Fear of Falling Avoidance Behavior Assessment and Intervention in Parkinson’s Disease: A Scoping Review

Figures & data

Figure 1 Search results, study selection, and inclusion process reported using the PRISMA Flow Diagram.

Notes: Adapted from: Tricco AC, Lillie E, Zarin W et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med. 2018;169(7):467–473. doi:10.7326/M18-0850.³⁸ Creative Commons.

Table 1 Main Characteristics of Included Studies

Author, Year (Country)	Study Purpose (Study Design)	Participants	Measurements and/or Interventions for FFAB	Key Findings Related to FFAB
Nilsson, Drake & Hagell, 2010^Citation46 (Sweden)	To investigate the validity and reliability of the Falls-Efficacy Scale and the Survey of Activities and Fear of Falling in the Elderly in people with PD. (Cross-sectional study)	n = 79 (56 males, 23 females, mean age = 64.5, mean PD duration = 15.9 years)	Falls Efficacy Scale (FES) Survey of Activities and Fear of Falling in the Elderly (SAFFE)	Although fall-related self-efficacy and activity avoidance are related, they are not interchangeable constructs. FES correlated the strongest with SAFFE, whereas SAFFE correlated stronger with physical functioning. FES and SAFFE were able to distinguish between fallers and non-fallers, FOF and unsteadiness while turning. Fallers and those reporting FOF had lower fall-related self-efficacy and higher FFAB. Individuals with PD reported the highest FFAB for going out when it is slippery, going to a place with crowds, walking half a mile, and traveling by public transportation.
Rahman, Griffin, Quinn & Jahanshahi, 2011^Citation44 (United Kingdom)	i. To identify the different aspects of FOF in PD in terms of perceived self-efficacy, feared consequences of falling, and range of activities avoided. ii. To investigate the impact of disease stage, previous falls, fall frequency, and the contribution of mobility and psychological factors of FOF in PD. iii. To identify the contribution of FOF to quality of life (QOL) in PD. (Cross-sectional study)	n = 130 (84 males, 46 females, median age = 66.7, mean duration of PD = 12.1 years, mean self-rated Hoehn and Yahr (H&Y) stage = 2.63).	Consequences of Falling Questionnaire (CoF) FES SAFFE	Of the measures used in this study, the SAFFE was identified as the best measure of FFAB, as it measures actual activity avoidance due to FOF. The presence of FFAB implies that the individual believes that a fall is likely, that a fall will have undesirable consequences, and these beliefs are strong enough to act on. Damage to identity was more commonly perceived as a likely consequence of falling than a loss of functional independence. Falls-related self-efficacy decreased with increasing task complexity and individuals with PD avoid similar activities as healthy elderly individuals, except for situations with large numbers of people, social events, and public transport, which are also avoided by individuals with PD. The SAFFE was the main predictor of QOL. FOF was significantly different between fallers and non-fallers and frequent and infrequent fallers with PD. Patient-rated disability significantly influenced FOF. Disability was the main predictor of FOF, depression was the main predictor of perceived consequences of falling, and anxiety was the main predictor of activity avoidance.
Nilsson, Rehncrona & Jarnlo, 2011^Citation47 (Sweden)	To explore whether FOF and fall rate were affected after subthalamic deep brain stimulation in people with PD. (Prospective cohort study)	n = 20 (13 males, 7 females, mean age = 65.3, mean PD duration = 12.7).	FES SAFFE Subthalamic deep brain stimulation	One year after surgery, the median SAFFE and instrumental activities of daily living (IADL) subscale of the FES demonstrated improvement, the activities of daily living (ADL) subscale of the FES did not improve, the rate of near falls significantly decreased, and no changes were observed in the rate of falls. Evidenced by the SAFFE and IADLs scores of the FES, fewer activities were avoided owing to the risk of falling and fall-related self-efficacy improved during complex activities one year after subthalamic deep brain stimulation.
Bryant, Rintala, Hou & Protas, 2015^Citation45 (United States)	To assess the extent of activity limitations in individuals with PD who experienced falls and identify factors associated with activity limitation and physical inactivity. (Cross-sectional study)	n = 83 (males = 59, females = 24; mean H&Y stage = 2.5)	Activities-specific Balance Confidence Scale (ABC) Physical Activity Scale for the Elderly (PASE)	FOF and fall frequency explained a significant amount of additional variance on activity limitations, above physical impairment. Fear of falling was associated with physical inactivity as measured by the PASE. Frequent fallers reported a decreased ability to perform ADLs, higher levels of FOF, and were less physically active compared to nonfallers.
Kader, Iwarsson, Odin & Nilsson, 2016^Citation42 (Sweden)	To examine how fall-related activity avoidance relates to a history of self-reported falls/near falls and fear of falling as well as to disease severity in people with PD. (Cross-sectional study)	n = 251 (61% were male, mean age = 70, mean PD duration = 8 years)	Modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE)	Individuals with PD with a history of self-reported falls or near falls and FOF report significantly more FFAB than those without. While FFAB increased with increased severity of PD, FFAB was reported among those without any history of falls and in mild stages of PD. The most avoided activity was going out when it was slippery, the second most avoided activity for single fallers was going to a crowded place, and for recurrent fallers, it was reaching overhead.
Landers, Lopkar, Newman, Gourlie, Sorenson & Vong, 2017^Citation21 (United States)	To examine avoidance behavior due to FOF in those with PD and to identify possible differences between avoiders and nonavoiders across five different domains: demographics, PD symptoms, balance and falls, physical performance, and psychological factors. (Cross-sectional study)	n = 59 (males = 45, females = 14, mean age = 72 years, H&Y median score = 2.0, mode = 3.0)	Fear of falling avoidance behavior questionnaire (FFABQ) ABC scale CoF	FFABQ can be used to dichotomize participants into avoider and nonavoider groups with a cut-point score of 20/56. There were no differences between avoiders and nonavoiders for demographic characteristics and fall history. Avoiders had poorer balance performance, lower balance confidence, more fall catastrophizing, higher levels of depression and anxiety, and worse scores on PD-symptom measures.
Jonasson, Nilsson, Lexell & Carlsson, 2018^Citation4 (Sweden)	To explore the experiences of fear of falling in persons with PD. (Qualitative study)	n = 12 (6 women, 6 men; median age = 70) -Inclusion criteria: PD and reported FOF.	Qualitative study – no specific assessments	Three themes emerged: (1) FOF as a disturbance in everyday life, (2) FOF as a varying experience, and (3) handling FOF by adopting different strategies. Within theme 1, participants reported a feeling of vulnerability and insecurity from FOF, that several activities, situations, and environments were potentially hazardous, and that a life without FOF was considered more active and offered more freedom. Within theme 2, the awareness of the increased risk of falling with PD impacted FOF, others’ experiences of falls augmented fear, and FOF was impacted by PD-related symptoms and disabilities, and the attitudes and treatment from other people. Within theme 3, all participants used strategies to handle FOF, people with PD handle FOF in four different ways: (1) adapt the behavior, so it can still be performed in a modified way, (2) avoid the behavior altogether, (3) perform the behavior with assistance, and (4) perform the behavior without assistance or modification. FOF restricts participation in meaningful activities and FFAB was influenced by PD-related symptoms and disabilities.
Leavy, Berntsson, Franzen & Roaldsen, 2019^Citation43 (Sweden)	To explore perceptions of balance and falls among people with mild to moderate PD 3–12 months following participation in supervised balance training. (Qualitative study)	n = 13 (females = 7, males = 6	Qualitative study – no specific assessments Intervention: Supervised balance training	Three main themes emerged: (1) Falls – avoided and intended demonstrated a wide spectrum of fall perceptions; (2) balance identity incorporates how gradual decline in balance served as a reminder of disease progression, those who identified themselves as “aware not afraid” helped maintain balance confidence despite everyday activity restriction; and (3) training as treatment recounts how participants used exercise as disease self-management to maintain independence with daily life. Some individuals expressed FOF and managed it through activity restriction and others were confident in their balance despite avoidance of balance-challenging activities. FOF was dependent on the environment, situation, or task at hand. Some informants expressed catastrophic thoughts surrounding falls, which were described as a reason for avoiding certain situations and activities by fallers and non-fallers. For some participants, balance training helped restore confidence in ADLs they had avoided prior to training. Some participants described avoidance of activities due to an increased awareness of their physical capacity and not provoked by fear.
Nilsson, Jonasson & Zijlstra, 2020^Citation22 (Sweden)	To identify predictive factors of fall-related activity avoidance among individuals with PD. (Cohort study)	n = 151 (males = 96, females = 55, mean age = 68)	mSAFFE Falls Efficacy Scale – International (FES-I)	FFAB prevalence and severity increased after three years. The strongest predictive factors for mSAFFE scores were concerns about falling, age, pain, and unsteadiness while turning. At baseline, the top 5 activities avoided from mSAFFE were: Going out when slippery, walking half a mile, reaching for something above the head, going to a crowded place, and traveling by public transport. Three years later, the only difference was going up and downstairs replaced traveling by public transport and reaching above the head and going to a crowded place switched spots in order of most avoided to least.

Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. ANN INTERN MED. 2018;169(7):467–473. doi:10.7326/M18-0850

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Nilsson MH, Drake A-M HP. Assessment of fall-related self-efficacy and activity avoidance in people with Parkinson’s disease. BMC Geriatr. 2010;10(1):78.

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Rahman S, Griffin HJ, Quinn NP, Jahanshahi M. On the nature of fear of falling in Parkinson’s disease. Behav Neurol. 2011;24(3):219–228.

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Nilsson MH, Rehncrona S, Jarnlo GB. Fear of falling and falls in people with Parkinson’s disease treated with deep brain stimulation in the subthalamic nuclei. Acta Neurol Scand. 2011;123(6):424–429.

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Bryant MS, Rintala DH, Hou J-G, Protas EJ. Relationship of falls and fear of falling to activity limitations and physical inactivity in Parkinson’s disease. J Aging Phys Act. 2015;23(2):187.

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Kader M, Iwarsson S, Odin P, Nilsson MH. Fall-related activity avoidance in relation to a history of falls or near falls, fear of falling and disease severity in people with Parkinson’s disease. BMC Neurol. 2016;16:84.

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Landers MR, Lopker M, Newman M, Gourlie R, Sorensen S, Vong R. A cross-sectional analysis of the characteristics of individuals with Parkinson disease who avoid activities and participation due to fear of falling. J Neurol Phys Ther. 2017;41(1):31–42.

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Jonasson SB, Nilsson MH, Lexell J, Carlsson G. Experiences of fear of falling in persons with Parkinson’s disease - A qualitative study. BMC Geriatr. 2018;18(1):44.

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Leavy B, Berntsson J, Franzén E, Skavberg Roaldsen K. Perceptions of balance and falls following a supervised training intervention - A qualitative study of people with Parkinson’s disease. Disabil Rehabil. 2019;41(8):934–940.

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Nilsson MH, Jonasson SB, Zijlstra GAR. Predictive factors of fall-related activity avoidance in people with Parkinson disease-A longitudinal study with a 3-year follow-up. J Neurol Phys Ther. 2020;44(3):188–194.

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