Floor-hugging Intervention: Managing Fear of Falling Through Floor Exposure and Developing After-fall Contingency

Background Fear of falling (FoF) is a serious public health problem affecting healthy and patient populations worldwide. It can range from a healthy caution that leads individuals to avoid environmental hazards such as icy, slippery roads or wet surfaces, to a disabling fear that forces them to stay at home, limiting their mobility and participation in activities of daily living. Several factors contribute to the development of FoF, including physical, cognitive, psychological, social and environmental influences. For example, in older adults, age-related declines in strength, sensation and cognitive function increase the risk of falling, which ultimately increases the FoF. Similarly, environmental factors such as icy winter conditions, particularly in Scandinavia, have been shown to increase FoF, not only in older adults but also in middle-aged and younger populations. FoF leads to self-imposed avoidance behaviors, meaning that individuals suffering from FoF voluntarily restrict their own mobility, which further worsens their health outcomes, increases their social isolation and reduces their overall quality of life. Ironically, this avoidance behavior, which is intended to prevent falls, has been reported to increase the risk of falling.

Despite the availability of interventions to reduce FoF, their effectiveness remains limited. One possible explanation is the lack of focus on the design of the environment, particularly on how individuals interact with the floor itself. In urbanized societies, direct contact with the floor through activities such as sitting, lying down or kneeling is rare. This lack of engagement can create a sense of unfamiliarity, similar to the discomfort a European might feel when eating with chopsticks in Asia, or a Swedish driver navigating left-hand traffic in the UK. Both examples illustrate how unfamiliarity with a task can lead to psychological uncertainty. For individuals with limited exposure to floor-based activities, this disconnect may similarly exacerbate psychological uncertainty about the floor and managing falls, intensifying FoF. Likewise, reduced engagement with floor-based activities in urbanized societies might also lead to deconditioning of the muscular strength and coordination needed to recover from falls. This could explain why adults who are do not know how to get back up after a fall experience heightened FoF.

These explanations are consistent with the uncertainty and anticipation model, which suggests that uncertainty about potential threats - such as falling - can increase threat expectancy. This overestimation of the risks associated with falling may in turn lead to maladaptive behaviors, including hypervigilance, avoidance, biased attention and poor updating of associative learning, all of which may contribute to increased FoF (10). Addressing this multifaceted problem therefore requires interventions that address underlying causes, such as limited ground exposure and inadequate post-fall recovery strategies, to mitigate the development of FoF.

The Floor Hugging Intervention (Floor-HI) is one such program that has been developed along these lines and may prove to be a potentially beneficial approach to alleviating FoF. The program comprises two main components: one aimed at enhancing familiarity with the floor and the other focused on developing post-fall strategies. Here, the first component of the Floor-HI, which deals with floor exposure, is based on emotional processing theory and allows for confrontation with the uncertainty of the floor and falls by asking individuals to lie on the floor in various positions while imagining that they have fallen. The act of spending time on the floor and imagining a fall in a safe environment is intended to create cognitive dissonance that can reshape and update fear structures to reduce the FoF. The second component of Floor-HI, which involves teaching individuals' strategies for getting back up after a fall, is intended to further empower individuals by increasing their self-efficacy in coping with falls, thereby further reducing the uncertainty (i.e. lack of post-fall contingencies) that also contributes to the development of FoF.

An innovative feature of Floor-HI is the use of printed surfaces that simulate high-risk environments such as icy, snowy, wet and cluttered surfaces, allowing participants to train in environments that reflect real-world challenges. This environmentally relevant approach ensures that training remains ecologically salient, safe while preparing individuals for potential hazards in a controlled and engaging manner. The program also addresses a critical gap in current government guidelines, which focus primarily on ground level strategies that rely on furniture for support. Such strategies may not be applicable in outdoor or unsupported environments. Floor-HI takes a personalized approach, allowing participants to choose between supported and unsupported floor-rising techniques based on their physical abilities.