“His feet don’t obey him and he is always afraid of falling, so it is better to let him sit still. That way is the safest.” Almost every caregiver of a person with Parkinson’s disease has said or heard these words. They come from caring, but the conclusion is the opposite of the truth: sitting all day is not safe and instead fuels the vicious circle. This article does not repeat the conclusion that balance training works (the article on balance training covers that in detail). It looks at a deeper question: why does the more afraid of falling and the less willing to move lead to more falls?
The message this article most wants to convey is that not moving at all out of fear of falling does not bring safety. On the contrary, it only speeds up the decline of the body and makes the patient more likely to fall. The real solution is neither activity with no precautions, done alone, nor sitting or lying all day. It is exercise that is “progressive, with someone watching beside the patient, and trains balance safely”. We must also say frankly that the benefit of this kind of exercise for preventing falls depends on certain conditions.
How being afraid to move leads, step by step, to more falls
This vicious circle is not an inference from instinct but has statistical evidence behind it. Landers et al. (2021) carried out a path analysis in a group of people with Parkinson’s disease and confirmed a self-reinforcing closed loop of four steps: postural instability → less balance confidence → avoiding activity out of fear of falling → decline in fitness and strength → even more postural instability. The path coefficients for the steps in the model ranged from −0.52 to −0.65, all at p<0.01, and the model fit CFI was as high as 0.985. In other words, the less the activity the worse the body, and the worse the body the less willing to be active, is not a figure of speech but a real mechanism that can be measured objectively.
The most dangerous thing about this circle is that every step seems reasonable on the surface. Because of fear of falling, activity is reduced. After reducing activity, there is indeed no fall in the short term. Since there has been no fall, the belief that not moving is the right thing to do grows stronger. Meanwhile quiet changes are taking place inside the body: the muscles waste from disuse, postural reflexes slow down and balance gradually declines. When the decline accumulates to a certain critical point, even getting up or going to the toilet, everyday movements that were once very low risk, become precarious. By then, sitting still not only fails to protect the patient but becomes the spark for a fall.
The more is avoided, the faster the body declines, and the more it declines, the more even the lowest-risk everyday movement is enough to cause a fall. Against the data, sitting still is safest turns out to be the opposite.
Fear of falling is a common clinical phenomenon, not timidity or weakness in the patient
To break this vicious circle, the first task is to take the fear of falling seriously. Fear of falling is not excessive worry or weak character but a phenomenon with measurement standards and clinical significance. The study by Kader et al. (2016, n=251) found that 41% of people with Parkinson’s disease avoid activity because of fear of falling. Among patients with definite fear of falling, the proportion avoiding activity is as high as 70%, far higher than 13% among those without fear. Fear is thus not simply a psychological burden but a core factor that directly drives patients to stop moving.
What deserves even more attention is that the avoidance of activity grows worse as the disease worsens. Kader et al. (2016) found that the proportion avoiding movement rises from about 24% in the early stage to 74% at the most severe stage. The more severe the disease, the less the patient dares to move, and the less the patient moves, the faster the body declines. This dose-response relationship confirms that the vicious circle does exist. Dealing with the fear of falling is therefore not as simple as telling the patient not to be afraid. The degree of fear needs to be measured with objective tools and a targeted intervention made.
Using assessment scales to understand how afraid the patient is
“Is the patient too afraid to move, or really unable to move?” It is important to make this distinction, because the first needs confidence rebuilt and the second needs fitness improved, and clinically the two are often intertwined. The therapist uses standardised scales to analyse the problem, and at the same time helps the patient and family to see where in the circle they are:
| FES-I (Falls Efficacy Scale International) | This scale assesses how worried the patient is about falling in everyday activities. After comparing four scales of fear of falling, Jonasson et al. (2014) concluded that the FES-I is the most suitable tool for people with Parkinson’s disease (and the only one with reliability reaching ICC>0.90). |
| ABC (Activities-specific Balance Confidence scale) | This scale assesses how confident the patient is of keeping balance in 16 everyday situations. The lower the score, the less confidence the patient has in balance, and the more the patient tends to avoid moving in daily life. |
| mFFABQ (modified Fear of Falling Avoidance Behaviour Questionnaire) | This scale directly measures how many daily activities the patient has avoided because of fear of falling, turning abstract worry into a concrete record of behaviour that is easy to follow up. |
The aim of assessing with these scales is absolutely not to frighten the patient with scores but to find the problem and treat it accordingly. Once the therapist knows which movements the patient fears most (for example turning, going downstairs, or standing up from a chair), the physiotherapist can arrange for the patient to manage these movements successfully, step by step, in a safe environment, and so slowly rebuild confidence and increase daily activity.
Why stopping activity makes balance worse and worse
To understand why sitting all day hides danger, it is necessary to know what happens in the body when there is no activity. Disuse decline is not as vague as a lack of exercise. It involves several physiological mechanisms occurring at the same time:
Not being active is not staying as one is but actively going backwards. The following three things go on quietly during avoidance:
- Disuse muscle atrophy—The strength of the leg muscles is the basis for holding the body up, taking body weight, and stepping out to steady oneself when about to fall. If the person is inactive for a long time, muscle mass and strength are lost faster, and in the end even a simple movement such as standing up from a chair becomes very hard.
- Decline of postural reflexes—Balance is a bodily skill that needs to be practised regularly. If weight is seldom shifted in different directions, then when the body is suddenly thrown off balance, the automatic adjustment to steady oneself becomes slow and dull.
- Worsening of freezing of gait—About half of people with Parkinson’s disease have freezing of gait, which means that when walking, the feet suddenly feel glued to the floor and cannot step. The less the patient walks, and the less the patient practises starting and turning in real settings, the more easily this sticking of the feet strikes at a critical moment and directly causes a fall.
When all three occur together, this explains why the vicious circle measured by Landers et al. (2021) keeps reinforcing itself: stopping activity lowers fitness, lower fitness makes daily movements really dangerous, and the patient becomes more frightened and less willing to move. The only way to break this deadlock is not to avoid more completely but to restart activity in the right way, within safe conditions.
Directions of exercise to improve balance and prevent falls
Since stopping activity is not a good strategy, is it then workable to ask the patient to train as hard as possible and walk about alone? The answer is no again. The right direction for training must be based on evidence-based medicine, and must also state honestly the strength of the benefit and the conditions that limit it. The firmest evidence at present is from the Cochrane review by Sherrington et al. (2019), which combined 108 randomised controlled trials covering 23,407 people and confirmed that exercise aimed at balance and function reduces the rate of falls by 24% (RaR 0.76, 95% CI 0.70 to 0.81, high-certainty evidence). In other words, exercise that deliberately challenges balance is the core means of preventing falls and not a source of danger.
On research specific to Parkinson’s disease, the tai chi randomised controlled trial by Li et al. (2012) in the New England Journal of Medicine (covering 195 patients at H&Y stages 1 to 4) confirmed that tai chi improves postural stability and reduces falls significantly more than stretching exercise. This high-quality evidence shows that supervised balance exercise to reverse the decline is no empty talk. Local research in Hong Kong has similar findings. Wong-Yu and Mak (2015, n=70) at The Hong Kong Polytechnic University found that task- and context-oriented balance training effectively improves dynamic balance and functional performance and reduces the number of people injured by falls six months later.
A realistic view of the fall-prevention effect of exercise
It would not be responsible to conclude from the single statement that exercise reduces falls by 24%. In the same body of medical literature, there is one very important detail that must be stated clearly: how well exercise prevents falls depends heavily on the stage of the disease. The randomised controlled trial by Canning et al. (2015) (n=231) gives the most direct warning on this:
- Falls in the exercise group fell by about 69% (IRR 0.31, 95% CI 0.15 to 0.62, p<0.001)
- The benefit for preventing falls is greatest in those with milder disease who can safely carry out a higher training dose
- Agrees with the conclusion of Sherrington et al. (2019) that balance exercise with enough challenge is the core
- The more severe group instead showed a trend towards more falls (IRR 1.61)
- The overall sample did not reach significance, and demanding that everyone train as hard as possible across the board is not safe
- More severe disease needs professional assessment and supervision, and the patient should not try alone
This contrast makes one thing clear: “blind activity” and “supervised progressive training” are completely different. The belief that sitting still is safest is a fallacy, but asking patients with more severe disease to greatly increase their exercise on their own is equally dangerous. The right approach is to design the training intensity and progress for the individual, according to the stage of the patient’s disease. A reasonable management of expectations is therefore that the most certain benefits of exercise are better balance confidence, more activity and a better quality of life. The actual effect on reducing falls depends on the stage of the disease and the training dose, and it is by no means a cure-all and cannot guarantee that the patient never falls again.
In caring for a patient, two extremes should be avoided: one extreme is sitting all day without moving for fear of falling, which speeds up the decline of the body. The other is leaving the patient to train as hard as possible with no one watching, and research shows that patients with more severe disease who do this tend to have more falls. The safest approach is to have a professional assessment first, and then practise step by step with someone watching.
Practical ways to practise balance safely
To turn the medical evidence above into daily practice, the point is not how complicated the movements are but to start with movements that are safe and certain to be completed, and build up a sense of success and fitness step by step. The general direction of training is set out below, but the specific content must be adjusted professionally for the individual illness by a physiotherapist:
- 1Step 1 | Static balance while holding onTo begin with, hold firm furniture or a corner of the wall, start with standing with the feet side by side and then close together, and slowly move on to stepping in different directions and standing on one leg. During practice there must be a firm handrail or furniture within reach to lean on, and a family member must be watching beside the patient.
- 2Step 2 | Practise weight shiftingPractise slowly shifting the body weight to the left, right, front and back and then back to the middle. Exercises such as tai chi and baduanjin, which stress slow shifting of weight, train exactly this ability, and the Elderly Health Service of the Department of Health in Hong Kong also recommends this kind of practice for older people.
- 3Step 3 | Add task-based movementsBuild balance practice into the movements done every day, for example practising how to turn safely, reach for things, and stand up from and sit down on a chair. The task- and context-oriented training studied by Wong-Yu and Mak (2015) was designed in this direction.
- 4Step 4 | Dual tasks (later stage, supervised)Only after the basic balance is steady can the patient try, in a safe environment, practising walking while attending to other simple things. The basic principle is that as soon as the patient feels unsteady, the patient should stop what is in hand and concentrate on standing steadily, and must not force it.
The key to balance training is that the movement should be “a little difficult, but still safe”. If a movement is too easy, however many times it is repeated, balance is not trained. But if it is too hard, or there is no one watching beside the patient, there is a risk of falling. Striking this just-right level of difficulty is exactly the role of the physiotherapist’s professional assessment.
When to ask a physiotherapist for a home assessment
Because about half of people with Parkinson’s disease have freezing of gait, forcing high-difficulty movements alone at home carries real risk. If the patient has any of the following, seek a detailed assessment from a physiotherapist (together with a neurologist if necessary) as soon as possible, and do not handle it alone:
- The patient has fallen, or has had a near fall.
- When walking, the feet suddenly feel glued to the floor and will not move, or the patient is generally unsteady on standing.
- On standing up from a chair or turning, the patient is especially frightened or especially prone to lose balance.
- Out of fear of falling, the patient has already clearly cut down on going out or daily activities.
- In the period when the medication effect wears off (wearing-off), balance gets clearly worse.
The greatest advantage of a home assessment is that the therapist can directly observe the patient’s habits of walking, turning and getting in and out of bed in the real living environment. Details such as the height of thresholds, where carpets are laid and the position of toilet handrails cannot be noticed in a clinic. Living conditions in Hong Kong are generally cramped with many steps, and toilet and bathroom space is small, so a patient afraid of falling often ends up stuck at home sitting still, which speeds up disuse decline. Waiting times for physiotherapy in public hospitals are long, and places in community rehabilitation are quite limited. Home physiotherapy can design a safe progressive training plan around the real risk points at home and guide the family on how to help with daily practice, which breaks the vicious circle of fear of falling, no activity and decline directly, and is far more practical than just telling the patient to be careful with everything.
There are about 12,000 people with Parkinson’s disease in Hong Kong at present (an estimate in local reports quoting information from the 香港柏金遜症基金, with about 1 person in every 800 affected), and the number is still rising as the population ages. Local support services include the 香港柏金遜症會, the Community Rehabilitation Network of the Hong Kong Society for Rehabilitation, and the Elderly Health Service of the Department of Health, and caregivers may make use of these community resources.