Prognostic accuracy of the one-legged balance test in predicting falls: 15-years of midlife follow-up in a British birth cohort study

Introduction: The one-legged balance test is a common screening tool for fall risk. Yet, there is little empirical evidence assessing its prognostic ability. The study aims were to assess the prognostic accuracy of one-legged balance performance in predicting falls and identify optimal cut-points to classify those at greater risk.
Methods: Data from up to 2000 participants from a British birth cohort born in 1946 were used. The times an individual could stand on one leg with their eyes open and closed were recorded (max:30s) at ages 53 and 60-64. Number of falls in the past year was self-reported at ages 53, 60-64 and 68; recurrent falls (0-1 vs 2+) and any fall (0 vs 1+) were considered binary outcomes. Four longitudinal associations between balance times and subsequent falls were investigated (age 53-->60-64; age 53-->68; age 60-64-->68; age 53 & 60-64-->68). For each temporal association, areas under the curve (AUC) were calculated and compared for a base sex-only model, a sex and balance model, a sex and fall history model and a combined model of sex, balance and fall history. The Liu method was used to identify optimal cut-points and sensitivity, specificity, and AUC at corresponding cut-points.
Results: Median eyes open balance time was 30s at ages 53 and 60-64; median eyes closed balance times were 5s and 3s, respectively. The predictive ability of balance tests in predicting either fall outcome was poor(AUC range for sex and balance models:0.577-0.600). Prognostic accuracy consistently improved by adding fall history to the model (range:0.604-0.634). Optimal cut-points ranged from 27s to 29s for eyes open and 3s to 5s for eyes closed; AUC consistently indicated that using ‘optimal’ cut-points to dichotomise balance time provided no discriminatory ability (AUC range:0.42-0.47), poor sensitivity (0.38-0.61) and poor specificity (0.23-0.56).
Discussion: Despite previous observational evidence showing associations between better one-legged balance performance and reduced fall risk, the one-legged balance test had limited prognostic accuracy in predicting recurrent falls. This contradicts ongoing translation of this test into clinical screening tools for falls and highlights the need to consider new and existing screening tools that can reliably predict fall risk.