Effects of a multifactorial falls prevention program for people with stroke returning home after rehabilitation: a randomized controlled trial

Batchelor FA, Hill KD, Mackintosh SF, Said CM, Whitehead CH. Effects of a multifactorial falls prevention program for people with stroke returning home after rehabilitation: a randomized controlled trial.ObjectivesTo determine whether a multifactorial falls prevention program reduces falls in people with stroke at risk of recurrent falls and whether this program leads to improvements in gait, balance, strength, and fall-related efficacy.DesignA single blind, multicenter, randomized controlled trial with 12-month follow-up.SettingParticipants were recruited after discharge from rehabilitation and followed up in the community.ParticipantsParticipants (N=156) were people with stroke at risk of recurrent falls being discharged home from rehabilitation.InterventionsTailored multifactorial falls prevention program and usual care (n=71) or control (usual care, n=85).Main Outcome MeasuresPrimary outcomes were rate of falls and proportion of fallers. Secondary outcomes included injurious falls, falls risk, participation, activity, leg strength, gait speed, balance, and falls efficacy.ResultsThere was no significant difference in fall rate (intervention: 1.89 falls/person-year, control: 1.76 falls/person-year, incidence rate ratio=1.10, P=.74) or the proportion of fallers between the groups (risk ratio=.83, 95% confidence interval=.60–1.14). There was no significant difference in injurious fall rate (intervention: .74 injurious falls/person-year, control: .49 injurious falls/person-year, incidence rate ratio=1.57, P=.25), and there were no significant differences between groups on any other secondary outcome.ConclusionsThis multifactorial falls prevention program was not effective in reducing falls in people with stroke who are at risk of falls nor was it more effective than usual care in improving gait, balance, and strength in people with stroke. Further research is required to identify effective interventions for this high-risk group.     

Effects of treadmill training with the eyes closed on gait and balance ability of chronic stroke patients

[Purpose] The purpose of this study was to compare the effect of treadmill walking with the eyes closed and open on the gait and balance abilities of chronic stroke patients. [Subjects and Methods] Thirty patients with chronic stroke participated in this study. The treadmill gait training for each group lasted 40 minutes, and sessions were held 3 times a week for 4 weeks. Gait ability was measured using a Biodex Gait Trainer Treadmill System. Balance ability was measured using a Biodex Balance System. [Results] After the treadmill training‚ the treadmill training with eyes closed (TEC) group showed significant improvements in walking distance‚ step length‚ coefficient of variation‚ and limit of stability (overall‚ lateral affected‚ forward lateral unaffected) compared to the treadmill training with eyes open (TEO) group. [Conclusion] The walking and balance abilities of the TEC participants showed more improvement after the treadmill walking sessions than those of the TEO participants. Therefore‚ treadmill walking with visual deprivation may be useful for the rehabilitation of patients with chronic stroke.Key words: Stroke, Treadmill training, Visual blocking     

Relationships of Stroke Patients’ Gait Parameters with Fear of Falling

[Purpose] The purpose of this study was to assess the correlation of gait parameters with fear of falling in stroke survivors. [Subjects] In total, 12 patients with stroke participated. [Methods] The subjects performed on a Biodex Gait Trainer 2 for 5 min to evaluate characteristic gait parameters. The kinematic gait parameters measured were gait speed, step cycle, step length, and time on each foot (step symmetry). All the subjects also completed a fall anxiety survey. [Results] Correlations between gait parameters and fear of falling scores were calculated. There was a moderate degree of correlation between fear of falling scores and the step cycle item of gait parameters. [Conclusions] According to our results, the step cycle gait parameter may be related to increased fall anxiety.Key words: Fall anxiety, Gait parameter, Stroke     

Effects of a Task-specific Exercise Program on Balance,Mobility, and Muscle Strength in the Elderly

[Purpose] The aim of this study was to investigate the effects of a task-specific exercise program based on motor learning on balance ability and strength of the lower extremity in the elderly with/without falling experiences. [Subjects and Methods] Individuals who had experiences of falling over 2 times within the past 6 months were included in the falling group. The task-specific exercise program consisted of 3 stages (weeks 1–2, 3–4, and 5–6) and was conducted according to the level of difficulty in this study. [Results] The scores of the Korean version of the Activities-Specific Balance Confidence Scale and Performance-Oriented Mobility Assessment were significantly changed in both the falling group and non-falling group after the task-specific exercise program. In comparisons between the falling group and non-falling group, there were also significant differences in the Korean version of the Activities-Specific Balance Confidence Scale and muscle strength of the semitendinosus and gastrocnemius. [Conclusion] The task-specific exercise program has a positive effect on balance ability and muscle strength related to falls in the elderly.Key words: Falling, Task-specific exercise, Elderly people     

The Effect of Underwater Gait Training on Balance Ability of Stroke Patients

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

The effect of modified trampoline training on balance,gait, and falls efficacy of stroke patients

[Purpose] This research was conducted to investigate the effects of modified trampoline training on the balance, gait, and falls efficacy of stroke patients. [Subjects] Twenty-four stroke patients participated in this study. The subjects were randomly allocated to one of two groups: the trampoline group (n=12) or the control group (n=12). [Methods] Both groups participated in conventional physical therapy for thirty minutes per day, three times a week for six weeks. The trampoline group also took part in trampoline training for thirty minutes per day, three times a week for six weeks. We evaluated balance (Berg balance scale, timed up and go test), gait (dynamic gait index), and falls efficacy (falls efficacy scale-K) to confirm the effects of the intervention. [Results] Both the trampoline and the control group showed significant improvements in balance, gait, and falls efficacy compared to before the intervention, and the improvements were significantly greater in the trampoline group than in the control group. [Conclusion] Modified trampoline training resulted in significantly improved balance, dynamic gait, and falls efficacy of stroke patients compared to the control group. These results suggest that modified trampoline training is feasible and effective at improving balance, dynamic gait, and falls efficacy after stroke.Key words: Trampoline, Stroke, Rehabilitation     

Fall prediction using decision tree analysis in acute care units

[Purpose] To present an accurate and straight-forward system of fall prediction by performing decision tree analysis using both the fall assessment sheet and Berg balance scale (BBS). [Participants and Methods] The participants in this retrospective study were inpatients from acute care units. We extracted the risk factors for falls from the fall assessment and performed a decision tree analysis using the extracted fall risk factors and BBS score. [Results] “History of more than one fall in the last 1 year”, “Muscle weakness”, “Use of a walking aid or wheelchair”, “Requires assistance for transfer”, “Use of Narcotics”, “Dangerous behavior”, and “High degree of self-reliance” were fall risk factors. The decision tree analysis extracted five fall risk factors, with an area under the curve of 0.7919. Patients with no history of falls and who did not require assistance for transfer or those with a BBS score ≥51 did not fall. [Conclusion] Decision tree-based fall prediction was useful and straightforward and revealed that patients with no history of falling and those who did not require assistance for transfer or had a BBS score ≥51 had a low risk of falling.Key words: Falling, Balance, Decision tree     

Community-based tai chi and its effect on injurious falls, balance, gait, and fear of falling in older people

BACKGROUND AND PURPOSE: It is important to determine the effect of adherence to a tai chi program on falls and related functional outcomes in older people. This study examined the effect of a community-based tai chi program on injurious falls, balance, gait, and fear of falling among people aged 65 years and older in Taiwan. SUBJECTS AND METHODS: In 6 rural villages in Taichung County, 1,200 subjects participated in the initial assessment. During a 1-year intervention period, all study villages were provided with education on fall prevention. Two villages had been provided tai chi exercise (n=472 participants or "tai chi villagers"), and 4 villages served as control villages (n=728 participants or "control villagers"). Injurious falls were ascertained by telephone interviews every 3 months over a 2-year study period; additionally, balance, gait, and fear of falling were assessed in 2 follow-up assessments. RESULTS: Eighty-eight subjects, 83 from the tai chi villages and 5 from the control villages, participated and practiced in the tai chi program (the group labeled "tai chi practitioners"). After the tai chi program, injurious falls among the control villagers significantly declined by 44% (adjusted rate ratio [RR]=0.56; 95% confidence interval [CI]=0.36-0.92). Compared with the results for the control villagers, the decline was 31% greater (RR=0.69; 95% CI=0.30-1.56) among the tai chi villagers and 50% greater (RR=0.5; 95% CI=0.11-2.17) among the tai chi practitioners; the results did not reach statistical significance. Furthermore, compared with the scores for the control villagers, the scores for the tai chi practitioners increased by 1.8 points (95% CI=0.2-3.4) on the Tinetti Balance Scale and increased by 0.9 point (95% CI=0.1-1.8) on the Tinetti Gait Scale. No significant changes in the fear of falling were detected among the tai chi practitioners, tai chi villagers, and control villagers. DISCUSSION AND CONCLUSION: Tai chi can prevent a decline in functional balance and gait among older people. However, the reduction in injurious falls attained with tai chi did not reach statistical significance; the statistical inefficiency may have resulted partly from the large decline in injurious falls in control villagers. Finally, the unexpected effect of educational intervention on reducing injurious falls in different settings needs to be further examined.     

Falls among stroke survivors: an online survey on perceptions and approaches among physiotherapists in Flanders

Objective.?To describe physiotherapists' perceptions of fall risk and appropriate fall prevention interventions in rehabilitating stroke patients.

Method.?A web-based survey addressed to physiotherapy units on a stroke unit, general neurology department or rehabilitation ward/centre in Flanders.

Results.?Hospital response rate was 66.3%. Sixty-five physiotherapy units were taken into account. About 84.6% recognised falls among stroke patients as an essential problem and 73.8% thought falls interfered with the outcome. About 56.9% agreed with the need of a standardised fall assessment at the beginning of the treatment and only 36.9% reported that on their department stroke patients are screened on risk of falling. The most used fall risk assessments are: Berg Balance scale and Tinetti-test. The most popular fall prevention measures are: specific exercises for balance, gait and functional abilities (100%), informative education (92.3%) and adapting or intensifying the treatment after a fall (81.5%).

Conclusions.?Physiotherapy units acknowledge falls as an essential threat, implying a need for risk screening and prevention. However, results reveal that perception of the necessity of such screening is lower and that the performance is even less. This discrepancy underlines the necessity of guidelines and education of therapists working with stroke patients.     

Comparison of the effectiveness of balance training using a reaching task between a sitting position and a standing position in the elderly

[Purpose] The purpose of this study was to compare the effectiveness of balance training using a reaching task between a sitting position and a standing position in the elderly. [Subjects and Methods] The study included 30 elderly women from D city. The subjects were divided into the following two groups, according to the training position: the sitting group (n = 15) and standing group (n = 15). Both groups performed training for 20 min, thrice a week for 8 weeks. The short form of the berg balance scale (SFBBS), timed 10-m walk test (10MWT), timed up & go test (TUG), and falls efficacy scale (FES) were used before and after training. [Results] SFBBS, 10MWT, and TUG values were significantly different between before and after training in both groups. However, FES values were significantly different in only the standing group. [Conclusion] Balance training in a standing position is helpful for improving activities that mainly use the lower extremities, such as gait, and training in a sitting position is somewhat helpful for improving balance ability. In addition, balance training in both positions can help overcome the fear of falling.Key words: Postural balance, Falls efficacy, Elderly     

Effects of community-based virtual reality treadmill training on balance ability in patients with chronic stroke

[Purpose] We aimed to examine the effectiveness of a community-based virtual reality treadmill training (CVRTT) program on static balance abilities in patients with stroke. [Subjects and Methods] Patients (n = 20) who suffered a stroke at least 6 months prior to the study were recruited. All subjects underwent conventional physical therapy for 60 min/day, 5 days/week, for 4 weeks. Additionally, the CVRTT group underwent community-based virtual reality scene exposure combined with treadmill training for 30 min/day, 3 days/week, for 4 weeks, whereas the control group underwent conventional physical therapy, including muscle strengthening, balance training, and indoor and outdoor gait training, for 30 min/day, 3 days/week, for 4 weeks. Outcome measurements included the anteroposterior, mediolateral, and total postural sway path lengths and speed, which were recorded using the Balancia Software on a Wii Fit^™ balance board. [Results] The postural sway speed and anteroposterior and total postural sway path lengths were significantly decreased in the CVRTT group. Overall, the CVRTT group showed significantly greater improvement than the control group. [Conclusions] The present study results can be used to support the use of CVRTT for effectively improving balance in stroke patients. Moreover, we determined that a CVRTT program for stroke patients is both feasible and suitable.Key words: Stroke rehabilitation, Community-based virtual reality, Balance     

Effects of gait training with horizontal impeding force on gait and balance of stroke patients

[Purpose] The purpose of this study was to investigate the effects of treadmill training with a horizontal impeding force applied to the center of upper body mass on the gait and balance of post-stroke patients. [Subjects and Methods] Twenty-four subjects with hemiplegia less than 3 months after stroke onset were randomly assigned to 2 groups: an applied horizontal impeding force on treadmill training (experimental) group (n = 12), and a control group (n = 12). Both groups walked on a treadmill at a comfortable or moderate speed for 20 minutes per day, 3 sessions per week for 8 weeks after a pre-test. The experimental group also had a horizontal impeding force applied to the center of their upper body mass. [Results] All groups demonstrated significant improvement after 8 weeks compared to baseline measurements. In intra-group comparisons, the subjects’ gait ability (CGS, MGS, cadence, and step length) and balance ability (TUG, BBS, and FRT) significantly improved. In inter-group comparisons, the experimental group’s improvement was significantly better in CGS MGS, cadence, step length, TUG, and BBS, but not in FRT. [Conclusion] Treadmill training was identified as an effective training method that improved gait and balance ability. A horizontal impeding force applied during treadmill training was more effective than treadmill walking training alone at improving the gait and dynamic balance of patients with stroke.Key words: Treadmill gait, Horizontal impeding force, Upper body     

Effect of Stationary Cycle Exercise on Gait and Balance of Elderly Women

[Purpose] A stationary bicycle exercise and a treadmill exercise were conducted in order to determine the effect of these exercises on the balance and walking ability of elderly women. [Subjects and Methods] Twenty-four elderly women aged 65 or older were equally assigned to a stationary bicycle exercise group and a treadmill exercise group, and they performed exercise three times per week for 8 weeks for 20 minutes each time. In order to examine gait, step length and time were measured as parameters of walking ability, and in order to examine dynamic balance, subjects were evaluated with the Berg balance scale (BBS). [Results] After the intervention, step time and step length and BBS significantly increased significantly decreased, in both groups. A comparison of BBS after the intervention between the two groups revealed that the stationary bicycle group showed larger increases than the treadmill group. [Conclusion] The stationary bicycle exercise group and treadmill exercise group showed significant improvements in gait and balance. Stationary bicycle exercise can help to prevent falls by improving the balance of elderly persons.Key words: Stationary bicycle exercise, Treadmill exercise, Elderly females     

The effects of ramp gait exercise with PNF on stroke patients’ dynamic balance

[Purpose] This study examined the effects of ramp gait training using lower extremity patterns of proprioceptive neuromuscular facilitation (PNF) on chronic stroke patients’ dynamic balance ability. [Subjects and Methods] In total, 30 stroke patients participated in this study, and they were assigned randomly and equally to an experimental group and a control group. The experimental group received exercise treatment for 30 min and ramp gait training with PNF for 30 min. The control group received exercise treatment for 30 min and ground gait training for 30 min. The interventions were conducted in 30 min sessions, three times per week for four week. The subjects were assessed with the Berg balance scale test, timed up and go test, and functional reach test before and after the experiment and the results were compared. [Results] After the intervention, the BBS and FRT values had significantly increased and the TUG value had significantly decreased in the experimental group; however, the BBS, FRT, and TUG values showed no significant differences in the control group. In addition, differences between the two groups before the intervention and after the intervention were not significant. [Conclusion] In conclusion, ramp gait training with PNF improved stroke patients’ dynamic balance ability, and a good outcome of ramp gait training with PNF is also expected for other neurological system disease patients.Key words: Stroke, Proprioception, Ramp gait     

脑卒中患者跌倒恐惧的影响因素及护理对策

目的:研究脑卒中患者跌倒恐惧的影响因素,并对各因素的影响程度进行多维度分析比较,针对性提出相应护理干预措施。方法:选取100例神经内科病房收治的脑卒中患者,包括住院和已出院回院复诊的患者,采用自制一般资料问卷收集患者基本信息;采用Berg平衡量表(BBS)和起立-行走计时试验(TUGT)测定患者平衡功能、移动能力及下肢运动功能;采用活动平衡信心量表(ABC)评估患者对活动平衡的信心。应用单因素分析法评估患者性别、年龄、跌倒史、视力情况、平衡功能、移动能力及下肢运动功能等因素与患者跌倒恐惧的相关性。采用多因素分析法比较其影响程度。结果:年龄、跌倒史、视力情况、平衡功能、移动能力及下肢运动功能均对患者跌倒恐惧有影响。结论:年龄、有跌倒史、平衡、移动能力及下肢运动功能是导致脑卒中患者跌倒恐惧的主要因素,针对脑卒中患者跌倒恐惧的主要因素提出针对性的护理干预措施,降低跌倒恐惧的发生率。     

New intervention program for preventing falls among frail elderly people: the effects of perturbed walking exercise using a bilateral separated treadmill

OBJECTIVE: To determine the effects of a perturbed walking exercise using a bilateral separated treadmill in physically disabled elderly. DESIGN: Participants of the study were 32 long-term care facility residents and outpatients aged 66-98 yrs. Participants were randomly assigned to a usual exercise group or to a treadmill exercise group. Perturbed gait exercise on a treadmill continued for 6 mos. Number of falls and time to first fall during a 6-mo period, balance and gait functions, and reaction time were evaluated before and after intervention. RESULTS: The treadmill exercise group showed significant improvement in balance and reaction time when compared with the usual exercise group. Number of falls in the treadmill exercise group was 21% lower than that in the usual exercise group. However, this difference was not significant. No significant differences were seen in time to first fall. CONCLUSIONS: Gait training with unexpected perturbation seems to have a beneficial impact on physical function in disabled elderly individuals. The results suggest that this program may be used as an exercise intervention to reduce falls in institutional settings.     

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.     

Fall prevention in assisted living: assessment and strategies

Residents in assisted living residences have similar risk factors for falls as do community-residing older adults and, as such, can benefit from the research findings on falls prevention conducted with that population. Some risk factors can be managed, such as, medication side effects, and muscle weakness; others such as degenerative neurological changes, cannot. Knowing a resident's falls history and conducting a full risk assessment, in combination with appropriate interventions, can reduce the probability of a future fall. Exercise appears to be the most effective factor in reducing the risk of falls and injuries from falls. The fear of falling, whether or not associated with a previous fall, is more common among older women and can seriously restrict their quality of life. This article describes evidence-based falls risk assessment instruments and interventions to reduce falls risk. T'ai chi, for example, can reduce falls risk by improving balance. The article describes a standard fall prevention program for older adults that can be part of a resident's care or service plan, criteria for an occurrence report, quality improvement monitoring, and a formula to calculate the residence's monthly falls rate.