national-clinical-guidelines-for-stroke-fourth-edition

National clinical guideline for stroke
Evidence to recommendations
The literature on balance training post-stroke contains small RCTs and systematic
reviews. These papers demonstrate a small consistent positive effect of balance training
but the research does not distinguish the optimum intervention and fails to report on
long-term follow-up beyond the intervention period.
Stroke survivors are often at high risk of falls at all stages post stroke. Stroke-related
balance deficits include reduced postural stability during standing, and delayed and less
coordinated responses to both self-induced and external balance perturbations. Gait
deficits include reduced propulsion at push-off, decreased hip and knee flexion at swingphase
and reduced stability at stance-phase. The high incidence of falls in stroke
survivors may be attributable to impaired cognitive function, and impaired planning and
execution of tasks. Factors that increase the risk of falling in older people are also
common impairments in stroke survivors. Falls may have serious consequences, both
physically and psychologically. Individuals with stroke have increased risk of hip fracture
(usually on the paretic side) and greater mortality and morbidity rates compared to
people without stroke. Fear of falling may lead to decreased physical activity, social
isolation and loss of independence.
Several studies have aimed to identify people with stroke at risk of falls using composite
and single tests. None have convincingly identified the person with stroke who is going to
fall. Despite evidence for the effectiveness of falls prevention (progressive muscle
strengthening and balance training) in older people living in the community, the
applicability of these interventions has not been evaluated in stroke patients. More
research is needed to evaluate interventions aimed at reducing falls in people with stroke.
Future studies should evaluate multifactorial interventions including strength and balance
training, vitamin D supplementation and strategies that target risk factors for falls.
6.9.1 Recommendations
A Any patient with significant impairment in maintaining their balance should receive
progressive balance training.
B Any patient with moderate to severe limitation of their walking ability should be
given a walking aid to improve their stability.
C Falls and injury prevention, and assessment of bone health, should be part of every
stroke rehabilitation plan including providing training for patients and carers about
how to get up after a fall.
D Stroke patients should have their nutritional status assessed and should be given
vitamin D3 (800 to 2000 International Units per day) and calcium supplementation if
they are at risk of deficiency, particularly if they are house-bound or reside in care
homes (see section 7.5).
6.9.2 Sources
A Marigold et al 2005; Duncan et al 2003; Goljar et al 2010; Lubetzky and Kartin 2010;
Tung et al 2010
B See section 6.8
86 © Royal College of Physicians 2012