Risk factors for fear of falling in stroke patients: a systematic review and meta-analysis

Contributing factors and interventions for fear of falling in stroke survivors: a systematic review

OBJECTIVES

The purpose of this study was to provide a comprehensive overview of the prevalence, measurement tools, influencing factors, and interventions for fear of falling (FOF) in stroke survivors.

METHODS

A PRISMA-guided systematic literature review was conducted. PubMed, EMBASE, Cochrane, and Web of Science were systematically searched. The search time was up to February 2023. All observational and experimental studies investigating FOF in stroke patients were included. The assessment tool of the Joanna Briggs Institute was used to assess the quality of the included studies and the risk of bias assessment. (PROSPERO: CRD42023412522).

RESULT

A total of 25 observational studies and 10 experimental studies were included. The overall quality of the included studies was "low" to "good." The most common tool used to measure the FOF was the Falls Efficacy Scale-International (FES-I). The prevalence of FOF was 42%- 93.8%. Stroke survivors with physical impairments have the highest prevalence of FOF. The main risk factors for the development of FOF in stroke survivors were female gender, use of assistive devices, balance, limb dysfunction, and functional mobility. The combination of cognitive behavioral and exercise interventions is the most effective strategy.

CONCLUSIONS

This review suggests that the prevalence of FOF in stroke survivors is high and that understanding the factors associated with FOF in stroke patients can help develop multifactorial prevention strategies to reduce FOF and improve quality of life. In addition, a uniform FOF measurement tool should be used to better assess the effectiveness of interventions for stroke survivors.

ETHICS APPROVAL

PROSPERO registration (CRD42023412522).

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.

Association between personality traits and concerns about falling among older patients: the mediating role of subjective age

Background

Older patients are at high risk of falling, and regular assessments of their concerns about falling (CaF) are often recommended. The present study aimed to investigate the association between CaF and personality traits among older patients as well as to elucidate the mediating role of subjective age.

Method

A cross-sectional study was conducted among 407 patients aged over 60 years in a tertiary hospital located in Chengdu, Sichuan Province, from March 2023 to May 2023. Predesigned electronic questionnaires were distributed to collect relevant data. Four different models (both crude and adjusted weighted linear regression models) were constructed based on the confounders. Confounders were gradually put into the models to control for bias and to examine the stability of the correlations. Bootstrap sampling was employed to examine the mediating role of subjective age.

Result

According to the fully adjusted model, neuroticism (β = 0.17, 95% CI: 0.02 to 0.31, p for trend = 0.02), extraversion (β = -0.07, 95% CI: -0.15 to 0.001, p for trend = 0.05), and subjective age (β = 2.02, 95% CI: 1.28 to 2.78, p for trend <0.001) were consistently correlated with CaF. Mediating analysis revealed that extraversion was negatively related with CaF both directly and indirectly, via subjective age [23.2% partial effect, bootstrap 95%CI: -0.024(-0.080, -0.000)]. Higher neuroticism was consistently related to older subjective age (β = 0.002, 95% CI: 0.001 to 0.004, p for trend = 0.006), while higher levels of conscientiousness, openness, and extraversion were consistently correlated with younger subjective age(β = -0.002, p for trend = 0.04; β = -0.003, p for trend = 0.003; β = -0.002, p for trend = 0.0, respectively).

Conclusion

Extraversion and neuroticism were significantly correlated with CaF. Moreover, subjective age partially mediated the relationship between extraversion and CaF. Furthermore, subjective age was found to be associated with both CaF and personality traits. These findings highlighted the important roles of personality traits and subjective age in assessments of CaF and in the development of strategies for preventing falls among older patients.

The global prevalence of and risk factors for fear of falling among older adults: a systematic review and meta-analysis

BACKGROUND

As a common psychological problem among older adults, fear of falling was found to have a wide range prevalence in different studies. However, the global prevalence of it was unknown and a lack of the large sample confirmed its risk factors.

OBJECTIVES

To report the global prevalence of fear of falling and to explore its risk factors among older adults for further developing precise interventions to systematically manage FOF.

DESIGN

A systematic review and meta-analysis was conducted by PRISMA guidelines.

METHODS

Searches were conducted in PubMed, Web of Science, EMBASE, the Cochrane Library and the manual search in August 20, 2022, updated to September 2, 2023. Observational studies published in English were included and two researchers independently screened and extracted the data. Fixed or random effects mode was used to estimate the pooled prevalence of and risk factors for fear of falling. Heterogeneity resources were analyzed by subgroup and sensitivity analysis. Publication bias was assessed through funnel plots, Egger's test and Begg's test.

RESULTS

A total of the 153 studies with 200,033 participants from 38 countries worldwide were identified. The global prevalence of fear of falling was 49.60%, ranging from 6.96-90.34%. Subgroup analysis found the estimates pooled prevalence of it was higher in developing countries (53.40%) than in developed countries (46.7%), and higher in patients (52.20%) than in community residents (48.40%). In addition, twenty-eight risk factors were found a significant associations with fear of falling, mainly including demographic characteristics, physical function, chronic diseases and mental problems.

CONCLUSION

The global prevalence of FOF was high, especially in developing countries and in patients. Demographic characteristics, Physical function, chronic diseases and mental problems were a significant association with FOF. Policy-makers, health care providers and government officials should comprehensively evaluate these risk factors and formulate precise intervention measures to reduce FOF.

TRIAL REGISTRATION

The study was registered in the International Database of Prospectively Registered Systematic Reviews (PROSPERO): CRD42022358031.

Clinical prediction rules for multi surfaces walking independence using the Berg Balance Scale or Mini-Balance Evaluation Systems Test in persons with stroke

BACKGROUND

A Clinical prediction rule (CPR) for determining multi surfaces walking independence in persons with stroke has not been established.

OBJECTIVES

To develop a CPR for determining multi surfaces walking independence in persons with stroke.

METHODS

This was a multicenter retrospective analysis of 419 persons with stroke. We developed a Berg Balance Scale (BBS)-model CPR combining the BBS, comfortable walking speed (CWS) and cognitive impairment, and a Mini-Balance Evaluation Systems Test (Mini-BESTest)-model CPR combining the Mini-BESTest, CWS, and cognitive impairment. A logistic regression analysis was conducted with multi surfaces walking independence as the dependent variable and each factor as an independent variable. The identified factors were scored (0, 1) based on reported cutoff values. The CPR's accuracy was verified by the area under the curve (AUC). We used a bootstrap method internal validation and calculated the CPR's posttest probability.

RESULTS

The logistic regression analysis showed that the BBS, CWS, and cognitive impairment were factors in the BBS model, and the Mini-BESTest was a factor in the Mini-BESTest model. The CPRs were 0-3 points for the BBS model and 0-1 points for the Mini-BESTest model. The AUCs (bootstrap mean AUC) of the CPR score were 0.89 (0.90) for the BBS model and 0.72 (0.72) for the Mini-BESTest model. The negative predictive value (negative likelihood ratio) was 97% (0.054) for CPR scores < 2 for the BBS model and 94% (0.060) for CPR scores < 1 for the Mini-BESTest model.

CONCLUSIONS

The CPR developed herein is useful for determining multi surfaces walking independence.

Enhancing safety in the ischaemic and haemorrhagic stroke population: exploring the efficacy of self-releasing chair alarm belts

INTRODUCTION

A quality improvement study evaluated the effectiveness of implementing self-releasing chair alarm belts in an inpatient rehabilitation facility (IRF) for patients who had a stroke. The objective of this study is to assess the effectiveness of self-releasing chair alarms as a chair-level fall preventive tool in patients who had a stroke in the IRF setting.

METHODS

A preintervention and postintervention quality improvement study was conducted in an IRF to address the high rate of falls in the stroke population. Falls from wheelchairs were identified as a significant concern, leading to the implementation of self-releasing safety belts (Posey HeadStart Notification Sensor Belts) with alarm systems as an intervention. In the preintervention phase (July 2021 to January 2022) falls from chairs while on standard fall precautions were recorded to establish a baseline. In the intervention phase, the self-releasing chair alarm belts were introduced along with standard fall precautions. The postintervention phase spanned from February 2022 to July 2022.

RESULTS

In the preintervention phase, 20 out of 86 stroke subjects experienced a total of 30 falls from chairs. However, in the postintervention phase, only one subject experienced a fall from a chair out of 104 stroke subjects. The mean percentage of subjects involved in falls decreased from 24±11.4% to 1±0.4% (p<0.00001), and the mean fall rate per 1000 patient days declined from 4.6±2 to 0.2±0.1 (p<0.0001).

CONCLUSIONS

The implementation of self-releasing chair alarm belts significantly reduced falls from chairs among patients who had a stroke in the IRF setting. These findings highlight the effectiveness of this intervention in improving patient safety and fall prevention in IRFs.

Advances in balance training to prevent falls in stroke patients: a scoping review

Objective

To summarize the status and characteristics of the available evidence, research gaps, and future research priorities for preventing falls in stroke patients through balance training.

Methods

We used a scoping review framework. A systematic search of PUBMED, Embase, and Cochrane databases for main articles was conducted. Our study only included articles that on balance training and fall-related indicators in stroke patients. Two researchers independently screened the literature according to the inclusion and exclusion criteria. The data of demographic, clinical characteristics, intervention, sample, and outcome indicators were extracted. The characteristics and limitations of the included literature were comprehensively analyzed.

Results

Of the 1,058 studies, 31 were included. The methods of balance training include regular balance training, Tai Chi, Yoga, task balance training, visual balance training, multisensory training, aquatic balance training, perturbation-based balance training, cognitive balance training, system-based balance training, and robot-assisted balance training. The commonly used outcome measures include clinical balance test, such as Berg balance scale (BBS), Timed Up-and-Go Test (TUG), Fall Risk Index assessment (FRI), Fall Efficacy Scale score (FES), and instrumented balance tests.

Conclusion

This scoping review summarizes the existing primary research on preventing falls in stroke patients by balance training. Based on the summary of the existing evidence, the characteristics of balance training and their relation to falls in stroke patients were found. The future researches should explore how to develop personalized training program, the sound combination of various balance training, to more effectively prevent falls.

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.

Adverse events related to physiotherapy practice: a scoping review

Introduction

While adverse events related to physiotherapy are possible, the type of adverse event and the area of physiotherapy practice in which they occur are not well understood. The purpose of this scoping review was to establish adverse events related to physiotherapy practice and understand the nature of these events and the circumstances in which they occurred.

Methods

Relevant literature from January 2014 to February 2024 was gathered from five electronic databases. Studies reporting adverse events within any physiotherapy practice (intervention or assessment) were eligible. Two reviewers independently assessed title and abstract, and full texts. Findings were synthesised by clinical streams.

Results

A total of 58 studies met the inclusion criteria. Common adverse events described in musculoskeletal physiotherapy involving manual therapy, exercise and electrotherapy were increased pain and stiffness. Cardiorespiratory physiotherapy interventions involving early mobilisation, exercise and airway clearance therapy reported desaturation and haemodynamic instability. Neurological physiotherapy studies reported falls and fatigue during gait and balance training and exercise. Oncology and aged care interventions involving exercise, balance training and lymphoedema management reported increased pain and muscle strain while studies including pelvic floor muscle training reported the adverse event of vaginal discomfort.

Conclusion

This review identified adverse events occurring during physiotherapy interventions or assessment procedures. Increased monitoring and proactive safety measures may be necessary to ensure patient safety during these treatments.

Evaluation of a novel biomechanics-informed walking frame, developed through a Knowledge Transfer Partnership between biomechanists and design engineers

BACKGROUND

Walking aids such as walking frames offer support during walking, yet paradoxically, people who self-report using them remain more likely to fall than people who do not. Lifting of walking frames when crossing door thresholds or when turning has shown to reduce stability, and certain design features drive the need to lift (e.g. small, non-swivelling wheels at the front). To overcome shortfalls in design and provide better stability, biomechanists and industrial engineers engaged in a Knowledge Transfer Partnership to develop a novel walking frame that reduces the need for lifting during everyday tasks. This paper presents the results for the final prototype regarding stability, safety and other aspects of usability.

METHODS

Four studies were conducted that explored the prototype in relation to the current standard frame: a detailed gait lab study of 9 healthy older adults performing repeated trials for a range of everyday tasks provided mechanical measures of stability, a real-world study that involved 9 users of walking frames provided measures of body weight transfer and lifting events, two interview studies (5 healthcare professionals and 7 users of walking frames) elicited stakeholder perceptions regarding stability, safety and usability.

RESULTS

Analysis of healthy older adults using a standard walking frame and the prototype frame demonstrated that the prototype increases stability during performance of complex everyday tasks (p < 0.05). Similarly, gait assessments of walking frame users in their home environment showed that the prototype facilitated safer usage patterns and provided greater and more continuous body weight support. Interviews with healthcare professionals and users showed that the prototype was perceived to be safe and effective and hence more usable.

CONCLUSIONS

The outcomes of the separate studies all support the same conclusion: the prototype is an improvement on the status quo, the typical front-wheeled Zimmer frame for indoor use which has not changed in design for decades. The significance of this work lies in the success of the Knowledge Transfer Partnership and in biomechanics-informed design leading to improvements, which in future may be applied to other walking aids, to benefit walking aid users by promoting safer, more stable use of their aid.

Relationship between fear of falling and fall risk among older patients with stroke: a structural equation modeling

BACKGROUND

With reduced balance and mobility, older patients with stroke are more susceptible to fear of falling (FOF). A maladaptive form of FOF can cause excessive activity restriction, poor balance, and recurrent falls, forming a self-reinforcing vicious cycle. This study applied and adapted the FOF model to investigate the interaction between FOF and fall risk in older stroke patients.

METHODS

A cross-sectional study was conducted among 302 older stroke patients aged 60 and over. All participants were invited to complete the FOF, fall risk, physical activity, and balance tests, which were measured by the Falls Efficacy Scale International (FES-I), Self-Rated Fall Risk Questionnaire (FRQ), the long-form International Physical Activity Questionnaire (IPAQ-LF) and the Four-Stage Balance Test (FSBT) respectively. Data were analyzed using structural equation modeling.

RESULTS

The mean age of the respondents was 68.62 ± 7.62 years; 8.94% reported a high level of FOF, and 18.21% reported a moderate level of FOF. The structural equation model showed that FOF was directly associated with fall risk (β=-0.38, p < 0.001), and was indirectly associated with fall risk via physical activity (β=-0.075, p < 0.05) and balance ability (β=-0.123, p < 0.05). Depression (β=-0.47, p < 0.001), fall history (β=-0.13, p < 0.05), and female sex (β=-0.16, p < 0.05) affected FOF, while anxiety was not associated with FOF.

CONCLUSIONS

The increased risk of falling in older stroke patients results from a maladaptive FOF affected by depression, fall history, poor balance ability, and limited physical activity. Our results suggest that greater attention should be paid to FOF during stroke recovery and fall prevention. A multifaced intervention program encompassing physiological and psychological factors should be designed to address FOF and prevent falls.

Effect of physical exercise on fear of falling in patients with stroke: A systematic review and meta-analysis

OBJECTIVE

To consolidate the evidence on the effect of physical exercise on fear of falling in individuals with stroke.

DATA SOURCES

PubMed, CINAHL, Cochrane Database and MEDLINE.

METHODS

An extensive database search was conducted to identify the randomised controlled trials that examined the effect of physical exercise on fear of falling post-stroke. Grading of Recommendation, Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence for each meta-analysis.

RESULTS

Fourteen trials totalling 1211 participants were included in this review. Thirteen of these (1180 participants) were included in the meta-analyses. In the primary analysis, very low-quality evidence suggested that exercise reduced fear of falling post-stroke (standardized mean difference (SMD) 0.48; 95% confidence interval (CI) 0.23 to 0.72). The effect was diminished at three- to six-month follow-up after exercise training ended (SMD -0.09; 95% CI -0.27 to 0.10; high-quality evidence). In the sensitivity analyses, the treatment effect was more pronounced in individuals with a lower baseline Berg balance score (BBS ≤45; SMD 0.53; 95%CI 0.17 to 0.88) and for those trials with exercise frequency of ≥3 sessions per week (SMD 0.70; 95%CI 0.39 to 1.01). Compared with circuit-based training consisting of a combination of walking, balance and strengthening exercises (SMD 0.27; 95% CI -0.09 to 0.63), walking programmes seemed to generate a larger effect on fear of falling (SMD 1.06; 95%CI 0.43 to 1.70).

CONCLUSION

Physical exercise was beneficial for reducing fear of falling in individuals with stroke, particularly those with poorer balance ability.

[Emotional disorders after stroke]

Emotional disorders are common among patients after stroke. They include anger, fear, emotional expression control (uncontrollable crying, laughing), emotional indifference (apathy), disorders of emotion recognition and emotional empathy. They might develop independently or as a presentation of depression, anxiety, catastrophic reaction, posttraumatic stress disorder etc. Treatment of post-stroke emotional disorders include pharmacotherapy, psychotherapy, neuromodulation.

The risk of falls among the aging population: A systematic review and meta-analysis

Aim

This study aims to clarify the risk factors for falls to prevent severe consequences in older adults.

Methods

We searched the PubMed, Web of Science, Embase, and Google Scholar databases using the terms "risk factors" OR "predicting factors" OR "predictor" AND "fall" OR "drop" to identify all relevant studies and compare their results. The study participants were divided into two groups, the "fall group" and the "control group", and differences in demographic characteristics, lifestyles, and comorbidities were compared.

Results

We included 34 articles in the analysis and analyzed 22 factors. Older age, lower education level, polypharmacy, malnutrition, living alone, living in an urban area, smoking, and alcohol consumption increased the risk of falls in the aging population. Additionally, comorbidities such as cardiac disease, hypertension, diabetes, stroke, frailty, previous history of falls, depression, Parkinson's disease, and pain increased the risk of falls.

Conclusion

Demographic characteristics, comorbidities, and lifestyle factors can influence the risk of falls and should be taken into consideration.