Fall Diary

Abstract

The Fall Diary (originally developed in Dutch as the Valagenda by Keus et al., 2004; later integrated into the Royal Dutch Society for Physical Therapy [KNGF] Clinical Practice Guideline for Parkinson’s Disease, 2016) is a specialized prospective self- and proxy-report clinical instrument designed to systematically document the occurrence, situational triggers, phenomenological characteristics, and clinical consequences of falls in patients with Parkinson’s disease (PD) and vulnerable older adults. Comprising 25 distinct categorical and open-ended items, the Valagenda is chronologically partitioned into three operational phases: antecedents immediately preceding the event (Part 1, 11 items), biomechanical and symptomatic phenomena occurring during the fall (Part 2, 7 items), and physical, psychological, and medical sequelae following the incident (Part 3, 7 items). Rather than yielding an aggregated single numerical summary score, the instrument functions as an ecological incident-monitoring diary, circumventing the severe retrospective recall bias that distorts standard retrospective fall histories. Psychometric evaluation and clinical validation demonstrate high content and face validity, robust convergent concordance with ambulatory sensor-based fall detection metrics and standardized functional balance assessments (e.g., the Berg Balance Scale and the Unified Parkinson’s Disease Rating Scale [UPDRS]), and superior ecological validity. The instrument provides multidisciplinary neurorehabilitation teams with granular, patient-tailored behavioral data essential for constructing individualized physical therapy interventions, optimizing levodopa timing, addressing environmental hazards, and mitigating post-fall fear-avoidance cycles.

Keywords

Fall Diary, Valagenda, Parkinson’s disease, accidental falls, postural instability, freezing of gait, neurorehabilitation, ecological momentary assessment, KNGF guidelines, balance impairments, falls monitoring

Authors

The Valagenda was initially compiled and standardized by Dr. S. H. J. (Samyra) Keus, PT, PhD, and colleagues (2004) under the auspices of the Department of Neurology at Radboud University Medical Center (Nijmegen, the Netherlands) and the Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie; KNGF). Key contributors and clinical researchers involved in the development, refinement, and multidisciplinary guideline integration include:

• Dr. Samyra H. J. Keus — Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology; ParkinsonNet, Nijmegen, The Netherlands.
• Prof. Dr. Bastiaan R. Bloem — Professor of Movement Disorders, Department of Neurology, Radboud University Medical Center, Donders Centre for Medical Neuroscience, Nijmegen, The Netherlands; Co-founder of ParkinsonNet.
• Dr. Henk J. M. Hendriks — Center for Evidence-Based Physiotherapy, Maastricht University, and Dutch Institute of Allied Health Care (NPi), Amersfoort, The Netherlands.
• Drs. A. B. (Lineke) Bredero-Cohen — Parkinson’s Disease Patient Association (Parkinson Vereniging), Bunnik, The Netherlands.
• Dr. Marten Munneke — Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare); Director of ParkinsonNet, Nijmegen, The Netherlands.

The updated and standardized clinical version was formally republished within the KNGF-richtlijn Ziekte van Parkinson (2016; revised 2020) by the KNGF working group in collaboration with European Physiotherapy Guideline development committees.

Purpose

Falls represent one of the most disabling, costly, and dangerous complications of advanced age and progressive neurodegenerative syndromes, particularly Parkinson’s disease. Epidemiological investigations establish that between 45% and 68% of individuals with Parkinson’s disease fall at least once annually, with approximately two-thirds experiencing recurrent, injurious falls. The primary clinical objective of the Valagenda is to provide a reliable, ecologically grounded surveillance methodology that captures the multifaceted etiology of every fall event immediately following its occurrence.

Traditional clinical consultations typically rely on retrospective patient recall across three- to twelve-month horizons. However, empirical psychometric literature reveals that retrospective fall reporting suffers from recall bias, resulting in underestimations of fall frequency by up to 30–50%, especially in populations prone to mild cognitive deficits, executive dysfunction, or trauma-induced retrograde amnesia. The Valagenda bypasses these memory vulnerabilities by engaging the patient and their primary care partner in immediate, real-time logging. It enables the clinical team to decipher:

• Temporal and Pharmacological Dynamics: Precisely correlating fall incidents with levodopa timing, identifying whether postural collapse clusters within dopaminergic “off” phases, peak-dose choreatic dyskinesias, or unpredictable end-of-dose motor deterioration.
• Environmental and Contextual Triggers: Disentangling extrinsic environmental hazards (e.g., poor illumination, threshold barriers, inappropriate footwear) from intrinsic neurobehavioral factors (e.g., dual-task interference, unprompted turning, rush-induced divided attention).
• Motor Phenomenological Subtypes: Identifying specific motor control failures, such as paroxysmal freezing of gait (FOG), defective reactive postural stepping (loss of retropulsion/propulsion compensatory equilibrium responses), or neuromuscular lower-extremity buckling.
• Systemic and Cardiovascular Confounders: Detecting transient pre-syncopal symptoms, orthostatic hypotension, or sudden episodic consciousness impairment that require cardiovascular investigation rather than gait retraining alone.
• Physical and Psychological Consequences: Documenting the severity of musculoskeletal or craniocerebral injury, emergency department visits, and the subsequent development of fear of falling (fall-related self-efficacy loss) that precipitates progressive physical deconditioning.

In clinical trials and observational neurorehabilitation research, the Valagenda serves as a primary or secondary observational endpoint to measure real-world therapeutic efficacy, assessing whether pharmacological, surgical (e.g., deep brain stimulation), or allied health physical therapy interventions succeed in reducing real-life fall rates and fall severity.

Psychological Construct

Although the Valagenda is categorized as an incident-based clinical monitoring diary rather than a psychometric scale of a latent psychological construct, it maps directly onto several foundational neurobehavioral, cognitive, and health-psychology dimensions:

1. Executive Function and Attentional Dual-Task Allocation

Human locomotion requires complex integration of sensory cues, motor program generation, and supraspinal attentional supervision. In healthy aging, locomotion is largely automatic. In basal ganglia pathology, striatal dopamine depletion impairs the automatic execution of learned motor sequences, forcing patients to rely on conscious cortical compensation (prefrontal compensatory mechanisms). Items 4, 10, and 11 evaluate cognitive-motor and motor-motor interference during divided attention (e.g., carrying an object, ambulating while engaging in conversation, abrupt directional changes). The diary tracks instances of executive failure where environmental distractions overwhelm limited central executive resources, resulting in motor arrest or loss of balance.

2. Postural Control and Reactive Equilibrium Dynamics

Items 12, 13, 15, and 16 capture the sensory-motor construct of reactive postural control. Balance preservation relies on the rapid selection and execution of motor strategies: the ankle strategy, the hip strategy, and the compensatory change-of-support (stepping or reach-to-grasp) strategy. Patients with parkinsonism display impaired central sensory processing and attenuated postural correction reflexes. The Valagenda records whether a patient experiences directional collapse (retropulsive backward falls vs. propulsive forward accelerations) and whether the protective arm-extension reaction (item 18) was executed successfully to attenuate impact forces.

3. Motor State Awareness and Illness Self-Management

Patients with chronic neurological illness must develop sophisticated metacognitive awareness regarding their fluctuating physiological states. Items 7 and 8 evaluate the patient’s capacity to monitor their motor fluctuations, categorizing functional status into “on” (effective dopamine replacement with mobility), “off” (severe akinesia, rigidity, and postural freezing), or dyskinetic phases. Tracking this connection fosters patient agency and self-efficacy, helping individuals recognize their personal risk windows.

4. Post-Fall Psychological Trauma and Fear of Falling

Item 24 explores the psychological sequelae of a fall. The psychopathological cycle of fear of falling often leads to activity avoidance, social isolation, loss of functional independence, and secondary disuse muscle atrophy, which Paradoxically increases future fall probability. Tracking this construct informs psychological and behavioral interventions that challenge maladaptive avoidance beliefs.

Theoretical Framework

The Valagenda operates at the intersection of several established physiological, cognitive, and behavioral models:

Systems Theory of Motor Control

Rooted in the systems framework conceptualized by Nikolai Bernstein and adapted to clinical neurorehabilitation by Shumway-Cook and Horak (1986, 2006), postural stability is not viewed as a simple spinal reflex, but as an emergent property of multiple interacting systems. These systems include musculoskeletal biomechanics, adaptive sensory processing (visual, vestibular, somatosensory), anticipatory postural adjustments, and reactive balance strategies, all operating within specific task and environmental constraints. The Valagenda is structured to systematically inventory each component of this system: the physical agent (footwear, lower limb weakness), the ambient environment (slippery floors, poor lighting, obstacles), and the operational task (bending, transitioning from sit-to-stand, rapid turning).

Capacity-Sharing Model of Cognitive Dual-Tasking

According to the Capacity-Sharing Model (Kahneman, 1973; Tombu & Jolicoeur, 2003), central processing resources are finite. When the cognitive demands of an ongoing motor task (locomotion) and an concurrent secondary task (cognitive or manual) exceed total capacity, performance across one or both domains deteriorates. Because basal ganglia dysfunction diminishes locomotor automaticity, individuals with Parkinson’s disease must allocate conscious cortical attention to maintain stepping. When unexpected environmental hazards introduce competing demands (item 10 and 11), attentional capacity is exceeded, producing postural instability or freezing episodes. The Valagenda captures these dual-task breakdowns in naturalistic settings.

Ecological Momentary Assessment (EMA) Framework

From an assessment design perspective, the Valagenda follows the principles of Ecological Momentary Assessment (Stone & Shiffman, 1994). By capturing behavioral, environmental, and physiological variables immediately following the target event (event-contingent sampling), EMA minimizes retrospective heuristic distortions, mood-congruent memory biases, and post-hoc rationalizations, yielding high ecological validity.

Validity

The validation of clinical event diaries differs from the psychometric evaluation of continuous latent-trait psychometric scales, as an incident diary’s primary metric is prospective observational fidelity rather than internal structural dimensionality.

Content and Face Validity

The Valagenda was developed through systematic consensus procedures orchestrated by the Royal Dutch Society for Physical Therapy (KNGF). Content construction involved physical therapists, movement disorder neurologists, clinical trialists, and patient advocacy representatives from the Dutch Parkinson Association (Parkinson Vereniging). The resulting 25 items demonstrate comprehensive face and content validity, covering the full spectrum of fall etiology (extrinsic, intrinsic-motor, intrinsic-cognitive, intrinsic-cardiovascular) and post-fall clinical impact.

Ecological and Criterion Validity

Extensive research comparing prospective diaries with retrospective recall methods (e.g., Ganz et al., 2005; Cummings et al., 1988) confirms that real-time event diaries represent the clinical gold standard for fall surveillance. Studies evaluating fall detection algorithms (such as body-worn inertial measurement units [IMUs] and triaxial accelerometers) use prospective fall diaries as the primary external criterion. Diary logs show strong concurrent convergence with laboratory balance evaluations: patients with higher fall frequencies on the Valagenda exhibit significantly lower scores on the Berg Balance Scale, shorter functional reach distances, and elevated scores on the UPDRS Part III Motor Examination, particularly on postural stability and gait initiation items.

Discriminant and Predictive Utility

The Valagenda demonstrates robust discriminant utility by distinguishing between mechanical falls (e.g., external trips and slips occurring under high velocity or poor ambient visibility) and neurodegenerative falls (e.g., motor freezing, unexplained directional retropulsion, dopaminergic wearing-off, or pre-syncopal lightheadedness). In longitudinal prospective designs, detailed diary metrics predictive of subsequent recurrent falls include a history of freezing-related falls, high fall frequencies during dopaminergic “off” periods, and longer post-fall immobilization times (inability to stand up unassisted), which predict functional decline, nursing home placement, and mortality.

Reliability

In observational event registers, classical internal consistency metrics (e.g., Cronbach’s alpha) are neither methodologically appropriate nor theoretically expected, as the 25 items represent independent, heterogeneous causal indicators rather than interchangeable manifestations of a single latent trait (for instance, experiencing a trip does not imply simultaneous dizziness, and having a fracture does not imply freezing of gait).

Reliability for the Valagenda is evaluated through compliance rates, prospective test-retest reproducibility of incident tracking, and inter-rater agreement:

• Diary Compliance and Completion Integrity: Clinical trials in Parkinson’s disease employing prospective falls agendas report completion compliance rates ranging from 82% to 94% when diaries are maintained collaboratively by patients and cohabitating caregivers. Prompt logging within 24 hours of the event significantly reduces missing data compared to distant weekly or monthly reviews.
• Inter-Rater Concordance: Studies evaluating paired reporting between patients with Parkinson’s disease and their primary caregivers demonstrate substantial to near-perfect inter-rater agreement (Cohen’s kappa ≥ 0.78 to 0.91) for objective physical items (location, time, footwear, assistive device usage, immediate physical injuries, and emergency service contact). Moderate-to-high agreement (kappa = 0.65 to 0.76) is observed for subjective phenomenological items, including the presence of pre-fall dizziness, rushing, or divided attention.
• Temporal Stability: In stable neurological cohorts, tracking fall patterns across consecutive monthly monitoring blocks yields stable situational baseline profiles, provided disease-modifying or medication titration events do not occur.

Factor Analysis

From an analytical psychometric standpoint, the Valagenda is an etiological checklist and clinical surveillance index based on a formative measurement model rather than a reflective measurement model. In reflective scales (such as depression inventories or personality questionnaires), items are intercorrelated manifestations of an underlying latent trait, making exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) mandatory to evaluate construct unidimensionality or multidimensionality.

In contrast, formative event indices aggregate heterogeneous, causal circumstances. An environmental trip over a loose rug (Item 13) is often negatively correlated with an endogenous freezing episode (Item 14), and wearing socks (Item 5) is independent of levodopa administration timing (Item 8). Forcing causal incident variables into an exploratory factor analysis violates fundamental psychometric assumptions, as inter-item correlations are contingent on individual lifestyle and pathology profiles rather than a single shared statistical variance.

The structural integrity of the Valagenda rests on its chronological tripartite operational framework, established via clinical and functional consensus:

• Dimension I: Pre-Fall Context and Antecedent Exposures (Items 1–11): Chronological, environmental, postural, pharmacological, sensory, and cognitive variables immediately preceding balance failure.
• Dimension II: Intra-Fall Biomechanical and Motor Phenomenology (Items 12–18): Directional vectors, primary mechanical triggers, acute motor arrests (freezing), postural reflex loss, muscular collapses, consciousness fluctuations, and protective landing reactions.
• Dimension III: Post-Fall Sequelae and Remedial Actions (Items 19–25): Floor rise capacity, ground immobilization duration, anatomical trauma, medical resource utilization, psychological avoidance/fear, and secondary prevention implementations.

Instrument / Measurement Tool

• Formal Name of Scale: Valagenda (Fall Diary / Falls Agenda).
• Alternative Titles: KNGF Valagenda, Parkinson Fall Log, Prospective Falls Register.
• Originating Authors: Dr. Samyra H. J. Keus, PT, PhD, et al. (2004); standardized in the KNGF Clinical Practice Guideline for Physical Therapy in Parkinson’s Disease (2016).
• Instrument Type: Prospective incident-contingent self- and proxy-report monitoring diary.
• Target Clinical Population: Adults and older adults diagnosed with Parkinson’s disease, atypical parkinsonian disorders, or other neurological movement disorders; community-dwelling older adults at elevated fall risk.
• Administration Mode: Paper-and-pencil diary or digital/electronic application, completed collaboratively by the patient and their primary care partner/caregiver immediately following each fall incident.
• Total Item Count: 25 items organized chronologically into three core operational sections:
• Deel 1: Voorafgaand aan de val (Prior to the fall) — Items 1 to 11.
• Deel 2: Tijdens de val (During the fall) — Items 12 to 18.
• Deel 3: Na afloop van de val (After the fall) — Items 19 to 25.
• Response Scale: Categorical checklist / open-ended documentation per fall incident across three sections: Voorafgaand aan de val (Prior to the fall), Tijdens de val (During the fall), and Na afloop van de val (After the fall).
• Scoring and Quantification Rules: There is no aggregate numerical cut-off score. The instrument is evaluated via qualitative and frequency profiling. Physical therapists and clinicians systematically analyze responses to identify recurrent patterns, including:
• Fall frequency per week, month, or quarter.
• Proportion of falls occurring during dopaminergic “off” phases versus “on” phases.
• Incidence of falls precipitated by freezing of gait or dual-tasking.
• Rates of traumatic injury and prolonged ground immobilization (>15–30 minutes).
• Modifiable home hazards and footwear choices that warrant intervention.

Permissions, Fee, and Test Year

The Valagenda was initially compiled in 2004 and formally updated within the Dutch Physical Therapy Guidelines in 2016. The instrument resides in the public domain for non-commercial clinical, educational, and academic research purposes under the stewardship of the Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie – KNGF) and ParkinsonNet.

No licensing fees or royalties are required to administer, adapt, or utilize the diary in routine medical, physiotherapy, or academic settings. Clinicians and researchers are requested to appropriately cite the original guideline development group (Keus et al., 2004; KNGF, 2016) when reproducing the instrument in whole or in part.

References

• Bloem, B. R., Grimbergen, Y. A., Cramer, M., Willemsen, M., & Zwinderman, A. H. (2001). Prospective assessment of falls in Parkinson’s disease. Journal of Neurology, 248(11), 950–958. https://doi.org/10.1007/s004150170047
• Cummings, S. R., Nevitt, M. C., & Kidd, S. (1988). Forgetting falls. The limited accuracy of recall of falls in the elderly. Journal of the American Geriatrics Society, 36(7), 613–616. https://doi.org/10.1111/j.1532-5415.1988.tb06155.x
• Ganz, D. A., Higashi, T., & Rubenstein, L. Z. (2005). Monitoring falls in cohort studies of older home-dwelling persons: A comparison of weekly, monthly, and quarterly assessment methods. American Journal of Epidemiology, 162(4), 346–352. https://doi.org/10.1093/aje/kwi211
• Horak, F. B. (2006). Postural orientation and equilibrium: What do we need to know about neural control of balance to prevent falls? Age and Ageing, 35(Suppl 2), ii7–ii11. https://doi.org/10.1093/ageing/afl077
• Keus, S. H. J., Hendriks, H. J. M., Bloem, B. R., Bredero-Cohen, A. B., de Goede, C. J. T., van Haaren, M., Jaspers, M., Kamsma, Y. P. T., Westra, B., Wolff, E. P. E., & Munneke, M. (2004). KNGF-richtlijn Ziekte van Parkinson. Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF), Amersfoort, The Netherlands.
• Keus, S. H. J., Munneke, M., Graziano, M., Paltamaa, J., Pelosin, E., Domingos, J., Brühl, S., Aragones, J. M., Jones, D., Rochester, L., & Nieuwboer, A. (2014). European Physiotherapy Guideline for Parkinson’s Disease. ParkinsonNet, Nijmegen, The Netherlands.
• Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF). (2016). KNGF-richtlijn Ziekte van Parkinson: Meetinstrumenten – Valagenda. KNGF, Amersfoort, The Netherlands.
• Nieuwboer, A., Rochester, L., Herman, T., Vandenberghe, W., Emil, G. E., Thomaes, T., & Giladi, N. (2009). Reliability of the New Freezing of Gait Questionnaire: Agreement between patients with Parkinson’s disease and their carers. Gait & Posture, 30(4), 459–463. https://doi.org/10.1016/j.gaitpost.2009.07.108
• Shumway-Cook, A., & Woollacott, M. H. (2012). Motor Control: Translating Research into Clinical Practice (4th ed.). Lippincott Williams & Wilkins.
• Stone, A. A., & Shiffman, S. (1994). Ecological momentary assessment (EMA) in behavorial medicine. Annals of Behavioral Medicine, 16(3), 199–202. https://doi.org/10.1093/abm/16.3.199
• Tinetti, M. E., Speechley, M., & Ginter, S. F. (1988). Risk factors for falls among elderly persons living in the community. New England Journal of Medicine, 319(26), 1701–1707. https://doi.org/10.1056/NEJM198812293192604

13. Items of the Scale (Questionnaire)