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The risk of falling is increased following stroke due to leg weakness, impaired balance, visual disturbances, functional dependence, cognitive impairment and sensory loss. During hospitalization for stroke rehabilitation, Teasell et al. (2002) reported that one third of patients of 238 patients admitted to a stroke rehabilitation unit sustained at least one fall during their stay and almost half of the fallers experienced at least 2 falls. Czernuszenko & Czlonkowska (2009) reported that during stroke rehabilitation, there were 252 falls that occurred in 189 (16.3%) patients. The incidence rate for any fall was 7.6 per 1,000 patient-days (95% CI 6.6–8.5). Almost two-thirds of falls occurred during the first two weeks after admission. Patients fell most often during transfers (34%), while sitting (21%) and during position changes such as going from a sitting to standing (13%). Most falls did not result in injury (72%), while minor injuries occurred in 27% of cases, with 1.2% resulting in serious injury (fracture).
Patients at highest risk of falling need to be identified as soon as possible so that appropriate preventative measures can be taken. However, there are few valid screening tools that exists. Breisinger et al. (2014) developed the Stroke Assessment of Fall Risk (SAFR) to identify patients at risk of falling during inpatient rehabilitation. SAFR is composed of 4 impairment items (impulsivity, hemi-neglect, static, and dynamic sitting balance) and 3 functional limitations items (lowest score on three FIM: transfers, problem solving, and memory), with possible scores ranging from 0 (low risk) to 49 (high risk). The area under the curve of the receiver operator curve was 0.73, which was significantly more accurate compared with a locally-developed, 3-item, non-stroke specific tool, which could identify the risk of fallers no better than chance. Nystrom & Hellstrom (2013) reported that higher scores on the Prediction of Falls in Rehabilitation Settings Tool (Predict FIRST), assessed during the first and forth day of admission to an acute stroke unit helped to predict falls that occurred during the next 6 weeks (OR=5.21, 95% CI 1.10 to 24.78, p=0.038). Predict FIRST is composed of 5 fall risk factors, each giving one point: male, central nervous system medications, a fall in the past year, frequent toileting, and inability to do tandem stance. The scale is cumulative (i.e. more risk factors give a higher risk of falling). Patients with a score of zero have a 2% chance of falling, while those with all 5 points have a 52% risk of falling during the inpatient rehabilitation period. Pinto et al. (2014) reported that longer time to complete The Timed Up and Go (TUG) test was predictive of falls among persons living in the community following a median of 13 months post stroke (OR=1.035, 95% CI 1.196 to 5.740, p=0.016). Fallers (n=56) took a median time of 18 seconds to complete the test compared with non fallers (n=94) at 14 seconds.
There have been very few RCTs conducted evaluating therapies to specifically designed to reduce the occurrence of falls following stroke, and of those, the evidence suggests that such interventions are not effective. Dean et al. (2012) randomized 151 community- based stroke patients to an intervention group that received exercise and task related training or control group that performed an upper-extremity strength training program and cognitive tasks. At 12-month follow up, although patients in the experimental group showed significantly improvement in gait speed, there was no significant difference between groups in the number of patients who fell. Batchelor et al. (2012) randomized 156 patients at high risk of falls into a tailored multifaceted falls prevention group or the control group which consisted of usual care. The falls prevention program consisted of an individualized home-based exercise program, falls risk strategies, education, and injury risk minimization strategies. There was no difference in the frequency of falls between groups. The intervention group had 1.89 falls/person-year, and the control group had 1.76 falls/person-year, incidence rate ratio=1.10, P=0.74). The proportion of fallers did not differ significantly between groups (risk ratio=0.83, 95% CI, 0.6-1.14), nor was the risk of injury between groups (incidence rate ratio=1.57, p=0.25). A Cochrane review (Verheyden et al. 2013) included 10 RCTs examining the effectiveness of interventions for preventing falls post stroke. There was no significant reduction in number of falls associated with exercise interventions in either the acute/subacute or chronic stages of stroke, or the number of fallers between the intervention and control groups in the chronic stage of stroke. Vitamin D was associated with declines in the number of falls in 2 trials (same group of authors).