Assessments and Risk Factors for Falls in Persons with Acute Stroke

Sammanfattning: Background: Early identification of risk factors is crucial for reducing the high fall risk associated with stroke, and sex differences in relation to falls need to be further investigated. There is a lack of uniform, standardized, and reliable testing procedures for postural reactions, and existing tests assessing negotiating obstacles while walking cannot be performed when walking aids are used.Aim: To investigate the predictive validity of fall risk in persons with acute stroke for easily administered data and assessments, as well as to investigate the psychometric properties of two new tests.Methods: The Postural Rections Test (PRT) and the Cone Evasion Walk Test (CEW) were developed based on literature, and on input from an expert panel. To estimate the reliability of the PRT and CEW, video-recordings of 20 persons with acute stroke performing each item in the PRT and CEW were assessed by 10 physiotherapists on two occasions, at least two weeks apart. The construct validity of the CEW (n = 221), was examined in relation to selected corresponding tests, and predictive validity by correlating the CEW to falls within six months. In 124 women and 160 men the results from the PRT and CEW, along with other easily administered data and assessments on participant characteristics, functions, and activities were analyzed in relation to the number of days to the first fall by Cox regression, while fall incidence was analyzed by negative binomial regression, both for the total cohort, and for women and men separately. Sex differences in monthly fall incidence were analyzed with Poisson regression.Results: For the intra-rater reliability of the PRT, the overall proportion of agreement was 87 − 92% for the different postural reactions, and in median 9–10 out of 10 physiotherapists scored the same value for inter-rater reliability. In the CEW the intra-class correlation coefficients for intra-rater and inter-rater reliability were 0.88–0.98. The results showed expected poor to moderate correlations to the selected tests for construct validity, and to falls within six months. Participants touched significantly more cones on the side that was opposite to the side of their lesion. The Cox regression analysis showed that intake of more than eight medications, paresis in the arms, paresis in the legs, impaired protective reactions in sitting, and limitations in self-care activities were decisive risk factors for the time to the first fall, and according to the negative binomial regression, limitations in mobility activities was a decisive risk factor for high fall incidence in the total cohort (p<0.0005). The assessor’s judgment of a person’s six-month fall risk, was particularly well suited for identification of individuals with a high risk for multiple falls; however only in women when analyzed for each sex separately (p<0.0005). Compared to men, a higher number of fall risk factors were identified in women, including impaired mental functions, paresis in the arms, and limitations in several activities of self-care and mobility (p<0.0005). In men, the most decisive fall risk factors were intake of a high number of medications, intake of antidepressants, and mobility limitations (p=0.001). Fall incidence during the first month from discharge was significantly higher in men compared to women.Conclusions: The PRT and CEW can be reliably used in persons with acute stroke, and are valid for assessment of fall risk. A high quantity and wide range of rapid and easily collected data can be used for identification of persons at high risk for falls. The risk factors differed in part when analyzing the time to the first fall, and six-month fall incidence, and different fall risk factors were the most decisive when analyzed separately in women and men. Monthly fall incidence was higher in men during the first month.