Repeat Fallers Research Articles

The incidence and consequences of falls in stroke patients during inpatient rehabilitation: Factors associated with high risk

Teasell R, McRae M, Foley N, Bhardwaj A. The incidence and consequences of falls in stroke patients during inpatient rehabilitation: factors associated with high risk. Arch Phys Med Rehabil 2002;83:329-33. Objectives: To determine the incidence of falls on a stroke rehabilitation unit; to assess the frequency and nature of injuries; and to identify risk factors predictive of falls, functional outcomes, and impairments. Design: Retrospective cohort study. Setting: An inpatient stroke rehabilitation unit. Participants: Two hundred thirty-eight consecutive stroke patient admissions. Interventions: Incident reports completed on patients who experienced a fall while on the unit were reviewed and resultant injuries categorized (abrasions, lacerations, fractures). Main Outcome Measures: Stroke impairments and admission functional assessments, FIM™ instrument, Berg Balance Scale (BBS), and Chedoke-McMaster (CM) Stroke Impairment Inventory of fallers were compared with nonfallers. Results: Of the 238 patients, 88 (37%) experienced at least 1 fall, and almost half of these (45 patients [19%]) experienced at least 2 falls. A total of 180 falls were reported over the 5-year period. Of the 180 reported falls, 33% occurred when patients were using their wheelchairs. Injuries occurred in 22% of the reported falls. These consisted of contusions (49%) and abrasions (41%), primarily of the upper (30.8%) and lower (25.6%) extremities. Only 1 fracture was reported. Fallers tended to have lower admission BBS scores (50% of patients with a score <30 fell vs 18% with a score >30, P <.01) and a lower score on the admission arm, leg, and foot components of the CM (P <.05). Patients who fell were also more likely to be apraxic (P <.014) and suffer from cognitive deficits (P <.01). Repeat fallers had lower admission FIM scores (P <.01) when compared with nonfallers. Conclusion: Although patients undergoing stroke rehabilitation experienced a significant number of falls, the incidence of serious injury was small. Patients who experienced at least 1 fall had significantly lower BBS, FIM, and CM arm, leg, and foot scores compared with nonfallers. These data suggest that groups of stroke patients who are at risk for falls within the rehabilitation setting can be identified by using a variety of impairment and functional assessments. This information may be potentially useful for designing interventions directed at reducing fall frequency among stroke survivors. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Development of a Checklist for Describing the Performance of Fall-related Activities by People with Parkinson's Disease

Introduction: Falls are a major problem for elderly people in general but those with Parkinson’s Disease (PD) are at greater risk of instability. Knowledge is limited about the ways in which repeat fallers move about their environment. The aims of this study were to develop a tool for describing the movement strategies used when turning and reaching and to test for inter-observer reliability. Method: People with PD (independently mobile and screened for cognitive dysfunction) were recruited through GPs. Video recordings of individuals turning and reaching high and low while making a cup of tea were made in participants’ homes. First, five skilled therapists independently identified movement strategies from the videos of seven people. Key strategies, agreed through consensus, formed the rating scale and comprised six items for turning (eg number of steps, turn type), five items for high reach (eg body alignment and support) and four items for low reach (eg instability and support). Inter-rater reliability was examined using two observers who independently rated the video recordings of performances. Results: The video recordings of 66 subjects with PD were analysed. Their median age was 73 years (range 36 to 88) and they had moderate disease severity (median grade III, Hoehn and Yahr). Eleven out of the 14 items reached acceptable agreement, using Kappa coeficients (0.6 to 1.00), but turn type (0.56) and observed instability when turning were not shown to be reliable (0.48). The difference in the number of steps counted by observers was analysed using a Bland Altman approach and showed high agreement (mean difference –0.06, 95% range of difference –1.4 to1.2). Conclusion: A checklist for analysing the components used when individuals turn and reach high and low when making a cup of tea was developed. Procedures for ensuring content validity and reliability were followed. The rating scale was designed for use in the home environment for assessment and evaluation of intervention.

Fall events among people with stroke living in the community: Circumstances of falls and characteristics of fallers

Hyndman D, Ashburn A, Stack E. Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers. Arch Phys Med Rehabil 2002;83:165-70. Objectives: To describe the frequency and circumstances of falls among a community sample of people with stroke and to compare characteristics of fallers and nonfallers. Design: Cross-sectional, observational study. Setting: Community. Participants: Forty-one community-dwelling people with stroke (26 men, 15 women; mean age, 69.7 ± 11.6y), of which 23 had right-hemisphere infarction, 16 left-hemisphere infarction, and 2 had a brainstem lesion. Time since onset of stroke ranged from 3 to 288 months (mean, 50mo). Interventions: Not applicable. Main Outcome Measures: Standardized tests were used to measure mobility, upper limb function, activities of daily living (ADL ability), and mood. Information about fall events was collected by using a questionnaire. Results: Twenty-one participants (50%) were classed as fallers, of whom 10 had fallen repeatedly. No significant differences were found between fallers and nonfallers on any of the measures used. However, those who had 2 or more falls (n = 10) had significantly reduced arm function (P =.018) and ADL ability (P =.010), compared with those who had not fallen or experienced near falls (n = 5). Loss of balance, misjudgment, and foot dragging during walking, turning, and sit to stand were reported by fallers as the suspected causes and activities leading to falls. Conclusions: The high risk of falling among people with stroke was evident in this community-based sample. Repeat fallers had greater mobility deficits and significantly reduced arm function and ADL ability than those who did not report any instability. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

How People with Parkinson's Disease Describe their Difficulties in Turning

Background: People with Parkinson’s disease (PD) fall more frequently than healthy elderly people (Nevitt et al,1989). Turning has been identified as an activity frequently associated with falls among people with PD (Stack and Ashburn, 1999). As part of a larger study comparing turning strategies used by repeat fallers and non-repeat fallers, participants were asked a series of questions about falling and turning. The aim of the study was to increase the understanding of the difficulties people with PD experience while turningand how they have attempted to overcome these difficulties. Method: Cross-sectional study of a community sample of 75 people with consultant-diagnosed PD. All subjects were independently mobile and were screened for cognitive impairment using the Middlesex Elderly Assessment of Mental State. Interviews took place in the participants’ own homes. Participants were asked how many times they had fallen in the previous 12 months and on the basis of this answer were categorised as repeat fallers or non-repeat fallers. They were asked to describe their location, activity at the time and suspected cause of each reported fall. In addition, participants were asked whether they experienced difficulty in turning, if they had consciously modified the way they turned and if they believed any modification made was successful. Contents of the interviews were categorised by two researchers. Results: Of the 75 participants, 32 were non-repeat fallers and 43 repeat fallers. Turning was identified as the second most common activity during which a reported fall had occurred (17%) after walking (41%). After loss of balance (21%), turning was identified as the second most common cause of the fall (14%). Difficulty in turning was reported by 45% of non-repeat fallers and 82% of repeat fallers. The most common difficulties experienced while turning were freezing (27%), falling (27%) and loss of balance (25%). 32% of non-repeat fallers and 61% of repeat fallers said they had attempted to modify the way they turned. Over 80% of all participats considered their modifications successful. Modifications included slowing down (22%), concentrating (20%) and holding on (17%). Conclusion: As previously shown, people with PD who have fallen frequently report turning as a causative factor. We have highlighted some of the reasons why turning can be difficult for people with PD and the modifications they have made to their movement strategies in an attempt to overcome these difficulties. What remains to be understood is which movement strategies used by people with PD when turning are beneficial stabilising adaptations and which are associated with an increased risk of falling.