Frances Batchelor

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.

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.

The FLASSH study: protocol for a randomised controlled trial evaluating falls prevention after stroke and two sub-studies

BackgroundFalls are common in stroke survivors returning home after rehabilitation, however there is currently a lack of evidence about preventing falls in this population. This paper describes the study protocol for the FLASSH (FaLls prevention After Stroke Survivors return Home) project.Methods and designThis randomised controlled trial aims to evaluate the effectiveness of a multi-factorial falls prevention program for stroke survivors who are at high risk of falling when they return home after rehabilitation. Intervention will consist of a home exercise program as well as individualised falls prevention and injury minimisation strategies based on identified risk factors for falls. Additionally, two sub-studies will be implemented in order to explore other key areas related to falls in this population. The first of these is a longitudinal study evaluating the relationship between fear of falling, falls and function over twelve months, and the second evaluates residual impairment in gait stability and obstacle crossing twelve months after discharge from rehabilitation.DiscussionThe results of the FLASSH project will inform falls prevention practice for stroke survivors. If the falls prevention program is shown to be effective, low cost strategies to prevent falls can be implemented for those at risk around the time of discharge from rehabilitation, thus improving safety and quality of life for stroke survivors. The two sub-studies will contribute to the overall understanding and management of falls risk in stroke survivors.Trial registrationThis trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN012607000398404).

Individualized home-based exercise programs for older people to reduce falls and improve physical performance: A systematic review and meta-analysis

There is considerable diversity in the types of exercise programs investigated to reduce falls in older people. The purpose of this paper was to review the effectiveness of individualized (tailored) home-based exercise programs in reducing falls and improving physical performance among older people living in the community. A systematic review and meta-analysis was conducted of randomized or quasi-randomized trials that utilized an individualized home-based exercise program with at least one falls outcome measure reported. Single intervention exercise studies, and multifactorial interventions where results for an exercise intervention were reported independently were included. Two researchers independently rated the quality of each included study. Of 16,871 papers identified from six databases, 12 met all inclusion criteria (11 randomized trials and a pragmatic trial). Study quality overall was high. Sample sizes ranged from 40 to 981, participants had an average age 80.1 years, and although the majority of studies targeted the general older population, several studies included clinical groups as their target (Parkinsons disease, Alzheimers disease, and hip fracture). The meta-analysis results for the five studies reporting number of fallers found no significant effect of the intervention (RR [95% CI]=0.93 [0.72-1.21]), although when a sensitivity analysis was performed with one study of participants recently discharged from hospital removed, this result was significant (RR [95% CI] = 0.84 [0.72-0.99]). The meta-analysis also found that intervention led to significant improvements in physical activity, balance, mobility and muscle strength. There were no significant differences for measures of injurious falls or fractures.

Risk factors for falls in people with a lower limb amputation: a systematic review

To review the evidence connecting risk factors to falls in adults with a lower limb amputation (LLA) across the continuum of care settings.

Do continence management strategies reduce falls? a systematic review.

Urinary incontinence is associated with increased fall risk, and fall prevention programs include recommendations to manage continence as one component of fall reduction. However, the evidence to support this recommendation is unclear. The aim of this study was to identify continence management interventions that are effective in decreasing falls. A systematic review of the literature was conducted. Studies were included if they evaluated the effect of any type of continence management strategy on falls in older adults. The included studies were assessed for quality, and data relating to participants, interventions and outcomes were extracted by two independent reviewers. Four articles met the inclusion criteria. Two studies were randomised controlled trials, one a retrospective cohort study and one an uncontrolled intervention study. Interventions included pharmacological agents, a toileting regime combined with physical activity and an individualised continence program. Only the study evaluating the combination of physical activity and prompted voiding found an effect on falls. It is surprising that there has been so little research into continence management interventions that include fall outcomes. A toileting regime combined with physical activity may reduce falls in residential care. There is a need for further studies investigating the impact of continence management on falls.

Falls efficacy and fear of falling in stroke: issues with measurement and interpretation

We read with interest “Falls efficacy among stroke survivors living in the community” [1] which examined the important and complex issue of fear of falling or falls efficacy in community dwelling people with stroke. The findings of this study contribute to an increased knowledge of the factors associated with falls efficacy in people with stroke, but the conclusions are somewhat misleading as the authors have used the term “high falls efficacy” throughout the paper corresponding to high scores on the Falls Efficacy Scale International (FES-I). Higher scores on the FES-I indicate more concern about falling in daily life [2,3] and this was acknowledged by the authors; however, this equates to low falls efficacy not high falls efficacy. Those with low fall-related efficacy have less confidence or more fear of falling. The source of confusion may relate to the fact that high scores on some falls efficacy tools, such as one version of Tinetti’s Falls Efficacy Scale (FES [4]), the Modified Falls Efficacy Scale (MFES [5]) and the stroke specific Falls Efficacy Scale Swedish Modification (FES-S [6]), indicate high self-efficacy This contrasts with the original FES [7] and the more recently developed FES-I [2,3] where higher scores equate to lower efficacy. In addition, we have concerns about the classification of participants into high and low falls efficacy groups. Although a dichotomous classification such as this has been used in a previous study of falls efficacy in stroke [8], the present study by Tsai et al does so on the basis of half the maximum score rather than a cut-off point for 50% of the population under study. Until further research on the incidence and prevalence of fear of falling (or more specifically the levels of fall-related efficacy) in people with stroke is conducted, it is difficult to determine what constitutes “high” or “low” falls efficacy. Finally, we would like to highlight some aspects of terminology. Although the terms fear of falling and falls efficacy are often used interchangeably in the literature and are indeed related, they are not the same. Whereas fear of falling has been described as the psychological trauma associated with falling (whether or not a fall has occurred [7]), fall-related efficacy refers to perceived confidence in undertaking activities without falling and is based on Bandura’s concept of self-efficacy [9–11]. Additionally, measurement names do not always reflect what they are measuring: FES-I retains the term “efficacy” as part of its name for historical reasons, but measures concern about falling rather than fallrelated efficacy [2]. We encourage those researching this area to be clear in what they are evaluating, how the measure relates to the outcome under evaluation and how the results are interpreted.

Factors Predicting Falls and Mobility Outcomes in Patients With Stroke Returning Home After Rehabilitation Who Are at Risk of Falling

OBJECTIVE To identify factors predicting falls and limited mobility in people with stroke at 12 months after returning home from rehabilitation. DESIGN Observational cohort study with 12-month follow-up. SETTING Community. PARTICIPANTS People with stroke (N=144) and increased falls risk discharged home from rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Falls were measured using monthly calendars completed by participants, and mobility was assessed using gait speed over 5m (high mobility: >0.8m/s vs low mobility: ≤0.8m/s). Both measures were assessed at 12 months postdischarge. Demographics and functional measures, including balance, strength, visual or spatial deficits, disability, physical activity level, executive function, functional independence, and falls risk, were analyzed to determine factors significantly predicting falls and mobility levels after 12 months. RESULTS Those assessed as being at high falls risk (Falls Risk for Older People in the Community [FROP-Com] score≥19) were 4.5 times more likely to fall by 12 months (odds ratio [OR], 4.506; 95% confidence interval [CI], 1.71-11.86; P=.002). Factors significantly associated with lower usual gait speed (≤0.8m/s) at 12 months in the multivariable analysis were age (OR, 1.07; 95% CI, 1.01-1.14; P=.033), physical activity (OR, 1.09; 95% CI, 1.03-1.17, P=.007), and functional mobility (OR, .83; 95% CI, .75-.93; P=.001). CONCLUSIONS Several factors predicted falls and limited mobility for patients with stroke 12 months after rehabilitation discharge. These results suggest that clinicians should include assessment of falls risk (FROP-Com), physical activity, and dual-task Timed Up and Go test during rehabilitation to identify those most at risk of falling and experiencing limited mobility outcomes at 12 months, and target these areas during inpatient and outpatient rehabilitation to optimize long-term outcomes.

Preparing patients at high risk of falls for discharge home after rehabilitation: Do we meet the guidelines?

To determine whether rehabilitation inpatients at high risk of falls receive adequate falls risk assessment, management and handover on discharge as per Australian Best Practice Guidelines.