Unraveling the dynamics of falls, fear and activity avoidance behavior in multiple sclerosis: A conceptual model and research protocol

Falls, fear of falling (FoF), and activity avoidance are critical concerns across pathological populations, including older adults. The prevailing Fear-Avoidance Theory suggests that falls trigger FoF, leading to avoidance behaviors, physical decline, and increased fall risk. However, this model has limitations and does not fully explain all observed patterns. To address this gap, we propose the Falls-Fear-Avoidance Triad of Causation, a novel multifactorial model, using a multi-wave longitudinal study to clarify the complex interplay between these variables. This study will examine 168 people with multiple sclerosis (pwMS), a population highly prone to falls and FoF. Participants will be classified into four subgroups: fearless non-fallers, FoF non-fallers, fearless fallers, and FoF fallers, and assessed at three-time points (baseline, 6 months, and 12 months). We aim to determine whether FoF can be a protective mechanism or lead to maladaptive consequences, including reduced social participation. Key research questions include: (1) What best predicts balance confidence, objective balance measures, psychological factors, or fall history? (2) Does the absence of FoF in individuals with impaired balance increase fall risk? (3) Can wearable technology provide predictive insights into falls, FoF, and activity avoidance? (4) How does interoceptive awareness relate to these factors? The findings will inform risk prediction models to identify individuals at higher risk for falls, FoF, and maladaptive avoidance behaviors. Beyond pwMS, this research has broader implications for the elderly and individuals with neurological or chronic conditions, guiding evidence-based prevention and intervention strategies to enhance quality of life.