Fear of Falling: Clinical and Psychological Determinants in Neurological Patients. A Cross-Sectional Observational Study.

Stroke survivors experience a substantially higher risk of falls than the general population, and this risk may persist for many years after the cerebrovascular event. Beyond the physical consequences of falls, many individuals develop a fear of falling (FOF), a condition characterized by concerns about falling during everyday activities. Fear of falling is highly prevalent after stroke and has been associated with reduced mobility, activity restriction, decreased participation in social and community life, poorer quality of life, and increased risk of future falls.

Traditionally, fear of falling has been considered a direct consequence of previous falls or physical impairment. However, contemporary theoretical models suggest that FOF is a multidimensional phenomenon influenced by the interaction of motor, cognitive, emotional, and behavioral factors. Studies conducted in community-dwelling older adults have shown that individuals may present different profiles of fear of falling depending not only on their physical abilities but also on psychological characteristics such as anxiety, self-efficacy, and risk perception. Similar mechanisms may be relevant in stroke populations, where motor deficits often coexist with cognitive impairment, emotional disturbances, and reduced awareness of deficits.

Previous research in stroke has primarily focused on isolated determinants of fear of falling, including balance impairment, reduced walking ability, history of falls, and use of walking aids. While these factors have consistently demonstrated associations with FOF, emerging evidence suggests that psychological variables, such as anxiety and depression, as well as cognitive functions, may also contribute substantially to the development and maintenance of fear of falling. Nevertheless, the relative contribution of motor, cognitive, and psychological factors remains insufficiently understood.

An additional limitation of the current literature is that stroke recovery is often treated as a homogeneous condition. Recovery after stroke is a dynamic process characterized by substantial changes over time. During the subacute phase, functional outcomes are strongly influenced by neurological recovery and motor impairment. In contrast, during the chronic phase, motor recovery often reaches a plateau, while cognitive and psychological factors may become increasingly important determinants of participation and perceived disability. Consequently, the factors associated with fear of falling may differ according to stroke chronicity.

The present observational study was designed to investigate fear of falling in individuals with ischemic or hemorrhagic stroke across different stages of recovery. A comprehensive multidimensional assessment was conducted, including clinical, motor, cognitive, emotional, behavioral, and awareness-related domains. By examining a broad range of factors simultaneously, the study aims to provide a more integrated understanding of the mechanisms underlying fear of falling after stroke.

The primary objective of the study is to evaluate the prevalence of fear of falling in stroke survivors and to identify the factors associated with its presence and severity. A secondary objective is to explore whether the determinants of fear of falling differ between individuals in the subacute and chronic phases of stroke recovery. Particular attention is devoted to understanding the relative contribution of motor functioning, cognitive performance, anxiety, depression, behavioral symptoms, personality traits, and awareness of deficits.

Improving the understanding of fear of falling after stroke may have important clinical implications. Identification of stage-specific determinants could support more accurate clinical characterization of patients and facilitate the development of targeted rehabilitation strategies. In particular, the findings may help clinicians determine whether interventions should primarily focus on motor recovery or whether cognitive and psychological factors should also be addressed to reduce fear of falling and its impact on daily functioning and participation.

Inclusion criteria

• signed informed consent
• age greater than 18 years
• diagnosis of ischemic or hemorrhagic stroke confirmed by magnetic resonance imaging (MRI) or computed tomography (CT)
• ability to walk, even with difficulty, with a Functional Ambulation Classification (FAC) score ≥ 1 (Holden et al., 1984)

Exclusion criteria

• concomitant presence of two or more of neurological diseases
• history of cognitive impairment
• history of intellectual disability
• severe language/comprehension deficits as assessed by the NIH Stroke Scale (NIHSS) (Brott et al., 1989)
• history of psychiatric disorders without pharmacological compensation
• non-neurological conditions (e.g., orthopedic problems) that affect deambulation
• patients with acute medical conditions requiring emergency care.