Understanding patients’ expectations key to improving preventive care after stroke

 Wow, these people don't understand a single thing about stroke survivor recovery! Fear of falling is solved by perturbation and fall prevention protocols, AND YOU HAVEN'T CREATED THEM YET? How incompetent can you be and still stay employed?

Understanding patients’ expectations key to improving preventive care after stroke

Key takeaways:

• Fear of falling is the main concern of stroke survivors who do not engage in recommended physical activity.
• Future clinical trials must address gaps in knowledge of proper post-stroke care(WRONG! SURVIVORS WANT 100% RECOVERY; NOT 'CARE', YOU BLITHERING IDIOTS!).

ORLANDO, Fla. — For stroke survivors, participation in preventive health behaviors, such as adhering to blood pressure medication and physical activity, depended on their outcome expectations, self-efficacy and agency, data show.

“We know that blood pressure is the most modifiable risk factor after stroke and we also know that about half of stroke survivors have uncontrolled blood pressure,” Imama A. Naqvi, MD, MS, assistant professor of neurology at Columbia University Irving Medical Center, said during a presentation at the American Neurological Association annual meeting. “We know that physical inactivity impairs recovery and that most of our stroke survivors are physically inactive.(Yeah, because you completely failed at getting them 100% recovery protocols! Own your failures and solve them!)”

New research conducted in an underserved area of New York City yielded three main themes which were likely to assist clinicians in improving patients’ post-stroke recovery knowledge and behaviors. Image: Adobe Stock

Naqvi and colleagues assessed various influential factors which led to preventive post-stroke behaviors — including medication adherence and physical activity — in a cohort of Black and Hispanic individuals from an underserved community in New York City.

They conducted two rounds of qualitative interviews with 14 adults (mean age, 58.9; 50% women) who survived minor stroke and who were discharged from a comprehensive stroke center to their homes. Primary subjects of the interviews were based on patient knowledge of blood pressure management and behavior intended to stimulate physical activity.

The assessment also included collection of sociodemographic information, knowledge of post-treatment health recommendations, perceptions of barriers to successful community reintegration and knowledge of persons or actions which could facilitate recovery. In addition, patient-reported measures such as the International Physical Activity Questionnaire (IPAQ) and Short Form and Stages of Change – Continuous Measure (URICA-E2) were included for analysis along with data logged from wearable devices to track physical activity for 1 month.

According to results of the assessment, gaps existed between knowledge of and participation in healthy behaviors related to post-stroke recovery.

Naqvi and colleagues identified three themes that were likely to lead to increased participation and greater patient adherence to post-stroke recovery: positive outcome expectations; the ability to effectively take control of a journey to recovery; and the agency to make decisions that aid the process.

Data such as the mean daily step count (5,533±2,861) registering significantly lower than the recommended 10,000 per day, as well as lower than mean scores on the Patient Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) scale (patient reported, 44.9 ±9.8; population mean, 50 ±10) as a function of limited knowledge of existing recommendations, along with fear of falling, provided context for these discrepancies.

The researchers posited that addressing these themes in future clinical studies may alter existing behaviors that are likely to promote continued health.

“[The study] was helpful in creating an advisory group,” Naqvi said. “These are mildly disabled patients. These are not people who have severe disability, but they are self-restricting because they are afraid of falling.”

Sources/Disclosures

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Source:

Naqvi IA, et al. Influences on preventive health behaviors after minor stroke: Understanding patient perceptions and practices in an urban underserved population. Presented at: American Neurological Association annual meeting; Sept. 14-17, 2024; Orlando.

Disclosures: Naqvi reports no relevant financial disclosures. The study was supported by the National Center for Advancing Translational Sciences and by a grant from the NIH.

Antidepressants May Reduce Risk of Falls in Older Adults

 Don't let your doctor use this as their go to intervention for preventing falls. They need to give you EXACT FALL PREVENTION PROTOCOLS WITH LOTS OF PERTURBATIONS!

The proper way for your doctor to prevent depression is to have EXACT 100% RECOVERY PROTOCOLS! In my opinion, if your doctor doesn't have that; you don't have a functioning stroke doctor!

Antidepressants May Reduce Risk of Falls in Older Adults

Results differ from previous studies suggesting an increased risk

by Michael DePeau-Wilson, Enterprise & Investigative Writer, MedPage Today August 27, 2024

First-line antidepressants were associated with a decreased risk of falls and related injuries among older adults, according to a cohort study.

Of more than 100,000 Medicare beneficiaries newly diagnosed with depression, use of first-line antidepressants was associated with a decreased risk of falls and related injuries compared with no treatment, with adjusted hazard ratios ranging from 0.74 (95% CI 0.59-0.89) for bupropion (Wellbutrin) to 0.83 (95% CI 0.67-0.98) for escitalopram (Lexapro), reported Wei-Hsuan Lo-Ciganic, PhD, MSPharm, of the University of Pittsburgh, and co-authors.

The event rates for falls and related injuries were also lower for patients treated with bupropion compared with those who did not receive treatment (63 vs 87 per 1,000 person-years), with event rates for all other antidepressants falling between those rates, they noted in JAMA Network Openopens in a new tab or window.

The restricted mean survival time, which represents the area under the survival curve up to a specific time point and can be interpreted as the mean time before the event or censoring points, ranged from 349 days (95% CI 346-350) for those who were untreated to 353 days (95% CI 350-356) for those treated with bupropion.

The authors also noted that psychotherapy was not associated with risk of falls and related injuries compared with no treatment (adjusted HR 0.94, 95% CI 0.82-1.17), with an event rate of 82 per 1,000 person-years.

"Over half of older adults with depression did not receive psychotherapy or first-line antidepressants within the first 90 days after their diagnosis," Lo-Ciganic told MedPage Today. "There have been concerns that the side effects of some antidepressants, such as drowsiness, balance problems, and changes in blood pressure, could increase the risk of falls and related injuries in older adults."

In fact, she explained that the 2019 American Geriatrics Society Beers Criteria recommended against using antidepressants in this patient population for fear of exacerbating those issues.

"However, this recommendation might not be practical, given the importance of treating depressive symptoms," Lo-Ciganic added. "Our study provides important safety information for clinicians to consider when choosing different first-line antidepressant treatments for older adults."

She noted that previous studies that suggested an increased risk of falls and injuries with antidepressants did not compare outcomes with all commonly used first-line antidepressants. They also did not account for depression as an underlying cause of a patient's falls, rather than the antidepressant medication.

For this study, the authors used 2016-2019 Medicare claims data on 101,953 eligible Medicare beneficiaries ages 65 and older with newly diagnosed depression. Mean age was 76 years, 62.1% were women, 80.3% were white, and 7.3% were Black.

They used a target trial emulation framework with a cloning-censoring-weighting approach to analyze the data. Rates of falls and related injuries were based on events recorded within 1 year of a participant's diagnosis using the Acute Care Algorithm.

Among the beneficiaries, 45.2% did not receive any treatment, and 14.6% received psychotherapy. The most common first-line antidepressants included sertraline (Zoloft; 9.2%), escitalopram (9%), citalopram (Celexa; 4.7%), mirtazapine (Remeron; 3.8%), duloxetine (Cymbalta; 3.1%), trazodone (2.9%), fluoxetine (Prozac; 2.8%), bupropion (2.3%), paroxetine (Paxil; 1.4%), and venlafaxine (Effexor XR; 1%).

Lo-Ciganic pointed out that this study had several limitations, including challenges with collecting data on falls and injuries that did not receive medical attention, which may have led to an underestimate of cases. Also, the authors did not account for unmeasured factors, like lifestyle and environment.

• 

  Michael DePeau-Wilson is a reporter on MedPage Today’s enterprise & investigative team. He covers psychiatry, long covid, and infectious diseases, among other relevant U.S. clinical news. Follow

Disclosures

Lo-Ciganic reported relationships with the National Institute on Aging; Merck, Sharp and Dohme; Bristol Myers Squibb; and Teva Pharmaceuticals.

Some co-authors reported providing expert testimony on falls that occur in the hospital, and receiving funding from Amgen, Novartis, Pfizer, Sanofi, and Takeda.

Primary Source

JAMA Network Open

Source Reference: Wang GHM, et al "Injurious fall risk differences among older adults with first-line depression treatments" JAMA Netw Open 2024; DOI: 10.1001/jamanetworkopen.2024.35535.

Dual-task improvement of older adults after treadmill walking combined with blood flow restriction of low occlusion pressure: the effect on the heart–brain axis

 Ask your competent? doctor if this is useful post stroke.

Dual-task improvement of older adults after treadmill walking combined with blood flow restriction of low occlusion pressure: the effect on the heart–brain axis

• Yi-Ching Chen,
• I-Ping Lo,
• Yi-Ying Tsai,
• Chen-Guang Zhao &
• Ing-Shiou Hwang 

Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 116 (2024) Cite this article

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Abstract

Objective

This study explored the impact of one session of low-pressure leg blood flow restriction (BFR) during treadmill walking on dual-task performance in older adults using the neurovisceral integration model framework.

Methods

Twenty-seven older adults participated in 20-min treadmill sessions, either with BFR (100 mmHg cuff pressure on both thighs) or without it (NBFR). Dual-task performance, measured through light-pod tapping while standing on foam, and heart rate variability during treadmill walking were compared.

Results

Following BFR treadmill walking, the reaction time (p = 0.002) and sway area (p = 0.012) of the posture dual-task were significantly reduced. Participants exhibited a lower mean heart rate (p < 0.001) and higher heart rate variability (p = 0.038) during BFR treadmill walking. Notably, BFR also led to band-specific reductions in regional brain activities (theta, alpha, and beta bands, p < 0.05). The topology of the EEG network in the theta and alpha bands became more star-like in the post-test after BFR treadmill walking (p < 0.005).

Conclusion

BFR treadmill walking improves dual-task performance in older adults via vagally-mediated network integration with superior neural economy. This approach has the potential to prevent age-related falls by promoting cognitive reserves.

Introduction

Adults aged 65 and above are subject to fall accidents. In addition to a reduction in muscle strength, fall accidents is related to cognitive decline due to loss of frontal integrity with aging [4]. The 'frontal aging hypothesis' predicts age-related impairments in attentional resource allocation and information processing speed [50], which impact executive functions for multitasking [29]. Due to frontal degeneration, it becomes challenging for older adults to flexibly shift attention between two concurrent tasks [34]. The loss of cognitive resilience partly contributes to age-related falls, particularly when they occur during dual-task scenarios [2, 49].

Blood flow restriction (BFR) is a training method originally used to stimulate muscular development under local hypoxia. It involves applying pneumatic tourniquets to impede venous outflow in the working musculature. The strength gain associated with combined BFR and low-load exercise results from the activation of protein synthesis signaling for enhanced mechanical tension and metabolic stress [38]. Despite its minimal exercise intensity, walking with BFR can augment muscle strength in the elderly [1]. BFR can also affect metabolic cost and cardiovascular responses [31]. It can induce vasoconstriction in the restricted muscles while causing vasodilation in non-restricted areas due to parasympathetic system activation and endothelial nitric oxide (NO) release [21]. The overall impact of BFR on cardiovascular responses is interactively influenced by factors such as occlusion pressure, exercise protocol (resistance vs. aerobic), and application mode (continuous vs. intermittent) [6].

To date, only a few studies have focused on the improvement of frontal executive function by the application of BFR. One study observed that patients with dementia who underwent 6 months of bilateral upper limb compression followed by reperfusion showed improvements in tests of attention and executive function [22]. In healthy older adults, an 8-week dual-task walking program with BFR (occlusion pressure up to 200 mmHg, 20 min/session, 3 sessions/week) resulted in greater improvements in Mini-Mental State Examination scores and increased levels of brain-derived neurotrophic factor (BNDF), compared to those of a control group that did not receive such training [25]. Interestingly, Sugimoto et al. [48] even demonstrated an immediate effect of 15-min BFR treadmill walking (occlusion pressure: 200 mmHg) on the color-word Stroop task, independent of the effect of BFR alone or walking alone. However, it remains uncertain whether a single bout of combined BFR with relatively low occlusion pressure and aerobic exercise can enhance the posture dual-task of older adults with superior neural efficiency. Answering this question is of clinical significance. Lower occlusion pressure (40% systolic artery pressure) has been shown to increase muscle strength without causing elevated blood pressure. Therefore, combining BFR of lower occlusion pressure with aerobic exercise may contribute to fall prevention in older adults by jointly addressing both age-related declines in cognitive function and muscle strength while minimizing the cardiac cost and sympathetic activity.

Supporting the neural connections between the prefrontal cortex, the central autonomic network, and the vagus nerve system [26], higher cardiac vagal activity is linked to superior executive functioning [45]. Within the context of the heart–brain axis, it is possible that dual-task performance can be improved through BFR-related regulation of the autonomic nervous system, which contributes to enhanced executive function and cognitive flexibility. The aim of this study was to compare the acute effects of treadmill walking with and without BFR of low occlusion pressure on posture dual-task performance in older adults, with a special focus on variations in heart rate and EEG characteristics. For older adults, we hypothesized the following: (1) treadmill walking with leg BFR of low occlusion pressure would lead to better performance on a posture dual-task compared to treadmill walking without leg BFR; and (2) the BFR-related organization of the HR kinetics, power spectra of local EEG, inter-regional EEG connectivity, and network topology in various sub-bands would differ from those observed during non-BFR treadmill walking. Scalp EEG of the theta (4–7 Hz), alpha (8–12 Hz), and beta (13–35 Hz) bands were targeted, as they link characteristically to cognitive workload during a posture dual-task in older adults [36].

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Clinical indications and protocol considerations for selecting initial body weight support levels in gait rehabilitation: a systematic review

 

For me body weight supported treadmill training was worthless. I needed the weight of my body to counteract the spasticity of my legs. And since spasticity never goes away, even now as I'm chronic this would do no good. Overground training is much better in my opinion since it normally gives you perturbations you need to deal with, giving you better balance and preventing falls. 

And of course my doctor and therapists DID NOTHING to cure my leg spasticity.

Clinical indications and protocol considerations for selecting initial body weight support levels in gait rehabilitation: a systematic review

• Sanne Ettema,
• Geertje H. Pennink,
• Tom J.W. Buurke,
• Sina David,
• Coen A.M. van Bennekom &
• Han Houdijk 

Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 97 (2024) Cite this article

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Abstract

Background

Body weight support (BWS) training devices are frequently used to improve gait in individuals with neurological impairments, but guidance in selecting an appropriate level of BWS is limited. Here, we aim to describe the initial BWS levels used during gait training, the rationale for this selection and the clinical goals aligned with BWS training for different diagnoses.

Method

A systematic literature search was conducted in PubMed, Embase and Web of Science, including terms related to the population (individuals with neurological disorders), intervention (BWS training) and outcome (gait). Information on patient characteristics, type of BWS device, BWS level and training goals was extracted from the included articles.

Results

Thirty-three articles were included, which described outcomes using frame-based (stationary or mobile) and unidirectional ceiling-mounted devices on four diagnoses (multiple sclerosis (MS), spinal cord injury (SCI), stroke, traumatic brain injury (TBI)). The BWS levels were highest for individuals with MS (median: 75%, IQR: 6%), followed by SCI (median: 40%, IQR: 35%), stroke (median: 30%, IQR: 4.75%) and TBI (median: 15%, IQR: 0%). The included studies reported eleven different training goals. Reported BWS levels ranged between 30 and 75% for most of the training goals, without a clear relationship between BWS level, diagnosis, training goal and rationale for BWS selection. Training goals were achieved in all included studies.

Conclusion

Initial BWS levels differ considerably between studies included in this review. The underlying rationale for these differences was not clearly motivated in the included studies. Variation in study designs and populations does not allow to draw a conclusion on the effectiveness of BWS levels. Hence, it remains difficult to formulate guidelines on optimal BWS settings for different diagnoses, BWS devices and training goals. Further efforts are required to establish clinical guidelines and to experimentally investigate which initial BWS levels are optimal for specific diagnoses and training goals.

Background

Over the last decades, gait rehabilitation technology has seized a firm spot in the rehabilitation of individuals with neurological gait disorders, such as stroke, spinal cord injury, cerebral palsy and multiple sclerosis [1, 2]. Rehabilitation technology is widely used to assess gait quality and behavior [3], and to improve gait function through the use of supportive training devices [1]. Many of these training devices have found their way into clinical practice and have been implemented within rehabilitation centers. Amongst these rapid innovative developments, there has been great interest in body weight support (BWS) devices. These devices have emerged as an appealing option to clinicians as they stimulate early gait training and reduce the physical burden on a therapist [4].

The use of BWS devices has shown promise in improving walking ability and avoiding the development of malfunctional compensatory movement patterns in various patient groups [4,5,6]. Generally, BWS is provided by an overhead suspension mechanism and a harness that apply vertical forces on a person’s pelvis or trunk causing partial weight reduction [7]. Initially, BWS training was mainly offered to individuals with a spinal cord injury, as its working mechanism was primarily associated with neuroplasticity [8, 9] and functional re-organization of neuronal networks [10]. Then, BWS devices were also used for other diagnoses, as they reduce the load on the lower limbs [11], improve vertical alignment and trunk stability [12], enhance gait initiation [13] and improve physical fitness [14]. It is also thought that BWS reduces the fear of falling through prevention mechanisms that ensure a safe walking environment [4].

Recently, BWS devices have developed from stationary, treadmill-coupled devices to more elaborate mobile and ceiling-mounted systems with multiple degrees of freedom that can be used during overground walking [15]. The current developments in BWS devices accompany the trend towards promoting active participation in training and providing assist-as-needed based on patient-specific requirements [16]. Roughly, four main categories of BWS devices can be distinguished: frame-based constructions (either stationary or mobile) and ceiling mounted devices (either unidirectional or multidirectional). Well-known examples of frame-based constructions are the Woodway Loko system (stationary, Woodway USA Inc., USA) and the LiteGait (mobile, Mobility Research, USA), whereas examples of ceiling-mounted devices are the ZeroG (unidirectional, Aretech, USA) and the RYSEN (multidirectional, Motek Medical, The Netherlands).

Although all different types of BWS devices are frequently used in rehabilitation programs, guidance in selecting an appropriate support level is limited. In literature, providing BWS up to 30% is generally recommended as this is shown to allow walking with close to normal kinematics [17, 18]. However, gait rehabilitation depends on more factors than solely normal gait kinematics and therapists may consider different reasons to select BWS levels, such as patient-specific characteristics or training goals. Guidelines on clinically relevant and feasible BWS selection are currently lacking and therapists often subjectively determine BWS levels based on visual inspection and patient’s feedback.

This systematic review aims to describe the initial BWS levels used during gait training, the rationale for this selection, the clinical goals that are aligned with the use of BWS and whether these differ between diagnoses. Moreover, the study aims to describe whether pursued training goals are more likely to be achieved at particular BWS levels and within a particular diagnosis. Insights from this study can serve as a first step towards developing clinical guidelines.

The Effect of Fall Biomechanics on Risk for Hip Fracture in Older Adults: A Cohort Study of Video-Captured Falls in Long-Term Care

What are the EXACT FALL PREVENTION AND PERTURBATION PROTOCOLS from your doctor and therapists? Don't have any? You don't have a functioning stroke doctor or hospital!

The Effect of Fall Biomechanics on Risk for Hip Fracture in Older Adults: A Cohort Study of Video-Captured Falls in Long-Term Care

Yijian Yang, Vicki Komisar, Nataliya Shishov, Bryan Lo, Alexandra MB Korall, Fabio Feldman, Stephen N Robinovitch

First published: 13 May 2020

https://doi.org/10.1002/jbmr.4048

Citations: 41

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ABSTRACT

Over 95% of hip fractures in older adults are caused by falls, yet only 1% to 2% of falls result in hip fracture. Our current understanding of the types of falls that lead to hip fracture is based on reports by the faller or witness. We analyzed videos of real-life falls in long-term care to provide objective evidence on the factors that separate falls that result in hip fracture from falls that do not. Between 2007 and 2018, we video-captured 2377 falls by 646 residents in two long-term care facilities. Hip fracture was documented in 30 falls. We analyzed each video with a structured questionnaire, and used generalized estimating equations (GEEs) to determine relative risk ratios (RRs) for hip fracture associated with various fall characteristics. All hip fractures involved falls from standing height, and pelvis impact with the ground. After excluding falls from lower than standing height, risk for hip fracture was higher for sideways landing configurations (RR = 5.50; 95% CI, 2.36–12.78) than forward or backward, and for falls causing hip impact (3.38; 95% CI, 1.49–7.67). However, hip fracture risk was just as high in falls initially directed sideways as forward (1.14; 95% CI, 0.49–2.67), due to the tendency for rotation during descent. Falling while using a mobility aid was associated with lower fracture risk (0.30; 95% CI, 0.09–1.00). Seventy percent of hip fractures involved impact to the posterolateral aspect of the pelvis. Hip protectors were worn in 73% of falls, and hip fracture risk was lower in falls where hip protectors were worn (0.45; 95% CI, 0.21–0.99). Age and sex were not associated with fracture risk. There was no evidence of spontaneous fractures. In this first study of video-captured falls causing hip fracture, we show that the biomechanics of falls involving hip fracture were different than nonfracture falls for fall height, fall direction, impact locations, and use of hip protectors. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Introduction

Falls cause 95% of hip fractures in older adults.1, 2 Nearly 25% of hip fracture patients will die within 1 year of the fracture, and 50% will have major declines in independence.3, 4 The rates of falls and hip fractures are especially high among older adults in long-term care (LTC). Only 6% of older adults in Canada live in LTC, but this population experiences 30% of hip fractures.5, 6 Strategies that are effective in preventing falls in community-dwelling seniors (eg, exercise) have been unsuccessful in LTC, due to the high prevalence of physical and cognitive impairment in residents.7 This highlights the importance of complementary strategies in LTC for preventing hip fracture in the event of a fall, through approaches such as vitamin D and calcium supplementation, pharmacologic therapy, and the use of wearable hip protectors,5, 8 which may be especially beneficial for individuals with low body mass index (BMI) who have higher risk for fracture.9-11 Improved understanding of the factors that separate injurious and noninjurious falls may lead to refinements to existing strategies, and new approaches to prevention.

Previous case-control studies in older adults have found that risk for hip fracture in a fall depends at least as much on the biomechanics of the fall, as it does on bone density.12, 39 In particular, although a one standard deviation (1SD) decline in bone density increased fracture risk twofold to threefold,12 falling sideways increased fracture risk sixfold,13 and landing on the hip increased fracture risk 30-fold.14 Furthermore, hip fractures were less common when the person landed on their hand, or grabbed or hit an object to break the fall.39 However, a major limitation of these studies is their reliance on interviews or questionnaires completed by the faller and witnesses (if any) to determine a narrow range of fall characteristics (fall direction, fall height, and contact sites). Recalling the circumstances of falls is challenging, especially for older adults with cognitive impairment.15, 16 Also, fallers who sustained a fracture may bias their response based on the notion that they must have landed on the hip for fracture to occur.11 To date, objective evidence on the circumstances of falls causing hip fracture has not been available to overcome these limitations.

In this study, we address this knowledge gap by analyzing videos of real-life falls experienced by older adults living in LTC, and comparing the characteristics of falls that did result in hip fracture versus those that did not result in hip fracture. We hypothesized that fracture risk would associate with fall characteristics that have previously been shown to be important, as reviewed above (fall height, fall direction, contact sites, use of hip protectors, and BMI). We considered initial fall direction and landing configuration separately, based on our previous observation that falls in LTC often involve rotation during descent.17 In addition to hip and hand impact, we examined knee impact (which may decrease impact severity to the hip), use of mobility aids, and attempts to recover balance by stepping, which we previously found to decrease hip impact velocity.18 We also tested whether fracture risk, as hypothesized by Cummings and Nevitt,19 associated with activity at the time of the fall (eg, walking versus standing), and with cause of imbalance.

 

More at link.

Fracture Risk Increases After Stroke or Transient Ischemic Attack and Is Associated With Reduced Quality of Life

What is your doctors EXACT FALL PREVENTION PROTOCOL? If it's not 100% recovery, you don't have a functioning stroke doctor!

Fracture Risk Increases After Stroke or Transient Ischemic Attack and Is Associated With Reduced Quality of Life

Lachlan L. Dalli,

Karen Borschmann,

Shae Cooke,

Monique F. Kilkenny,

Nadine E. Andrew,

David Scott,

Peter R. Ebeling,

Natasha A. Lannin,

Rohan Grimley,

Vijaya Sundararajan,

… See all authors

Originally published15 Aug 2023https://doi.org/10.1161/STROKEAHA.123.043094Stroke. 2023;54:2593–2601

Abstract

BACKGROUND:

Fractures are a serious consequence following stroke, but it is unclear how these events influence health-related quality of life (HRQoL). We aimed to compare annualized rates of fractures before and after stroke or transient ischemic attack (TIA), identify associated factors, and examine the relationship with HRQoL after stroke/TIA.

METHODS:

Retrospective cohort study using data from the Australian Stroke Clinical Registry (2009–2013) linked with hospital administrative and mortality data. Rates of fractures were assessed in the 1-year period before and after stroke/TIA. Negative binomial regression, with censoring at death, was used to identify factors associated with fractures after stroke/TIA. Respondents provided HRQoL data once between 90 and 180 days after stroke/TIA using the EuroQoL 5-dimensional 3-level instrument. Adjusted logistic regression was used to assess differences in HRQoL at 90 to 180 days by previous fracture.

RESULTS:

Among 13 594 adult survivors of stroke/TIA (49.7% aged ≥75 years, 45.5% female, 47.9% unable to walk on admission), 618 fractures occurred in the year before stroke/TIA (45 fractures per 1000 person-years) compared with 888 fractures in the year after stroke/TIA (74 fractures per 1000 person-years). This represented a relative increase of 63% (95% CI, 47%–80%). Factors associated with poststroke fractures included being female (incidence rate ratio [IRR], 1.34 [95% CI, 1.05–1.72]), increased age (per 10-year increase, IRR, 1.35 [95% CI, 1.21–1.50]), history of prior fracture(s; IRR, 2.56 [95% CI, 1.77–3.70]), and higher Charlson Comorbidity Scores (per 1-point increase, IRR, 1.18 [95% CI, 1.10–1.27]). Receipt of stroke unit care was associated with fewer poststroke fractures (IRR, 0.67 [95% CI, 0.49–0.93]). HRQoL at 90 to 180 days was worse among patients with prior fracture across the domains of mobility, self-care, usual activities, and pain/discomfort.

CONCLUSIONS:

Fracture risk increases substantially after stroke/TIA, and a history of these events is associated with poorer HRQoL at 90 to 180 days after stroke/TIA.

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Fallers after stroke: a retrospective study to investigate the combination of postural sway measures and clinical information in faller’s identification

 If your therapists aren't constantly perturbing your walking to increase your ability to prevent falls, you don't have the best therapists.

Fallers after stroke: a retrospective study to investigate the combination of postural sway measures and clinical information in faller’s identification

Johanna Jonsdottir^1*, Fabiola Giovanna Mestanza Mattos², Alessandro Torchio¹, Chiara Corrini¹ and Davide Cattaneo^1,2

• ¹IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
• ²Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy

Background: Falls can have devastating effects on quality of life. No clear relationships have been identified between clinical and stabilometric postural measures and falling in persons after stroke.

Objective: This cross-sectional study investigates the value of including stabilometric measures of sway with clinical measures of balance in models for identification of faller chronic stroke survivors, and the relations between variables.

Methods: Clinical and stabilometric data were collected from a convenience sample of 49 persons with stroke in hospital care. They were categorized as fallers (N = 21) or non-fallers (N = 28) based on the occurrence of falls in the previous 6 months. Logistic regression (model 1) was performed with clinical measures, including the Berg Balance scale (BBS), Barthel Index (BI), and Dynamic Gait Index (DGI). A second model (model 2) was run with stabilometric measures, including mediolateral (SwayML) and anterior–posterior sway (SwayAP), velocity of antero-posterior (VelAP) and medio-lateral sway (VelML), and absolute position of center of pressure (CopX abs). A third stepwise regression model was run including all variables, resulting in a model with SwayML, BBS, and BI (model 3). Finally, correlations between independent variables were analyzed.

Results: The area under the curve (AUC) for model 1 was 0.68 (95%CI: 0.53–0.83, sensitivity = 95%, specificity = 39%) with prediction accuracy of 63.3%. Model 2 resulted in an AUC of 0.68 (95%CI: 0.53–0.84, sensitivity = 76%, specificity = 57%) with prediction accuracy of 65.3%. The AUC of stepwise model 3 was 0.74 (95%CI: 0.60–0.88, sensitivity = 57%, specificity = 81%) with prediction accuracy of 67.4%. Finally, statistically significant correlations were found between clinical variables (p < 0.05), only velocity parameters were correlated with balance performance (p < 0.05).

Conclusion: A model combining BBS, BI, and SwayML was best at identifying faller status in persons in the chronic phase post stroke. When balance performance is poor, a high SwayML may be part of a strategy protecting from falls.

Introduction

People with hemiparesis following stroke have various neuromotor and sensory disorders that can lead to balance problems and falls during activities of daily living. Their risk of falling is up to triple that of an age-matched population, making fall prevention an important healthcare goal (1–4). Accurate identification of the pathological and functional factors contributing to balance disorders in persons with stroke is of utmost importance in providing adequate appropriate treatment and reducing the risk of falls (5). Postural control and balance have been extensively studied with clinical measures concerning risk of falling (3, 6–10). Simpson and colleagues followed a study population for 1 year after a stroke and found that balance was the only common independent predictor of falls in persons with stroke (11). The difference in fall rates could be explained by the difference in balance scores on clinical scales. Similarly, Mackintosh and colleagues reported reduced mobility and balance in recurrent faller’s post-stroke (9), while on the contrary Hyndman and colleagues found no differences between fallers and non-fallers using clinical scales (10).

Overall, clinical measures focusing on balance performance have proven to be only moderately good at identifying fallers or those at risk of falling. However, since balance with its underlying body functions is a complex construct it is possible that adding information from objective balance control measures might give a more complete picture of balance. This would improve our understanding of factors most likely to impact on fall risk in persons post stroke (12). Stabilometric platform measures give information on weight bearing symmetry, amount of sway, and velocity of sway during quiet standing and may give added insight into the specific underlying abnormalities in postural control and the consequential imbalance leading to falls. There are some indications that stabilometric measures related to mediolateral sway and velocity of sway, are associated with falls in healthy elderly persons, with several studies reporting an association of falls with increased mediolateral sway and increased velocity of antero-posterior sway with eyes open and closed in that population (13–18). Differences have been found in weight bearing symmetry and postural sway parameters between healthy subjects and persons with stroke, with the latter having larger and faster sway, especially in the frontal plane (10, 19–21). However, studies on the relationship of these postural impairments to the occurrence of falls in persons with stroke have reported rather ambivalent results (22). Sackley et al. found a significant relationship between increased body sway and the number of falls in persons with stroke, with however, only a small amount of the variation in the number of falls explained by body sway (23). In a study by Jørgensen instead, larger body sway did not result being a significant risk factor for falls (1). Similarly, in a recent study, Bower and colleagues found that quiet standing body sway parameters did not predict falls in the subacute phase after stroke (24). On the other hand, Lee and Jung reported postural sway at 3 months post-stroke as contributing to increased risk of falls at around 1-year post-stroke (25). As is evident, no clear relationships have been identified between postural sway impairments and falling in persons in the chronic phase after stroke and, to our knowledge, no studies have put together clinical and stabilometric measures in faller prediction models for that population (25, 26). Given the importance of improving detection of fallers and identification of potential fall risk markers, the primary aim of this study was to investigate the relative accuracy of commonly used clinical measures in stroke for identifying faller status, and the added value of quantitative measures of postural sway in quiet standing. For that purpose, we included measures of balance and mobility performance, as well as, as well as quantitative measures of postural sway in predictive models. Further, associations between clinical and stabilometric variables were explored.

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