫺24.67 to 4.95)
0.13 (0.09 to 0.17)
0.70 (0.44 to 0.96)
.14
.03
.41
.31
⫺0.98 (⫺1.51 to ⫺0.44)
⫺11.75 (⫺22.46 to ⫺1.04)
0.09 (0.04 to 0.13)
0.29 (0.01 to 0.56)
.14
.07
.32
.03
⫺0.19 (⫺0.42 to 0.05)
⫺2.66 (⫺7.49 to 2.18)
0.03 (0.01 to 0.04)
0.18 (0.04 to 0.27)
.04
.02
.15
.21
⫺0.16 (⫺0.39 to 0.06)
⫺2.44 (⫺7.02 to 2.15)
0.01 (⫺0.01 to 0.03)
0.13 (0.01 to 0.24)
.04
.04
.12
.06
⫺0.41 (⫺0.82 to 0.00)
2.60 (⫺5.86 to 11.07)
0.03 (0.00 to 0.06)
0.31 (0.15 to 0.47)
.06
.01
.05
.19
⫺0.30 (⫺0.70 to 0.10)
3.23 (⫺4.76 to 11.22)
⫺0.01 (⫺0.04 to 0.02)
0.35 (0.14 to 0.56)
.04
.01
.00
.19
2‡
*Interpretation: average change in the dependent variable per unit change in the predictor variable adjusting for the other variables (if any)
in the model.
†
Proportion of variability in the dependent variable uniquely explained by the predictor variable adjusting for higher-order variables in the
model. Sums may be influenced by rounding.
‡
Proportion of variability in the dependent variable explained by the model.
current health status an average of 69⫾16 points out of 100
(range, 40⫺100) on the EQ VAS.
Table 5 presents the results of multivariable modeling. Balance self-efficacy was a significant predictor of physical function and physical health, explaining 3% and 6% of the variability in scores on the PF scale and the PCS, respectively, after
adjusting for age, sex, and functional walking capacity. Advancing 15 points on the ABC scale predicted a 4-point improvement on the PF scale and a 2-point improvement on the
PCS. A 15-point gain on the ABC scale is achievable; of the 41
subjects randomly assigned the walking intervention in the
original trial, 12 (29%) persons experienced a gain of 15 points
or greater in ABC ratings following training. Multivariable
models explained 56% and 26% of the variability in PF scale
and PCS scores, respectively.
Balance self-efficacy was also a significant predictor of
perceived health status and explained 19% of the variability in
EQ VAS scores after controlling for age, sex, and functional
walking capacity. Advancing 15 points on the ABC scale
predicted a 5-point improvement on the EQ VAS. This group
of predictors explained 24% of the variability in perceived
health status.
DISCUSSION
Findings of this study support the relevance of balance selfefficacy as an outcome of stroke rehabilitation. Balance selfefficacy appears diminished poststroke even in this sample of
ambulatory subjects. Average balance self-efficacy in the current
study was lower than that observed in older adults reporting no
health problems (mean, 91 points) or a single chronic health
condition (mean, ⱖ70 points), but higher than that of home
care clients (mean, 36 points).11
It was surprising that balance self-efficacy did not decrease
with increasing age. With aging, levels of personal efficacy are
expected to decrease with deterioration in physical and mental
health, the observation of similar declines in peers, social
encounters that emphasize this decline, and the experience of
physiologic symptoms related to illness and aging.49,50 Findings of the current study suggest that the degree of strokeArch Phys Med Rehabil Vol 87, March 2006
related walking deficit and the level of depressive symptoms
superseded any influence of the aging process.
As hypothesized, women reported lower levels of self-efficacy than men. Although this has been noted previously in
other patient groups,11,13,18-21,24 it has not been observed in 2
studies of persons with stroke,3,5 potentially due to insufficient
power in one of these studies.3 The influence of sex on selfefficacy beliefs has been the focus of some discussion. Clark49
hypothesizes that the combination of lower educational level,
monthly income, and occupational status noted in women compared to men results in a decreased sense of control and,
subsequently, self-efficacy. Other investigators51 feel that men
may have higher levels of self-efficacy than women due to
societal influences that make certain roles and opportunities
more available to them. In stroke rehabilitation, which focuses
to a large extent on enhancing physical ability, it may be that
men report higher than actual levels of self-efficacy to offer an
image of strength and control.
In contrast to previous work,11,13,19,20,51,52 balance self-efficacy was not significantly associated with monthly income or
educational level that are indicators of socioeconomic status.
Compared with low educational levels, high educational levels
are likely to yield better employment opportunities and stature
that enhances feelings of competence and mastery.51 Although
these factors are not modifiable through rehabilitation interventions, they help to explain the variable strength of self-efficacy
beliefs among subjects.
Balance self-efficacy was also unrelated to the number of
comorbid conditions in contrast to findings among the elderly.11,13
As with age, the overwhelming impact of stroke on the ability
to balance and walk may have superseded any influence of
comorbidity on ratings of balance self-efficacy.
Balance self-efficacy tended to be lower in persons with
cognitive impairment compared with persons without impairment. Persons with cognitive deficits are expected to have a
limited ability to process information drawn from positive
experiences that should enhance self-efficacy.53 These include
experiencing success in the practice of a task (mastery experience),53,54 observing peers successfully accomplish a task
BALANCE SELF-EFFICACY POSTSTROKE, Salbach
(vicarious experience), receiving affirmation of ability from
a respected health professional (verbal persuasion) and obtaining feedback on negative physiologic symptoms and
having therapy in a secure environment (physiologic and
emotional arousal).53,54
The association observed between balance self-efficacy and
the level of depressive symptoms was expected given similar
findings in the elderly,11,13,19,20 as well as among persons with
cardiac disease22 and stroke.30 Although it would appear that
low self-efficacy is an indicator of vulnerability in physical as
well as psychosocial domains, persons with severe depressive
symptoms have demonstrated impressive gains in balance selfefficacy after walking retraining.2 Although this finding requires confirmation, it indicates that these individuals may not
require special intervention other than task-specific therapy
delivered in a group setting.
It was not surprising that subjects with low balance selfefficacy were more likely to have diminished physical capacity
and basic ADL function than persons with high self-efficacy.
This finding supports the influence of mastery experience on
self-efficacy and is consistent with previous reports in younger
and older persons with stroke5,6 and in the elderly.11,12,14,21 The
relation between self-efficacy and physical capacity is considered reciprocal wherein low ability levels may lead to low
self-efficacy and low self-efficacy may result in activity restriction.51 In fact, older adults with low balance12 or falls55 selfefficacy report activity avoidance which places them at risk for
deconditioning, falls,21 deterioration in functioning,13,21 and
health-related quality of life.21 This phenomenon requires investigation in persons with stroke because of the potential
burden on the individual as well as the health care system.
The links between self-efficacy and physical function, physical health, and perceived health status observed in this study
contribute new information for persons with stroke that is
consistent with findings reported for other clinical populations.14,18,29,30 Although balance self-efficacy was a strong
univariate predictor of physical function, its effects were
largely supplanted after controlling for functional walking capacity in multivariable modeling. Conversely, functional walking capacity contributed relatively little to perceptions of health
status, whereas balance self-efficacy was a strong determinant.
Given the importance of perceived health status, this finding
provides an important rationale for targeting aspects of mental
health, such as self-efficacy, in stroke rehabilitation.
Study Limitations
This study was not without limitations. The study was not
designed a priori to address the current objectives and, thus,
analyses were subject to limitations, such as reduced power,
that are inherent in post hoc analyses. The moderate to high
ambulatory level of the subjects who had returned home after
stroke restricts the generalizability of study findings to persons
with severe walking deficits or to those who live in assisted
care facilities. The difficulty in grasping the concept of rating
confidence levels observed in some subjects underlines the
challenge in measuring self-efficacy in persons with cognitive
and/or language impairment caused by stroke. Finally, although the verification of hypothetical relations in this study
contributes evidence of the construct validity56 of the ABC
scale, a comprehensive psychometric evaluation of this measure in persons with stroke has not yet been reported.
CONCLUSIONS
Balance self-efficacy is impaired among subjects living in
the community after stroke and relates to sex, level of depres-
369
sive symptoms, and physical functioning in a manner that
enhances our understanding of how cognitive processes can
determine activity and participation levels after stroke. Findings show that self-efficacy not only contributes to the performance of meaningful physical activities but it also contributes
to how individuals feel about their health. These important
findings support the recommendation to evaluate and target
self-efficacy as a stroke rehabilitation outcome. Study results
suggest that enhancing balance self-efficacy in addition to
functional walking capacity is expected to enhance physical
function and perceived health status to a greater extent than
enhancing functional walking capacity alone.
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