The Effects of Earthquake on Fear of Movement and Fear of Falling
Condition: Fear of Movement; Fear of Falling
Study type: Observational [Patient Registry]

Summary: 
      In February-March 2023, a series of major earthquakes occurred in 11 provinces of Turkey
      (Adana, Adıyaman, Diyarbakır, Gaziantep, Hatay, Kahramanmaraş, Kilis, Malatya, Osmaniye,
      Şanlıurfa and Elazığ). The current study is planned as a observational cross-sectional study
      with the participation of the survivors who experienced the 2023 earthquakes and aftershocks
      in Turkey without any physical injury during or after the earthquake. It is planned for the
      participants to fill out the questionnaires by considering the time periods before and after
      the earthquake. While the primary outcome is fear of movement and fear of falling, the
      secondary outcome is level of physical activity and intensity of pain. Psychological
      resilience level was considered as a predictive factor.

      The aim of the current study is to determine the effect of earthquake experience on the fear
      of movement and falling in earthquake victims and to investigate the factors related with
      them. Fear of movement, fear of falling, level of physical activity, intensity of pain and
      psychological resilience are evaluated with the Causes of Fear of Movement Scale, Modified
      Falls Efficacy Scale, Short Form of International Physical Activity Questionnaire, Numerical
      Pain Scale and Connor-Davidson Psychological Resilience Scale respectively.
    

Detailed description: 
      INTRODUCTION: Major earthquakes increase the risk of mental and emotional diseases such as
      anxiety disorders, sleep disorders and post-traumatic stress disorder as well as physical and
      biological complaints such as dizziness, vertigo and balance disorder.

      An elaborate study conducted by Nomura et al., propounded the concept of Post-Earthquake
      Dizziness Syndrome (PEDS) for dizziness like features in earthquake victims. Their study also
      indicated that a previous history of vertigo was not related to the prevalence of PEDS.
      However, they noted that people prone to motion sickness were found to have a significantly
      higher prevalence of post-earthquake dizziness episodes.

      In a previous review study conducted in 2021, the results showed that the prevalence of
      balance disorders increased significantly after the major earthquakes when compared to before
      the earthquakes. Exposure to major earthquakes and aftershocks has been shown to cause
      post-earthquake balance disorders by causing sensory conflicts mediated by vestibular
      dysfunction and/or psychological factors. In addition, that study stated that this increase
      in the prevalence of balance disorders may also be caused by psychological factors, which is
      consistent with previous studies in the literature.

      The mechanisms of equilibrium dysfunction are likely to be explained by the sensory conflict
      theory/postural instability theory. The basic pathology of equilibrium dysfunction is
      attributed to disruption of interplay between vestibular, neurological, visual and
      proprioceptive functions of the human body. Psychological stress and maladaptive
      visual/somatosensory inputs caused by the earthquake may cause changes in the sense of
      movement, which is an important component of proprioception sense. Moreover, disruptions in
      the vestibular system may trigger the fear of falling, leading to decreases in physical
      activity capacity.

      Although some previous studies have reported the presence of diziness or equilibrium
      disorders, in survivors after the earthquake, no study has investigated the fear of movement
      and fear of falling in these individuals.

      Considering Turkey's geographical location in a high-risk seismic zone, determining the
      prevalence of fear of movement and falling in earthquake-exposed individuals would greatly
      contribute to the development of a better empirical approach to post-earthquake disaster
      management.

      The primary aim of the present study is to determine the prevalence of fear of movement and
      falling in post-earthquake victims without physical injury, while the secondary aim is to
      reveal the relationship between these two parameters, as well as physical activity level, and
      pain intensity. Psychological resilliance is considered as a predictıve factor.

      According to the the results of current study, it will be determined whether earthquake
      survivorship should be taken into account in preventing physical inactivity and related
      complications. In cases where this necessity is determined, rehabilitation programs should be
      revised depending on the earthquake victim's status.

      MATERYAL-METHOD Design of the Study The present study is planned as a observational
      cross-sectional study and it will include victims of the 2023 earthquake in Türkey. Approval
      will be obtained from the Atılım University Ethics Committee with 02.05.2023 date and
      E-59394181-604.01.02-60355 number to be determined.

      After providing information about the study, participants who voluntarily agree to
      participate will be included after obtaining written consent.

      For the current study, sample selection will be planned with the simple randomization method.
      The advantages of this method are that it provides a fair chance for each unit in the
      population to be selected, eliminates potential biases, and allows for statistical inferences
      to be made.

      The data will be collected through communication with local authorities at the aid points
      located in the earthquake-affected cities. Surveys will be conducted face-to-face with
      earthquake victims living in different cities.

      In this study, participants will answer the questions by considering two different time
      periods: first considering the three-week period before the earthquake, and then considering
      the three-week period after the earthquake. The evaluation will be completed when there are
      no unanswered questions.

      Participants The participants in this study will include individuals who meet the following
      inclusion criteria: they must be victims of the 2023 earthquake in Turkey and be between the
      ages of 18 and 60.

      Exclusion criteria for participation in the study will be the presence of pre-existing
      cognitive and/or psychological illness, physical injury status after the earthquake, and
      illiteracy.

      Data collection The primary outcomes of this study are fear of movement and fear of falling,
      while the secondary outcomes are the level of physical activity and intensity of pain.
      Psychological resilience level is considered as a predictive variable.

      These outcomes will be assessed using the Causes of Fear of Movement Scale, Modified Falls
      Efficacy Scale, Short Form of International Physical Activity Questionnaire, Numerical Pain
      Scale, and Connor-Davidson Psychological Resilience Scale, respectively.

      Sociodemographic characteristics The sociodemographic characteristics of the participants,
      such as age, height, weight, body mass index, education status, occupation, income status
      (income-expenditure relationship), presence of chronic diseases, shelter status, and marital
      status, will be recorded in a descriptive manner.

      Assessment of fear of movement: The fear of movement will be assessed using the Turkish
      version of the Causes of Fear of Movement Scale. This questionnaire, developed by Janusz
      Kocjan et al. in 2014, consists of 20 questions and aims to diagnose and identify the causes
      of motor inactivity.

      The questionnaire is divided into two parts, biological and psychological, to determine the
      reasons for the fear of movement. This structure enables the identification of individual
      causes of kinesiophobia and the determination of biological and psychological causes
      separately. The total score obtained from the questionnaire is calculated as the average of
      the scores obtained from the biological and physiological sub-dimensions. In the updated
      version from 2018, the total score ranges from 0 to 5. The scale uses a 5-point Likert
      scoring system (1=I totally disagree, 5=I totally agree). A high score indicates a higher
      level of fear of movement.

      Asseement of fear of falling: The Modified Falls Efficacy Scale with 14 items (10 indoor and
      4 outdoor activities) will be used to assess fear of falling. It evaluates participants'
      confidence during different daily tasks and is a reliable and valid scale for estimating
      balance and mobility problems. The scale includes items scored between 0 (not confident) and
      10 (completely confident) to assess participants' self-efficacy levels regarding falling. The
      scale score is calculated by dividing the sum of the scores per question by the number of
      questions. High score means that the sense of safety and competence against falling are high.
      Cronbach's alpha internal consistency coefficient (ICC) of the scale was found to be 0.93.
      The Turkish version developed by Çetişli-Korkmaz et al. will be used in this study.

      Level of Physical Activity: Turkish version of the Short Form of the International Physical
      Activity Questionnaire is used in order to determine the level of physical activity and
      sedentary lifestyles.

      The durations of physical activities are multiplied by the Metabolic Equivalent of Task (MET)
      values per activity, and the results of all items are summed to create a total score for
      overall physical activity. Physical activity levels are classified into three categories:
      physically inactive (<600 MET min/week), low physical activity level (600-3000 MET min/week),
      and sufficient physical activity level (>3000 MET min/week).

      Intensity of pain: A 10 cm Numerical Pain Scale will be used to determine the severity of
      pain, with numbers ranging from "0" (no pain) to "10" (unbearable pain).

      Psychological Resilience Status: Psychological Resilience Status will be assessed using the
      Connor-Davidson Resilience Scale (CD-RISC-25). The Turkish version, developed by Karaırmak,
      consists of 25 questions and three sub-dimensions, namely perseverance and personal
      competence, tolerance for negative events and spiritual tendency. The first sub-dimension,
      'perseverance and personal competence,' has a maximum score of 60, the second sub-dimension,
      'tolerance for negative events,' has a maximum score of 24, and the third sub-dimension,
      'spiritual tendency,' has a maximum score of 16. The scale uses a 5-point Likert-type scoring
      system, ranging from 0-4 points, with "never true" (0 points) to "almost always true" (4
      points) as response options. The highest possible score is 100 points, indicating a higher
      level of psychological resilience as the score increases.

      Sample size calculation: Sample size will be calculated after a pilot study.

      Statistics:

      The data collected from the participants will be analyzed using SPSS statistical software.
      Descriptive statistics such as mean, standard deviation, and frequency distributions will be
      used to describe the demographic characteristics and study variables. The normality of the
      distribution of the study variables will be tested using the Shapiro-Wilk test. If the
      distribution is normal, the paired sample t-test will be used to compare the pre- and
      post-earthquake scores of fear of movement, fear of falling, intensity of pain, and physical
      activity level. In case of non-normal distribution, the Wilcoxon signed-rank test will be
      used for analysis. Additionally, Pearson correlation coefficient analysis will be used to
      investigate the relationships between fear of movement, fear of falling, intensity of pain,
      and physical activity level. A significance level of p<0.05 will be used for all statistical
      tests.
    

Observational model: Other
Time perspective: Cross-Sectional
Sampling method: Probability Sample
Study population: 
        Uninjured survivors of the 2023 earthquake who voluntarily agree to participate will be
        included. For the current study, sample selection will be planned with the simple
        randomization method. The data will be collected through communication with local
        authorities at the aid points located in the earthquake-affected cities. Surveys will be
        conducted face-to-face with earthquake victims living in different cities.
      
Keywords: Earthquake; Kinesiophobia