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

Prevalence of falls and associations with family functioning among community-dwelling older adults in Guangzhou, China

Introduction

Falls are the primary cause of unintentional fatalities among individuals aged 65 and older. Enhancing research on fall prevention among older adults is an urgent priority. Consequently, this study aims to investigate the prevalence and influencing factors of falls among community-dwelling older adults in Guangzhou, China, with a particular emphasis on the impact of family functioning.

Methods

We used a multi-stage stratified cluster random sampling technique to successfully survey 2,399 individuals aged 65 and above across 11 districts in Guangzhou City. Data on sociodemographic characteristics, health and lifestyle factors, and fall incidents were collected through telephone interviews. Chi-square tests, Lasso regression, and logistic regression were utilized to pinpoint fall risk factors. Association rule mining uncovered the relationships between falls and associated variables.

Results

A total of 390 participants reported experiencing falls, the prevalence of falls among older adults was 16.3% (95%CI: 14.82% ~ 17.78%). Logistic regression analysis identified several risk factors for falls among older adults: female [OR = 1.511, 95%CI (1.188-1.922)], age 85 years and older [OR = 2.332, 95%CI (1.447-3.758)], stroke [OR = 1.821, 95%CI (1.038-3.192)], hypoglycemia [OR = 1.639, 95%CI (1.228-2.186)], visual impairment [OR = 1.418, 95%CI (1.097-1.833)], need to be cared for [OR = 1.722, 95%CI (1.339-2.215)], chronic pain [OR = 1.663, 95%CI (1.302-2.124)], and anxiety [OR = 1.725, 95%CI (1.243-2.395)]. In addition, it was shown that a well-functioning family was a protective factor against falls [OR = 0.589, 95%CI (0.44-0.789)].

Conclusion

The prevalence of falls among community-dwelling older adults in Guangzhou City was high, and the influencing factors were complex. It is recommended to develop and implement comprehensive intervention measures for high-risk groups, including those who are females, older adults, and suffer from chronic diseases while paying special attention to the care of family members for older adults.

Falls characteristics experienced by working-age adults during inpatient post-stroke rehabilitation and their impact on length of stay, discharge functional status, ambulation and destination

BACKGROUND

In-hospital falls are frequent post-stroke medical complications and will remain of concern because it may not be possible to prevent all of them. We aimed to i) compare admission clinical and sociodemographic characteristics between fallers and non-fallers ii) determine falls characteristics iii) compare length of stay (LOS), discharge functional independence, ambulation and destination between fallers and non-fallers.

METHODS

A matched case-control study, comparing individuals (n = 302) who fell during inpatient post-acute rehabilitation, matched (on time to admission, age and motor Functional Independence Measure (mFIM)) to individuals (n = 302) who didn´t fall, admitted within 3 months post-injury to a center between 2008 and 2023. Ambulation was assessed using the Functional Ambulation Category (FAC).

RESULTS

Mean age at admission was 50±8 years. No baseline differences were seen between groups in the proportion of patients with aphasia, diabetes, dyslipidemia, hypertension, neglect, atrial fibrillation, dysphagia, dominant side affected, medication for depression, FAC assessment, body mass index and educational level. A first-fall in the first week was experienced by 22.2 % and in the first three weeks by 54.3 %. Most falls occurred at the patients' room (75.1 %) mostly due to distractions (55.3 %) and transferring without help (32.4 %) with 18 % occurring in the bathroom, fallers were alone in 68.6 % of the cases. Fallers had an 8-day longer mean LOS compared to non-fallers, yet there were no differences in discharge mFIM or FAC scores. While non-fallers had a higher proportion of poor mFIM outcomes (28.5 % vs. 17.9 %) and no ambulation (20.7 % vs. 12.4 %), fallers showed greater mFIM gains (26 vs. 22 points). Discharge destinations were similar across both groups.

CONCLUSIONS

Despite no baseline differences, fallers experienced longer stays with comparable independence and ambulation scores at discharge. Most falls occurred in patients' rooms during unsupervised activities. Preventive recommendations have been provided to address these risks and enhance patient safety.

Noninvasive Neuromodulation Combined With Rehabilitation Therapy Improves Balance and Gait Speed in Patients With Stroke: A Systematic Review and Network Meta-analysis

OBJECTIVE

This study aimed to determine repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and cranial nerve noninvasive neuromodulation affect functional balance, gait speed, and walking cadence in stroke patients.

METHODS

We searched PubMed, Embase, Cochrane, and Scopus (June 22, 2022) for randomized controlled trials. Three reviewers independently performed data extraction and assessed the risk of bias. Network and pairwise meta-analyses were performed to assess indirect and direct comparisons.

RESULTS

We included 34 studies ( N = 915 patients). Sixty percent had moderate-to-high methodological quality. The meta-analyses showed positive effects of repetitive transcranial magnetic stimulation combined with rehabilitation therapy compared with sham on gait speed, walking cadence, and balance function with weighted mean differences and 95% confidence interval of 0.08 (0.03 to 0.13), 7.16 (3.217 to 11.103), and 3.05 (0.52 to 5.57), respectively. Transcranial direct current stimulation showed improvement on the time up and go test (-0.88 [-1.68 to -0.08]). From the surface under the cumulative ranking analyses, repetitive transcranial magnetic stimulation is the best ranked treatment for gait speed and functional balance improvement compared with transcranial direct current stimulation and sham interventions. There were not enough studies to include cranial nerve noninvasive neuromodulation in the meta-analysis.

CONCLUSIONS

Walking cadence and speed, functional balance significantly improved after repetitive transcranial magnetic stimulation with short-term effects, which were superior to that of transcranial direct current stimulation and sham treatments. Transcranial direct current stimulation showed short-term beneficial effects on the Time Up and Go test.

Functional electrical stimulation to enhance reactive balance among people with hemiparetic stroke

BACKGROUND

Individuals with stroke demonstrate a twofold higher fall incidence compared to healthy counterparts, potentially associated with deficits in reactive balance control, which is crucial for regaining balance from unpredictable perturbations to the body. Moreover, people with higher stroke-related motor impairment exhibit greater falls and cannot recover balance during higher perturbation intensities. Thus, they might need supplemental agents for fall prevention or even to be included in a perturbation-based protocol. Functional electrical stimulation is a widely used clinical modality for improving gait performance; however, it remains unknown whether it can enhance or interfere with reactive balance control.

METHODS

We recruited twelve ambulatory participants with hemiparetic stroke (61.48 ± 6.77 years) and moderate-to-high motor impairment (Chedoke-McMaster Stroke Leg Assessment ≤ 4/7). Each participant experienced 4 unpredicted paretic gait-slips, with and without functional electrical stimulation (provided 50-500 ms after perturbation) in random order. The paretic quadriceps muscle group was chosen to receive electrical stimulation, considering the role of support limb knee extensors for preventing limb-collapse. Outcomes including primary (laboratory falls), secondary (reactive stability, vertical limb support) and tertiary (compensatory step length, step initiation, execution time) measures were compared between the two conditions.

RESULTS

Participants demonstrated fewer falls, higher reactive stability, and higher vertical limb support (p < 0.05) following gait-slips with functional electrical stimulation compared to those without. This was accompanied by reduced step initiation time and a longer compensatory step (p < 0.05).

CONCLUSION

The application of functional electrical stimulation to paretic quadriceps following gait-slips reduced laboratory fall incidence with enhanced reactive balance outcomes among people with higher stroke-related motor impairment. Our results lay the preliminary groundwork for understanding the instantaneous neuromodulatory effect of functional electrical stimulation in preventing gait-slip falls, future studies could test its therapeutic effect on reactive balance. Clinical registry number: NCT04957355.

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.

Oblique direction reach test: evaluating psychometric properties in stroke population

Background

Post-stroke individuals are observed to have reduced limits of stability (LOS) in all directions. Functional activities are rarely performed in pure cardinal planes; instead, they are most likely to be performed in an oblique direction. Existing tools are either expensive or sophisticated to assess the LOS in an oblique direction. Therefore, this study's primary objective is to evaluate the intra-rater, inter-rater reliability, and validity of the oblique direction reach test (ODRT) among stroke subjects.

Materials & Methods

A total of 96 first-time stroke patients with age, gender, height, and weight-matched healthy controls aged 18-80 years were recruited for the study. Oblique, forward, and lateral reach distances were assessed using the standard procedure of ODRT, Functional Reach Test (FRT), and Lateral Reach Test (LRT), respectively. Validity was tested by correlating the ODRT distance with the Berg Balance Scale (BBS) Score using Spearman's rank correlation coefficient. Intraclass correlation coefficients (ICCs) and Bland Altman analysis were used to establish inter-rater reliability. ICCs were used to find intra-rater reliability. The Mann-Whitney U test was used to establish the mean difference of the FRT, LRT, and ODRT. Spearman's rank correlation coefficient and linear regression were used to correlate the distance of FRT and LRT with ODRT.

Results

A high concurrent validity was found between BBS and ODRT with an r-value of 0.905 (p < 0.001). Inter-rater reliability was high with an ICC of 0.997 (95% CI [0.996-0.998]), and intra-rater reliability was highly significant with an ICC of 0.996 (95% CI [0.994-0.998]). The stroke subjects reached a significantly shorter distance than healthy individuals in FRT, ODRT, and LRT. ODRT was highly correlated with FRT (r = 0.985) and LRT (r = 0.978) (p < 0.001) and had an R2 = 0.987.

Conclusion

ODRT is a highly valid and reliable tool that can be used to evaluate balance in stroke patients. Individuals who reached less in the forward and lateral directions showed reduced reach distance in the oblique direction.

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.

Fatigue in stroke survivors: a 5-year follow-up of the Fall study of Gothenburg

Longer term knowledge of post-stroke fatigue (PSF) is limited. Our aim was to describe the prevalence of, and to identify baseline predictors associated with, PSF 5 years after stroke. We undertook a follow-up of stroke survivors from the 504 consecutively recruited participants in the observational "The Fall Study of Gothenburg", conducted between 2014 and 2016. The dependent variable, PSF, was assessed using the Swedish version of the Fatigue Assessment Scale (S-FAS) and defined as having a S-FAS score ≥ 24. The S-FAS questionnaire was mailed to potential participants in August 2020. The independent variables, previously obtained from medical records, included age; sex; comorbidities; stroke severity; hospital length of stay; body mass index (BMI); number of medications and lifestyle factors at index stroke. To identify predictors of PSF, univariable and multivariable logistic regression analyses were performed. Of the 305 eligible participants, 119 (39%) responded with complete S-FAS. Mean age at index stroke was 71 (SD 10.4) years and 41% were female. After a mean of 4.9 years after stroke, the prevalence of PSF was 52%. Among those with PSF, almost two thirds were classified as having both physical and mental PSF. In the multivariable analysis, only high BMI predicted PSF with an odds ratio of 1.25 (95% CI 1.11-1.41, p < 0.01). In conclusion, half of the participants reported PSF 5 years after index stroke and higher body mass index was identified as a predictor. The findings from this study are important for healthcare professionals, for planning health-related efforts and rehabilitation of stroke survivors.ClinicalTrials.gov, Identifier NCT02264470.

Health-related quality of life in stroke survivors: a 5-year follow-up of The Fall Study of Gothenburg (FallsGOT)

BACKGROUND

There are limited data on long-term prevalence and predictors of health-related quality of life (HRQoL) in stroke survivors. Therefore, the aim was to describe the prevalence of impaired HRQoL, and to identify factors in acute stroke that are associated with impaired HRQoL, 5 years after stroke.

METHODS

The 305 (60.5%) stroke survivors of the original 504 participants from The Fall Study of Gothenburg were invited to participate in a 5-year follow-up including assessment of HRQoL using the EuroQol 5 Dimensions 3 Levels questionnaire (EQ-5D-3L). To identify baseline predictors of impaired HRQoL, based on the EQ-5D-3L's five dimensions, univariate and multivariate logistic regression analyses were performed.

RESULTS

A total of 129 participants (42.3% of the survivors) completed the questionnaire at a median follow-up time of 58 months. At baseline, their mean age was 70.6 years, and they had a median NIHSS score of 1. The median (interquartile range [IQR]) EQ-5D-3L index score was 0.87 (0.71-0.93) and the median (IQR) EQ-visual analogue scale was 70 (49.8-88). In total, 102 (79%) participants were classified as having impaired HRQoL, stated primarily (among 68.5%) related to Pain/Discomfort. Higher age was identified as a predictor of impaired HRQoL related to Mobility (Odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.10) and Self-Care (OR 1.09, 95% CI 1.02-1.17), and longer hospital stay at baseline was identified as a predictor related to Mobility (OR 1.09, 95% CI 1.01-1.18), Self-Care (OR 1.10, 95% CI 1.02-1.18)) and Usual Activities. (OR 1.10, 95% CI 1.03-1.18).

CONCLUSION

At 5 years after stroke, four out of five participants (79%) reported impaired HRQoL related to any of the five dimensions assessed by using the EQ-5D-3L. Most reported, impaired HRQoL was related to Pain/Discomfort. Higher age and longer hospital care period at index stroke were associated with impaired HRQoL. The findings could assist to identify individuals at high risk of low HRQoL, who might benefit from special attention and psychological support.

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.

Effects of Compression Stockings on Body Balance in Hemiplegic Patients with Subacute Stroke

(1) Background: Stroke patients with hemiplegia have an increased risk of developing deep vein thrombosis (DVT). DVT increases the risk of life-threatening pulmonary embolism and is associated with poor prognosis. The early wearing of compression stockings can help prevent DVT. This study aimed to assess the impact of compression stockings on body balance in stroke patients with unilateral lower extremity muscle weakness; (2) Methods: Hemiplegic stroke patients in the subacute phase who were able to walk with assistance were recruited. The patients were divided into two groups: one group received rehabilitation treatment with compression stockings, and the other received treatment without compression stockings. The rehabilitation treatment involved hospitalization for 4 weeks, the Trunk Control Test (TCT), the Trunk Impairment Scale (TIS), and the Berg Balance Scale (BBS). The patients were evaluated before and 4 weeks after the start of treatment. The differences in BBS, TCT, and TIS before and after treatment between the two groups were compared; (3) Results: Altogether, 236 hemiplegic stroke patients were recruited. There was an improvement in body balance after treatment in both groups, and BBS, TCT, and TIS scores significantly increased in the group that received rehabilitation treatment with compression stockings; (4) Conclusions: In patients with hemiplegic stroke in the subacute period, rehabilitation while wearing compression stockings appears to improve body balance.

A cohort study on longitudinal changes in postural balance during the first year after stroke

INTRODUCTION

Many patients with strokes report increased incidence of fall that can be due to impaired postural balance. The recovery of balance in patients with varying degrees of impairments and activity limitations is less studied, and whether individuals with mild paresis can recover their balance faster is unclear. Better knowledge about factors influencing the recovery of postural balance can be used to guide clinical management after stroke to provide the right rehabilitation to the right person at the right time, and thus to avoid potential fall incidences.

OBJECTIVE

This study aims to examine longitudinal changes in postural balance during the first year after stroke.

METHODS

Postural balance was assessed using the Berg Balance Scale (BBS) within 5 days, 1, 2, and 3 months and 1-year post-stroke. Stroke severity was stratified using a cluster analysis by including multidimensional baseline measures. A longitudinal mixed-effect model was constructed to analyze changes in proportional balance impairment by stroke severity over time. Individuals with a cut-off of BBS below 45 scores were identified through a classification algorithm using baseline predictors.

RESULTS

A total of 135 patients were stratified to mild stroke (77 [57%] patients) or moderate stroke (58 [43%] patients). Ninety-three patients were included in the longitudinal analysis. Significant recovery was found at 1-year for moderate stroke (48% recovery from the initial impaired postural balance, adjusted P < 0.001), but not for mild stroke, after adjusting for age and cognition. Both stroke severities had a maximal recovery in postural balance at 3 months post-stroke, but the moderate stroke group deteriorated after that. Patients with higher age and worse cognition had more severe balance impairments. The classification model achieved a sensitivity of 0.95 (95% confidence interval [CI]: 0.91-0.98) and a specificity of 0.99 (95% CI: 0.98-1.0) for classifying individuals with BBS below 45 points.

CONCLUSIONS

This study indicates that continuous improvements in postural balance ends at 3 months regardless for mild or moderate stroke groups, and patients with moderate stroke significantly deteriorate in postural balance after 3 months.

Age differences in functioning and contextual factors in community-dwelling stroke survivors: A national cross-sectional survey

Background

Our study aimed to map functioning and contextual factors among community-dwelling stroke survivors after first stroke, based on the International Classification of Functioning, Disability and Health (ICF), and to explore if these factors differ among older-old (75 years and older), younger-old (65–74 years), and young (18–65 years) stroke survivors.

Methods

A cross-sectional population-based national survey among community-dwelling stroke survivors, 1–2 years after their first stroke. Potential participants were approached through hospital registries. The survey had 56.2% response rate. Participants (N = 114, 50% men), 27 to 94 years old (71.6±12.9 years), were categorized as: older-old (n = 51), younger-old (n = 34) and young (n = 29). They answered questions on health, functioning and contextual factors, the Stroke Impact Scale (SIS) and the Behavioural Regulation Exercise Questionnaire-2. Descriptive analysis was used, along with analysis of variance for continuous data and Fisher´s exact tests for categorical variables. TukeyHSD, was used for comparing possible age-group pairings.

Results

The responses reflected ICF´s personal and environmental factors as well as body function, activities, and participation. Comparisons between age-groups revealed that the oldest participants reported more anxiety and depression and used more walking devices and fewer smart devices than individuals in both the younger-old and young groups. In the SIS, the oldest participants had lower scores than both younger groups in the domains of activities of daily living and mobility.

Conclusion

These findings provide important information on needs and opportunities in community-based rehabilitation for first-time stroke survivors and reveal that this population has good access to smart devices which can be used in community integration. Moreover, our results support the need for analysis in subgroups of age among the heterogenous group of older individuals in this population.

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.

Exploring possible risk factors for time to first fall and 6-month fall incidence in persons with acute stroke

Objectives:

The aim was to explore how the time to the first fall and 6-month fall incidence relates to rapidly and easily collected data in persons with acute stroke.

Methods:

Out of consecutively admitted patients with stroke at three stroke units, 284 with at least one follow-up were included in this prospective cohort study. During 6 months following discharge, participants reported falls using a diary and monthly phone calls. Data about participants’ characteristics, functions, and activities were collected during hospital stay and analyzed in relation to time to first fall by Cox regression and fall incidence by negative binomial regression.

Results:

Use of ⩾9 medications, paresis in arms, paresis in legs (National Institutes of Health Stroke Scale), impaired protective reactions in sitting (Postural Reactions Test), and limitations in self-care (Barthel Index) were decisive risk factors for time to first fall. Limitations in mobility (Step Test, 30-s Chair Stand Test) were decisive risk factors for high fall incidence (p < 0.0005).

Conclusion:

Several easily collected participant characteristics, functions, and activities were identified as risk factors for falls. The findings emphasize the width of assessments that can be used for the identification of individuals at risk for falls and that the risk factors vary in different strata of the population. These results are important when developing multivariate risk models. The risk factors differed in part when analyzing the time to the first fall and 6-month fall incidence.

Functional standing frame programme early after severe sub-acute stroke (SPIRES): a randomised controlled feasibility trial

BACKGROUND

Early mobilisation (> 24 h post-stroke) is recommended for people with stroke. However, there is a paucity of evidence about how to implement early mobilisation for people who have had a severe stroke. Prolonged standing and task-specific training (sit-to-stand repetitions) have separately been evaluated in the literature; however, these functionally linked tasks have not been evaluated in combination for people with severe sub-acute stroke.

METHODS

The objective was to determine the feasibility of conducting a randomised controlled trial (RCT) of a functional standing frame programme compared with usual physiotherapy for people with severe sub-acute stroke. An assessor-blinded feasibility RCT with nested qualitative component (interviews and focus group) and process evaluation was adopted. Participants were aged ≥ 18 years with new diagnosis of severe sub-acute stroke (modified Rankin Scale (mRS) 4/5) from four Stroke Rehabilitation Units across South West England. Participants were randomised to receive either: (1) functional standing frame programme (30 min. standing plus sit-to-stand repetitions) plus 15 min of usual physiotherapy daily (intervention); (2) usual physiotherapy (45 min) daily (control). Both programmes were protocolised to be undertaken a minimum of five sessions per week for 3 weeks. Feasibility indicators included process, resource, management, and safety. Adherence, fidelity, and acceptability of the trial and intervention were evaluated using data recorded by therapists, observation of intervention and control sessions, interviews and one focus group. Patient measures of motor impairment, activities/participation, and quality of life were carried out by blinded assessors at baseline, 3, 15, 29, and 55 weeks post-randomisation.

RESULTS

Forty-five participants (51-96 years; 42% male, mRS 4 = 80% 5 = 20%) were randomised (n = 22 to intervention). Twenty-seven (60%) participants were followed-up at all time points. Twelve participants (27%) died during the trial; no deaths were related to the trial. Adherence to the minimum number of sessions was low: none of the participants completed all 21 sessions, and only 8 participants (18%) across both groups completed ≥ 15 sessions, over the 3 weeks; 39% intervention; 51% control sessions were completed; mean session duration 39 min (SD 19) control, 37 min intervention (SD 11). Intervention group: mean standing time 13 min (SD 9); mean sit-to-stand repetitions/session 5 (SD 4). Interviews were conducted with 10 participants, four relatives and six physiotherapists. Five physiotherapists attended a focus group.

CONCLUSIONS

The majority of progression criteria for this feasibility trial were met. However, adherence to the interventions was unacceptably low. This aspect of the trial design needs to be addressed prior to moving to a definitive RCT of this standing frame intervention in people with severe sub-acute stroke. Solutions have been identified to address these concerns.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN15412695 . Registration 19 December 2016.

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

We aimed to identify determinants in acute stroke that are associated with falls during the stroke unit stay. In order to enable individualized preventive actions, this knowledge is fundamental. Based on local and national quality register data on an unselected sample of 5065 stroke patients admitted to a stroke unit at a Swedish university hospital, univariable and multivariable logistic regression analyses were performed. The dependent variable was any fall during stroke unit stay. The independent variables related to function, activity, personal factors, time to assessment, comorbidities and treatments. Determinants of falls were: being male (odds ratio (OR) 2.25, 95% confidence interval (95% CI) 1.79–2.84), haemorrhagic stroke (OR 1.39, 95% CI 1.05–1.86), moderate stroke symptoms according to the National Institutes of Health Stroke Scale (NIHSS score 2–5 vs. NIHSS score 0–1) (OR 1.43, 95% CI 1.08–1.90), smoking (OR 1.70, 95% CI 1.29–2.25), impaired postural control in walking (OR 4.61, 95% CI 3.29–6.46), impaired postural control in standing (OR 1.60, 95% CI 1.25–2.05), stroke-related arm- and hand problems, OR 1.45, 95% CI 1.11–1.91), impaired cognition (OR 1.43, 95% CI 1.04–1.95), and urinary tract infection (OR 1.91, 95% CI 1.43–2.56). The findings from this study are useful in clinical practice and might help to improve patient safety after stroke.

Comparison of the psychometric properties of three commonly used fall risk assessment tools: a prospective observational study for stroke patients

BACKGROUND

A reliable tool recommendation is needed to identify the risk of falling in hospitalized stroke patients.

OBJECTIVES

The aim of this study was to identify the most reliable fall risk assessment tool among the Morse Fall Scale (MFS), Itaki Fall Risk Scale (Itaki FRS) and Hendrich II Fall Risk Model (HIIFRM) for stroke patients.

METHODS

The study was planned as an observational prospective study. It was carried out over the period July-December 2018 with 125 stroke patients. The Functional Independence Measure (FIM), Itaki FRS, HIIFRM, and MFS were used for the study data. The fall risk and incidents of falling were monitored on a daily basis over the course of the patients' stay at the hospital. The differentiation between the fall risk tools was assessed with sensitivity-specificity analysis and the ROC curve.

RESULTS

The mean age of the research participants was 71.47 ± 11.16 years. It was determined that 9.6% of the patients fell at least once during the follow-up period, which was 8.66 ± 1.80 days on average. The sensitivity and specificity rates of the fall risk assessment tools were respectively 75.0% and 63.7% for the Itaki FRS, 83.3% and 50.4% for the HIIFRM, and 91.7% and 73.5% for the MFS. The cutoff points on the tools were 14 for the Itaki FRS, 4.5 for the HIIFRM, and 66.2 for the MFS.

CONCLUSION

MFS is a more reliable tool than Itaki FRS or HIIFRM in determining fall risk in hospitalized stroke patients.

Prediction of fear of falling at 6 months after stroke based on 279 individuals from the Fall Study of Gothenburg

The early identification of individuals at risk of fear of falling after stroke is crucial in order to individualise preventive actions and interventions. The aim of this study was to identify the incidence of, and baseline factors in acute stroke that are associated with fear of falling at 6 months after stroke. Fear of falling was assessed by one question, which was answered by 279 of 452 eligible individuals. Univariable and multivariable logistic regression analyses were performed to determine the factors that were associated with fear of falling. The dependent variable was fear of falling at 6 months after stroke. The independent variables were related to function, activity and participation, including personal and environmental factors. Fear of falling was reported by 117 (41.9%) individuals. Poor postural control in acute stroke, measured using the modified version of the Postural Assessment Scale for Stroke Patients (odds ratio [OR]: 2.60, 95% confidence interval [CI]: 1.26–5.36), and being physically inactive prior to the stroke, measured using the Saltin-Grimby Physical Activity Scale (OR: 2.04, 95% CI: 1.01–4.12), were found to be associated with fear of falling at 6 months after stroke. The findings in this study are useful in clinical practice to optimise rehabilitation after stroke.

Falls After Stroke: A Follow-up after Ten Years in Lund Stroke Register

OBJECTIVES

To evaluate incidence of self-reported falls and associated factors in a ten-year perspective after stroke.

METHODS

From a population-based cohort of first-ever stroke patients (n = 416) included in the Lund Stroke Register between March 1, 2001, and February 28, 2002, we performed a follow up of all 145 survivors ten years after stroke. We collected data on age, gender, main stroke type, living and housing situation, general health status (question 1 in the Short Form Health Survey (SF-36), dizziness, physical activity, Barthel Index, mobility aids, moving ability inside/outside, and health-related quality of life as defined by the EuroQol 3 dimension scale (EQ-5D-3L). Factors that may relate to falls were compared between those who had experienced falls after stroke or not.

RESULTS

Ten years after stroke, 49 patients (34 %) reported falls and 96 patients (66 %) reported no falls. Compared to patients with no falls, those who reported falls were older (median age 83.3 years vs 75.6 years; p < 0.001), more often lived alone, were more dependent in daily living, had less physical activity, poorer general health status, more often needed mobility aids, were more often unable to move alone outside, and had poorer health-related quality of life in all items in EQ-5D-3L except pain/discomfort.

CONCLUSIONS

Falls had occurred in approximately one third of the participants ten years after the stroke, and were strongly associated with several measures of frailty. Our results indicate that fall prevention should in particular focus on those at high risk of falls.

Automated fall risk assessment of elderly using wearable devices

Introduction

Falls cause major expenses in the healthcare sector. We investigate the ability of supporting a fall risk assessment by introducing algorithms for automated assessments of standardized fall risk-related tests via wearable devices.

Methods

In a study, 13 participants conducted the standardized 6-Minutes Walk Test, the Timed-Up-and-Go Test, the 30-Second Sit-to-Stand Test, and the 4-Stage Balance Test repeatedly, producing 226 tests in total. Automatedalgorithms computed by wearable devices, as well as a visual analysis of the recorded data streams, were compared to the observational results conducted by physiotherapists.

Results

There was a high congruence between automated assessments and the ground truth for all four test types (ranging from 78.15% to 96.55%), with deviations ranging all well within one standard deviation of the ground truth. Fall risk (assessed by questionnaire) correlated with the individual tests.

Conclusions

The automated fall risk assessment using wearable devices and algorithms matches the validity of the ground truth, thus providing a resourceful alternative to the effortful observational assessment, while minimizing the risk of human error. No single test can predict overall fall risk; instead, a much more complex model with additional input parameters (e.g., fall history, medication etc.) is needed.

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.

Immediate Effects of Tibialis Anterior and Calf Muscle Taping on Center of Pressure Excursion in Chronic Stroke Patients: A Cross-Over Study

Stroke patients often have muscles spasticity, difficulty with posture control, and tend to fall. This study investigated the use of kinesiology tape for patients with spasticity of ankle muscles after stroke. This study had a randomized, repeated measures design, and evaluated the immediate effect of kinesiology tape on the center of pressure (COP) excursion when applied to the calf and tibialis anterior muscles in stroke survivors. We determined that the taping attachment direction affects the COP movement. Twenty subjects were randomly assigned to the tibialis anterior taping condition, calf taping condition, or nontaping condition. Condition excursion was assessed. The measured variables included the paretic side area, nonparetic side area, forward area, and backward area of COP. All evaluations were conducted immediately after taping. COP excursion for chronic stroke survivors improved after tibialis anterior and calf taping (p < 0.05). Calf taping conditions increased significantly in the forward area (p < 0.05), and tibialis anterior taping conditions increased significantly in the backward area (p < 0.05). Kinesiology tape immediately increased the forward and backward COP excursion for patients with stroke.

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

OBJECTIVE

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

DESIGN

Prospective follow-up study.

SETTING

Stroke unit and community.

PARTICIPANTS

Patients (N=504) with acute stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Developing ActivABLES for community-dwelling stroke survivors using the Medical Research Council framework for complex interventions

BACKGROUND

Novel technical solutions are called for to promote home-based exercise among community-dwelling stroke survivors supported by their caregivers. Lack of resources and knowledge about how to accomplish it, has been demonstrated. The objective of this study is to describe in detail the development of ActivABLES, a technical intervention to promote home-based exercise and physical activity engagement of community-dwelling stroke survivors with support from their caregivers.

METHODS

The technical development process of ActivABLES was guided by the Medical Research Council (MRC) framework for development and evaluation of complex interventions as well as by principles of human-centred design and co-design. The main steps included: (1) Synthesis of evidence supporting the inclusion of balance exercises, mobility and walking exercises and exercises for the upper arm; (2) Implementation of initial user studies with qualitative data collection from individual interviews with stroke survivors, and focus group interviews with caregivers and health professionals; (3) Preliminary testing of eight prototypes with seven stroke survivors and their caregivers.

RESULTS

After the preliminary testing of eight prototypes, four prototypes were not further developed whereas four prototypes were modified further. In addition, two new prototypes were developed, leaving six prototypes for further modification: 1) ActivFOAM for balance exercises, 2) WalkingSTARR to facilitate walking, 3) ActivBALL for hand exercises, 4) ActivSTICKS for upper arm exercises, and 5) ActivLAMP and 6) ActivTREE which both give visual feedback on progress of daily exercise and physical activities. ActivFOAM, ActivBALL and ActivSTICKS are all connected to a tablet where exercise instructions are given. All the exercise prototypes can be connected to ActivLAMP and ActivTREE to give feedback on how much exercise the user has done. Settings can be individualised and recommended daily time and/or repetition can easily be changed as the user progresses to higher activity levels.

CONCLUSIONS

The development process of ActivABLES was guided by the principles of human-centred design, with iterative testing of future users, and by the MRC framework of complex intervention, with a repeated process of development and testing. This process resulted in six prototypes which are available for feasibility testing among a small group of community-dwelling stroke survivors.