After stroke: the Cinderella of falls prevention research

Key message: There is a lack of evidence on interventions which aim to prevent falls in people after they have had a stroke. This is in contrast to good evidence on some effective  preventive measures for older people living in the community.

It’s Age UK’s annual Falls Awareness Week this week, with an emphasis this year on healthy feet. The excellent review from the Cochrane Bone, Joint and Muscle Trauma Group on preventing falls in older people living in the community, which we blogged about when it was updated last autumn, has useful evidence on a range of strategies to prevent falls, including some relating to feet! Using an anti-slip shoe device reduced falls in icy conditions, while adding foot and ankle exercises to regular podiatry for people with disabling foot pain also reduced falls. Another review, also updated last autumn, found less clear evidence on how to prevent falls in older people in care homes and hospitals but did find that vitamin D supplements reduced falls in care homes, probably because the residents had low levels of vitamin D to start with. You can read the story of these reviews, which started as one, in an editorial by author Lesley Gillespie.

This month saw the publication of a new review from the Cochrane Stroke Group on strategies which aim to prevent falls in people who have had a stroke. Falls are a common problem in this population but it is unclear how much research has been done on the effects of interventions to prevent them falling. The reviewers searched for randomized controlled trials (RCTs) of any intervention which aimed to prevent falls in people at any of three stages after having a stroke: the acute stage (in a stroke unit or hospital ward), subacute stage (in a rehabilitation ward or clinic after discharge from an acute ward, or receiving intensive support at home) or chronic stage (after discharge from rehabilitation). Like the reviews looking at falls prevention in a more general population, this review looked at the effect of interventions on the rate of falls (number of falls divided by length of follow-up) and the number of fallers. Ten RCTs with 1004 people were included. One involved people in the acute and subacute stages while the rest involved those in the chronic stage. The interventions looked at were:

  • exercise (7 studies involving different types of exercise including walking, balance and strengthening exercises, stair climbing, upper limb exercises and whole-body vibration)
  • medicine (2 studies, vitamin D compared with placebo and alendronate compared with alphacalcidol)
  • single lens distance vision glasses compared with multifocal glasses (1 study)

What did they find?

  • Exercise did not reduce the rate of falls or the number of fallers either in the chronic stage (combined results of 4 studies with 412 people and 6 studies with 616 people respectively) or the acute/subacute stage
  • Quality of life was measured in different ways in all of the exercise trials and three reported a significant improvement in favour of the intervention group
  • Vitamin D was associated with significantly reduced rate of falls and number of fallers in hospitalised women as was alendronate when compared to alphacalcidol in hospitalised people after stroke
  • No differences were seen between people wearing single lens or multifocal lens glasses after discharge from rehabilitation

How good was the evidence?

Most studies were judged to be at low risk of bias on all items assessed apart from blinding, where they were at high risk of bias. Falls were not defined in three studies and definitions varied in the other studies.

There were very few trials to include with a small number of people, in contrast to the 159 trials and over 79,000 people in the review of falls prevention for older people living in the community. Sample sizes were small and may have lacked power to detect differences. Some of the included trials had missing information.

What does this mean in practice?

Regrettably, the evidence on falls prevention after stroke is insufficient to guide those working in this area. There is much to be done in terms of future research. The reviewers note that even the positive findings for vitamin D and alendronate need to be replicated before this influences clinical practice. Exercise programmes, especially with balance and strength training elements, have been shown to reduce falls in the general population of older people and more research is needed on its potential benefits for people after stroke. Only one study included people in the acute and subacute phase yet around 7% of people fall in the first week after stroke.

Meanwhile, a brand new NICE guideline on Stroke has been published this month, with evidence from five Cochrane reviews and a Falls guideline has also been issued to replace an earlier one, still with five Cochrane reviews included and the addition of new data for falls in hospital patients.

For more information about Falls Awareness Week and a selection of fact sheets about falls, here’s the link to the Age UK website.

Links:

Verheyden GSAF, Weerdesteyn V, Pickering RM, Kunkel D, Lennon S, Geurts ACH, Ashburn A. Interventions for preventing falls in people after stroke. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD008728. DOI: 10.1002/14651858.CD008728.pub2.

Cochrane summary http://summaries.cochrane.org/CD008728/interventions-for-preventing-falls-in-people-after-stroke

Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub3.

Cochrane summary and podcast http://summaries.cochrane.org/CD007146/interventions-for-preventing-falls-in-older-people-living-in-the-community

Evidently Cochrane blog Keeping the over-65s on their feet: new review evidence tells us how. October 15th 2012.

Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD005465. DOI: 10.1002/14651858.CD005465.pub3

Cochrane summary and podcast http://summaries.cochrane.org/CD005465/interventions-for-preventing-falls-in-older-people-in-care-facilities-and-hospitals

Gillespie LD. Preventing falls in older people: the story of a Cochrane Review [editorial]. Cochrane Database of Systematic Reviews 2013 28 Feb;2:ED000053. DOI:10.1002/14651858.ED000053.

National Clinical Guideline Centre; National Institute for Health and Care Excellence (commissioner). Stroke rehabilitation: long term rehabilitation after stroke. London: National Clinical Guideline Centre, Royal College of Physicians; 2013 (NICE CG162). [Issued June 2013]. Available from URL: http://guidance.nice.org.uk/CG162/Guidance/pdf/English

Centre for Clinical Practice, National Institute for Health and Care Excellence. Falls: assessment and prevention of falls in older people. Manchester: Centre for Clinical Practice, National Institute for Health and Care Excellence; 2013 (NICE CG161). [Issued June 2013]. Available from URL: http://guidance.nice.org.uk/CG161/NICEGuidance/pdf/English

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