Breaking the Fall: Addressing the Fear of Falling in Rehab Therapy

By Holly Hester, PT, DPT, CHC, CHPC

As the U.S. population ages and seniors strive to maintain wellness and independence, one of our jobs as physical therapists is to assess fall risks in older patients. In doing so, we’ve been trained to focus on the physical aspects of the patient that may lead to falls including strength, balance, gait, proprioception, and vestibular function.

These core elements of physical function certainly play a critical role in fall prevention. But there’s one piece of the puzzle that too often gets overlooked: how patients perceive their own risk of falling.

Falls are no doubt a serious issue for older adults. By 2030, the Centers for Disease Control and Prevention predicts seniors will experience a staggering 52 million falls annually. Today, approximately 3 million seniors end up in emergency departments each year with injuries like hip fractures and head trauma.

As they heal from these injuries, we as rehab therapists are tasked with helping get these patients back on their feet and moving. In striving toward this goal, it’s important to remember that physical ability is only half the battle.

Both industry research and my own experience has found that fear of falling can be just as debilitating as any balance or strength deficit when it comes to preventing seniors from suffering from a recurrent fall. It’s a fear that can hold them back, causing them to avoid activities which, in many cases, leads to a downward spiral of inactivity.

Roughly 19% of older adults have said they avoid certain activities because they’re afraid they might fall. This avoidance often leads to weaker muscles, declining balance, and reduced confidence. Before they know it, the very fear of falling that was supposed to protect them has increased their fall risk.

This is why assessing and addressing fear should be a part of all comprehensive fall risk assessments. It’s not enough to gauge how strong or steady someone is. When we combine the physical with the psychological, we can create a more effective and holistic approach to fall prevention.

Objectively Measuring a Fear of Falling

Of course, we as physical therapists know that fear can play a significant role in causing falls, especially in older adults. But is fear quantifiable? This is where it gets tricky for rehab therapists who have been trained to focus on objective measurements like strength, balance, and mobility.

Fear, on the other hand, feels indefinable. It’s a deeply personal feeling that can vary widely from patient to patient. Many therapists may not know how to assess something as seemingly subjective as fear—at least in a way that fits our usual framework of objectivity.

Yet, fear permeates—it even grows—as patients recover from injuries. One study that looked at the fall-related fears of patients in a skilled-nursing facility (SNF) found that these fears were actually higher four weeks after discharge (82.1%) than they were at admission (62.5%). This lowered their ability to perform instrumental activities of daily living (IADL) when at home.

Fortunately, patient-reported balance assessment tools exist which focus on fear of falling and balance confidence (or balance self-efficacy). These tools provide key information about patients’ risk for falls and the tendency or likelihood the patient may limit their activities based on a fear of falling.

Below, I highlight three of these tools.

Falls Efficacy Scale International (FES-I)

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. The FES-I has been validated cross-culturally, for patients with and without cognitive impairment, and for those with Parkinson’s disease.

Using a scale of 1 to 10, with 1 being “very confident” and 10 being “not confident at all,” patients are asked to rate the confidence they have in performing a range of activities without falling. These activities include taking a bath or shower, reaching into cabinets or closets, walking around the house, getting out of bed, getting dressed and undressed, visiting friends and relatives, going out to a social event, and going up and down the stairs.

The FES-I is scored between 16 and 64, with scores ranging from 28-64 equating to a high risk for falls.

Activities-Specific Balance Confidence Scale (ABC)

Like the FES-I, the Activity-Specific Balance Confidence Scale (ABC) assesses an individual’s level of confidence with performing 16 activities on a scale of 0% to 100% confidence.

The patient is asked, “How confident are you that you will not lose your balance or become unsteady when you…” and is then given a list of activities. These include walking around the house, going up and down stairs, bending over to pick up a slipper from the front of the closet floor, sweeping the floor, getting in and out of the car, walking up and down a ramp, etc.

The lower the score, the less confident the person is with performing the activity without losing his or her balance. A score of 67 or below indicates a high risk of falls.

Fear of Falling Avoidance Behavior Questionnaire (FFABQ)

The Fear of Falling Avoidance Behavior Questionnaire (FFABQ) quantifies avoidance behavior and activity curtailment related to the fear of falling. 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 five-point Likert scale (i.e. completely disagree, disagree, unsure, agree, completely agree). Scores can total up to 56 points with higher scores indicating greater activity limitations and participation restrictions.

The activities listed within this questionnaire are based on the International Classification of Function (ICF). They include things such as walking, lifting, and carrying objects (i.e. a cup or a 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 Balance Scale, the Dynamic Gait Index (DGI), and the Timed Up and Go (TUG) test.

Ways to Address a Fear of Falling

Once a rehab therapist has measured and better understands a patient’s fear of falling—I recommend performing these assessments early in the rehab process and again just before discharge—steps can be taken restore confidence, ensure safety, and prevent a reduction in activity.

These steps start with education and include exercise incentives and environmental modifications. Here’s a breakdown.

Educate Patients and Caregivers

Part of reducing fear involves education. Rehab therapists should consistently educate patients and their caregivers (i.e. family, loved ones, neighbors, etc.) on the patient’s progress and ways they can avoid the spiral that comes with inactivity.

What is the patient capable of doing once they’re home, and what activities are they still working to accomplish through continued rehab therapy? How can one help the patient work toward their goals from home? What are ways caregivers can assist patients at home while still encouraging confidence-building behaviors?

Rehab therapists should assist caregivers in answering these and other questions both at and after discharge.

Tailor Exercises and Balance Training

Create treatment plans for each patient that combine physical exercises with strategies to address fear. By gradually exposing patients to activities that lead to fear responses, but within a controlled environment, therapists can help patients regain confidence and reduce anxiety around falling.

It’s also important that rehab therapists provide patients with referrals and resources that enable them to connect with other therapy-based professionals and groups following discharge. This may include a referral to see a home-based or outpatient rehab therapist to further develop strength and balance, or it may be a suggestion to join fall prevention exercise group for seniors.

Focus on Environmental Modifications

Post-discharge fears can also be reduced by helping the patient ensure their home environment is safe. Identifying and recommending modifications like removing rugs, securing loose objects, and improving lighting can help patients feel more secure in their ability to move around their home without falling.

Fall Prevention is a Key Component of Value-Based Care

Fall prevention is not only vital for patient safety but also a critical aspect of value-based care. As the healthcare industry continues to emphasize quality outcomes over the quantity of services, providers are increasingly evaluated on their ability to reduce falls, especially among high-risk older adults.

This shift impacts everything from public ratings to reimbursement, making effective fall prevention a priority for facilities like SNFs, inpatient rehab, and home health agencies.

Tracking fall-related injuries, particularly those resulting in serious harm, is an essential part of quality reporting. These outcomes can have a direct influence on a facility’s reputation and financial performance. A focus on fall prevention and reducing fall-related injuries is key to success in many value-based payment arrangements.

To meet these expectations, rehab therapists must embrace a more comprehensive approach to fall prevention. While physical assessments of strength, balance, and gait remain important, addressing the psychological factors—such as fear of falling—through objective measures is just as critical.

By combining these assessments, therapists can create a more holistic plan that improves both physical and mental confidence, enhancing patient outcomes and contributing to success in value-based care.