Shylie Mackintosh

Falls and injury prevention should be part of every stroke rehabilitation plan

Objective: To evaluate falls incidence, circumstances and consequences in people who return home after stroke rehabilitation, so that appropriate falls and injury prevention strategies can be developed. Design: Prospective cohort study. Setting: Community. Subjects: Fifty-six subjects with stroke who were participating in a rehabilitation programme and returning to live in a community setting completed the study. Main measures: Subjects completed a prospective falls diary for six months after discharge from rehabilitation, and were interviewed after falls. Physical function was measured by the Berg Balance Scale (BBS) and the Functional Independence Measure (FIM). Results: Forty-six per cent of people (26/56) fell, with most falls (63/103 falls) occurring in the two months after discharge from rehabilitation. One subject had 37 similar falls and these falls were excluded from further analysis. Falls occurred more often indoors (50/66), during the day (46/66) and towards the paretic side (25/66). People required assistance to get up after 25 falls (38%) and 36 falls (55%) resulted in an injury. People sought professional health care after only 16 falls, and activity was restricted after 29 falls (44%). The Berg Balance Scale and Functional Independence Measure scores were lower in people who had longer lies after a fall, and who restricted their activity after a fall (p < 0.05). Lower physical function scores were also associated with falling in the morning, wearing multifocal glasses at the time of a fall, and injurious falls (p < 0.05). Conclusion: Falls are common when people return home after stroke. Of concern are the small number seeking health professionals’ assistance after a fall, the high proportion restricting their activity as a result of a fall and the number of falls occurring towards the paretic side.

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.

Functional Independence Measure

Recommended Instrument for CP, CM, SCI-Pediatric, and TBI Page 1 of 3 Availability: The FIM is proprietary. For further information about obtaining the scale, syllabus, and training materials please contact: Uniform Data System for Medical Rehabilitation 270 Northpointe Parkway, Suite 300 Amherst, New York 14228 (716) 817-7800 FAX (716) 568-0037 Email: info@udsmr.org Web site: Please click here for more information about the Functional Independence Measure Classification: Supplemental: Cerebral Palsy (CP), Chairi I Malformation (CM), Spinal Cord Injury (SCI)-Pediatric (age 0 to 7 years), Traumatic Brain Injury (TBI)

Aerobic Exercise to Improve Cognitive Function in Adults With Neurological Disorders: A Systematic Review

OBJECTIVE To evaluate whether aerobic exercise improves cognition in adults diagnosed with neurologic disorders. DATA SOURCES The Cochrane Central Register of Controlled Clinical Trials, MEDLINE, CINAHL, PubMed, EMBASE, PEDro, AMED, SPORTDiscus, PsycINFO, ERIC, and Google Scholar, with the last search performed in December 2010. STUDY SELECTION We included controlled clinical trials and randomized controlled trials with adults diagnosed with a neurologic disorder. Studies were included if they compared a control group with a group involved in an aerobic exercise program to improve cardiorespiratory fitness and if they measured cognition as an outcome. DATA EXTRACTION Two reviewers independently extracted data and methodologic quality of the included trials. DATA SYNTHESIS From the 67 trials reviewed, a total of 7 trials, involving 249 participants, were included. Two trials compared the effectiveness of yoga and aerobic exercise in adults with multiple sclerosis. Two trials evaluated the effect of exercise on patients with dementia, and 2 trials evaluated the effectiveness of exercise to improve cognition after traumatic brain injury. One trial studied the effect of a cycling program in people with chronic stroke. Lack of commonality between measures of cognition limited meta-analyses. Results from individual studies show that aerobic exercise improved cognition in people with dementia, improved attention and cognitive flexibility in patients with traumatic brain injury, improved choice reaction time in people with multiple sclerosis, and enhanced motor learning in people with chronic stroke. CONCLUSIONS There is limited evidence to support the use of aerobic exercise to improve cognition in adults with neurologic disorders. Of the 67 studies retrieved, less than half included cognition as an outcome, and few studies continued the aerobic exercise program long enough to be considered effective. Further studies investigating the effect of aerobic exercise interventions on cognition in people with neurologic conditions are required.

Falls incidence and factors associated with falling in older, community-dwelling, chronic stroke survivors (>1 year after stroke) and matched controls

Background and aims: Using data from the Australian Longitudinal Study of Ageing, this study aimed at: 1) investigating differences in the incidence of falls between chronic Stroke subjects (n=181) and matched Non-stroke subjects (n=181) who were 65 years or older and community dwellers, and 2) establishing factors associated with falling within chronic Stroke subjects. Methods: Subjects reporting a history of stroke 12 or more months ago, and age- and gender-matched Non-stroke subjects were extracted from the first wave of the Australian Longitudinal Study of Ageing database. Falls incidence and factors associated with falling were examined. Falls data were collected based on recall of the number of falls in the past year, including falls that did not result in injury. Results: Significantly more Stroke subjects reported falling in the previous twelve months than Non-stroke subjects (36 vs 24%, p<0.05). When comparing Stroke Fallers to Stroke Non-fallers within the Stroke group, Stroke Fallers were significantly more likely to report (i) difficulty in stooping or kneeling, (ii) getting up in the night to urinate more than once, and (iii) having a greater number of Instrumental Activities of Daily Living problems (p<0.05). Self-reported difficulty in stooping or kneeling was the most significant factor associated with falling in the Stroke group (OR 2.44, 95% CI 1.30–4.58). Conclusions: Falls are a problem for community dwelling older people with chronic stroke and are associated with physical function difficulties. Factors identified in this and other similar studies should form the basis for targeted falls prevention programs in this high falls risk clinical group.

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.

Differences in foot kinematics between young and older adults during walking

Our understanding of age-related changes to foot function during walking has mainly been based on plantar pressure measurements, with little information on differences in foot kinematics between young and older adults. The purpose of this study was to investigate the differences in foot kinematics between young and older adults during walking using a multi-segment foot model. Joint kinematics of the foot and ankle for 20 young (mean age 23.2 years, standard deviation (SD) 3.0) and 20 older adults (mean age 73.2 years, SD 5.1) were quantified during walking with a 12 camera Vicon motion analysis system using a five segment kinematic model. Differences in kinematics were compared between older adults and young adults (preferred and slow walking speeds) using Students t-tests or if indicated, Mann-Whitney U tests. Effect sizes (Cohens d) for the differences were also computed. The older adults had a less plantarflexed calcaneus at toe-off (-9.6° vs. -16.1°, d = 1.0, p = <0.001), a smaller sagittal plane range of motion (ROM) of the midfoot (11.9° vs. 14.8°, d = 1.3, p = <0.001) and smaller coronal plane ROM of the metatarsus (3.2° vs. 4.3°, d = 1.1, p = 0.006) compared to the young adults. Walking speed did not influence these differences, as they remained present when groups walked at comparable speeds. The findings of this study indicate that independent of walking speed, older adults exhibit significant differences in foot kinematics compared to younger adults, characterised by less propulsion and reduced mobility of multiple foot segments.

Foot orthoses for adults with flexible pes planus: a systematic review

BackgroundFoot orthoses are widely used in the management of flexible pes planus, yet the evidence to support this intervention has not been clearly defined. This systematic review aimed to critically appraise the evidence for the use of foot orthoses for flexible pes planus in adults.MethodsElectronic databases (Medline, CINAHL, Cochrane, Web of science, SportDiscus, Embase) were systematically searched in June 2013 for randomised controlled, controlled clinical and repeated measure trials where participants had identified flexible pes planus using a validated and reliable measure of pes planus and the intervention was a rigid or semi-rigid orthoses with the comparison being a no-orthoses (shoes alone or flat non-posted insert) condition. Outcomes of interest were foot pain, rearfoot kinematics, foot kinetics and physical function.ResultsOf the 2,211 articles identified by the searches, 13 studies met the inclusion criteria; two were randomised controlled trials, one was a controlled trial and 10 were repeated measure studies. Across the included studies, 59 relevant outcome measures were reported with 17 calculated as statistically significant large or medium effects observed with use of foot orthoses compared to the no orthoses condition (SMD range 1.13 to -4.11).ConclusionsNo high level evidence supported the use of foot orthoses for flexible pes planus. There is good to moderate level evidence that foot orthoses improve physical function (medial-lateral sway in standing (level II) and energy cost during walking (level III)). There is low level evidence (level IV) that foot orthoses improve pain, reduce rearfoot eversion, alter loading and impact forces; and reduce rearfoot inversion and eversion moments in flexible pes planus. Well-designed randomised controlled trials that include appropriate sample sizes, clinical cohorts and involve a measure of symptom change are required to determine the efficacy of foot orthoses to manage adult flexible pes planus.

Individual nutrition therapy and exercise regime: A controlled trial of injured, vulnerable elderly (INTERACTIVE trial)

BackgroundProximal femoral fractures are amongst the most devastating consequences of osteoporosis and injurious accidental falls with 25–35% of patients dying in the first year post-fracture. Effective rehabilitation strategies are evolving however, despite established associations between nutrition, mobility, strength and strength-related functional outcomes; there has been only one small study with older adults immediately following fragility fracture where a combination of both exercise and nutrition have been provided. The aim of the INTERACTIVE trial is to establish whether a six month, individualised exercise and nutrition program commencing within fourteen days of surgery for proximal femur fracture, results in clinically and statistically significant improvements in physical function, body composition and quality of life at an acceptable level of cost and resource use and without increasing the burden of caregivers.Methods and DesignThis randomised controlled trial will be performed across two sites, a 500 bed acute hospital in Adelaide, South Australia and a 250 bed acute hospital in Sydney, New South Wales. Four hundred and sixty community-dwelling older adults aged > 70 will be recruited after suffering a proximal femoral fracture and followed into the community over a 12-month period. Participants allocated to the intervention group will receive a six month individualised care plan combining resistance training and nutrition therapy commencing within 14 days post-surgery. Outcomes will be assessed by an individual masked to treatment allocation at six and 12 months. To determine differences between the groups at the primary end-point (six months), ANCOVA or logistic regression will be used with models adjusted according to potential confounders.DiscussionThe INTERACTIVE trial is among the first to combine nutrition and exercise therapy as an early intervention to address the serious consequence of rapid deconditioning and weight loss and subsequent ability to regain pre-morbid function in older patients post proximal femoral fracture. The results of this trial will guide the development of more effective rehabilitation programs, which may ultimately lead to reduced health care costs, and improvements in mobility, independence and quality of life for proximal femoral fracture sufferers.Trial registrationAustralian Clinical Trials Registry: ACTRN12607000017426.