Interventions for preventing falls in people after stroke
Elizabeth Scruth
Abstract
Persons suffering from a stroke often experience long-lasting complications after rehabilitation. One of the most common complications involves falls (Denissen et al., 2019). The decline of neuromotor performance caused by the underlying disease resulting in a stroke contributes to the majority of falls in stroke survivors (Yang and Butler, 2020). Muscle weakness, impairment in balance, loss of sensation, and limited mobility after a stroke increase the likelihood of a fall (Yang and Butler, 2020). Falls result in further complications for stroke survivors placing both psychological and economic burdens on the person and the family. Walking recovery for stroke survivors is the most important priority. Research to date has shown that only 50% of stroke survivors demonstrate walking improvements after rehabilitation (Little, Perry, Mercado, Kautz, & Patten, 2020) Nurses caring for stroke survivors play an important role in balancing the goals of the patient with the trajectory of the diagnosis and aims of rehabilitation. Additionally, nurses must understand the type of gait disorders the stroke has resulted in. Stroke survivors often have gait asymmetries, which fall into two categories: spatial and temporal. Both gait asymmetries are predictors of falls in stroke survivors (Little et al., 2020). Preventing falls in stroke survivors has resulted in various exercise-based fall prevention training programs being developed and outcomes published (Little et al., 2020). Interventions aimed at preventing falls in stroke survivors in the literature to date include assistive devices, post-hospitalization intensive therapy through home visits, brain stimulation, and targeted exercises (Denissen et al., 2019). Preventing falls both in the hospital setting and in the home for the stroke survivor starts early in the hospitalization with the nurse and other healthcare team members and involves many different interventions. The aim of the Cochrane Review was to explore interventions in the published literature aimed at preventing falls in stroke survivors (Denissen et al., 2019) The review was an updated version from the one published in 2013. The primary objective of the review was to look at the effect of the interventions on the number of falls per person per year and the number of fallers. There were several components to the secondary objective, which explored the effects of the interventions for preventing falls on (a) the number of fall-related fractures, (b) the number of fall-related hospital admissions, (c) near-fall events, (d) economic evaluation, (e) quality of life, and (f) adverse effects of the interventions. The review considered randomized controlled trials (RCTs) and crossover trials whose data were collected prospectively or retrospectively. The trials included in the review were inclusive of adults over 18 years of age with a confirmed diagnosis of stroke either ischemic or hemorrhagic and in any phase of a stroke including the chronic phase. The chronic phase for purposes of the review was defined as the stroke occurring at least 6 months earlier. The inclusion criteria for the interventions reviewed included anywhere the primary or secondary aim was to prevent falls. The interventions of interest were categorized into single or multiple interventions. Trials were excluded if they did not report an outcome measure related to the falls or number of fallers. Adverse events were classified as injuries resulting from the intervention. The databases searched were the Cochrane Stroke Group (September 2018), and Cochrane Bone, Joint and Muscle Trauma Group (October 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 9); MEDLINE (1950 to September 2018); EMBASE (1980 to September 2018); CINHAL (1982 to September 2018); PsychINFO (1806 to August 2018); AMED (1985 to December 2017); and PEDro (September 2018) and trial registries. The review included 14 individually randomized trials inclusive of 1,358 participants. Six of the studies were new since the original review conducted in 2013. For the primary outcome of the rate of falls post-stroke, the evidence showed that exercise may reduce the rate although there was some uncertainty (rate ratio, 0.72; 95% confidence interval [CI], 0.54–0.94; 765 participants, low-quality evidence). Further analysis for single-exercise interventions found exercise may reduce the rate of falls (rate ratio, 0.66; 95% CI 0.50–0.87; 626 participants). For the outcome of fallers, the effect of exercises demonstrated low-quality evidence and uncertainty (risk ratio, 1.03; 95% CI, 0.90–1.19; 969 participants). Other interventions in the studies reviewed revealed very low-quality evidence resulting in low certainty of a non-effect of predischarge home visits, provision of single-lens distance glasses to wearers of multifocal glasses, and a servo-assistive rollator on falls poststroke. One study using direct current stimulation examining the effects of falls poststroke resulted in low certainty (risk ratio, 0.30; 95% CI, 0.14–0.63; 60 participants). Given the low quality of evidence in the RCTs and limited number of RCTs exploring the primary outcomes of a number of falls per person per year and the number of fallers, further RCTs including people with stroke are needed to provide the evidence necessary to make a firm recommendation. The review revealed that exercises may reduce falls but do not reduce the number of fallers. None of the studies reported on fall-related hospital admissions. Only three trials reported specifically on adverse outcomes. Many of the studies did not have adequate numbers of participants, which is needed to further validate the benefits of exercise poststroke, and none of the studies reported an economic evaluation. Quality of life could not be analyzed due to the wide variety of outcome measures used in the studies. Managing falls poststroke is relevant to nursing practice as a mobility assessment is an important part of the overall patient assessment conducted routinely in hospitals. Reducing the risk of falls is also a regulatory requirement and falls are publicly reported in hospital grades. Awareness of current research and conducting research to explore areas identified as needing further exploration should be of interest and a priority for nurses both in the hospital and the community. Nurses spend the most time with patients both in the hospital and community setting. There are opportunities during interactions with stroke survivors to explore options to prevent falls. A thorough assessment of the environment and assistive devices is required to reduce the risk of falls. The exercise undertaken should be supervised by a qualified professional to determine the safety of the intervention both short and long term. A team approach to reduce falls in stroke survivors is needed to ensure that all available interventions have been explored and their efficacy determined. The Mission of Cochrane Nursing (CN) is to support Cochrane's work by increasing the use of their library and provide an international evidence base for nurses and related healthcare professionals involved in delivering, leading, or researching nursing care. The CN produces 'Cochrane Corner' columns (summaries of recent nursing-care-relevant Cochrane reviews) that are regularly published in the group's collaborating nursing-care-related journals. The original authors and full citations of the Cochrane reviews are noted in each published column. These published summaries reach a much wider group of nurses and related healthcare agencies internationally and allow direct access to highly relevant evidence outcomes that frontline healthcare workers might not otherwise have access to. Information on the processes this group has developed can be accessed at https://nursing.cochrane.org/