Determinants of falls after stroke based on data on 5065 patients from the Swedish Väststroke and Riksstroke Registers

Risk-taking behaviour and executive functions, a major component of the risk of fall factors after recent stroke

OBJECTIVE

This study investigated the weight of different cognitive disorders on patient behaviour influencing the risk of falls after recent stroke.

DESIGN

Survey and retrospective monocentric study.

SUBJECTS/PATIENTS

74 professionals/108 patients.

METHODS

Survey of professionals to ask for their thoughts concerning the weight of different cognitive disorders on the risk of falls and a retrospective study of patients post-stroke to determine whether these cognitive deficits could distinguish fallers from non-fallers. Univariate and multivariate logistic regression analyses were conducted.

RESULTS

In part 1, major cognitive disorders identified were anosognosia, confusion, inattention, precipitation, and unilateral spatial neglect. In part 2, 25 patients (23%) were fallers. After adjustment for length of rehabilitation stay and disease severity, on multivariate analysis, the cognitive disorders significantly associated with risk of falls were anosognosia (odds ratio 16), precipitation (13.3), inattention (8.3), and perseveration (4.9). Unilateral spatial neglect was not independently associated. Aphasia did not play a role.

CONCLUSION

Some cognitive disorders, easily identified before any neuropsychological assessment, strongly modify patient behaviour in terms of risk of falls. It is proposed that these disorders should not be considered as an additional factor along with physical and general factors but rather as a multiplying factor applied to the others.

Establishment and validation of a nomogram for predicting the risk of hip fracture in patients with stroke: A multicenter retrospective study

PURPOSE

There are currently no models for predicting hip fractures after stroke. This study wanted to investigate the risk factors leading to hip fracture in stroke patients and to establish a risk prediction model to visualize this risk.

PATIENTS AND METHODS

We reviewed 439 stroke patients with or without hip fractures admitted to the Affiliated Hospital of Xuzhou Medical University from June 2014 to June 2017 as the training set, and collected 83 patients of the same type from the First Affiliated Hospital of Harbin Medical University and the Affiliated Hospital of Xuzhou Medical University from June 2020 to June 2023 as the testing set. Patients were divided into fracture group and non-fracture group based on the presence of hip fractures. Multivariate logistic regression analysis was used to screen for meaningful factors. Nomogram predicting the risk of hip fracture occurrence were created based on the multifactor analysis, and performance was evaluated using receiver operating characteristic curve (ROC), calibration curves, and decision curve analysis (DCA). A web calculator was created to facilitate a more convenient interactive experience for clinicians.

RESULTS

In training set, there were 35 cases (7.9 %) of hip fractures after stroke, while in testing set, this data was 13 cases (15.6 %). In training set, univariate analysis showed significant differences between the two groups in the number of falls, smoking, hypertension, glucocorticoids, number of strokes, Mini-Mental State Examination (MMSE), visual acuity level, National Institute of Health stroke scale (NIHSS), Berg Balance Scale (BBS), and Stop Walking When Talking (SWWT) (P<0.05). Multivariate analysis showed that number of falls [OR=17.104, 95 % CI (3.727-78.489), P = 0.000], NIHSS [OR=1.565, 95 % CI (1.193-2.052), P = 0.001], SWWT [OR=12.080, 95 % CI (2.398-60.851), P = 0.003] were independent risk factors positively associated with new fractures. BMD [OR = 0.155, 95 % CI (0.044-0.546), P = 0.012] and BBS [OR = 0.840, 95 % CI (0.739-0.954), P = 0.007] were negatively associated with new fractures. The area under the curve (AUC) of nomogram were 0.939 (95 % CI: 0.748-0.943) and 0.980 (95 % CI: 0.886-1.000) in training and testing sets, respectively, and the calibration curves showed a high agreement between predicted and actual status with an area under the decision curve of 0.034 and 0.109, respectively.

CONCLUSIONS

The number of falls, fracture history, low BBS score, high NIHSS score, and positive SWWT are risk factors for hip fracture after stroke. Based on this, a nomogram with high accuracy was developed and a web calculator (https://stroke.shinyapps.io/DynNomapp/) was created.

The Effectiveness of Goal-Oriented Dual Task Proprioceptive Training in Subacute Stroke: A Retrospective Observational Study

OBJECTIVE

To show the effectiveness of goal-oriented proprioceptive training in subacute stroke for balance, autonomy, and fall risk.

METHODS

Out a total of 35 patients, consistent in age (75.31±8.65 years), type of stroke (ischemic, 3 to 11 weeks before), and motor impairment, 18 patients underwent solely proprioceptive rehabilitation, the other 17 dual task exercises. The study assessed autonomy using Barthel Index, fall risk with Timed Up and Go Test (TUG), balance through Berg Balance Scale (BBS) and Tinetti test.

RESULTS

After two months, significant improvements were recorded in Barthel Index, BBS (p<0.0001), Tinetti test (p<0.0001 in dual task group, p=0.0029 in single task group), and TUG (p=0.0052 in dual task group, p=0.0020 in single task group) in both groups. Comparing the two groups, dual task group showed a significant difference in Tinetti balance assessment (p=0.0052), between the total score of Tinetti test and TUG in single (p=0.0271), and dual task (p=0.0235). Likewise, Tinetti gait test was significantly related to TUG in single (p=0.0536), and dual task (p=0.0466), while Tinetti balance test to Barthel Index (p=0.0394), BBS (p<0.0001), and TUG in single (p=0.0219), and dual task (p=0.0196). Lastly, there is a positive correlation of the use of aids with BBS (p=0.0074), and total score of Tinetti test (p=0.0160).

CONCLUSION

In subacute stroke, goal-oriented proprioceptive training improved balance, but only partially autonomy. Furthermore, the use of aids after dual-task exercises improved recovery of balance, but did not reduced falls.

Inpatient Rehabilitation Falls: Comparing Patients With Traumatic Brain Injury Versus Patients With Stroke

BACKGROUND

Cognitively impaired neurological rehabilitation inpatients are at an increased risk for falls; yet, little is known regarding fall risk of different groups, such as stroke versus traumatic brain injury.

OBJECTIVES

To determine if rehabilitation patients' fall characteristics differ for patients with stroke versus patients with traumatic brain injury.

METHODS

This retrospective observational cohort study evaluates inpatients with stroke or traumatic brain injury admitted to a rehabilitation center in Barcelona, Spain, between 2005 and 2021. We assessed independence in daily activities with the Functional Independence Measure. We compared fallen versus nonfallen patients' features and examined the association between time to first fall and risk using Cox proportional hazards models.

RESULTS

A total of 1,269 fall events were experienced by 898 different patients with traumatic brain injury ( n = 313; 34.9%) and stroke ( n = 585; 65.1%). A higher proportion of falls for patients with stroke occurred while performing rehabilitation activities (20.2%-9.8%), whereas falls were significantly higher for patients with traumatic brain injury during the night shift. Fall timing revealed completely different behaviors (stroke vs. traumatic brain injury), for example, an absolute peak at 6 a.m. due to young male traumatic patients. Nonfallen patients ( n = 1,363; 78.2%) were younger, with higher independence in daily activities scores, and having a larger time since injury to admission; all three were significant fall predictors.

CONCLUSIONS

Patients with traumatic brain injury and stroke showed different fall behaviors. Knowledge of fall patterns and characteristics in the inpatient rehabilitation setting can help design management protocols to mitigate their risk.

Determining an optimal posturography dataset to identify standing behaviors in the post-stroke subacute phase. Cross-sectional study

BACKGROUND

A key issue for posturography is the expression of robust results, in a simplified way. Most studies of individuals post-stroke concern the chronic phase, with small sample sizes.

OBJECTIVES

By reducing the number of posturographic indices, we aimed to determine an optimal dataset and understand typical postural behaviors in the subacute post-stroke phase.

METHODS

In this cross-sectional study ancillary to the DOBRAS cohort, individuals were assessed as soon they could complete a full posturography session (with and without vision) after a first hemispheric stroke. Body-weight distribution on the mediolateral (ML) axis, position of the center of pressure on the antero-posterior (AP) axis, and postural sway on both axes were computed. Balance ability in daily life was quantified with the Postural Assessment Scale for Stroke. Data were analyzed by principal component and hierarchical clustering analyses as well as multiple linear regression.

RESULTS

We enrolled 95 individuals (median age: 67.0 years [Q1; Q3 56.0; 72.0]; 68% males). Vision suppression had a marginal effect, only increasing postural sway. Regardless of the visual condition, posturographic behavior was captured by a set of 3 indices that explained almost all the information. One postural sway index (ML or AP) gave more information (48%) than both position indices (ML 26% and AP 15%). These 3 indices identified 3 standing behaviors: 1) stable and symmetric, 2) asymmetric, unstable, and positioned backward, and 3) very unstable and positioned forward. Balance ability in daily life was explained (49% of the information, 95%CI [35; 63]) by weight-bearing asymmetry and postural sway on the ML axis, which played an independent role (both p<10-5), with similar impact.

CONCLUSIONS

Three typical behaviors allow standing after stroke: described by only 3 posturographic indices. Weight-bearing asymmetry is not the primary parameter and should not be considered in isolation as an outcome. To increase the feasibility of posturography in the early subacute phase and to simplify evaluation sessions, trials could be limited to eyes open.

REGISTRATION

NCT03203109.

Association Between Falling and Activities of Daily Living Measured by the Longshi Scale in Patients Poststroke: A Cross-sectional Study

BACKGROUND

Activities of daily living comprise an important risk factor for falls among patients who have suffered a stroke.

PURPOSE

To investigate the incidence of falls in patients with stroke, categorized by their Longshi grades (bedridden, domestic, community), and to explore their risk factors for falls.

METHODS

A cross-sectional descriptive design was used. Patients completed a survey during face-to-face interviews.

RESULTS

Of the 869 participants, 15.7% experienced a fall. Those in the domestic Longshi group had the highest rate of falls. Approximately 30% experienced either a moderate or severe injury as a result of falling. In addition, being older than 70 years was significantly correlated with fall risk. Intermediate Longshi grades, from moderately dependent to slightly dependent, were also positively correlated with falls.

CONCLUSION

Patients with stroke in the domestic Longshi group have a higher rate of falls. The risk of falling increased significantly in those with intermediate Longshi grades.

Receiver Operating Characteristic Curve Analysis of the Somatosensory Organization Test, Berg Balance Scale, and Fall Efficacy Scale–International for Predicting Falls in Discharged Stroke Patients

Background: Although fall prevention in patients after stroke is crucial, the clinical validity of fall risk assessment tools is underresearched in this population. The study aim was to determine the cut-off scores and clinical validity of the Sensory Organization Test (SOT), the Berg Balance Scale (BBS), and the Fall Efficacy Scale–International (FES-I) in patients after stroke. Methods: In this prospective cross-sectional study, we analyzed data for patients admitted to a rehabilitation unit after stroke from 2018 through 2021. Participants underwent SOT, BBS, and FES-I pre-discharge, and the fall incidence was recorded for 6 months. We used an area under the receiver operating characteristic curve (AUC) to calculate predictive values. Results: Of 84 included patients (median age 68.5 (interquartile range 67–71) years), 32 (38.1%) suffered a fall. All three tests were significantly predictive of fall risk. Optimal cut-off scores were 60 points for SOT (AUC 0.686), 35 and 42 points for BBS (AUC 0.661 and 0.618, respectively), and 27 and 29 points for FES-I (AUC 0.685 and 0.677, respectively). Conclusions: Optimal cut-off scores for SOT, BBS, and FES-I were determined for patients at risk for falls after a stroke, which all three tools classified with a good discriminatory ability.