May 17, 2015

Falls and Stroke Survivors: 5 Studies in 5 Continents, and 5 of My Tips for Preventing Falls

I'm out of the hospital. The reason I was in there at all for two weeks is because of blood clots--in my leg (DVT) and lung (pulmonary embolism, PE as an acronym). 

No matter what you call it, I feel like a ticking time bomb, never knowing if the time will come where another clot ultimately goes to my brain, and it's lights out--permanently. The docs assured me that wouldn't happen, but who knows? It's just the docs' educated guesses, one after another. I have an educated guess, too. I may be fucked.

A stroke survivor
So to take my mind off death, for the moment, I started to research falls as related to stroke survivors. Between 40 to 70% of stroke survivors worldwide have serious falls within a year of their stroke. I had many falls, most my own fault out of chancy stupidity and a few not. Here's some of my favorite findings, from 5 of the 7 continents. South America has an excuse. (And is anybody even living in Antarctica?) All continents used international and certifiable scales as related to stroke survivors and the falls they encountered.


Focus: Improving walking and reducing falls post-stroke

Background: California researchers understood that better comprehension of falls was imperative, as broken bones, hips the most common, and head trauma might be the result. 

So ambulatory stroke survivors were enrolled in Locomotor Experience Applied Post Stroke (LEAPS) and were assessed 2 months post-stroke. Falls were assessed for 12 months post-stroke and participants were characterized as: multiple or injurious (M/I); single, non-injurious (S/NI); or non-fallers. 

Results: The results were alarming. Among the 408 participants, 36%  were M/I, 21% S/NI, and 43% non-fallers. A majority of falls occurred at home in the first 3 months. Although multiple fallers are not at higher risk for injury for any given fall, cumulative injury risk increases with each fall. Thus, falls prediction and management for individuals post-stroke should focus on multiple falls.

A primary goal of stroke rehabilitation is to improve individuals’ mobility in the presence of motor, balance, and visual-spatial deficits. Yet, increasing mobility and physical activity increases exposure to fall risks. A review of exercise in older people strongly implies that strength and balance exercises reduce falls, whereas walking training alone may increase them.

Participants were assigned to one of three groups:
* a locomotor training program (LTP) that included use of the treadmill followed by walking practice 2 months post-stroke
* a progressive strength and balance exercise program provided by a physical therapist in the home started 2 months post-stroke.  
* late LTP, 6-months post-stroke

Each program was provided for 36 sessions over 16 weeks and was monitored between 2 and 12 months post-stroke. The researchers defined a fall as, “A person has a fall if they end up on the ground or floor when they did not expect to. Most often a fall starts while a person is on their feet, but a fall could also start from a chair or bed. If a person ends up on the ground, either on their knees, their belly, their side, their bottom, or their back, they have had a fall."

Of individuals who fell, 74% had at least one fall from which they could not get up independently. Fall rate per person year was 1.76 overall, 1.33 for moderately impaired walkers, and 2.13 for severely impaired walkers. But here's the thing: Of the three groups, there was no difference in overall fall incidence between 2 and 12 months post-stroke. And between 2 and 6-months post-stroke, both groups receiving early intervention had a higher fall rate than individuals in the late-LTP group. Over-confidence, the researchers theorized.

Focus: Falls in older adults with strokes

Background: This Australian study aimed at two things: probe the  differences in the incidence of falls between chronic stroke subjects and matched non-stroke subjects who were 65 years or older and community dwellers, and establishing factors associated with falling with chronic stroke survivors.

Results: More stroke survivors reported falling in the previous twelve months after the stroke than non-stroke subjects (36% vs 24%). When comparing stroke survivors who fell to stroke survivors without any falls, the first group were more likely to report to have difficulty in stooping or kneeling, getting up in the night to urinate more than once, and having a greater problem with activities that involved hygiene, that is, bathing or showering.





Focus: Risk factors and management in stroke survivors who have fallen

Background: Israeli researchers found that falls are common events among hospital inpatients and constitute a major health problem in rehabilitation. Many risk factors for stroke falls such as muscle weakness, hypotension, and medication side effects have been identified.

Results: In a 5-year study of 56 falls in 41 stroke patients hospitalized for rehabilitation, 30 patients fell once, 9 patients twice and 2 patients four times, obtained from the medical and nursing records.
Most falls occurred among male patients who had reduced muscular tone (70%), paralysis (54%) and/or hemiparesis (one-sided body weakness). In addition, 48% percent of the falls occurring during the first month, 70% during the morning or the afternoon, and 62% occurred close to the patient's bed.
Also, 89% of stroke survivors' falls were attributed to medication side effects, 29% to communication disorders, 21% to blindness, and 18% visual sensory disorders.


Focus: Patient Falls in Stroke Rehabilitation

Background: Falling is a major complication in stroke rehabilitation. This study intends to investigate the incidence, characteristics, and consequences of falls in an in-patient stroke rehabilitation setting.

Precisely 161 patients were admitted to a geriatric stroke rehabilitation unit. Falls that occurred during their stay were registered and analyzed. The study was performed at the stroke rehabilitation unit of the geriatric clinic at UmeƄ 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.

Results: 62 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. 17 falls (11%) were classified as the result of extrinsic mechanisms, 49 (32%) were intrinsic falls, 39 (25%) occurred in a sitting or lying position, 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.

(Per the above: For falls with an extrinsic precipitating cause, the most significant risk factors were: age, diabetes mellitus, a history of falling, and treatment with neuroleptics or oral bronchodilators. For falls with an intrinsic precipitating cause, the independent risk factors were: age, diabetes, dementia, alterations of gait and balance, previous falls, and treatment with digitalins, neuroleptics or antidepressants).

Focus: Gait and balance performance of stroke survivors in South Western Nigeria

Background: Stroke survivors are often left with neurological and functional deficits, which impair their ability to walk and affect their balance. This study assessed gait parameters and balance performance among stroke survivors.

Results: Seventy stroke survivors (65% males) who were 6 months or more post stroke participated in this study. The gait of participants was assessed by gait speed and cadence (rhythmic flow). Balance performance was assessed using the Activities-specific Balance Confidence scale for balance self-efficacy and Functional Reach Test for standing balance.

Participants were 43 to 65 years in age. Forty five (64%) stroke survivors had hemorrhagic strokes while 25 (36%) had ischemic stroke. There were significant relationships between gait speed and balance self-efficacy and between cadence and functional reach distance.

The study concluded that stroke survivors with higher cadences had higher functional reach distances, and those with higher gait speeds had better balance.

About 35% of survivors with initial paralysis of the leg do not regain useful walking function, and 25% of all survivors are unable to walk without full physical assistance. They also demonstrate postural control problems such as loss of anticipatory activation during voluntary movements, increased sway during quiet standing, especially on the affected side, and decreased area of stability during weight shifting while standing.

Postural balance is closely related to gait ability. A strong relationship has been reported between gait velocity and dynamic balance in the acute rehabilitation period among patients with first time stroke. 

"We did not find significant differences in the gait speed and cadence between fallers and non-fallers, though the non-fallers had higher gait speed and cadence values. The reason for this result may be because all our participants could ambulate independently and therefore had similar gait speeds and balance performance," say the researchers.

Stroke survivors with higher cadences had higher functional reach distances, and those with higher gait speeds had better balance. This implies that gait speed and cadence are factors related to balance performance and should be considered during balance and gait retraining.


There should have been 6 continents in my review about falls and stroke survivors, but The American Heart Association says the following about South America:

"Current knowledge of stroke risk factors and epidemiology is
based mostly on North American or European studies; so scarce data have been published from developing countries. Stroke will be a public health problem in South America during the next decades because of an increase in life expectancy and changes in the lifestyle of the population. Because epidemiological and clinical characteristics of stroke vary according to environmental, racial, and socio-cultural factors, we need to be aware of the peculiarities of stroke on 
this continent to reduce the impact burden of this epidemic."

Preventing Falls 
These are my new ways to go about preventing falls. I tried all of them and I haven't had any falls in a year since I began implementing these tips:
  • Use nightlights in bedrooms, bathrooms and hallways. If the light bothers your eyes, wear a mask. I don't. I deal with it. But either way.
  • Sit on a bench or stool with a handle in the shower and use a hand-held showerhead.
  • Secure area rugs with double-sided tape.
  • Review medications with your doctor as some may cause dizziness and balance problems.
  • Slow down and take all the time you need when walking. There is no need to hurry, and it may be safer to go more slowly. By the way, since most of my falls were in the kitchen, bending over to pick up something that landed me on the floor, I bought a used wheelchair, got a new cushion, and always use it when I've dropped something on the floor. I sit, retrieve, and stand. So much easier!
Granted, all strokes suck, but falling compounds strokes, like broken hips or bleeding heads. Keep that in mind.

May 10, 2015

A Life Interrupted and Then Somehow Regained

While I am finishing the post  "Falls and Stroke Survivors: Sooner or Later, Don't Be Surprised If You Tumble," I had to write something in the meantime because...well, I had to. 

Brain post stroke

I am still in the hospital for one more day. Blood clots in my leg. And lung. I have been here for what seems like a long time. Truth is, 2 weeks is all. I have seen some things that you don't want to see. Ever. It was a reminder, how I reacted to therapy, hospitals. I met all of them in therapy, and they were stroke survivors. Confused, unhappy, filter-less, poor judgment stroke survivors.
The man who didn't know where he was in space and time. He was fixed on looking to his right and the therapist put the plastic cones on his left. He saw the box that used to contain the cones on his right. But the therapist had to gently push his face to the left in order for the task of replacing the cones in the box to be accomplished. The patient therapist and the man who only saw to his right. It was me. 

The woman who was crying. Her mouth always in a frown. The therapist tried to make her laugh, something about if she touched her feet, she would giggle. The patient managed to give a half smile and then cried again. A family member talked to her in a hushed tone. More crying. It was me.

Another woman who wanted to share in my therapy. She was churning on the Nu-Step. "Do the cones falling down mean that it's bad for Joyce?" "Uh oh, you missed getting it on the ring." I knew what it was. No filters. But the therapist told her to keep pedaling on the Nu-Step. That it didn't concern her. It was me.

Still another woman who always wanted to get up from her wheelchair. She was belted in but still, she wanted to go. Anywhere. The therapist threatened her, that if she was trying to stand up, the nurse would put a buzzer beneath her wheelchair cushion and bed that would bring everybody come running. It was me.

Fact is, you can see yourself as you are now--clear-minded, joyous, level-headed, sensical--how much progress you made, only by looking back to where you were. It is me.

May 2, 2015

You. Never. Know. aka The Shit Misses the Fan

I wrote a post called "The Chances of Getting a Second Stroke, aka Who Me? Worry?"( with the mindset that I was past the 5-year danger zone of getting a second stroke when the 6th year post-stroke approached. 

I bought an exercise bike, learned how to stretch, and used leg weights religiously. I ate healthy, was energetic, and kept my post-stroke hospital weight (size 8-10).

But the trouble started about a year and a half ago when I moved to Pittsburgh and saw a well-known hematologist. He told me, in no uncertain terms, that some doctor, a long time ago, should have taken me off of Coumadin [a blood thinner]. 

So in three days, I weaned off of Coumadin and I was free--no more weekly blood monitoring, no more foods to avoid like cranberries, leafy green vegetables, and a lot of Vitamin K. 

But on Wednesday night, April 22, my knee was swollen, I was more tired than usual, and I was randomly winded. I attributed my swelling to too much exercise (no pain, no gain, right?), my fatigue to too much activity (shop 'til you drop), and my breathlessness to allergies (wheeze, cough). 

My knee was getting increasingly worse, and now it was crimson and warm, my whole leg swollen. Fatigue and breathing difficulty continued, too, through the weekend. I went to the internist on Monday.

"If I were to take an educated guess," she said slowly and paused, as if she didn't want to give me bad news, "I would say it's a blood clot. Go to the hospital and take a Doppler."

Color ultrasound showing blood flow
Of course, I knew what a Doppler was. I had a few of them. The Mayo Clinic defines it best: "A Doppler ultrasound is a noninvasive test that can be used to estimate your blood flow through blood vessels by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells." (A regular ultrasound can't show blood flow).

I went and it was, just like the doctor had educationally guessed. But there was more. On the advice of the ER doc, I took an ultrasound of my lungs and his educated guess proved right, a clot that traveled to my lungs called a pulmonary embolism. I had the vena cava (Greenfield) filter from the stroke 6 years ago, but it only takes care of big clots. The small ones get away and travel, to the lung or brain, for example. 

The hematologist said the clots must have been from the painful flexor tenotomy ( that I had 3 weeks ago when I laid on the sofa for days. But who really knows? It was just another educated guess.

So the takeaway is this (do you see the pattern?): don't do as I did.
1. If you have swelling, redness, and/or increasing heat on any part of your body, especially your legs, don't diagnose yourself with an uneducated guess. Go to the ER or call 911.
2. If you're more tired than usual for no particular reason, go to the ER or call 911.
3. If you're breathless, go to the ER or call 911.

I've been in the hospital for 5 days and counting. I am expecting I'll be here for 2 or 3 weeks. My balance is good, but my endurance sucks. So they transferred me to the in-patient rehab floor where I'll build up to where I was.   

Bad news: blood clots suck. Good news: I'm still writing this blog. And I'm back on Coumadin to keep the clots from forming again.

The hematologist said, "I made a mistake in taking you off Coumadin. 

I was tempted to say, "Fuck, yeah!" But for once, I kept my mouth shut. 

Question: How often do doctors admit they made a mistake? Answer: Rarely to never! I was glad he admitted it. And that was enough for me, making me believe, once again, that doctors sometimes don't know what the fuck they're talking about. Just educated guesses is all.