Interventions for preventing falls in people after stroke
Denissen S, Staring W, Kunkel D, Pickering RM, Lennon S, Geurts AC, Weerdesteyn V, Verheyden GS. Cochrane Database Syst. Rev. 2019; 10: CD008728.
Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium.
(Copyright © 2019, The Cochrane Collaboration, Publisher John Wiley and Sons)
DOI 10.1002/14651858.CD008728.pub3 PMID 31573069
BACKGROUND: Falls are one of the most common complications after stroke, with a reported incidence ranging between 7% in the first week and 73% in the first year post stroke. This is an updated version of the original Cochrane Review published in 2013.
OBJECTIVES: To evaluate the effectiveness of interventions aimed at preventing falls in people after stroke. Our primary objective was to determine the effect of interventions on the rate of falls (number of falls per person-year) and the number of fallers. Our secondary objectives were to determine the effects of interventions aimed at preventing falls on 1) the number of fall-related fractures; 2) the number of fall-related hospital admissions; 3) near-fall events; 4) economic evaluation; 5) quality of life; and 6) adverse effects of the interventions. SEARCH METHODS: We searched the trials registers of the Cochrane Stroke Group (September 2018) and the Cochrane Bone, Joint and Muscle Trauma Group (October 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 9) in the Cochrane Library; MEDLINE (1950 to September 2018); Embase (1980 to September 2018); CINAHL (1982 to September 2018); PsycINFO (1806 to August 2018); AMED (1985 to December 2017); and PEDro (September 2018). We also searched trials registers and checked reference lists. SELECTION CRITERIA: Randomised controlled trials of interventions where the primary or secondary aim was to prevent falls in people after stroke. DATA COLLECTION AND ANALYSIS: Two review authors (SD and WS) independently selected studies for inclusion, assessed trial quality and risk of bias, and extracted data. We resolved disagreements through discussion, and contacted study authors for additional information where required. We used a rate ratio and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person-year) between intervention and control groups. For risk of falling we used a risk ratio and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate and applied GRADE to assess the quality of the evidence. MAIN RESULTS: We included 14 studies (of which six have been published since the first version of this review in 2013), with a total of 1358 participants. We found studies that investigated exercises, predischarge home visits for hospitalised patients, the provision of single lens distance vision glasses instead of multifocal glasses, a servo-assistive rollator and non-invasive brain stimulation for preventing falls.Exercise compared to control for preventing falls in people after strokeThe pooled result of eight studies showed that exercise may reduce the rate of falls but we are uncertain about this result (rate ratio 0.72, 95% CI 0.54 to 0.94, 765 participants, low-quality evidence). Sensitivity analysis for single exercise interventions, omitting studies using multiple/multifactorial interventions, also found that exercise may reduce the rate of falls (rate ratio 0.66, 95% CI 0.50 to 0.87, 626 participants). Sensitivity analysis for the effect in the chronic phase post stroke resulted in little or no difference in rate of falls (rate ratio 0.58, 95% CI 0.31 to 1.12, 205 participants). A sensitivity analysis including only studies with low risk of bias found little or no difference in rate of falls (rate ratio 0.88, 95% CI 0.65 to 1.20, 462 participants).
METHODological limitations mean that we have very low confidence in the results of these sensitivity analyses.For the outcome of number of fallers, we are very uncertain of the effect of exercises compared to the control condition, based on the pooled result of 10 studies (risk ratio 1.03, 95% CI 0.90 to 1.19, 969 participants, very low quality evidence). The same sensitivity analyses as described above gives us very low certainty that there are little or no differences in number of fallers (single interventions: risk ratio 1.09, 95% CI 0.93 to 1.28, 796 participants; chronic phase post stroke: risk ratio 0.94, 95% CI 0.73 to 1.22, 375 participants; low risk of bias studies: risk ratio 0.96, 95% CI 0.77 to 1.21, 462 participants).Other interventions for preventing falls in people after strokeWe are very uncertain whether interventions other than exercise reduce the rate of falls or number of fallers. We identified very low certainty evidence when investigating the effect of predischarge home visits (rate ratio 0.85, 95% CI 0.43 to 1.69; risk ratio 1.48, 95% CI 0.71 to 3.09; 85 participants), provision of single lens distance glasses to regular wearers of multifocal glasses (rate ratio 1.08, 95% CI 0.52 to 2.25; risk ratio 0.74, 95% CI 0.47 to 1.18; 46 participants) and a servo-assistive rollator (rate ratio 0.44, 95% CI 0.16 to 1.21; risk ratio 0.44, 95% CI 0.16 to 1.22; 42 participants).Finally, transcranial direct current stimulation (tDCS) was used in one study to examine the effect on falls post stroke. We have low certainty that active tDCS may reduce the number of fallers compared to sham tDCS (risk ratio 0.30, 95% CI 0.14 to 0.63; 60 participants). AUTHORS’ CONCLUSIONS: At present there exists very little evidence about interventions other than exercises to reduce falling post stroke. Low to very low quality evidence exists that this population benefits from exercises to prevent falls, but not to reduce number of fallers.Fall research does not in general or consistently follow methodological gold standards, especially with regard to fall definition and time post stroke. More well-reported, adequately-powered research should further establish the value of exercises in reducing falling, in particular per phase, post stroke.
Effectiveness of Wii Fit Balance board in comparison with other interventions for post-stroke balance rehabilitation. Systematic review and meta-analysis
Garcia-Munoz C, Casuso-Holgado MJ. Rev. Neurol. 2019; 69(7): 271-279.
Universidad de Sevilla, Sevilla, Espana.
(Copyright © 2019, Revista de Neurologia)
DOI 10.33588/rn.6907.2019091 PMID 31559625
INTRODUCTION: Virtual reality is a booming therapeutic tool within the neurorehabilitation field. Among the different non-inmersive virtual reality systems, the most outstanding is the platform, Wii Fit Balance.
AIM: To review the scientific literature published in recent years about the effectiveness of Wii Fit Balance tool. The use of this platform for balance training in patients who have suffered a stroke compared to conventional therapies is going to be analyzed from a quantitative and qualitative point of view.
SUBJECTS AND METHODS: A search of the databases has been carried out: PubMed, Lilacs, PEDro, Scopus, Web of Science and Cochrane Library. Descriptors employed were “Wii Fit Balance”, “Wii”, “stroke”, “ictus” and “balance”. Studies were analyzed methodologically by PEDro Scale. For those possible variables a meta-analysis was elaborated.
RESULTS: Sixteen randomized clinical trials were selected for the systematic review and six of them were included in the meta-analysis.
RESULTS for the descriptive analysis were heterogeneous. This situation is confirmed through the meta-analysis results, because the analyzed variables for static and dynamic balance show intra-group improvement and no significant differences between groups post-intervention.
CONCLUSION: Wii Fit Balance, virtual reality platform, is an available therapeutic tool which has been shown at least as effective as conventional balance training in post-stroke patients.
Effects of visual feedback training and visual targets on muscle activation, balancing, and walking ability in adults after hemiplegic stroke: a preliminary, randomized, controlled study
Pak NW, Lee JH. Int. J. Rehabil. Res. 2019; ePub(ePub): ePub.
Department of Physical Therapy, College of Health and Medical Science, Cheongju University, Cheongju City, Republic of Korea.
(Copyright © 2019, Lippincott Williams and Wilkins)
DOI 10.1097/MRR.0000000000000376 PMID 31633580
The aim of this randomized, controlled study was to investigate the effect of visual feedback through visual targets on muscle activity, balance, and gait in stroke patients. Patients were recruited from the inpatient unit of a rehabilitation hospital. Twenty-one patients who had experienced hemiplegic stroke were randomly assigned to two groups: an experimental group (visual feedback training with visual targets on gradual weight shifting), and a control group (visual feedback training on gradual weight shifting). All patients performed 30 minutes of comprehensive rehabilitation therapy followed by an additional 20 minutes of gradual weight shifting using visual feedback training with or without visual targets: three sets per day, five times a week, for 4 weeks. Significantly larger gains were identified in the experimental group compared to the control group due to gluteus medius muscle activation and the weight-bearing ability of the paretic side. Visual feedback training with visual targets during gradual weight bearing on the paretic side appears to improve the muscle activation and balancing abilities of hemiplegic stroke patients compared to visual feedback training alone.
The six-minute walk test as a fall risk screening tool in community programs for persons with stroke: a cross-sectional analysis
Regan E, Middleton A, Stewart JC, Wilcox S, Pearson JL, Fritz S. Top. Stroke Rehabil. 2019; ePub(ePub): ePub.
Department of Exercise Science, University of South Carolina , Columbia , SC , USA.
(Copyright © 2019, Informa – Taylor and Francis Group)
DOI 10.1080/10749357.2019.1667657 PMID 31622172
Background and Purpose
: Persons with stroke have increased risk for recurrent stroke. Group exercise programs like cardiac rehabilitation might reduce this risk. These programs commonly use the six-minute walk test to measure aerobic capacity. However, failure to assess fall risk may compromise safety for persons with stroke. The study aim was to determine the association between the six-minute walk test and fall risk in persons with stroke.
: Cross-sectional analysis measured the association between the six-minute walk test and fall risk in 66 persons with stroke with a mean age of 66 years (SD 12) and median stroke chronicity of 60.9 months (range 6.0-272.1). The six-minute walk test was evaluated using logistic regression. The best fit model was used in Receiver Operating Characteristic analysis. Likelihood ratios and post-test probabilities were calculated.
: Lower six-minute walk test distance was associated with increased fall risk in logistic regression (p =.002). The area under the curve for the univariate six-minute walk test model (best fit) was 0.701 (p =.006). The cutoff for increased fall risk was six-minute walk test <331.65 m. The post-test probability of fall risk increased to 74.3% from a pre-test probability of 59.1%.
: The moderate association between fall risk and six-minute walk test suggests that in addition to assessing capacity, the six-minute walk test provides insight into fall risk/balance confidence.
: Using the six-minute walk test cutoff to screen fall risk in community exercise programs may enhance safety for persons with stroke without additional testing required.
Stroke; community programs; fall risk
Efficacy of dual-task training with two different priorities instructional sets on gait parameters in patients with chronic stroke
Sengar S, Raghav D, Verma M, Alghadir AH, Iqbal A. Neuropsychiatr. Dis. Treat. 2019; 15: 2959-2969.
Rehabilitation Research Chair, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.
(Copyright © 2019, Dove Press)
DOI 10.2147/NDT.S197632 PMID 31695387
PURPOSE: Balance is controlled through a complex process involving sensory, visual, vestibular and cerebral functioning which get affected by various neurological disorders such as in stroke. Various types of exercises are designed to address the imbalance that is developed due to these neurological disorders. This study aimed to compare the efficacy of dual-task training using two different priority instructional sets in improving gait parameters in patients with chronic stroke.
METHODS: This study was a randomized, pretest-posttest experimental group design that compared between two different priority instructional sets (fixed versus variable) of the dual-task training. A convenience sample of thirty patients with chronic stroke due to ruptured middle cerebral artery (mean age±SD = 55.76±5.23; range 48-65 years) was recruited and equally allocated into two groups. Group 1 received dual-task training with fixed priority instructional sets and group 2 received dual-task training with variable priority instructional sets. Both groups were trained for a period of 45 mins each session, 3-sessions per week for 4 weeks. The timed 10-m walk test and foot prints on walkway paper were used to assess the gait parameters (walking speed, stride length and step length) before and after the training session.
RESULTS: Within-group analysis revealed a significant improvement (p<0.05) on gait parameters for both the groups. Furthermore, Cohen’s d calculation for the treatment effect size revealed highly larger effect size on gait parameters in group 2 (Cohen’s d>2 SD) than group 1 (Cohen’s d<2 SD) for the all variables.
CONCLUSION: The dual-task training with variable priority instructional sets (group 2) was more effective than dual-task training with fixed priority instructional sets (group 1) in improving gait parameters such as gait speed, stride length, and step length in patients with chronic stroke. Physiotherapists should spread awareness and use this specific set of exercises
dual-task balance training; fixed priority training; gait velocity; step length; stride length; stroke; variable priority training
Effects of visual feedback training using transient Fresnel prism glasses on balance ability in stroke patients without hemispatial neglect
Ha SY, Kim SY, Sung YH. J. Exerc. Rehabil. 2019; 15(5): 683-687.
Department of Physical Therapy, Graduate School of Industry & Business Administration, Kyungnam University, Changwon, Korea.
(Copyright © 2019, Korean Society of Exercise Rehabilitation)
DOI 10.12965/jer.1938498.249 PMID 31723557
The center of mass of the body in patients with stroke was oriented toward the nonparetic side. Abnormal weight shift increases the risk of falls. Therefore, many therapists make an effort to help their functional recovery through balance training. Our aim was to investigate the effect of visual feedback intervention using a Fresnel prism on static and dynamic balance in stroke patients without hemispatial neglect. Participants were assigned to control group (n=10) and experimental group (n=9). In the control group, neurodevelopmental therapy was performance for 30 min. In the experimental group, Fresnel prism glasses were applied with neurodevelopmental therapy for 30 min. We executed motor-free visual perception test for visual perception, balancia for static balance ability, and functional reach test and Berg balance test for dynamic balance ability, respectively. All tests were measured immediately after intervention. The visual perception function showed significant difference between unaffected side performance behaviors and visual perceptual processing time (P<0.05). In the static balance, there was a significant difference in sway velocity and sway distances (P<0.05). Dynamic balance was also significant different between groups (P<0.05). Visual feedback using Fresnel prism helps to control the static and dynamic balance ability by inducing weight shift toward the affected side in stroke patients. Therefore, a Fresnel prism may be suggested as an intervention tool to assist weight training for patients with stroke.
Dynamic balance; Fresnel prism; Static balance; Stroke; Visual feedback
Can the wii fit balance board be used as a fall risk assessment tool among poststroke patients?
Beato MC, Morton E, Iadarola C, Winterberger L, Dawson N. J. Stroke Cerebrovasc. Dis. 2019; ePub(ePub): ePub.
School of Kinesiology and Physical Therapy, University of Central Florida, Orlando, Florida.
(Copyright © 2019, National Stroke Association (U.S.A.), Publisher Elsevier Publishing)
DOI 10.1016/j.jstrokecerebrovasdis.2019.104500 PMID 31818679
BACKGROUND: The prevalence of falls can be as high as 73% in the stroke population. Falls occur as a result of multiple factors. Factors such as balance impairments can be improved through physical therapy intervention. However, insurance payers limit the number of visits per patient. It is crucial to find other ways to assess balance after discharge from rehabilitation.
PURPOSE: The purpose of this study is to determine if the Nintendo Wii Fit can be used as a fall risk assessment tool among the poststroke population.
METHODOLOGY: A sample of 11 stroke survivors were recruited (mean age 63.36 years). Each participant completed a balance and fall risk assessment using the Berg Balance Scale, Timed Up & Go, Four Square Step Test, Five Times Sit-to-Stand and 8-Foot Walk Test. Bivariate correlation will examine the validity of the Nintendo Wii Fit as a fall risk assessment tool in this population.
RESULTS: The Nintendo Wii Fit Balance Test was found to be correlated with gait speed measured by the 8-Foot Walk Test. There is no correlation between the Wii Fit Balance Tests and most common standardized fall risk measures. Standardized fall risk outcome measures also significantly correlate with each other.
CONCLUSIONS: The study suggests that while there is a potential utility of the game system to be used at home by patient and caregivers, the Wii Fit Balance Test may not be an appropriate substitute to the standardized fall risk assessment tool for stroke patients in the clinical setting.
Stroke; Wii Fit; balance; falls; game system; outcome measure; rehabilitation
Effects of hydrokinesitherapy on balance and walking ability in stroke survivors: a systematic review and meta-analysis of randomized controlled studies
Xie G, Wang T, Jiang B, Su Y, Tang X, Guo Y, Liao J. Eur. Rev. Aging Phys. Activ. 2019; 16: e21.
5Kunming Municipal Hospital of Traditional Chinese Medicine, 223 Guanxing Road, Guan Du District, Kunming, 650200 Yunnan China.
(Copyright © 2019, Holtzbrinck Springer Nature Publishing Group)
DOI 10.1186/s11556-019-0227-0 PMID 31754406
BACKGROUND: Balance and walking impairment are common dysfunctions after stroke. Emerging data has demonstrated that hydrokinesitherapy may have a positive influence on improvement of balance and walking ability. However, there is no firm evidence to support these results. Therefore, the aim of this review is to evaluate the effects of hydrokinesitherapy in stroke survivors systematically.
METHODS: Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, CINAHL and SPORTDiscus were systemic searched from their inception to Septemter 30, 2018. RevMan 5.3 software was used to perform data synthesis. The fixed-effect model or random-effect model was employed according to the results of heterogeneity test. The mean differences (MD) or standardized mean difference (SMD) was used to evaluate the pooled effect of hydrokinesitherapy on balance function, walking ability and activty of daily life (ADL).
RESULTS: A total of 13 studies were included involving 381 stroke survivors. Meta-analysis results indicated that hydrokinesitherapy could improve balance ability based on three test: Berg balance scale (BBS: MD = 3.84, 95% confidence interval (95% CI) 2.84 to 4.86, P < 0.001), Time Up To Go Test (TUGT: MD = - 1.22, 95% CI - 2.25 to - 0.18, P = 0.02, fixed-effect model), Functional Reach Test (FRT: MD = 2.41, 95% CI 1.49 to 3.33, P < 0.001). Additionally, we found a weakly positive effect on walking speed (SMD = 0.75, 95% CI 0.26 to 1.25, P = 0.003) and walking ability test (SMD = 0.36, 95% CI 0.04 to 0.68, P = 0.03). There was no significant difference between experimental group and control group in terms of ADL. SHORT CONCLUSION: Hydrokinesitherapy can improve balance function and had a weakly positive effect on walking ability in stroke survivors. We did not find sufficient evidence to indicate that hydrokinesitherapy could improve the ADL of stroke survivors. However, due to the methodological shortcoming and small number of included studies, caution is needed when interpreting these results. Due to imprecision and publication bias, the quality of the evidence was downgraded to “low-quality” for the primary outcomes of balance and walking ability. TRIAL REGISTRATION: CRD42018110787.
Balance; Hydrokinesitherapy; Meta-analysis; Stroke; Walking ability