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NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery
NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery

5. Falls Prevention and Management

Recommendations and/or Clinical Considerations
  1. All individuals with stroke should be screened for fall risk, including fall history at admission, at all transition points, after a fall, and whenever there is a change in health status, using validated tools [Strong recommendation; High quality of evidence]. 
    1. Screening should include identification of medical, physical, cognitive, medication related, and environmental factors associated with risk of falling, fear of falling, and fall injuries [Strong Recommendation; Moderate quality of evidence]. 
  2. Individuals identified as being at risk for falls should undergo a comprehensive interdisciplinary assessment using validated tools [Strong Recommendation; Moderate quality of evidence].
    1. Comprehensive falls assessment should include medical and functional history, evaluation of mobility, vision, perception, cognition, cardiovascular status, medications, and environment [Strong Recommendation; Moderate quality of evidence]. 
  3. Based on assessment findings, an individualized falls prevention plan and fall prevention strategies should be implemented [Strong Recommendation; Moderate quality of evidence]. Refer to appropriate topics within this module for strategies to mitigate falls risk, (e.g. leg weakness, impaired balance, visual disturbances, cognitive impairment, sensory loss).
    1. The individual with stroke, family, and caregiver should be made aware of the individual’s increased risk for falls and provided education on precautions and strategies to reduce their risk of falling [Strong Recommendation; Moderate quality of evidence].  
    2. The individual with stroke, their family and caregivers should receive skills training to enable them to safely transfer and mobilize, including what to do if a fall occurs and how to get up from a fall [Strong Recommendation; Low quality of evidence].
    3. For individuals with stroke who are at risk of falling, an individualized exercise program should be provided including balance training and advice on safety [Strong Recommendation; Moderate quality of evidence].
    4. The individual with stroke their family, and caregivers should receive education regarding recommended and appropriate mobility aids, footwear, and transfer devices, with consideration of the healthcare, home and community environments [Strong Recommendation; Low quality of evidence].
  4. Where applicable, bed and chair alarms should be provided for individuals with stroke at high risk for falls in accordance with local organizational fall prevention protocols [Strong Recommendation; Low quality of evidence]. 
  5. If an individual with stroke experiences a fall, they should be assessed for possible injury and the circumstances surrounding the fall to identify precipitating factors. Pre-existing falls prevention plans should be reviewed and modified to reduce the risk of further falls [Strong Recommendation; Low quality of evidence].
Rationale +-

Individuals with stroke are at higher risk for falls than many other hospitalized individuals. The reported incidence ranges from 14 to 65 percent. 152 Falls occur often within the first week following stroke during the acute phase, and then again as an individual with stroke’s mobility increases. The interdisciplinary care team must be cognizant of the risk for falls and ensure appropriate assessments and interventions take place.

Falls are a significant concern for individuals with stroke, occurring frequently due to impaired balance, mobility, and strength. The risk of falling is heightened by factors such as spasticity, sensory deficits, and cognitive impairments, which can lead to a lack of awareness of one's surroundings and poor coordination. These falls can result in serious injuries, such as fractures or head trauma, further complicating recovery and rehabilitation efforts. The fear of falling can be overwhelming, impact mental health, deter individuals from engaging in physical activities, and may cause an individual to retreat to ‘safe’ environments, leading to decreased mobility and social isolation. Individuals with stroke and their families spoke to the challenges of navigating new environments, which can be more require greater amount of concentration to prevent falls, and of asking for and accepting assistance for activities they were previously able to do safely independently. They encouraged speaking to others about a fear of falling and seeking mental health support where available.

Individuals with stroke emphasized the importance of individualized early and ongoing education and strategies for the individual with stroke, family and caregivers about fall prevention and management that is unique to the individual’s abilities and situation. They valued information about how stroke impairments can impact falls risk, and environmental strategies for reducing falls risk, such as decluttering the home environment and home safety alarm devices. They also stressed the importance of learning how to strengthen their balance and attention to safety, and how to reduce injury and get up from a fall.  

In addition, individuals with stroke expressed the importance of neck/wrist fall alarms/emergency button systems, especially for individuals experiencing aphasia and/or apraxia and the importance of being provided information about availability and usability.   Balance is a concerning issue discussed by individuals with stroke and should be evaluated even if the individual is not presenting with any obvious balance difficulties, as there may be ‘invisible’ impairments that increase risk of falls (e.g., vision or cognitive changes). 

Performance Measures +-

System Indicators

  1. Fall incidence rate for individuals with stroke admitted to hospital (acute care or rehabilitation).
  2. Proportion of stroke programs with a defined falls prevention program in place.
  3. Availability of education and training for all staff on falls prevention and management. 
  4. Proportion of individuals with stroke who experience a fall during inpatient rehabilitation or in the community.

Process Indicators:

  1. Proportion of individuals with stroke admitted to inpatient rehabilitation assessed for falls risk with standardized tool within 2 days of hospital admission (aligns to Accreditation Canada).

Patient-Oriented Indicators:

  1. Proportion of individuals with stroke with falls who experience injuries during a fall incident.
  2. Proportion of individuals with stroke with falls who experience a prolonged length of stay as a result of the fall.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 5

The risk of falling is increased following stroke due to leg weakness, impaired balance, visual disturbances, functional dependence, cognitive impairment and sensory loss. The reported frequency of falls is difficult to estimate, and will vary across the time since stroke, the severity of stroke and associated comorbidities.  Czernuszenko & Czlonkowska 153 reported that during stroke rehabilitation, there were 252 falls that occurred in 189 (16.3%) patients. The incidence rate for any fall was 7.6 per 1,000 patient-days (95% CI 6.6–8.5). Almost two-thirds of falls occurred during the first two weeks after admission. Patients fell most often during transfers (34%), while sitting (21%) and during position changes such as going from a sitting to standing (13%). Most falls did not result in injury (72%), while minor injuries occurred in 27% of cases, with 1.2% resulting in serious injury (fracture). In a systematic review that included 21 studies examining risk factors for falling post stroke, Xu et al. 154 reported the strongest predictors of falling (odds ratio [OR] >2) were reduced balance (OR=3.87, 95% CI 2.39 to 6.26), use of sedative & psychotropic medications (OR=3.19, 955 CI 1.36 to 7.48) disability in self-care (OR=2.30, 95% CI 1.51 to 3.49), and depression (OR=2.11, 95% CI 1.18 to 3.75). Non-significant factors included age, sex, duration of stroke, visual impairment, multiple strokes, motor impairment, and urinary incontinence.

Patients at highest risk of stroke need to be identified as soon as possible so that appropriate preventative measures can be taken. In a systematic review that sought to identify all fall risk assessment tools, regardless of patient population or setting, 38 tools were identified among 115 publications. 155 Two screening tools were developed for use in the hospital setting for patients following stroke: The Stroke Assessment of Fall Risk (SAFR), and The Royal Melbourne Hospital Falls Risk Assessment Tool (RMH FRAT). Breisinger et al. 156 developed the Stroke Assessment of Fall Risk (SAFR) to identify patients at risk of falling during inpatient rehabilitation. SAFR is composed of 4 impairment items (impulsivity, hemi-neglect, static, and dynamic sitting balance) and 3 functional limitations items (lowest score on three Functional Independence Measure items: transfers, problem solving, and memory), with possible scores ranging from 0 (low risk) to 49 (high risk). The area under the curve of the receiver operator curve was 0.73, which was significantly more accurate compared with a locally developed, 3-item, non-stroke specific tool, which could identify the risk of fallers no better than chance. Nystrom & Hellstrom 157 reported that higher scores on the Prediction of Falls in Rehabilitation Settings Tool (Predict FIRST), assessed during the first and fourth day of admission to an acute stroke unit helped to predict falls that occurred during the next 6 weeks (OR=5.21, 95% CI 1.10 to 24.78, p=0.038). Predict FIRST is composed of 5 fall risk factors, each giving one point: male, central nervous system medications, a fall in the past year, frequent toileting, and inability to do tandem stance. The scale is cumulative (i.e. more risk factors give a higher risk of falling). Patients with a score of zero have a 2% chance of falling, while those with all 5 points have a 52% risk of falling during the inpatient rehabilitation period. Pinto et al. 158 reported that longer time to complete the Timed Up and Go (TUG) test was predictive of falls among persons living in the community following a median of 13 months post stroke (OR=1.035, 95% CI 1.196 to 5.740, p=0.016). Fallers (n=56) took a median time of 18 seconds to complete the test compared with non-fallers (n=94) at 14 seconds.

There have been very few RCTs conducted evaluating therapies to specifically designed to reduce the occurrence of falls following stroke, and of those, the evidence suggests that such interventions are not effective. Mansfield et al. 159 found that an individualized perturbation balance training (PBT) program delivered for 6 weeks to 83 participants recruited from the community in the chronic stage of stroke did not reduce the rate of falls during 12 months (1.45 falls/ person-year in the PBT group vs. 1.72 falls/person-year in the control group; rate ratio=0.85, 95% CI 0.42 to 1.69), although participants in the PBT group had greater improvement in reactive balance. Dean et al. 160 randomized 151 community- based stroke patients to an intervention group that received exercise and task related training or control group that performed an upper-extremity strength training program and cognitive tasks. At 12-month follow up, although patients in the experimental group showed significantly improvement in gait speed, there was no significant difference between groups in the number of patients who fell. Batchelor et al. 161 randomized 156 patients at high risk of falls into a tailored multifaceted falls prevention group or the control group which consisted of usual care. The falls prevention program consisted of an individualized home-based exercise program, falls risk strategies, education, and injury risk minimization strategies. There was no difference in the frequency of falls between groups. The intervention group had 1.89 falls/person-year, and the control group had 1.76 falls/person-year, incidence rate ratio=1.10, p=0.74). The proportion of fallers did not differ significantly between groups (risk ratio=0.83, 95% CI, 0.6-1.14), nor was the risk of injury (incidence rate ratio=1.57, p=0.25). 

A Cochrane review 162 included 14 RCTs (n=1,358) examining the effectiveness of interventions for preventing falls post stroke. In most trials, an “exercise” intervention was examined. Under this broad umbrella term, interventions included a combination of treadmill +/- overground walking, task-related training with progressive balance and strengthening exercises, community physiotherapy, whole-body vibration, agility training with stretching and weight-shifting exercises, perturbation training and Tai Chi. In some of these trials, falling was a secondary outcome. Other interventions included non-invasive brain stimulation, predischarge home visits, distance glasses, and a servo-assistive rollator. Combined exercise interventions were associated with a significantly reduced risk of falling (relative risk [RR]=0.72, 95% CI 0.54 to 0.94; 765 participants), although the certainty of evidence was low, while exercise was not associated with a significantly reduced risk of falling (RR=1.03, 95% CI 0.90 to 1.19; 10 trials, 969 participants). In a more recent systematic review, Yang et al. 163 reported that overall, falls prevention interventions were not associated with a significant reduction in falls (OR=0.88, 95% CI 0.64 to 1.21, n=15 interventions). In subgroups analysis, no category of intervention was associated with a reduction in falls (walking-based training, physical therapy-based interventions, or exercise-based interventions).

Sex & Gender Considerations

Women are often at a higher risk of falling after a stroke due to factors such as osteoporosis, frailty and an older age at stroke onset, which can contribute to balance issues and reduced motivation to engage in rehabilitation. Women may also be more likely to experience muscle weakness or joint stiffness, especially in the lower extremities, which can impair mobility and increase the risk of falls. Men often have higher risk of physical impairments related to stroke which can also elevate their risk of falling; however, they may be less likely to acknowledge these difficulties or seek out help, due to societal expectations around masculinity and independence, which can result in delayed intervention and increased fall risk. 

Currently, there is a lack of specific research examining sex differences associated with falls prevention interventions following a stroke. While some studies have explored sex differences for broader stroke outcomes, such as long-term mortality and functional recovery, these do not specifically address falls prevention. The Cochrane review that evaluated various interventions aimed at preventing falls following stroke did not include sex in subgroup analysis.162

Stroke Resources
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