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In-Hospital Predictors of Falls in Community-Dwelling Individuals After Stroke in the First 6 Months After a Baseline Evaluation: A Prospective Cohort Study

      Abstract

      Alemdaroğlu E, Uçan H, Topçuoğlu AM, Sivas F. In-hospital predictors of falls in community-dwelling individuals after stroke in the first 6 months after a baseline evaluation: a prospective cohort study.

      Objective

      To determine predictors of falls in stroke patients in the first 6 months after a baseline evaluation before their discharge from inpatient rehabilitation.

      Design

      Prospective cohort study.

      Setting

      Rehabilitation hospital, then home.

      Participants

      Consecutive stroke patients (N=66) were followed at home after discharge from the rehabilitation hospital.

      Interventions

      Not applicable.

      Main Outcome Measures

      Fall occurrence within 6 months after a baseline evaluation. All patients were assessed for baseline data during their inpatient rehabilitation (1.5±1.2wk before discharge). Data regarding cerebrovascular accident (CVA) date, number of attacks, and brain imaging results were obtained; motor function and balance impairment were examined by the Fugl-Meyer Assessment Scale. The FIM and Functional Ambulation Category were also used. Presence of urinary incontinence, drug use, fall history, postural hypotension, neglect, cognitive status, poor vision, and hearing were evaluated. Six months after the baseline evaluation, any fall occurrence was ascertained via telephone calls to the caregivers of each patient. Multivariate logistic regression analysis was used to identify risk factors.

      Results

      The mean age ± SD was 64±10 years. The median time elapsed since CVA at the time of admission was 4 months. Twenty-four (36%) patients fell within the 6-month period. The fall rate was significantly higher in patients with left (47%) versus right (21%) hemispheric stroke. Left hemispheric lesion (vs right) showed a 4 times greater risk of fall within 6 months (odds ratio=4.093; 95% confidence interval, 1.082–15.482). There were no other significant differences between fallers and nonfallers with respect to the other evaluated factors.

      Conclusions

      Our results suggest that the fall risk within 6 months after a baseline evaluation is greater in patients with left hemispheric lesions versus those with right hemispheric lesions.

      Key Words

      List of Abbreviations:

      ADLs (activities of daily living), BBS (Berg Balance Scale), CT (computerized tomography), CVA (cerebrovascular accident), FAC (Functional Ambulation Category), FMAS (Fugl-Meyer Assessment Scale), LH (left hemisphere), MMSE (Mini-Mental State Examination), MRI (magnetic resonance imaging), RH (right hemisphere)
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      70%
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      showed that most falls occurred in the first 6 months postdischarge from inpatient stroke rehabilitation. The necessity of assessing fall predictors before discharge to identify at-risk patients and prevent possible complications has also been indicated.
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      Fear of falling among stroke survivors after discharge from inpatient rehabilitation.
      Watanabe
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      found no relationship between the inpatient factors and falls, while Mackintosh et al
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      • Culham E.G.
      Balance score and a history of falls in hospital predict recurrent falls in the 6 months following stroke rehabilitation.
      found that a history of inpatient falls combined with a poor balance score predicted recurrent falls within 6 months after discharge. Forster and Young
      • Forster A.
      • Young J.
      Incidence and consequences of falls due to stroke: a systematic inquiry.
      investigated the in-hospital fall predictors at home after discharge and indicated in-hospital falls as the single predictor of recurrent falls. Only 1 of these studies included first-time fallers,
      • Watanabe Y.
      Fear of falling among stroke survivors after discharge from inpatient rehabilitation.
      though even 1 fall can result in life-threatening complications. While Mackintosh
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      • Hill K.D.
      • Dodd K.J.
      • Goldie P.A.
      • Culham E.G.
      Balance score and a history of falls in hospital predict recurrent falls in the 6 months following stroke rehabilitation.
      excluded patients with higher cognitive dysfunction, Forster and Young
      • Forster A.
      • Young J.
      Incidence and consequences of falls due to stroke: a systematic inquiry.
      included only patients with high disability and subjects over 60 years old. Hence, a need remains for an investigation that assesses in-hospital fall predictors after inpatient stroke rehabilitation without selection based on disability or cognitive function levels or ignoring 1-time fallers.
      We applied a series of assessments to stroke patients during their in-hospital rehabilitation in an effort to identify any factor that could be related to falls during the following 6 months. The factors assessed included physical and cognitive impairments because of stroke. We also aimed to identify basic differences between fallers and nonfallers.

      Methods

      This prospective cohort study was performed with the approval of the institutional review board.

      Participants

      Consecutive individuals after stroke who fulfilled the World Health Organization definition
      • Hatano S.
      Experience from a multicentre stroke register: a preliminary report.
      of stroke and had computerized tomography (CT) or magnetic resonance imaging (MRI) confirmation of stroke were recruited if they were hospitalized for rehabilitation, regardless of the length of stay or time to discharge. Exclusion criteria were the presence of coexisting neurologic disease, amputation or other orthopedic problems that would increase fall risk, and those unable to complete the 6-month follow-up. Patients with previous stroke were not excluded.
      All patients received an individualized conventional rehabilitation program 5 days per week for 3 to 6 weeks including range of motion exercises, progressive resistive exercise, neurodevelopmental treatment (Bobath method), ambulation training, and orthotic and walking aid training, if applicable. All the patients were discharged home. Informed consent was obtained from each patient.

      Baseline Measurements

      All patients who met the study criteria were assessed by 2 physiatrists at a mean ± SD of 1.5±1.2 weeks before discharge (Fugl-Meyer Assessment Scale [FMAS], FIM, Mini-Mental State Examination [MMSE], and neglect tests were performed and recorded by A.M.T, and the rest of the records were completed by E.A.). The examination lasted approximately 1 hour.
      Cerebrovascular accident (CVA) date, number of attacks, brain imaging results, brain lesion side, and previous fall histories were recorded. The presence of urinary incontinence, use of sedative, antidepressant, diuretic, antiarrhythmic, or other medications at the time of the evaluation, and walking aid necessity during the rehabilitation program were recorded. Symptoms of postural hypotension were questioned.
      • Figueroa J.J.
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      • Low P.A.
      Preventing and treating orthostatic hypotension: as easy as A, B, C.
      Visual and hearing impairment(s) were tested by showing 10-mm block letters at a reading distance and by talking in a normal voice from a distance of 1m.
      • Nyberg L.
      • Gustafson Y.
      Fall prediction index for patients in stroke rehabilitation.
      As previously recommended for stroke patients,
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      • Pollock A.
      • Dutton G.N.
      • et al.
      Visual neglect following stroke: current concepts and future focus.
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      • Tenovuo O.
      • Brunila T.
      • Voeten M.J.
      • Hämäläinen H.
      Clinical assessment of hemispatial neglect: evaluation of different measures and dimensions.
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      • Vilkki J.
      How to detect visual neglect in acute stroke.
      visuospatial neglect was assessed with a test battery of star cancellation,
      • Halligan P.
      • Wilson B.
      • Cockburn J.
      A short screening test for visual neglect in stroke patients.
      line bisection,
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      Spatial neglect in acute stroke: the line bisection test.
      and line-crossing tests
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      A simple test of visual neglect.
      and was assessed as positive when the star cancellation test, previously shown to have the best sensitivity and accuracy,
      • Halligan P.W.
      • Marshall J.C.
      • Wade D.T.
      Visuospatial neglect: underlying factors and test sensitivity.
      and at least 1 of the other 2 tests was positive.
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      • Zinnuroğlu M.
      • Beyazova M.
      A new approach for neglect in stroke patients: electrical stimulation with mesh-glove.
      Motor functions and balance impairment were evaluated using the FMAS, a standardized, valid,
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      and reliable method
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      Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident.
      for measuring motor function and balance. The maximum motor score is 66 for the upper extremity and 34 for the lower extremity. The postural stability score of FMAS was used as a measure of balance.
      • Nyberg L.
      • Gustafson Y.
      Fall prediction index for patients in stroke rehabilitation.
      The FIM, a validated,
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      The functional independence measure: a new tool for rehabilitation.
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      Interrater reliability of the 7-level functional independence measure (FIM).
      • Dodds T.A.
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      A validation of the functional independence measurement and its performance among rehabilitation inpatients.
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      The Functional Independence Measure: a comparative validity and reliability study.
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      Reliability of an interview approach to the Functional Independence Measure.
      reliable functional assessment tool, was used for evaluating activities of daily living (ADLs). The FIM consists of 2 subscales: the motor subscale includes ratings on 8 self-care activities, 3 mobility skills, and 2 sphincter control items; the cognitive subscale includes 2 language and 3 psychosocial ratings. Scores range from 1 (totally dependent) to 7 (totally independent) for each item.
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      The Functional Ambulation Category (FAC), which gives information about locomotion status and need of support both inside and outside, was used to determine the patient's ambulation level.
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      The cognitive status of the patients was tested with the MMSE,
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      “Mini-mental state” A practical method for grading the cognitive state of patients for the clinician.
      • Schultz-Larsen K.
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      Mini-Mental Status Examination: mixed Rasch model item analysis derived two different cognitive dimensions of the MMSE.
      which was recommended by the American Heart Association for screening cognitive function in stroke patients.
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      • Robertson J.T.
      • Broderick J.P.
      • et al.
      The American Heart Association Stroke Outcome Classification: executive summary.

      Outcome Measures

      The primary outcome measure was fall occurrence within 6 months after the baseline examination. Our fall record forms define a fall as a sudden, unexpected, accidental event in which the patient descends from a standing, sitting, or horizontal position, including slipping from a chair to the floor, resulting in contact with the ground, regardless of whether or not the patient was alone. Each caregiver was interviewed once at the end of the sixth month after the baseline evaluation. The participants' responses were based on fall record forms. Any fall occurrence within 6 months, fall date, a brief description of the event, any injury or any need for hospital admission, any walking aid use at the time of the event, and the number of falls were obtained via telephone calls to caregivers. Individuals who fell at least once after stroke were defined as fallers and those who did not fall were defined as nonfallers.

      Statistics

      Descriptive statistics were used to calculate the mean, SD, and median values. The chi-square test was used for comparison of the dichotomous variables between fallers and nonfallers, including the presence of balance/cognitive/visual/hearing impairment, urinary incontinence, sedative/diuretic/antidepressant use, previous fall history, visuospatial neglect, postural hypotension, walking aids use, and lesion side. The independent sample t test was used for comparison of age (normally distributed according to Kolmogorov-Smirnov test) and the Mann-Whitney U test was used for comparison of nonnormally distributed data (FMAS, FIM, MMSE, and FAC scores and time since CVA) between fallers and nonfallers. Multivariate logistic regression analysis was performed to determine the effect of possible risk factors on fall occurrence when they were present together. Thus, on the basis of univariate analysis, any variable significantly related with fall occurrence and those with a result of P<.25 were drawn into the analysis.
      • Hosmer D.W.
      • Lemeshow S.
      Model building strategies and methods for logistic regression.
      Age was included in the model as a biological factor that could contribute to fall risk.
      • Miller K.E.
      • Zylstra R.G.
      • Standridge J.B.
      The geriatric patient: a systematic approach to maintaining health.
      • Wilson E.B.
      Preventing patient falls.
      The SPSS version 11.5a for Windows was used for statistical analysis, and values of P<.05 were considered significant.

      Results

      Participant Characteristics

      Seventy-three consecutive patients hospitalized for stroke were approached for the study. Thirty-four women (52%) and 32 men (48%) were included. Two patients were excluded during the hospitalization phase due to aphasia (n=1) and speech impediment (n=1) to prevent inadequate evaluation of cognitive function or motor and balance status. One patient was excluded due to the lack of a consistently available family member or caregiver. Four patients were excluded during follow-up due to death (n=2), diagnosis of Parkinson's disease (n=1), and being lost to follow-up (n=1).
      The mean age ± SD was 64±10 years. The median time elapsed since CVA was 4 months at the time of baseline measurements. Nineteen patients had previous stroke. Forty-two percent (n=28) of patients had right hemisphere (RH) lesion and 52% (n=34) had left hemisphere (LH) lesion, while 6% (n=4) had bilateral hemisphere lesions. The mean FIM score ± SD of the patients was 81±24, and the mean MMSE score ± SD was 17±6. Seventy-four percent of the patients had ischemic brain lesions, while 26% had hemorrhagic brain lesions.

      Fall Events

      Twenty four (36%) of the patients had fallen within the 6-month period; 14 (21%) fell once and 10 (15%) fell more than once. The distribution of recurrent falls (number of falls [number of patients]) was as follows: 2 falls [n=4]; 3 falls [n=3]; 4 falls [n=1]; 5 falls [n=1]; and 10 falls [n=1]. Patients fell while walking inside [n=8], walking outside [n=4], standing up [n=4], bathing [n=1], transferring to bed [n=1], walking and transferring [n=1], walking and standing up [n=3], walking and climbing stairs [n=1], and trying to sit [n=1]. Three of the 24 patients who fell were injured (12% of the fallers; 2 with humerus fracture, 1 with soft tissue injury).

      Predictors of Fall

      Hemispheric lesion side (P=.036) and variables with a result of P<.25 on univariate analysis (table 1) (existence of hearing impairment [P=.189], visuospatial neglect [P=.08], and sex [P=.177]) were drawn into the logistic regression analysis. Age was also included in the model. Multivariate logistic regression analysis revealed that having an LH lesion versus an RH lesion was an independent risk factor (4-fold) for falls within 6 months (table 2).
      Table 1Comparison of Characteristics of Fallers and Nonfallers, Results of the Univariate Analysis
      CharacteristicsFallers (n=24)Nonfallers (n=42)Odds Ratio (95% Confidence Interval)P
      Age, mean ± SD (y)65±1062±101.022 (0.973–1.074).387
      Sex (male/female), n (%)9 (37)/15 (62)24 (57)/18 (42)2.018 (0.723–5.627).177
      Disease duration, median (mo)3.54.51.002 (0.986–1.018).819
      Right hemispheric lesion, n (%)6 (25)22 (52)1 (NA)NA
      Left hemispheric lesion, n (%)16 (67)18 (43)3.259 (1.057–10.051).036
      P<.05.
      Ischemic lesion, n (%)19 (79)29 (70)0.636 (0.193–2.097).455
      Hemorrhagic lesion, n (%)5 (20)12 (29)
      FMAS motor score upper extremity, median18280.996 (0.972–1.020).727
      FMAS motor score lower extremity, median23240.972 (0.910–1.038).396
      FIM motor score, median53530.995 (0.970–1.021).692
      FIM cognitive score, median28310.986 (0.929–1.046).646
      FIM total, median81800.996 (0.975–1.017).735
      FMAS postural stability score ± SD6±37±30.953 (0.815–1.114).545
      Balance impairment, n (%)16 (66)30 (71)0.800 (0.271–2.358).686
      Cognitive impairment, n (%)19 (79)31 (73)1.348 (0.406–4.484).625
      Urinary incontinence, n (%)5 (20)10 (23)0.842 (0.250–2.836).781
      Sedative use, n (%)4 (16)4 (9.5)1.900 (0.429–8.413).448
      Diuretic use, n (%)13 (54)19 (45)1.431 (0.523–3.916).485
      Antidepressant use, n (%)6 (25)10 (23)1.067 (0.333–3.421).914
      Previous history of fall, n (%)11 (45)20 (47)0.931 (0.340–2.545).889
      Postural hypotension, n (%)6 (25)8 (19)1.417 (0.425–4.717).569
      Visuospatial neglect, n (%)1 (4)9 (21)0.159 (0.019–1.346).080
      Visual impairment, n (%)12 (50)17 (40)1.471 (0.536–4.037).453
      Hearing impairment, n (%)6 (25)5 (11)2.467 (0.663–9.176).189
      Abbreviation: NA, not applicable.
      low asterisk P<.05.
      Table 2Results of Multiple Logistic Regression Analysis
      PredictorsOdds Ratio95% Confidence IntervalWald StatisticP
      Age1.0370.978–1.0991.501.221
      Sex (female vs male)1.9770.603–6.4851.266.261
      Hearing impairment2.5280.507–12.5981.280.258
      Visuospatial neglect0.3270.033–3.2290.916.339
      Hemispheric lesion (left vs right)4.0931.082–15.4824.311.038
      Significant P value.
      Constant0.015NA4.337.037
      Significant P value.
      Abbreviation: NA, not applicable.
      low asterisk Significant P value.
      As the lesion side was the single predictor of falls, we provided a comparison of the patients according to lesion side for FMAS, FIM, and MMSE scores (table 3). FIM-cognitive (P=.002) and MMSE (P=.011) scores were significantly lower in patients with LH stroke.
      Table 3Comparisons of FMAS, FIM, and MMSE Scores Due to the Lesion Side
      Assessment TestsRH Lesion (n=28)LH Lesion (n=34)P
      P<.05.
      FMAS upper extremity29.4±21.927.4±20.40.656
      FMAS lower extremity23.9±822.2±7.40.301
      FMAS postural stability score6.9±3.37.3±3.10.738
      FIM motor55.3±20.449.6±25.50.949
      FIM cognitive31.1±6.624.2±8.80.002
      P<.05.
      MMSE20.1±6.015.1±7.00.011
      P<.05.
      NOTE. Values are mean ± SD or as otherwise indicated.
      low asterisk P<.05.

      Comparison of Fallers and Nonfallers

      Sixty-six individuals with stroke were separated into 2 groups according to the occurrence (n=24, 36%) or not (n=42, 64%) of falls within 6 months from the evaluation date. Age and sex were not statistically different between groups. Time elapsed since CVA, number of attacks, and the ratio of CVA type (hemorrhagic, ischemic) were not statistically different between fallers and nonfallers.
      Among the stroke-related factors evaluated at baseline, FMAS-motor score, FMAS-postural stability score, FAC, FIM-motor score, FIM-cognitive score, and presence of visuospatial neglect were not significantly different between fallers and nonfallers (P>.05). No differences were determined between fallers and nonfallers regarding the presence of urinary incontinence, drug use, previous fall history, postural hypotension, or visual and hearing impairment (see table 1).
      The involved brain side was significantly different between fallers and nonfallers. Forty-seven percent (n=16) of the individuals with LH stroke (n=34) and 21% (n=6) of the individuals with RH stroke (n=28) had fallen within the 6 months since evaluation, and the difference was statistically significant (χ2 test; P<.05; odds ratio=3.259; 95% confidence interval, 1.057–10.051). Two of the 4 patients with bilateral lesions fell. Topographic lesion localizations of fallers and nonfallers are described in table 4.
      Table 4Descriptions of Lesion Localization in Faller and Nonfaller Groups
      Lesion LocalizationFallers (n=22)Nonfallers (n=40)Fallers (n=2)Nonfallers (n=2)
      Lesion SideRight (n=6)Left (n=16)Right (n=22)Left (n=18)Bilateral (n=2)Bilateral (n=2)
      Frontal lobe0 (0)1 (6.3)0 (0)1 (5.6)0 (0)0 (0)
      Frontal-temporal-parietal lobes0 (0)7 (43.8)4 (18.2)1 (5.6)0 (0)1 (50.00)
      Frontal-temporal lobes1 (16.7)0 (0)0 (0)0 (0)0 (0)0 (0)
      Frontal-parietal lobes0 (0)0 (0)1 (4.5)0 (0)0 (0)0 (0)
      Temporal-parietal lobes1 (16.7)1 (6.3)2 (9.1)3 (16.7)0 (0)0 (0)
      Parietal lobe2 (33.3)0 (0)2 (9.1)1 (5.6)0 (0)0 (0)
      Subcortical area0 (0)1 (6.3)0 (0)0 (0)0 (0)0 (0)
      Mixed cortical-subcortical area1 (16.7)0 (0)3 (13.6)1 (5.6)1 (50.00)1 (50.00)
      Lenticulocapsular area-basal ganglia0 (0)5 (31.3)5 (22.7)8 (44.4)0 (0)0 (0)
      Thalamus0 (0)1 (6.3)4 (18.7)2 (11.1)0 (0)0 (0)
      Cerebellum1 (16.7)0 (0)0 (0)0 (0)1 (50.00)0 (0)
      Pons0 (0)0 (0)0 (0)1 (5.6)0 (0)0 (0)
      Occipito-temporal lobes0 (0)0 (0)1 (4.5)0 (0)0 (0)0 (0)
      NOTE. Values are n (%).
      We compared the patients with left frontal-temporal-parietal lesion and those with right frontal-temporal-parietal lesion to understand why most of the patients with left-sided lesions fell (7 of 8 patients), while none of those with right-sided lesions (n=4) fell (P<.05). FIM-motor score, FMAS-motor score, and Brunnstrom level of upper and lower extremity had a trend of being slightly higher in patients with LH compared with RH stroke (P>.05). FIM-cognitive scores of patients with LH stroke were significantly lower compared to those with RH stroke (P<.05) (table 5).
      Table 5Comparison of Patients With Frontal-Parietal-Temporal Unilateral Stroke
      Assessment TestsPatients With Right Frontal-Parietal-Temporal Lesion (n=4)Patients With Left Frontal-Parietal-Temporal Lesion (n=8)
      Brunnstrom level of upper extremity/lower extremity/hand1/3/12/4/1
      FMAS motor/postural stability score29/4.535.5/6.5
      FIM motor/cognitive/total score36.5/35/71.545/19.5
      P<.05.
      /63.5
      MMSE16.513
      low asterisk P<.05.

      Discussion

      This is the first study, to our knowledge, in the literature that describes LH lesion as being more closely related with falls than RH lesions in stroke patients. Several previous studies have found no difference in fall rates according to lesion side.
      • Andersson A.G.
      • Kamwendo K.
      • Seiger A.
      • Appelros P.
      How to identify potential fallers in a stroke unit: validity indexes of 4 test methods.
      • Wagner L.M.
      • Philips V.L.
      • Hunsaker A.E.
      • Forducey P.G.
      Falls among community-residing stroke survivors following inpatient rehabilitation: a descriptive analysis of longitudinal data.
      Two studies found RH stroke to be more frequent than LH stroke in fallers
      • Uğur C.
      • Gücüyener D.
      • Uzuner N.
      • Özkan S.
      • Özdemir G.
      Characteristics of falling in patients with stroke.
      • Pinto E.B.
      • Marinho C.
      • Nascimento C.
      • Myllane-Fernandes P.
      • Oliveria-Filho J.
      Right cerebral hemisphere lesion is an independent predictor of falls in stroke patients.
      ; however, both of these lack cognitive assessment that would affect the accuracy of fall history. In one of them, Uğur et al
      • Uğur C.
      • Gücüyener D.
      • Uzuner N.
      • Özkan S.
      • Özdemir G.
      Characteristics of falling in patients with stroke.
      investigated the history of falls and mood status using a standard questionnaire; risk factors for stroke, type of stroke, and CT and MRI findings of 293 stroke patients were obtained from the hospital records. Even though their sample size was greater than in our study, individual physical examination of patients and logistic regression analysis of their data were lacking. The other study, which comprised 116 consecutive patients, showed that RH lesion was a predictor of fall history in stroke patients who were able to walk independently.
      • Pinto E.B.
      • Marinho C.
      • Nascimento C.
      • Myllane-Fernandes P.
      • Oliveria-Filho J.
      Right cerebral hemisphere lesion is an independent predictor of falls in stroke patients.
      In that study, most of the stroke patients who were dependent or bedridden, but still at a risk for falls, were excluded. The current study is superior to these 2 studies, due to its prospective design, consecutive patient recruitment, and patient assessment for cognitive, functional, motor, and balance status. The method of recording falls in the current study is more reliable because of the standardization of data collection. One prospective observational study that recruited 101 home-dwelling stroke patients found that RH stroke was one of the predictors of only repeat falls.
      • Wada N.
      • Sohmiya M.
      • Shimizu T.
      • Okamoto K.
      • Shirakura K.
      Clinical analysis of risk factors for falls in home-living stroke patients using functional evaluation tools.
      That study is similar to ours in design, except that it exclusively comprised outpatients. The hemiparesis side was not different when they compared fallers with nonfallers.
      Each affected side of the brain has its own characteristics. There are some differences in perceptual and learning abilities between patients with RH versus LH stroke. Patients with RH stroke tend to be impulsive, unorganized, lack insight into problems, have impaired judgment, and do not learn from mistakes and instructions, properties which may preclude them from becoming independent in ADLs because they generally cannot be trusted alone.
      • Garrison S.J.
      • Rolak L.A.
      Rehabilitation of stroke patient.
      However, patients with RH involvement fell less in our sample. The need for continuous supervision of individuals after RH stroke and their inability to be independent may be protective factors against falls.
      On the other hand, patients with LH lesions have communication problems and intact visuomotor perception and memory. They learn by demonstration and from mistakes, and are able to synthesize parts of a task.
      • Garrison S.J.
      • Rolak L.A.
      Rehabilitation of stroke patient.
      They can become more independent physically and require less supervision. This may explain why individuals after LH stroke had a greater number of falls in our study. After unilateral left-sided CVA, in addition to the neurologic deficits observed on the contralateral side of the body (right hemiplegia), impairment of motor coordination in the ipsilateral upper limb (left hand)
      • Debaere F.
      • Van Assche D.
      • Kiekens C.
      • Verschueren S.M.
      • Swinnen S.P.
      Coordination of upper and lower limb segments: deficits on the ipsilesional side after unilateral stroke.
      • Schaefer S.Y.
      • Haaland K.Y.
      • Sainburg R.L.
      Ipsilesional motor deficits following stroke reflect hemispheric specializations for movement control.
      and decreased use of trunk displacement in a pointing movement involving trunk displacement
      • Esparza D.Y.
      • Archambault P.S.
      • Winstein C.J.
      • Levin M.F.
      Hemispheric specialization in the co-ordination of arm and trunk movements during pointing in patients with unilateral brain damage.
      have been reported in experimental studies. Multijoint coordination deficits in individuals after LH stroke may be a clue for increased fall probability.
      Bilateral involvement was determined to be significantly related with falls in a study among 124 home-dwelling women with stroke.
      • Lamb S.E.
      • Ferrucci L.
      • Volapto S.
      • Fried L.P.
      • Guralnik J.M.
      Risk factors for falling in home-dwelling older women with stroke: the Women's Health and Aging Study.
      However, in that 12-month follow-up study, nearly 40% of the patients were unable to recall the side of the attack and no image results were used. Because only a very small portion of our sample had bilateral involvement, the effect of bilateral involvement could not be appropriately evaluated.
      Even though extension of the lesion was not a fall predictor in our study, patients with extended involvement (frontal-temporal-parietal region) of the LH (mean motor/cognitive FIM scores: 45/19.5) fell more (7/8 patients), while none of the patients with extended involvement of RH (mean motor/cognitive FIM scores: 36.5/35) had falls (0/4 patients). This fact may be explained by the higher motor and lower cognitive functions of patients with extended LH involvement than in their RH counterparts (see table 5).
      Loss of balance may result in a fall. Each hemisphere contributes to maintaining balance. Vestibular cortical function,
      • Dieterich M.
      • Bense S.
      • Lutz S.
      • et al.
      Dominance for vestibular cortical function in the non-dominant hemisphere.
      perception of body verticality,
      • Pérennou D.A.
      • Mazibrada G.
      • Chauvineau V.
      • et al.
      Lateropulsion, pushing and verticality perception in hemisphere stroke: a causal relationship?.
      postural control,
      • Spinazzola L.
      • Cubelli R.
      • Della Sala S.
      Impairments of trunk movements following left or right hemisphere lesions: dissociation between apraxic errors and postural instability.
      and spatial awareness
      • Malhotra P.
      • Coulthard E.
      • Husain M.
      Hemispatial neglect, balance and eye-movement control.
      have been reported to be achieved by the RH, while the LH has been shown to have an important role in axial movement planning.
      • Spinazzola L.
      • Cubelli R.
      • Della Sala S.
      Impairments of trunk movements following left or right hemisphere lesions: dissociation between apraxic errors and postural instability.
      Listing phenomenon, which can be observed in any stroke patient, lateropulsion, seen in brainstem lesions, and pusher syndrome, seen in lesions of both the right and left posterolateral thalamus, are the other situations found to be associated with balance impairment.
      • Karnath H.O.
      Pusher syndrome–a frequent but little-known disturbance of body orientation perception.
      Even though the RH plays a dominant role in maintaining balance and RH involvement has been reported to be related to balance impairment in stroke studies,
      • Pérennou D.
      • Bénaïm C.
      • Rouget E.
      • Rousseaux M.
      • Blard J.M.
      • Pélissier J.
      Postural balance following stroke: towards a disadvantage of the right brain-damaged hemisphere.
      • Rode G.
      • Tiliket C.
      • Boisson D.
      Predominance of postural imbalance in left hemiparetic patients.
      the balance score of the RH stroke patients was not different from that of the LH stroke patients in our sample.
      In our study, there were no differences in motor and balance impairment test scores between fallers and nonfallers, similar to 3 previous studies.
      • Ashburn A.
      • Hyndman D.
      • Pickering R.
      • Yardley L.
      • Harris S.
      Predicting people with stroke at risk of falls.
      • Lamb S.E.
      • Ferrucci L.
      • Volapto S.
      • Fried L.P.
      • Guralnik J.M.
      Risk factors for falling in home-dwelling older women with stroke: the Women's Health and Aging Study.
      • Harris J.E.
      • Eng J.J.
      • Marigold D.S.
      • Tokuno C.D.
      • Louis C.L.
      Relationship of balance and mobility to fall incidence in people with chronic stroke.
      However, there are studies in the literature in which the Berg Balance Scale (BBS)
      • Andersson A.G.
      • Kamwendo K.
      • Seiger A.
      • Appelros P.
      How to identify potential fallers in a stroke unit: validity indexes of 4 test methods.
      • Mackintosh S.F.
      • Hill K.D.
      • Dodd K.J.
      • Goldie P.A.
      • Culham E.G.
      Balance score and a history of falls in hospital predict recurrent falls in the 6 months following stroke rehabilitation.
      • Maeda N.
      • Kato J.
      • Shimada T.
      Predicting the probability of fall incidence in stroke patients using Berg Balance Scale.
      was found to be important for falls in individuals after stroke. We used the postural stability score of the FMAS, which was previously used by Nyberg and Gustafson,
      • Nyberg L.
      • Gustafson Y.
      Fall prediction index for patients in stroke rehabilitation.
      for balance assessment. The FMAS has been reported as a valid tool in stroke.
      • Harvey R.L.
      • Roth E.J.
      • Heinemann A.W.
      • Lovell L.L.
      • McGuire J.R.
      • Diaz S.
      Stroke rehabilitation: clinical predictors of resource utilization.
      The BBS is reported to have adequate to excellent correlation with the FMAS balance subscale
      • Blum L.
      • Korner-Bitensky N.
      Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review.
      ; however, the weakness of the balance section has also been reported.
      • Malouin F.
      • Pichard L.
      • Bonneau C.
      • Durand A.
      • Corriveau D.
      Evaluating motor recovery early after stroke: comparison of the Fugl-Meyer Assessment and the Motor Assessment Scale.
      The postural stability score was unable to predict fallers and nonfallers in our sample. In our experience, most of the patients were unable to succeed in the item related to parachute reaction and thus were unable to achieve the maximum score. The best score obtained by patients was 10, while 9 was accepted as impaired balance. The most appropriate balance test for fall prediction in stroke needs to be investigated further.
      In a study including hospital fall records, fall events usually occurred in bed.
      • Tutuarima J.A.
      • van der Meulen J.H.
      • de Haan R.J.
      • van Straten A.
      • Limburg M.
      Risk factors for falls of hospitalized stroke patients.
      In another study, transfers and position changing were the most common event.
      • Nyberg L.
      • Gustafson Y.
      Patient falls in stroke rehabilitation A challenge to rehabilitation strategies.
      In a community setting, walking and transfers were the most frequent event reported at the time of fall.
      • Forster A.
      • Young J.
      Incidence and consequences of falls due to stroke: a systematic inquiry.
      Most of the falls in our study occurred while walking at home. These rates are probably due to more active mobilization of patients at home and the inclusion in our sample of individuals with stroke at later periods of the disease (postrehabilitation).

      Study Limitations

      Our study has several limitations. We were unable to evaluate the home living conditions of the patients, and therefore some environmental risk factors for falls may have been missed. Our data do not include periodic visits, and therefore the deterioration or improvement of the patient over the 6 months may also be a potential variable. Because the time interval from the baseline evaluation to the telephone interview was 6 months, there might have been some underreported falls. The structures in the brain that control human upright body orientation are in close proximity to those areas that induce aphasia in the LH
      • Karnath H.O.
      Pusher syndrome–a frequent but little-known disturbance of body orientation perception.
      ; thus, including that aphasic patient would have strengthened our results. The sample size was also small.
      Determining the relationship of falls with brain lesion localization by measuring lesion volumes quantitatively is a topic for future studies. Furthermore, interventions to reduce fall risk in stroke patients represent another topic worthy of future studies.

      Conclusions

      In our small sample, fall risk was greater in patients with LH lesions compared with those with RH lesions within the first 6 months after the baseline evaluation. Particularly patients with extensive brain lesion of the LH should be considered at risk for fall, because they are still active, but cognitively impaired.
      • a
        SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606-6307.

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