Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers

Chronic stroke patients show early and robust improvements in muscle and functional performance in response to eccentric-overload flywheel resistance training: a pilot study

BACKGROUND

Resistance exercise comprising eccentric (ECC) muscle actions enhances muscle strength and function to aid stroke patients in conducting daily tasks. The purpose of this study was to assess the efficacy of a novel ECC-overload flywheel resistance exercise paradigm to induce muscle and functional performance adaptations in chronic stroke patients.

METHODS

Twelve patients (~8 years after stroke onset) performed 4 sets of 7 coupled concentric (CON) and ECC actions using the affected limb on a flywheel leg press (LP) device twice weekly for 8 weeks. Maximal CON and ECC isokinetic torque at 30, 60 and 90°/s, isometric knee extension and LP force, and CON and ECC peak power in LP were measured before and after training. Balance (Berg Balance Scale, BBS), gait (6-Min Walk test, 6MWT; Timed-Up-and-Go, TUG), functional performance (30-s Chair-Stand Test, 30CST), spasticity (Modified Ashworth Scale) and perceived participation (Stroke Impact Scale, SIS) were also determined.

RESULTS

CON and ECC peak power increased in both the trained affected (34 and 44%; P < 0.01), and the untrained, non-affected leg (25 and 34%; P < 0.02). Power gains were greater (P = 0.008) for ECC than CON actions. ECC isokinetic torque at 60 and 90°/s increased in the affected leg (P < 0.04). The increase in isometric LP force for the trained, affected leg across tests ranged 10-20% (P < 0.05). BBS (P = 0.004), TUG (P = 0.018), 30CST (P = 0.024) and SIS (P = 0.058) scores improved after training. 6MWT and spasticity remained unchanged.

CONCLUSIONS

This novel, short-term ECC-overload flywheel RE training regime emerges as a valid, safe and viable method to improve muscle function, balance, gait and functional performance in men and women suffering from chronic stroke.

Effect of a 2-week trial of functional electrical stimulation on gait function and quality of life in people with multiple sclerosis

BACKGROUND

Footdrop is a common gait deviation in people with multiple sclerosis (MS) leading to impaired gait and balance as well as decreased functional mobility. Functional electrical stimulation (FES) provides an alternative to the current standard of care for footdrop, an ankle-foot orthosis (AFO). FES stimulates the peroneal nerve and activates the dorsiflexor muscles, producing an active toe clearance and a more normal gait. This study was undertaken to determine the effects of a 2-week FES Home Assessment Program on gait speed, perceived walking ability, and quality of life (QOL) among people with MS-related footdrop.

METHODS

Participants completed the Timed 25-Foot Walk test (T25FW) and two self-report measures: 12-item Multiple Sclerosis Walking Scale (MSWS-12) and 29-item Multiple Sclerosis Impact Scale (MSIS-29). Measures were taken without FES before and with FES after 2 weeks of full-time FES wear.

RESULTS

A total of 19 participants (10 female, 9 male) completed the study; mean age and duration of disease were 51.77 ± 10.16 and 9.01 ± 7.90 years, respectively. Use of FES for 2 weeks resulted in a significant decrease in time to complete the T25FW (P < .0001), the MSWS-12 standardized score (P < .0001), and the MSIS-29 total (P < .0001), Physical subscale (P < .0001), and Psychological subscale (P = .0006) scores.

CONCLUSIONS

These results suggest that use of FES can significantly improve gait speed, decrease the impact of MS on walking ability, and improve QOL in people with MS-related footdrop even over a short period of time.

Circumstances and consequences of falls among people with chronic stroke

Falls are common after stroke; however, circumstances and consequences are relatively unknown. Our objectives were to identify the differences between fallers and non-fallers among people with chronic stroke, identify the circumstances of fall events, and examine the consequences of the falls. This is a secondary data analysis; all participants included sustained a stroke. Variables included demographics, stroke characteristics, and comorbidities. Falls were collected via self-report, and circumstances and consequences were derived from participant description of the event and categorized as appropriate. Among 160 participants, 53 (33%) reported a fall during the 1 yr period. Circumstances of falls were categorized as intrinsic or extrinsic. Location and circumstance of the fall were included: 70% occurred at home and 40% were associated with impaired physical or mental state (e.g., inattention to tying shoes). Additionally, 21% of falls were associated with activities of daily living and mobility and 34% with slips or trips. The majority who fell sustained an injury (72%). Injuries ranged from bruising to fractures, and 55% of those with an injury sought medical care (32% to emergency department). Poststroke falls are associated with an alarming rate of injury and healthcare utilization. Targeting mental and physical states may be key to fall prevention.

Simulated visual field loss does not alter turning coordination in healthy young adults

Turning, while walking, is an important component of adaptive locomotion. Current hypotheses regarding the motor control of body segment coordination during turning suggest heavy influence of visual information. The authors aimed to examine whether visual field impairment (central loss or peripheral loss) affects body segment coordination during walking turns in healthy young adults. No significant differences in the onset time of segments or intersegment coordination were observed because of visual field occlusion. These results suggest that healthy young adults can use visual information obtained from central and peripheral visual fields interchangeably, pointing to flexibility of visuomotor control in healthy young adults. Further study in populations with chronic visual impairment and those with turning difficulties are warranted.

Effects of dual task on turning ability in stroke survivors and older adults

BACKGROUND

Turning is an integral component of independent mobility in which stroke survivors frequently fall.

OBJECTIVE

This study sought to measure the effects of competing cognitive demands on the stepping patterns of stroke survivors, compared to healthy age-match adults, during turning as a putative mechanism for falls.

METHODS

Walking and turning (90°) was assessed under single (walking and turning alone) and dual task (subtracting serial 3s while walking and turning) conditions using an electronic, pressure-sensitive walkway. Dependent measures were time to turn, variability in time to turn, step length, step width and single support time during three steps of the turn. Turning ability in single and dual task conditions was compared between stroke survivors (n=17, mean ± SD: 59 ± 113 months post-stroke, 64 ± 10 years of age) and age-matched healthy counterparts (n=15).

RESULTS

Both groups took longer, were more variable, tended to widen the second step and, crucially, increased single support time on the inside leg of the turn while turning and distracted.

CONCLUSIONS

Increased single support time during turning may represent biomechanical mechanism, within stepping patterns of turning under distraction, for increased risk of falls for both stroke survivors and older adults.

Scoping review of common secondary conditions after stroke and their associations with age and time post stroke

BACKGROUND

Health care providers need to be alert to secondary conditions that might develop after stroke so that these conditions can be prevented or treated early to reduce further deterioration of health and quality of life.

OBJECTIVES

To review and describe the prevalence of secondary conditions after stroke and to summarize associations between secondary conditions and age and time post stroke.

METHODS

A scoping review of studies pertaining to secondary conditions after stroke published between 1986 and 2011 was conducted.

RESULTS

Seventy-six articles provided information regarding 6 secondary conditions: depression, pain, falls, fatigue, bowel/bladder problems, and sleep difficulties. Prevalence varied widely across studies for each condition. The limited repeated-measures evidence suggests that secondary conditions tend to occur in the first weeks or months post stroke and may remain relatively stable over time. Other evidence from regression analyses suggests either no significant associations between time post stroke or age or mixed results. Secondary conditions appear to be most commonly associated with severity of impairments.

CONCLUSIONS

Health care providers need to be alert to the development of secondary conditions after stroke in individuals as they age as well as in the poststroke time span. Obtaining a clear understanding of the prevalence of secondary conditions and associations with age and time post stroke is difficult because of variations in research methodologies. Future research is needed to define secondary condition prevalence and risk factors more clearly and to identify interventions that could reduce the prevalence and impact of these conditions on quality of life.

The effects of peroneal nerve functional electrical stimulation versus ankle-foot orthosis in patients with chronic stroke: a randomized controlled trial

BACKGROUND

Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist.

OBJECTIVE

To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke.

METHODS

In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority.

RESULTS

A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found.

CONCLUSIONS

Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance.

Walking adaptability after a stroke and its assessment in clinical settings

Control of walking has been described by a tripartite model consisting of stepping, equilibrium, and adaptability. This review focuses on walking adaptability, which is defined as the ability to modify walking to meet task goals and environmental demands. Walking adaptability is crucial to safe ambulation in the home and community environments and is often severely compromised after a stroke. Yet quantification of walking adaptability after stroke has received relatively little attention in the clinical setting. The objectives of this review were to examine the conceptual challenges for clinical measurement of walking adaptability and summarize the current state of clinical assessment for walking adaptability. We created nine domains of walking adaptability from dimensions of community mobility to address the conceptual challenges in measurement and reviewed performance-based clinical assessments of walking to determine if the assessments measure walking adaptability in these domains. Our literature review suggests the lack of a comprehensive well-tested clinical assessment tool for measuring walking adaptability. Accordingly, recommendations for the development of a comprehensive clinical assessment of walking adaptability after stroke have been presented. Such a clinical assessment will be essential for gauging recovery of walking adaptability with rehabilitation and for motivating novel strategies to enhance recovery of walking adaptability after stroke.

Falls and Use of Assistive Devices in Stroke Patients with Hemiparesis: Association with Balance Ability and Fall Efficacy

PURPOSE

This study investigates balance ability and the fall efficacy with regard to the experiences of stroke patients with hemiparesis.

METHODS

The experience of falling, the use of assistive devices, and each disease-related characteristic were assessed using face-to-face interviews and a self-reported questionnaire. The Berg Balance Scale and Fall Efficacy Scale were used to measure balance ability and confidence.

RESULTS

The fall efficacy was significantly lower in participants who had experienced falls than those who had not. The participants who used assistive devices exhibited low balance ability and fall efficacy compared to those who did not use assistive devices.

CONCLUSIONS

Stroke patients with fall experience and walking aids might be considered at increased risk of falling.

CLINICAL RELEVANCE

Preventive measures for individuals using walking aids may be beneficial in reducing the fall rate of community-dwelling stroke patients.

The effect of underwater gait training on balance ability of stroke patients

[Purpose] The purpose of this study was to investigate the effects of underwater treadmill gait training on the balance ability of stroke patients. [Subjects] Twenty-two patients with stroke were randomly assigned to an underwater treadmill group (n =11) or a control group (n =11). [Methods] Both groups received general rehabilitation for 30 min per session, 5 times per week, over a 4-week period. The underwater treadmill group received additional underwater gait training for 30 min per session, 5 times per week, over the same 4-week period. Static and dynamic balances were evaluated before and after the intervention. [Results] The means of static and dynamic balance ability increased significantly in both groups, but there was no significant difference between the two groups. [Conclusion] Compared to the general rehabilitation program, underwater treadmill gait training was not more effective at improving the balance ability of stroke patients than land-based training.

Factors affecting falls in community-dwelling individuals with stroke in Singapore after hospital discharge

INTRODUCTION

This study aimed to investigate the factors affecting the incidence of falls among individuals with stroke living in the community one year after discharge from a rehabilitation hospital in Singapore.

METHODS

A cross-sectional telephone survey of individuals with stroke living in the community was carried out one year after discharge. The interview covered aspects such as incidence and circumstances of fall, use of walking aids, and presence of environmental obstacles. Each participant's case record was retrospectively reviewed using discharge Fugl-Meyer (FM) assessment of the upper and lower limbs, functional independence measure (FIM) and Berg Balance Scale (BBS).

RESULTS

A total of 126 individuals with stroke were interviewed. Overall, 24% fell in the year following their discharge. Factors associated with falls were longer length of hospital stay, lower BBS and lower-limb FM scores, and lower discharge FIM scores for the Bladder and Bowel Management, Transfer, Mobility, Communication, and Social Cognition domains (p < 0.05). The fallers were more likely to use walking aids, and required help with basic activities of daily living after discharge (p < 0.05). Multivariate logistic regression analysis revealed that only the Transfer domain was an independent factor for falls.

CONCLUSION

Discharge FIM outcomes, especially for the Transfer domain, can be used to identify communitydwelling individuals with stroke who have a high fall risk after discharge. Identification of such individuals will enable early fall prevention management, which will in turn minimise fall events in the community.

A novel video-based paradigm to study the mechanisms underlying age- and falls risk-related differences in gaze behaviour during walking

PURPOSE

The current study aimed to quantitatively assess differences in gaze behaviour between participants grouped on the basis of their age and measures of functional mobility during a virtual walking paradigm.

METHODS

The gaze behaviour of nine young adults, seven older adults with a relatively low risk of falling and seven older adults with a relatively higher risk of falling was measured while they watched five first-person perspective movies representing the viewpoint of a pedestrian walking through various environments. Participants also completed a number of cognitive tests: Stroop task, visual search, trail making task, Mini Mental Status Examination, and reaction time, visual tests (visual acuity and contrast sensitivity) and assessments of balance (Activities Balance Confidence Scale and Berg Balance Scale) to aid in the interpretation of differences in gaze behaviour.

RESULTS

The high risk older adult group spent significantly more time fixating aspects of the travel path than the low risk and young adult groups. High risk older adults were also significantly slower in performing a number of the cognitive tasks than young adults. Correlations were conducted to compare the extent to which travel path fixation durations co-varied with scores on the tests of visual search, motor, and cognitive function. A positive significant correlation was found between the speed of response to the incongruent Stroop task and travel path fixation duration r21  = 0.44, p < 0.05.

CONCLUSIONS

The results indicate that our movie-viewing paradigm can identify differences in gaze behaviour between participants grouped on the basis of their age and measures of functional mobility and that these differences are associated with cognitive decline.

The capacity to restore steady gait after a step modification is reduced in people with poststroke foot drop using an ankle-foot orthosis

BACKGROUND

A reduced capacity to modify gait to the environment may contribute to the risk of falls in people with poststroke foot drop using an ankle-foot orthosis.

OBJECTIVE

This study aimed to quantify their capacity to restore steady gait after a step modification.

DESIGN

This was a cross-sectional, observational study.

METHODS

Nineteen people in the chronic phase (>6 months) after stroke (mean age=55.0 years, SD=10.1) and 20 people of similar age (mean age=54.6 years, SD=12.0) who were able-bodied were included. Participants were instructed to avoid obstacles that were suddenly released in front of the paretic leg (stroke group) or left leg (control group) while walking on a treadmill. Outcomes were success rates of obstacle avoidance as well as post-crossing step length, step duration, hip flexion angle at foot-strike, and peak hip extension of the steps measured within 10 seconds following obstacle release.

RESULTS

Success rates of obstacle avoidance were lower for people poststroke. Moreover, their first post-crossing step length and duration (ie, the nonparetic step) deviated more from steady gait than those of people in the control group (ie, the right step), with lower values for people poststroke. Similar deviations were observed for post-crossing hip flexion and extension excursions.

LIMITATIONS

People poststroke were relatively mildly impaired and used an ankle-foot orthosis, which may limit the generalizability of the results to other populations poststroke.

CONCLUSIONS

People with poststroke foot drop using an ankle-foot orthosis had reduced gait adaptability, as evidenced by lower success rates of obstacle avoidance as well as an impaired capacity to restore steady gait after crossing an obstacle. The latter finding unveils their difficulty in incorporating step modifications in ongoing gait.

Mediolateral foot placement ability during ambulation in individuals with chronic post-stroke hemiplegia

Mediolateral (ML) foot placement is an effective way to redirect the lateral trajectory of the body center of mass (BCoM) during ambulation, but has only been partly characterized in the chronic post-stroke population despite their increased risk for falling [1]. During able-bodied gait, the locomotor system coordinates lower limb swing phase kinematics such that an appropriate ML foot placement occurs upon foot contact. Muscle weakness and abnormal motor patterns may impair foot placement ability post-stroke. The purpose of this study was to characterize ML foot placement ability during post-stroke ambulation by quantifying ML foot placement accuracy and precision, for the both sound and affected feet. Age matched able-bodied individuals were recruited for comparison. All participants were instructed to target step widths ranging from 0 to 45% leg length, as marked on the laboratory floor. Results of this study confirmed that ML foot placement accuracy and precision were significantly lower for the post-stroke group as compared to the control group (p=0.0). However, ML foot placement accuracy and precision were not significantly different between the affected and sound limbs in the post-stroke group. The lowest accuracy for post-stroke subjects was observed at both extreme step width targets (0 and 45%). Future work should explore potential mechanisms underlying these findings such as abnormal motor coordination, lower limb muscle strength, and abnormal swing phase movement patterns.

Sit-to-Stand in People with Stroke: Effect of Lower Limb Constraint-Induced Movement Strategies

Background. Weight-bearing asymmetry and impaired balance may contribute to the increased fall risk in people with stroke when rising to stand from sitting. Objective. This study investigated the effect of constraint-induced movement (CIM) strategies on weight-bearing symmetry and balance during sit-to-stand in people with stroke. Methods. A nonrandom convenience sample of fifteen people with stroke performed the sit-to-stand task using three CIM strategies including a solid or compliant (foam) block strategy, with the unaffected limb placed on the block, and an asymmetrical foot position strategy, with the unaffected limb placed ahead of the affected limb. Duration of the task, affected limb weight-bearing, and centre of pressure and centre of mass displacement were measured in the frontal and sagittal plane. Results. Affected limb weight-bearing was increased and frontal plane centre of pressure and centre of mass moved toward the affected limb compared to baseline with all CIM strategies. Centre of mass displacement in the sagittal plane was greater with the compliant block and asymmetrical foot strategies. Conclusions. The CIM strategies demonstrated greater loading of the affected limb and movement of the centre of pressure and centre of mass toward the affected limb. The compliant block and asymmetrical foot conditions may challenge sagittal plane balance during sit-to-stand in people with stroke.

Gait and balance performance of stroke survivors in South-Western Nigeria--a cross-sectional study

INTRODUCTION

Stroke survivors are often left with neurological and functional deficits, which impair their ability to walk and affect their balance. This study assessed gait parameters and balance performance among stroke survivors and examined the relationship between these two factors.

METHODS

Seventy stroke survivors (65.7% males) who were 6 months or more post stroke participated in this study. Using Observational Gait Analysis, the gait of participants was assessed by gait speed and cadence. Balance performance was assessed using the Activities-specific Balance Confidence scale for balance self-efficacy and Functional Reach Test for standing balance.

RESULTS

Participants had a mean age of 53.5 ± 10.4 years. Forty five (64.3%) stroke survivors had haemorrhagic stroke while 25 (35.7%) had ischaemic stroke. The mean gait speed and cadence were 0.6 ± 0.3m/s and 69.1 ± 38.1 steps/min, respectively. The mean balance self-efficacy score was 66.5 ± 17.7 and mean functional reach distance was 18.7 ± 2.6 cm. There were significant relationships between gait speed and balance self-efficacy (r =0.461, p =0.001) and between cadence and functional reach distance (r =0.247, p =0.020).

CONCLUSION

This study concluded that stroke survivors with higher cadences had higher functional reach distances, and those with higher gait speeds had better balance self-efficacy. Gait speed and cadence are factors related to balance performance. These factors should be considered during gait and balance retraining and should go pariparsu in the rehabilitation of stroke survivors.

Influence of gaze distance and downward gazing on postural sway in hemiplegic stroke patients

Gaze distance and head flexion suppress postural sway in healthy subjects. However, the effects of these factors on stroke patients have not been fully elucidated. In this study, we aimed to evaluate the effects of gaze distance and downward gazing on postural sway in stroke patients. We examined 15 stroke patients and 14 elderly controls. Postural sway was measured in the subjects under the following 5 conditions: eyes fixed forward on a marker located 600 cm ahead (600-cm condition); eyes fixed forward on a marker located 150 cm ahead (150-cm condition); eyes fixed downward (downward condition); the subject facing straight ahead but with eyes closed (closed-forward condition); and the subject facing downward but with eyes closed (closed-downward condition). The root mean squares of the anteroposterior (A-P RMS) and the mediolateral (M-L RMS) directions were determined. The results showed that the short gaze distance decreased the M-L RMS in both the stroke patients and controls (p < 0.001, r = 0.66; p = 0.024, r = 0.43, respectively). In the control group, the downward condition increased the M-L RMS when compared with the 600-cm condition (p = 0.011, r = 0.48). The downward condition decreased the A-P and M-L RMS in the stroke patients when compared with the 600-cm condition (A-P RMS: p < 0.001; r = 0.66, M-L RMS: p = 0.001; r = 0.59). Our results showed that the short gaze distance decreased postural sway in both groups, and downward gazing decreased it only in the stroke group.

Visual cue training to improve walking and turning after stroke: a study protocol for a multi-centre, single blind randomised pilot trial

Background

Visual information comprises one of the most salient sources of information used to control walking and the dependence on vision to maintain dynamic stability increases following a stroke. We hypothesize, therefore, that rehabilitation efforts incorporating visual cues may be effective in triggering recovery and adaptability of gait following stroke. This feasibility trial aims to estimate probable recruitment rate, effect size, treatment adherence and response to gait training with visual cues in contrast to conventional overground walking practice following stroke.

Methods/design

A 3-arm, parallel group, multi-centre, single blind, randomised control feasibility trial will compare overground visual cue training (O-VCT), treadmill visual cue training (T-VCT), and usual care (UC). Participants (n = 60) will be randomly assigned to one of three treatments by a central randomisation centre using computer generated tables to allocate treatment groups. The research assessor will remain blind to allocation. Treatment, delivered by physiotherapists, will be twice weekly for 8 weeks at participating outpatient hospital sites for the O-VCT or UC and in a University setting for T-VCT participants.

Individuals with gait impairment due to stroke, with restricted community ambulation (gait speed <0.8m/s), residual lower limb paresis and who are able to take part in repetitive walking practice involving visual cues (i.e., no severe visual impairments, able to walk with minimal assistance and no comorbid medical contraindications for walking practice) will be included.

The primary outcomes concerning participant enrolment, recruitment, retention, and health and social care resource use data will be recorded over a recruitment period of 18 months. Secondary outcome measures will be undertaken before randomisation (baseline), after the eight-week intervention (outcome), and at three months (follow-up). Outcome measures will include gait speed and step length symmetry; time and steps taken to complete a 180° turn; assessment of gait adaptability (success rate in target stepping); timed up and go; Fugl-Meyer lower limb motor assessment; Berg balance scale; falls efficacy scale; SF-12; and functional ambulation category.

Discussion

Participation and compliance measured by treatment logs, accrual rate, attrition, and response variation will determine sample sizes for an early phase randomised controlled trial and indicate whether a definitive late phase efficacy trial is justified.

Trial registration

Clinicaltrials.gov, NCT01600391.

Serious adverse events experienced by survivors of stroke in the first year following discharge from inpatient rehabilitation

PURPOSE

To identify the incidence of adverse events (AE) that occurred in stroke survivors during the first year following discharge from inpatient rehabilitation and to determine the type and patterns of AE.

METHODS

Data were collected for 12 months on events resulting in admissions to the emergency department, hospital, long-term care facility, or death. Descriptive statistics were used to depict the patterns of AE and univariate comparisons were made of the differences between survivors who did or did not experience one or more AE.

RESULTS

Of the 159 participants, 50% reported a total of 163 AE. Most AE (82.2%) were unexpected and the majority occurred during the first 6 months; 12 recurrent strokes and 6 transient ischemic attacks occcurred.

CONCLUSIONS

Education on prevention and treatment of common AE is important prior to discharge. Anticipatory guidance may help survivors and caregivers modify their lifestyle and prevent common AE.

Balance is associated with quality of life in chronic stroke

OBJECTIVE

To investigate the association between balance and quality of life (QOL) in chronic stroke survivors by (1) examining the associations between balance and QOL scores; (2) identifying the frequency of balance impairment and poststroke falls; and (3) determining the differences in QOL scores between persons with and those without balance impairment.

METHODS

This is a secondary analysis of a cross-sectional study. People who had a stroke more than 6 months earlier from 3 Midwest states were included in the study if they met the following criteria: were referred to occupational or physical therapy for poststroke physical deficits; had self-reported stroke-related physical deficits; completed all stroke-related rehabilitation; had residual functional disability; had a score of ≥4 out of 6 on the short 6-item Mini-Mental State Examination; and were between 50 and 85 years old (n = 59). The main outcome measures included the Berg Balance Scale (BBS) to assess balance and the Stroke Specific Quality of Life Scale (SS-QOL) to assess QOL. Number of falls since stroke was self-reported.

RESULTS

Mean BBS score was 44 ± 8 and mean SS-QOL score was 46 ± 8; these scores were significantly correlated (r = .394, P = .002). Seventy-six percent of the sample reported a fall since stroke. Persons with balance impairment (BBS score ≤46; n = 29; 49%) had an average BBS score of 39 ± 7 and significantly worse SS-QOL scores than those without balance impairment (42 ± 8 vs 49 ± 7; P = .001).

CONCLUSION

In the chronic stroke population, balance impairment and fall risk are associated with lower QOL scores. If balance can be improved and maintained into the chronic phases of stroke, it is likely that individuals will benefit with improved QOL.

Frequency and circumstances of falls in people with inclusion body myositis: a questionnaire survey to explore falls management and physiotherapy provision

OBJECTIVES

To survey the incidence and circumstances of falls for people with inclusion body myositis (IBM) in the UK, and to investigate the provision of physiotherapy and falls management.

DESIGN

Postal questionnaire survey.

SETTING

Participants completed questionnaires at home.

PARTICIPANTS

Ninety-four people diagnosed with IBM were screened against the inclusion criteria. Seventy-two potential participants were sent a questionnaire, and 62 were completed and returned. Invited participants were sent an adapted Falls Event Questionnaire pertaining to falls, perceived causes of falls and the provision of physiotherapy. Questionnaires were returned anonymously.

MAIN OUTCOME MEASURES

The proportions of respondents who reported a fall or a near fall, along with the frequencies of falls and near falls were calculated. Descriptive data of falls were collected pertaining to location and cause. Data analysis was performed to investigate provision of physiotherapy services.

RESULTS

The response rate was 86% [62/72, mean (standard deviation) age 68 (8) years]. Falls were reported by 98% (61/62) of respondents, with 60% (37/62) falling frequently. In this study, age was not found to be an indicator of falls risk or frequency. Twenty-one percent (13/62) of respondents had not seen a physiotherapist in relation to their IBM symptoms, and of those that had, 31% (15/49) had not seen a physiotherapist until more than 12 months after IBM was diagnosed. Only 18% (11/61) of fallers reported that they had received falls management input.

CONCLUSIONS

Falls are a common occurrence for people with IBM, independent of age and years since symptoms first presented, and are poorly addressed by appropriate physiotherapy management. National falls guidelines are not being followed, and referral rates to physiotherapy need to improve.

Psychometric properties of the Mini-Balance Evaluation Systems Test (Mini-BESTest) in community-dwelling individuals with chronic stroke

BACKGROUND

The Mini-Balance Evaluation Systems Test (Mini-BESTest) is a new balance assessment, but its psychometric properties have not been specifically tested in individuals with stroke.

OBJECTIVES

The purpose of this study was to examine the reliability and validity of the Mini-BESTest and its accuracy in categorizing people with stroke based on fall history.

DESIGN

An observational measurement study with a test-retest design was conducted.

METHODS

One hundred six people with chronic stroke were recruited. Intrarater reliability was evaluated by repeating the Mini-BESTest within 10 days by the same rater. The Mini-BESTest was administered by 2 independent raters to establish interrater reliability. Validity was assessed by correlating Mini-BESTest scores with scores of other balance measures (Berg Balance Scale, one-leg-standing, Functional Reach Test, and Timed "Up & Go" Test) in the stroke group and by comparing Mini-BESTest scores between the stroke group and 48 control participants, and between fallers (≥1 falls in the previous 12 months, n=25) and nonfallers (n=81) in the stroke group.

RESULTS

The Mini-BESTest had excellent internal consistency (Cronbach alpha=.89-.94), intrarater reliability (intraclass correlation coefficient [3,1]=.97), and interrater reliability (intraclass correlation coefficient [2,1]=.96). The minimal detectable change at 95% confidence interval was 3.0 points. The Mini-BESTest was strongly correlated with other balance measures. Significant differences in Mini-BESTest total scores were found between the stroke and control groups and between fallers and nonfallers in the stroke group. In terms of floor and ceiling effects, the Mini-BESTest was significantly less skewed than other balance measures, except for one-leg-standing on the nonparetic side. The Berg Balance Scale showed significantly better ability to identify fallers (positive likelihood ratio=2.6) than the Mini-BESTest (positive likelihood ratio=1.8).

LIMITATIONS

The results are generalizable only to people with mild to moderate chronic stroke.

CONCLUSIONS

The Mini-BESTest is a reliable and valid tool for evaluating balance in people with chronic stroke.

Turning-Based Treadmill Training Improves Turning Performance and Gait Symmetry After Stroke

Background. Turning is a challenging task for stroke patients. Programs that effectively target turning, however, have not been established. Objective. This study examined the effects of a novel turning-based treadmill training on turning performance, gait symmetry, balance, and muscle strength in patients with chronic stroke. Methods. Thirty participants were randomly assigned to the experimental group that received 30 minutes of turning-based treadmill training or to the control group that received 30 minutes of regular treadmill training, followed by a 10-minute general exercise program for 12 sessions over 4 weeks. Primary outcomes (overground turning speed and temporal–spatial characteristics of straight walking) and secondary outcomes (balance and muscle strength) were assessed at baseline, after training, and at 1-month follow-up. Results. Fifteen participants per group were 54.2 ± 9.6 years old, poststroke 2.6 ± 1.9 years, and walked overground at 0.59 ± 0.28 m/s. Sixteen had an ischemic and 14 a hemorrhagic stroke. There were significant interaction effects between groups and time on turning speed regardless of turning direction, straight-walking performance (speed and temporal symmetry), strength of hip muscles and ankle dorsiflexors, and balance control (Berg Balance Scale, weight shifting in the forward direction and vestibular function). Compared with the control group, the experimental group showed greater improvements in these measures following training. These improvements persisted at the 1-month follow-up evaluation. Conclusions. Turning-based treadmill training may be a feasible and effective strategy to improve turning ability, gait symmetry, muscle strength, and balance control for individuals with chronic stroke.

Vertical force and wrist deviation angle in a sample of elderly people using walkers

Walkers are frequently used by elderly people with weak lower limbs and limited balance, but the ergonomic relationship between the use of a walker and stress on the upper limbs is relatively unstudied. The current study assessed wrist deviation and vertical force among elderly individuals using a walker for assistance in walking. 60 elderly volunteers (M age = 81.0 yr., SD = 8.8) participated, 30 of whom frequently used a walker, and 30 who had no such prior experience. Data were obtained from four load cells and a twin-axis wrist goniometer during assisted ambulation using the walker. No significant group difference was found in gait cycle. Significant wrist deviation occurred, with ulnar deviation/dorsiflexion of the right hand, which was greater than that of the left. Non-experienced participants had larger dorsiflexion than experienced participants. Experienced participants produced larger vertical force than non-experienced participants. The greaterthe wrist deviation, the greater was the vertical force. The horizontal handles of most marketed walkers cause wrist deviations. This is a concern for users, clinicians, and related industries. Improvements in walker design should be considered.

Medo de cair e sua relação com a medida da independência funcional e a qualidade de vida em indivíduos após Acidente Vascular Encefálico

O objetivo deste estudo transversal foi avaliar o medo de cair em 52 indivíduos na fase crônica após Acidente Vascular Encefálico (AVE) e verificar sua relação com medidas de independência funcional e de qualidade de vida (QV). O medo de cair foi verificado através da versão brasileira da Falls Efficacy Scale International (FES-I-BRASIL), independência funcional através da Medida da Independência Funcional (MIF) e QV através da Escala de QV Específica para AVE (EQVE-AVE). Coeficientes de correlação de Spearman foram calculados para verificar associações entre a FES-I-BRASIL e os demais instrumentos, e o teste U de Mann-Whitney para comparar grupos com baixa e alta preocupação em cair. Houve predomínio de indivíduos com alta preocupação em cair, maior QV e independentes. A FES-I-BRASIL foi estatisticamente associada à MIF e à EQVE-AVE, sendo o mesmo observado nas subescalas transferências e locomoção da MIF e nos domínios energia, papéis familiares, linguagem, mobilidade, humor, autocuidado e função do membro superior da EQVE-AVE. Assim, o medo de cair pode contribuir para a redução da independência funcional e da QV de indivíduos pós-AVE, devendo ser inserido na avaliação desses pacientes, para que maiores benefícios possam ser garantidos na reabilitação.

Whole-body vibration has no effect on neuromotor function and falls in chronic stroke

PURPOSE

Whole-body vibration therapy has gained increasing popularity in enhancing neuromotor function in various patient populations. It remains uncertain, however, whether whole-body vibration is beneficial when used in stroke patients. The aim of this randomized controlled trial was to examine the efficacy of whole-body vibration in optimizing neuromotor performance and reducing falls in chronic stroke patients.

METHODS

Eighty-two chronic stroke patients were randomly assigned to either the experimental group or control group. The experimental group received 9-15 min of whole-body vibration (vertical vibration; frequency = 20-30 Hz. amplitude = 0.44-0.60 mm, peak acceleration = 9.5-15.8 m·s or 0.97-1.61 U of Earth gravitational acceleration (g) while performing a variety of dynamic leg exercises on the vibration platform. The control group performed the same exercises without vibration. The subjects underwent their respective training three times a week for 8 wk. Balance (Berg balance scale), mobility (10-m walk test and 6-min walk test), knee muscle strength (isokinetic dynamometry), and fall-related self-efficacy (activities-specific balance confidence scale) were assessed at baseline, immediately after the 8-wk training and at a 1-month follow-up. The incidence of falls was recorded until 6 months after the termination of training.

RESULTS

Intention-to-treat analysis revealed similar significant improvement in all balance, mobility, muscle strength, and fall-related self-efficacy measures in both groups after the 8-wk treatment period (P < 0.001), and these were maintained at the 1-month follow-up. The incidence of falls did not differ significantly between the two groups (P > 0.05).

CONCLUSIONS

The addition of the presently used whole-body vibration paradigm to a leg exercise protocol was no more effective in improving neuromotor performance and reducing the incidence of falls than leg exercises alone in chronic stroke patients who have mild to moderate motor impairments.

Efeitos de curto prazo de um programa de imaginação sobre o medo de queda de indivíduos pós acidente vascular encefálico

O medo de cair é um dos principais problemas em indivíduos pós acidente vascular encefálico (AVE). A imaginação pode ser uma experiência sucedida para diminuir este aspecto. O objetivo deste estudo foi verificar o efeito de um programa de imaginação de curto prazo no medo de quedas em indivíduos pós-AVE. Sete indivíduos acometidos por AVE participaram do estudo. A Escala Internacional de Eficácia de Quedas (FES-I-Brasil) foi aplicada antes (PRÉ), depois (PÓS) e sete dias após a intervenção (RET). Foram realizadas quatro sessões de familiarização e seis de prática da imaginação. Não houve diferença significativa no escore total da FES-I-Brasil após intervenção (p=0,46), exceto na tarefa subir/descer escadas (PRÉ e PÓS, p=0,04; PRÉ e RET; p=0,01). Apesar da melhoria na tarefa subir/descer escadas, alterações nos demais itens da escala não foram encontradas o que pode representar um efeito relativamente reduzido do programa de imaginação de curto prazo.

Reliability and concurrent validity of Four Square Step Test scores in subjects with chronic stroke: a pilot study

OBJECTIVES

To establish (1) the intrarater and interrater reliability of Four Square Step Test (FSST) times in persons with chronic stroke; (2) the concurrent validity of FSST times with standing balance and functional mobility measures; and (3) the FSST cutoff score for distinguishing the differences in dynamic balance performance of persons with chronic stroke from healthy control adults.

DESIGN

Cross-sectional study.

SETTING

University-based rehabilitation center.

PARTICIPANTS

Convenience sample of subjects (N=30) consisting of community-dwelling persons with chronic stroke (n=15) and healthy control adults (n=15).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FSST scores; balance and functional mobility measured using Berg Balance Scale (BBS) scores; Timed Up & Go (TUG) test scores; and limits of stability (LOS) measured by dynamic posturography.

RESULTS

FSST times showed good intrarater reliability, with intraclass correlation coefficients ranging from .82 to .83 and an interrater reliability >.99. An FSST cutoff score of 11 seconds was able to discriminate between healthy adults older than 50 years and persons with stroke (sensitivity, 73.3%; specificity, 93.3%). FSST times were correlated with LOS scores for directional control in the backward direction (r=.64; P=.01). FSST was approaching a significant correlation with TUG scores (r=.59; P=.02) and LOS scores for endpoint excursion in the forward direction (r=-.58; P=.02). However, there was no correlation with BBS scores.

CONCLUSION

FSST is an easy-to-administer clinical test with good intrarater and interrater reliability in persons with chronic stroke to assess dynamic standing balance. FSST times of 11 seconds are able to differentiate between persons with chronic stroke and healthy adults older than 50 years. The correlation of FSST times with standing balance and functional mobility measures requires further research with a larger sample size.

Fear of falling in subacute hemiplegic stroke patients: associating factors and correlations with quality of life

Objective

To determine the associating factors of fear of falling (FOF) and the correlations between FOF and quality of life (QOL) on subacute stroke patients in Korea.

Method

Fifty hemiplegic subacute stroke patients in our clinic were recruited. We directly asked patients with their fear of falling and interviewed them with the Korean version of falls efficacy scale-international (KFES-I). We divided the participants into two groups; with FOF and without FOF. We compared these groups with the strength of hemiplegic hip abductor, knee extensor, ankle plantar flexor, functional ambulation category (FAC) scale, stroke specific quality of life (SSQOL), and hospital anxiety depression scale (HADS).

Results

Thirty-four participants were enrolled, and more than half of the patients with subacute stroke had FOF. We compared the patients with and without FOF. According to the results, FOF was associated with the strength of hemiplegic hip abductor, knee extensor and ankle plantar flexor, FAC, total SSQOL, and domains (energy, mobility, self care, upper extremity function) of SSQOL (p<0.05). FOF was also associated with the anxiety score of HADS (p<0.05). KFES-I had a significant negative correlation with the strength of hemiplegic hip abductor, knee extensor and ankle plantar flexor, FAC, total SSQOL, and domains (energy, mobility, self care, upper extremity function) of SSQOL (p<0.01).

Conclusion

The FOF was associated with not only QOL but also with the physical and psychological factors, and in particular, anxiety. Therefore, further concerns about FOF in subacute stroke patients might be required.

Deficits in motor response to avoid sudden obstacles during gait in functional walkers poststroke

BACKGROUND

Safe community ambulation requires the capacity to adapt gait to environmental changes on short notice. Reduced adaptability may contribute to an increased risk for falls.

OBJECTIVE

This study investigated gait adaptability in community-dwelling persons poststroke and sought to understand some of the mechanisms of reduced adaptability.

METHODS

Participants were 25 poststroke persons (Functional Ambulation Categories score 5) and 25 healthy controls of similar age. During treadmill walking, 30 obstacles were suddenly dropped in front of the affected leg or left leg of controls. The participants had to avoid the obstacle by either lengthening or shortening the ongoing stride. The obstacle avoidance success rates were determined. Electromyography activity of bilateral biceps femoris, rectus femoris, tibialis anterior, and gastrocnemius medialis muscles was recorded as well as concomitant knee and hip angle courses and spatial characteristics of the avoiding stride.

RESULTS

Poststroke persons demonstrated markedly decreased obstacle avoidance success rates, most prominently under time pressure. They showed normal avoidance strategies but had delayed and reduced electromyography responses, smaller joint angle deviations from unperturbed walking, and smaller horizontal margins from the foot to the obstacle.

CONCLUSIONS

Even in persons who were only mildly affected by stroke, gait adaptability may be reduced, which may place them at risk of falling. Delayed and decreased muscle responses were identified as one possible mechanism with diminished ability to adapt the length of the avoiding stride. Rehabilitation interventions could focus on these impairments.

Reduced gait stability in high-functioning poststroke individuals

Falls during walking are a major cause of poststroke injury, and walking faster may decrease the ability to recover following a gait perturbation. We compared gait stability between high-functioning poststroke individuals and controls and evaluated the effect of gait speed on gait stability. Ten stroke subjects and ten age-matched controls walked on a self-paced treadmill at two speeds (matched/faster). Movement of the nonparetic/dominant leg was arrested unexpectedly at early swing. Poststroke individuals lowered the perturbed leg following perturbation (58% of cases) while controls maintained the leg elevated (49% of cases; P < 0.01). In poststroke individuals, double-support duration was restored later than in controls (4.6 ± 0.8 vs. 3.2 ± 0.3 strides; P < 0.007), and long-term phase shifts of arm and leg movements were larger and less coordinated on the paretic side. A moderate speed increase (~20%) enhanced the incidence of leg lowering in controls but not in stroke subjects. Faster walkers in both groups had a more coordinated response, limited to the nonparetic side in the stroke group. However, faster walkers were not more stable following perturbation. Our results suggest that gait perturbations can target basic control processes and identify neurological locomotor deficits in individuals with fall risk. Central regulation of body translation in space is involved in recovery of steady-state walking. Impaired descending control (stroke) decreases the ability of the motor system to recover from perturbations and regulate interlimb phase relationships, especially when changing gait speed. However, interlimb coordination may not be a major factor in the recovery of gait stability.

Incidence and risk factors of poststroke falls after discharge from inpatient rehabilitation

OBJECTIVE

To investigate the incidence of falls and risk factors for falls in persons who had a stroke.

DESIGN

Telephone survey.

SETTING

Tertiary university hospital.

PATIENTS AND METHODS

Patients who had a stroke and were admitted to the rehabilitation unit between April 2006 and July 2008 were listed and contacted by telephone from February 2009 to August 2009.

MAIN OUTCOME MEASUREMENTS

Information obtained from the interviews, which were performed 20 ± 8 months after discharge from inpatient rehabilitation, included demographic data, information about falls, and current ambulatory function. After the telephone interview, medical records of participants during admission were reviewed.

RESULTS

Of the 404 enrolled patients, 330 were included in the analysis. Of the 330 patients, 62 (19%) had a history of a fall after stroke onset. Of 222 ambulatory patients, 51 patients (23%) fell. Falls frequently occurred in winter, and most falls occurred indoors (70%). Twenty-nine percent of patients experienced repeated falls. About half of those who fell were injured, and 11% sustained fractures. Patients who had a stroke and had severe deficits showed a lower probability of poststroke falls. In a subgroup analysis of patients with ambulatory capacity, left-sided hemiplegia/hemiparesis was associated with an increased risk of falls.

CONCLUSIONS

This study reveals a high incidence of poststroke falls after discharge from inpatient rehabilitation. More caution should be taken for patients with ambulatory ability and left hemiplegia/hemiparesis because they are more vulnerable to falls after a stroke. An increased prevalence of fear of falling in people who fell suggests that an appropriate intervention to reduce fear of falling should be provided to patients who have had a stroke.

Turning Ability in Stroke Survivors: A Review of Literature

The aim of this paper is to explore the research literature on the turning ability among stroke survivors. Stroke is one of the top five leading causes of death and disability in Malaysia. Stroke survivors reported a higher rate of fall incidences with turning while walking has been the major contributor in most of the incidences. The attentional task requires stroke survivors to have higher cognitive and attention function, and sound muscle coordination in order to perform multitask activities such as driving, walking and turning while talking, carrying an object (holding a plastic bag), navigating corners and overcoming obstacles within the base of support. Most of the previous studies have focused on the kinematic and gait parameters measurement of turning ability among stroke survivors. However, studies conducted on muscle activity using electromyography to evaluate the time pattern of muscle contraction during turning event is lacking. With regards to dual-task ability among stroke survivors, there is insufficient information or research into dual task (motor and cognitive) ability during turning. Further studies are needed to understand the effects of dual-task activity on muscle activity and gait parameters and how this impairment affects the turning ability. This needs to be addressed in order to prevent falls among stroke survivors.

Cognitive function as a prospective predictor of falls

OBJECTIVE

This study examined speed of processing, executive functioning, and psychomotor speed as independent prospective predictors of falls and recurrent falls across 3 years.

METHOD

The participants were 509 community-dwelling older adults. Measures of speed of processing, executive function, psychomotor speed, and known risk factors of falling were included in correlation and logistic regression analyses.

RESULTS

Poor executive function (Trail Making Test), slower speed of processing (Digit Symbol Substitution [DSS] Test), and slower psychomotor speed (Digit Symbol Copy Test) were significantly associated with falls. Poor executive function and speed of processing performance (Stroop Test, Trail Making Test, and DSS Test) as well as slower psychomotor speed were significantly related to recurrent falls. Logistic regression results indicated that only medication use, far visual acuity, and psychomotor speed were significant independent predictors of falls. Regarding recurrent falls, being white, medication use, and balance were significant predictors.

DISCUSSION

Although cognitive measures at baseline were significantly associated with falls and recurrent falls at follow-up, these measures did not predict falling after considering known risk factors of falls and psychomotor speed. Thus, it may be that simple measures of psychomotor speed are more salient predictors of falls than cognitive measures.

Arm training in standing also improves postural control in participants with chronic stroke

PURPOSE

To prove the concept that postural control will improve without specific balance control training during arm training in standing with individuals with chronic stroke.

METHODS

Nine participants (mean age 64±7) received training involving hand orthotic assisted grasp, reach and release in standing 1 h, 3×'s/week for 6 weeks. Training focused on task completion with no explicit instructions provided for postural alignment, weight shift or balance strategy. Testing consisted of quantified measures using NeuroCom™ Balance Master, Berg Balance Scale (BBS) and Activities-specific Balance Confidence Scale (ABC).

RESULTS

Post training participants demonstrate increased (p<.05) composite stability scores for sensory organization testing (mean 71.55±12.7-75.55±11). Velocity and directional control of COP weight shift improved for all 9 subjects with 6/9 achieving 100% target acquisition. Directional control improved (p<.05) for medial/lateral movements for all speeds and composite score. Anterior/posterior rhythmic weight shifting increased significantly in COP velocity control at moderate and fast velocities and composite score. Increases in mean BBS (p<.01) from 41.33±10.1-46.88±8.03 exceeded the clinically important cutoff for the scale. Balance confidence improved with ABC mean scores 70.22±14.5-79.55±12.86 (p<.05). Seven participants demonstrated changes above the minimally important difference for this scale.

CONCLUSIONS

Postural control improved following task oriented arm training in standing without explicit postural control goals, instruction or feedback challenging current training paradigms of isolated postural control training with conscious attention directed to center of pressure location and movement.

Changes in balance and walking from stroke rehabilitation to the community: a follow-up observational study

OBJECTIVES

To investigate (1) whether clinical test scores at discharge predict falls or limited community mobility after discharge from inpatient stroke rehabilitation; and (2) how walking and dynamic standing balance change after discharge.

DESIGN

Follow-up observational study between 6 and 36 months after discharge.

SETTING

Rehabilitation setting.

PARTICIPANTS

Community-dwelling stroke survivors (N=30) who could walk unassisted when discharged from inpatient rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Six-minute walk test (6MWT), Four Square Step Test (FSST), Step Test (ST), Environmental Analysis of Mobility Questionnaire (EAMQ), Falls Efficacy Scale-International (FES-I), and self-reported falls.

RESULTS

Follow-up occurred at a median of 14.5 months postdischarge. Significant improvements occurred between discharge and follow-up for the 6MWT (mean difference [MD]=110.1m; 95% confidence interval [CI], 70.8-149.4; P<.001), ST (MD=1.8 steps; 95% CI, 0.3-3.4; P=.03), and FSST (MD=4.3s; 95% CI, -10.3 to 1.6; P=.05). Despite this, 40% of participants reported falling. The group who fell had lower clinical test scores at discharge and follow-up than nonfallers. Specific cutoff scores for the clinical tests accurately classified falls history in 70% to 78% of participants. The cutoff scores were <250m for the 6MWT, <10 steps on the ST, and a failure or ≥15 seconds to complete the FSST. Participants performing under the cutoff scores reported lower levels of community mobility (EAMQ, P<.04). Concern about falling was only higher for those classified at risk by the FSST (FES-I, P=.008).

CONCLUSIONS

The FSST, ST, and 6MWT scores at discharge had good falls prediction. People classified at risk of falls avoided more tasks in their home and community than those not classified at risk.

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.

Interventions for coordination of walking following stroke: systematic review

Impairments in gait coordination may be a factor in falls and mobility limitations after stroke. Therefore, rehabilitation targeting gait coordination may be an effective way to improve walking post-stroke. This review sought to examine current treatments that target impairments of gait coordination, the theoretical basis on which they are derived and the effects of such interventions. Few high quality RCTs with a low risk of bias specifically targeting and measuring restoration of coordinated gait were found. Consequently, we took a pragmatic approach to describing and quantifying the available evidence and included non-randomised study designs and limited the influence of heterogeneity in experimental design and control comparators by restricting meta-analyses to pre- and post-test comparisons of experimental interventions only. Results show that physiotherapy interventions significantly improved gait function and coordination. Interventions involving repetitive task-specific practice and/or auditory cueing appeared to be the most promising approaches to restore gait coordination. The fact that overall improvements in gait coordination coincided with increased walking speed lends support to the hypothesis that targeting gait coordination gait may be a way of improving overall walking ability post-stroke. However, establishing the mechanism for improved locomotor control requires a better understanding of the nature of both neuroplasticity and coordination deficits in functional tasks after stroke. Future research requires the measurement of impairment, activity and cortical activation in an effort to establish the mechanism by which functional gains are achieved.

Characterizing and identifying risk for falls in the LEAPS study: a randomized clinical trial of interventions to improve walking poststroke

BACKGROUND AND PURPOSE

Better understanding of fall risk poststroke is required for developing screening and prevention programs. This study characterizes falls in the Locomotor Experience Applied Post-Stroke (LEAPS) randomized clinical trial, describes the impact of 2 walking recovery interventions on falls, and examines the value of clinical assessments for predicting falls.

METHODS

Community-dwelling ambulatory stroke survivors enrolled in LEAPS were assessed 2 months poststroke. Falls were monitored until 12 months poststroke and participants were characterized as multiple or injurious (M/I); single, noninjurious; or nonfallers. Incidence and time to M/I falls were compared across interventions (home exercise and locomotor training initiated 2 months [early-LTP] or 6 months [late-LTP] poststroke). Predictive value of 2-month clinical assessments for falls outcome was assessed.

RESULTS

Among the 408 participants, 36.0% were M/I, 21.6% were single, noninjurious, and 42.4% were nonfallers. Most falls occurred at home in the first 3 months after assessment. Falls incidence was highest for those with severe walking impairment who received early-LTP (P=0.025). Berg Balance Scale score ≤ 42/56 was the single best predictor of M/I falls.

CONCLUSIONS

As individuals with stroke improve in walking capacity, risk for M/I falls remains high. Individuals walking <0.4 m/s are at higher risk for M/I falls if they receive early-LTP training. Berg Balance Scale score at 2 months poststroke is useful for informing falls risk, but it cannot account for the multifactorial nature of the problem. Falls prevention in stroke will require multifactorial risk assessment and management provided concomitantly with exercise interventions to improve mobility.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00243919.