Stroke Rehabilitation for Falls and Risk of Falls in Southeast Asia: A Scoping Review With Stakeholders' Consultation

Understanding the implication of task conditions on asymmetry in gait of post-stroke individuals using an Integrated Wearable System

Hemiplegic individuals often demonstrate gait abnormality causing asymmetry in lower-limb muscle activation-related (implicit) and gait-related (explicit) measures (offering complementary information on one's gait) while walking. Added to hemiplegia, such asymmetry can be aggravated while walking under varying task conditions, namely, walking without speaking (single task), walking while counting backwards (dual task), and walking while holding an object and counting backwards (multiple task). This emphasizes the need to quantify the extent of aggravated implication of multiple-task and dual-task on gait asymmetry compared to single task. Here, we used Integrated Wearable System and carried out a study with a group of age-matched hemiplegic (Grp_S) and healthy (Grp_H) individuals to understand the potential of our system in quantifying asymmetry in explicit and implicit measures of gait, implication of hemiplegic condition and varying task conditions on these asymmetry measures along with their clinical relevance. Results showed the potential of our system in quantifying asymmetry in both explicit and implicit measures of gait, and these measures were statistically higher (p-value < 0.05) in Grp_S than Grp_H irrespective of the task conditions. Also, for Grp_S, these asymmetry measures became more pronounced as task demand increased, and again, these measures have shown a correlation with their risk of fall specifically during more attention-demanding tasks that could be clinically relevant.

Effectiveness of multifaceted interventions including motivational interviewing and home-based rehabilitation program for improving mental and physical health in stroke patients: A randomized controlled trial

Background

In Vietnam, early screening and intervention for post-stroke mental health are limited, with rising demand for home-based rehabilitation due to the scarcity of inpatient programs.

Objectives

We aimed to evaluate the effectiveness of multifaceted interventions, including Motivational Interviewing and home-based rehabilitation, in improving the mental and physical health of stroke patients.

Design

A randomized controlled trial at the Vietnam National Geriatric Hospital assessed a multi-intervention approach for stroke survivors from 2021 to 2022. Ninety-two participants (aged over 45 with a stroke diagnosis) were randomly assigned to an intervention group (Motivational Interviewing and home-based rehabilitation) or a control group (standard care), with 46 participants in each group. Outcomes for mental health (Patient Health Questionnaire-9, Fatigue Severity Scale, Mini-Mental State Examination) and physical health (Barthel Index) were measured at baseline and after 1, 3, and 6 months. Statistical analyses used t-tests, Cohen's d, and repeated measures ANOVA.

Results

Over 6 months, 37 participants completed the intervention program. Baseline characteristics were similar except for age, lesion locations, and National Institutes of Health Stroke Scale scores. The intervention group showed significant improvements in mental health and physical function. Patient Health Questionnaire-9 scores decreased from 9.1 to 1.8, and Fatigue Severity Scale scores dropped from 28.5 to 17.8, while Barthel Index scores improved from 58.8 to 68.8 (p < 0.001).

Conclusions

We found that participants who underwent Motivational Interviewing therapy and home-based rehabilitation were more likely than those receiving standard care to experience substantial improvements in both mental and physical health metrics.

Registration

The research protocol was registered on ClinicalTrials.gov on August 1, 2021 (Identifier: NCT04941482, link: https://clinicaltrials.gov/study/NCT04941482).

A scoping review of patient and public involvement in empirical stroke research

BACKGROUND

Impactful, evidence-based solutions in surveillance, prevention, acute care, and rehabilitation for stroke survivors are required to address the high global burden of stroke. Patient and public involvement (PPI), where patients, their families, and the public are actively involved as research partners, enhances the relevance, credibility, and impact of stroke-related research.

AIMS

This scoping review, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Scoping Review guidelines, aims to identify and summarize how PPI is currently implemented and reported in empirical stroke research using a participatory approach.

SUMMARY OF REVIEW

A comprehensive search strategy was developed and implemented across Medline, CINAHL, EMBASE, PsynchINFO, and Cochrane electronic databases, supplemented by gray literature searches. Empirical stroke research articles in the English language, published from 2014 up to 2023, and documenting PPI activity were included. Of the 18,143 original articles identified, 2824 full-text manuscripts matching from this time window were screened. Only 2% (n = 72) of these directly reported embedded PPI activity in empirical research. The majority were qualitative in design (60%) and conducted in high-income countries (96%). Only one included study originated from a developing country, where the burden of stroke is highest. Most studies (94%) provided some information about the activities carried out with their PPI partners, mainly centered on the study design (57%) and management (64%), with only 4% of studies integrating PPI across all research cycle phases from funding application to dissemination. When studies were examined for compliance with the Guidance for Reporting Involvement of Patients and the Public (GRIPP) short-form checklist, only 11% of included studies were 100% compliant. Twenty-one studies (29%) reported barriers and facilitators to including PPI in stroke research. Organization, authentic partnership, and experienced PPI representatives were common facilitators and identified barriers reflected concerns around adequate funding, time required, and diversity in perspectives. A positive reporting bias for PPI impact was observed, summarized as keeping the patient perspective central to the research process, improved care of study participants, validation of study findings, and improved communication/lay-summaries of complex research concepts.

CONCLUSIONS

PPI is underutilized and inconsistently reported in current empirical stroke research. PPI must become more widely adopted, notably in low- and middle-income countries. Consensus-driven standards for inclusion of PPI by funding organizations and publishers are required to support its widespread adoption.

Risk Factors and Profiles of Falls Among Inpatients in Vietnam: A Multicenter Nested Case-Control Study

Purpose

Falls among inpatients represent a significant global health concern and are among the leading causes of accidental death. However, hospital falls are context- and population dependent. This study aimed to investigate the risk factors contributing to falls and the fall profiles among Vietnamese inpatients.

Methods

A nested case-control study was conducted at nine public hospitals in Ho Chi Minh City. For every fall identified through the medical fall incident reporting system, four controls (ie, nonfall patients) were also selected from medical records within the same department and timeframe. Medical records were extracted, which included detailed information about the falls.

Results

Among 101 fall cases and 404 nonfall controls, several risk factors for falls were found, including reduced strength and mobility (OR=3.08, 95% 1.30-7.30), nocturia (OR=9.08, 95% CI 4.04-20.45), having more than two diseases (OR=2.76, 95% CI 1.53-4.98), using walking aids (OR=23.26, 95% CI 10.20-53.03), using medical devices (OR=3.44, 95% CI 1.92-6.15) and using antiepileptics (OR=3.94, 95% CI 1.22-12.77). About 19.8% of the falls occurred within the first 24 hours from admission and the most common time of falls was from 0:00 am to 5:59 am (44.6%). The patient bed and bathroom were the most frequent locations for falls, accounting for 44.55% and 37.62% of the cases, respectively. More than 40% of the falls occurred when the patients were with their personal caregivers.

Conclusion

Although intervention programs can use these risk factors to target those who have a high risk of falling, to optimize resources, such programs should consider the fall patterns found in our study.

Hearing loss, gait and balance impairments and falls among individuals with sub-acute stroke: A comparative cross-sectional study

Background

The impact of hearing loss in stroke is less explored. This study aimed to compare hearing loss in patients with sub-acute stroke with healthy controls and evaluate its association with gait and balance impairments and falls.

Methods

This study involved 78 ambulant sub-acute stroke patients and 78 age-sex-matched controls. Hearing loss was assessed with pure tone average, while gait and balance impairments were assessed with the Timed Up and Go test, Berg Balance Scale, Functional Gait Assessment and 10-m walk test (gait speed). Fall occurrence was evaluated by a self-report questionnaire.

Results

The prevalence of hearing loss (pure tone average of >25 dB) was higher in stroke patients than in controls (64.1% vs. 35.9%; p < 0.001). The mean pure tone average of stroke patients showed a significant positive correlation with Timed Up and Go test (r = 0.357; p = 0.001) and fall occurrence (r = 0.253; p = 0.025), and a significant negative correlation with Berg Balance Scale (r = -0.299; p = 0.008) and Functional Gait Assessment (r = -0.452; p < 0.001). There was a non-significant negative correlation with gait speed (r = -0.166; p = 0.147). Multiple regression showed that mean pure tone average was associated with Timed Up and Go test (B = 0.096; 95%CI: 0.010, 0.183) and Functional Gait Assessment (B = -0.087; 95%CI: -0.157, -0.017), but not with gait speed (B = -0.003; 95%CI: -0.007, 0.001) and Berg Balance Scale (B = -0.058; 95%CI: -0.165, 0.049).

Conclusion

Hearing loss is more prevalent among patients with sub-acute stroke compared with age-sex-matched controls. Hearing loss is also associated with gait and balance impairments and falls among sub-acute stroke patients. We recommend that hearing screening and rehabilitation be incorporated into post-stroke rehabilitation programmes as part of strategies to improve balance and gait and reduce or prevent falls.

A systematic review of perturbation-based balance training on reducing fall risk among individuals with stroke

BACKGROUND

Perturbation-based balance training has been proven effective to reduce falls in older adults. However, it remains inconclusive if this training paradigm reduces falls in the stroke population. This review sought to summarize the existing literature to assess the effects of perturbation-based balance training on falls and some common fall risk factors in people with stroke.

METHODS

Seven databases were searched for studies, which included at least one perturbation-based balance training group and a control group. The primary outcome was the proportion of fallers, and the secondary outcomes encompassed commonly used fall risk factors: balance, balance confidence, reactive stepping characteristics, functional mobility, and muscle strength.

FINDINGS

This review included nine studies that enrolled 364 participants. The training protocols were significantly heterogeneous among studies, with variations in the training duration, number of sessions, session length, and type of devices used. The results indicated insufficient evidence supporting that perturbation-based balance training reduces falls in the laboratory and everyday living conditions for people with stroke. Furthermore, the effects of perturbation-based balance training on fall risk factors are also inconsistent between studies.

INTERPRETATION

The existing evidence does not conclusively support the reduction in falls and improvements in fall risk factors resulting from perturbation-based balance training among people with stroke. Such an inconsistent finding could be due to the small sample sizes and variations in perturbation-based balance training protocols across studies. More high-quality studies are needed to further determine the effects of perturbation-based balance training on reducing fall risk in people with stroke.

Fear of falling and associated factors among older adults in Southeast Asia: a systematic review

OBJECTIVES

The aim of this study was to provide a comprehensive overview of the prevalence, measurement scales, related factors and interventions for fear of falling (FOF) among older adults in Southeast Asia.

STUDY DESIGN

This was a systematic review.

METHODS

Published research studies on FOF among older adults were searched using the following databases: PubMed, Cochrane Library, Scopus, ASEAN Citation Index, Thai Journal Citation Index, Malaysian Journal Citation Report and Google Scholar. All observational and experimental studies investigating FOF among community-dwelling older adults in Southeast Asia were eligible. A narrative synthesis was used to describe the findings. The Joanna Briggs Institute checklist was used to assess the quality and risk of bias of the included studies.

RESULTS

A total of 15 observational studies and three experimental studies were included after screening 2112 titles and abstracts. These studies, published between 2011 and 2021, were conducted in Malaysia, Singapore, Thailand and Vietnam. The FOF prevalence ranged from 21.6% to 88.2%. The most commonly used FOF assessment tool was the Falls Efficacy Scale-International. Well-reported related factors of FOF were female sex, advanced age, balance impairment and fall history. All experimental studies utilising single- or multi-component interventions comprised an exercise approach. Limited studies have considered environmental factors.

CONCLUSIONS

Various related factors of FOF and the interventions implemented were revealed. Public health researchers and policymakers should consider the factors related to FOF in practical FOF intervention and prevention strategies. Further evidence on FOF issues is required to understand the multidimensional characteristics of FOF, specifically the environmental aspects of older adults in Southeast Asia.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cross-Cultural Adaptation and Reliability of the Home Falls and Accidents Screening Tool (HOME FAST) in Assessing Fall-Risk Home Hazards for Stroke Using Technologies over a Conventional Home Visit

Objective

This study is aimed at translating the Home Falls and Accidents Screening Tool (HOME FAST) into the three main languages spoken in Malaysia and investigating its reliability through an alternative technology-based evaluation.

Methods

Translation into three languages and cross-cultural adaptation of the HOME FAST was conducted via the five steps adopted from the Mapi Institute. For interrater reliability, occupational therapists who attended a face-to-face home hazard workshop were recruited. Each therapist rated the HOME FAST by using the provided combination of videos and photographs of stroke survivors manoeuvring in their home. For test-retest reliability, the same occupational therapists were invited to rate the same combination of photographs and videos again. Reliability was analysed using Gwet's AC₁ and Bland and Altman's plot to describe agreement.

Results

The translation challenges were minimal and rectifiable. A Bahasa Melayu, Mandarin, and Tamil versions of the HOME FAST were developed. Overall interrater reliability for both video (AC₁ = 0.91) and photograph (AC₁ = 0.91) were good. The test-retest reliability yielded similar outcome (video: overall AC₁ = 0.92 and photograph: overall AC₁ = 0.93).

Conclusion

Using alternative technology (video and photograph) to do a home hazard assessment was feasible. However, the asynchronous nature of these methods has limitations in clarifying certain aspects in the home. Moving forward, potential investigation on other technologies such as telehealth for synchronous and real-time interaction is warranted.

The Application of Technological Intervention for Stroke Rehabilitation in Southeast Asia: A Scoping Review With Stakeholders' Consultation

Background

The technological intervention is considered as an adjunct to the conventional therapies applied in the rehabilitation session. In most high-income countries, technology has been widely used in assisting stroke survivors to undergo their treatments. However, technology use is still lacking in Southeast Asia, especially in middle- and low-income countries. This scoping review identifies and summarizes the technologies and related gaps available in Southeast Asia pertaining to stroke rehabilitation.

Methods

The JBI manual for evidence synthesis was used to conduct a scoping study. Until September 2021, an electronic search was performed using four databases (Medline, CINAHL, Scopus, ASEAN Citation Index). Only the studies that were carried out in Southeast Asia were chosen.

Results

Forty-one articles were chosen in the final review from 6,873 articles found during the initial search. Most of the studies reported the implementation of technological intervention combined with conventional therapies in stroke rehabilitation. Advanced and simple technologies were found such as robotics, virtual reality, telerehabilitation, motion capture, assistive devices, and mobility training from Singapore, Thailand, Malaysia, and Indonesia. The majority of the studies show that technological interventions can enhance the recovery period of stroke survivors. The consultation session suggested that the technological interventions should facilitate the needs of the survivors, caregivers, and practitioners during the rehabilitation.

Conclusions

The integration of technology into conventional therapies has shown a positive outcome and show significant improvement during stroke recovery. Future studies are recommended to investigate the potential of home-based technological intervention and lower extremities.

Effect of Dual-Task Motor-Cognitive Training in Preventing Falls in Vulnerable Elderly Cerebrovascular Patients: A Pilot Study

Falling is a frequent and major clinical problem among older adults, as well as in patients with chronic cerebrovascular diseases (CVD). At present, sequential (mixed) and simultaneously (dual-task) motor-cognitive trainings are the best approaches to affording patients more autonomy in their everyday motor independence while reducing fall risks and consequences. The objective of this study was to evaluate the efficacy of an advanced and innovative dual-task motor-cognitive rehabilitation program on fall risks in vulnerable older persons with chronic CVD. To this purpose, 26 consecutive older fallers with chronic CVD were recruited, and completed a mixed motor-cognitive or a dual-task motor-cognitive training program. Each patient also underwent two test evaluations to assess balance, gait, fear of falling, and walking performance at pre-and post-intervention. We found that our experimental motor-cognitive dual-task rehabilitation program could be an effective method to improve walking balance, gait, walking speed, and fear of falling, while reducing the risk of falls in older people with chronic CVD. Furthermore, results show that the simultaneous motor-cognitive training is more effective than the sequential motor-cognitive training. Therefore, our study brings innovative data, which can contribute positively to the management of this population.