Association of stroke subtypes with risk of hip fracture: a population-based study in Taiwan

Screening cutoff values to identify the risk of falls after stroke: A scoping review

OBJECTIVE

The present scoping review aimed to summarize and determine the accuracy of the variables and cutoff values reported to date for identifying fall risk in patients with stroke and identify the commonalities, limitations, and clinical implications.

METHODS

Articles published by the end of 2023 were searched using PubMed, Cumulative Index of Nursing and Allied Health Literature, and Scopus electronic databases. Two reviewers created a search formula, searched the databases, and conducted primary and secondary screenings.

RESULTS

This review included 21 articles. The most commonly used individual indicator for identifying fall risk after stroke was the Berg Balance Scale; the cutoff values were relatively consistent, ranging between 46.5 and 50.5 points (area under the curve: 0.72-0.81). For the Timed Up and Go test and Falls Efficacy Scale-International, the cutoff values were in the range of 15-19 s and 27-29 points, respectively, and were relatively consistent across the articles. However, the area under the curve values were low (0.66-0.70 and 0.68-0.71, respectively).

CONCLUSION

Among various assessments, the Berg Balance Scale is the most extensively studied tool, with established cutoff values associated with falls risk. It serves as a reliable indicator for detecting fall risk, especially in community-dwelling individuals with chronic stroke.

New-onset stroke on the risk of hip fracture: the Kailuan cohort study in China

PURPOSE

Stroke is a documented risk factor for hip fracture(HF). However, no data is currently available on this issue in mainland China, we therefore assessed the risk of hip fracture after new-onset stroke using a cohort study.

METHODS

This study included 165,670 participants without a history of stroke at baseline from the Kailuan study. All participants were followed biennially until December 31, 2021. During follow-up, a total of 8,496 new-onset stroke cases were identified. For each case subject, four control subjects was randomly selected, matched for age (± 1 years) and sex. The final analysis comprised 42,455 pair-matched cases and controls. A multivariate Cox proportional hazard regression model was used to estimate the effect of new-onset stroke on the risk of hip fracture.

RESULTS

During an average follow-up of 8.87 (3.94) years, a total of 231 hip fracture cases occurred, 78 cases in the stroke group and 153 cases in the control group, with incidence rates of 1.12 and 0.50 per 1000 person-years, respectively. The cumulative incidence of the stroke group was higher than that of the controls (P < 0.01). The adjusted hazard ratio (95% confidence interval) of hip fractures in the stroke group was 2.35 (1.77 to 3.12) (P < 0.001) to controls. After stratifying by gender, age, and body mass index, the higher risk was revealed in female (HR 3.10, 95 CI: 2.18 to 6.14, P < 0.001), age < 60 years old (HR 4.12, 95% CI: 2.18 to 7.78, P < 0.001), and non-obesity (BMI<28 kg/m²) (HR 1.74, 95% CI:1.31 to 2.31, P < 0.001) subgroup.

CONCLUSIONS

Stroke significantly increases the risk of hip fracture, strategy for protecting stroke patients from falls and hip fractures should be emphasized in poststroke long-term management, particularly the female, age < 60 years old, and non-obese patients.

A validity study to consult on a protocol of a home hazard management program for falls prevention among community dwelling stroke survivors

OBJECTIVE

A fall after a stroke is common but the consequences can be devastating not only for the stroke survivors, but also for caregivers, healthcare, and the society. However, research on falls prevention among the stroke population are limited, particularly on home hazards assessment and home modifications, demanding for a study to be conducted. The aim of the study is to validate the protocol and content of a home hazard management program guided by the Person-Environment-Occupation (PEO) Model for falls prevention among community dwelling stroke survivors.

METHOD

Researchers developed their own questionnaire for content validation which consist of 23 items that covers two domains, namely justification for telehealth home hazard management practice and the protocol's overall methodology. Occupational therapists with at least one year of experience in conducting a home hazard assessment were consulted for the content validation of a two-group clinical controlled trial protocol utilizing a home hazard assessment, home modifications and education over the usual care. Written consent was obtained prior to the study. The occupational therapists were given a Google Form link to review the protocol and intervention based on the questionnaire and rated each item using a four-point Likert scale for relevance and feasibility. Open-ended feedback was also recorded on the google form. Content Validity Index (CVI), Modified Kappa Index and Cronbach's Alpha was calculated for the content validity and reliability analysis.

RESULTS

A total of sixteen occupational therapists participated in the study. 43.7% of participants had a master's degree, 93.7% worked in the government sector and 56.2% had six years and more experience on conducting home hazard assessments. Content validity of the protocol is satisfactory for relevancy and feasibility (CVI = 0.84, ranging from 0.5 to 1.00), and for the reliability (α = 0.94 (relevance) and α = 0.97 (feasibility), respectively. The Modified Kappa ranged from 0.38 to 1.00 for all items. Feedback was also received regarding the design and procedure of the study protocol which included participant's selection criteria, sample size, equipment provided, cost, location, and care for the participants during the intervention.

CONCLUSIONS

Introducing a home hazard management program to prevent falls among the stroke population is viewed relevant and feasible. Practical suggestions from the consultation panel were adopted, and minor adjustments were required to strengthen the protocol's overall methodology. This study established a rigorous and robust experimental protocol for future undertaking.

Factors associated with 90-day acute ischemic stroke in patients ≥70 years old with total hip arthroplasty for hip fracture

Background

Postoperative ischemic stroke is a devastating complication following total hip arthroplasty (THA). The purpose of the current study was to investigate the incidence of postoperative acute ischemic stroke (AIS) in patients ≥70 years old with THA for hip fracture after 90 days and independent risk factors associated with 90-day AIS.

Methods

A multicenter retrospective study was conducted, patients ≥70 years old with THA for hip fracture under general anesthesia were included from February 2017 to March 2020. Patients with AIS within 90 days after THA were identified as AIS group; patients with no AIS were identified as no AIS group. The baseline characteristics and risk factors were collected, multivariable logistic regression was used to identify independent risk factors of 90-dayAIS.

Results: 2517 patients (mean age 76.18 ± 6.01) were eligible for inclusion in the study. 2.50% (63/2517) of patients had 90-day AIS. Compared with no AIS, older age, diabetes, hyperlipidemia, atrial fibrillation (AF) and higher D-dimer value were more likely in patients with AIS (P < 0.05), and anticoagulant use was fewer in patients with AIS. ROC curve analysis showed that the optimal cut point of D-dimer for AIS was D-dimer≥4.12 μg/ml. Multivariate logistic regression analysis showed that D-dimer≥4.12 μg/ml [adjusted odds ratio (aOR), 4.44; confidence interval (CI), 2.50–7.72; P < 0.001], older age (aOR, 1.08; 95%CI, 1.03–1.12; P < 0.001), hyperlipidemia (aOR, 2.28; 95%CI, 1.25–4.16; P = 0.007), atrial fibrillation (aOR, 5.84; 95% CI, 1.08–15.68; P = 0.001), and diabetes (aOR, 2.60; 95% CI, 1.56–4.39; P < 0.001) were associated with increased risk of 90-day AIS after THA.

Conclusions

In conclusion, we found that the incidence of 90-day AIS in patients≥70 years old with THA for hip fracture was 2.5%. Older age, diabetes, hyperlipidemia, AF and higher D-dimer value were independent risk factors for 90-day AIS in patients≥70 years old with THA for hip fracture.

Associations between stroke type, stroke severity, and pre-stroke osteoporosis with the risk of post-stroke fracture: A nationwide population-based study

Background Recognizing the post-stroke fracture risk factors is crucial for targeted intervention and primary fracture prevention. We aimed to investigate whether stroke types, stroke severity, and pre-stroke osteoporosis are associated with post-stroke fracture. Methods In a nationwide cohort, we identified previously fracture-free patients who suffered from first-ever stroke, either acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH), between 2003 and 2015. Information regarding stroke severity, osteoporosis, comorbidity, and medication information was collected. The outcomes analyzed included hip fracture, spine fracture, and other fractures. Cumulative incidence functions (CIFs) were used to estimate the cumulative incidence of fractures over time after accounting for competing risk of death. Multivariable Fine and Gray models were used to determine the adjusted hazard ratio (HR) and 95% confidence interval (CI). Results Of the 41,895 patients with stroke, the 5-year CIFs of any incident fracture, hip fracture, spine fracture, and other fractures were 8.03%, 3.42%, 1.87%, and 3.05%, respectively. The fracture risk did not differ between patients with AIS and ICH. While osteoporosis increased the risk of post-stroke fracture (adjusted HR [95% CI],1.42 [1.22-1.66]), stroke severity was inversely associated with post-stroke fracture (moderate, 0.88 [0.81-0.96] and severe, 0.39 [0.34-0.44], compared with mild stroke severity). Conclusions Stroke survivors had an over 8% fracture risk at 5 years after stroke. Mild stroke severity and osteoporosis were significantly associated with post-stroke fracture risk, whereas stroke type was not. Our results call for effective measures for bone health screening and fracture prevention in patients with stroke.

Approach to patients with hip fracture and concurrent stroke

We report a case of a 70-year-old man who presented with concomitant hip fracture and stroke. Our patient underwent surgical correction of a hip fracture despite the increased perioperative and postoperative risks associated with an acute stroke. He achieved good functional outcome after surgery and subsequent rehabilitation. There are no clear guidelines on the factors to determine whether a patient with concomitant stroke and hip fracture is a good candidate for surgical hip repair. Furthermore, there is also no consensus on the appropriate timing of surgical repair for such patients. We postulate that factors such as functional status, comorbidities, type and severity of stroke will affect the decision to proceed with surgical repair, and that there is a benefit in advocating for surgery in appropriate patients by a multidisciplinary orthogeriatric care team.

Incidence and risk factors associated with postoperative stroke in the elderly patients undergoing hip fracture surgery

OBJECTIVES

Stroke is one of the rare but devastating complications after hip fracture in the elderly. By far, there is still scarce data on postoperative stroke in elderly patients with hip fractures.

METHODS

This was a retrospective study of prospectively collected data. Between October 2014 to December 2018, patients aged above 65 years who underwent operative treatment for hip fractures were included. Inpatient medical surveillance and scheduled telephone follow-up at 1, 3, 6, and 12 months after operation was conducted to identify who developed an incident stroke. Variables of interests were extracted from patients' inpatient medical records. Univariate analysis and multivariate logistic regression analysis were used to identify the independent risk factors associated with stroke.

RESULTS

During the study period, a total of 3743 patients were included, among whom 56 were found to have a stroke after operation, representing an incidence of 1.5% (95% CI, 1.1 to 1.9%). The multivariate analyses showed that advanced age (1-year increment; OR, 1.32; 95% CI, 1.08 to 1.48), history of previous stroke (OR, 4.79; 95% CI, 1.86 to 6.56), ASA III and above (OR, 2.62; 95% CI, 1.27 to 3.68), long-term use of aspirin (OR, 3.63; 95% CI, 1.41 to 4.78), and elevated RDW level (each increment of 1%, OR, 1.21; 95% CI, 1.02 to 1.36) were independently associated with postoperative stroke.

CONCLUSIONS

Although most are not modifiable, these risk factors help in counseling patients regarding the risk of postoperative stroke, individual risk stratification, and targeted optimization of medical conditions and should be firmly kept in treating surgeon's mind.

Determinants of Recurrent Falls Poststroke: A 1-Year Follow-up of the Fall Study of Gothenburg

OBJECTIVE

To identify the occurrence of recurrent falls and the determinants in the acute phase poststroke that are associated with recurrent falls within the first year poststroke.

DESIGN

Prospective follow-up study.

SETTING

Stroke unit and community.

PARTICIPANTS

Patients (N=504) with acute stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The dependent variable was recurrent falls, defined as ≥2 falls, within the first year poststroke. The independent baseline variables were related to function, activity, participation, personal and environmental factors, and comorbidity and were assessed within 4 days after admission to a stroke unit. Fall data were registered at the stroke unit, and self-reported fall data were collected during follow-up using a standardized questionnaire. Determinants of recurrent falls were identified using univariable and multivariable logistic regression analyses.

RESULTS

Within 12 months poststroke, 95 of 348 participants (27%) had experienced recurrent falls. Poor postural control (odds ratio [OR] 5.85; 95% confidence interval [CI], 2.84-12.02; P<.0001), moderate postural control (OR 2.41; 95% CI, 1.21-4.80; P=.012), and using a walking aid in the acute phase (OR 2.51; 95% CI, 1.45-4.36; P=.0010) are statistically significant determinants that are associated with recurrent falls within the first year poststroke. The determinant of using a walking aid appears to be primarily driven by those younger than 80 years. In addition to impaired postural control and using a walking aid, a fall at the stroke unit is a determinant associated with recurrent falls after discharge within 6 months poststroke.

CONCLUSIONS

More than 1 in 4 individuals with stroke experienced recurrent falls within the first year poststroke. Impaired postural control, using a walking aid in the acute phase, and fall during hospitalization are determinants associated with recurrent falls during follow-up. The determinants differ somewhat at different ages.

Do rheumatoid arthritis patients have more major complications and length of stay after lower extremities fracture surgery?: A nationwide data with propensity score matching

Patients with rheumatoid arthritis (RA) have a high risk of cardiovascular diseases and fractures. This retrospective cohort study explored whether patients with RA face higher complication risks or longer hospital stays than other patients when they had a lower limb fracture that required the surgery. Patients aged >45 years who received lower limb fracture surgeries between 2005 and 2012 were selected from the National Health Insurance Research Database, and 10 related variables including sex and age were used in propensity score matching to pair RA patients with non-RA patients in a 1:4 ratio. The final study sample comprised 1109 patients with RA and 4436 non-RA patients. The results indicated that 5.57% of the study sample had postoperative complications, accounting for 5.05% of patients with RA and 5.70% of the control group. After conditional logistic regression analysis was performed, the risk of major complications has no significant differences between patients with RA and the control group (odds ratio [OR] = 0.87; 95% confidence interval [CI]: 0.61-1.24; P > .05). However, the comorbidity severity score exerted a significant effect on complications; patients with scores ≥3 were 2.78 times more likely to experience complications (OR = 2.78; 95% CI 1.52-5.07). When considering different types of complications, patients with RA were less likely to be exposed to the risk of stroke (OR = 0.48). After controlling all related factors, no significant differences were observed in the complication risks or deaths between the 2 groups (P > .05). Regarding hospitalization length, the average stay for all patients was 8.12 days; after controlling related factors, the hospitalization length for patients with RA was 0.97 times that of the control group, which was nonsignificant (P > .05). These results may provide some information to healthcare professionals when providing treatments.

Early prediction of falls after stroke: a 12-month follow-up of 490 patients in The Fall Study of Gothenburg (FallsGOT)

OBJECTIVE:

To identify the incidence of falls and factors present shortly after stroke, which are associated with the occurrence of falls over the first 12 months after stroke onset, following discharge from inpatient rehabilitation.

DESIGN:

Prospective follow-up study.

SETTING:

Stroke unit and outpatient department.

SUBJECTS:

A total of 490 individuals with acute stroke.

METHODS:

Postural control was assessed using the Swedish modified version of the Postural Assessment Scale for Stroke Patients. Data on self-reported falls were collected using a standardized questionnaire at three months after discharge and six and 12 months after stroke onset. Associations between characteristics during the acute phase after a stroke and falls after six and 12 months were investigated using univariable and multivariable regression analyses.

MAIN MEASURES:

The endpoint was a self-reported fall.

RESULTS:

Within three months after discharge, 38 of 165 respondents (23%) had experienced at least one fall. Within six and 12 months after stroke onset, respectively, 108 of 376 (29%) and 140 of 348 (40%) of the respondents had experienced at least one fall. Poor postural control (odds ratio 3.92, 95% confidence interval 2.07-7.45, P < 0.0001) and using a walking aid (odds ratio 2.84, 95% confidence interval 1.71-4.72, P < 0.0001) were predictors of falls after discharge within 12 months after stroke onset. The same variables were independent predictors of falls within six months.

CONCLUSION:

Poor postural control and using a walking aid in the acute phase after a stroke are associated with falls after discharge from a stroke unit within 12 months after stroke onset.

Reliability of test procedures for postural reactions in people with acute stroke

Background/Aims:

Regaining and maintaining balance requires postural reactions such as righting reactions, equilibrium reactions, and protective reactions. There is a lack of uniform, standardised, and reliable testing procedures for postural reactions. The aim of the present study was to examine the intra- and interrater reliability of a newly developed postural reactions assessment for use in people with acute stroke.

Methods:

The Postural Reactions Test was developed based on the literature, on previous tests, and on input from an expert panel. A total of 10 physiotherapists assessed a total of 20 video recordings of people with acute stroke performing each postural reaction. These assessments were carried out on two occasions at least 2 weeks apart. The study thus included 400 ratings.

Findings:

For intrarater reliability, the overall proportion of agreement was 86 − 93% for the different postural reactions. For interrater reliability, the most common score for each participant and the number of physiotherapists giving that score were noted. A median of 9–10 out of 10 physiotherapists scored the same value.

Conclusions:

The results indicate that the Postural Reactions Test can be used to reliably assess function in people with acute stroke and that the test can complement the existing assessments for people with affected postural control.