An integrative review of factors associated with falls during post-stroke rehabilitation

Dual-Task Assessments for Predicting Future Falls in Neurologic Conditions: A Systematic Review

ABSTRACT

This review investigated the ability of dual-task tests to predict falls in people with neurological disorders. Databases were searched to identify prospective cohort studies that analyzed dual-task testing and falls in people with neurological disorders. Reviewers screened studies for eligibility and extracted key information like participant characteristics, intervention details, outcome measures, and significant outcomes. Reviewers assessed methodological quality of eligible studies using the Standard Quality Assessment Criteria. Eighteen studies of strong methodological qualified with 1750 participants were included in the review. Dual-task performances were predictive of future falls in people with Huntington's disease, spinal cord injury, and moderate cognitive impairment, although only one independent study was included for each disability type. In people with stroke, 37% of eligible studies showed dual-task assessments to be predictive of future falls. No dual-task tests predicted prospective falling in people with Alzheimer's or Parkinson's disease. Complex dual tasks seemed to be more predictive of fall risk than simpler dual tasks. Results suggest that disability type, severity of disability, and task complexity play a role in the predictive ability of dual-task assessments and future falling in neurological disorders. Future studies may benefit from using this review to guide the design of effective dual-task assessments and fall interventions.

White matter fibre density in the brain's inhibitory control network is associated with falling in low activity older adults

Recent research has indicated that the relationship between age-related cognitive decline and falling may be mediated by the individual's capacity to quickly cancel or inhibit a motor response. This longitudinal investigation demonstrates that higher white matter fibre density in the motor inhibition network paired with low physical activity was associated with falling in elderly participants. We measured the density of white matter fibre tracts connecting key nodes in the inhibitory control network in a large sample (n = 414) of older adults. We modelled their self-reported frequency of falling over a 4-year period with white matter fibre density in pathways corresponding to the direct and hyperdirect cortical-subcortical loops implicated in the inhibitory control network. Only connectivity between right inferior frontal gyrus and right subthalamic nucleus was associated with falling as measured cross-sectionally. The connectivity was not, however, predictive of future falling when measured 2 and 4 years later. Higher white matter fibre density was associated with falling, but only in combination with low levels of physical activity. No such relationship existed for selected control brain regions that are not implicated in the inhibitory control network. Albeit statistically robust, the direction of this effect was counterintuitive (more dense connectivity associated with falling) and warrants further longitudinal investigation into whether white matter fibre density changes over time in a manner correlated with falling, and mediated by physical activity.

Predictive Validity of the Johns Hopkins Fall Risk Assessment Tool for Older Patients in Stroke Rehabilitation

The aim of this retrospective, cross-sectional, observational study was to assess the frequency of falls and evaluate the predictive validity of the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) among patients aged ≥65 years, transferred to the rehabilitation ward of a university hospital. The predictive ability was assessed using receiver operating characteristic curve analysis, and the optimal threshold was established using the Youden index. We analyzed the overall cohort (N = 175) with subacute stroke and the subgroup with a low unaffected handgrip strength (HGS; men: <28 kg, women: <18 kg). Overall, 135/175 patients (77.1%) had a low HGS. The fall rate was 6.9% overall and 5.9% for patients with a low HGS. The JHFRAT predictive value was higher for patients with a low HGS than that for the overall cohort, but acceptable in both. The optimal cutoff score for the overall cohort was 11 (sensitivity, 67%; specificity, 68%), whereas that for the subgroup was 12 (sensitivity, 75%; specificity: 72%). These results are expected to aid nurses working in rehabilitation wards in more effectively utilizing JHFRAT outcomes for post-stroke older patients with a low HGS and contribute to the development of more appropriate fall prevention strategies for high-risk patients in the future.

Effect of Qigong exercise on motor function in stroke patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Motor impairment is one of the most common defects after stroke, which could seriously affect the life quality of stroke patients. Exercise intervention gradually becomes a popular alternative rehabilitation therapy because of its safety and applicability.

OBJECTIVES

To systematically assess the effect of Qigong exercise on motor function in stroke patients.

METHODS

Randomized controlled trials that evaluated the effect of Qigong on motor function of stroke patients were obtained from PubMed and Chinese National Knowledge Infrastructure through May 2022. Mean values and standard deviations of the post-intervention score in both experimental group and control group were collected to calculate the mean difference (MD) and corresponkding 95% confidence interval (95% CI) of each study, which were quantificationally summarized using the Review Manager 5.3 software.

RESULTS

Nineteen randomized controlled trials enrolling 1487 stroke patients were included. Pooled results indicated that Qigong exercise had beneficial effect on balance function (Berg Balance Scale [MD: 7.56, 95% CI: 4.09-11.02]), limb motor function (Fugl-Meyer Assessment [total score: MD: 7.54, 95% CI: 6.38-8.69; upper limb: MD: 3.57, 95% CI: 0.71-6.43; lower limb: MD: 2.44, 95% CI: 0.59-4.29]) and walking function (6-min walking test [MD: 62.21, 95% CI: 11.70-112.73]) of stroke patients. It was also found to be associated with an improvement in trunk function as indicated by the Trunk Impairment Scale.

CONCLUSIONS

Available evidence supported potential benefits of Qigong exercise for improving motor functions of stroke patients. As a safe and widely applicable exercise, Qigong is worthy of further promotion in the rehabilitation of stroke patients.

Fall Risk Assessment in Stroke Survivors: A Machine Learning Model Using Detailed Motion Data from Common Clinical Tests and Motor-Cognitive Dual-Tasking

BACKGROUND

Falls are common and dangerous for stroke survivors. Current fall risk assessment methods rely on subjective scales. Objective sensor-based methods could improve prediction accuracy.

OBJECTIVE

Develop machine learning models using inertial sensors to objectively classify fall risk in stroke survivors. Determine optimal sensor configurations and clinical test protocols.

METHODS

21 stroke survivors performed balance, Timed Up and Go, 10 Meter Walk, and Sit-to-Stand tests with and without dual-tasking. A total of 8 motion sensors captured lower limb and trunk kinematics, and 92 spatiotemporal gait and clinical features were extracted. Supervised models-Support Vector Machine, Logistic Regression, and Random Forest-were implemented to classify high vs. low fall risk. Sensor setups and test combinations were evaluated.

RESULTS

The Random Forest model achieved 91% accuracy using dual-task balance sway and Timed Up and Go walk time features. Single thorax sensor models performed similarly to multi-sensor models. Balance and Timed Up and Go best-predicted fall risk.

CONCLUSION

Machine learning models using minimal inertial sensors during clinical assessments can accurately quantify fall risk in stroke survivors. Single thorax sensor setups are effective. Findings demonstrate a feasible objective fall screening approach to assist rehabilitation.

Association between fear of falling and falls following acute and chronic stroke: a systematic review with meta-analysis

OBJECTIVES

To examine the association between falls and fear of falling in people with stroke and to evaluate the differences between patients with acute stroke and those with chronic stroke with regard to any such association.

METHODS

Articles were searched in Medline, CINAHL, AMED, Embase, PsycINFO, Cochrane Library of Reviews and PEDro from inception until March 2023. Experimental, observational or explorative studies investigating the association between fear of falling and falls in people with stroke were included. Articles were screened by 2 independent reviewers. Data were extracted by an independent reviewer.

RESULTS

A total of 26 reports were included in this review (n = 2863). Fear of falling, assessed by a single-question survey, was significantly associated with falls (relative risk = 1.44; 95% confidence interval (95% CI) = 1.22, 1.70; I2 = 0%) in people with acute stroke. Significant mean differences in fear of falling, based on the Falls Efficacy Scale (mean difference = 12.80; 95% CI = 1.81, 23.78; I² = 28%) and Activities-specific Balance Confidence Scale (mean difference = -9.99; 95% CI = -15.36, -4.62; I² = 57%), were also reported between fallers and non-fallers in people with chronic stroke.

CONCLUSION

A small, but significant, association exists between falls and fear of falling in both acute and chronic stroke patients.

Identifying best fall-related balance factors and robotic-assisted gait training attributes in 105 post-stroke patients using clinical machine learning models

BACKGROUND

Despite the promising effects of robot-assisted gait training (RAGT) on balance and gait in post-stroke rehabilitation, the optimal predictors of fall-related balance and effective RAGT attributes remain unclear in post-stroke patients at a high risk of fall.

OBJECTIVE

We aimed to determine the most accurate clinical machine learning (ML) algorithm for predicting fall-related balance factors and identifying RAGT attributes.

METHODS

We applied five ML algorithms- logistic regression, random forest, decision tree, support vector machine (SVM), and extreme gradient boosting (XGboost)- to a dataset of 105 post-stroke patients undergoing RAGT. The variables included the Berg Balance Scale score, walking speed, steps, hip and knee active torques, functional ambulation categories, Fugl- Meyer assessment (FMA), the Korean version of the Modified Barthel Index, and fall history.

RESULTS

The random forest algorithm excelled (receiver operating characteristic area under the curve; AUC = 0.91) in predicting balance improvement, outperforming the SVM (AUC = 0.76) and XGboost (AUC = 0.71). Key determinants identified were knee active torque, age, step count, number of RAGT sessions, FMA, and hip torque.

CONCLUSION

The random forest algorithm was the best prediction model for identifying fall-related balance and RAGT determinants, highlighting the importance of key factors for successful RAGT outcome performance in fall-related balance improvement.

Blind Spots in Hospital Fall Prevention: Falls in Stroke Patients Occurred Not Only in Those at a High Risk of Falling

OBJECTIVES

Although the standard falls prevention strategy is to identify and respond to patients with high-risk conditions, it remains unclear whether falls in patients with high fall risk account for most observed falls. In this study, fall risk and number of falls were calculated based on patients' motor and cognitive abilities, and the relationship between the two was examined.

DESIGN

We conducted a retrospective cohort study.

SETTING AND PARTICIPANTS

We included 2518 consecutive patients with stroke who were admitted to a rehabilitation hospital.

METHODS

Data on falls during hospitalization and biweekly assessed Functional Independence Measure scores were retrieved from the medical records. The average Functional Independence Measure scores for the motor and cognitive items were obtained and categorized as complete dependence, modified dependence, and independence. The fall rate (falls/1000 person-days) and number of observed falls in each combined condition were investigated.

RESULTS

Modified dependence on motor ability and complete dependence on cognitive ability had the highest risk of falls, with a fall rate of 10.8/1000 person-days and 51 fall observations, which accounted for 4.3% of all falls. Independent motor and cognitive ability had the lowest risk of falls, a fall rate of 2.6/1000 person-days and 146 observed falls, accounting for 12.4% of all falls, which was 2.8 times higher than the number of falls observed in the highest risk of falls condition.

CONCLUSIONS AND IMPLICATIONS

The combined motor-cognitive ability with the highest risk of falls in stroke inpatients did not have the highest number of observed falls. Rather, the combined motor-cognitive ability with the lowest risk of falls tended to have a high number of observed falls. A different strategy is needed to reduce the total number of falls.

Comparative Analysis of Fall Risk Assessment Features in Community-Elderly and Stroke Survivors: Insights from Sensor-Based Data

Fall-risk assessment studies generally focus on identifying characteristics that affect postural balance in a specific group of subjects. However, falls affect a multitude of individuals. Among the groups with the most recurrent fallers are the community-dwelling elderly and stroke survivors. Thus, this study focuses on identifying a set of features that can explain fall risk for these two groups of subjects. Sixty-five community dwelling elderly (forty-nine female, sixteen male) and thirty-five stroke-survivors (twenty-two male, thirteen male) participated in our study. With the use of an inertial sensor, some features are extracted from the acceleration data of a Timed Up and Go (TUG) test performed by both groups of individuals. A short-form berg balance scale (SFBBS) score and the TUG test score were used for labeling the data. With the use of a 100-fold cross-validation approach, Relief-F and Extra Trees Classifier algorithms were used to extract sets of the top 5, 10, 15, 20, 25, and 30 features. Random Forest classifiers were trained for each set of features. The best models were selected, and the repeated features for each group of subjects were analyzed and discussed. The results show that only the stand duration was an important feature for the prediction of fall risk across all clinical tests and both groups of individuals.

Predicting Falls in Rehabilitation: A Comparison of Three Instruments Including Hester Davis

PURPOSE

The aim of this study was to evaluate the ability of the Hester Davis Scale (HDS), Section GG, and facility fall risk assessment scores to predict patients who fall during inpatient rehabilitation.

DESIGN

This study is an observational quality improvement project.

METHODS

Nurses administered the HDS in parallel to the facility's current fall risk assessment and Section GG of the Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility Patient Assessment Instrument. Receiver operating characteristic curves were compared in 1,645 patients. Relationships of individual scale items to falls were also assessed.

RESULTS

The HDS (area under the curve [AUC] = .680, 95% CI [.626, .734]), facility fall risk assessment (AUC = .688, 95% CI [.637, .740]), and Section GG scores (AUC = .687, 95% CI [.638, .735]) adequately identified patients who fell. AUCs did not significantly differ between assessments. HDS scores of ≥13, facility scores of ≥14, and Section GG scores of ≤51 resulted in the highest sensitivity/specificity balance.

CONCLUSIONS

HDS, facility fall risk assessment, and Section GG scores adequately and similarly identified patients of mixed diagnoses at risk of falling in inpatient rehabilitation.

CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING

Rehabilitation nurses have several options including the HDS and Section GG to identify patients at greatest risk of falling.

Falls in Patients With Communication Disability Secondary to Stroke

Patients with stroke are at high risk of falls during inpatient rehabilitation admission. Communication disability is common following stroke; however, this population is often excluded from falls research. This study aimed to examine the falls of patients with communication disability following stroke, including the circumstances, contributing factors, and outcomes of the fall. This medical record review used the Generic Reference Model of patient safety as the analytical lens and data were analyzed descriptively. The study included 109 patients who experienced 308 falls. The most common type of fall was an "unwitnessed roll from bed." Patient factors contributed to half of all falls, injuries occurred in 15% of falls, and impacts to the hospital system included additional costs and staffing. Understanding the reasons why patients are attempting to get out of bed may identify ways to reduce the risk and incidence of falls in this population.

Anosognosia for Hemiplegia and Falls After Stroke: A Prospective Correlational Study

PURPOSE

The aim of this study was to explore the association between the presence and severity of anosognosia for hemiplegia (AHP) and falls in stroke survivors.

DESIGN

A prospective, correlational research design was utilized.

METHODS

Primary instrumentation included demographic information and the Visual-Analogue Test for Anosognosia for motor impairment (VATA-m). Correlational and regression analyses were performed between a priori variables.

RESULTS

There was no statistically significant relationship found between AHP and falls. An incidental finding included that clinicians erroneously charted that their patients were aware of their physical limitations 100% of the time, which indicates that there is discord between clinicians and patients regarding physical limitations.

CONCLUSIONS

Though no statistically significant relationship was found between AHP and falls, the incidental finding of dissonance between the patient and the clinician has important clinical implications.

RELEVANCE

The relationship between AHP and stroke rehabilitation outcomes is still not understood, and incorporating part of the VATA-m into patient assessment could improve clinician understanding of patient awareness.

Transcranial direct current stimulation in neglect rehabilitation after stroke: a systematic review

Hemispatial neglect is one of the most frequent attention disorders after stroke. The presence of neglect is associated with longer hospital stays, extended rehabilitation periods, and poorer functional recovery. Transcranial direct current stimulation (tDCS) is a new technique with promising results in neglect rehabilitation; therefore, the objective of this systematic review, performed following the PRISMA guidelines, is to evaluate the effectiveness of tDCS on neglect recovery after stroke. The search was done in MEDLINE (PubMed), Web of Science, Scopus, Cochrane Library, and BioMed Central databases. A total of 311 articles were found; only 11 met the inclusion criteria, including 152 post-stroke patients in total. Methodological quality and risk of bias were assessed for all the studies, and methodological characteristics of the studies, sample sizes, methods, main results, and other relevant data were extracted. tDCS intervention ranged from one to twenty sessions distributed in 1 day to 4 weeks, with intensity ranged from 1 to 2 mA. We found moderate evidence for the efficacy of tDCS in the rehabilitation of hemispatial neglect after a stroke, being more effective in combination with other interventions. Nonetheless, the limited number of studies and some studies' design characteristics makes it risky to draw categorical conclusions. Since scientific evidence is still scarce, further research is needed to determine the advantage of this treatment in acute, sub-acute and chronic stroke patients. Future studies should include larger samples, longer follow-ups, and broader neurophysiological assessments, with the final aim of establishing the appropriate use of tDCS as an adjuvant intervention in neurorehabilitation settings.

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.

Optimizing falls risk prediction for inpatient stroke rehabilitation: A secondary data analysis

BACKGROUND

Identifying individuals at risk for falls during inpatient stroke rehabilitation can ensure timely implementation of falls prevention strategies to minimize the negative personal and health system consequences of falls.

OBJECTIVES

To compare sociodemographic and clinical characteristics of fallers and non-fallers; and evaluate the ability of the Berg Balance Scale (BBS) and Morse Falls Scale (MFS) to predict falls in an inpatient stroke rehabilitation setting.

METHODS

A longitudinal study involving a secondary analysis of health record data from 818 patients with stroke admitted to an urban, rehabilitation hospital was conducted. A fall was defined as having ≥1 fall during the hospital stay. Cut-points on the BBS and MFS, alone and in combination, that optimized sensitivity and specificity for predicting falls, were identified.

RESULTS

Low admission BBS score and admission to a low-intensity rehabilitation program were associated with falling (p < .05). Optimal cut-points were 29 for the BBS (sensitivity: 82.4%; specificity: 57.4%) and 30 for the MFS (sensitivity: 73.2%; specificity: 31.4%) when used alone. Cut-points of 45 (BBS) and 30 (MFS) in combination optimized sensitivity (74.1%) and specificity (42.7%).

CONCLUSIONS

A BBS cut-point of 29 alone appears superior to using the MFS alone or combined with the BBS to predict falls.

Barriers and facilitators to the implementation of a structured visual assessment after stroke in municipal health care services

BACKGROUND

Stroke is a leading cause of disability worldwide. Visual impairments (VIs) affect 60% of stroke survivors, and have negative consequences for rehabilitation and post-stroke life. VIs after stroke are often overlooked and undertreated due to lack of structured routines for visual care after stroke. This study aims to identify and assess barriers and facilitators to the implementation of structured visual assessment after stroke in municipal health care services. The study is part of a larger knowledge translation project.

METHODS

Eleven leaders and municipal interdisciplinary health care professionals participated in qualitative interviews. During two workshops, results from the interviews were discussed with 26 participants from municipal health care services and user representatives. Data from interviews and workshops were collected before the intervention was implemented and analyzed using content analysis.

RESULTS

The analysis identified individual and contextual barriers and facilitators. The individual barriers were related to the participants' experiences of having low competence of visual functions and vision assessment skills. They considered themselves as generalists, not stroke experts, and some were reluctant of change because of previous experiences of unsuccessful implementation projects. Individual facilitators were strong beliefs that including vision in stroke care would improve health care services. If experienced as useful and evidence based, the new vision routine would implement easier. Contextual barriers were experiences of unclear responsibility for vision care, lack of structured interdisciplinary collaboration and lack of formal stroke routines. Time constraints and practical difficulties with including the vision tool in current medical records were also expressed barriers. Contextual facilitators were leader support and acknowledgement, in addition to having a flexible work schedule.

CONCLUSIONS

This study shows that improving competence about VIs after stroke and skills in assessing visual functions are particularly important to consider when planning implementation of new vision routines in municipal health care services. Increased knowledge about the consequences of living with VIs after stroke, and the motivation to provide best possible care, were individual facilitators for changing clinical practice. Involving knowledge users, solutions for integrating new knowledge in existing routines, along with easily accessible supervision in own practise, are essential facilitators for promoting a successful implementation.

Does Exercise-Based Conventional Training Improve Reactive Balance Control among People with Chronic Stroke?

Background: Exercise-based conventional training has predominantly benefited fall-associated volitional balance control domain; however, the effect on reactive balance control is under-examined. Therefore, the purpose of this study was to examine the effect of exercise-based conventional training on reactive balance control. Methods: Eleven people with chronic stroke (PwCS) underwent multi-component training for six weeks (20 sessions) in a tapering manner. Training focused on four constructs-stretching, functional strengthening, balance, and endurance. Volitional balance was measured via movement velocity on the Limits of Stability (LOS) test and reactive balance via center of mass (COM) state stability on the Stance Perturbation Test (SPT). Additionally, behavioral outcomes (fall incidence and/or number of steps taken) were recorded. Results: Movement velocity significantly increased on the LOS test (p < 0.05) post-intervention with a significant decrease in fall incidence (p < 0.05). However, no significant changes were observed in the COM state stability, fall incidence and number of recovery steps on the SPT post-intervention. Conclusion: Although volitional and reactive balance control may share some neurophysiological and biomechanical components, training based on volitional movements might not significantly improve reactive balance control for recovery from large-magnitude perturbations due to its task-specificity.

Falls in hospital patients with acquired communication disability secondary to stroke: A systematic review and meta-analysis

BACKGROUND

Falls are a common safety incident in people with stroke. Studies report that between 14% and 65% of people with stroke fall at least once during their hospital admission. Risk factors for falls in people with stroke have been reported to include neglect, balance and dependence for activities of daily living. Communication disability has been identified as a risk factor for patient safety incidents in hospital that has not been closely examined as a potential risk factor for falls in people with stroke.

AIM

To determine the association between communication disability secondary to stroke and falls in people with stroke in hospital.

METHODS & PROCEDURES

Systematic searches of five electronic databases were conducted in June 2019 using the key concepts of 'falls' and 'stroke' (PROSPERO CRD 42019137199). Included studies provided comparative data of falls in patients with stroke with and without communication disability. The methodological quality of the studies was examined using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Both a narrative synthesis and a meta-analysis were completed.

MAIN CONTRIBUTION

A total of 15 studies met the criteria for inclusion and 11 were included in a meta-analysis. Three studies found people with communication disability had an increased rate of falls in hospital. However, a meta-analysis showed no significant association between a non-specific classification of communication disability and an increased risk of falls. There was some indication from individual studies that higher risk of falls may be associated with severe communication disability, but there were insufficient data reported on the severity of the communication disability to draw robust conclusions.

CONCLUSION & IMPLICATIONS

The results of this systematic review suggest that a generic classification of communication disability following stroke is not a risk factor for falls. However, further research that is inclusive of this population and considers severity of communication disability more specifically is required. What this paper adds What is already known on the subject The association between communication disability following stroke and falls in hospital is unclear. The literature reports mixed results regarding the impact of a communication disability following stroke on falls risk or rates of falls during hospital admission. What this paper adds to existing knowledge This review is the first to bring together this diverse literature to examine the association between communication disability following stroke and falls in hospital. The results suggest that a generic classification of communication disability following stroke is not a risk factor for falls. What are the potential or actual clinical implications of this work? There is a possibility that moderate to severe communication disability may be related to falls in patients in hospital. Further research is indicated to be more inclusive of people with communication disability, including those with severe communication disability.

Slip-Fall Predictors in Community-Dwelling, Ambulatory Stroke Survivors: A Cross-sectional Study

BACKGROUND AND PURPOSE

Considering the multifactorial nature and the often-grave consequences of falls in people with chronic stroke (PwCS), determining measurements that best predict fall risk is essential for identifying those who are at high risk. We aimed to determine measures from the domains of the International Classification of Functioning, Disability and Health (ICF) that can predict laboratory-induced slip-related fall risk among PwCS.

METHODS

Fifty-six PwCS participated in the experiment in which they were subjected to an unannounced slip of the paretic leg while walking on an overground walkway. Prior to the slip, they were given a battery of tests to assess fall risk factors. Balance was assessed using performance-based tests and instrumented measures. Other fall risk factors assessed were severity of sensorimotor impairment, muscle strength, physical activity level, and psychosocial factors. Logistic regression analysis was performed for all variables. The accuracy of each measure was examined based on its sensitivity and specificity for fall risk prediction.

RESULTS

Of the 56 participants, 24 (43%) fell upon slipping while 32 (57%) recovered their balance. The multivariate logistic regression analysis model identified dynamic gait stability, hip extensor strength, and the Timed Up and Go (TUG) score as significant laboratory-induced slip-fall predictors with a combined sensitivity of 75%, a specificity of 79.2%, and an overall accuracy of 77.3%.

DISCUSSION AND CONCLUSIONS

The results indicate that fall risk measures within the ICF domains-body, structure, and function (dynamic gait stability and hip extensor strength) and activity limitation (TUG)-could provide a sensitive laboratory-induced slip-fall prediction model in PwCS.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A323).

Predicting Falls Using the Stroke Assessment of Fall Risk Tool

BACKGROUND

Falls in the inpatient stroke population are common, resulting in increased morbidity and slow rehabilitation progress. Falls may result from stroke-specific neurologic deficits; however, assessment of these deficits is lacking in many fall screening tools.

OBJECTIVE

To compare the ability to predict falls of the Stroke Assessment of Fall Risk (SAFR) tool, which includes items related to stroke-specific neurologic deficits, and the commonly used Morse Fall Scale, which does not include these items.

DESIGN

Prospective cohort study.

SETTING

Inpatient tertiary stroke rehabilitation unit.

PARTICIPANTS

Patients (N = 220) with acute stroke.

MAIN OUTCOME MEASURES

Falls were captured by the medical records from January 2017 to September 2018. Logistic regression analysis evaluated both screening tools for predicting falls by calculating sensitivity, specificity, area under the receiver operating characteristic (AUC-ROC) curve, and odds ratio (OR). We compared SAFR and Morse mean scores between fallers and non-fallers using t-tests.

RESULTS

Forty-eight (21.8%) patients experienced ≥1 fall. SAFR, but not Morse, scores showed a statistically significant difference between fallers and non-fallers (P = .001 vs P = .24, respectively). Higher SAFR score was associated with higher odds of falls (OR 1.36, 95% CI [1.12, 1.64]), whereas Morse was not (OR 1.04, 95% CI [0.97, 1.12]). SAFR showed a statistically significant difference in hemi-neglect between fallers and non-fallers (P = .03). Sensitivity and specificity of SAFR were 47.9% and 76.7%, vs 45.8% and 68.0% for Morse, respectively. SAFR positive predictive value and negative predictive value were 36.5% and 84.1%, respectively, similar to Morse (28.6% and 81.8%). The AUC-ROC was 0.65 for SAFR and 0.56 for Morse.

CONCLUSIONS

SAFR was significantly associated with fall risk and had better discrimination between fallers and non-fallers than Morse. The neurologic-specific hemi-neglect component of SAFR, a component not present on the Morse, was a fall risk factor. Further research evaluating the predictive value of fall scales that include neurologic deficits is needed.

Cognition assessments to predict inpatient falls in a subacute stroke rehabilitation setting

Background: Stroke-related falls occur at especially high rates in rehabilitation settings. Inpatient-hospital falls have been identified as one of the most common medical complications after stroke, negatively influencing recovery, nevertheless, the role of cognition in relation to falls during inpatient rehabilitation is largely unexplored. Objective. We aim to predict inpatient falls in a subacute stroke rehabilitation setting using previously reported variables such as stroke severity, gender, age, ataxia, hemiparesis, and functionality in activities of daily living, further extending them with specific cognition variables assessing memory, verbal fluency, attention, and orientation. Methods: This observational study included 158 stroke patients admitted to a rehabilitation center between 2007 and 2019, with less than 30 days since stroke onset to admission. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS). Four logistic regressions were performed including NIHSS, age, sex, ataxia, and hemiparesis plus one of the following: (1) Functional Independence Measure cognitive (C-FIM) and motor (M-FIM) subtests. (2) individual C-FIM items, (3) Ray Auditory Verbal Memory Test (RAVLT) and (4) verbal fluency test (PMR), Digit Span from Wechsler Adult Intelligence Scale (WAIS III), and Orientation from Test Barcelona. Results: Neither NIHSS, age, sex, ataxia nor hemiparesis predicted falls. C-FIM was a significant predictor (AUC:0.891), but not M-FIM. The problem solving C-FIM item (AUC:0.836), the RAVLT learning subtest (AUC:0.879), and PMR verbal fluency (AUC:0.871) were significant predictors for each model, respectively. Conclusions: Cognition assessments, i.e., one FIM item, one RAVLT item, or a one-minute verbal fluency test are significant falls predictors.

"Invisible" visual impairments. A qualitative study of stroke survivors` experience of vision symptoms, health services and impact of visual impairments

BACKGROUND

Visual impairments (VIs) have a negative impact on life and affect up to 60% of stroke survivors. Despite this, VIs are often overlooked. This paper explores how persons with VIs experience vision care within stroke health services and how VIs impact everyday life the first 3 months post stroke.

METHODS

Individual semi-structured interviews were conducted with 10 stroke survivors 3 months post stroke, and analyzed using qualitative content analysis.

RESULTS

The main theme, "Invisible" visual impairments, represents how participants experience VIs as an unknown and difficult symptom of stroke and that the lack of attention and appropriate visual care leads to uncertainty about the future. VIs were highlighted as a main factor hindering the participants living life as before. The lack of acknowledgement, information, and systematic vision rehabilitation leads to feelings of being unsupported in the process of coping with VIs.

CONCLUSION

VIs are unknown symptoms pre stroke and sequelas after stroke that significantly affect everyday life. VIs and vision rehabilitation needs more attention through all phases of stroke health services. We request a greater awareness of VIs as a presenting symptom of stroke, and that visual symptoms should be included in stroke awareness campaigns. Further, we suggest increased competence and standardized evidence-based clinical pathways for VIs to advance all stroke health services including rehabilitation in order to improve outcomes and adaptation to future life for stroke survivors with VIs.

Clinical features of fallers among inpatient subacute stroke: an observational cohort study

BACKGROUND AND PURPOSE

The aim of this study is to observe the differences between fallers, common fallers, and non-fallers in stroke patients compared with the global ability in a rehabilitation setting.

MATERIALS AND METHODS

An observational and prospective study has been carried out. A total of 476 subacute stroke patients have been observed. The main outcome measures were assessed using the Canadian Neurological Scale (CNS), Barthel Index (BI), Functional Ambulatory Category (FAC), and Trunk Control Test (TCT) at admission to the rehabilitation unit and after 90 days of the rehabilitation treatment (nearly 3 h for day for 5 days for week) at the discharge with intermediate evaluations after the first and second months.

RESULTS

Out of 397 patients, 109 reported 1 or more falls (27.5%), of whom 67 fell 1 time (fallers) in the hospital (16.9%) and 42 fell 2 or more times (common fallers) (10.6%). For fallers, BI and FAC scores had a significant effect (p = 0.003 for both). Common fallers had statistically significant differences in BI (p = 0.002), FAC (p = 0.012), and TCT scores (0.023) compared with non-fallers.

CONCLUSIONS

The severity of stroke may directly increase the risk of fall, and also indirectly, lengthening the hospitalization. Our study seems to suggest that patients with BI scores of between 21 and 30 on admission are more prone to fall in the first period of hospitalization, whereas in the second month, those with scores of between 11 and 20 on admission have a higher risk of falls. In the third month, patients with BI scores below 10 on admission are more susceptible to falls.

The long-term effects of an implantable drop foot stimulator on gait in hemiparetic patients

Drop foot is a frequent abnormality in gait after central nervous system lesions. Different treatment strategies are available to functionally restore dorsal extension during swing phase in gait. Orthoses as well as surface and implantable devices for electrical stimulation of the peroneal nerve may be used in patients who do not regain good dorsal extension. While several studies investigated the effects of implanted systems on walking speed and gait endurance, only a few studies have focussed on the system’s impact on kinematics and long-term outcomes. Therefore, our aim was to further investigate the effects of the implanted system ActiGait on gait kinematics and spatiotemporal parameters for the first time with a 1-year follow-up period. 10 patients were implanted with an ActiGait stimulator, with 8 patients completing baseline and follow-up assessments. Assessments included a 10-m walking test, video-based gait analysis and a Visual Analogue Scale (VAS) for health status. At baseline, gait analysis was performed without any assistive device as well as with surface electrical stimulation. At follow-up patients walked with the ActiGait system switched off and on. The maximum dorsal extension of the ankle at initial contact increased significantly between baseline without stimulation and follow-up with ActiGait (p = 0.018). While the spatio-temporal parameters did not seem to change much with the use of ActiGait in convenient walking speed, patients did walk faster when using surface stimulation or ActiGait compared to no stimulation at the 10-m walking test at their fastest possible walking speed. Patients rated their health better at the 1-year follow-up. In summary, a global improvement in gait kinematics compared to no stimulation was observed and the long-term safety of the device could be confirmed.

A systematic review of falls in hospital for patients with communication disability: Highlighting an invisible population

BACKGROUND

Patients with communication disability, associated with impairments of speech, language, or voice, have a three-fold increased risk of adverse events in hospital. However, little research yet examines the causal relationship between communication disability and risk for specific adverse events in hospital.

OBJECTIVE

To examine the impact of a patient's communication disability on their falls risk in hospital.

METHODS

This systematic review examined 61 studies on falls of adult hospital patients with communication disability, and patients at high risk of communication disability, to determine whether or not communication disability increased risk for falls, and the nature of and reasons for any increased risk.

RESULTS

In total, 46 of the included studies (75%) reported on participants with communication disability, and the remainder included patients with health conditions placing them at high risk for communication disability. Two thirds of the studies examining falls risk identified communication disability as contributing to falls. Commonly, patients with communication disability were actively excluded from participation; measures of communication or cognition were not reported; and reasons for any increased risk of falls were not discussed.

CONCLUSIONS

There is some evidence that communication disability is associated with increased risk of falls. However, the role of communication disability in falls is under-researched, and reasons for the increased risk remain unclear. Practical applications: Including patients with communication disability in falls research is necessary to determine reasons for their increased risk of adverse events in hospital. Their inclusion might be helped by the involvement of speech-language pathologists in falls research teams.

Drug Treatment, Postural Control, and Falls: An Observational Cohort Study of 504 Patients With Acute Stroke, the Fall Study of Gothenburg

OBJECTIVE

To identify whether, and to what extent, treatment with cardiovascular drugs and neurotropic drugs are associated with postural control and falls in patients with acute stroke.

DESIGN

Observational cohort study.

SETTING

A stroke unit at a university hospital.

PARTICIPANTS

A consecutive sample of patients (N=504) with acute stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Postural control was assessed using the modified version of the Postural Assessment Scale for Stroke Patients. Data including baseline characteristics, all drug treatments, and falls were derived from medical records. Univariable and multivariable logistic regression and Cox proportional hazards models were used to analyze the association of drug treatment and baseline characteristics with postural control and with falls.

RESULTS

In the multivariable logistic regression analysis, factors significantly associated with impaired postural control were treatment with neurotropic drugs (eg, opioids, sedatives, hypnotics, antidepressants) with an odds ratio (OR) of 1.73 (95% confidence interval [CI], 1.01-2.97, P=.046); treatment with opioids (OR 9.23, 95% CI, 1.58-54.00, P=0.014); age (OR 1.09, 95% CI, 1.07-1.12, P<.0001), stroke severity, which had a high National Institutes of Health Stroke Scale-score (OR 1.29, 95% CI, 1.15-1.45, P<.0001), and sedentary life style (OR 4.32, 95% CI, 1.32-14.17, P=.016). No association was found between neurotropic drugs or cardiovascular drugs and falls.

CONCLUSIONS

Treatment with neurotropic drugs, particularly opioids, in the acute phase after stroke, is associated with impaired postural control. Since impaired postural control is the major cause of falls in patients with acute stroke, these results suggest opioids should be used with caution in these patients.

Stroke Survivor and Caregiver Perspectives on Post-Stroke Visual Concerns and Long-Term Consequences

Approximately 800,000 people in the United States have a stroke annually. Up to two thirds of stroke survivors have some visual problems, which result in disability and can affect survivors' overall rehabilitation outcomes. Although some post-stroke visual impairments can be corrected and respond well to intervention, ocular signs can be subtle and may not be recognized or reported by the stroke survivor but rather by a vigilant caregiver. The purpose of this study was to explore the post-stroke visual concerns and consequences expressed by stroke survivors and caregivers. This study employed a qualitative design using semistructured interviews conducted with a convenience sample of stroke survivors and caregivers recruited from either a community support group or skilled nursing and long-term care facilities. Interviews were recorded and transcribed verbatim. Comparative content analysis was used to identify vision-related themes by two independent coders. All research team members completed quality checking of coding. Twenty participants (11 stroke survivors and 9 caregivers) expressed visual concerns or consequences following stroke: (1) eye movement problems, (2) perceptual issues, and (3) consequences of vision problems or issues, which affected their daily life/quality of life. Stroke survivors and caregivers reported receiving vision care from (1) eye doctors, (2) occupational therapists, and (3) other healthcare professionals. All vision care providers need to be observant of potential post-stroke visual concerns. Stroke survivors should have a thorough vision evaluation to optimize their independence in everyday activities and quality of life.

Stroke

Stroke, or cerebrovascular accident, involves injury to the central nervous system as a result of a vascular cause, and is a leading cause of disability worldwide. People with stroke often experience sensory, cognitive, and motor sequelae that can lead to difficulty walking, controlling balance in standing and voluntary tasks, and reacting to prevent a fall following an unexpected postural perturbation. This chapter discusses the interrelationships between stroke-related impairments, problems with control of balance and gait, fall risk, fear of falling, and participation in daily physical activity. Rehabilitation can improve balance and walking function, and consequently independence and quality of life, for those with stroke. This chapter also describes effective interventions for improving balance and walking function poststroke, and identifies some areas for further research in poststroke rehabilitation.

Implementation and feasibility of the stroke nursing guideline in the care of patients with stroke: a mixed methods study

Background

Nurses often have difficulties with using interdisciplinary stroke guidelines for patients with stroke as they do not focus sufficiently on nursing. Therefore, the Stroke Nursing Guideline (SNG) was developed and implemented. The aim of this study was to determine the implementation and feasibility of the SNG in terms of changes in documentation and use of the guideline in the care of stroke patients on Neurological and Rehabilitation wards, barriers and facilitators, and nurses’ and auxiliary nurses’ view of the implementation.

Methods

A sequential explorative mixed method design was used including pre-test post-test measures and post intervention focus groups interviews. For the quantitative part retrospective electronic record data of nursing care was collected from 78 patients and prospective measures with Barriers and Facilitators Assessment Instrument (BFAI) and Quality Indicator Tool (QIT) from 33 nursing staff including nurses and auxiliary nurses. In the qualitative part focus groups interviews were conducted with nursing staff on usefulness of the SNG and experiences with implementation.

Results

Improved nursing documentation was found for 23 items (N = 37), which was significant for nine items focusing mobility (p = 0.002, p = 0.024, p = 0.012), pain (p = 0.012), patient teaching (p = 0.001, p = 0.000) and discharge planning (p = 0.000, p = 0.002, p = 0.004). Improved guideline use was found for 20 QIT-items (N = 30), with significant improvement on six items focusing on mobility (p = 0.023), depression (p = 0.033, p = 0.025, p = 0.046, p = 0.046), discharge planning (p = 0.012). Facilitating characteristics for change were significantly less for two of four BFAI-subscales, namely Innovation (p = 0.019) and Context (p = 0.001), whereas no change was found for Professional and Patient subscales. The findings of the focus group interviews showed the SNG to be useful, improving and providing consistency in care. The implementation process was found to be successful as essential components of nursing rehabilitation were defined and integrated into daily care.

Conclusion

Nursing staff found the SNG feasible and implementation successful. The SNG improved nursing care, with increased consistency and more rigorous functional exercises than before. The SNG provides nurses and auxiliary nurses with an important means for evidence based care for patients with stroke. Several challenges of implementing this complex nursing intervention surfaced which mandates ongoing attention.

Electronic supplementary material

The online version of this article (10.1186/s12912-017-0262-y) contains supplementary material, which is available to authorized users.

Management of Acute Stroke in the Older Person

The majority of people who suffer a stroke are older adults. The last two decades have brought major progress in the diagnosis and management of stroke, which has led to significant reductions in mortality, long-term disability, and the need for institutional care. However, acute, interventional and preventative treatments have mostly been trialled in younger age groups. In this article we will provide an overview of the evidence for acute stroke treatments in relation to age, discuss special considerations in the older person, and contemplate patient choice, quality of life, and end-of-life-decisions.

Multi-sensor assessment of dynamic balance during gait in patients with subacute stroke

The capacity to maintain upright balance by minimising upper body oscillations during walking, also referred to as gait stability, has been associated with a decreased risk of fall. Although it is well known that fall is a common complication after stroke, no study considered the role of both trunk and head when assessing gait stability in this population. The primary aim of this study was to propose a multi-sensor protocol to quantify gait stability in patients with subacute stroke using gait quality indices derived from pelvis, sternum, and head accelerations. Second, the association of these indices with the level of walking ability, with traditional clinical scale scores, and with fall events occurring within the six months after patients' dismissal was investigated. The accelerations corresponding to the three abovementioned body levels were measured using inertial sensors during a 10-Meter Walk Test performed by 45 inpatients and 25 control healthy subjects. A set of indices related to gait stability were estimated and clinical performance scales were administered to each patient. The amplitude of the accelerations, the way it is attenuated/amplified from lower to upper body levels, and the gait symmetry provide valuable information about subject-specific motor strategies, discriminate between different levels of walking ability, and correlate with clinical scales. In conclusion, the proposed multi-sensor protocol could represent a useful tool to quantify gait stability, support clinicians in the identification of patients potentially exposed to a high risk of falling, and assess the effectiveness of rehabilitation protocols in the clinical routine.

Therapeutic Effect of Virtual Reality on Post-Stroke Patients: Randomized Clinical Trial

OBJECTIVES

The study aimed to check the therapeutic effect of virtual reality associated with conventional physiotherapy on gait balance and the occurrence of falls after a stroke.

METHODS

This was a randomized, blinded clinical trial conducted with post-stroke patients, randomized into two groups-treatment group and control group-and subjected to balance assessments by the Dynamic Gait Index and investigation of falls before and after 20 intervention sessions. Statistically significant difference was considered at P < .05.

RESULTS

We selected 30 patients, but there were three segment losses, resulting in a total of 13 patients in the control group and 14 in the treatment group. There was an improvement in gait balance and reduced occurrence of falls in both groups. After intervention, the differences in gait balance in the control group (P = .047) and the reduction in the occurrence of falls in the treatment group (P = .049) were significant. However, in intergroup analysis, there was no difference in the two outcomes.

CONCLUSIONS

Therapy with games was a useful tool for gait balance rehabilitation in post-stroke patients, with repercussions on the reduction of falls.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Ischemic Stroke

Each year, more than 795,000 people in the United States suffer a stroke and by 2030, it is estimated that 4% of the U.S. population will have had a stroke. Home healthcare clinicians will be increasingly called upon to assist stroke survivors and their caregivers adjust to disability and assist the survivor during their reintegration into the community. Therapeutic modalities are changing with advanced technology. Great strides are being made in the treatment of acute stroke; particularly endovascular interventions. More patients are surviving the acute stroke event and therefore will need to learn how to live with various degrees of disability. It is important for home healthcare clinicians to understand the process from acute event to medical stabilization, and from rehabilitation to long-term adaptation.

The Role of Cognitive Factors in Predicting Balance and Fall Risk in a Neuro-Rehabilitation Setting

Introduction

There is a consistent body of evidence supporting the role of cognitive functions, particularly executive function, in the elderly and in neurological conditions which become more frequent with ageing. The aim of our study was to assess the role of different domains of cognitive functions to predict balance and fall risk in a sample of adults with various neurological conditions in a rehabilitation setting.

Methods

This was a prospective, cohort study conducted in a single centre in the UK. 114 participants consecutively admitted to a Neuro-Rehabilitation Unit were prospectively assessed for fall accidents. Baseline assessment included a measure of balance (Berg Balance Scale) and a battery of standard cognitive tests measuring executive function, speed of information processing, verbal and visual memory, visual perception and intellectual function. The outcomes of interest were the risk of becoming a faller, balance and fall rate.

Results

Two tests of executive function were significantly associated with fall risk, the Stroop Colour Word Test (IRR 1.01, 95% CI 1.00–1.03) and the number of errors on part B of the Trail Making Test (IRR 1.23, 95% CI 1.03–1.49). Composite scores of executive function, speed of information processing and visual memory domains resulted in 2 to 3 times increased likelihood of having better balance (OR 2.74 95% CI 1.08 to 6.94, OR 2.72 95% CI 1.16 to 6.36 and OR 2.44 95% CI 1.11 to 5.35 respectively).

Conclusions

Our results show that specific subcomponents of executive functions are able to predict fall risk, while a more global cognitive dysfunction is associated with poorer balance.

A Human-machine-interface Integrating Low-cost Sensors with a Neuromuscular Electrical Stimulation System for Post-stroke Balance Rehabilitation

A stroke is caused when an artery carrying blood from heart to an area in the brain bursts or a clot obstructs the blood flow to brain thereby preventing delivery of oxygen and nutrients. About half of the stroke survivors are left with some degree of disability. Innovative methodologies for restorative neurorehabilitation are urgently required to reduce long-term disability. The ability of the nervous system to reorganize its structure, function and connections as a response to intrinsic or extrinsic stimuli is called neuroplasticity. Neuroplasticity is involved in post-stroke functional disturbances, but also in rehabilitation. Beneficial neuroplastic changes may be facilitated with non-invasive electrotherapy, such as neuromuscular electrical stimulation (NMES) and sensory electrical stimulation (SES). NMES involves coordinated electrical stimulation of motor nerves and muscles to activate them with continuous short pulses of electrical current while SES involves stimulation of sensory nerves with electrical current resulting in sensations that vary from barely perceivable to highly unpleasant. Here, active cortical participation in rehabilitation procedures may be facilitated by driving the non-invasive electrotherapy with biosignals (electromyogram (EMG), electroencephalogram (EEG), electrooculogram (EOG)) that represent simultaneous active perception and volitional effort. To achieve this in a resource-poor setting, e.g., in low- and middle-income countries, we present a low-cost human-machine-interface (HMI) by leveraging recent advances in off-the-shelf video game sensor technology. In this paper, we discuss the open-source software interface that integrates low-cost off-the-shelf sensors for visual-auditory biofeedback with non-invasive electrotherapy to assist postural control during balance rehabilitation. We demonstrate the proof-of-concept on healthy volunteers.

Effectiveness of a fall-risk reduction programme for inpatient rehabilitation after stroke

PURPOSE

To evaluate effectiveness of fall-risk-assessment-based fall prevention for stroke rehabilitation inpatients.

METHOD

A consecutive series of 232 patients admitted for the first time to a subacute stroke-rehabilitation ward during 2010-2011 was studied in detail. The Assessment Sheet for Fall Prediction in Stroke Inpatients (ASFPSI by Nakagawa et al.) was used to assess fall-risk upon admission. Association of ASFPSI score and patient characteristics with actual falls was statistically tested. Yearly incidence of falls per 1000 hospital days (HD) was retrospectively audited for the 2006-2014 period to evaluate effectiveness of fall-risk reduction measures.

RESULTS

The observed incidence of falls over the detailed-study-period was 3.0/1000 HD; 39% of the fallers fell during the first week after admission. ASFPSI score was not significantly associated with falls. Longer hospital stay, left body-side affected and non-extreme FIM score (55-101) were associated with higher odds of fall. Introduction of fall-risk reduction measures followed by compulsory fall-risk assessment lead to incidence of falls dropping from 7.1/1000 HD in 2006 to 2.8/1000 HD in 2011 and remaining at that level until 2014.

CONCLUSIONS

The fall-risk-assessment-based measures appear to have led to decreasing falls risk among post-stroke rehabilitation inpatients classified as being at high risk of falls. The fall prevention programme as a whole was successful. Patients with non-extreme level of functional independence should receive enhanced fall prevention. Implications for Rehabilitation Recognising the fall risk upon the patient's admission is essential for preventing falls in rehabilitation wards. Assessing the fall risk is a team tasks and combines information from various sources. Assessing fall risk in stroke patients using the assessment sheet by Nakagawa et al. immediately upon admission systematically draws attention to the risk of falls in each individual patient.

Health-related quality of life of community-dwelling stroke survivors: a comparison of fallers and non-fallers

[Purpose] The purpose of this study was to compare the health-related quality of life (HRQOL) of stroke survivors between fallers and non-fallers. [Subjects] The subjects were community-dwelling stroke patients (n = 4,560) in South Korea. All stroke patients were diagnosed by a doctor. [Methods] This study used raw data from the 2014 Korean Community Health Survey. The survey was conducted from August 16, 2014, to October 31, 2014. Trained surveyors visited households selected from the sample and conducted face-to-face interviews. The content of the survey included demographic data and HRQOL. [Results] Fallers were 1,425 (31.25%), non-fallers 3,125 (68.53%), and 10 (0.22%) answered unknown. Gender, living status, occupation, and smoking experience differed significantly between the fallers and non-fallers. The domains of HRQOL, excluding VAS, also differed significantly between the fallers and non-fallers. [Conclusion] These results provide important base data for rehabilitation services for fallers among stroke survivors.

Asymmetry in the Collision Judgments of People With Homonymous Field Defects and Left Hemispatial Neglect

PURPOSE

Although the impact of homonymous visual field defects (HFDs) on mobility has been investigated previously, the emphasis has been on obstacle detection. Relatively little is known about HFD patients' ability to judge collisions once an obstacle is detected. We investigated this using a walking simulator.

METHODS

Patients with HFDs (n = 29) and subjects with normal vision (NV; n = 21) were seated in front of a large screen on which a visual simulation of walking was displayed. They made collision judgments for a human figure that appeared for 1 second at lateral offsets from the virtual walking path. A perceived-collision threshold was calculated for right and left sides.

RESULTS

Symmetrical collision thresholds (same on left and right sides) were measured for participants with NV (n = 21), and right (n = 9) and left (n = 7) HFD without hemispatial neglect. Participants with left neglect (n = 10) showed significant asymmetry with thresholds smaller (compared to the NV group and other HFD groups) on the blind (P < 0.001) and larger on the seeing (P = 0.05) sides. Despite the asymmetry, the overall width of the zone of perceived collision risk was not different, suggesting a relatively uniform rightward deviation in judgments of the left neglect group.

CONCLUSIONS

Left neglect was associated with rightward asymmetry in collision judgments, which may cause collisions on the left side even when an obstacle is detected. These behaviors may represent the spatial misperceptions in body midline described previously in patients with left neglect.

Risk factors related to falling in stroke patients: a cross-sectional study

[Purpose] The purpose of this study was to investigate a comprehensive understanding of the factors associated with falls in poststroke patients. [Subjects] Forty-eight stroke patients (22 males and 26 females; age 63.79 years) participated in this study. [Methods] This study applied a cross-sectional design. Fear of falling [Falls Efficacy Scale (FES)], balance function [Berg Balance Scale (BBS) and Modified Rivermead Mobility Index (MRMI)], ADL performance level [Modified Barthel Index (MBI)] and cognitive function [Loewenstein Occupational Therapy Cognitive Assessment for Geriatric Populations (LOTCA-G)] were assessed. [Results] Falls efficacy was moderately correlated with ADL performance, balance, and cognition. In addition, stepwise linear regression analysis revealed that ADL performance was the explanatory variable closely associated with falls efficacy in stroke patients. [Conclusion] ADL performance was the primary explanatory variable of falls efficacy according to regression analysis. Thus, we suggest that these results may be used as basic data for developing rehabilitation programs for prevention of falls in stroke patients.

Clinical evaluation of balance in hemiparetic adults: a systematic review

Introduction Hemiparesis is a common post-stroke impairment often associated with balance deficits. Standardized instruments for balance assessment may be useful in identifying individuals at risk of falling and evaluating intervention outcomes. Objectives To identify instruments with adequate psychometric properties and clinical application to assess balance in hemiparetic cases within the scope of physiotherapy and to verify tools most frequently used in studies that evaluated the effects of therapeutic interventions in order to improve the balance of hemiparetic patients. Methods A search was conducted in the Medline, Lilacs, PEDro, and Web of Science databases by two independent researchers, who selected and analyzed studies that evaluated the reliability and validity of balance assessment instruments and intervention results. Results and discussion The Berg Balance Scale was the most frequently used instrument in the intervention studies. Nine single-task tests (timed up and go, functional reach test, step test, four-square step test, side step test, supported standing balance, standing arm raise, static tandem standing, and weight shifting) and six multiple-task tests (Berg balance scale, Brunel balance assessment, Fugl-Meyer Assessment/balance section, mini balance evaluation systems test, and postural assessment scale for stroke patients) demonstrated adequate psychometric properties and clinical applications to assess balance in hemiparetic individuals. Conclusions The Berg Balance Scale had the most widely studied psychometric properties and was the most frequently used scale in the intervention studies. Further studies are required to validate and adapt other instruments for the Brazilian population.