Catherine M. Said

Falls after Stroke

Falls are common at all stages after stroke, occurring in the acute, rehabilitative, and chronic phases. Consequences of falls include death or serious injury, minor injuries, functional limitations, reduced mobility and activity, and fear of falling. These consequences can have implications for independence and quality of life after stroke. The high frequency of falls may be due to a combination of existing falls risk factors prior to the stroke as well as impairments from the stroke, such as decreased strength and balance, hemineglect, perceptual problems, and visual problems. This paper reviews the magnitude of the problem of falls in people with stroke, highlights risk factors, and summarizes the limited randomized controlled trial evidence on falls prevention in this population. There is a need for further high quality research investigating the effectiveness of interventions to reduce falls and injury in people with stroke from onset through to the chronic stage.

What Works in Falls Prevention After Stroke?: A Systematic Review and Meta-Analysis

Background and Purpose— Falls are common after stroke. Despite evidence that single and multifactorial interventions can reduce falls in older people, this issue remains relatively underexplored in stroke survivors. Effective fall prevention in this population has the potential to prevent injury, improve quality of life, and decrease the likelihood of subsequent fear of falling and activity restriction. The aim of this article was to review and integrate the research evidence relating to interventions that reduce falls after stroke. Methods— Published studies evaluating interventions to reduce falls in stroke survivors were retrieved and screened according to predetermined criteria. Included studies were independently assessed. Quality of trials was assessed using the Physiotherapy Evidence Database score. Pooling of results was undertaken for similar interventions with comparable outcomes using the inverse variance method. Results— Thirteen studies met the inclusion criteria, with pooling of results possible for only 2 types of intervention. Methodological quality of the included studies was variable with the main bias because of lack of blinding of participants and those administering the intervention. Variability in falls data reporting was seen across the studies. The only intervention shown to be effective in reducing falls was vitamin D for female stroke survivors in an institutional setting. Other interventions were no more effective than usual care. Conclusions— Fall risk is high in stroke survivors; however, the only intervention shown to be effective in reducing falls in this review was vitamin D supplementation. Consistency in outcome measurement would enable comparisons across studies. Additionally, further research evaluating a range of single and multifactorial interventions for fall prevention in the stroke population is required.

Obstacle crossing in subjects with stroke

OBJECTIVE To study the ability of subjects with stroke to successfully step over an obstacle during ambulation. SETTING A geriatric rehabilitation unit in a tertiary referral hospital. SUBJECTS Twenty-four inpatients with stroke (median time poststroke 27 days, interquartile range 21 to 44.5 days) able to walk 10 m unassisted without walking aids; also, 22 healthy subjects. METHOD Subjects were required to step over obstacles of various heights and widths, ranging from 1cm to 8cm. A fail was scored if the obstacle was contacted by either lower limb or if assistance or upper limb support was required. The choice of leading limb and the presence of visual deficits and neglect were also recorded in the stroke subjects. Subjects were tested on two occasions. RESULTS Significantly more fails were recorded for stroke subjects, with 13 subjects failing at least once. No preference was shown for leading either with the affected or with the unaffected leg. Stroke subjects showed inconsistent performance over the two testing sessions. CONCLUSION The ability to negotiate obstacles was compromised and inconsistent in stroke subjects undergoing inpatient rehabilitation. This suggests that gait safety in this population remains threatened.

Balance and mobility dysfunction and falls risk in older people with mild to moderate Alzheimer disease.

ObjectiveThis study aimed to identify the magnitude and type of balance and mobility impairments in people with Alzheimer disease by comparing their performance with that of older people without cognitive impairment. DesignTwenty-five community-dwelling people with mild to moderate Alzheimer disease and a comparison group of 25 cognitively intact age- and sex-matched people completed a comprehensive balance and mobility assessment. This included computerized posturography measures of static and dynamic balance under various conditions, clinical balance, and mobility measures, and measures of falls and falls risk. ResultsThe level of falls risk was higher in people with Alzheimer disease. Standing balance in people with Alzheimer disease was significantly impaired across a range of static and dynamic balance conditions. Activity level, gait, and mobility measures were also impaired, particularly turning and dual tasks. ConclusionsThe findings of the study highlight the value of including balance screening as a routine component of early dementia assessment. This would allow for the early detection of balance dysfunction and the introduction of balance retraining before impairments progress to more advanced levels.

Effectiveness and feasibility of virtual reality and gaming system use at home by older adults for enabling physical activity to improve health-related domains: a systematic review

BACKGROUND use of virtual reality and commercial gaming systems (VR/gaming) at home by older adults is receiving attention as a means of enabling physical activity. OBJECTIVE to summarise evidence for the effectiveness and feasibility of VR/gaming system utilisation by older adults at home for enabling physical activity to improve impairments, activity limitations or participation. METHODS a systematic review searching 12 electronic databases from 1 January 2000-10 July 2012 using key search terms. Two independent reviewers screened yield articles using pre-determined selection criteria, extracted data using customised forms and applied the Cochrane Collaboration Risk of Bias Tool and the Downs and Black Checklist to rate study quality. RESULTS fourteen studies investigating the effects of VR/gaming system use by healthy older adults and people with neurological conditions on activity limitations, body functions and physical impairments and cognitive and emotional well-being met the selection criteria. Study quality ratings were low and, therefore, evidence was not strong enough to conclude that interventions were effective. Feasibility was inconsistently reported in studies. Where feasibility was discussed, strong retention (≥70%) and adherence (≥64%) was reported. Initial assistance to use the technologies, and the need for monitoring exertion, aggravation of musculoskeletal symptoms and falls risk were reported. CONCLUSIONS existing evidence to support the feasibility and effectiveness VR/gaming systems use by older adults at home to enable physical activity to address impairments, activity limitations and participation is weak with a high risk of bias. The findings of this review may inform future, more rigorous research.

Smart-home technologies to assist older people to live well at home

Background: With the rapid population ageing that is occurring world-wide, there is increasing interest in “smart home” technologies that can assist older adults to continue living at home with safety and independence. This systematic review and critical evaluation of the world wide literature assesses the effectiveness and feasibility of smart-home technologies for promoting independence, health, well-being and quality of life, in older adults. Methods: A total of 1877 “smart home” publications were identified by the initial search of peer reviewed journals. Of these, 21 met our inclusion criteria for the review and were subject to data extraction and quality assessment. Results: Smart-home technologies included different types of active and passive sensors, monitoring devices, robotics and environmental control systems. One study assessed effectiveness of a smart home technology. Sixteen reported on the feasibility of smart-home technology and four were observational studies. Conclusion: Older adults were reported to readily accept smart-home technologies, especially if they benefited physical activity, independence and function and if privacy concerns were addressed. Given the modest number of objective analyses, there is a need for further scientific analysis of a range of smart home technologies to promote community living.

Feasibility, safety and preliminary evidence of the effectiveness of a home-based exercise programme for older people with Alzheimer’s disease: a pilot randomized controlled trial

Objective: To evaluate the feasibility and safety of a home-based exercise programme for people with Alzheimer’s disease, and to provide preliminary evidence of programme effectiveness in improving balance and mobility and reducing falls risk. Design: A randomized controlled trial. Setting: Community. Participants: Forty people with mild to moderate Alzheimer’s disease (mean age 81.9, SD 5.72; 62.5% female). Interventions: Participants were randomized to a six-month home-based individually tailored balance, strengthening and walking exercise programme (physiotherapist) or a six-month home-based education programme (control) (occupational therapist). Both programmes provided six home-visits and five follow-up phone calls. Main measures: Balance, mobility, falls and falls risk were measured at baseline and programme completion. Intention-to-treat analysis using a generalized linear model with group allocation as a predictor variable was performed to evaluate programme effectiveness. Feasibility and adverse events were systematically recorded at each contact. Results: Fifty-eight per cent of the exercise group finished the programme, completing an average of 83% of prescribed sessions, with no adverse events reported. Functional Reach improved significantly (P = 0.002) in the exercise group (mean (SD), 2.28 (4.36)) compared to the control group (–2.99 (4.87)). Significant improvement was also observed for the Falls Risk for Older People – Community score (P = 0.008) and trends for improvement on several other balance, mobility, falls and falls risk measures for the exercise group compared to the control group. Conclusions: The exercise programme was feasible and safe and may help improve balance and mobility performance and reduce falls risk in people with Alzheimer’s disease.

Physical activity by elderly patients undergoing inpatient rehabilitation is low: an observational study

QUESTION Are there differences in physical activity between older adults undergoing inpatient rehabilitation and those living in the community? Are there differences in physical activity within and between these two groups on weekdays compared to weekends? Are there differences in physical activity within and between these two groups over the day? DESIGN An observational study. PARTICIPANTS Twenty-five elderly patients (aged 81 years) undergoing rehabilitation and 25 age- and gender-matched community-dwelling people (aged 80 years). OUTCOME MEASURES The Positional Activity Logger was used to measure the frequency and duration of time spent upright (uptime), over three consecutive days, including a weekend day. RESULTS The inpatient group achieved a median daily uptime of 1.3 hours which was significantly less than the community groups median of 5.5 hours (p < 0.001). Uptime for inpatients was significantly greater on weekdays (1.6 hours) when therapy was available than on weekend days (1.1 hours) when therapy was generally not available (p < 0.001), whereas uptime for community participants was no different on weekdays (5.9 hours) than on weekend days (4.8 hours) (p = 0.05). Median uptime was significantly less for the inpatient group than for the community group at all times of day (p < 0.001). CONCLUSION Elderly patients undergoing rehabilitation spend much of the day less physically active than their community peers.

Effects of a Multifactorial Falls Prevention Program for People With Stroke Returning Home After Rehabilitation: A Randomized Controlled Trial

OBJECTIVES To determine whether a multifactorial falls prevention program reduces falls in people with stroke at risk of recurrent falls and whether this program leads to improvements in gait, balance, strength, and fall-related efficacy. DESIGN A single blind, multicenter, randomized controlled trial with 12-month follow-up. SETTING Participants were recruited after discharge from rehabilitation and followed up in the community. PARTICIPANTS Participants (N=156) were people with stroke at risk of recurrent falls being discharged home from rehabilitation. INTERVENTIONS Tailored multifactorial falls prevention program and usual care (n=71) or control (usual care, n=85). MAIN OUTCOME MEASURES Primary outcomes were rate of falls and proportion of fallers. Secondary outcomes included injurious falls, falls risk, participation, activity, leg strength, gait speed, balance, and falls efficacy. RESULTS There was no significant difference in fall rate (intervention: 1.89 falls/person-year, control: 1.76 falls/person-year, incidence rate ratio=1.10, P=.74) or the proportion of fallers between the groups (risk ratio=.83, 95% confidence interval=.60-1.14). There was no significant difference in injurious fall rate (intervention: .74 injurious falls/person-year, control: .49 injurious falls/person-year, incidence rate ratio=1.57, P=.25), and there were no significant differences between groups on any other secondary outcome. CONCLUSIONS This multifactorial falls prevention program was not effective in reducing falls in people with stroke who are at risk of falls nor was it more effective than usual care in improving gait, balance, and strength in people with stroke. Further research is required to identify effective interventions for this high-risk group.

Retest reliability of balance and mobility measurements in people with mild to moderate Alzheimer’s disease

BACKGROUND To interpret changes of balance and mobility in people with Alzheimers disease (AD), we require measures of balance and mobility that have demonstrated reliability in this population. The aim of the study was to determine the safety, feasibility and retest reliability of clinical and forceplate balance and mobility measurements in people with AD. METHODS Relative and absolute reliabilities were examined in 14 older people with mild to moderate AD. Relative reliability was calculated using the intraclass correlation coefficient, two-way mixed model (ICC3,1). Absolute reliability was calculated using the standard error of measurement (SEM), the minimum detectable change (MDC) and the coefficient of variation (CV). RESULTS All measurements were clinically feasible and could be safely administered. ICC values were excellent and CVs were less than 11% in all clinical balance and mobility measures except the Timed Up & Go test with cognitive or manual task (ICC3,1 = 0.5 and 0.7, and CV = 14% and 10%, respectively). Most balance and mobility measures tested on the Neurocom™ forceplate (modified Clinical Test of Sensory Interaction on Balance, Walk Across (step width, step length parameters), and Sit to Stand (rising index parameter)) had excellent relative reliability (ICC3,1 ranging from 0.75 to 0.91). ICC values were fair to good for the other measures. CONCLUSIONS Retest reliability of the balance and mobility measures used in this study ranged between fair to good, and good to excellent. Clinicians should consider retest reliability when deciding which balance and mobility measures are used to assess people with AD.