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(Stroke. 1995;26:838-842.)
© 1995 American Heart Association, Inc.

Articles

Patient Falls in Stroke Rehabilitation

A Challenge to Rehabilitation Strategies

Lars Nyberg, BSc Yngve Gustafson, MD, DMSc

From the Department of Geriatric Medicine, Umeå University (Sweden).

Correspondence to Lars Nyberg, RPT, Department of Geriatric Medicine, Umeå University, S-901 87 Umeå, Sweden.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose The risk of falls is very high among stroke patients, and falling is a major complication in stroke rehabilitation. This study aimed to investigate the incidence, characteristics, and consequences of falls in an inpatient stroke rehabilitation setting.

Methods One hundred sixty-one patients consecutively admitted to a geriatric stroke rehabilitation unit were studied. Falls that occurred during their rehabilitation stay were prospectively registered and analyzed.

Results Sixty-two of the patients (39%) suffered falls. The total number of falls was 153, which corresponds to an incidence rate of 159 falls per 10 000 patient-days. Most falls occurred during transfers or from sitting in a wheelchair or on some other kind of furniture. Seventeen falls (11%) were classified as the result of extrinsic mechanisms, 49 (32%) were intrinsic falls, 39 (25%) occurred in a nonbipedal position (while sitting or lying), and 48 falls (31%) remained unclassified. No injury was observed in 109 of 153 incidents (71%), whereas 6 falls (4%) involved fractures or other serious injury.

Conclusions Since falls are so frequent, they must be considered a significant problem in stroke rehabilitation. Fall prevention strategies should therefore be developed and included in rehabilitation programs.

Key Words: accidental falls • cerebrovascular disorders • complications • hospitalization • rehabilitation

	Introduction

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Patient falls are a major health problem in geriatric care and rehabilitation. In various forms of geriatric care, approximately 80% to 90% of patient injuries are caused by falls.^{1 2 3 4} The risk of falls is especially high among stroke patients,^{5 6 7} and falling is one of the most frequent complications among stroke patients in rehabilitation.⁸ There is also an overrepresentation of patients with previous strokes among hip-fracture patients.⁹

During the last few decades, rehabilitation has become an increasingly significant element in stroke care. This is a favorable development in many respects, but the risk of falls might also increase, at least in the short perspective, as patients' mobility and independence are promoted. Consequently, reducing these risks should be an essential element in rehabilitation strategies, and yet very little attention is paid to this issue in the rehabilitation literature.^{10 11 12}

There appears to be a lack of knowledge about the problem of patient falls in stroke rehabilitation, with few reports in the literature. Individual risk factors associated with falls in stroke patient populations in acute care and rehabilitation settings have been studied to some extent.^{13 14 15} However, from a preventive point of view, there is also a need to study the nature of these falls. Therefore, the aim of this study was to investigate the incidence, characteristics, and consequences of patient falls in a stroke rehabilitation setting.

	Subjects and Methods

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The study was performed at the stroke rehabilitation unit of the geriatric clinic at Umeå University Hospital, Sweden. This unit is a 24-bed ward that specializes in stroke care and rehabilitation; patients are usually admitted from acute-care clinics 2 to 4 weeks after their strokes.

All patients (n=138) admitted for rehabilitation after cerebrovascular accidents or other clinically similar conditions from November 1, 1991, to October 31, 1992, were included in the study. In addition, 23 patients who met the same inclusion criteria and who had been admitted to the unit before the start of the study were also included. Therefore, a total of 161 patients were studied. Table 1 summarizes the basic characteristics of the study population. The diagnoses were based on clinical examination and CT, in accordance with the routines of the stroke unit of Umeå University Hospital. The criteria for stroke diagnoses and concurrent disorders have been published previously.¹⁸ Performance in activities of daily living was assessed according to the Katz Index,¹⁶ and cognitive state was assessed with the Mini-Mental State Examination (MMSE).¹⁷ The median time between the onset of the stroke and the inclusion in the study was 23 days (range, 3 to 265 days).

View this table: [in this window] [in a new window]   Table 1. Basic Description of Study Population Characteristics at Inclusion in Study (n=161)

Patients were observed regarding the accidental falls that occurred during their stay at the rehabilitation unit. Falls were defined as incidents in which the subject unintentionally came to rest on a level below knee height. All falls that came to the knowledge of the nursing staff were reported on special fall report forms, which included patient identification data; the date, time, and location of the fall; the presence of witnesses; a description of the fall; and a description of the injuries or other consequences caused by the incident. For those already admitted at the start of the study, the observation period covered the remainder of their stay at the unit.

Based on the information derived from fall report descriptions and interviews with the patient involved and/or witnesses to the incident, one of the authors (L.N.) subsequently classified the causative mechanisms of the falls by means of the St Louis Older Adult Service and Information System (OASIS).¹⁹ This system classifies falls into four main categories: extrinsic falls (caused by environmental factors), intrinsic falls (caused by impaired balance or other subject-specific factors), nonbipedal falls (from a nonbipedal stance position, ie, falls from beds or chairs), and nonclassifiable (because of unclear or insufficient information). Each main category has its subcategories, which in some cases are broken down into a third level of classification categories, thus allowing a detailed description of the probable cause of the fall and of contributing factors.

Furthermore, it was noted whether protective recommendations and restrictions from the rehabilitation team had been followed at the time of the fall or if they had been neglected by either the staff or the patients themselves.

The results are presented as frequencies and as incidence rates (I) according to the formula I=A/R, where A is the number of incidents and R is the number of patient-days during the observation period. The confidence intervals of the incidence rates were set to the 95% level (CI_0.95) and calculated according to the approximate formula CI_0.95=I±1.96*(I/R)^1/2. For differences in proportions between groups, the ² test and Fisher's exact test were used, with P<.05 indicating statistical significance.

The study was approved by the Ethics Committee of the Medical Faculty of Umeå University, and all subjects or their families gave their informed consent.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
There were 153 falls registered during the period when the patients studied stayed at the rehabilitation unit. The incidence rate was 159 falls per 10 000 patient-days or, in other terms, 579 falls per 100 patient-years. Sixty-two patients of 161 (39%) suffered falls, and 39 (24%) suffered more than one fall. Multiple falls accounted for 130 (85%) of the incidents. A maximum number of 12 falls were registered for one individual patient.

Fig 1 shows the distribution of falls during night and day. Peak frequencies were recorded from 10 AM to 11 AM and from 5 PM to 6 PM. Falls were evenly distributed among the days of the week.

View larger version (40K): [in this window] [in a new window]   Figure 1. Bar graph shows distribution of patient falls during 24 hours (n=151, data missing in 2 cases).

Fig 2 shows the incidence rate of falls in relation to the duration of hospitalization at the rehabilitation unit. Since confidence intervals overlapped, no statistically significant trend was found.

View larger version (12K): [in this window] [in a new window]   Figure 2. Line graph shows incidence rate of patient falls in relation to duration of hospitalization at rehabilitation unit; 95% confidence intervals are indicated. Only falls of the 138 patients studied throughout their stay are included in the graph.

The most frequent location for patient falls was the patient's own room (93 falls), followed by the day room/dining room (23), the bathroom/toilets (17), the corridor (12), and various other locations (8). In a majority of the incidents (93 of 153 [61%]), nobody witnessed the fall.

As Table 2 shows, 57 falls (37%) occurred during transfers or while changing position from standing to sitting or vice versa. In three of these cases a staff member was assisting the patient. Many falls also occurred while patients were in a sitting position, usually in a wheelchair. Few falls occurred during walks or exercise. In a few cases, patients fell while they performed clearly risky activities such as unsupervised balance training at their own initiative, climbing bed rails, or trying to overcome obstacles.

View this table: [in this window] [in a new window]   Table 2. Activities Performed in Connection With Falls

Table 3 shows the classification of falling mechanisms according to two hierarchical levels of the OASIS system. Falls caused by extrinsic mechanisms, particularly those concerning slips and trips, were few. For extrinsic falls, a displaced center of gravity was the most common cause. These incidents were mostly the result of inertial effects such as the forces acting when a door that is pulled suddenly opens or when an unstable object used as support during transfer gives way. Falls caused by intrinsic mechanisms, on the other hand, were frequent. In this category, mechanisms related to impaired balance, especially postural instability, dominated. Other common mechanisms were mobility system failure (eg, legs giving way) and cognitive impairment (perceptual error and sensory distraction or inattention). Nonbipedal falls were also frequent. This type of fall primarily involved accidents in which the patients either slid off their chairs due to poor sitting balance or leaned out too far when reaching for objects. Almost one third of the accidents could not be classified, in almost all cases because they concerned patients with memory or communication disorders and there were no witnesses.

View this table: [in this window] [in a new window]   Table 3. Classification of Patient Falls According to the OASIS System1

In 14 cases (9%) the staff had neglected the instructions concerning physical restraints and bed rails or otherwise failed to take the protective measures that had been recommended. In 89 cases (58%) the patient acted against the instructions given by the rehabilitation team, eg, he or she transferred or walked without the recommended supervision or aids. A significantly larger proportion of the patients involved in such incidents were cognitively impaired (MMSE score <24) compared with other patients who fell (P<.01).

The injury rates were low. No injury was observed in 109 of 153 cases (71%). In 37 cases (24%) there were only minor injuries (bruises, soft tissue tenderness, or minor wounds requiring no sutures). Six falls (4%) resulted in serious injury. Those cases concerned three fractures (hip, radius, and pelvis), two major wounds that required sutures, and a fatal intracerebral hematoma. Injury rates were higher, however, when calculated per individual instead of per incident; 27 of 62 patients who fell (44%) suffered some kind of injury from the falls that occurred during their stay at the rehabilitation unit, and 5 (8%) suffered serious injury. Falls caused by extrinsic mechanisms resulted in injury in 1 of 17 cases (6%) compared with 29 (33%) of the other 88 classified falls (P<.05).

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Falls are very common among patients in geriatric stroke rehabilitation. In this study more than one third of the patients suffered falls during their rehabilitation stay. The incidence rate of falls in our study was high in comparison with most other findings concerning patient falls in various facilities for the rehabilitation and care of the elderly.^{7 20 21 22 23} In accordance with other studies,^{7 13 22 23} injury rates were very low, however, and only a small fraction of the falls resulted in serious injury. Nevertheless, since there were so many falls, a considerable number of fall-related injuries occurred in stroke rehabilitation. In our study approximately one of six patients admitted for rehabilitation was injured during the stay. Falls caused by extrinsic mechanisms were less likely to cause important injury than the intrinsic and nonbipedal falls. An explanation for this could be that the fall-protective reactions of patients who fall as a result of intrinsic mechanisms, such as postural instability, may have deteriorated. Injuries and other consequences resulting from falls, eg, restricted activity as a result of the fear of new falls,²⁴ are likely to have a negative effect on the rehabilitation outcome.

Certain periods of high fall frequency were identified, and in accordance with the findings of other studies,^{20 25 26} they coincided with the periods of greatest activity among the patients. Interestingly enough, these peak frequencies also coincided with the periods of the highest staff-patient ratio on the wards, particularly regarding the midafternoon peak. This may indicate that the staff were busier attending to other duties than attending to and protecting the patients from falling during these periods. It might also indicate a higher activity level made possible by the large number of staff on duty.²⁷ To some extent, the late afternoon/evening peak could also be explained by the occurrence of the sundown syndrome among cognitively impaired patients.²⁸

Contradictory to most other findings concerning falls in geriatric care and rehabilitation settings,^{20 22 23} we found no clear tendency indicating that falls are most frequent during the first few weeks after hospitalization or reallocation.

Some patients are apparently more fall-prone than others. In this study a quarter of the patients fell multiple times, accounting for 85% of the falls. The identification of these fall-prone patients is very important from a preventive point of view.^{29 30} A few studies suggest a number of individual risk factors in stroke patients,^{13 14 15} but the issue needs further investigation. However, risk factor analysis was not the focus of this particular study, but we intend to address this issue in a forthcoming report.

Obviously, the rehabilitation team judged a number of patients to be fall-prone because they were subject to restrictions or special instructions regarding physical activity. However, it seems that these measures did not have the intended effect, since more than half of the falls occurred when patients ignored such restrictions and instructions. This emphasizes the problem of managing patients who suffer from confusion and other cognitive impairments, which are common conditions after stroke.^{11 31} It seems inadequate that patients with serious cognitive impairments are expected to understand and remember verbal instructions and recommendations regarding ambulation and physical activity. Furthermore, in a population of right-hemisphere stroke patients undergoing rehabilitation, Rapport et al¹⁵ found a positive connection between impulsive behavior and increasing fall risk. This shows how important it is that the staff make certain that the instructions given are fully understood, that patients do not wait too long when they have called for assistance, and that patients who continually tend to place themselves in hazardous situations are carefully supervised.

Very few falls were caused by extrinsic mechanisms. Moreover, most of the extrinsic falls that occurred were caused by displacement of the center of gravity, when accurate balance reactions are highly significant for the maintenance of equilibrium. Consequently, the main target of fall prevention strategies in stroke rehabilitation should be to improve patients' sensorimotor ability and postural stability and to promote safe locomotion and ambulation. In accordance with other studies,^{22 23 32} position changes and transfers seem to be activities associated with a large number of falls and should therefore be the focus of special attention. Another area of particular interest in fall prevention regards patients suffering from postural instability or limited functional reach while placed in wheelchairs, which has also been noted in a previous study.²³ Interestingly enough, very few falls occurred during exercise, although exercise is often designed to balance on the limits of the patient's functional capacity.¹² Likewise, few falls occurred while nursing staff assisted the patients in activities of daily living.

Because of the prospective design of this study and the fact that the authors made a very close follow-up on the ward during the study period, we have reason to believe that our data are accurate. We also believe that our study population is fairly representative of stroke patients in hospital rehabilitation. The incidence rate of falls presented must be seen as a minimum rate, however. Naturally, a certain number of falls are likely to occur without the staff knowing about them. By using a reliable and detailed instrument for the classification of falling mechanisms, we intended to make a precise description of the nature and the causative mechanisms of the falls. Still, a relatively large proportion of the falls remained nonclassifiable, because the majority of the falls had no witness and many of the patients were unable to give an adequate or reliable description of the incident.

Since falls are so common in stroke rehabilitation, a major challenge is to reduce the number of falls and injuries without lowering the levels of activity. Many falls are caused by intrinsic mechanisms and occur during transfers and changes in position and in most cases by the patient acting against the instructions given. Therefore, a major goal of stroke rehabilitation is to improve postural stability, motor performance, and the patient's self-perception and awareness of the risk of falls, thereby improving the patient's ability to behave safely in ambulation and locomotion.

	Acknowledgments

 
This study was supported by grants from the Borgerskapet of Umeå Research Foundation, the 1987 Foundation for Stroke Research, the Fund for Medical Research of Umeå University, the Joint Committee of the Northern Health Region of Sweden, the Swedish Society of Medicine (reference No. 340.0), and the Västerbotten County Council. The authors would like to thank Mai Mattsson, MD, and Ulrica Radsjö, RPT, for their contribution to the study.

Received October 31, 1994; revision received February 6, 1995; accepted February 7, 1995.

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