CommentaryFragility, fear of falling, physical activity and falls among older persons: Some theoretical considerations to interpret mediation
Introduction
In their letters to the editor, Lacherez et al. (2008) and Hafeman and Schwartz (2008) questioned the correctness of using the term ‘mediation’ in our paper (Wijlhuizen et al., 2007). In this paper, we concluded that (outdoor) physical activity mediates the relationship between fear of falling and outdoor falls. Both letters suggested that it would be more appropriate to use the term ‘suppression’, and expressed the need for a theoretical basis for the terminology used to describe this relationship. Lacherez et al. (2008) specifically mentioned the lack of evidence for assuming a causal relationship between fear of falling and falls.
The purpose of this letter is to describe the relationship between fear of falling, physical activity, and falls within a causal model, and investigate whether the term ‘inconsistent mediation’ might be a more appropriate term to use in this context.
Section snippets
Theoretical considerations: a hypothesized causal model of falls
People fall when it becomes too difficult for them to control their balance, that is, when the demands on balance control (e.g., exposure to indoor and outdoor environmental influences) at a certain point in time become greater than their capabilities (body function) to control balance (Wijlhuizen et al., 2007). For the current purpose only the following three factors which theoretically independently increase the risk of falling (Fig. 1) are included in the causal model. Other factors related
Conclusion
In this model (Fig. 2), the reduction in physical activity (the indirect pathway) due to fear suppresses the counteracting effect of a combination of ‘Fragility’ and ‘Hesitancy’. Two causal pathways between fear and falls are assumed, with the causal pathway going from Fear of falling via Physical activity to Falls counteracting (is inconsistent with) the causal pathway going from Fear of falling via Hesitancy to Falls. These causal paths operate within a relative small time frame, because in
References (15)
- et al.
Assessing mediation: The necessity of theoretical considerations
Prev. Med.
(2008) - et al.
Does activity level mediate or suppress the association between fear of falling and falls?
Prev. Med.
(2008) - et al.
Assessment of motor recovery and decline
Gait Posture
(2002) - et al.
Effects of postural anxiety on the soleus H-reflex
Hum. Mov. Sci.
(2007) - et al.
Older persons afraid of falling reduce physical activity to prevent outdoor falls
Prev. Med.
(2007) - et al.
The Physical Performance Test as a predictor of frequent fallers: a prospective community-based cohort study
Clin. Rehabil.
(2006) - et al.
Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention
J. Am. Geriatr. Soc.
(2002)
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2022, Annals of Physical and Rehabilitation MedicineCitation Excerpt :It was an unexpected finding that PA and SB were associated with fear of falling but not falls or fractures because we hypothesized that these outcomes would be similarly associated. However, this finding underscores the importance of understanding engagement in PA (or lack thereof) and SB as health behaviours to which fear of falling poses a psychological barrier [72,73]. Fear of falling is a common psychological symptom and can be the consequence of a fall and associated with poor quality of life independent of the actual number of falls [74].
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2010, Preventive MedicineCitation Excerpt :According to Skelton (2001) and Jørstad-Stein et al. (2005), while exercise has a beneficial effect on a person's balance, it can also be considered a general measure of that person's exposure to hazardous situations that put demands on that person's ability to control balance. In this respect, Wijlhuizen et al. (2007) found that outdoor falls occurred more often among persons who walked and bicycled more frequently, and that falls at home occurred most frequently at those times of the day that persons are most physically active (Wijlhuizen et al., 2008a,b). In addition, Lawton et al. (2009) found more falls and injuries among an intervention group which was encouraged to become more physically active, and Ebrahim et al. (1997) reported that brisk walking may increase the risk of falls.
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2020, Brazilian Journal of Physical TherapyCitation Excerpt :The fear of falling reported by participants reinforces the view that a fall involving traumatic injury can be a physically and emotionally debilitating experience. Older adults who perceive at risk of falling outside the home adjust their behavior to reduce their exposure to activities that may lead to further falls30 and negatively decrease their level of physical activity.31 This restriction can lead to in-home confinement,32 increased dependency and increased risk of future falls.33