The Impact of Fear of Falling

The Impact of Fear of Falling

Falls, particularly falls among older adults, are among the 20 most expensive medical conditions in the United States according to the CDC, costing more than $50 billion in 2015. Therapists in every venue routinely screen and assess patients for fall risk and implement treatment interventions to mitigate this risk and prevent future falls. Performance-based standardized tests and assessments, such as the Berg Balance Scale, the Tinetti Performance Oriented Motor Assessment, the Functional Reach and the Timed Up and Go, are commonly used to quantify fall risk and measure progress during a therapy episode of care.

While important and objective, these performance-based tools do not consider a critical element of fall risk: the fear of falling. Self-reported balance assessment tools focus on fear of falling and balance confidence (or balance self-efficacy), and provide key information about the individual’s risk for falls and the tendency or likelihood to self-limit activities because of the fear that he/she may fall. Limiting activity, leads to further weakness and decreased mobility which increases the risk of another fall (O’Halloran et al., 2011).

Denkinger et al. (2010) demonstrated that falls-related self-efficacy (i.e., balance confidence) significantly predicts therapy outcomes related to activities of daily living (ADL), gait, and overall function at discharge and four months later. Visschedijk, Caljouw, Bakkers, van Balen, and Achterberg (2015) analyzed fear of falling during and after rehabilitation in a skilled nursing facility (SNF) and its relationship to instrumental activities of daily living (IADL) performance after discharge from the SNF. Of the 280 study participants, 62.5 percent of participants had fear of falling on admission to the SNF, and, four weeks after discharge, 82.1 percent had fear of falling. In addition, IADL performance was considerably lower in the group that reported fear of falling. The authors postulate that the increase in fear of falling after discharge from the SNF could be because patients can’t foresee all of the possible challenges and consequences of being discharged home (and, of note, 70 percent of the patients in the study lived alone).

The results of this study support Denkinger’s earlier findings – that falls-related self-efficacy affects rehab outcome after discharge. Therapists must acknowledge that fear of falling and balance confidence are significant factors in fall management and risk reduction and address these issues during treatment.  Use of a standardized patient-reported outcome tool to assess fear of falling and balance confidence assists in not only identifying the presence and impact of the individual’s perception of his or her fall risk, but also determining the activities and environment that present the greatest risk of falling for the individual.

The Falls Efficacy Scale International (FES-I) measures an individual’s level of concern about falling during 16 social and physical activities both inside and outside the home (Yardley et al., 2005). The FES-I has been validated cross-culturally, for patients with and without cognitive impairment, and for those with Parkinson’s disease. Instructions are as follows, “On a scale from 1 to 10 with 1 being very confident and 10 being not confident at all, how confident are you that you could do the following activities without falling?” Activities include thing like: take a bath or shower, reach into cabinets or closets, walk around the house, get in and out of bed, get dressed and undressed, visit friends and relatives, go out to a social event, and go up and down stairs. The FES-I is scored between 16 and 64, with scores ranging from 28-64 equating to a high risk for falls.

The Activity-specific Balance Confidence Scale (ABC) assesses an individual’s level of confidence with performing 16 activities on a scale of 0 – 100 percent confidence (Powell & Myers, 1995). The individual is asked, “How confident are you that you will not lose your balance or become unsteady when you…” walk around the house, go up and down stairs, bend over to pick up a slipper from the front of the closet floor, sweep the floor, get in and out of the car, walk up and down a ramp, etc. The lower the score, the less confident the person is with performing the activity without losing his/her balance. A score of 67 or below indicates a high risk for falls.

The Fear of Falling Avoidance Behavior Questionnaire (FFABQ) quantifies avoidance behavior and activity curtailment related to the fear of falling (Landers, Durand, Powell, Dibble, & Young, 2011).  The premise of the FFABQ is that individuals with a fear of falling (secondary to a previous fall or the awareness of the negative consequences of falling) will avoid activities that put them at risk for a fall. Each item begins with “Due to my fear of falling I avoid…” and answers are ranked on a 5-point Likert scale (Completely Disagree, Disagree, Unsure, Agree, Completely Agree), for a total of 56 points with higher scores indicating greater activity limitations and participation restrictions. The activities are identified based on the International Classification of Function (ICF) and include things such as walking, lifting and carrying and objects (e.g., cup, child), going up and down stairs, walking in crowded places, leaving home, getting in and out of a chair, showering and/or bathing, and preparing meals. The FFABQ is correlated with the ABC and the original Falls Efficacy Scale (developed by Mary Tinetti in 1990), as well as with the Berg, the Dynamic Gait Index (DGI), and the TUG.

Therapists must understand and address the impact of fear of falling and lack of balance confidence on the patient’s fall risk and functional independence. Several studies have demonstrated that exercise, balance training, gait training, along with patient education and cognitive strategies such as personal goal-setting, have reduced fear of falling and improved balance self-efficacy (Zijlstra et al., 2007; Barban et al., 2017).

Therapists often have patient’s completed standardized tests and assessments to obtain a score that can be used to help objectively describe and quantify the patient’s level of impairment and progress. However, the score is not the only purpose of doing a standardized test or measure. The test items themselves indicate specific tasks or skills the patient needs assistance with, what types of activities he or she may be avoiding, or in the case of fall risk and fear of falling, which activities put the patient at greatest risk for a fall. Analysis of these results should guide treatment. For example, if a patient completes the ABC and confirms that she is not confident with picking up a slipper from the front of the closet floor or with reaching for objects at eye level or overhead, then treatment should work on these tasks and skills.

Use the information gleaned from these tests to discuss goals and objectives of therapy intervention with your patients. Clarify their goals and what types of activities and skills they need to be able to perform safely to maximize their independence.



Barban, F., Annicchiarico, R., Melideo, M., Federici, A., Lombardi, M. G., … Caltagirone, C. (2017). Reducing fall risk with combined motor and cognitive training in elderly fallers. Brain Sciences, 19(7).

Denkinger, M. D., Igl, W., Lukas, A., Bader, A., Bailer, S., … Jamour, M. (2010). Relationship between fear of falling and outcomes of an inpatient geriatric rehabilitation population – fear the fear of falling. Journal of the American Geriatric Society, 59(4), 664-673.

Donoghue, O. A., Setti, A., O’Leary, N., & Kenny, R. A. (2017). Self-reported unsteadiness predicts fear of falling, activity restriction, falls, and disability. Journal of the American Medical Directors Association, 18(7), 597-602.

Landers, M. R., Durand, C., Powell, D. S., Dibble, L. E., & Young, D. L. (2011). Development of a scale to assess avoidance behavior due to a fear of falling: the fear of falling avoidance behavior questionnaire. Physical Therapy, 91(8), 1253-1265.

O’Halloran, A. M., Pénard, N., Galli, A., Fan, C. W., Robertson, I. H., & Kenny, R. A. (2011). Falls and falls efficacy: the role of sustained attention in older adults. BMC Geriatrics, 11, 85.

Powell, L. E. & Myers, A. M. (1995). The activities-specific balance confidence (ABC) scale. Journal of Gerontology, 50, M28-34.

Visschedijk, J. H. M., Caljouw, M. A. A., Bakkers, E., van Balen, R., & Achterberg, W. P. (2015). Longitudinal follow-up study on fear or falling during and after rehabilitation in skilled nursing facilities. BMC Geriatrics, 15, 161.

Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., & Todd, C. (2005). Development and initial validation of the falls efficacy scale – international (FES-I). Age and Ageing, 34(6), 614-619.

Zijlstra, G. A., van Haastregt, J. C., van Rossum, E., van Eijk, J. T., Yardley, L., & Kempen, G. I. (2007). Interventions to reduce fear of falling in community-living older people: a systematic review. Journal of the American Geriatric Society, 55(4), 603-615.

Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Quality, as well as the Compliance Officer. She provides regulatory guidance and interpretation, clinical programming and content development, education and training steerage, and compliance support for the company. As a physical therapist for more than 20 years, Holly has multi-venue clinical and management experience, giving her a unique perspective on the integration of compliance and training with therapy service delivery and clinical practice.
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