The First Fall is the Deepest: Fear of Falling after Stroke and Psychogenic Causes of Poor Balance, Posture and Gait

If you replace the word “cut” with “fall” in Cat Stevens song ” the first cut is the deepest”  the lyrics actually proves the same point as this article. Falls are common occurrences in hospitals and nursing homes, in fact there are so common that falls prevention committees and falls risk wrist bands and signs have become an integral part of healthcare facilities (Visschedijk, et al, 2015). we are all familiar with those elderly patients who grab for everything and anything within reach even when they are sitting in a chair, well, they are the famous “grabbers”. One thing these patients have in common is the existence of a neurological disease, such as history of stroke,  Alzheimer’s, Parkinson’s, MS, etc… These individuals also have another thing in common, they all had something called “the first fall” . Even if these patients  were not injured during the fall incident, their activity levels gradually decrease to almost 50% within the first 6 months after the fall.  Despite fall prevention interventions such as chair and mattress alarms patient continue to fall and at some point become a “grabber” or develop a phobia about falling.

Inpatient first fall incidence hours and days after stroke

Now let’s change our focus to the stroke population and see how a fall incidence can change the course of rehabilitation, mobility and independence of a stroke survivor in a chronological manner.

Regardless of what theory of neuropathology you believe in, impulsivity, and lack of proprioception combined with hypoesthesia could be the main reason why stroke patients attempt to go to the bathroom at night after waiting over two hours for the night nurse ( this part is a joke, just in case if you have an altered sense of humour) .

Although most patients end up falling more than once in the first couple of weeks ( depending on their level of mobility) but early falls are associated with poor balance and greater gait abnormalities. Unfortunately, there is not enough epidemiological data put there to prove the correlation between first falls and its long term effects (Kader, et al, 2016), but I have seen many patients who had a dramatic gait change after their falls. There are many reasons behind this phenomenon, but based on my observations and anecdotal evidence nursing and rehab staff usually educate these patients after a fall by using phrases such as ” Mr.X, you are on anticoagulants, and one side of your body does not work, you think you can walk but you cannot! if you attempt to climb out of bed and go to the bathroom by yourself, you are going to fall, fracture a bone, hit your head, and die from a brain bleed”  These kinds of explanatory techniques almost always work! They never do thing on their own again!  and as a result their gait changes, usually the unaffected upper extremity goes into abduction while walking (like walking on a wire with arms stretched out),  the trunk is not in a vertical line and the centre of gravity changes and patients develop a stooped posture always trying to reach for grab bars, walls tables and anything that can give them assurance. Do not get me wrong, these patients did not have any balance issues and were able to maintain their balance prior to the fall, also, neuroimaging results confirm the integrity of the posterior regions such as cerebellum, and no other parenchymal post-fall abnormalities can be detected.

There are multiple reasons behind such sudden behavioural changes in the stroke population, our brains usually prevents us from repeating the same painful or fearful experiences (most people) the incidence combined with the educational conversations as mentioned above could be one of the main reasons why these patients see a dramatic change in their abilities to transfer or walk (Hornyak et al., 2013).

Also, the fact that sometimes these changes become ingrained and an inseparable part of patients body mechanics could be due to the fact that brain plasticity increases after traumatic brain injuries as a mechanism to resolve the issue. This phenomenon has not been tested empirically, but I have observed in many cases, patients become focused and attentive in order to regain their mobilities and learn new an better techniques to improve their independence in ADLs. It is as if though their brains regain the childhood spasticity and absorbs everything there is to know about recovery. If you have ever noticed a stroke patient with a paretic upper extremity, they tend to hold on to the paretic hand with the unaffected hand, perhaps due to the same educational lesson from the staff , but in this case shoulder pain and subluxation is the cause of such educational tips.


Appropriate re-education about the risks of falling in an informative and educational way, and avoiding fear tactics are essential to avoid future psychogenic processes. Transfer, balance and weight shifting training combined with videography and visual feedback are also important components of a successful treatment plan.


Examples of weight shifting and standing balance activities:











Image 1                                                                                                              Image 2

In Image 1:  the affected L/E is bearing weight: 1: shows the direction of weight shift, 2: highlights the walking on the wire phenomenon, due to lack of sensation and proprioception in the affected L/E, and uncertainty of balance, 3: shows the C shaped upper trunk due two weakness in the posterior and anterior core muscles. 4: Malalignment  of shoulder girdle creates an asymmetrical posture.

In Image 2: The unaffected L/E bearing the body weight. 1: Weight is shifted to the right in order for the affected L/E to lift ( mod assist for hip flexion/knee extension) 2: the unaffected knee bends while lifting the affected L/E as a compensatory mechanism to improve the clearance. 3: walk on the wire phenomenon due uncertainty of balance and lack of proprioceptive and sensation input.

*It is important to note, that verbal cues and visual feedback play a crucial role. these points must be communicated with the patient and corrections and improvement could be observed following the treatment.

* These activities are not physical exercises, they require a high level of neural activities and should be thought of as a cognitive treatment. Research have shown that the binding of prefrontal cortex, motor and sensory corteces, basal ganglia, thalamus, as well as the vestibular and visual systems are all required to achieve postural stability, weight shifting and the maintenance of balance.





  • Hornyak, V., Brach, J. S., Wert, D. M., Hile, E., Studenski, S., & VanSwearingen, J. M. (2013). What is the relation between fear of falling and physical activity in older adults? Archives of Physical Medicine and Rehabilitation, 94(12), 2529–2534.
  • Kader, M., Iwarsson, S., Odin, P., & Nilsson, M. H. (2016). Fall-related activity avoidance in relation to a history of falls or near falls, fear of falling and disease severity in people with Parkinson’s disease. BMC Neurology, 16.
  • Simpson, L. A., Miller, W. C., & Eng, J. J. (2011). Effect of Stroke on Fall Rate, Location and Predictors: A Prospective Comparison of Older Adults with and without Stroke. PLoS ONE, 6(4).
  • Visschedijk, J. H. M., Caljouw, M. A. A., Bakkers, E., van Balen, R., & Achterberg, W. P. (2015). Longitudinal follow-up study on fear of falling during and after rehabilitation in skilled nursing facilities. BMC Geriatrics, 15.


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