Which intervention modalities reduce falling post stroke?
Falls are commonly reported and occur in up to 73% of people one year post stroke. Not all falls are serious enough to require medical attention but even non-serious falls may lead to activity restrictions and 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 in preventing falls in people after their stroke, either with haemorrhagic or ischaemic aetiology.
3 September 2018
After searching the literature, we included 14 studies with a total of 1358 participants. We found studies that investigated various interventions for preventing falls: physical 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. Included studies conducted their investigations in early to chronic inpatient, outpatient, and community dwelling settings.
Study funding sources
Exercises appear to reduce the rate of falls, but not the number of people falling post stroke. Among the studies that used exercises as an intervention condition, the majority of studies asked participants to solely perform exercises. 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.
Besides exercises, several other interventions aiming to prevent falls post stroke were investigated in the literature. One study administered non-invasive brain stimulation to people after stroke and the results showed a potential to decrease the number of people falling, but this study needs to be replicated before consideration in clinical practice. There is no evidence at the moment that predischarge home visits, single lens distance vision glasses instead of multifocal glasses or a servo-assistive rollator reduce the rate of falls or the number of people falling.
None of the included studies reported serious harm related to the intervention conditions.
In summary: there is little evidence that interventions other than exercises are beneficial for preventing falls in people after stroke. 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. In addition, studies related to falling do not consistently follow known methodological guidelines, particularly in fall definition and time post stroke. More well-reported, consensual research with an adequate number of participants might further establish the value of exercises in reducing falling post stroke.
Quality of the evidence
The quality of the evidence regarding rate of falls and number of fallers ranged from very low to low across the five comparisons, meaning that we have very low to low certainty in these results. The main reasons for downgrading the evidence were the lack of blinding of fall outcome and the majority of comparisons including only one study.
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.
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.
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.
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.
Randomised controlled trials of interventions where the primary or secondary aim was to prevent falls in people after stroke.
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.
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 stroke
The 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 stroke
We 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).