CURRENT ISSUES
Falls and Use of Assistive Devices in Stroke Patients with Hemiparesis: Association with Balance Ability and Fall Efficacy Oksoo Kim1, PhD, RN & Jung-Hee Kim2, PhD, RN 1 Division of Nursing, College of Health Sciences, Ewha Womans University, Seoul, Korea 2 Department of Nursing, College of Health Sciences, Dankook University, Cheonan, Korea
Keywords
Abstract
Fall; balance; self-help device; stroke. Correspondence Jung-Hee Kim, Assistant Professor, Department of Nursing, College of Health Sciences, Dankook University, 119, Dandae-ro, Cheonan 330-714, Korea. E-mail: [email protected] Accepted March 26, 2014. doi: 10.1002/rnj.173
Purpose: This study investigates balance ability and the fall efficacy with regard to the experiences of stroke patients with hemiparesis. Methods: The experience of falling, the use of assistive devices, and each disease-related characteristic were assessed using face-to-face interviews and a selfreported questionnaire. The Berg Balance Scale and Fall Efficacy Scale were used to measure balance ability and confidence. Results: The fall efficacy was significantly lower in participants who had experienced falls than those who had not. The participants who used assistive devices exhibited low balance ability and fall efficacy compared to those who did not use assistive devices. Conclusions: Stroke patients with fall experience and walking aids might be considered at increased risk of falling. Clinical Relevance: Preventive measures for individuals using walking aids may be beneficial in reducing the fall rate of community-dwelling stroke patients.
Introduction The risk of falling is reported to be higher among individuals who have experienced a stroke than among the general population (Ashburn, Hyndman, Pickering, Yardley, & Harris, 2008; Belgen, Beninato, Sullivan, & Narielwalla, 2006; Kerse et al., 2008; Schmid et al., 2013). Belgen et al. (2006) reported that the overall fall rate among community-dwelling stroke survivors was 40– 73%. Considering that the annual fall rate among community-dwelling people older than 65 years is approximately 30% or higher (Lord, 2007), the fall rate among stroke patients is significantly high. Up to 66% of stroke patients are injured, a frequent consequence of falls for people with chronic stroke (Harris, Eng, Marigold, Tokuno, & Louis, 2005; Schmid et al., 2013). Due to the incidence and prevalence of stroke increasing with age (Ashburn et al., 2008), and more fatal results such as hip fracture and its complications (Harris © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 267–274
et al., 2005; Mackintosh, Hill, Dodd, Goldie, & Culham, 2005), fall injuries remain a serious health problem throughout the poststroke lifespan (Weerdestyn, de Niet, van Duijnhoven & Geurts, 2008). The fall efficacy could be a crucial factor for increased falls in stroke patients (Batchelor, Mackintosh, Said, & Hill, 2012; Ng, 2011; Pang & Eng, 2008) as it might lead to a restriction of activities. Inactivity results in a decline in physical function and balance ability (Harris et al., 2005; Mackintosh et al., 2005). Therefore, fall-related efficacy is considered to be a more powerful predictor of activities of daily living (ADLs) than objective measures of balance are (Chu et al., 2011). In previous research, the level of ADL functioning was the important risk factor that differentiated the fallers from the nonfallers (Hyndman & Ashburn, 2003; Hyndman, Ashburn, & Stack, 2002; Soyer & Ozturk, 2007; Yamashita, Noe, & Bailer, 2012). Several studies identified balance and gait deficits as risk factors for stroke patients
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Falls and Use of Assistive Devices in Stroke Patients
consistently falling (Belgen et al., 2006; Hyndman & Ashburn, 2003; Mackintosh, Hill, Dodd, Goldie, & Culham, 2006; Mansfield, Inness, Lakhani, & McIlroy, 2012; Soyer & Ozturk, 2007). Most stroke patients reported that their falls occurred during ADLs such as walking or dressing (Belgen et al., 2006). Over half of all reported falls occurred toward the paretic side, and up to 55% of stroke patients were injured (Harris et al., 2005; Mackintosh et al., 2005). Soyer and Ozturk (2007) showed that the impairment of balance and walking were important indicators for risk of falling in chronic stroke patients. Stroke patients have been shown to have great anterior–posterior sway, reduced velocity, and reduced stride length when walking (Hsu, Tang, & Jan, 2003; Hyndman, Ashburn, Yardley, & Stack, 2006), and also to walk with inefficient, asymmetrical, or unsafe gait (Verma, Arya, Sharma, & Garg, 2012). The use of walking aids has been suggested to improve the quality, stability, and/or efficiency of walking and also prevent falls in stroke patients (Medley, Thompson, & French, 2006). However, some studies have found that the use of a walking aid is a prospective predictor of increased number of falls in stroke survivors, and their use increased the odds of falling fivefold (Nilsag ard, Lundholm, Denison, & Gunnarsson, 2009). The effect of walking aids on a stroke patient’s risk for falls should be evaluated as these effects are less clear (Weerdestyn et al., 2008). Thus, the association between the use of assistive devices and stroke patient’s falls should be determined to help prevent falls. Many studies have been conducted to identify the pathophysiological mechanisms and predictors of falls among stroke patients. However, few studies have investigated the differences between groups with varied fall experience and use of walking aids. One exception was Byers, Arrington, and Finstuen’s study (1990), which compared fall groups that were distinguished by stroke duration. A better understanding of the associations between experience of falls, fall efficacy, balance ability, and use of an assistive could enhance interventions that aim to prevent falls and enhance the fall efficacy. This would improve the quality of life of stroke survivors. Therefore, the purpose of this study was to investigate the factors associated with the experience of falling in stroke patients with hemiparesis. These factors include the use of walking aids, the magnitude of balance ability, and fall-related self-efficacy.
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Materials and Methods Participants and Sampling The patient sample was drawn from a larger study designed to develop a health education program for Korean stroke patients. Participants who visited a convalescent center for exercise in November and December 2009 were invited to participate in the study. The convalescent center in Korea is the Health and Welfare Service Institute for the Disabled and the Elderly. The facilities they provide include exercise equipment, computers, a library, and a healthcare program for the handicapped. Inclusion criteria for this study were as follows: patients with a confirmed diagnosis of stroke living in a community home setting and with hemiparesis after stroke. Patients with a speech disorder that interfered with the completion of the questionnaire and cognitive dysfunction (MMSE-K scores of ≤19) were excluded. Trained registered nurses conducted all of the face-toface interviews and balance tests. The participants were assured of anonymity and confidentiality. Informed consent was obtained from all participants, and the study was approved by the appropriate institutional ethics committee. The mean (SD) age of participants was 63.09 (9.16) years and ages ranged from 41 to 78 years. The sample contained 24 women and 57 men. The time since diagnoses ranged from 9 to 240 months with a mean (SD) of 95.48 (50.20) months. Forty-eight participants had right hemiparesis, and 33 had left hemiparesis. Measures A fall is defined as “an episode of unintentionally coming to rest on the ground or lower surface that was not the result of dizziness, fainting, sustaining a violent blow, loss of consciousness, or other overwhelming external factor” (Belgen et al., 2006). The participants were asked whether they had experienced a fall during the last 6 months. During fall interviews, the interviewer decided whether a reported fall fit the definition of a fall. The use of walking aids was determined by the following question: “Do you use an assistive device for walking inside or outside, such as a wheelchair, crutches, or a cane?” Participants were asked to respond with “yes” or “no.” Self-reported recovery was assessed by the following question: “How do you rate your recovery from your © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 267–274
O. Kim and J.-H. Kim
stroke?” Participants were asked to respond with “not sufficient,” “moderate,” or “sufficient.” The Fall Efficacy Scale (FES) is a self-report questionnaire that measures the perceived confidence of participants in task performance (Tinetti, Richman, & Powell, 1990). It is a widely used and reliable measure that was validated and adopted for Korea’s elderly population by Jang et al. (Jang, Cho, Ou, Lee, & Baik, 2003). The FES contains 10 items that assess a person’s level of confidence in performing ADLs. Each item is scored on a scale of 0–10, and the total summed scores range from 0 to 100. A high score indicates high confidence in performing ADLs without falling. The Berg Balance Scale (BBS) was used to measure balance ability. This scale is a widely used measure with proven validity and reliability for stroke patients (Berg, Wood Dauphinee, & Williams, 1995; Jung et al., 2006; Wee, Wong, & Palepu, 2003). Scores range from 0 to 64 points, and higher scores indicate better balance ability. The test–retest and intraclass correlation coefficients were 0.98 (Berg et al., 1995) and 0.97 (Jung et al., 2006), respectively, in the present study. Statistics Statistical tests (2-tailed, p < 0.05) were performed using SPSS (Version 17.0; SPSS Inc., Chicago, IL, USA). Selfreported recovery state data were analyzed using chisquare and Fisher’s exact tests to test the association between falls and the use of walking aids, according to sex, age, muscle weakness, period since diagnosis and having an ability to stand on one leg. The item, standing on one leg, which had the good sensitivity and specificity for the fall prediction in the BBS items was selected (Alzayer, Beninato, & Portney, 2009). The score of 0 was regarded as no ability, and between 1 and 4 were considered as fully or partially having the ability to stand on one leg. These tests were also used to test the stroke patients’ fall experiences and their use of walking aids according to health-related characteristics. T-tests were used to test balance ability and fall efficacy according to stroke patients’ fall experiences and their use of walking aids. Results In total, 26 of the 81 participants (32.0%) had at least one confirmed fall during the 6 months before the study. Walking aids were used by 36 (44.4%) participants. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 267–274
Falls and Use of Assistive Devices in Stroke Patients
Among the participants who experienced a fall, 21 (80.8%) had had a stroke more than 3 years prior (Fisher’s exact p = .032), and 18 (69.2%) had insufficient recovery (v2 = 8.703, p = .013). In addition, 21.8% of the participants who perceived their recovery state as sufficient had not experienced a fall during the last 6 months. There was no significant difference in the experience of falls according to the use of assistive devices (v2 = 2.722, p = .099). The level of fall efficacy was low for participants who had experienced a fall (t = 2.614, p = .011). Among those who experienced a fall during the last 6 months, 46.2% of the participants were unable to try or needs assist under the instruction for standing on one leg experienced a fall (v2 = 4.195, p = .041). However no significant difference was found for balance ability score between the fall and nonfall groups (Table 1). Among the participants who used walking aids, 30 (83.3%) were aged 65 years or older; this percentage is significantly higher that the percentage of participants who did not use walking aids (v2 = 5.455, p = .020). Among those who did not use walking aids, 71.1% had right hemiparesis; among the participants who did use walking aids, 44.4% had right hemiparesis (v2 = 5.891, p = .014). Twenty-three (63.9%) of the participants who used walking aids had insufficient recovery (v2 = 9.208, p = .010). Among those who use walking aids, 44.4% of the participants who are unable to try or needs assist under the instruction for standing on one leg (v2 = 5.601, p = 0.018). The level of fall efficacy was low for participants who used walking aids (t = 3.088, p = .003). Participants who used walking aids had reduced balance ability (t = 4.051, p = .000) (Table 2). Discussion This study investigated the factors associated with the experience of falling, the use of walking aids, and the magnitude of balance ability and fall-related self-efficacy in stroke patients with hemiparesis. In this study, 26 of the 81 participants (32.0%) had at least one confirmed fall during the last 6 months. Kerse et al. (2008) reported that 37% of stroke patients experienced at least one fall, and Ashburn et al. (2008) reported that 55% of the participants in their study experienced one or more falls. Compared to these studies, the fall rate in the current study was low. The differences in fall incidence rates between studies could be explained by differences in the characteristics of the stroke groups across
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Falls and Use of Assistive Devices in Stroke Patients
O. Kim and J.-H. Kim
Table 1 Experience of Fall Among Stroke Patients (N = 81) Experience of Fall
Variable Sex Age (years) Muscle weakness Ability to stand on one leg Period since diagnosis (years) Self-reported recovery state
Use of walking aid
Category Male Female
Falls and Use of Assistive Devices in Stroke Patients with Hemiparesis: Association with Balance Ability and Fall Efficacy Oksoo Kim1, PhD, RN & Jung-Hee Kim2, PhD, RN 1 Division of Nursing, College of Health Sciences, Ewha Womans University, Seoul, Korea 2 Department of Nursing, College of Health Sciences, Dankook University, Cheonan, Korea
Keywords
Abstract
Fall; balance; self-help device; stroke. Correspondence Jung-Hee Kim, Assistant Professor, Department of Nursing, College of Health Sciences, Dankook University, 119, Dandae-ro, Cheonan 330-714, Korea. E-mail: [email protected] Accepted March 26, 2014. doi: 10.1002/rnj.173
Purpose: This study investigates balance ability and the fall efficacy with regard to the experiences of stroke patients with hemiparesis. Methods: The experience of falling, the use of assistive devices, and each disease-related characteristic were assessed using face-to-face interviews and a selfreported questionnaire. The Berg Balance Scale and Fall Efficacy Scale were used to measure balance ability and confidence. Results: The fall efficacy was significantly lower in participants who had experienced falls than those who had not. The participants who used assistive devices exhibited low balance ability and fall efficacy compared to those who did not use assistive devices. Conclusions: Stroke patients with fall experience and walking aids might be considered at increased risk of falling. Clinical Relevance: Preventive measures for individuals using walking aids may be beneficial in reducing the fall rate of community-dwelling stroke patients.
Introduction The risk of falling is reported to be higher among individuals who have experienced a stroke than among the general population (Ashburn, Hyndman, Pickering, Yardley, & Harris, 2008; Belgen, Beninato, Sullivan, & Narielwalla, 2006; Kerse et al., 2008; Schmid et al., 2013). Belgen et al. (2006) reported that the overall fall rate among community-dwelling stroke survivors was 40– 73%. Considering that the annual fall rate among community-dwelling people older than 65 years is approximately 30% or higher (Lord, 2007), the fall rate among stroke patients is significantly high. Up to 66% of stroke patients are injured, a frequent consequence of falls for people with chronic stroke (Harris, Eng, Marigold, Tokuno, & Louis, 2005; Schmid et al., 2013). Due to the incidence and prevalence of stroke increasing with age (Ashburn et al., 2008), and more fatal results such as hip fracture and its complications (Harris © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 267–274
et al., 2005; Mackintosh, Hill, Dodd, Goldie, & Culham, 2005), fall injuries remain a serious health problem throughout the poststroke lifespan (Weerdestyn, de Niet, van Duijnhoven & Geurts, 2008). The fall efficacy could be a crucial factor for increased falls in stroke patients (Batchelor, Mackintosh, Said, & Hill, 2012; Ng, 2011; Pang & Eng, 2008) as it might lead to a restriction of activities. Inactivity results in a decline in physical function and balance ability (Harris et al., 2005; Mackintosh et al., 2005). Therefore, fall-related efficacy is considered to be a more powerful predictor of activities of daily living (ADLs) than objective measures of balance are (Chu et al., 2011). In previous research, the level of ADL functioning was the important risk factor that differentiated the fallers from the nonfallers (Hyndman & Ashburn, 2003; Hyndman, Ashburn, & Stack, 2002; Soyer & Ozturk, 2007; Yamashita, Noe, & Bailer, 2012). Several studies identified balance and gait deficits as risk factors for stroke patients
267
Falls and Use of Assistive Devices in Stroke Patients
consistently falling (Belgen et al., 2006; Hyndman & Ashburn, 2003; Mackintosh, Hill, Dodd, Goldie, & Culham, 2006; Mansfield, Inness, Lakhani, & McIlroy, 2012; Soyer & Ozturk, 2007). Most stroke patients reported that their falls occurred during ADLs such as walking or dressing (Belgen et al., 2006). Over half of all reported falls occurred toward the paretic side, and up to 55% of stroke patients were injured (Harris et al., 2005; Mackintosh et al., 2005). Soyer and Ozturk (2007) showed that the impairment of balance and walking were important indicators for risk of falling in chronic stroke patients. Stroke patients have been shown to have great anterior–posterior sway, reduced velocity, and reduced stride length when walking (Hsu, Tang, & Jan, 2003; Hyndman, Ashburn, Yardley, & Stack, 2006), and also to walk with inefficient, asymmetrical, or unsafe gait (Verma, Arya, Sharma, & Garg, 2012). The use of walking aids has been suggested to improve the quality, stability, and/or efficiency of walking and also prevent falls in stroke patients (Medley, Thompson, & French, 2006). However, some studies have found that the use of a walking aid is a prospective predictor of increased number of falls in stroke survivors, and their use increased the odds of falling fivefold (Nilsag ard, Lundholm, Denison, & Gunnarsson, 2009). The effect of walking aids on a stroke patient’s risk for falls should be evaluated as these effects are less clear (Weerdestyn et al., 2008). Thus, the association between the use of assistive devices and stroke patient’s falls should be determined to help prevent falls. Many studies have been conducted to identify the pathophysiological mechanisms and predictors of falls among stroke patients. However, few studies have investigated the differences between groups with varied fall experience and use of walking aids. One exception was Byers, Arrington, and Finstuen’s study (1990), which compared fall groups that were distinguished by stroke duration. A better understanding of the associations between experience of falls, fall efficacy, balance ability, and use of an assistive could enhance interventions that aim to prevent falls and enhance the fall efficacy. This would improve the quality of life of stroke survivors. Therefore, the purpose of this study was to investigate the factors associated with the experience of falling in stroke patients with hemiparesis. These factors include the use of walking aids, the magnitude of balance ability, and fall-related self-efficacy.
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O. Kim and J.-H. Kim
Materials and Methods Participants and Sampling The patient sample was drawn from a larger study designed to develop a health education program for Korean stroke patients. Participants who visited a convalescent center for exercise in November and December 2009 were invited to participate in the study. The convalescent center in Korea is the Health and Welfare Service Institute for the Disabled and the Elderly. The facilities they provide include exercise equipment, computers, a library, and a healthcare program for the handicapped. Inclusion criteria for this study were as follows: patients with a confirmed diagnosis of stroke living in a community home setting and with hemiparesis after stroke. Patients with a speech disorder that interfered with the completion of the questionnaire and cognitive dysfunction (MMSE-K scores of ≤19) were excluded. Trained registered nurses conducted all of the face-toface interviews and balance tests. The participants were assured of anonymity and confidentiality. Informed consent was obtained from all participants, and the study was approved by the appropriate institutional ethics committee. The mean (SD) age of participants was 63.09 (9.16) years and ages ranged from 41 to 78 years. The sample contained 24 women and 57 men. The time since diagnoses ranged from 9 to 240 months with a mean (SD) of 95.48 (50.20) months. Forty-eight participants had right hemiparesis, and 33 had left hemiparesis. Measures A fall is defined as “an episode of unintentionally coming to rest on the ground or lower surface that was not the result of dizziness, fainting, sustaining a violent blow, loss of consciousness, or other overwhelming external factor” (Belgen et al., 2006). The participants were asked whether they had experienced a fall during the last 6 months. During fall interviews, the interviewer decided whether a reported fall fit the definition of a fall. The use of walking aids was determined by the following question: “Do you use an assistive device for walking inside or outside, such as a wheelchair, crutches, or a cane?” Participants were asked to respond with “yes” or “no.” Self-reported recovery was assessed by the following question: “How do you rate your recovery from your © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 267–274
O. Kim and J.-H. Kim
stroke?” Participants were asked to respond with “not sufficient,” “moderate,” or “sufficient.” The Fall Efficacy Scale (FES) is a self-report questionnaire that measures the perceived confidence of participants in task performance (Tinetti, Richman, & Powell, 1990). It is a widely used and reliable measure that was validated and adopted for Korea’s elderly population by Jang et al. (Jang, Cho, Ou, Lee, & Baik, 2003). The FES contains 10 items that assess a person’s level of confidence in performing ADLs. Each item is scored on a scale of 0–10, and the total summed scores range from 0 to 100. A high score indicates high confidence in performing ADLs without falling. The Berg Balance Scale (BBS) was used to measure balance ability. This scale is a widely used measure with proven validity and reliability for stroke patients (Berg, Wood Dauphinee, & Williams, 1995; Jung et al., 2006; Wee, Wong, & Palepu, 2003). Scores range from 0 to 64 points, and higher scores indicate better balance ability. The test–retest and intraclass correlation coefficients were 0.98 (Berg et al., 1995) and 0.97 (Jung et al., 2006), respectively, in the present study. Statistics Statistical tests (2-tailed, p < 0.05) were performed using SPSS (Version 17.0; SPSS Inc., Chicago, IL, USA). Selfreported recovery state data were analyzed using chisquare and Fisher’s exact tests to test the association between falls and the use of walking aids, according to sex, age, muscle weakness, period since diagnosis and having an ability to stand on one leg. The item, standing on one leg, which had the good sensitivity and specificity for the fall prediction in the BBS items was selected (Alzayer, Beninato, & Portney, 2009). The score of 0 was regarded as no ability, and between 1 and 4 were considered as fully or partially having the ability to stand on one leg. These tests were also used to test the stroke patients’ fall experiences and their use of walking aids according to health-related characteristics. T-tests were used to test balance ability and fall efficacy according to stroke patients’ fall experiences and their use of walking aids. Results In total, 26 of the 81 participants (32.0%) had at least one confirmed fall during the 6 months before the study. Walking aids were used by 36 (44.4%) participants. © 2014 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 267–274
Falls and Use of Assistive Devices in Stroke Patients
Among the participants who experienced a fall, 21 (80.8%) had had a stroke more than 3 years prior (Fisher’s exact p = .032), and 18 (69.2%) had insufficient recovery (v2 = 8.703, p = .013). In addition, 21.8% of the participants who perceived their recovery state as sufficient had not experienced a fall during the last 6 months. There was no significant difference in the experience of falls according to the use of assistive devices (v2 = 2.722, p = .099). The level of fall efficacy was low for participants who had experienced a fall (t = 2.614, p = .011). Among those who experienced a fall during the last 6 months, 46.2% of the participants were unable to try or needs assist under the instruction for standing on one leg experienced a fall (v2 = 4.195, p = .041). However no significant difference was found for balance ability score between the fall and nonfall groups (Table 1). Among the participants who used walking aids, 30 (83.3%) were aged 65 years or older; this percentage is significantly higher that the percentage of participants who did not use walking aids (v2 = 5.455, p = .020). Among those who did not use walking aids, 71.1% had right hemiparesis; among the participants who did use walking aids, 44.4% had right hemiparesis (v2 = 5.891, p = .014). Twenty-three (63.9%) of the participants who used walking aids had insufficient recovery (v2 = 9.208, p = .010). Among those who use walking aids, 44.4% of the participants who are unable to try or needs assist under the instruction for standing on one leg (v2 = 5.601, p = 0.018). The level of fall efficacy was low for participants who used walking aids (t = 3.088, p = .003). Participants who used walking aids had reduced balance ability (t = 4.051, p = .000) (Table 2). Discussion This study investigated the factors associated with the experience of falling, the use of walking aids, and the magnitude of balance ability and fall-related self-efficacy in stroke patients with hemiparesis. In this study, 26 of the 81 participants (32.0%) had at least one confirmed fall during the last 6 months. Kerse et al. (2008) reported that 37% of stroke patients experienced at least one fall, and Ashburn et al. (2008) reported that 55% of the participants in their study experienced one or more falls. Compared to these studies, the fall rate in the current study was low. The differences in fall incidence rates between studies could be explained by differences in the characteristics of the stroke groups across
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Falls and Use of Assistive Devices in Stroke Patients
O. Kim and J.-H. Kim
Table 1 Experience of Fall Among Stroke Patients (N = 81) Experience of Fall
Variable Sex Age (years) Muscle weakness Ability to stand on one leg Period since diagnosis (years) Self-reported recovery state
Use of walking aid
Category Male Female
