Document Type


Publication Date


Publication Title

Clinical Parkinsonism and Related Disorders




Background: Postural instability (PI) in Parkinson's disease (PD) is associated with several negative downstream consequences. Objective: The purpose was to explore the validity of a theoretical model of these downstream consequences arranged in a vicious cycle wherein PI leads to decreased balance confidence, which in turn leads to increased fear of falling (FOF) avoidance behavior, which in turn leads to decreased physical conditioning, which then feeds back and negatively affects PI. Methods: A path analysis of cross-sectional data from 55 participants with PD was conducted. The four constructs in the model connected in succession were: 1. PI (principal components analysis (PCA) composite of the Unified Parkinson's Disease Rating Scale PI and Gait Difficulty score, Timed Up and Go test, and Berg Balance Scale); 2. balance confidence (Activities-Specific Balance Confidence Scale); 3. FOF avoidance behavior (PCA composite of the FOF Avoidance Behavior Questionnaire and average number of steps per day); and, 4. physical conditioning (2-Minute Step Test). Results: The path model was an excellent fit to the data, χ2 (7) = 7.910, p =.341, CFI = 0.985, TLI = 0.968, RMSEA = 0.049 (90% CI: 0.000 to 0.179). The moderate to strong and uniformly significant parameter estimates were −0.519, −0.651, −0.653, and −0.570, respectively (ps < 0.01). Conclusions: PI directly and inversely predicted balance confidence, which in turn directly and inversely predicted FOF avoidance behavior. Furthermore, FOF avoidance behavior directly and inversely predicted physical conditioning, which directly and inversely predicted PI, thereby closing the cycle. These findings highlight the downstream consequences of PI in PD and support the notion of a vicious cycle of FOF avoidance behavior.


Avoidance behavior; Balance confidence; Falls; Fear of falling; Gait; Postural balance; Postural instability


Diseases | Motor Control

File Format


File Size

595 KB


IN COPYRIGHT. For more information about this rights statement, please visit

Creative Commons License

Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.

UNLV article access

Search your library