First year post-stroke healthcare costs and fall-status among those discharged to the community

Outcomes of importance to people with multiple sclerosis, Parkinson's disease and stroke following a falls prevention intervention: a qualitative study to inform a core outcome set

Purpose: Falls are a major issue for people with neurological conditions, and the evaluation of falls prevention interventions is of high priority. To date, the views of patient groups regarding outcomes of importance have been largely overlooked. The purpose of this study was to explore outcomes of interest among people with Multiple Sclerosis (MS), Parkinson's disease (PD) and stroke upon completion of falls prevention interventions to inform the development of a core outcome set (COS).Materials and methods: Five online focus groups and one semi-structured interview were conducted among people with PD (n = 10), MS (n = 7), and post-stroke (n = 3), one of whom also had PD. Transcripts were analysed using reflexive thematic analysis.Results: Four themes were developed; (1) Fall events are not homogeneous, (2) Exercise-based programmes are beneficial but falls services are not meeting user needs, (3) Programme success beyond the reduction in falls, and (4) Acquisition of skills to self-manage falls beyond the life of the programme.Conclusions: This study presents new perspectives across patient groups regarding important outcomes upon completion of falls prevention interventions. Taken together with the findings of a literature review, this data will inform the development of a COS.Implications for rehabilitationPeople with multiple sclerosis, Parkinson's disease and stroke consider the success of a falls prevention intervention to be dependent on improvements across a wide range of outcomes.The design and implementation of falls prevention interventions should align with patient preferences.Clinicians and researchers should consider the use of multidomain interventions to facilitate improvements in the desired outcomes of patients.

Association Between Falling and Activities of Daily Living Measured by the Longshi Scale in Patients Poststroke: A Cross-sectional Study

BACKGROUND

Activities of daily living comprise an important risk factor for falls among patients who have suffered a stroke.

PURPOSE

To investigate the incidence of falls in patients with stroke, categorized by their Longshi grades (bedridden, domestic, community), and to explore their risk factors for falls.

METHODS

A cross-sectional descriptive design was used. Patients completed a survey during face-to-face interviews.

RESULTS

Of the 869 participants, 15.7% experienced a fall. Those in the domestic Longshi group had the highest rate of falls. Approximately 30% experienced either a moderate or severe injury as a result of falling. In addition, being older than 70 years was significantly correlated with fall risk. Intermediate Longshi grades, from moderately dependent to slightly dependent, were also positively correlated with falls.

CONCLUSION

Patients with stroke in the domestic Longshi group have a higher rate of falls. The risk of falling increased significantly in those with intermediate Longshi grades.

Comparison of the psychometric properties of three commonly used fall risk assessment tools: a prospective observational study for stroke patients

BACKGROUND

A reliable tool recommendation is needed to identify the risk of falling in hospitalized stroke patients.

OBJECTIVES

The aim of this study was to identify the most reliable fall risk assessment tool among the Morse Fall Scale (MFS), Itaki Fall Risk Scale (Itaki FRS) and Hendrich II Fall Risk Model (HIIFRM) for stroke patients.

METHODS

The study was planned as an observational prospective study. It was carried out over the period July-December 2018 with 125 stroke patients. The Functional Independence Measure (FIM), Itaki FRS, HIIFRM, and MFS were used for the study data. The fall risk and incidents of falling were monitored on a daily basis over the course of the patients' stay at the hospital. The differentiation between the fall risk tools was assessed with sensitivity-specificity analysis and the ROC curve.

RESULTS

The mean age of the research participants was 71.47 ± 11.16 years. It was determined that 9.6% of the patients fell at least once during the follow-up period, which was 8.66 ± 1.80 days on average. The sensitivity and specificity rates of the fall risk assessment tools were respectively 75.0% and 63.7% for the Itaki FRS, 83.3% and 50.4% for the HIIFRM, and 91.7% and 73.5% for the MFS. The cutoff points on the tools were 14 for the Itaki FRS, 4.5 for the HIIFRM, and 66.2 for the MFS.

CONCLUSION

MFS is a more reliable tool than Itaki FRS or HIIFRM in determining fall risk in hospitalized stroke patients.

The Cost of Living with Inherited Ataxia in Ireland

Inherited ataxias are a heterogenous group of neurodegenerative disorders characterised by progressive impairment of balance and coordination, typically leading to permanent and progressive disability. Diagnosis and management of these disorders incurs a range of direct and indirect financial costs. The aim of this study was to collect individual ataxia-related healthcare resources in a large cohort of individuals with different subtypes of inherited ataxia and calculate the associated cost of illness in the Republic of Ireland. One hundred twenty-nine respondents completed a cross-sectional study on healthcare resource utilisation for progressive ataxia in Ireland. Costs were calculated using a prevalence-based approach and bottom-up methodology. The COI for inherited ataxia in 2016 was €59,993 per person per year. Results were similar between participants with Friedreich’s ataxia (FRDA, n = 56), non-FRDA (n = 18) and those with undetermined ataxia (n = 55). Indirect costs, based on productivity losses by participants or caregivers, accounted for 52% of the cost of illness. Inherited ataxia is associated with significant health and social care costs. Further funding for inherited ataxia to ease the financial burden on patients, caregivers and healthcare system and improve standards of care compliance is warranted.

Effectiveness of Physical Therapy Interventions in Reducing Fear of Falling Among Individuals With Neurologic Diseases: A Systematic Review and Meta-analysis

OBJECTIVE

To summarize the effectiveness of physical therapy interventions to reduce fear of falling (FOF) among individuals living with neurologic diseases.

DATA SOURCES

PubMed, Physiotherapy Evidence Database, Scopus, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, and SportDiscuss were searched from inception until December 2019.

STUDY SELECTION

Clinical trials with either the primary or secondary aim to reduce FOF among adults with neurologic diseases were selected.

DATA EXTRACTION

Potential articles were screened for eligibility, and data were extracted by 2 independent researchers. Risk of bias was assessed by the Cochrane Risk of Bias tool for randomized controlled trials and the National Institutes of Health Quality Assessment Tool for pre-post studies. A meta-analysis was performed among trials presenting with similar clinical characteristics. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to rate the overall quality of evidence.

RESULTS

Sixty-one trials with 3954 participants were included in the review and 53 trials with 3524 participants in the meta-analysis. The included studies presented, in general, with a low to high risk of bias. A combination of gait and balance training was significantly more effective compared with gait training alone in reducing FOF among individuals with Parkinson disease (PD) (mean difference [MD]=11.80; 95% CI, 8.22-15.38; P<.001). Home-based exercise and leisure exercise demonstrated significant improvement in reducing FOF over usual care in multiple sclerosis (MS) (MD=15.27; 95% CI, 6.15-24.38; P=.001). No statistically significant between-groups differences were reported among individuals with stroke and spinal cord injury. The overall quality of evidence presented in this review ranges from very low to moderate according to the assessment with the GRADE approach.

CONCLUSIONS

Gait with lower limb training combined with balance training is effective in reducing FOF in individuals with PD. Also, home-based or leisure exercise is effective among individuals with MS. However, because of several limitations of the included studies, further research is needed to examine the effectiveness of FOF intervention among individuals with neurologic diseases.

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.

Efficacy of Controlled Whole-Body Vibration Training on Improving Fall Risk Factors in Stroke Survivors: A Meta-analysis

Background. Controlled whole-body vibration (CWBV) training has been applied to people with stroke. However, it remains inconclusive if CWBV reduces fall risk in this population. Objective. To (1) assess the immediate and retention effects of CWBV training on fall risk factors in people at postacute and chronic stages of stroke and (2) examine if CWBV dosage is correlated with the effect size (ES) for 3 fall risk factors: body balance, functional mobility, and knee strength. Methods. Twelve randomized controlled trials were included. ES was calculated as the standardized mean difference, and meta-analyses were completed using a random-effects model. Results. CWBV training may lead to improved balance and mobility immediately after training (ES = 0.27, P = .03 for balance; ES = 0.34, P = .02 for mobility) but not at the 3-month follow-up test (ES = 0.02, P = .89 for balance; ES = 0.70, P = .11 for mobility). CWBV affects knee strength capacity with mild ES (ES = 0.08 and 0.11, respectively, for immediate and retention effect; P ≥ .68 for both). Metaregression indicated that the immediate ES is strongly correlated with training dosage for balance (r = 0.649; P = .029) and mobility (r = 0.785; P = .036). Conclusions. CWBV training may benefit balance and mobility immediately, but the training effect may not persist among people with stroke. Additionally, the CWBV dosage correlates with the ES for body balance and mobility. More high-quality studies are needed to determine the retention effects of CWBV training.

Rasch Analysis of the Activities-Specific Balance Confidence Scale in Individuals Poststroke

Objective

To examine the psychometric properties of the Activities-specific Balance Confidence (ABC) scale using Rasch analysis for individuals poststroke.

Design

Retrospective cohort.

Setting

Data was extracted from the Locomotor Experience Applied Post-Stroke phase 3, multisite, randomized controlled clinical trial.

Participants

Community-dwelling, ambulatory, older adults (N = 406) (mean age ± SD, 61.97±12.76y; 45.07% female) approximately 2 months poststroke.

Intervention

None.

Main Outcome Measures

We examined unidimensionality, local dependence, rating-scale structure, item and person fit, person-item match, and separation index of the ABC scale.

Results

Confirmatory and exploratory factor analysis showed the ABC scale was adequately unidimensional and 3-item pairs had local dependence. A collapsed 5-category rating scale was superior to the 101-category scale. The hardest item was "walking outside on an icy sidewalk," the easiest item was "getting into or out of a car," and no items misfit. The ABC scale had high person reliability (0.93), despite 10.5% of individuals misfitting the expected response pattern. Mean ability level of the sample was slightly lower (-0.56 logits) than the mean item difficulty indicating that the ABC scale adequately matched our sample's balance confidence. The ABC scale did not have a floor or ceiling effect and separated individuals into 5 statistically distinct strata (separation index = 3.71).

Conclusions

The Rasch model supports the use of the ABC scale to measure balance confidence in individuals poststroke. The consistency of our results with previous Rasch analyses on the ABC scale demonstrates the instrument responds similarly across multiple populations; community-dwelling older-adults, outpatient orthopedic physical therapy, stroke, Parkinson disease, and lower-limb amputation. Recommendations include collapsing the rating scale and developing a computerized-adaptive test version of the scale to enhance clinical utility.