Interventions for preventing falls in people after stroke

Falls are commonly seen in people who have had a stroke and occur in 7% of people in the first week after their stroke. In the later phase after stroke, 55% to 73% of people experience a fall one year after their stroke. Not all falls are serious enough to require medical attention but even non-serious falls may lead to people developing a fear of falling. They are a factor for predicting future falls, which may restrict the person's activities of daily living and therefore require attention. This review investigated which methods are effective for preventing falls in people after their stroke. After searching the literature, we included 10 studies with a total of 1004 participants. We found studies that investigated exercises, medication, and the provision of single lens distance vision glasses instead of multifocal glasses for preventing falls. Exercises did not appear to reduce the rate of falls or the number of people falling. The majority of studies asked participants to do exercises only. One study offered exercises together with additional components such as educational sessions about falls. Another study offered exercises together with a comprehensive risk assessment and subsequent referrals, such as a review by an optometrist or new shoes, leading to a personalised programme for preventing falls. Neither of these two studies reduced the rate of falls or the number of people falling. One study, which gave vitamin D to women after their stroke who had low vitamin D levels and were admitted to long-term care, showed a reduction in the rate of falls and the number of people falling. In another study, alendronate led to a reduction in the rate of falls and the number of people falling in people hospitalised after their stroke. More studies of this kind should be done to confirm these findings before the results are implemented into clinical practice. There is no evidence at the moment that single lens distance vision glasses instead of multifocal glasses reduce the rate of falls or the number of people falling. In summary, there is little evidence that interventions for preventing falls in people after stroke are beneficial. The main reason is that there were only a limited number of studies focusing on people after stroke or that included a stroke subgroup in the study. More research in this important area for people after stroke is therefore warranted.

Authors' conclusions: 

There is currently insufficient evidence that exercises or prescription of single lens glasses to multifocal users prevent falls or decrease the number of people falling after being discharged from rehabilitation following their stroke. Two studies testing vitamin D versus placebo and alendronate versus alphacalcidol found a significant reduction in falls and the number of people falling. However, these findings should be replicated before the results are implemented in clinical practice.

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Background: 

Falls are one of the most common medical complications after stroke with a reported incidence of 7% in the first week after stroke onset. Studies investigating falls in the later phase after stroke report an incidence of up to 73% in the first year post-stroke.

Objectives: 

To evaluate the effectiveness of interventions aimed at preventing falls in people after stroke.

Search strategy: 

We searched the trials registers of the Cochrane Stroke Group (November 2012) and the Cochrane Bone, Joint and Muscle Trauma Group (May 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2012, Issue 5, MEDLINE (1950 to May 2012), EMBASE (1980 to May 2012), CINAHL (1982 to May 2012), PsycINFO (1806 to May 2012), AMED (1985 to May 2012) and PEDro (May 2012). We also searched trials registers, checked reference lists and contacted authors.

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: 

Review authors independently selected studies for inclusion, assessed trial quality, and extracted data. 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.

Main results: 

We included 10 studies with a total of 1004 participants. One study evaluated the effect of exercises in the acute and subacute phase after stroke but found no significant difference in rate of falls (rate ratio 0.92, 95% CI 0.45 to 1.90, 95 participants). The pooled result of four studies investigating the effect of exercises on preventing falls in the chronic phase also found no significant difference for rate of falls (rate ratio 0.75, 95% CI 0.41 to 1.38, 412 participants).

For number of fallers, one study examined the effect of exercises in the acute and subacute phase after stroke but found no significant difference between the intervention and control group (risk ratio 1.19, 95% CI 0.83 to 1.71, 95 participants). The pooled result of six studies examining the effect of exercises in the chronic phase also found no significant difference in number of fallers between the intervention and control groups (risk ratio 1.02, 95% CI 0.83 to 1.24, 616 participants).

The rate of falls and the number of fallers was significantly reduced in two studies evaluating the effect of medication on preventing falls; one study (85 participants) compared vitamin D versus placebo in institutionalised women after stroke with low vitamin D levels, and the other study (79 participants) evaluated alendronate versus alphacalcidol in hospitalised people after stroke.

One study provided single lens distance glasses to regular wearers of multifocal glasses. In a subgroup of 46 participants post-stroke there was no significant difference in the rate of falls (rate ratio 1.08, 95% CI 0.52 to 2.25) or the number of fallers between both groups (risk ratio 0.74, 95% CI 0.47 to 1.18).

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