Influence of Fear of Falling and Multiple Falls Risks on Gait Performance under Single and Dual-Task Conditions

Special Article - Fall Prevention

Gerontol Geriatr Res. 2016; 2(4): 1021.

Influence of Fear of Falling and Multiple Falls Risks on Gait Performance under Single and Dual-Task Conditions

Wollesen B*, Köhler B and Mattes K

Department of Human Movement Science, University of Hamburg, Germany

*Corresponding author: Wollesen B, Department of Human Movement Science, University of Hamburg, Turmweg 2, 20148 Hamburg, Germany

Received: August 08, 2016; Accepted: September 28, 2016; Published: September 30, 2016


Fear of Falling (FOF), Balance Declines (BD) and Multiple Falls Risks (MFR) influence gait performance in older adults. This study evaluates if and how these factors affect gait variables under Single-Task (ST) and Dual-Task (DT) conditions. A total of 223 participants of females (n=160) and males (n=63) were examined in (a) ST cognitive performance: visual-verbal Stroop test, (b) ST: walking, and (c) DT: walking + Stroop test. The FES-I, self-reported fall risks and SPPB were used to analyze influence factors on gait on a Zebris treadmill (FDM-T) with F-tests (SPSS 22).

ST and DT walking analyzing MFR led to different Peak Forces (PF) of the forefoot (F=4.92; p= .028). BD influenced the gait-line (left: F=3.81; p=0.05; right: F=5.44; p=0.012) and accompanying PF from ST to DT. Additionally, they increased step width (F=6.25; p=0.013), decreased step length and PF for the forefoot. FOF increased step width (F=5.27; p=0.023), reduced step length (left: F=21.80; p< .001; right: F=22.23; p< .001) reduced gait-line (left: F=14.18; p<0.001; right: F=15.83; p<0.001) and decreased PF in the midfoot and heel. Differences from ST to DT were found for step width and step length.

Overall, FOF and balance declines led to reduced walking quality under ST and DT conditions. However, one has to assume that the DT effect might be independent from the evaluated factors since there was no interaction effect.

The data indicates that FOF might have the most impact on gait performance whereas self-reported fall risks do not. It has to be discussed whether selfreported functional declines is accurate in determining an individual’s falls risk. Future studies should further investigate on the use of the SPPB and the FES-I as tools to identify reduced stability in ST and DT walking.

Keywords: Fear of falling; Multiple fall risks; Gait kinematics; Dual task walking


ANOVA: Analysis Of Variance; DT: Dual-Task; DTC: Dual Task Costs; FES-I: Falls Efficacy Scale-International; FDM-T: Force Distribution Measurement System from Zebris; PF: Peak Forces; ST: Single-Task; SPPB: Short Physical Performance Battery


Due to demographic changes, the question of how to stay healthy, mobile and independent into old age, is becoming more and more important not only for the individual, but also for the wider community.

The ability to walk safely is one of the key aspects of mobility and independence in old age, because it allows social participation and prevents falls [1-4]. Therefore, it is of great interest to identify factors that influence gait patterns and that may be modified with appropriate training programs [5,6].

Several studies have already shown that postural control, which means the ability to control the center of pressure over the base of support, is of great importance for gait stability [7,8]. Postural control consists of two main functions: first, there is balance coordinationwhich refers to the interactions of the motor cognitive system to maintain postural control. Second, there is balance recovery which refers to the ability to (re)gain postural stability following external disturbances [9,10].

Beside the postural control, other biomechanical or kinematical aspects have shown to be important in maintaining gait stability. For example, active rolling movements of the foot and ankle joint as well as stabilization of the pelvis from heel strike to mid-stance are necessary to maintain balance while moving forward [7]. Therefore, the peak reaction forces, gait-line, step length and step width have proved to be important characteristics of gait stability. Furthermore, a review by Hamacher et al. [11], has shown that the variability of stride, swing and stance time is an indicator of gait stability and can be used to discriminate between fallers and non-fallers [11].

Other aspects influencing gait are the surrounding conditions. Mostly, gait is not performed as a single-task, but more often is part of a dual- or multitask performance in which walking is combined with other cognitive or motor tasks [12]. These dual-task conditions lead to so called dual task costs (DTCs), which means that the performance in one or both tasks decreases in comparison to a singletask- condition due to higher cognitive demands. And these DTCs are even higher in old age [13-15].

While some of the changes of walking kinematics in dual-task situations might be a positive strategy in order to maintain a stable gait pattern (e.g. reduced gait speed), others are more negative and may increase the risk of falling [10]. In several studies, a higher gait variability (e.g. variability of step length and velocity), a lower step length and reduced rolling movements with additional shift of plantar pressure were observed in dual-task situations for older adults and are seen as indicators of a higher falls risk [13,15,16].

Beside these biomechanical and dual-task aspects, several preexisting illnesses or fall risks may influence gait patterns [2,17], have shown that seniors with pre-disability have a slower gait velocity and shorter stride length in different walking conditions [17]. A crosssectional study by Montero-Odasso et al. [18] has also proven that several quantitative gait parameters beyond velocity (e.g. stride time variability) are associated with the functional status of elderly people assessed via frailty-indexes [18-21].

Another important intrinsic aspect influencing gait is the anxiety or fear of falling of the elderly. Several studies have already shown, that fear of falling is related to activity restrictions, often followed by a decrease in physical capacity and an increase in the risk for future falls [22,23]. Observing gait performance, people with a fear of falling show a slower gait speed compared to those with no such fear [24,25].

As in the dual-task related gait changes, some studies indicate that the anxiety-related gait changes (e.g. the slower gait velocity) may be beneficial in order to reduce the risk of falling and do not necessarily represent a decreased balance capacity. For example, Brown and colleagues showed that people with fear of falling used a more conservative gait pattern in order to avoid obstacles on a walkway [24]. However, the slower gait velocity may also be an indicator of a fearful gait pattern, which may lead to a decline in walking and other activities of daily living [26].

In conclusion, it seems clear that there are many factors that influence gait or are somehow related to gait. To the best of our knowledge, there is no study that has examined the influence of fear of falling, reduced balance performance and multiple falls risks as a result of physical declines on single and dual-task gait variables like gait-line and peak pressure, which are important factors of gait stability. Moreover, previous studies did not distinguish between the influence of fear of falling and multiple fall risks on the performance on ST and DT walking conditions.

The aim of this study therefore is to evaluate if and how fear of falling, reduced balance performance and multiple fall risks influence gait kinematics and gait stability under single-Task (ST) and Dual- Task (DT) conditions. We hypothesize that the higher the fear of falling and the more fall risks are existent, the higher the decline on gait performance from single to DT condition.



Two hundred twenty-three participants between 65 and 79 years of age (Table 1) participated in the study. They were recruited via advertisements in popular newspapers. The inclusion criteria were: independent-living, age above 65 years, and sufficient mobility to join the experimental sessions. Exclusion criteria were: acute or chronic diseases with a documented influence on balance control (e.g. Parkinson’s disease; diabetes) or cognition; use of gait assistance (e.g. walking frames, rolling walkers). All participants were German native speakers.