A Cross-sectional Analysis of the Characteristics of Individuals With Parkinson Disease Who Avoid Activities and Participation Due to Fear of Falling

Role of virtual reality in examining the effect of fear of falling (FOF) on postural stability in individuals without and with Parkinson's disease in Egypt: a mixed-methods feasibility study protocol

BACKGROUND

Falls are common in older people and individuals with neurological conditions. Parkinson's disease (PD) is known for postural instability causing mobility disabilities, falls and reduced quality of life. The fear of falling (FOF), a natural response to unstable balance, can worsen postural control problems. Evaluating FOF relies largely on affected persons' subjective accounts due to limited objective assessment methods available. The aim of this mixed-methods feasibility study is to develop an assessment method for FOF while in motion and walking within virtual environments. This study will assess a range of FOF-related responses, including cognitive factors, neuromuscular response and postural stability.

METHODS AND ANALYSIS

This feasibility study will consist of four phases: the first two phases will include people without PD, while the other two will include people diagnosed with PD. Participants will be assessed for direct and indirect responses to real life, as well as virtual environment walking scenarios that may induce FOF. Data from questionnaires, different neurophysiological assessments, movement and gait parameters, alongside evaluations of usability and acceptability, will be collected. Semistructured interviews involving both participants and research assistants shall take place to elicit their experiences throughout different phases of the assessments undertaken. Demographic data, the scores of assessment scales, as well as feasibility, usability and acceptability of the measurement methods, will be illustrated via descriptive statistics. Movement and gait outcomes, together with neurophysiological data, will be extracted and calculated. Exploring relationships between different factors in the study will be achieved using a regression model. Thematic analysis will be the approach used to manage qualitative data.

ETHICS AND DISSEMINATION

This feasibility study was approved by the Ethics Committee of the Faculty of Physical Therapy, Kafr El Sheikh University, Egypt (number: P.T/NEUR/3/2023/46). The results of this study will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05931692).

The psychometric properties of the modified fear of falling avoidance behavior questionnaire in Parkinson's disease and older adults

Introduction

The Fear of Falling Avoidance Behavior Questionnaire (FFABQ) has good psychometric properties. However, we have recently modified the FFABQ (mFFABQ) to improve the clarity of the questions and Likert responses. This study aimed to examine the reliability and validity of this modified version in older adults and people with Parkinson's disease (PD).

Methods

A total of 88 participants, 39 with PD (age = 72.2 ± 9.5; 29 males, 10 females) and 49 older adults (age = 72.8 ± 5.0; 13 males, 36 females), answered the mFFABQ twice, separated by 1 week, for test-retest reliability. Construct validity was evaluated through correlational analyses with fall history, Activities-Specific Balance Confidence Scale (ABC), Berg Balance Scale (BBS), Timed Up and Go, 30-Second Sit to Stand, Sensory Organization Test, Zung Anxiety Scale, Beck Depression Inventory, Consequences of Falling Questionnaire (CoFQ), and average daily activity levels using an activity monitor.

Results

The mFFABQ had good overall test-retest reliability (intraclass correlational coefficient [ICC] = 0.822; older adult ICC = 0.781, PD ICC = 0.806). The mFFABQ correlated with fall history (r = -0.430) and exhibited high correlation with the ABC (rho = -0.804) and moderate correlations with CoFQ (rho = 0.582) and BBS (rho = -0.595). The mFFABQ also correlated with time stepping (rho = -0.298) and number of steps (rho = -0.358).

Conclusion

These results provide supportive evidence for the reliability and validity of the mFFABQ in older adults and people with PD, which supports its suitability as a clinical and research tool for the assessment of fear of falling avoidance behavior.

Activity Monitoring in Parkinson Disease: A Qualitative Study of Implementation Determinants

BACKGROUND AND PURPOSE

There is interest in incorporating digital health technology in routine practice. We integrate multiple stakeholder perspectives to describe implementation determinants (barriers and facilitators) regarding digital health technology use to facilitate exercise behavior change for people with Parkinson disease in outpatient physical therapy.

METHODS

The purposeful sample included people with Parkinson disease (n = 13), outpatient physical therapists (n = 12), and advanced technology stakeholders including researchers and reimbursement specialists (n = 13). Semistructured interviews were used to elicit implementation determinants related to using digital health technology for activity monitoring and exercise behavior change. Deductive codes based on the Consolidated Framework for Implementation Research were used to describe implementation determinants.

RESULTS

Key implementation determinants were similar across stakeholder groups. Essential characteristics of digital health technology included design quality and packaging, adaptability, complexity, and cost. Implementation of digital health technology by physical therapists and people with Parkinson disease was influenced by their knowledge, attitudes, and varied confidence levels in using digital health technology. Inner setting organizational determinants included available resources and access to knowledge/information. Process determinants included device interoperability with medical record systems and workflow integration. Outer setting barriers included lack of external policies, regulations, and collaboration with device companies.

DISCUSSION AND CONCLUSIONS

Future implementation interventions should address key determinants, including required processes for how and when physical therapists instruct people with Parkinson disease on digital health technology, organizational readiness, workflow integration, and characteristics of physical therapists and people with Parkinson disease who may have ingrained beliefs regarding their ability and willingness to use digital health technology. Although site-specific barriers should be addressed, digital health technology knowledge translation tools tailored to individuals with varied confidence levels may be generalizable across clinics.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content available at: http://links.lww.com/JNPT/A436 ).

Fear of Falling Avoidance Behavior in Parkinson's Disease: Most Frequently Avoided Activities

BACKGROUND

Fear of falling avoidance behavior (FFAB) is common in Parkinson's disease (PD).

OBJECTIVES

The objectives of the study are to determine what activities are most avoided due to FFAB among people with PD and whether any associations exist with demographic factors or fall history.

METHOD

Cross-sectional analysis of 174 individuals with PD using the Modified FFAB Questionnaire.

RESULTS

Walking in dimly lit, unfamiliar places, and different surfaces, lifting and carrying objects, walking in crowded places, recreational/leisure activities, and going up/downstairs were most avoided. Fallers reported more FFAB (ps < .029). FFAB for certain activities was associated with increased or decreased odds of falling.

CONCLUSION

Individuals with PD avoid walking in compromised situations and engaging in recreational/leisure activities due to FFAB. While excessive FFAB may increase the odds of falling, protective forms may be associated with decreased odds. Targeting FFAB among individuals with PD may increase safe participation in meaningful occupations in the home and community.

The predictive relationships between advanced dynamic balance and physical activity/quality of life in Parkinson's disease

Gait and balance problems commonly occur in Parkinson's disease (PD). However, balance tasks with only one performance objective (e.g., sit-to-stand) may not be sufficient, compared to dual motor tasks (e.g., carrying a tray while walking), to be applied to the assessments and interventions which are designed to promote PD patients' balance functioning, physical activity (PA) and health-related quality of life (HQoL). The aim of this study, therefore, was to determine whether advanced dynamic balance, measured by a demanding motor-motor dual task, is a significant predictor of PA/HQoL in older adults with and without PD. Participants with (n = 22) and without (n = 23) PD were assessed using the Berg Balance Scale (BBS), the single leg hop and stick series task (SLHS), the Physical Activity Scale for the Elderly (PASE), and the Parkinson's Disease Questionnaire-39 (PDQ39). We calculated the R² change, namely the incremental validity, between the multiple regression models before and after adding the scores on the BBS/SLHS. While controlling for biological and socioeconomic covariates, competence in the SLHS task provided moderate and large levels of incremental validity to PA (ΔR² = 0.08, Cohen's f² = 0.25, p = .035) and HQoL (ΔR² = 0.13, Cohen's f² = 0.65, p < .001), respectively. In particular for participants with PD, the SLHS explained significantly more variance in HQoL in relation to psychosocial functioning (ΔR² = 0.25, Cohen's f² = 0.42, p = .028) compared to the BBS (p = .296). Assessing advanced dynamic balance by means of a highly demanding dual-task paradigm was not only strongly associated with PA but also covered a wider spectrum of HQoL components. This approach is recommended for use in evaluations and interventions carried out in clinical and research settings in order to promote healthy living.

The mediator role of frailty in the effect of fear of falling avoidance behavior on quality of life in older adults admitted to hospital

The aim of this research was to determine the mediator role of frailty in the effect of fear of falling avoidance behavior on quality of life in the older adults. This descriptive and cross-sectional study was conducted with 312 individuals in Istanbul between June-October 2021. The Edmonton Frail Scale (EFS) score was 7.06±3.69, Fear of Falling Avoidance Behavior Questionnaire (FFABQ) score was 17.84±15.3. Quality of Life Scale (SF-12) physical component score was 34.21±25.12 and mental component score was 41.81±17.87. EFS plays a mediating role in the effect of FFABQ on SF-12 and strengthens its negative effect on SF-12. The frailty severity of the participants was moderate, activity limitation and participation restriction due to fear of falling were low, and their quality of life in physical and mental components was low. Avoidance behavior has a direct effect on quality of life and an indirect effect with the role of frailty.

Psychological Factors Associated With Fear of Falling Avoidance Behavior in Parkinson's Disease: The Role of Depression, Anxiety, and Catastrophizing

PURPOSE

The purpose of this study was to examine the relationship between psychological factors (depression, anxiety, and catastrophizing) and fear of falling avoidance behavior (FFAB) among individuals with Parkinson's disease (PD).

METHODS

A secondary analysis of cross-sectional data from 59 individuals with PD using hierarchical multiple regression.

RESULTS

Disease severity (Movement Disorder Society - Unified PD Rating Scale) and catastrophizing (Consequences of Falling Questionnaire (CoF)) explained approximately 48.2% of the variance in the FFAB Questionnaire scores (P < .001). Catastrophizing was the only significant psychological variable (P < .001). The damage to identity subscale of the CoF was significant in the final model (P < .001).

CONCLUSIONS

Catastrophizing about the consequences of falls explained the largest portion of variability in FFAB after controlling for disease severity. Catastrophizing about the immediate consequences of falling may play a prominent role in FFAB and may be a potential treatment target for mitigating FFAB.

A Novel Way of Measuring Dual-Task Interference: The Reliability and Construct Validity of the Dual-Task Effect Battery in Neurodegenerative Disease

BACKGROUND

Decreased automaticity is common among individuals with neurodegenerative disease and is often assessed using dual-task (DT) paradigms. However, the best methods for assessing performance changes related to DT demands remain inconclusive.

OBJECTIVE

To investigate the reliability and validity of a novel battery of DT measures (DT Effect-Battery (DTE-B)) encompassing three domains: task-specific interference, task prioritization, and automaticity.

METHODS

Data for this retrospective cross-sectional study included 125 participants with Parkinson's disease (PD), 127 participants with Alzheimer's disease (AD), and 84 healthy older adults. Reliability analyses were conducted using a subset of each population. DTE-B measures were calculated from single and DT performance on the Timed Up and Go test and a serial subtraction task. Construct validity was evaluated via associations within the DTE-B and with theoretically supported measures as well as known-groups validity analyses.

RESULTS

Good to excellent reliability was found for DTE-B measures of task interference (motor and cognitive DT effects) (ICCs≥.658) and automaticity (combined DT effect (cDTE)) (ICCs≥.938). Evidence for convergent validity was found with associations within the hypothesized constructs. Known-groups validity analyses revealed differences in the DTE-B among the healthy group and PD and AD groups (ps≤.001), excepting task prioritization (ps≥.061).

CONCLUSIONS

This study provides evidence to support the DTE-B as a reliable measure of multiple constructs pertinent to DT performance. The cDTE demonstrated evidence to support its validity as a measure of automaticity. Further investigation of the utility of the DTE-B in both PD and AD, as well as other populations, is warranted.

Translation, Cross-Cultural Adaptation, and Measurement Properties of the Brazilian-Portuguese Version of the Fear of Falling Avoidance Behavior Questionnaire in Older Adults

The aim of this study was to translate and culturally adapt the Fear of Falling Avoidance Behavior Questionnaire (FFABQ) into Brazilian-Portuguese (FFABQ-B), and to examine its reliability and validity in Brazilian older adults. The FFABQ-B was translated and tested in 10 Brazilian older adults. We assessed 52 community-dwellers, 68.7 (±6.2) years, using the FFABQ-B, BERG Balance Scale, Activities-specific Balance Confidence Scale, Falls Efficacy Scale, 6-Minute Walk Test, Timed Up and Go test, and activity monitor. Internal consistency, test-retest reliability, construct validity, and floor and ceiling effects were analyzed. The FFABQ-B had adequate internal consistency (Cronbach's α = .90) and test-retest reliability (intraclass correlation coefficient = .81; 95% confidence interval [.68, .90]). The FFABQ-B was associated with 6-Minute Walk Test, Timed Up and Go, BERG Balance Scale, physical activity time (p < .05), Activities-specific Balance Confidence scale, and Falls Efficacy Scale (p < .001). The FFABQ-B is both reliable and valid to assess avoidance behavior in activities and participation due to fear of falling in Brazilian community-dwelling older adults.

A theoretical framework for addressing fear of falling avoidance behavior in Parkinson's disease

Postural instability in Parkinson's disease (PD) is associated with several downstream consequences that ultimately lead to a greater risk of falling. Among the prominent downstream consequences is fear of falling (FOF), which is both common and problematic in PD. It can lead to a vicious cycle of FOF avoidance behavior that results in more sedentary behavior, physical deconditioning, and weakening of already impaired balance systems. This, in turn, may make the person with PD more susceptible to a future fall even with benign daily tasks. While FOF activity avoidance can be adaptive (appropriate), it can also be maladaptive (inappropriate or exaggerated). When this adaptive and maladaptive FOF avoidance behavior is contextualized to gait/balance performance, it provides a theoretical framework that can be used by clinicians to match patterns of behavior to a concordant treatment approach. In the theoretical framework proposed in this perspective, four different patterns related to FOF avoidance behavior and gait/balance performance are suggested: appropriate avoiders, appropriate non-avoiders, inappropriate avoiders, and inappropriate non-avoiders. For each of the four FOF avoidance behavior patterns, this paper also provides suggested treatment focuses, approaches and recommendations.

Social withdrawal in Parkinson's disease: A scoping review

BACKGROUND

Parkinson's disease (PD) can interfere with individuals' social functioning and lead to social withdrawal. Social withdrawal may result in negative outcomes for persons with PD and their caregivers, such as decreased quality of life. It is necessary to understand the nature of social withdrawal in PD in order to develop strategies to address this issue and prevent negative outcomes.

OBJECTIVE

The purpose of this scoping review was to synthesize existing evidence regarding social withdrawal in PD.

METHODS

We searched PubMed, CINAHL, and PsycINFO for studies of social withdrawal in individuals living with PD. Findings were organized according to study characteristics, measurement and description of social withdrawal, prevalence, associated factors, and interventions.

RESULTS

Fifty-eight studies were included. We found that persons with PD reduced social activities voluntarily and involuntarily, and social withdrawal was related to various factors including physical, cognitive, and psychiatric symptoms and perceived stigma. Community-based social activity programs appeared to improve social participation. Few studies employed longitudinal methods or tested interventions to reduce social withdrawal.

CONCLUSIONS

Social withdrawal is associated with various negative outcomes in PD, though more research is needed to understand the true scope of this problem. Limitations in social withdrawal research include vague conceptualization and methodological limitations (i.e., instrumentation and study design), as well as a paucity of interventional studies. The findings of this review can be used to guide hypothesis generation and future study design, with the ultimate goal of mitigating social withdrawal and improving quality of life for people with PD.

Factors predicting fear of falling avoidance behavior in parkinsonisms

BACKGROUND

Fear of falling avoidance behavior (FFAB) is common in parkinsonisms and results in potentially mitigable downstream consequences.

OBJECTIVE

Determine the characteristics of individuals with parkinsonisms most associated with FFAB.

METHODS

A retrospective, cross-sectional study was conducted from medical records data of 142 patients with parkinsonisms. These data included: demographics (age, sex), disease severity (Movement Disorders Society -Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS III), years since diagnosis), fall history (number of fall injuries in previous year), and gait and balance function (five times sit to stand, MiniBESTest, Timed Up and Go (TUG), dual-task TUG, ten-meter walk test (10MWT), observed freezing of gait (FOG) (MDS-UPDRS III item 11)).

RESULTS

10MWT (p <  .001) and MDS-UPDRS III item 11 (p <  .014) were significantly associated with FFAB above and beyond disease severity, which also contributed significantly to the overall model (ps <  .046). Fall history was not associated with FFAB.

CONCLUSION

Our findings suggest that the largest portion of variability in FFAB is explained by gait velocity and FOG; however, disease severity also explains a significant portion of the variability of FFAB. Further investigation into factors predictive of FFAB and mitigation of downstream consequences, using more robust designs, is warranted.

Fear-of-falling activity-avoidance behavior in people with Parkinson's disease: a scoping review protocol

OBJECTIVE

The objective of this review is to explore existing literature related to fear of falling activity avoidance behavior and identify what is known about this phenomenon in people with Parkinson's disease.

INTRODUCTION

Falling and fear of falling are significant concerns for persons with Parkinson's disease. Fear of falling is a significant problem over and above falling itself and can lead to activity avoidance. Activity-avoidance behavior is a risk factor for increased falls and can lead to further functional decline. A better understanding of the fear of falling and the associated avoidance behavior can inform screening, evaluation, and interventions to decrease fall risk and improve activity engagement and quality of life for persons with Parkinson's disease.

INCLUSION CRITERIA

This review will consider studies published in English that include individuals diagnosed with Parkinson's disease experiencing fear of falling that impacts activity engagement with no limit on participant age or time of publication.

METHODS

JBI methodology will be used to conduct this scoping review. A three-step search strategy will be utilized. The databases to be searched include MEDLINE (PubMed), Embase (Elsevier), Scopus (Elsevier), APA PsycINFO (EBSCO), CINAHL (EBSCO), Papers First (OCLC), and ProQuest Dissertations and Theses (ProQuest). Two independent reviewers will screen the titles, abstracts, and full text of the selected studies. Data collection will be performed with a tool developed by the researchers based on the standardized tool from JBI SUMARI. Data will be presented in a comprehensive narrative summary.

The Relationship Between Anxiety Disorders and Parkinson's Disease: Clinical and Therapeutic Issues

PURPOSE OF REVIEW

This paper seeks to describe anxiety's different symptomatologic presentations in Parkinson's disease (PD), its longitudinal course and predictors, as well as its motor and non-motor correlates. It also reviews the available screening tools and different treatment modalities.

RECENT FINDINGS

In PD, longitudinal predictors of anxiety are mostly non-motor non-dopaminergic symptoms. The longitudinal course of anxiety is mainly a stable one. The Parkinson Anxiety Scale and the Geriatric Anxiety Scale are the 2 recommended screening tools. A third of PD patients suffer from an anxiety disorder at any time point. It can precede or follow PD motor symptoms. Anxiety is associated with demographic, disease-related motor and non-motor features. There is a lack of studies evaluating psychotropic treatment of anxiety in PD. Adjustment of dopaminergic treatment is indicated when anxiety is associated with motor fluctuations. DBS can be useful as well as CBT and body-mind interventions.

A vicious cycle of fear of falling avoidance behavior in Parkinson's disease: A path analysis

BACKGROUND

Postural instability (PI) in Parkinson's disease (PD) is associated with several negative downstream consequences.

OBJECTIVE

The purpose was to explore the validity of a theoretical model of these downstream consequences arranged in a vicious cycle wherein PI leads to decreased balance confidence, which in turn leads to increased fear of falling (FOF) avoidance behavior, which in turn leads to decreased physical conditioning, which then feeds back and negatively affects PI.

METHODS

A path analysis of cross-sectional data from 55 participants with PD was conducted. The four constructs in the model connected in succession were: 1. PI (principal components analysis (PCA) composite of the Unified Parkinson's Disease Rating Scale PI and Gait Difficulty score, Timed Up and Go test, and Berg Balance Scale); 2. balance confidence (Activities-Specific Balance Confidence Scale); 3. FOF avoidance behavior (PCA composite of the FOF Avoidance Behavior Questionnaire and average number of steps per day); and, 4. physical conditioning (2-Minute Step Test).

RESULTS

The path model was an excellent fit to the data, χ2 (7) = 7.910, p = .341, CFI = 0.985, TLI = 0.968, RMSEA = 0.049 (90% CI: 0.000 to 0.179). The moderate to strong and uniformly significant parameter estimates were -0.519, -0.651, -0.653, and -0.570, respectively (ps < 0.01).

CONCLUSIONS

PI directly and inversely predicted balance confidence, which in turn directly and inversely predicted FOF avoidance behavior. Furthermore, FOF avoidance behavior directly and inversely predicted physical conditioning, which directly and inversely predicted PI, thereby closing the cycle. These findings highlight the downstream consequences of PI in PD and support the notion of a vicious cycle of FOF avoidance behavior.

Balance confidence and physical activity participation of independently ambulatory youth with cerebral palsy: an exploration of youths' and parents' perspectives

AIM

Youth with cerebral palsy generally participate in less physical activity than typically developing peers. In adults with physical disabilities, balance confidence is a strong predictor of participation and community re-integration. However, balance confidence has not been studied in youth with cerebral palsy.

METHOD

Qualitative descriptive methodology with interviews of eight youth with cerebral palsy (9-17 years old, three girls) in Gross Motor Function Classification System Levels I-III, and eight parents (five mothers) of youth with cerebral palsy (9-17 years old, two girls) in Levels I-III.

RESULTS

Three themes arose: (1) youth in Gross Motor Function Classification System Levels I-II are more concerned about losing their balance during physical activities than those in Level III; (2) when balance is lost, embarrassment and frustration are more common than fear, especially for those in Levels I-II; and (3) social factors can create a favorable participation environment when balance confidence is low, especially for youth in Levels I-II.

CONCLUSION

Balance confidence may have greater influence on physical activity participation for youth in Gross Motor Function Classification System Levels I-II than those in Level III. Youth in Levels I-II may draw greater benefit from interventions targeting balance confidence when addressing physical activity goals.IMPLICATIONS FOR REHABILITATIONBalance confidence may have a greater influence on activity avoidance for youth with cerebral palsy in Gross Motor Function Classification System Levels I and II (who are independently ambulatory without walkers or cane(s)) than for those in Level II (who use walkers or cane(s) to ambulate).Youth who are independently ambulatory without walkers or cane(s) may benefit more from interventions directed at balance confidence (e.g., enactive mastery and verbal persuasion) to address their physical activity participation goals.For youth who are independently ambulatory without walkers or cane(s), addressing factors that could reduce the influence of balance confidence on physical activity participation, such as providing a positive and supportive social environment in which to participate, may be beneficial.

A new postural stability-indicator to predict the level of fear of falling in Parkinson's disease patients

BACKGROUND

Fear of falling (FoF) is defined as a lasting concern about falling that causes a person to limit or even stop the daily activities that he/she is capable of. Seventy percent of Parkinson's disease (PD) patients report activity limitations due to FoF. Timely identification of FoF is critical to prevent its additional adverse effects on the quality of life. Self-report questionnaires are commonly used to evaluate the FoF, which may be prone to human error.

OBJECTIVES

In this study, we attempted to identify a new postural stability-indicator to objectively predict the intensity of FoF and its related behavior(s) in PD patients.

METHODS

Thirty-eight PD patients participated in the study (mean age, 61.2 years), among whom 10 (26.32%) were identified with low FoF and the rest (73.68%) with high FoF, based on Falls Efficacy Scale-International (FES-I). We used a limit of stability task calibrated to each individual and investigated the postural strategies to predict the intensity of FoF. New parameters (FTRis; functional time ratio) were extracted based on the center of pressure presence pattern in different rectangular areas (i = 1, 2, and 3). The task was performed on two heights to investigate FoF-related behavior(s).

RESULTS

FTR1/2 (the ratio between FTR1 and FTR2) was strongly correlated with the FES-I (r = - 0.63, p < 0.001), Pull test (r = - 0.65, p < 0.001), Timed Up and Go test (r = - 0.57, p < 0.001), and Berg Balance Scale (r = 0.62, p < 0.001). The model of FTR1/2 was identified as a best-fitting model to predicting the intensity of FoF in PD participants (sensitivity = 96.43%, specificity = 80%), using a threshold level of ≤ 2.83.

CONCLUSIONS

Using the proposed assessment technique, we can accurately predict the intensity of FoF in PD patients. Also, the FTR1/2 index can be potentially considered as a mechanical biomarker to sense the FoF-related postural instability in PD patients.

Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates

BACKGROUND

Patients with chronic diseases commonly report fears of illness or symptoms recurring or worsening. These fears have been addressed from an illness-specific perspective (e.g., fear of cancer recurrence), a generic illness perspective (e.g., fear of progression), and a psychiatric perspective (DSM-5 illness anxiety disorder and somatic symptom disorder). The broader concept of health anxiety (HA) can also be applied to patients with a chronic disease. This review was conducted to investigate the conceptual, theoretical, measurement-overlap, and differences between these distinct perspectives. We also aimed to summarize prevalence, course, and correlates of these fears in different chronic illnesses.

METHODS

We used PsycINFO, PubMED, CINAHL, Web of Science, SCOPUS, and PSYNDEX to conduct a systematic review of studies pertaining to these fears in chronic illness published from January 1996 to October 2017. A total of 401 articles were retained.

RESULTS

There were commonalities across different conceptualizations and diseases: a high prevalence of clinical levels of fears (>20%), a stable course over time, and a deleterious impact on quality of life. Reviewed studies used definitions, models, and measures that were illness-specific, with only a minority employing a psychiatric perspective, limiting cross-disease generalizability. There appears to be some applicability of DSM-5 disorders to the experience of fear of illness/symptoms in patients with a chronic illness. While conceptualizing HA on a continuum ranging from mild and transient to severe may be appropriate, there is a lack of agreement about when the level of fear becomes 'excessive.' The definitions, models, and measures of HA across chronic illnesses involve affective, cognitive, behavioral, and perceptual features.

CONCLUSIONS

The concept of HA may offer a unifying conceptual perspective on the fears of illness/symptoms worsening or returning commonly experienced by those with chronic disease.

Fear of falling avoidance behavior affects the inter-relationship between vision impairment and diminished mobility in community-dwelling older adults

BACKGROUND

Age-related decline in vision may contribute to the development of fear of falling (FOF) behavior and reduced mobility, which are related to increased fall risk in older adults.

PURPOSE

To investigate the inter-relationship between vision impairment, physical mobility performance, and FOF behavior in community-dwelling older adults.

METHODS

A total of 400 participants from community centers (267 females; age = 74.8 (6.4), range = 65-97 years) participated in this cross-sectional study. Presence of age-related eye diseases (e.g. macular degeneration, cataracts, glaucoma, and retinopathy) and visual acuity (VA) was assessed. Physical mobility and FOF avoidance behavior were assessed using the Timed Up-and-Go (TUG) test and the Fear of Falling Avoidance Behavior Questionnaire (FFABQ). The inter-relationships between parameters were analyzed using mediation model analysis.

RESULTS

Significant decreases in mobility performance were observed in those with eye disease (eye disease = 9.56 [5.2] sec, no eye disease = 8.54 [2.75] sec; p = .037) and FOF avoidance behavior (avoiders = 12.87 [6.04] sec, non-avoiders = 8.51 [3.56] sec; p < .001). Furthermore, FOF behavior was found to significantly influence the inter-relationship between presence of eye disease and TUG performance (p = .004). VA alone had no significant effect on mobility (p = .69).

CONCLUSION

The presence of eye disease and the associated FOF behavior was related to decreased mobility and potentially increased fall risk. We recommend clinicians to inquire about the presence of eye disease and FOF behavior to identify risk factors related to falls in older adults.

Interindividual Balance Adaptations in Response to Perturbation Treadmill Training in Persons With Parkinson Disease

BACKGROUND AND PURPOSE

Perturbation training is a promising approach to reduce fall incidence in persons with Parkinson disease (PwPD). This study aimed to evaluate interindividual differences in balance adaptations in response to perturbation treadmill training (PTT) and identify potential outcome predictors.

METHODS

PwPD (n = 43, Hoehn & Yahr stage 1-3.5) were randomly assigned to either 8 weeks of PTT or conventional treadmill training (CTT) without perturbations. At baseline and following intervention, data from 4 domains of balance function (reactive, anticipatory, dynamic postural control, and quiet stance) were collected. Using responder analysis we investigated interindividual differences (responder rates and magnitude of change) and potential predictive factors.

RESULTS

PTT showed a significantly higher responder rate in the Mini Balance Evaluation Systems Test (Mini-BESTest) subscore reactive postural control, compared with CTT (PTT = 44%; CTT = 10%; risk ratio = 4.22, confidence interval = 1.03-17.28). Additionally, while between-groups differences were not significant, the proportion of responders in the measures of dynamic postural control was higher for PTT compared with CTT (PTT: 22%-39%; CTT: 5%-10%). The magnitude of change in responders and nonresponders was similar in both groups. PTT responders showed significantly lower initial balance performance (4/8 measures) and cognitive function (3/8 measures), and were older and at a more advanced disease stage, based on descriptive evaluation.

DISCUSSION AND CONCLUSIONS

Our findings suggest that PTT is beneficial to improve reactive balance in PwPD. Further, PTT appeared to be effective only for a part of PwPD, especially for those with lower balance and cognitive function, which needs further attention.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A1).

Five times sit-to-stand following stroke: Relationship with strength and balance

BACKGROUND

Rising from a chair is an important functional measure after stroke. Originally developed as a measure of lower-limb strength, the five times sit-to-stand test has shown associations with other measures of impairment, such as balance ability. We aimed to compare strength and balance in their relationship with the five times sit-to-stand test following stroke.

METHODS

Sixty-one participants following stroke were recruited from two hospitals in this cross-sectional observational study. Participants underwent assessment of the five times sit-to-stand (measured with a stopwatch), bilateral lower-limb muscle strength of seven individual muscle groups (hand-held dynamometry), and standing balance (computerised posturography). Partial correlations (controlling for body mass and height) were used to examine bivariate associations. Regression models with partial F-tests (including pertinent covariates) compared the contribution of strength (both limbs) and balance to five times sit-to-stand time.

RESULTS

The strength of the majority of lower-limb muscle groups (6/7) on the paretic side had a significant (P < 0.05) partial correlation with five times sit-to-stand time (r = -0.34 to -0.47) as did all balance measures (r = -0.27 to -0.56). In our regression models, knee extensor strength, total path length, and anteroposterior path velocity provided the largest contribution to five times sit-to-stand over covariates amongst strength and balance measures (R² = 16.6 to 17.9 %). Partial F-tests revealed that both lower-limb strength and balance contribute to five times sit-to-stand time independent of each other. A regression model containing knee extensor strength and anteroposterior path velocity accounted for 25.5 % of the variance in five times sit-to-stand time over covariates.

CONCLUSIONS

The strength of the knee extensor muscle group along with measures of standing balance ability (total path length and anteroposterior path velocity) both independently contribute to five times sit-to-stand time. Further research is required to examine how other important impairments post stroke impact five times sit-to-stand performance.

Effects of Fatigue on Balance in Individuals With Parkinson Disease: Influence of Medication and Brain-Derived Neurotrophic Factor Genotype

BACKGROUND AND PURPOSE

Because falls can have deleterious consequences, it is important to understand the influence of fatigue and medications on balance in persons with Parkinson disease (PD). Thus, the purpose of this study was to investigate the effects of fatigue on balance in individuals with PD. Because brain-derived neurotrophic factor (BDNF) has been shown to be related to motor performance, we also explored its role.

METHODS

A total of 27 individuals (age = 65.4 ± 8.1 years; males = 14, females = 13) with neurologist-diagnosed PD with 13 genotyped for BDNF as Val66Val, 11 as Val66Met, 2 as Met66Met (1 refused). Participants were tested both on and off medication, 1 week apart. On both days, they completed a pre- and posttest separated by a fatiguing condition. Factorial analyses of variance were performed for the following balance domains: (1) anticipatory postural responses; (2) adaptive postural responses; (3) dynamic balance; (4) sensory orientation; and (5) gait kinematics. For BDNF, t-tests were conducted comparing genotype for the pre-post difference scores in both the on and off medication states.

RESULTS

There were no interactions between time (pre- and postintervention) and medication for any of the domains (Ps ≥ 0.187). Participants with BDNF Met alleles were not significantly different from Val66Val participants in balance (Ps ≥ 0.111) and response to a fatiguing condition (Ps ≥ 0.070).

DISCUSSION AND CONCLUSIONS

Fatigue does not appear to have a detrimental effect on balance, and there was not a differential effect of medication in individuals with PD. These results also indicate that participants with a BDNF Met allele did not have a greater decay in function after a fatiguing condition.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A196).

The Association of Balance, Fear of Falling, and Daily Activities With Drug Phases and Severity of Disease in Patients With Parkinson

Introduction:

In the elderly, functional balance, fear of falling, and independence in daily living activities are interrelated; however, this relationship may change under the influence of drug phase and the severity of disease in individuals with idiopathic Parkinson disease. This study aimed to investigate the association of functional balance, fear of falling, and independence in the Activities of Daily Living (ADL) with the drug on- and drug off-phases.

Methods:

A total of 140 patients with Parkinson disease (age: Mean±SD; 60.51±12.32 y) were evaluated in terms of their functional balance, fear of falling, and independence in their daily activities by the Berg Balance Scale (BBS), Fall Efficacy Scale-International (FES-I), and Unified Parkinson Disease Rating Scale-ADL (UPDRS-ADL), respectively, in drug on- and drug off-phases. The Hoehn and Yahr scale recorded global disease rating. The Spearman coefficient, Kruskal-Wallis, and Mann-Whitney tests were used to find out whether the distribution of scale scores differs with regard to functional balance or disease severity.

Results:

A strong correlation was found between the functional balance, fear of falling, and independence in ADL with both drug phases. The results also showed the significant difference in the distribution of the FES-I and UPDRS-ADL scores with regard to functional balance (except independence in ADL in drug off-phase). Also, the distribution of the scores of BBS, FES-I, and UPDRS-ADL showed significant differences with regard to disease severity.

Conclusion:

The study showed a strong correlation between functional balance, fear of falling, and independence in ADL that can be affected by the drug phase and severity of the disease. However, more studies are needed to understand this relationship precisely.

Catastrophizing mediates the relationship between non-motor symptoms and quality of life in Parkinson's disease

BACKGROUND

The non-motor symptoms of Parkinson's disease (PD), pain, depression, anxiety and sleep disturbances are highly prevalent in persons with PD and have a profound impact on their quality of life (QOL). Catastrophizing is a negative coping style known to influence individuals' ability to cope with their medical symptoms and contributes to negative health-related outcomes, yet, it has not been studied in persons with PD.

OBJECTIVE

The objectives of this study were to measure catastrophizing in PD and explore its role as a mediator of the relationship between non-motor symptoms and QOL.

METHODS

One-hundred and three individuals diagnosed with PD completed questionnaires regarding pain catastrophizing, QOL and non-motor symptoms: pain, depression, anxiety and sleep disturbances.

RESULTS

More than half of the sample exhibited high levels of pain, anxiety and sleep disturbances. Catastrophizing was significantly correlated with QOL and with all of the non-motor symptoms. Catastrophizing mediated the relationship between all of non-motor symptoms and QOL as well as the relationship between age and QOL.

CONCLUSIONS

Negative psychologic coping, specifically catastrophizing, has an important role in determining how destructive non-motor symptoms can be on the QOL of persons with PD. This is the first study to measure catastrophizing in this population and demonstrate its negative impact on QOL. Our findings emphasize the need to identify persons at risk for poor QOL and referrer them to appropriate psychological care. Evidence based interventions that target catastrophizing should be tested for their efficacy in persons with PD.

Association of Strength and Physical Functions in People with Parkinson's Disease

Background

Parkinson's disease is responsible for decrease of activities of daily living and mobility limitations. Association of strength with physical capacities and disease time can improve training methodologies and predict changes in physical fitness for this population, since the control center of movements and strength is the same.

Objective

Therefore, the aim of this study is to analyze if there are correlation between strength with functional tests (the sit-to-stand, the six-minute walk, and the timed-up-go) and disease time in people with Parkinson's disease.

Results

All functional tests correlations are significant, p < 0.05. The strength is positively correlated with the sit-to-stand and the six-minute walk. The strength is negatively correlated with the timed-up-go.

Conclusion

There are a correlation between strength with functional tests in people with PD, and changes in strength assessment can be used as predictor to changes in aerobic capacity.

Parkinson disease

Parkinson disease (PD) is a complex, multisystem disorder with both neurologic and systemic nonmotor manifestations. It is neurodegenerative in nature in which disordered balance, gait, and falls are universal problems that can be present at initial diagnosis, and which progress over time. Freezing of gait is a particularly debilitating feature of PD that becomes more prevalent over time with disease progression, being present in approximately 7% after 2 years of disease and 28% after 5 years. Approximately 60% of people with PD fall each year, with around 70% of fallers falling recurrently, and some recurrent fallers falling multiple times per week. Many risk factors for falls in people with PD have been identified; these include a history of falls, freezing of gait, and abnormalities in measures of balance, leg muscle strength, mobility, cognition, and fear of falling. Therapies for improving physical function and mobility include levodopa, cholinesterase inhibitors, methylphenidate, deep-brain stimulation, cuing for freezing of gait, and exercise. This chapter reviews the clinical, pathologic, and physiologic correlates of gait disturbance and falls in PD, as well as the evidence for medical and nonmedical interventions.

Perceptions of balance and falls following a supervised training intervention - a qualitative study of people with Parkinson's disease

PURPOSE

To explore perceptions of balance and falls among people with mild to moderate Parkinson's disease 3 - 12 months following participation in supervised balance training.

MATERIALS AND METHODS

This qualitative study used in-depth individual interviews for data collection among 13 people with Parkinson's disease. Interviews were systematically analyzed using qualitative content analysis with an inductive approach.

RESULTS

Three main themes arose: Falls - avoided and intended highlights the wide spectrum of fall perceptions, ranging from worse-case scenario to undramatized events; Balance identity incorporates how gradual deterioration in balance served as a reminder of disease progression and how identifying themselves as "aware not afraid" helped certain participants to maintain balance confidence despite everyday activity restriction; Training as treatment recounts how participants used exercise as disease self-management with the aim to maintain independence in daily life. Interpretation of the underlying patterns of these main themes resulted in the overarching theme Training as treatment when battling problems with balance and falls.

CONCLUSIONS

Whereas certain participants expressed a fear of falling which they managed by activity restriction, others described being confident in their balance despite avoidance of balance-challenging activities. Training was used as treatment to self-manage disease-related balance impairments in order to maintain independence in daily life. Implication for Rehabilitation People with Parkinson's disease require early advice about the positive effects of physical activity as well as strategies for self-management in order to ease the psychological and physical burden of progressive balance impairment. Fear of falling should be investigated alongside activity avoidance in this group in order to provide a more accurate insight into the scope of psychological concerns regarding balance and falls in everyday life. Certain people with Parkinson's disease define their balance according to activities they continue to participate in, while others who express fear-related activity avoidance require help to adapt balance-challenging activities in order to maintain balance confidence and avoid physical inactivity.