Fall-related experiences of stroke survivors: a meta-ethnography

PURPOSE: Health professionals view falls after stroke as common adverse events with both physical and psychological consequences. Stroke survivors' experiences are less well understood. The aim of this systematic review was to explore the perception of falls-risk within the stroke recovery experience from the perspective of people with stroke. METHODS: A systematic literature search was conducted. Papers that used qualitative methods to explore the experiences of individuals with stroke around falls, falls-risk and fear of falling were included. Two reviewers independently assessed the methodological quality of papers. Meta-ethnography was conducted. Concepts from each study were translated into each other to form theories that were combined through a "lines-of-argument" synthesis. RESULTS: Four themes emerged from the six included qualitative studies: (i) Fall circumstances, (ii) perception of fall consequences, (iii) barriers to community participation and (iv) coping strategies. The synthesis revealed that stroke survivors' perceived consequences of falls exist on a continuum. Cognitive and emotional adjustment may be required in the successful adoption of coping strategies to overcome fall-related barriers to participation. CONCLUSIONS: Stroke survivors' fall-related experiences appear to exist within the context of activity and community participation. Further research is warranted due to the small number of substantive studies available for synthesis. Implications for Rehabilitation Health care professionals should recognize that cognitive and emotional adjustment may berequired for stroke survivors to accept strategies for overcoming falls-risk, including dependenceon carers and assistive devices. Several factors in addition to physical interventions may be needed to minimize falls-risk whileincreasing activity participation. These factors could include increasing public awareness about the effects of stroke and falls-risk,and ensuring access to psychological services for stroke survivors. Rehabilitation professionals should reflect on whether they perceive there to be an appropriatelevel of fear of falling post-stroke. They should understand that stroke survivors might not conceptualize falls-risk in this way.PURPOSE: Health professionals view falls after stroke as common adverse events with both physical and psychological consequences. Stroke survivors' experiences are less well understood. The aim of this systematic review was to explore the perception of falls-risk within the stroke recovery experience from the perspective of people with stroke. METHODS: A systematic literature search was conducted. Papers that used qualitative methods to explore the experiences of individuals with stroke around falls, falls-risk and fear of falling were included. Two reviewers independently assessed the methodological quality of papers. Meta-ethnography was conducted. Concepts from each study were translated into each other to form theories that were combined through a "lines-of-argument" synthesis. RESULTS: Four themes emerged from the six included qualitative studies: (i) Fall circumstances, (ii) perception of fall consequences, (iii) barriers to community participation and (iv) coping strategies. The synthesis revealed that stroke survivors' perceived consequences of falls exist on a continuum. Cognitive and emotional adjustment may be required in the successful adoption of coping strategies to overcome fall-related barriers to participation. CONCLUSIONS: Stroke survivors' fall-related experiences appear to exist within the context of activity and community participation. Further research is warranted due to the small number of substantive studies available for synthesis. Implications for Rehabilitation Health care professionals should recognize that cognitive and emotional adjustment may berequired for stroke survivors to accept strategies for overcoming falls-risk, including dependenceon carers and assistive devices. Several factors in addition to physical interventions may be needed to minimize falls-risk whileincreasing activity participation. These factors could include increasing public awareness about the effects of stroke and falls-risk,and ensuring access to psychological services for stroke survivors. Rehabilitation professionals should reflect on whether they perceive there to be an appropriatelevel of fear of falling post-stroke. They should understand that stroke survivors might not conceptualize falls-risk in this way

Systematic review of risk prediction models for falls after stroke

BACKGROUND: Falls are a significant cause of morbidity after stroke. The aim of this review was to identify, critically appraise and summarise risk prediction models for the occurrence of falling after stroke. METHODS: A systematic literature search was conducted in December 2014 and repeated in June 2015. Studies that used multivariable analysis to build risk prediction models for falls early after stroke were included. 2 reviewers independently assessed methodological quality. Data relating to model calibration, discrimination (C-statistic) and clinical utility (sensitivity and specificity) were extracted. A narrative review of models was conducted. PROSPERO reference: CRD42014015612. RESULTS: The 12 included articles presented 18 risk prediction models. 7 studies predicted falls among inpatients only and 5 recorded falls in the community. Methodological quality was variable. A C-statistic was reported for 7 models and values ranged from 0.62 to 0.87. Models for use in the inpatient setting most frequently included measures of hemi-inattention, while those predicting community events included falls (or near-falls) history and balance measures most commonly. Only 2 studies reported any form of validation, and none presented a validated model with acceptable performance. CONCLUSIONS: A number of falls-risk prediction models have been developed for use in the acute and subacute stages of stroke. Future research should focus on validating and improving existing models, with reference to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) guidelines to ensure quality reporting and expedite clinical implementation.BACKGROUND: Falls are a significant cause of morbidity after stroke. The aim of this review was to identify, critically appraise and summarise risk prediction models for the occurrence of falling after stroke. METHODS: A systematic literature search was conducted in December 2014 and repeated in June 2015. Studies that used multivariable analysis to build risk prediction models for falls early after stroke were included. 2 reviewers independently assessed methodological quality. Data relating to model calibration, discrimination (C-statistic) and clinical utility (sensitivity and specificity) were extracted. A narrative review of models was conducted. PROSPERO reference: CRD42014015612. RESULTS: The 12 included articles presented 18 risk prediction models. 7 studies predicted falls among inpatients only and 5 recorded falls in the community. Methodological quality was variable. A C-statistic was reported for 7 models and values ranged from 0.62 to 0.87. Models for use in the inpatient setting most frequently included measures of hemi-inattention, while those predicting community events included falls (or near-falls) history and balance measures most commonly. Only 2 studies reported any form of validation, and none presented a validated model with acceptable performance. CONCLUSIONS: A number of falls-risk prediction models have been developed for use in the acute and subacute stages of stroke. Future research should focus on validating and improving existing models, with reference to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) guidelines to ensure quality reporting and expedite clinical implementation

Patient and hospital-level factors associated with time to surgery after hip fracture in Ireland: Analysis of national audit data 2016–2020

Introduction: In hip fracture care, time to surgery (TTS) is a commonly used quality indicator associated with  patient outcomes including mortality. This study aimed to identify patient and hospital-level characteristics  associated with TTS in Ireland.  Methods: National data from the Irish Hip Fracture Database (IHFD) (2016–2020) were analysed along with  hospital-level characteristics obtained from a 2020 organisational survey. Generalised linear model regression  was used to explore the association of TTS with case-mix, surgical details, hospital-level staffing and specific  protocols recommended to expedite surgery.  Results: A total of 14,951 patients with surgically treated hip fracture from 16 hospitals were included (Mean  age= 80.6 years (SD=8.8), 70.4% female). Mean TTS was 40.9 h (SD=60.3 h). Case-mix factors associated with  longer TTS were male sex and higher American Society of Anaesthesiologists (ASA) grade. Other factors found to  be associated with longer TTS included low pre-morbid mobility, inter-hospital transfer, weekday presentation,  pre-operative medical physician assessment, intracapsular fracture type, arthroplasty surgery, general anaesthesia, consultant grade of surgeon and lower hospital-level orthopaedic surgical capacity. The oldest age-group  and pre-fracture nursing home residence were associated with shorter TTS when adjusted for other case-mix  factors. None of four explored protocols for expediting surgery were associated with TTS.  Conclusion: Patients with more comorbidity experience longer surgical delay after hip fracture in Ireland, in line  with international research. Low availability of senior orthopaedic surgeons in Ireland may be delaying hip  fracture surgery. Pathway of presentation, including via inter-hospital transfer or hospital bypass, is an important  factor that requires further exploration. Further research is required to identify successful system-level protocols  and interventions that may expedite hip fracture surgery within this setting.  </p

Existing validated clinical prediction rules for predicting response to physiotherapy interventions for musculoskeletal conditions have limited clinical value: a systematic review

Objective: To systematically review clinical prediction rules (CPRs) that have undergone validation testing for predicting response to physiotherapy-related interventions for musculoskeletal conditions. Study design and setting: PubMed, EMBASE, CINAHL and Cochrane Library were systematically searched to September 2020. Search terms included musculoskeletal (MSK) conditions, physiotherapy interventions and clinical prediction rules. Controlled studies that validated a prescriptive CPR for physiotherapy treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility. Original derivation studies of each CPR were identified. Risk of bias was assessed with the PROBAST tool (derivation studies) and the Cochrane Effective Practice and Organisation of Care group criteria (validation studies). Results: Nine studies aimed to validate seven prescriptive CPRs for treatment response for MSK conditions including back pain, neck pain, shoulder pain and carpal tunnel syndrome. Treatments included manipulation, traction and exercise. Seven studies failed to demonstrate an association between CPR prediction and outcome. Methodological quality of derivation studies was poor and for validation studies was good overall. Conclusion: Results do not support the use of any CPRs identified to aid physiotherapy treatment selection for common musculoskeletal conditions, due to methodological shortcomings in the derivation studies and lack of association between CPR and outcome in validation studie

Falls related EvEnts in the first year after StrokE in Ireland: results of the multi-centre prospective FREESE cohort study

Introduction: Falls are common post-stroke adverse events. This study aimed to describe the first-year falls incidence, circumstances and consequences among persons discharged home after stroke in Ireland, and to examine the association between potential risk factors and recurrent falls. Patients and Methods: Patients with acute stroke and planned home-discharge were recruited consecutively from five hospitals. Variables recorded pre-discharge included: age, stroke severity, comorbidities, fall history, prescribed medications, hemi-neglect, cognition, and functional independence (Barthel Index). Falls were recorded with monthly diaries, and six and 12-month interviews. The association of pre-discharge factors with recurrent falls (>1 fall) was examined using univariable logistic regression. Results: 128 participants (mean age=68.6, SD=13.3) were recruited. 110 completed 12-month follow-up. The first-year falls-incidence was 44.5% (95%CI=35.1-53.6) with 25.6% falling repeatedly (95%CI=18.5- 34.4). Fallers experienced 1-18 falls (median=2) and five reported fractures. 47% of fallers experienced at least one fall outdoors. Only 10% of recurrent fallers had bone health medication prescribed at discharge. Lower Barthel Index scores (<75/100, RR=4.38, 1.64-11.72) and psychotropic medication prescription (RR=2.10, 1.13-3.91) were associated with recurrent falls. Discussion: This study presents prospectively collected information about falls circumstances. It was not powered for multivariable analysis of risk factors. Conclusion: One quarter of stroke survivors discharged to the community fall repeatedly and mostly indoors in the first year. Specific attention may be required for individuals with poor functional independence or those on psychotropic medication. Future falls-management research in this population should explore falls in younger individuals, outdoor as well as indoor falls and post-stroke bone health status

First year post-stroke healthcare costs and fall-status among those discharged to the community

  Introduction: Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community. Patients and methods: Survivors of acute stroke with planned home discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation. Results: A total of 109 stroke survivors with complete follow-up data (mean age = 68.5 years (SD = 13.5 years)) were included. Fifty-three participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p = 0.02 and p Discussion: The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included. Conclusion: This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/tertiary care (including inpatient re-admissions) and allied healthcare. Future research could compare the cost-effectiveness of inpatient versus community-based fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction.</p

Validation of two risk-prediction models for recurrent falls in the first year after stroke: a prospective cohort study

Background: Several multivariable models have been derived to predict post-stroke falls. These require validation before integration into clinical practice. The aim of this study was to externally validate two prediction models for recurrent falls in the first year post-stroke using an Irish prospective cohort study. Methodology: Stroke patients with planned home-discharges from five hospitals were recruited. Falls were recorded with monthly diaries and interviews six and 12 months post-discharge. Predictors for falls included in two risk-prediction models were assessed at discharge. Participants were classified into risk-groups using these models. Model 1, incorporating inpatient falls-history and balance, had a six-month outcome. Model 2, incorporating inpatient near-falls history and upper limb function, had a twelve-month outcome. Measures of calibration, discrimination (area under the curve (AUC)) and clinical utility (sensitivity/ specificity) were calculated. Results: 128 participants (mean age=68.6 years, SD=13.3) were recruited. The fall status of 117 and 110 participants was available at six and 12 months respectively. Seventeen and 28 participants experienced recurrent falls by these respective timepoints. Model 1 achieved an AUC=0.56 (95% CI 0.46–0.67), sensitivity=18.8% and specificity=93.6%. Model 2 achieved AUC=0.55 (95% CI 0.44–0.66), sensitivity=51.9% and specificity=58.7%. Model 1 showed no significant difference between predicted and observed events (Risk Ratio (RR)=0.87, 95% CI 0.16–4.62). In contrast, model 2 significantly over-predicted fall events in the validation cohort (RR=1.61, 95% CI 1.04–2.48). Conclusions: Both models showed poor discrimination for predicting recurrent falls. A further large prospective cohort study would be required to derive a clinicallyuseful falls-risk prediction model for a similar population

First year post-stroke healthcare costs and fall-status among those discharged in the community

Introduction: Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community. Patients and Methods: Survivors of acute stroke with planned home-discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation. Results: 109 stroke survivors with complete follow-up data (mean age=68.5 years (SD=13.5 years)) were included. 53 participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p=0.02 and p<0.01, respectively). Discussion: The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included. Conclusion: This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/ tertiary care (including inpatient re-admissions) and allied health care. Future research could compare the cost-effectiveness of inpatient versus communitybased fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction

Addressing cognitive impairment following stroke: systematic review and meta-analysis of non-randomised controlled studies of psychological interventions.

OBJECTIVE: Cognitive impairment is a pervasive outcome of stroke, reported in over half of patients 6 months post-stroke and is associated with increased disability and a poorer quality of life. Despite the prevalence of post-stroke cognitive impairment, the efficacy of existing psychological interventions for the rehabilitation of cognitive impairment following stroke has yet to be established. The aim of this study is to identify psychological interventions from non-randomised studies that intended to improve post-stroke cognitive function and establish their efficacy. DESIGN: Systematic review and meta-analysis of non-randomised studies of psychological interventions addressing post-stroke cognitive impairment. DATA SOURCES: Electronic searches were performed in the Pubmed, EMBASE and PsycINFO databases, the search dating from inception to February 2017. ELIGIBILITY CRITERIA: All non-randomised controlled studies and quasi-randomised controlled trials examining psychological interventions to improve cognitive function following stroke were included, such as feasibility studies, pilot studies, experimental studies, and quasi-experimental studies. The primary outcome was cognitive function. The prespecified secondary outcomes were functional abilities in daily life and quality of life. METHODS: The current meta-analyses combined the findings of seven controlled studies, examining the efficacy of psychological interventions compared with treatment-as-usual controls or active controls, and 13 one-group pre-post studies. RESULTS: Results indicated an overall small effect on cognition across the controlled studies (Hedges' g=0.38, 95% CI=0.06 to 0.7) and a moderate effect on cognition across the one-group pre-post studies (Hedges' g=0.51, 95% CI=0.3 to 0.73). Specific cognitive domains, such as memory and attention also demonstrated a benefit of psychological interventions. CONCLUSIONS: This review provides support for the potential of psychological interventions to improve overall cognitive function post-stroke. Limitations of the study, in terms of risk of bias and quality of included studies, and future research directions are explored. PROSPERO REGISTRATION NUMBER: CRD42017069714.</p

Managing cognitive impairment following stroke: protocol for a systematic review of non-randomised controlled studies of psychological interventions.

Introduction Stroke is one of the primary causes of death and disability worldwide, leaving a considerable proportion of survivors with persistent cognitive and functional deficits. Despite the prevalence of poststroke cognitive impairment, there is no established treatment aimed at improving cognitive function following a stroke. Therefore, the aims of this systematic review are to identify psychological interventions intended to improve poststroke cognitive function and establish their efficacy. Methods and analysis A systematic review of non-randomised controlled studies that investigated the efficacy of psychological interventions aimed at improving cognitive function in stroke survivors will be conducted. Electronic searches will be performed in the PubMed, Embase and PsycINFO databases, the search dating from the beginning of the index to February 2017. Reference lists of all identified relevant articles will be reviewed to identify additional studies not previously identified by the electronic search. Potential grey literature will be reviewed using Google Scholar. Titles and abstracts will be assessed for eligibility by one reviewer, with a random sample of 50% independently double-screened by second reviewers. Any discrepancies will be resolved through discussion, with referral to a third reviewer where necessary. Risk of bias will be assessed with the Risk of Bias in Non-randomized Studies of Interventions tool. Meta-analyses will be performed if studies are sufficiently homogeneous. This review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The quality of the evidence regarding cognitive function will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation. Ethics and dissemination This systematic review will collect secondary data only and as such ethical approval is not required. Findings will be disseminated through presentations and peer-reviewed publication. This review will provide information on the effectiveness of psychological interventions for poststroke cognitive impairment, identifying which psychological interventions are effective for improving poststroke cognitive function.</p