Fear of falling among stroke survivors after discharge from inpatient rehabilitation

Examining the association between balance self-efficacy and virtual balance performance in individuals with stroke: a cross-sectional study

BACKGROUND

Balance self-efficacy is a strong predictor of fall risk after stroke and is related to performance on balance and walking tests. The use of telerehabilitation for delivering stroke rehabilitation has increased in recent years and there is a need to adapt common clinical assessments to be administered in virtual formats, but the association between balance self-efficacy and virtually administered clinical tests of balance performance has yet to be established. This study examined the association between the Activities-specific Balance Confidence (ABC) Scale and virtually administered Timed Up and Go (TUG), Tandem Stand, and Functional Reach tests (FRT) in individuals with stroke.

METHODS

This was a secondary analysis of baseline data from two telerehabilitation trials with individuals with stroke. All assessments were administered by trained physical therapists through videoconferencing software. Multivariate regression analyses were used to examine the associations between the ABC scale and TUG test, Tandem Stand test, and FRT, adjusted for age and number of comorbidities.

RESULTS

Data from 51 participants (n = 11 female, median age = 64 [IQR: 18] years, 9.3 ± 4.6 months poststroke) were analyzed. The ABC scores were associated with TUG (R2 = 0.56, F(3,47) = 20.26, p < 0.01), but not Tandem Stand (R2 = 0.18, F(5,45) = 1.93, p = 0.11) or FRT (R2 = 0.14, F(3,47) = 2.55, p = 0.07) tests.

CONCLUSION

We observed associations between the ABC scores and virtual TUG, but not with Tandem Stand or FRT, which may be attributed to the context-specificity of balance self-efficacy. As virtual administration of outcomes assessments becomes part of common practice in stroke rehabilitation, our study supports the use of virtually administered TUG in stroke.

Is lateral external perturbation training more beneficial for protective stepping responses than voluntary stepping training in stroke? A pilot randomized control study

The study examined whether lateral perturbation training could improve stepping performance and balance in individuals post-stroke. Thirty-one participants with hemiparesis were randomly allocated to PERT (external perturbation) or VOL (voluntary stepping) step training. The PERT and VOL group consisted of 80 step trials predominantly in the lateral direction, with a small proportion of steps in the anterior/posterior direction. Outcome measures based on step type (medial and lateral) included step initiation time, step length, step clearance, step velocity during an induced waist pull perturbation and voluntary step, and clinical balance assessments. The PERT group initiated a lateral step faster with the non-paretic leg during the induced waist pull perturbation step (P = 0.044) than the VOL group after training. Both groups improved the non-paretic step length and step velocity during lateral steps. During the voluntary steps, the PERT group significantly initiated a voluntary step faster. No significant changes were observed in the paretic leg. Both groups significantly improved on the Community Balance & Mobility Scale and Activities Specific Balance Confidence Scale. Overall, we demonstrated that an exercise to improve stepping performance with external perturbations might provide more benefits in protective stepping responses than training with voluntary steps for individuals with a stroke.

Do proprioceptive training strategies with dual-task exercises positively influence gait parameters in chronic stroke? A systematic review

OBJECTIVE

This study aims to assess the impact of proprioceptive training strategies with dual-task exercises on gait in people with chronic stroke.

STUDY DESIGN

Systematic review.

PATIENTS

Chronic stroke.

METHODS

Searches were conducted in accordance with PRISMA guidelines and PICOS criteria. PubMed, Web of Science, and Scopus databases were systematically searched from November 2020 to February 2022, for eligible clinical trials. Two independent reviewers thoroughly screened potential articles for relevance and assessed the methodology quality. In accordance with the GRADE, PICOS criteria, and Cochrane risk of bias tools, the authors included articles concerning the effectiveness of dual-task in proprioceptive training on gait parameters in people with chronic stroke.

RESULTS

Of 3075 identified studies, 11 articles met the inclusion criteria: 7 were randomized clinical trials, 1 was not randomized, and 3 were observational studies. The overall quality of evidence, assessed using the GRADE framework, was high, indicating a high level of confidence in the systematic review's findings. The papers involved 393 stroke patients; 241 underwent dual-task in proprioceptive training, with 152 participants in other stroke rehabilitation; within the dual-task group, 71 engaged in cognitive tasks, and 170 participated in motor tasks. dual-task in proprioceptive training improved gait speed, cadence, stride time, stride length, and step length. The best effects were observed with training 3 times a week for 4 weeks, with each session lasting 30 minutes, on speed, cadence, stride length, and step length.

CONCLUSION

Current evidence suggests that proprioceptive training strategies with dual-task exercises improved walking abilities in people with chronic stroke. Specifically, it enhanced gait speed, a key indicator of clinical severity.

Reduced trunk muscle mass in patients with stroke is associated with reduced balance function recovery

BACKGROUND & AIMS

Skeletal muscles are essential for postural retention and balance function. However, the relationship between trunk muscle mass (TMM) and balance function has not yet been clarified. This study aimed to examine the impact of TMM on the change in balance function in patients with stroke from admission to a rehabilitation hospital to discharge.

METHODS

This retrospective observational study included patients aged ≥65 years with cerebral infarction admitted to our rehabilitation hospital from May 2018 to July 2022. The trunk muscle mass index (TMI) was calculated at admission and discharge using bioelectrical impedance analysis. Patients were divided into low and high TMI groups according to the median TMI at admission. The primary outcome was the change in the Berg Balance Scale (BBS) score (BBS score at discharge - BBS score at admission).

RESULTS

A total of 315 patients (mean age, 78.9 ± 8.0 years; 172 men and 143 women) were included. The median TMI was 7.31 kg/m2 in men and 6.30 kg/m2 in women. Among male patients, the high TMI group had higher BBS scores at admission (31.2 ± 18.2 vs. 23.4 ± 17.7, P = 0.005) and discharge (43.0 ± 15.3 vs. 33.4 ± 19.0, P < 0.001) than those in the low TMI group. After adjusting for confounding factors, TMI at admission was independently associated with the change in BBS score (β = 0.587, P = 0.002).

CONCLUSIONS

Reduced TMM negatively influences balance function recovery in patients after stroke. A strategy aimed at increasing TMM could have beneficial effects on balance function.

Association between fear of falling and falls following acute and chronic stroke: a systematic review with meta-analysis

OBJECTIVES

To examine the association between falls and fear of falling in people with stroke and to evaluate the differences between patients with acute stroke and those with chronic stroke with regard to any such association.

METHODS

Articles were searched in Medline, CINAHL, AMED, Embase, PsycINFO, Cochrane Library of Reviews and PEDro from inception until March 2023. Experimental, observational or explorative studies investigating the association between fear of falling and falls in people with stroke were included. Articles were screened by 2 independent reviewers. Data were extracted by an independent reviewer.

RESULTS

A total of 26 reports were included in this review (n = 2863). Fear of falling, assessed by a single-question survey, was significantly associated with falls (relative risk = 1.44; 95% confidence interval (95% CI) = 1.22, 1.70; I2 = 0%) in people with acute stroke. Significant mean differences in fear of falling, based on the Falls Efficacy Scale (mean difference = 12.80; 95% CI = 1.81, 23.78; I² = 28%) and Activities-specific Balance Confidence Scale (mean difference = -9.99; 95% CI = -15.36, -4.62; I² = 57%), were also reported between fallers and non-fallers in people with chronic stroke.

CONCLUSION

A small, but significant, association exists between falls and fear of falling in both acute and chronic stroke patients.

Mild Stroke, Serious Problems: Limitations in Balance and Gait Capacity and the Impact on Fall Rate, and Physical Activity

BACKGROUND

After mild stroke persistent balance limitations may occur, creating a risk factor for fear of falling, falls, and reduced activity levels. Objective. To investigate whether individuals in the chronic phase after mild stroke show balance and gait limitations, elevated fall risk, reduced balance confidence, and physical activity levels compared to healthy controls.

METHODS

An observational case-control study was performed. Main outcomes included the Mini-Balance Evaluation Systems Test (mini-BEST), Timed Up and Go (TUG), 10-m Walking Test (10-MWT), and 6-item version Activity-specific Balance Confidence (6-ABC) scale which were measured in 1 session. Objectively measured daily physical activity was measured for 7 consecutive days. Fall rate in daily life was recorded for 12 months. Individuals after a mild stroke were considered eligible when they: (1) sustained a transient ischemic attack or stroke longer than 6 months ago, resulting in motor and/or sensory loss in the contralesional leg at the time of stroke, (2) showed (near-) complete motor function, that is, ≥24 points on the Fugl-Meyer Assessment-Lower Extremity (range: 0-28).

RESULTS

Forty-seven healthy controls and 70 participants after mild stroke were included. Participants with stroke fell more than twice as often as healthy controls, had a 2 point lower median score on the mini-BEST, were 1.7 second slower on TUG, 0.6 km/h slower on the 10-MWT, and had a 12% lower 6-ABC score. Intensity for both total activity (8%) as well as walking activity (6%) was lower in the participants with stroke, while no differences were found in terms of duration.

CONCLUSIONS

Individuals in the chronic phase after a mild stroke demonstrate persistent balance limitations and have an increased fall risk. Our results point at an unmet clinical need in this population.

Effect of physical exercise on fear of falling in patients with stroke: A systematic review and meta-analysis

OBJECTIVE

To consolidate the evidence on the effect of physical exercise on fear of falling in individuals with stroke.

DATA SOURCES

PubMed, CINAHL, Cochrane Database and MEDLINE.

METHODS

An extensive database search was conducted to identify the randomised controlled trials that examined the effect of physical exercise on fear of falling post-stroke. Grading of Recommendation, Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence for each meta-analysis.

RESULTS

Fourteen trials totalling 1211 participants were included in this review. Thirteen of these (1180 participants) were included in the meta-analyses. In the primary analysis, very low-quality evidence suggested that exercise reduced fear of falling post-stroke (standardized mean difference (SMD) 0.48; 95% confidence interval (CI) 0.23 to 0.72). The effect was diminished at three- to six-month follow-up after exercise training ended (SMD -0.09; 95% CI -0.27 to 0.10; high-quality evidence). In the sensitivity analyses, the treatment effect was more pronounced in individuals with a lower baseline Berg balance score (BBS ≤45; SMD 0.53; 95%CI 0.17 to 0.88) and for those trials with exercise frequency of ≥3 sessions per week (SMD 0.70; 95%CI 0.39 to 1.01). Compared with circuit-based training consisting of a combination of walking, balance and strengthening exercises (SMD 0.27; 95% CI -0.09 to 0.63), walking programmes seemed to generate a larger effect on fear of falling (SMD 1.06; 95%CI 0.43 to 1.70).

CONCLUSION

Physical exercise was beneficial for reducing fear of falling in individuals with stroke, particularly those with poorer balance ability.

A validity study to consult on a protocol of a home hazard management program for falls prevention among community dwelling stroke survivors

OBJECTIVE

A fall after a stroke is common but the consequences can be devastating not only for the stroke survivors, but also for caregivers, healthcare, and the society. However, research on falls prevention among the stroke population are limited, particularly on home hazards assessment and home modifications, demanding for a study to be conducted. The aim of the study is to validate the protocol and content of a home hazard management program guided by the Person-Environment-Occupation (PEO) Model for falls prevention among community dwelling stroke survivors.

METHOD

Researchers developed their own questionnaire for content validation which consist of 23 items that covers two domains, namely justification for telehealth home hazard management practice and the protocol's overall methodology. Occupational therapists with at least one year of experience in conducting a home hazard assessment were consulted for the content validation of a two-group clinical controlled trial protocol utilizing a home hazard assessment, home modifications and education over the usual care. Written consent was obtained prior to the study. The occupational therapists were given a Google Form link to review the protocol and intervention based on the questionnaire and rated each item using a four-point Likert scale for relevance and feasibility. Open-ended feedback was also recorded on the google form. Content Validity Index (CVI), Modified Kappa Index and Cronbach's Alpha was calculated for the content validity and reliability analysis.

RESULTS

A total of sixteen occupational therapists participated in the study. 43.7% of participants had a master's degree, 93.7% worked in the government sector and 56.2% had six years and more experience on conducting home hazard assessments. Content validity of the protocol is satisfactory for relevancy and feasibility (CVI = 0.84, ranging from 0.5 to 1.00), and for the reliability (α = 0.94 (relevance) and α = 0.97 (feasibility), respectively. The Modified Kappa ranged from 0.38 to 1.00 for all items. Feedback was also received regarding the design and procedure of the study protocol which included participant's selection criteria, sample size, equipment provided, cost, location, and care for the participants during the intervention.

CONCLUSIONS

Introducing a home hazard management program to prevent falls among the stroke population is viewed relevant and feasible. Practical suggestions from the consultation panel were adopted, and minor adjustments were required to strengthen the protocol's overall methodology. This study established a rigorous and robust experimental protocol for future undertaking.

The association between fatigue severity and risk of falls among middle-aged and older Australian stroke survivors

Background

Fatigue is a common and often debilitating symptom experienced by many stroke survivors. Significant post stroke fatigue may predispose individuals to other health complications, such as falls, which can lead to fractures and soft tissue injuries. Only limited research has examined the association between fatigue and falls in stroke survivors.

Methods

Data were obtained from the Sax Institute’s 45 and Up Study, from a subset of individuals who had experienced a stroke. The Modified Fatigue Impact Scale—5-item version (MFIS-5) was used to measure the level of fatigue. A logistic regression model, adjusted for stroke characteristics and comorbidities, was used to determine the magnitude of association between change in fatigue score and odds of having had a fall.

Results

A total of 576 participants completed the questionnaire. A total of 214 (37.2%) participants reported having had a fall in the previous 12 months. There was a statistically significant association between fatigue scores and fall status (p < 0.001). Specifically, for every 1-point increase in the fatigue score (MFIS-5) (i.e. higher level of fatigue), the odds of a person having a fall is 1.10 times greater (AOR = 1.10; 95% CI 1.05, 1.15; p < 0.001).

Conclusion

This study revealed an association between an increasing risk of falls with increasing severity of post stroke fatigue. Accurate detection and management of fatigue may help reduce the risk of falls and should be the focus of future research.

Risk factors for fear of falling in stroke patients: a systematic review and meta-analysis

OBJECTIVE

Even though 32%-83% for fear of falling (FoF) in patients with stroke, very little is known about the predictors of the problems. Therefore, we systematically reviewed the literature on risk factors for FoF in patients with stroke.

DESIGN

A systematic review and meta-analysis DATA SOURCES: PubMed, Embase, Cochrane Library database, Web of Science, CINAHL, PsycINFO, Grey literature and other relevant databases for related publications were searched (from inception to 17 July 2021).

RESULTS

Eight studies involving 1597 participants were selected to analyse risk factors for patients with stroke with FoF. The quality of all included studies was assessed and categorised as medium or high quality. Review Manager V.5.3 merged the OR value and 95% CI of the potential risk factors. Meta-regression and Egger's test were performed by Stata V.15.1. The risk factors for FoF in patients with stroke were women (OR=2.13, 95% CI 1.47 to 3.09), impaired balance ability (OR=5.54; 95% CI 3.48 to 8.81), lower mobility (OR=1.12; 95% CI 1.05 to 1.19), history of falls (OR=2.33; 95% CI 1.54 to 3.53) and walking aid (OR=1.98; 95% CI 1.37 to 2.88), anxiety (OR=2.29; 95% CI 1.43 to 3.67), depression (OR=1.80; 95% CI 1.22 to 2.67), poor lower limb motor function (OR=1.14; 95% CI 1.00 to 1.29) and physically inactiveness (OR=2.04; 95% CI 1.01 to 4.12). Measurement of heterogeneity between studies was high for all outcomes (I² =0%-93%), indicating that the substantial interstudy heterogeneity in estimated proportions was not attributed to the sampling error. Sensitivity analysis (leave-one-out method) showed that the pooled estimate was stable.

CONCLUSION

This meta-analysis indicated that female population, impaired balance ability, lower mobility, history of falls and walking aid in patients with stroke might be at greater risk for FoF. Future studies are recommended to determine other risk factors specific to patients with stroke.

Cognitive -behavioral therapy for managing depressive and anxiety symptoms after stroke: a systematic review and meta-analysis

BACKGROUND

Post-stroke anxiety and depression can be disabling and result in impaired recovery. Cognitive-behavioral therapy (CBT) has been demonstrated to be effective for anxiety and depression; however, determining its efficacy among those with stroke is warranted. Our objectives to evaluate CBT for anxiety and depression post-stroke .

METHODS

This review was registered with PROSPERO (REG# CRD42020186324). Medline, PsycInfo, and EMBR Cochrane were used to locate studies published before May 2020, using keywords such as stroke and CBT. A study was included if: (1) interventions were CBT-based, targeting anxiety and/or depression; (2) participants experienced a stroke at least 3 months previous; (3) participants were at least 18 years old. Standardized mean differences ± standard errors and 95% confidence intervals were calculated, and heterogeneity was determined. The Cochrane Risk of Bias tool was used.

RESULTS

The search yielded 563 articles, of which 10 (N = 672) were included;6 were randomized controlled trials. Primary reasons for exclusion included: (1) wrong population (2) insufficient data provided for a meta-analysis; (3) wrongoutcomes. CBT showed large effects on reducing overall anxiety (SMD ± SE: 1.01 ± 0.32, p < .001) and depression (SMD ± SE: 0.95 ± 0.22, p < .000) symptoms at the end of the studies. CBT moderately maintained anxiety (SDM ± SE: 0.779 ± 0.348, p ˂.025) and depression (SDM ± SE: 0.622 ± 0.285, p ˂ .029) scores after 3-months. Limitations included small sample size, limited comparators, and lack of follow-up data.

CONCLUSION

The results of this meta-analysis provide substantial evidence for the use of CBTto manage post-stroke anxiety and depression.

Investigating Relationships between Balance Confidence and Balance Ability in Older Adults

Increasing balance confidence in older individuals is important towards improving their quality of life and reducing activity avoidance. Here, we investigated if balance confidence (perceived ability) and balance performance (ability) in older adults were related to one another and would improve after balance training. The relationship of balance confidence in conjunction with balance performance for varied conditions (such as limiting vision, modifying somatosensory cues, and also base of support) was explored. We sought to determine if balance confidence and ability, as well as their relationship, could change after several weeks of training. Twenty-seven healthy participants were trained for several weeks during standing and walking exercises. In addition, seven participants with a higher risk of imbalance leading to falls (survivors of stroke) were also trained. Prior to and after training, balance ability and confidence were assessed via the Balance Error Scoring System (BESS) and Activities Specific Balance Confidence (ABC) Scale, respectively. Both groups showed improvements in balance abilities (i.e., BESS errors significantly decreased after training). Balance confidence was significantly higher in the healthy group than in the stroke group; however, ABC results reflected that balance confidence did not significantly increase after training for each. The correlations between balance ability and balance confidence were explored. Encouragingly, healthy participants displayed a negative correlation between BESS errors and ABC (i.e., enhancements in balance confidence (increases in ABC Scale results) were related to improvements in balance ability (decreases in BESS errors)). For the stroke participants, despite improvements in balance ability, our results showed that there was no relation to balance confidence (i.e., no correlation between BESS errors and ABC) in this group.

Risk Factors Related to Falling in Patients after Stroke

Background:

The aim of this study was to identify the risk factors associated with falling in post stroke patients.

Methods:

This retrospective case-control study included 561 neurology patients hospitalized for a stroke and divided into two groups: falling patients and non-falling patients. They referred to the Special Hospital for Cerebrovascular Diseases “Sveti Sava” in Belgrade, Serbia, from 2018–2019. Logistic regression analysis was applied to examine socio-economic factors associated with predictors of unmet healthcare needs.

Results:

A significant difference was seen in the length of hospitalization of falling patients compared to the non-falling (P<0.001). We established statistically significant differences in mental status (P<0.001), sensibility (P=0.016), depressed mood (P<0.001), early (P=0.001) and medium insomnia (P=0.042), psychomotor slowness (P=0.030), somatic anxiety (P=0.044) and memory (P<0.001).

Conclusion:

Cerebrovascular disease distribution and the degree of neurological deficit primarily altered mental status, which could be recognized as one of the more important predictors for falling after stroke. The identification of risk factors may be a first step toward the design of intervention programs for preventing a future fall among hospitalized stroke patients.

Enhanced error facilitates motor learning in weight shift and increases use of the paretic leg during walking at chronic stage after stroke

The purpose of this study was to determine whether the application of lateral pelvis pulling force toward the non-paretic side during the stance phase of the paretic leg would enhance forced use of the paretic leg and increase weight shift toward the paretic side in stroke survivors. Eleven chronic stroke survivors participated in two experimental sessions, which consisted of (1) treadmill walking with the application of "pelvis resistance" or "pelvis assistance" and (2) overground walking. During the treadmill walking, the laterally pulling force was applied during the stance phase of the paretic leg toward the non-paretic side for the "pelvis resistance" condition or toward the paretic side for the "pelvis assistance" condition during the stance phase of the paretic leg. After force release, the "pelvis resistance" condition exhibited greater enhancement in muscle activation of hip ABD, ADD, and SOL and greater improvement in lateral weight shift toward the paretic side, compared with the effect of the "pelvis assistance" condition (P < 0.03). This improved lateral weight shift was associated with the enhanced muscle activation of hip ABD and ADD (R² = 0.67, P = 0.01). The pelvis resistance condition also improved overground walking speed and stance phase symmetry when measured 10 min after the treadmill walking (P = 0.004). In conclusion, applying pelvis resistance forces to increase error signals may facilitate motor learning of weight shift toward the paretic side and enhance use of the paretic leg in chronic stroke survivors. Results from this study may be utilized to develop an intervention approach to improve walking in stroke survivors.

Multidirectional Overground Robotic Training Leads to Improvements in Balance in Older Adults

For the rapidly growing aging demographic worldwide, robotic training methods could be impactful towards improving balance critical for everyday life. Here, we investigated the hypothesis that non-bodyweight supportive (nBWS) overground robotic balance training would lead to improvements in balance performance and balance confidence in older adults. Sixteen healthy older participants (69.7 ± 6.7 years old) were trained while donning a harness from a distinctive NaviGAITor robotic system. A control group of 11 healthy participants (68.7 ± 5.0 years old) underwent the same training but without the robotic system. Training included 6 weeks of standing and walking tasks while modifying: (1) sensory information (i.e., with and without vision (eyes-open/closed), with more and fewer support surface cues (hard or foam surfaces)) and (2) base-of-support (wide, tandem and single-leg standing exercises). Prior to and post-training, balance ability and balance confidence were assessed via the balance error scoring system (BESS) and the Activities specific Balance Confidence (ABC) scale, respectively. Encouragingly, results showed that balance ability improved (i.e., BESS errors significantly decreased), particularly in the nBWS group, across nearly all test conditions. This result serves as an indication that robotic training has an impact on improving balance for healthy aging individuals.

Prediction of fear of falling at 6 months after stroke based on 279 individuals from the Fall Study of Gothenburg

The early identification of individuals at risk of fear of falling after stroke is crucial in order to individualise preventive actions and interventions. The aim of this study was to identify the incidence of, and baseline factors in acute stroke that are associated with fear of falling at 6 months after stroke. Fear of falling was assessed by one question, which was answered by 279 of 452 eligible individuals. Univariable and multivariable logistic regression analyses were performed to determine the factors that were associated with fear of falling. The dependent variable was fear of falling at 6 months after stroke. The independent variables were related to function, activity and participation, including personal and environmental factors. Fear of falling was reported by 117 (41.9%) individuals. Poor postural control in acute stroke, measured using the modified version of the Postural Assessment Scale for Stroke Patients (odds ratio [OR]: 2.60, 95% confidence interval [CI]: 1.26–5.36), and being physically inactive prior to the stroke, measured using the Saltin-Grimby Physical Activity Scale (OR: 2.04, 95% CI: 1.01–4.12), were found to be associated with fear of falling at 6 months after stroke. The findings in this study are useful in clinical practice to optimise rehabilitation after stroke.

Potential contributing factors to upper limb associated reactions in people with acquired brain injury: an exploratory study

PURPOSE

To determine which potential contributing factors are associated with upper limb associated reaction (AR) expression in individuals with acquired brain injury (ABI).

METHODS

Forty-two participants underwent three-dimensional motion analysis at self-selected walking speed to generate the AR outcome measure, quantifying their upper limb kinematic deviation compared to healthy controls. Clinical assessment included: upper and lower limb hypertonicity, spasticity and strength, balance, dynamic walking stability, arm and leg function, anxiety, arm pain/discomfort, and fear of falling.

RESULTS

Significant, moderate-to-strong correlations (r = 0.42-0.74, p < 0.05) existed between upper limb ARs and both hypertonicity and spasticity of the upper limb muscles and the knee extensors. Significant, moderate correlations to ARs (r = 0.42-0.59, p < 0.05) existed for balance, dynamic stability, upper limb strength, and arm function. The severity of AR was significantly different between those with and without hypertonicity of the four tested upper limb muscles, elbow and long finger flexor spasticity, knee extensor spasticity, and reduced dynamic stability (p < 0.05; effect sizes ≥0.80). However, these contributing factors were not present in all participants.

CONCLUSIONS

Associated reactions are complex and multi-factorial. There were several significant correlations indicating that factors may influence AR severity. While positive upper motor neuron syndrome features should be prioritised for clinical assessment, these factors are not prerequisites for ARs.IMPLICATIONS FOR REHABILITATIONUpper limb associated reactions are a complex and multi-factorial phenomenon.Upper limb muscle hypertonicity and spasticity should be prioritised for assessment; however, they are not prerequisites for associated reactions.Hypertonicity and spasticity should be differentiated as they may have differing relationships to associated reactions.Knee extensor hypertonicity and spasticity, postural stability, upper limb strength, and arm function may also be contributing factors to consider.

Effect of Cognitive Function on Balance and Posture Control after Stroke

Hemiplegic gait is the most common sequela of stroke. Patients with hemiplegic gait are at a risk of falling because of poor balance. The theory of cognitive-motor networks paved the way for a new field of research. However, the mechanism of the relationship of cognition with gait or posture control networks is unclear because of the dynamic characteristics of walking and changing postures. To explore differences in the balance function and fall risk between patients with and without cognitive impairment after stroke, we utilized the Berg balance scale, Timed “Up and Go” test, and 10 m walking test. Patients were divided into two groups: the observation group (16 patients, female 6 and male 10), comprising patients with cognitive impairment after stroke, and the control group (16 patients, female 7 and male 9), comprising patients without cognitive impairment after stroke. We found that patients with cognitive impairment had worse balance function and a higher risk of falls. They needed a longer time to turn around or sit down. Our findings indicated that posture control in turning around and sitting down required more cognitive resources in daily life.

Determining the optimal dose of reactive balance training after stroke: study protocol for a pilot randomised controlled trial

INTRODUCTION

Falls risk poststroke is highest soon after discharge from rehabilitation. Reactive balance training (RBT) aims to improve control of reactions to prevent falling after a loss of balance. In healthy older adults, a single RBT session can lead to lasting improvements in reactive balance control and prevent falls in daily life. While increasing the dose of RBT does not appear to lead to additional benefit for healthy older adults, stroke survivors, who have more severely impaired balance control, may benefit from a higher RBT dose. Our long-term goal is to determine the optimal dose of RBT in people with subacute stroke. This assessor-blinded pilot randomised controlled trial aims to inform the design of a larger trial to address this long-term goal.

METHODS AND ANALYSIS

Participants (n=36) will be attending out-patient stroke rehabilitation, and will be randomly allocated to one of three groups: one, three or six RBT sessions. RBT will replace a portion of participants' regular physiotherapy so that the total physical rehabilitation time will be the same for the three groups. Balance and balance confidence will be assessed at: (1) study enrolment; (2) out-patient rehabilitation discharge; and (3) 6 months postdischarge. Participants will report falls and physical activity for 6 months postdischarge. Pilot data will be used to plan the larger trial (ie, sample size estimate using fall rates, and which groups should be included based on between-group trends in pre-to-post training effect sizes for reactive balance control measures). Pilot data will also be used to assess the feasibility of the larger trial (ie, based on the accrual rate, outcome completion rate and feasibility of prescribing specific training doses).

ETHICS AND DISSEMINATION

Institutional research ethics approval has been received. Study participants will receive a lay summary of results. We will also publish our findings in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04219696; Pre results.

Determinants of Recurrent Falls Poststroke: A 1-Year Follow-up of the Fall Study of Gothenburg

OBJECTIVE

To identify the occurrence of recurrent falls and the determinants in the acute phase poststroke that are associated with recurrent falls within the first year poststroke.

DESIGN

Prospective follow-up study.

SETTING

Stroke unit and community.

PARTICIPANTS

Patients (N=504) with acute stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The dependent variable was recurrent falls, defined as ≥2 falls, within the first year poststroke. The independent baseline variables were related to function, activity, participation, personal and environmental factors, and comorbidity and were assessed within 4 days after admission to a stroke unit. Fall data were registered at the stroke unit, and self-reported fall data were collected during follow-up using a standardized questionnaire. Determinants of recurrent falls were identified using univariable and multivariable logistic regression analyses.

RESULTS

Within 12 months poststroke, 95 of 348 participants (27%) had experienced recurrent falls. Poor postural control (odds ratio [OR] 5.85; 95% confidence interval [CI], 2.84-12.02; P<.0001), moderate postural control (OR 2.41; 95% CI, 1.21-4.80; P=.012), and using a walking aid in the acute phase (OR 2.51; 95% CI, 1.45-4.36; P=.0010) are statistically significant determinants that are associated with recurrent falls within the first year poststroke. The determinant of using a walking aid appears to be primarily driven by those younger than 80 years. In addition to impaired postural control and using a walking aid, a fall at the stroke unit is a determinant associated with recurrent falls after discharge within 6 months poststroke.

CONCLUSIONS

More than 1 in 4 individuals with stroke experienced recurrent falls within the first year poststroke. Impaired postural control, using a walking aid in the acute phase, and fall during hospitalization are determinants associated with recurrent falls during follow-up. The determinants differ somewhat at different ages.

Factors affecting fear of falls in patients with chronic stroke

Objective: The aim of this study was to find the factors associated with fear of falls in patients having chronic stroke.Methods: Inclusion criterion was subjects with cerebral stroke for more than 3 months. A structured interview of 82 subjects was conducted with a questionnaire with questions regarding personal factors such as gender, side affected, number of comorbidities, and setting of physical therapy sessions. Depression was assessed using Patient Health Questionnaire-9, lower extremity motor function was assessed using Fugl-Meyer scale, and functional mobility was assessed using Timed Up and Go. Chi-square analysis was done on the above factors to find significant factors followed by logistic regression of the factors found significant in Chi square.Results: Lower extremity Fugl-Meyer score was significantly associated with fear of falls (p value 0.047 with Odds ratio of 1.136, 95% CI 1.002-1.287) in patients having chronic stroke while treatment factors, such as setting of physical therapy sessions, and personal factors, such as gender, side affected, number of comorbidities, depression, functional mobility, or use of walking aid, were not found to have significant association.Conclusion: The lower extremity Fugl-Meyer score is associated with fear of falls in patients having chronic stroke.

The effect of ankle-foot orthoses on fall/near fall incidence in patients with (sub-)acute stroke: A randomized controlled trial

Falls are commonly reported post-stroke. Ankle-foot orthoses (AFOs) are often provided to improve safety and walking, but the effect of their use in the reduction of falls after stroke is unknown. A randomized controlled trial (RCT) on the effects of AFO-provision after stroke was performed. Effects on clinical scales, 3D-gait kinematics and muscle-activity were previously reported. This paper aims to study the effects of AFO-provision on occurrence and circumstances of falls/near falls. The RCT included unilateral hemiparetic stroke patients. AFOs were provided either early (study week 1) or delayed (study week 9). Both groups were compared in the first eight weeks of the study and diaries were used to register falls/near falls and their circumstances. Follow-up measurements were performed in week 9–52, in which both groups were provided with AFOs. Functional Ambulation Categories and Berg Balance Scale were assessed to determine walking independence and balance, respectively. Last known scores were noted in case of an incident. Thirty-three subjects were included (16 early, 17 delayed). In week 1–8, the early group, who were provided with AFOs, fell significantly more frequently compared with the delayed group, 11 versus 4 times, respectively (Incidence Rate Ratio = 2.9, p = 0.039). Out of the falls recorded in the early group, 63.6% occurred without wearing AFOs. Most of these falls occurred during transfers (36.4%) and standing (27.3%), and notably it were the subjects who did not have independent walking ability. No differences were found for near falls in week 1–8, or for falls/near falls in week 9–52. Six severe consequences (including fractures) were reported from a fall. To conclude, the subjects provided with AFOs early after stroke reported a higher number of falls, compared to the subjects that had not yet been provided with AFOs. However, in the subjects provided with AFOs, 63.6% of the falls occurred whilst without wearing the AFO. Furthermore, the majority of these incidents took place whilst subjects had no independent walking ability. This raises an interesting question of the importance of careful instructions to patients and their relatives, and the influence of potential cognitive impairments on the ability of the subjects to take on these instructions.

New Insights on Emotional Contributions to Human Postural Control

It has been just over 20 years since the effects of height-induced threat on human postural control were first investigated. Raising the height of the support surface on which individuals stood increased the perceived consequences of instability and generated postural control changes. Since this initial work, converging evidence has accumulated supporting the efficacy of using height-induced threat to study the effects of emotions on postural control and confirming a direct influence of threat-related changes in arousal, anxiety, and fear of falling on all aspects of postural control, including standing, anticipatory, and reactive balance. In general, threat-related postural changes promote a greater physical safety margin while maintaining upright stance. We use the static balance literature to critically examine the current state of knowledge regarding: (1) the extent to which threat-related changes in postural control are sensitive to threat-related changes in emotions; (2) the underlying neurophysiological and cognitive mechanisms that may contribute to explaining the relationship between emotions and postural control; and (3) the generalizability of threat-related changes across different populations and types of threat. These findings have important implications for understanding the neuromechanisms that control healthy balance, and highlight the need to recognize the potential contributions of psychological and physiological factors to balance deficits associated with age or pathology. We conclude with a discussion of the practical significance of this research, its impact on improving diagnosis and treatment of postural control deficits, and potential directions for future research.

Therapists' perspectives on adapting the Stepping On falls prevention programme for community-dwelling stroke survivors in Singapore

Purpose: This study investigates the perspectives of rehabilitation therapists on the implementation of fall prevention programmes with community-dwelling stroke survivors in the Singapore context, and elicits recommendations to adapt the Stepping On programme with stroke survivors. Method: Qualitative data were elicited during 4 focus groups with 23 rehabilitation therapists (15 occupational therapists [OTs]; 8 physiotherapists [PTs]) who had received training to deliver the original Stepping On programme, and had experienced delivery of fall-prevention intervention programmes locally. Collected data were analysed using thematic analysis method. Results: Three themes emerged from the focus groups describing: (a) limitations of existing falls prevention intervention for stroke clients; (b) the need to adapt the Stepping On programme to use with stroke clients; and (c) challenges in implementing fall prevention programmes in the stroke context. A series of new components were suggested to be included as part of the Stepping On after stroke (SOAS) programme, including involvement of family members and caregivers, and tailored community reintegration sessions (such as taking public transport and shopping). Conclusions: Rehabilitation therapists describe challenges in addressing fall prevention within a stroke context, and findings highlight the need for a structured, stroke-specific fall prevention programme rather than a more general approach to education and training. Contextual components identified provide valuable inputs towards the development of a culturally relevant fall prevention programme for stroke survivors in Singapore. Implications for Rehabilitation Stroke survivors living in the community are at a high risk of falls. A structured and culturally relevant fall prevention programme for community-living stroke survivors is needed. Falls prevention for community-living stroke survivors should be multi-dimensional and targeting the modifiable risk factors for falls in this group. Both stroke survivors and caregivers should be involved in any fall prevention after stroke programmes.

Hip fractures in the elderly without osteoporosis

In clinical practice, hip fracture is a very common reason for hospital admission in the elderly. Most subjects over the age of 65 years, experience an injury at the hip mostly after a fall. Many elderly persons suffer from osteoporosis, which is characterised by loss of bone mass and deterioration of bone microarchitecture thus increasing the susceptibility to fracture. Osteoporosis is defined by WHO as a Bone Mineral Density (BMD) of 2.5 standard deviations (SD) below that of a young adult as assessed by dual energy x-ray absorptiometry (DXA). It has been shown that some patients with a hip fracture have either normal or "osteopenic" hips as defined by DXA (-2.5 <T-score<1). Other diseases that usually affect the elderly population may constitute independent risk factors for falls and fractures, such as diabetes mellitus, neurologic conditions, sarcopenia, use of medication. The clinician's role apart from treating osteoporosis is also to address secondary causes related to increase risk of fracture including falls in order to decrease the incidence of hip fractures. This article addresses some common pathological conditions that have been shown to predispose for hip fractures individuals regardless of their DXA BMD status.

Stroke

Stroke, or cerebrovascular accident, involves injury to the central nervous system as a result of a vascular cause, and is a leading cause of disability worldwide. People with stroke often experience sensory, cognitive, and motor sequelae that can lead to difficulty walking, controlling balance in standing and voluntary tasks, and reacting to prevent a fall following an unexpected postural perturbation. This chapter discusses the interrelationships between stroke-related impairments, problems with control of balance and gait, fall risk, fear of falling, and participation in daily physical activity. Rehabilitation can improve balance and walking function, and consequently independence and quality of life, for those with stroke. This chapter also describes effective interventions for improving balance and walking function poststroke, and identifies some areas for further research in poststroke rehabilitation.

Developing a falls prevention program for community-dwelling stroke survivors in Singapore: client and caregiver perspectives

PURPOSE

Drawing on the perspectives of stroke survivors, family members and domestic helpers, this study explores participants' experiences of self-perceived fall risk factors after stroke, common fall prevention strategies used, and challenges to community participation after a fall.

METHODS

Semi-structured interviews were conducted in Singapore with community-dwelling stroke survivors with a previous fall (n = 9), family caregivers (n = 4), and domestic helpers (n = 4) who have cared for a stroke survivor with a previous fall. Purposive sampling was used for recruitment; all interviews were audio-recorded with permission and transcribed. Thematic analysis was conducted using NVivo (v10) software.

RESULTS

All participants shared their self-perceived intrinsic and extrinsic fall risk factors and main challenges after a fall. For stroke participants and family caregivers, motivational factors in developing safety strategies after a previous fall(s) include social connectedness, independent living and community participation. For family caregivers and domestic helpers, the stroke survivor's safety is their top priority, however this can also lead to over-protective behavior outside of the rehabilitation process.

CONCLUSIONS

Reducing the risk of falls in community-dwelling stroke survivors seems to be more important than promoting community participation among caregivers. The study findings highlight that a structured and client-centered fall prevention program targeting stroke survivors and caregivers is needed in Singapore. Implications for rehabilitation Falls after stroke can lead to functional decline in gait and mobility and restricted self-care activities. Community-dwelling stroke survivors develop adaptive safety strategies after a fall and want to be socially connected. However, caregivers see the safety of the stroke survivors as their top priority and demonstrate over-protective behaviors. Fall prevention programs for community-dwelling stroke survivors should target both stroke survivors and their caregivers. A structured and client-centered fall prevention program targeting at multiple risk factors post-stroke is needed for community-living stroke survivors.

Lateral Perturbation-Induced Stepping: Strategies and Predictors in Persons Poststroke

BACKGROUND AND PURPOSE

Falls commonly occur as weight is transferred laterally, and impaired reactive stepping responses are associated with falls after stroke. The purpose of this study was to examine differences in and the determinants of mediolateral (M-L) protective stepping strategies when pulled off balance toward the paretic and nonparetic sides.

METHODS

Eighteen individuals more than 6 months poststroke were pulled in the M-L direction by a lateral waist-pull perturbation system. Step type (crossover, medial, and lateral) and count were recorded, along with first-step initiation time, length, and clearance. Sensorimotor variables including hip adductor/abductor and ankle plantar flexor/dorsiflexor peak isokinetic torques, paretic foot plantar cutaneous sensation, and motor recovery were used to predict step type by discriminant function analyses (DFAs).

RESULTS

Regardless of pull direction, nearly 70% of trials required 2 or more recovery steps, with more frequent nonparetic leg first steps, 63.5%. The step type was significantly different for pull direction (P = 0.005), with a greater percentage of lateral steps when pulled toward the nonparetic side (45.1%) compared with the paretic side (17.5%). The M-L step length of the lateral step was increased (P < 0.001), with a reduced step clearance (P = 0.05), when pulled toward the paretic side compared with a pull toward the nonparetic side. DFAs revealed that nonparetic and paretic-side pulls could respectively classify step type 64% and 60% of the time, with foot cutaneous sensation discriminating for pull direction.

DISCUSSION AND CONCLUSIONS

Balance recovery initiated with the nonparetic leg occurred more frequently in response to M-L perturbations, and paretic foot cutaneous sensation was an important predictor of the stepping response regardless of the pull direction.Video Abstract available for more insights from the authors (see Video, Supplementary Digital Content 1, http://links.lww.com/JNPT/A190).

A survey to explore what information, advice and support community-dwelling people with stroke currently receive to manage instability and falls

PURPOSE

To describe and determine the benefits of the information and support services currently offered to people with stroke experiencing instability and falls.

METHODS

A cross-sectional survey study. Two hundred and fifty-six surveys were sent out to community stroke groups in Hampshire and the Isle of Wight, as well as to people with stroke on a patient register.

RESULTS

One hundred and twenty-five surveys were returned. A total of 107 participants (86%) reported instability and 62 (50%) had experienced a fall in the preceding year; 29 (28%) had reportedly received information on falls prevention. Forty-four participants (43%) sought help from health professionals following instability and falls; just over half reported that the information they received was useful. One quarter (n = 11) of those seeking help were referred on to falls clinics; all attended and 86% felt attending had been beneficial. However, only one participant was followed up by these clinics.

CONCLUSIONS

Findings suggest that the majority of people with stroke who have experienced instability and falls did not receive any information and support, with very few referred on to falls clinics. Health professionals play a key role in information provision and facilitating access to falls prevention programs. Further research is required to determine the most effective ways to implement current guidelines to manage instability and falls in this high-risk group. Implications for rehabilitation: Many community-dwelling people with stroke did not receive any information, help or support after experiencing instability and falls. Clinicians must stress that falls are a complication, not an expectation, post-stroke. Information on falls prevention and available support services should be offered to individuals prior to discharge from hospital, in GP practices and in rehabilitation settings. All individuals with stroke seeking health professional help following instability and falls should be referred on to falls clinics for individualized multifactorial assessment and intervention to comply with current guidelines.

Risk Factors for Falls in Community Stroke Survivors: A Systematic Review and Meta-Analysis

OBJECTIVE

To identify the risk factors for falls in community stroke survivors.

DATA SOURCES

A comprehensive search for articles indexed in MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, and Web of Science databases was conducted.

STUDY SELECTION

Prospective studies investigating fall risk factors in community stroke survivors were included. Reviewers in pair independently screened the articles and determined inclusion through consensus. Studies meeting acceptable quality rating using the Q-Coh tool were included in the meta-analysis.

DATA EXTRACTION

Data extraction was done in duplicate by 4 reviewers using a standardized data extraction sheet and confirmed by another independent reviewer for completeness and accuracy.

DATA SYNTHESIS

Twenty-one articles met the minimum criteria for inclusion; risk factors investigated by ≥3 studies (n=16) were included in the meta-analysis. The following risk factors had a strong association with all fallers: impaired mobility (odds ratio [OR], 4.36; 95% confidence interval [CI], 2.68-7.10); reduced balance (OR, 3.87; 95% CI, 2.39-6.26); use of sedative or psychotropic medications (OR, 3.19; 95% CI, 1.36-7.48); disability in self-care (OR, 2.30; 95% CI, 1.51-3.49); depression (OR, 2.11; 95% CI, 1.18-3.75); cognitive impairment (OR, 1.75; 95% CI, 1.02-2.99); and history of fall (OR, 1.67; 95% CI, 1.03-2.72). A history of fall (OR, 4.19; 95% CI, 2.05-7.01) had a stronger association with recurrent fallers.

CONCLUSIONS

This study confirms that balance and mobility problems, assisted self-care, taking sedative or psychotropic medications, cognitive impairment, depression, and history of falling are associated with falls in community stroke survivors. We recommend that any future research into fall prevention programs should consider addressing these modifiable risk factors. Because the risk factors for falls in community stroke survivors are multifactorial, interventions should be multidimensional.

Does Perturbation Training Prevent Falls after Discharge from Stroke Rehabilitation? A Prospective Cohort Study with Historical Control

BACKGROUND

Individuals with stroke fall frequently, and no exercise intervention has been shown to prevent falls post stroke. Perturbation-based balance training (PBT), which involves practicing reactions to instability, shows promise for preventing falls in older adults and individuals with Parkinson's disease. This study aimed to determine if PBT during inpatient stroke rehabilitation can prevent falls after discharge into the community.

METHODS

Individuals with subacute stroke completed PBT as part of routine inpatient rehabilitation (n = 31). Participants reported falls experienced in daily life for up to 6 months post discharge. Fall rates were compared to a matched historical control group (HIS) who did not complete PBT during inpatient rehabilitation.

RESULTS

Five of 31 PBT participants, compared to 15 of 31 HIS participants, reported at least 1 fall. PBT participants reported 10 falls (.84 falls per person per year) whereas HIS participants reported 31 falls (2.0 falls per person per year). When controlled for follow-up duration and motor impairment, fall rates were lower in the PBT group than the HIS group (rate ratio: .36 [.15, .79]; P = .016).

CONCLUSIONS

These findings suggest that PBT is promising for reducing falls post stroke. While this was not a randomized controlled trial, this study may provide sufficient evidence for implementing PBT in stroke rehabilitation practice.

Observational Study of 180° Turning Strategies Using Inertial Measurement Units and Fall Risk in Poststroke Hemiparetic Patients

Objective

We analyzed spontaneous 180° turning strategies in poststroke hemiparetic patients by using inertial measurement units (IMUs) and the association of turning strategies with risk of falls.

Methods

We included right paretic (RP) and left paretic (LP) post-stroke patients, and healthy controls (HCs) from a physical and rehabilitation department in France between July 2015 and October 2015. All subjects were right-handed and right-footed for mobilization tasks. Participants were instructed to turn 180° in a self-selected direction after a 10-m walk while wearing three IMUs on their trunk and both feet. We defined three turning patterns based on the number of external steps (pattern I = 1; II = 2–4 steps; and III ≥ 5) and four turning strategies based on the side chosen to turn (healthy or paretic) and the stance limb used during the first step of the turn (healthy or paretic). Falls in the 6 months after measurement were investigated.

Results

We included 17 RP [mean (SD) age 57.5 (9.5) years (range 43–73)], 20 LP patients [mean age 60.7 (8.8) years (range 43–63)], and 15 HCs [mean age 56.7 (16.1) years (range 36–83)]. The LP and RP groups behaved similarly in turning patterns, but 90% of LP patients turned spontaneously to the paretic side versus 59% of RP patients. This difference increased with turning strategies: 85% of LP versus 29% of RP patients used strategy 4 (paretic turn side with paretic limb). Patients using strategy 4 had the highest rate of falls.

Conclusion

We propose to consider spontaneous turning strategies as new indicators to evaluate the risk of fall after stroke. IMU could be routinely used to identify this risk and guide balance rehabilitation programs.

Real-Time Fall Risk Assessment Using Functional Reach Test

Falls are common and dangerous for survivors of stroke at all stages of recovery. The widespread need to assess fall risk in real time for individuals after stroke has generated emerging requests for a reliable, inexpensive, quantifiable, and remote clinical measure/tool. In order to meet these requests, we explore the Functional Reach Test (FRT) for real-time fall risk assessment and implement the FRT function in mStroke, a real-time and automatic mobile health system for poststroke recovery and rehabilitation. mStroke is designed, developed, and delivered as an Application (App) running on a hardware platform consisting of an iPad and one or two wireless body motion sensors based on different mobile health functions. The FRT function in mStroke is extensively tested on healthy human subjects to verify its concept and feasibility. Preliminary performance will be presented to justify the further exploration of the FRT function in mStroke through clinical trials on individuals after stroke, which may guide its ubiquitous exploitation in the near future.

The Impact of Falls on Motor and Cognitive Recovery after Discharge from In-Patient Stroke Rehabilitation

BACKGROUND

Falls are common among community-dwelling stroke survivors. The aims of this study were (1) to compare motor and cognitive outcomes between individuals who fell in the 6 months' postdischarge from in-patient stroke rehabilitation and those who did not fall, and (2) to explore potential mechanisms underlying the relationship between falls and recovery of motor and cognitive function.

METHODS

Secondary analysis of a prospective cohort study of individuals discharged home from in-patient rehabilitation was conducted. Participants were recruited at discharge and completed a 6-month falls monitoring period using postcards with follow-up. Nonfallers and fallers were compared at the 6-month follow-up assessment on the Berg Balance Scale (BBS), the Chedoke-McMaster Stroke Assessment (CMSA), gait speed, and the Montreal Cognitive Assessment (MoCA). Measures of balance confidence and physical activity were also assessed.

RESULTS

Twenty-three fallers were matched to 23 nonfallers on age and functional balance scores at discharge. A total of 43 falls were reported during the study period (8 participants fell more than once). At follow-up, BBS scores (P = .0066) and CMSA foot scores (P = .0033) were significantly lower for fallers than for nonfallers. The 2 groups did not differ on CMSA leg scores (P = .049), gait speed (P = .47), or MoCA score (P = .23). There was no significant association between change in balance confidence scores and change in physical activity levels among all participants from the first and third questionnaire (r = .27, P = .08).

CONCLUSIONS

Performance in balance and motor recovery of the foot were compromised in fallers when compared to nonfallers at 6 months post discharge from in-patient stroke rehabilitation.

Relationships between fear of falling, balance confidence, and control of balance, gait, and reactive stepping in individuals with sub-acute stroke

Fear of falling is common in individuals with stroke; however, the associations between fear of falling, balance confidence, and the control of balance and gait are not well understood for this population. This study aimed to determine whether, at the time of admission to in-patient rehabilitation, specific features of balance and gait differed between individuals with stroke who did and did not report fear of falling, and whether these features were related to balance confidence. Individuals with stroke entering in-patient rehabilitation were asked if they were afraid of falling, and completed the Activities-Specific Balance Confidence Scale. Participants performed quiet standing, gait, and reactive stepping tasks, and specific measures were extracted for each (quiet standing: centre of pressure amplitude, between-limb synchronization, and Romberg quotients; gait: walking velocity, double support time, and variability measures; reactive stepping: number of steps, frequency of grasp reactions, and frequency of assists). No significant differences were identified between individuals with and without fear of falling. Balance confidence was negatively related to centre of pressure amplitude, double support time, and step time variability, and positively related to walking velocity. Low balance confidence was related to poor quiet standing balance control and cautious behavior when walking in individuals with sub-acute stroke. While the causal relationship between balance confidence and the control of balance and gait is unclear from the current work, these findings suggest there may be a role for interventions to increase balance confidence among individuals with stroke, in order to improve functional mobility.

Do Falls Experienced During Inpatient Stroke Rehabilitation Affect Length of Stay, Functional Status, and Discharge Destination?

OBJECTIVE

To compare length of stay, functional status, and discharge destination between individuals who fell during inpatient stroke rehabilitation and those who did not fall.

DESIGN

Retrospective cohort study.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Individuals who fell during inpatient stroke rehabilitation (n=106; fallers group; mean age, 67.8±12.9y; mean time poststroke, 26.4±28.3d) were matched to individuals who did not fall (n=106; nonfallers group; mean age, 67.3±13.6y; mean time poststroke, 21.9±28.8d) on age and functional status (N=212).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Total length of stay, FIM assessed at discharge, and discharge destination.

RESULTS

The mean length of stay for fallers was 11 days longer than nonfallers (P=.0017). Nonfallers and fallers did not differ on discharge total FIM scores (P=.19), and both groups were discharged home after inpatient rehabilitation (nonfallers: 77%; fallers: 74%; P=.52).

CONCLUSIONS

This study suggests that falls experienced during inpatient stroke rehabilitation may have contributed to a longer length of stay; however, falls did not affect discharge functional status or discharge destination.

Investigation of psychometric properties of the Falls Efficacy Scale using Rasch analysis in patients with hemiplegic stroke

[Purpose] The purpose of this study was to investigate the psychometric properties of the Falls Efficacy Scale using Rasch analysis in patients with hemiplegic stroke. [Subjects] Fifty-five community-dwelling hemiplegic stroke patients were selected as participants. [Methods] Data were analyzed using the Winsteps program (version 3.62) with the Rasch model to confirm the unidimensionality through item fit, reliability, and appropriateness of the rating scale. [Results] There were no misfit persons or items. Furthermore, infit and outfit statistics appeared adjacent. The person separation value was 3.07, and the reliability coefficient was 0.90. The reliability of all items was at an acceptable level for patients with hemiplegic stroke. [Conclusion] This was the first study to investigate the psychometric properties of the Falls Efficacy Scale using Rasch analysis. The results of this study suggest that the 6-point Falls Efficacy Scale is an appropriate tool for measuring the self-perceived fear of falling in patients with hemiplegic stroke.

Accelerometry-based gait characteristics evaluated using a smartphone and their association with fall risk in people with chronic stroke

BACKGROUND

The smartphone, which contains inertial sensors, is currently available and affordable device and has the potential to provide a self-assessment tool for health management. The aims of this study were to use a smartphone to record trunk acceleration during walking and to compare accelerometry variables between poststroke subjects with and without a history of falling.

METHODS

This cross-sectional study was conducted in 2 day care centers for elderly adults. Twenty-four community-dwelling adults with chronic stroke (mean age, 71.6 ± 9.7 years; mean time since stroke, 68.5 ± 38.7 months) were enrolled. Acceleration of the trunk during walking was recorded in the anteroposterior and mediolateral directions and quantified using the autocorrelation coefficient, harmonic ratio, and interstride variability (coefficient of variation of root mean square acceleration). Fall history in the past 12 months was obtained by self-report.

RESULTS

Eleven participants (45.8%) reported at least one fall in the past 12 months and were classified as fallers. Fallers exhibited significantly higher interstride variability of mediolateral trunk acceleration than nonfallers. In the logistic regression analysis, interstride variability of mediolateral trunk acceleration was significantly associated with fall history (adjusted odds ratio, 1.462; 95% confidence interval, 1.009-2.120). The area under the receiver operating characteristic curve for interstride variability of mediolateral trunk acceleration to discriminate fallers from nonfallers was .745 (95% confidence interval, .527-.963).

CONCLUSIONS

The results suggest that quantitative gait assessment using a smartphone can provide detailed and objective information about subtle changes in the gait pattern of stroke subjects at risk of falling.

Osteoporosis Treatment for Patients with Stroke

PURPOSE

Little is known about the frequency of use of medications to maintain bone health for patients with stroke. This study was undertaken at an urban academic rehabilitation center to determine the prevalence of use of agents that could reduce bone loss in the stroke population.

METHOD

A clinical database was searched for all patients 18 years old and over with stroke. The sample included 1,219 inpatients and 2,776 outpatients. Demographic information (age, gender, and race) and medications were obtained for each patient.

RESULTS

Among inpatients with stroke, 7.1% were taking osteoporosis medications (bisphosphonates, calcitonin, parathyroid hormone, or hormone replacement therapy), 11.3% were taking calcium supplements, 5.9% were taking vitamin D supplements, and 45.1% were taking multivitamin supplements. Among outpatients with stroke, 5.7% were taking osteoporosis medication, 5.8% were taking calcium supplements, 2.2% were taking vitamin D supplements, and 16.0% were taking multivitamin supplements. Patients being treated with specific osteoporosis therapies tended to be older and female by calculated odds ratios. The use of multivitamins was not related to age, gender, or race.

CONCLUSION

Overall, relatively few stroke patients were taking osteoporosis medications or supplements. There is a need to increase the recognition, prevention, and treatment of bone loss in this high-risk population.

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.

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.

Treating anxiety after stroke using cognitive-behaviour therapy: two cases

Anxiety disorders are common after stroke. However, information on how to treat them with psychotherapy in this population is highly limited. Modified cognitive-behaviour therapy (CBT) has the potential to assist. Two cases of individuals treated with modified CBT for anxiety after stroke are presented. The modification was required in light of deficits in executive and memory function in one individual and in the context of communication difficulties in the other. The anxiety symptoms were treated over seven and nine sessions, respectively. Both participants improved following the intervention, and these improvements were maintained at 3 month follow-ups. Further case-series and randomised controlled designs are required to support and develop modified CBT for those with anxiety after stroke.

Relação entre depressão e desequilíbrio postural em idosos que sofreram acidente vascular encefálico

INTRODUÇÃO: A incidência de Acidente Vascular Encefálico (AVE) aumenta com o envelhecimento e duplica a cada década de vida a partir dos 55 anos de idade. Entre as complicações decorrentes de um AVE estão o desequilíbrio postural e a depressão. OBJETIVOS: Avaliar e correlacionar equilíbrio postural e depressão em idosos com e sem AVE. MATERIAIS E MÉTODOS: Foram avaliados 38 sujeitos (19 com AVE e 19 sem AVE). O equilíbrio foi avaliado pela Escala de Equilíbrio de Berg e a depressão pela Escala de Depressão de Yesavage. RESULTADOS: Idosos com AVE apresentaram depressão quando comparados com idosos sem a doença (p < 0,0001). O risco de cair em idosos com AVE foi 102 vezes maior do que em idosos sem AVE. Houve correlação entre depressão e equilíbrio (r = -0,55; p = 0,01). CONCLUSÃO: Pacientes idosos com sequelas de AVE apresentam maior desequilíbrio e maior depressão, quando comparados com idosos de mesma faixa etária sem a doença.