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

Fear of falling: an emerging issue after stroke

PURPOSE

Qualitative data regarding stroke survivors' recovery experiences were used to describe factors important in the development of fear of falling (FoF) during the first 6 months after stroke.

METHOD

Stroke survivors were interviewed 1 and 6 months after stroke to obtain data on their experiences related to stroke recovery trajectory. Analyses identified FoF as a naturally occurring part of stroke survivors' descriptions of their everyday lives. Interviews were reexamined to identify and describe personal experiences related to FoF in this population.

RESULTS

Forty-two (32%) veterans who participated in the larger study discussed FoF during the first 6 months after stroke. Analyses indicate three important factors may be associated with the development of poststroke FoF: (a) the initial fall coinciding with stroke onset, (b) perception of poststroke body changes, and (c) a pervasive everyday fear of future falls.

CONCLUSION

These factors related to FoF need to be further studied in the poststroke population. It is possible that individualized interventions may be necessary to assist stroke survivors to manage FoF, decrease fear, and reduce falls after discharge home poststroke.

The effect of spasticity, sense and walking aids in falls of people after chronic stroke

OBJECTIVE

To study the effects of spasticity, sensory impairment, and type of walking aid on falls in community dwellers with chronic stroke.

METHODS

Functional Independence Measure (FIM) Instrument, Joint Position Sense Evaluation (JPS), the Rivermead motor assessment scale (RMA), Ashworth Scale, Tinetti Assessment Tool were used to assess 100 cases.

RESULTS

Fifty-three of the cases were grouped as nonfallers, 36 as one-time fallers and 11 as repeat fallers. These 3 groups were found to be different from each other in respect to FIM, Tinetti test and RMA (p < 0.001). In respect to knee JPS, nonfallers and one-time faller groups were found to be different from repeat fallers (p = 0.001). There is a difference among the groups in respect to Ashworth assessment (p < 0.001), use of walking aid (p = 0.01) and type of walking aid (p = 0.01). Some 43% of the cases use a walking aid (58.1% cane, 41.9% high cane). According to Ordinal logistic regression analysis, it was found that the possibility of fall increased (p < 0.01), as the value of spasticity increased while the possibility of the fall of the individuals with stroke decreased (p < 0.00 - 0.01) as Tinetti, RMA and FIM variables increased.

CONCLUSIONS

In respect to falls, spasticity is also an indicator for chronic stroke patients, as is motor impairment, functional situation, impairment of balance and walking. Sensory impairment, using a walking aid and the type were found to be ineffective.

Quantification of trunk rotations during turning and walking in Parkinson's disease

OBJECTIVE

To develop a reliable, objective and sensitive measure of axial trunk rotations in PD, which can be applied in an ambulatory setting.

METHODS

To quantify turning motion, two angular velocity transducers attached to the lower back measured angular velocity of the trunk in the yaw plane (i.e., around the longitudinal axis) and the roll plane (i.e., medio-lateral movements) in freely moving subjects who were instructed to walk and make various types of turning movements.

RESULTS

Turn duration was longer in PD patients compared to controls. Peak yaw and peak roll angular velocities were lower in PD patients compared to controls during all turning tasks.

CONCLUSIONS

This new approach to measure trunk sway during a simple turning task might serve as an instrument to objectively quantify turning while walking in PD.

SIGNIFICANCE

It proves difficult to objectively assess turning performance based upon history taking or clinical examination alone. Objective and easy measurement of axial turning in PD might be used for clinical evaluation, but also in a domestic setting as outcome measure in intervention studies. Further research should focus on the clinical relevance of the new quantitative approach described in this paper, e.g., to detect freezing of gait episodes.

Validity of the postural control and balance for stroke test

BACKGROUND AND PURPOSE

To determine the construct and predictive validity and sensitivity of the sub-scale items for postural changes, sitting balance and standing balance of the Postural Control and Balance for Stroke (PCBS) test over a 90-day follow-up.

METHOD

In the initial phase of stroke the PCBS test scores were compared with values obtained for the Barthel Index (BI) and the four neuropsychological domains most widely studied in the literature: memory; language; visuo-spatial functions; and visual inattention. The ability of the PCBS test at an early stage to predict functional status, as measured by the BI, and tendency to falls at 90 days after stroke was studied. The sensitivity of the PCBS test in evaluating postural control was studied by comparing the changes between the initial and 90 days' measures, and by examining the ability of the test to discriminate between healthy people and stroke patients. Forty stroke patients (aged 51-89 years), measured 7 and 90 days post-stroke, and 35 healthy control subjects (aged 50-90 years) participated in the study.

RESULTS

Moderate correlations were found between the initial PCBS test and the BI (Spearman's r = 0.56-0.79) and a negative correlation between the sum variables for visual inattention and postural changes (Spearman's r = -0.39) and sitting balance (Spearman's r = -0.55). The score for postural changes predicted functional capacity (p < 0.002) and standing balance predicted falls at the three-month follow-up (p < 0.007). The PCBS test proved to be sensitive to change: the median change in the PCBS test scores during the three-month follow-up was 6.06. The control subjects mostly obtained maximum scores, indicating that the PCBS test was able to discriminate between healthy individuals and those with stroke.

CONCLUSIONS

The results confirm that the PCBS test has good construct validity, good ability to predict functional capacity and safe moving, and it is sensitive to changes in balance control after stroke.

Balance Score and a History of Falls in Hospital Predict Recurrent Falls in the 6 Months Following Stroke Rehabilitation

OBJECTIVE

To investigate predictors of recurrent falls in adults who return to community dwelling after stroke rehabilitation.

DESIGN

Prospective observational study.

SETTING

Community.

PARTICIPANTS

Fifty-five adults with stroke (mean age +/- standard deviation, 68.1+/-12.8y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Baseline measures included balance, gait speed, muscle strength and tone, activity level, hemianopia, visual contrast sensitivity, hemineglect, medication use, fear of falling, and depression. Participants kept a 6-month prospective falls diary after discharge from rehabilitation.

RESULTS

Twenty-five (45%) participants reported falling, 12 had recurrent falls (> or =2 falls), and 13 fell once. Participants who fell recurrently had histories of falling during hospitalization or rehabilitation, poorer physical function measures, were taking more medications, and were more likely to have hemineglect than participants who fell once or did not fall (P<.05). A history of falling in the hospital or during rehabilitation, combined with poor balance (either Berg Balance Scale score <49 or step test score <7), predicted recurrent falls with sensitivity and specificity values greater than 80%.

CONCLUSIONS

Falls are a common occurrence after stroke. The predictive model developed can be used to identify people who are likely to have recurrent falls in the 6 months after stroke rehabilitation.

THE RELATIONSHIP BETWEEN MORPHOLOGICAL INDICATORS OF HUMAN BODY AND POSTURE

BACKGROUND

Posture and Stability Control is a process of maintaining balance and position of the body and its parts in a constantly changing environment. It is an important regulatory mechanism of the body, because it precedes movement, is upon the completion of which this system tries to maintain the body position.

AIM

The purpose of this long term study is to determinate by special testing which morphological indicators and how influence postural stability and its control.

METHOD

This study used testing with NeuroCom Balance-12 protocols, anthropometric measuring - 32 values, anamnestic questionnaire. For this article we analyzed one chosen protocol: Weight Bearing Squat Test.

RESULTS

In this research, 41 individuals took part in it. 22 (53.66 %) were female, 19 (46.34 %) were male. Interesting statistically significant coherences were discovered during analysis of Weight Bearing Squat protocol on level p < 0.01, p < 0.05 and the Student's two-optional T-test proved statistically significantly higher values of Left Body Weight erect position and Left Body Weight 30 degrees knee flexion in men in comparison with women.

CONCLUSIONS

This study shows us a direction and we may consider it a convenient base for more specific continuation in this problematic area.

Kinematics of podokinetic after-rotation: similarities to voluntary turning and potential clinical implications

We examined the kinematics of voluntary turning in place at three different speeds and of inadvertent turning in place during attempts to step in place following stepping on a rotating disc (podokinetic after-rotation, PKAR). We hypothesized that voluntary turning in place, like online turning during walking, would be characterized by a top-down sequence of yaw rotations in the direction of the turn, i.e. the head would rotate first, followed by the trunk and then the foot. We also hypothesized that in place PKAR would be characterized by a bottom-up sequence of yaw rotations, i.e. the foot would rotate first, followed by the trunk and the head. The alternative possibility was that PKAR, like voluntary turning, would be initiated by the head and trunk and the foot would rotate last. As expected, voluntary turning in place was characterized by a top-down sequence similar to that noted previously during online turning in the midst of walking. Turning velocity did not alter the sequence of rotations in voluntary turning. In place PKAR was also characterized by a top-down sequence, indicating that PKAR may access the same neural circuits employed during voluntary turning. These data suggest that the rotating treadmill may be a useful training tool for addressing difficulties with turning that are experienced by individuals with Parkinson disease (PD).

The Association of Balance Capacity and Falls Self-Efficacy With History of Falling in Community-Dwelling People With Chronic Stroke

OBJECTIVES

To describe the frequency of falls; to relate capacity-based and self-efficacy measures to fall history; and to determine to what extent capacity-based and self-efficacy measures are explained by subject characteristics and stroke impairments.

DESIGN

Cross-sectional.

SETTING

Community.

PARTICIPANTS

Convenience sample of 50 people with chronic stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Fall history, Falls Efficacy Scale-Swedish Version, fear of falling, and the mood subscore of the Stroke Impact Scale. Balance, strength, and functional mobility were measured using the Berg Balance Scale, timed sit to stand, and Timed Up & Go, respectively.

RESULTS

Falls were reported by 40% (n=20) of subjects; 22% (n=11) reported multiple falls. Subjects with fall history had more fear of falling (relative risk [RR], 2.4; 95% confidence interval [CI], 1.1-4.9), had less falls-related self-efficacy (P=.04), and more depressive symptoms (P=.02) than nonfallers. Subjects with multiple fall history had poorer balance (P=.02), more fear of falling (RR=5.6; 95% CI, 1.3-23), and used a greater number of medications (P=.04) than non- and 1-time fallers. Strength partially explained balance, mobility, and falls-related self-efficacy.

CONCLUSIONS

Balance and falls-related self-efficacy are associated with fall history and should be addressed in people with chronic stroke.

Altered timing of postural reflexes contributes to falling in persons with chronic stroke

The purpose of this study was to determine differences in the timing of postural reflexes and changes in kinematics between those who fell (fallers) in response to standing platform translations and those who did not (non-fallers). Forty-four persons with stroke were exposed to unexpected forward and backward platform translations while standing. Surface electromyography from bilateral tibialis anterior, gastrocnemius, rectus femoris, and biceps femoris were recorded along with kinematic data. Those that fell in response to the translations were compared to those who did not fall in terms of (1) postural reflex onset latency, (2) the time interval between the activation of distal and proximal muscles (i.e. intralimb coupling), and (3) changes in joint angles and trunk motion. Approximately 85% of falls occurred in response to the forward translations. Postural reflex onset latencies were delayed and intralimb coupling durations were longer in the faller versus non-faller group. At the time that the platform completed the translating motion (300 ms), the faller group demonstrated higher trunk velocity, greater change in paretic ankle angle, and the trunk was further behind the ankle compared to the non-faller group. This study suggests that following platform translations, delays in the timing of postural reflexes and disturbed intralimb coupling result in changes in kinematics, which contribute to falls in persons with stroke.

Postural instability during reaching tasks in Parkinson's disease

BACKGROUND AND PURPOSE

Reaching, like turning and rising from sitting, is an activity commonly associated with falls by people with Parkinson's disease. We set out to: (a) identify how people with moderate and severe Parkinson's disease performed high and low reaches and (b) to explore in detail the standard functional reach (functional reach) test and the fall histories of those who appeared unstable when reaching.

METHOD

In this cross-sectional study, people with moderate or severe Parkinson's disease (Hoehn and Yahr Grade III or IV) were video-recorded at home, reaching above shoulder height and below knee level. Blinded observers rated stability, alignment, foot position, floor contact, use of support and reach type. Functional reach was also measured and participants were interviewed about falls.

RESULTS

Of 51 participants, 33 (65%) had moderate Parkinson's disease and 18 (35%) severe. A greater proportion of the latter used support when reaching high (p = 0.029) and aligned forward when reaching low (p = 0.015); otherwise, strategies were similar across groups. Six people (all with severe Parkinson's disease) appeared unstable when reaching: they had a shorter functional reach than the others (median 10 cm versus 18 cm; p = 0.042) and had fallen frequently (median five falls in a year), although rarely when reaching.

CONCLUSIONS

Reaching tasks challenge postural stability in severe Parkinson's disease. People who appear unstable when reaching are likely to be repeat-fallers and at risk of further falls during more demanding activities. Research should address whether discouraging potentially destabilizing manoeuvres (such as squatting and toe-standing) and promoting safety-enhancing strategies (such as using support and facing forward), with or without balance retraining, reduces the risk of falling among people with severe Parkinson's disease.

Reduced hip bone mineral density is related to physical fitness and leg lean mass in ambulatory individuals with chronic stroke

Following a stroke, the reduced level of physical activity and functional use of the paretic leg may lead to bone loss and muscle atrophy. These factors and the high incidence of falls may contribute to hip fractures in the stroke population. This study was the first to examine total proximal femur bone mineral content (BMC) and bone mineral density (BMD) and their relationship to stroke-specific impairments in ambulatory individuals with chronic stroke (onset >1 year). We utilized dual-energy X-ray absorptiometry (DXA) to acquire proximal femur and total body scans on 58 (23 women) community-dwelling individuals with chronic stroke. We reported total proximal femur BMC (g) and BMD (g/cm2) derived from the proximal femur scans, and lean mass (g) and fat mass (g) for each leg derived from the total body scans. Each subject was evaluated for ambulatory capacity (Six-Minute Walk Test), knee extension strength (hand-held dynamometry), physical fitness [maximal oxygen uptake (VO2max)] and spasticity (Modified Ashworth Scale). Results showed that the paretic leg had significantly lower proximal femur BMD, lean mass and percent lean mass, but higher fat mass than the non-paretic leg for both men and women. Proximal femur BMD of the paretic leg was significantly related to ambulatory capacity (r=0.33, P=0.011), muscle strength (r=0.39, P=0.002), physical fitness (r=0.57, P<0.001), but not related to spasticity (r=-0.23, P=0.080). Multiple regression analysis showed that lean mass in the paretic leg was a major predictor (r2=0.371, P<0.001) of the paretic proximal femur BMD. VO2max was a significant predictor of both paretic proximal femur BMD (r2=0.325, P<0.001) and lean mass in the paretic leg (r2=0.700, P<0.001). Further study is required to determine whether increasing physical fitness and lean mass are important to improve hip bone health in chronic stroke.

Changes in perception of active but not passive turning following stepping on the rotating treadmill

The purpose of this work was to determine whether walking on a rotating disc would cause changes in perception of active and passive turning. Ten healthy control subjects wore a blindfold and earplugs while completing trials of active and passive turning. For active conditions, subjects were told the direction and amplitude of the desired turn and then attempted to turn in place the specified amount via actively stepping. For passive conditions, subjects were told that the disc they stood on would turn and they were to press a button when they had traveled the specified amplitude. Subjects completed active and passive trials to the left and right with amplitudes of 90, 180, 270, and 360 degrees. Subjects then stepped in place for 15 min on a disc rotating clockwise at 90 degrees /s, after which they repeated the trials of active and passive turning. Following rotating treadmill stimulation, subjects asked to turn in the direction opposite disc rotation (i.e., to the left) consistently and significantly overshot their targets in active trials. There were no changes in accuracy of active turning to the right or passive turning in either direction. This indicates that adaptation to the rotating treadmill is expressed even when subjects have a conscious intent to turn. The positive after-effects of the rotating treadmill add to the intended active turning in the direction of the after-effect but there is no decrement in active turning in the direction opposite the after-effect.

Fear of falling among stroke survivors after discharge from inpatient rehabilitation

The objectives of this study were to assess the incidence of falls and fall consequences among patients who were discharged from inpatient stroke rehabilitation and to investigate the proportion of those who experienced a fear of falling following a fall. This was a follow-up postal questionnaire study of patients who were admitted to the rehabilitation ward in a local hospital (Japan) for stroke rehabilitation. Seventy-three patients who met inclusion criteria were sent questionnaires and 49 (67%) responded to the questionnaire. Thirty-three patients had at least one fall after discharge from the hospital and of these, four patients experienced fractures resulting from their falls. Twenty-nine patients developed a fear of falling. As falls are common in stroke survivors, more attention should be paid to falls after stroke during inpatient rehabilitation to prevent physical and emotional consequences of falls.

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.

Incidence, circonstances et conséquences des chutes chez les patients en rééducation après un premier accident vasculaire cérébral

OBJECTIVES

To describe the incidence, circumstances, and consequences of falls in patients admitted in a rehabilitation ward after a stroke.

METHODS

Prospective monitoring of falls over four years in a neurological rehabilitation unit. Use of fall registry.

INCLUSION CRITERIA

age < 75 years, admission < 45 days after stroke onset, single stroke of 1 cerebral hemisphere (nonlacunar) or of the brain stem. Only falls due to loss of balance were considered; falls caused by a seizure or syncope were not considered.

RESULTS

Of 217 consecutive patients with the inclusion criteria, 34 had fallen at least once (15.7%) and 10 twice (4.1%). Fall incidence, defined as the number of falls per patient per day was 2.2 per thousand. Half of the patients fell the first three weeks after admission. Most falls involved getting to or from the wheelchair or the bed; 1 patient had recovered minimal postural abilities at the gym but was not independent. Traumatic lesions were noted in 13 patients: they were minor in nine and severe in four, including three fractures.

CONCLUSION

Falls due to loss of balance are a major problem in patients undergoing rehabilitation after a stroke. Getting to and from wheelchairs in the bedroom and bathroom by patients who are not allowed to do so play a key role in many falls. Prevention programs should consider this information.

Contribution of muscle strength and integration of afferent input to postural instability in persons with stroke

OBJECTIVE

To determine the relationship of muscle strength to postural sway in persons with stroke under standing conditions in which vision and ankle proprioception were manipulated.

METHODS

Forty persons with stroke and 40 healthy older adult controls were recruited from the community and underwent balance testing consisting of 6 conditions that manipulate vision and somatosensory information while standing. Postural sway was measured during each condition. In addition, lower extremity joint torques and cutaneous sensation from the plantar surface of the foot were assessed.

RESULTS

Postural sway was increased with more challenging standing conditions (i.e., when multiple sensory systems were manipulated) to a greater extent with the group with stroke compared to controls. Muscle strength was only correlated to sway during the most challenging conditions. Furthermore, a greater number of persons with stroke fell during the balance testing compared to controls.

CONCLUSIONS

Impairments in re-weighting/integrating afferent information, in addition to muscle weakness, appear to contribute to postural instability and falls in persons with stroke. These findings can be used by clinicians to design effective interventions for improving postural control following stroke.

Validation of a fall risk index in stroke rehabilitation

A fall risk index has previously been developed to identify fall-prone individuals in stroke rehabilitation. The purpose of this study was to validate the predictive accuracy of the index. The validation sample (n = 158) consisted of patients admitted to a specialized geriatric stroke rehabilitation ward. The index was scored for each subject, and the relationship between the score and falls was assessed. The index was then remodeled and cross-validated in the sample from which it was derived (model fit sample, n = 135). The total index score (0-11) was significantly connected with the time to first fall (hazard ratio, 1.22; confidence interval [CI], 1.03-1.44). However, the classification of subjects into groups with low, intermediate, and high risk of falling could not be correlated with the time to first fall. A remodeled index contained 3 of the separate original index items. Its relationship to fall risk in the model fit sample was (hazard ratio, 1.82; CI, 1.38-2.40). The fall risk index showed some correlation with the fall risk among patients in stroke rehabilitation, but the results indicate that it should be modified to reach acceptable accuracy. A remodeled index showed a higher association with fall risk.

Galvanic evoked vestibulospinal and vestibulocollic reflexes in stroke

OBJECTIVE

Following stroke, the startle reflex, mediated via the reticulospinal tract, is often facilitated. Vestibulospinal reflexes are another bulbospinal reflex, abnormalities of which may contribute to impaired body posture and stance following stroke. We recorded galvanic evoked vestibulospinal and vestibulocollic reflexes to assess whether these showed similar changes to those for startle following stroke affecting the pons and above.

METHODS

Twenty-four stroke subjects (aged 40-82) were studied in the vestibulospinal part of the study, 21 stroke subjects (aged 40-81 years) were studied in the vestibulocollic part, including 18 studied in both. Transmastoid galvanic (DC) current was used to stimulate the vestibular nerve. Vestibulocollic responses were recorded from the sternocleidomastoid muscles and vestibulospinal responses from over soleus in standing subjects.

RESULTS

Vestibulocollic reflex amplitudes and latencies showed no significant differences between the two sides. Similarly short latency (SL) and medium latency (ML) vestibulospinal reflexes did not differ significantly in frequency, latency or amplitude between the affected and unaffected legs.

CONCLUSIONS

Vestibular reflexes are not facilitated by stroke at or above the pontine level. The exaggeration of startle by stroke may be specific to this reflex.

Falls in a community of older adults: findings and implications for practice

The purpose of this study was to describe the falls that occurred over a 5-year period in a group of older adults living in a continuing care retirement community (CCRC) and to test two models, one mediating whether or not the individual fell and the second the number of falls the individual experienced. Of the 312 participants, 177 (57%) residents experienced at least one fall. There were a total of 594 falls with the mean number of falls per person being 1.9 (SD = 3.0), and the range of falls from 1 to 19. Age, gender, and neurologic disease significantly influenced whether or not a fall occurred. Mental health, regular use of alcohol, and neurologic problems all significantly influenced the number of falls that occurred.

Does balance or motor impairment of limbs discriminate the ambulatory status of stroke survivors?

OBJECTIVE

This study was performed to determine if ambulatory function is governed by motor impairment of limbs or balance ability in subjects with hemiplegia caused by stroke.

DESIGN

Seven patients who walked with physical assistance (FIM 4) after stroke and 13 who walked independently with assistive devices (FIM 6) were compared with 13 healthy subjects. Motor impairment of limbs was evaluated with the Fugl-Meyer Assessment. The Berg Balance Scale and limit of stability test of the Smart Balance Master were used to evaluate balance ability.

RESULTS

The FIM 6 group and the controls were best differentiated by motor impairment of the paretic limbs and limit of stability in the backward direction. Motor impairment of the upper limb and limit of stability in direction toward the paretic side separated the FIM 4 from the FIM 6 group. Upper limb motor impairment and the Berg Balance Scale consistently separated the three subject groups.

CONCLUSIONS

Motor impairment in the paretic upper limb and balance dysfunction should be addressed in treatments working toward independent ambulation.