D. Hyndman

Predicting people with stroke at risk of falls

BACKGROUND falls are common following a stroke, but knowledge about predicting future fallers is lacking. OBJECTIVE to identify, at discharge from hospital, those who are most at risk of repeated falls. METHODS consecutively hospitalised people with stroke (independently mobile prior to stroke and with intact gross cognitive function) were recruited. Subjects completed a battery of tests (balance, function, mood and attention) within 2 weeks of leaving hospital and at 12 months post hospital discharge. RESULTS 122 participants (mean age 70.2 years) were recruited. Fall status at 12 months was available for 115 participants and of those, 63 [55%; 95% confidence interval (CI) 46-64] experienced one or more falls, 48 (42%; 95% CI 33-51) experienced repeated falls, and 62 (54%) experienced near-falls. All variables available at discharge were screened as potential predictors of falling. Six variables emerged [near-falling in hospital, Rivermead leg and trunk score, Rivermead upper limb score, Berg Balance score, mean functional reach, and the Nottingham extended activities of daily living (NEADL) score]. A score of near-falls in hospital and upper limb function was the best predictor with 70% specificity and 60% sensitivity. CONCLUSION participants who were unstable (near-falls) in hospital with poor upper limb function (unable to save themselves) were most at risk of falls.

Interference between balance, gait and cognitive task performance among people with stroke living in the community

Purpose. To explore differences in cognitive-motor interference between people with stroke and controls when performing functional tasks and to compare dual task performance of stroke fallers and non-fallers. Method. Thirty-six people with stroke (mean age 66.5, SD 11.8, mean time since onset 16 months, range 7 – 56) and 24 controls (mean age 62.3, SD 11.61) performed balance and gait tasks in isolation and in conjunction with a cognitive task (remembering a seven item-shopping list). Three-dimensional movement analysis was used to assess anterior posterior (AP) and lateral (ML) sway; 5 m walk time, stride length and velocity. Results. In the single task condition, people with stroke had greater AP sway, reduced velocity and stride length and a longer 5 m walk time than controls (p < 0.01). In the dual task condition, sway reduced and gait slowed in both groups (p < 0.01 for AP sway, stride length, velocity, walk time); only the increase in walk time was greater in people with stroke than in the controls (F = 4.2, p = 0.046). Cognitive performance was maintained during the balance trials but deteriorated during the dual task gait trials in people with stroke (p = 0.017). Similar trends were noted for fallers and non-fallers with stroke: Only group effects for stride length and velocity reached significance (p < 0.05) and only the reduction in stride length was significantly greater among fallers than non-fallers (F = 12.3, p = 0.001). Conclusions. People with stroke and controls employed similar strategies during the simultaneous performance of simple functional and silent cognitive tasks and maintained postural stability. Increased walk time and decreased cognitive recall were greater for people with stroke and reduced stride length distinguished fallers from non-fallers.

“Stops walking when talking” as a predictor of falls in people with stroke living in the community

Objective: To test “Stops walking when talking” (SWWT) as a predictor of falls among people with stroke living in the community. Methods: People with stroke were identified through hospital records. Mobility, ADL (activites of daily living) ability, mental state, mood, and SWWT were assessed in a single session. Participants were followed prospectively for six months, using falls diaries and regular telephone calls. Results: Sixty three participants (36 men, 27 women; mean (SD) age 68.4 (10.6)) were recruited. Four subjects had a brainstem lesion, 30 had right hemisphere, and 29 left hemisphere infarctions. Mean time since onset of stroke was 20 months (range 2–72). Twenty six subjects stopped walking when a conversation was started and 16 of them fell during the six month follow up period (11 experienced repeated falls). For all fallers (⩾1) the positive predictive value of SWWT was 62% (16/26), the negative predictive value 62% (23/37), specificity 70% (23/33) and sensitivity 53% (16/30). For repeat fallers (⩾2) the positive predictive value of SWWT was 42% (11/26), the negative predictive value 89% (33/37), specificity 69% (33/48) and sensitivity 73% (11/15). Those who stopped walking were significantly more disabled (p<0.001)—that is, they were more dependent in activities of daily living, had worse gross function as well as worse upper and lower limb function, and had depression (p = 0.012). Conclusions: The specificity of the SWWT test was lower but sensitivity was higher than previously reported. Although the SWWT test was easy to use, its clinical usefulness as a single indicator of fall risk in identifying those community dwelling people with stroke most at risk of falls and in need of therapeutic intervention is questionable.

The influence of attention deficits on functional recovery post stroke during the first 12 months after discharge from hospital

Background: Attention deficits have been linked to poor recovery after stroke and may predict outcome. We explored the influence of attention on functional recovery post stroke in the first 12 months after discharge from hospital. Methods: People with stroke completed measures of attention, balance, mobility and activities of daily living (ADL) ability at the point of discharge from hospital, and 6 and 12 months later. We used correlational analysis and stepwise linear regression to explore potential predictors of outcome. Results: We recruited 122 men and women, mean age 70 years. At discharge, 56 (51%) had deficits of divided attention, 45 (37%) of sustained attention, 43 (36%) of auditory selective attention and 41 (37%) had visual selective attention deficits. Attention at discharge correlated with mobility, balance and ADL outcomes 12 months later. After controlling for the level of the outcome at discharge, correlations remained significant in only five of the 12 relationships. Stepwise linear regression revealed that the outcome measured at discharge, days until discharge and number of medications were better predictors of outcome: in no case was an attention variable at discharge selected as a predictor of outcome at 12 months. Conclusions: Although attention and function correlated significantly, this correlation was reduced after controlling for functional ability at discharge. Furthermore, side of lesion and the attention variables were not demonstrated as important predictors of outcome 12 months later.

Reduced sway during dual task balance performance among people with stroke at 6 and 12 months after discharge from hospital

Background. Cognitive motor interference has been linked to poor recovery and falls. Little is known about recovery of dual-task balance ability poststroke. Methods. In this experimental study, postural sway was examined while standing on a force plate in preferred stance, with feet together, and with eyes closed, at 6 and 12 months postdischarge from hospital. Sway was assessed in isolation and while participants performed a cognitive (shopping list) task. Results . Seventy-six people with stroke (mean age 67 years; range, 21-91 years) took part. Fifty-four completed both assessments. When compared with the single task, sway during the dual-task condition was significantly lower in both the medial lateral (ML) and anterior posterior (AP) directions (both P < .0001). Sway in both directions was influenced by the difficulty of the balance task (both P < .0001). There was a trend of reduced sway at the 12-month assessment compared with the 6-month assessment: significant only in the ML direction (P = .0056). Repeat fallers swayed more than non—repeat fallers, with increases of 48% and 44% in the ML (P = .0262) and AP (P = .0134) directions, respectively. No significant variation in the dual-task reduction in sway was found: the dual-task effect was remarkably consistent over all the conditions tested, particularly in the AP direction. Conclusions. Sway decreased under dual-task conditions and changed as the difficulty of the balance task changed. Stroke fallers swayed more than nonfallers and there was evidence of a reduction in sway over time, particularly in the ML direction.

Rehabilitation content and clinical stroke subtype: a small observational study

Purpose. The Oxford classification categorises stroke according to clinical features. Differences in terms of mortality, institutionalisation, recurrence and achievement of mobility milestones have been demonstrated across clinical subtypes. This study aimed to describe differences in content of occupational therapy and physiotherapy activities, according to clinical stroke subtype. Method. This retrospective study forms part of a larger research project (n = 419). Ten patients from each of five clinical subtypes were randomly selected and therapy content was recoded from the medical notes using a coding tool. Results. The content of therapy sessions varied across subtypes, for both occupational therapy and physiotherapy sessions. Kruskal–Wallis analysis showed significant difference between subtypes for passive movements and transfers (p < 0.05) and standing balance, walking and stairs (p < 0.01). Similarly, significant differences between subtypes were seen in personal activities of daily living and the assessment or treatment of mood/cognitive problems (p < 0.05). Conclusions. The results show differences in the content of occupational and physiotherapy sessions across clinical stroke subtypes. Findings from this study could be used to help workforce planning and inform future studies with a larger sample.

Development of a assessment protocol to explore postural control and head activity in stroke using video analysis and CODAmotion

Background: This study examines the effect of additional trunk activity on trunk performance in subacute stroke patients in an inpatient rehabilitation setting. Methods: In addition to usual therapy, subjects randomly allocated to an experimental group (n = 14) received 4 times a week 30 min of hands-on trunk therapy, for 5 weeks. Patients in the control group (n = 11) received no additional therapy. Main outcome measures were the Trunk Impairment Scale (TIS) total and subscale scores (static and dynamic sitting balance and trunk coordination). Because of a significant difference in age between the experimental and control group, a 2-way ANCOVA analysis was used. Paired t tests evaluated the evolution in the experimental and control group separately. Results: A significant effect of additional trunk therapy was found for the dynamic sitting balance subscale of the TIS (P = 0.027). When looking at the experimental and control group separately, significant improvements were found for the dynamic sitting balance subscale in the experimental group (P < 0.0001), the coordination subscale in the experimental (P = 0.022) and control group (P < 0.0001) and the total TIS score for the experimental (P < 0.0001) and control group (P = 0.008). Conclusion: This pilot study indicates that there is a potentially beneficial effect of additional trunk rehabilitation for stroke patients. Clinical practice and stroke research would benefit from future studies with larger number of patients and a placebo treatment for the control group.Background: A major challenge in stroke rehabilitation is to minimize psychologic morbidity to promote the reintegration of stroke survivors into their family and community. The prevalence of depression among Chinese stroke survivors has been found to range from 17% to 63%, and a clear understanding of this and the factors influencing its outcome helps health care professionals plan effective interventions to minimize such psychologic consequences. Methods: This was a longitudinal study and data were collected from 206 stroke survivors during a period of 6 months after their discharge from 2 rehabilitation hospitals. Data collection took place in either the patient’s home or other discharge destination such as old age home. The majority of patients were male, married, and with a right-side stroke. Results: At 6 months after discharge, 71 (35%) of patients screened positive for depression and was found to be significantly related to handicap (r = –.50), state self-esteem (r = –.75), social support (r = –.62), and functional ability (r = –.30). Those who lived in an old age home were more likely to have mild to severe depression. Regression analysis indicated that handicap, state selfesteem, and social support were predictors of depression and accounted for 63% of the variance. Conclusion: The results highlight the importance of assessing and attending to the psychologic sequelae of stroke to promote successful recovery. This investigation was supported by HK Health Care and Promotion Fund.Background: To assess the outcome of systematic physical activity in water for stroke survivors on endurance, gait speed, mobility in water, spasticity, anxiety and quality of life. Methods: 11 stroke survivors (greater than 12 months poststroke) followed a program of water activities 3 to 4 times a week during a 5-week period. The activities were designed to help the participants: 1) be safe and comfortable in water, 2) achieve independent movement, and 3) improve their cardiorespiratory fitness level through actual swimming. Results: All participants completed the 5-week intervention. There were significant improvements in 6-min endurance walking, (39.1%; P < 0.01), gait speed (16.7%; P = 0.02), and speed for 10-m water movement (23.5%; P = 0.02). Indications of depression were absent at the end of intervention in those with an initial level. Follow- up after 7 weeks showed a significant improvement in 6-min walking speed compared to baseline (25.4%; P = 0.02) but no further change compared to the 5th week. Gait speed slightly decreased compared to 5 weeks but remained better than baseline (P = 0.07). Feeling of well-being did not increase after 5 weeks but did at follow-up (8.9%; P < 0.01). No changes in spasticity or in anxiety and other parts of the EQ-5D were demonstrated during or after the intervention. Conclusion: Systematic physical activities in water are well tolerated by chronic stroke survivors and tend to improve their fitness level as well as the feeling of well-being, without an increase in the level of spasticity.