Managing Parkinson's during the COVID-19 pandemic: Perspectives from people living with Parkinson's and health professionals.

OBJECTIVES: The aim of this study was to understand how people living with Parkinson's and healthcare professionals perceived their care management and interactions with health services were affected during the COVID-19 pandemic. BACKGROUND: During the COVID-19 pandemic, many governments introduced restrictions and services that support Parkinson's care management had to cease or be delivered remotely. These changes may have had an impact on the well-being of people living with Parkinson's. METHODS: A qualitative exploratory UK study was carried out. Semi-structured individual interviews with people living with Parkinson's and health professionals were recorded, transcribed verbatim and analysed using Braun´s and Clarke´s thematic analysis. Eleven patients and 10 health professionals were recruited between April and September 2020. The study was reported using the COREQ. RESULTS: Two main themes were identified. In the first theme, many patients and professionals reported that the COVID-19 pandemic made some people living with Parkinson's feel isolated and vulnerable due to disruptions to their social networks and usual activities related to Parkinson's disease care. However, other patients remained connected with their networks. In the second theme, patients and most professionals mentioned that some clinical practices were cancelled, delayed or transformed to remote consultation. CONCLUSION: The COVID-19 restrictions had an impact on how people living with Parkinson's managed their care and in their interactions with healthcare services. Health professionals should assess the risk of vulnerability, social isolation, physical inactivity and confidence with remote consultations in people living with Parkinson's. This might inform a rethinking of existing clinical interactions with people living with Parkinson's towards a flexible, sustainable, person-centred care model. RELEVANCE TO CLINICAL PRACTICE: This study has shown that Parkinson's care management and interactions with healthcare services should provide personalised and flexible support. To meet this challenge, the design of the organisation of health services should include greater involvement of patients and person-centred care models.

Footwear characteristics and foot problems in community dwelling people with stroke: a cross-sectional observational study.

PURPOSE: To explore footwear characteristics and foot problems in community dwelling people with stroke as most research to date focused on the general elderly population. METHODS: Thirty people with mild to moderate stroke (nine men, mean age 68, mean time since onset 67 months) attended a single session to assess footwear and foot problems using established podiatry foot (wear) and ankle assessments. RESULTS: Most participants wore slippers indoors (n = 17, 57%) and walking shoes outdoors (n = 11, 37%). Over half wore unsupportive ill-fitting shoes indoors and 47% of outdoor shoes fitted badly. All participants had foot problems (mean 6.5 (3.1), 95% CI: 5.4-7.7), including impaired single limb heel raise (93%), reduced range of movement (77%), sensation (47%), and muscle strength (43%). Many had foot-pain, hallux valgus (both 50%), or swollen feet (40%). Foot problems were associated with reduced balance confidence, activity, and community participation (all p < 0.05). A greater proportion of fallers (13/16) than non-fallers (4/14) reported foot problems (p = 0.029). CONCLUSIONS: Many community-dwelling people with stroke wore poorly fitting shoes; all had foot problems. Foot problems were linked to reduced mobility. Finding more effective pathways to support people with stroke to select supportive, well-fitting indoor and outdoor footwear is indicated.Implications for rehabilitationPeople with stroke often wear unsupportive ill-fitting shoes and experience foot problems.Assessment of foot problems and footwear advice should be considered during stroke rehabilitation particularly when interventions target fall prevention or improvements in balance and mobility.Information on appropriate footwear and signposting that new shoe purchases should include measuring feet to ensure a good fit is recommended.

A novel approach for modelling and classifying sit-to-stand kinematics using inertial sensors.

Sit-to-stand transitions are an important part of activities of daily living and play a key role in functional mobility in humans. The sit-to-stand movement is often affected in older adults due to frailty and in patients with motor impairments such as Parkinson's disease leading to falls. Studying kinematics of sit-to-stand transitions can provide insight in assessment, monitoring and developing rehabilitation strategies for the affected populations. We propose a three-segment body model for estimating sit-to-stand kinematics using only two wearable inertial sensors, placed on the shank and back. Reducing the number of sensors to two instead of one per body segment facilitates monitoring and classifying movements over extended periods, making it more comfortable to wear while reducing the power requirements of sensors. We applied this model on 10 younger healthy adults (YH), 12 older healthy adults (OH) and 12 people with Parkinson's disease (PwP). We have achieved this by incorporating unique sit-to-stand classification technique using unsupervised learning in the model based reconstruction of angular kinematics using extended Kalman filter. Our proposed model showed that it was possible to successfully estimate thigh kinematics despite not measuring the thigh motion with inertial sensor. We classified sit-to-stand transitions, sitting and standing states with the accuracies of 98.67%, 94.20% and 91.41% for YH, OH and PwP respectively. We have proposed a novel integrated approach of modelling and classification for estimating the body kinematics during sit-to-stand motion and successfully applied it on YH, OH and PwP groups.

Cost-effectiveness of the PDSAFE personalised physiotherapy intervention for fall prevention in Parkinson's: an economic evaluation alongside a randomised controlled trial.

BACKGROUND: PDSAFE is an individually-tailored, physiotherapist-delivered, balance, strength and strategy training programme aimed at preventing falls among people with Parkinson's. We evaluated the cost-effectiveness of PDSAFE compared with usual care for people with Parkinson's at higher risk of falling, from a UK National Health Service and Personal Social Service perspective. METHODS: Resource use and quality of life data (EQ-5D-3L) were collected from 238 participants randomised to the PDSAFE intervention and 236 participants randomised to control, at baseline, 3 months, 6 months (primary outcome), and 12 months. Adjusted cost and quality-adjusted life-years (QALYs) were estimated using generalised linear models and uncertainty estimated using a non-parametric bootstrap. RESULTS: Over 6 months, the PDSAFE intervention was associated with an incremental cost of £925 (95% CI £428 to £1422) and a very small and statistically insignificant QALY gain of 0.008 (95% CI - 0.006 to 0.021). The resulting incremental cost-effectiveness ratio (ICER) was £120,659 per QALY and the probability of the intervention being cost-effective at a UK threshold of £30,000/QALY was less than 1%. The ICER varied substantially across subgroups although no subgroup had an ICER lower than the £30,000 threshold. The result was sensitive to the time horizon with the ICER reducing to £55,176 per QALY when adopting a 12-month time horizon and assuming a sustained treatment effect on QoL, nevertheless, the intervention was still not cost-effective according to the current UK threshold. CONCLUSIONS: Evidence from this trial suggests that the PDSAFE intervention is unlikely to be cost-effective at 6 months. The 12-month analysis suggested that the intervention became closer to being cost-effective if quality of life effects were sustained beyond the intervention period, however this would require confirmation. Further research, including qualitative studies, should be conducted to better understand the treatment effect of physiotherapy and its impact on quality of life in people with Parkinson's given existing mixed evidence on this topic. TRIAL REGISTRATION: ISRCTN48152791. Registered 17 April 2014. http://www.isrctn.com/ISRCTN48152791.

The trouble with footwear following stroke: a qualitative study of the views and experience of people with stroke.

Purpose: Foot problems and suboptimal footwear are risk factors for falls among the elderly. Footwear choice may, therefore, be important for people with balance impairment following stroke, but little is known about their experience. This study explored foot problems experienced following stroke, factors influencing footwear choices and views of footwear in use.Methods: Semi-structured interviews with 15 people with stroke, purposively sampled from respondents to a screening survey.Results: Participants typically experienced impaired mobility with balance problems and felt at risk of falling. Stroke related foot problems, including altered sensation, edema, and foot drop, predominantly on the stroke affected side, influenced footwear priorities. Footwear choices prioritized comfort, security, and convenience, sometimes in tension with concern about appearance. Challenges included choosing appropriate indoor footwear and finding shoes to accommodate their orthoses and edema. Participants highlighted perceived lack of footwear advice from health care professionals and variable experience of shoe shopping.Conclusions: Foot problems, as well as gait and balance impairment, have implications for footwear priorities following stroke, but people felt unsupported in making healthy footwear choices. Health care professionals could be trained to routinely deliver footwear assessment and advice and facilitate referrals to podiatrist, when appropriate.Implications for rehabilitationFoot problems, as well as gait and balance impairment, have implications for footwear priorities following stroke.People with stroke perceive a lack of professional advice about footwear and feel unsupported making healthy footwear choices.Health care professionals could be trained to routinely deliver an initial footwear assessment and advice as part of stroke rehabilitation.A greater transparency and knowledge of referral pathways into podiatry services for Health care professionals and patients would give access to specialist advice where appropriate.

Interventions for preventing falls in people after stroke.

BACKGROUND: Falls are one of the most common complications after stroke, with a reported incidence ranging between 7% in the first week and 73% in the first year post stroke. This is an updated version of the original Cochrane Review published in 2013. OBJECTIVES: To evaluate the effectiveness of interventions aimed at preventing falls in people after stroke. Our primary objective was to determine the effect of interventions on the rate of falls (number of falls per person-year) and the number of fallers. Our secondary objectives were to determine the effects of interventions aimed at preventing falls on 1) the number of fall-related fractures; 2) the number of fall-related hospital admissions; 3) near-fall events; 4) economic evaluation; 5) quality of life; and 6) adverse effects of the interventions. SEARCH METHODS: We searched the trials registers of the Cochrane Stroke Group (September 2018) and the Cochrane Bone, Joint and Muscle Trauma Group (October 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 9) in the Cochrane Library; MEDLINE (1950 to September 2018); Embase (1980 to September 2018); CINAHL (1982 to September 2018); PsycINFO (1806 to August 2018); AMED (1985 to December 2017); and PEDro (September 2018). We also searched trials registers and checked reference lists. SELECTION CRITERIA: Randomised controlled trials of interventions where the primary or secondary aim was to prevent falls in people after stroke. DATA COLLECTION AND ANALYSIS: Two review authors (SD and WS) independently selected studies for inclusion, assessed trial quality and risk of bias, and extracted data. We resolved disagreements through discussion, and contacted study authors for additional information where required. We used a rate ratio and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person-year) between intervention and control groups. For risk of falling we used a risk ratio and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate and applied GRADE to assess the quality of the evidence. MAIN RESULTS: We included 14 studies (of which six have been published since the first version of this review in 2013), with a total of 1358 participants. We found studies that investigated exercises, predischarge home visits for hospitalised patients, the provision of single lens distance vision glasses instead of multifocal glasses, a servo-assistive rollator and non-invasive brain stimulation for preventing falls.Exercise compared to control for preventing falls in people after strokeThe pooled result of eight studies showed that exercise may reduce the rate of falls but we are uncertain about this result (rate ratio 0.72, 95% CI 0.54 to 0.94, 765 participants, low-quality evidence). Sensitivity analysis for single exercise interventions, omitting studies using multiple/multifactorial interventions, also found that exercise may reduce the rate of falls (rate ratio 0.66, 95% CI 0.50 to 0.87, 626 participants). Sensitivity analysis for the effect in the chronic phase post stroke resulted in little or no difference in rate of falls (rate ratio 0.58, 95% CI 0.31 to 1.12, 205 participants). A sensitivity analysis including only studies with low risk of bias found little or no difference in rate of falls (rate ratio 0.88, 95% CI 0.65 to 1.20, 462 participants). Methodological limitations mean that we have very low confidence in the results of these sensitivity analyses.For the outcome of number of fallers, we are very uncertain of the effect of exercises compared to the control condition, based on the pooled result of 10 studies (risk ratio 1.03, 95% CI 0.90 to 1.19, 969 participants, very low quality evidence). The same sensitivity analyses as described above gives us very low certainty that there are little or no differences in number of fallers (single interventions: risk ratio 1.09, 95% CI 0.93 to 1.28, 796 participants; chronic phase post stroke: risk ratio 0.94, 95% CI 0.73 to 1.22, 375 participants; low risk of bias studies: risk ratio 0.96, 95% CI 0.77 to 1.21, 462 participants).Other interventions for preventing falls in people after strokeWe are very uncertain whether interventions other than exercise reduce the rate of falls or number of fallers. We identified very low certainty evidence when investigating the effect of predischarge home visits (rate ratio 0.85, 95% CI 0.43 to 1.69; risk ratio 1.48, 95% CI 0.71 to 3.09; 85 participants), provision of single lens distance glasses to regular wearers of multifocal glasses (rate ratio 1.08, 95% CI 0.52 to 2.25; risk ratio 0.74, 95% CI 0.47 to 1.18; 46 participants) and a servo-assistive rollator (rate ratio 0.44, 95% CI 0.16 to 1.21; risk ratio 0.44, 95% CI 0.16 to 1.22; 42 participants).Finally, transcranial direct current stimulation (tDCS) was used in one study to examine the effect on falls post stroke. We have low certainty that active tDCS may reduce the number of fallers compared to sham tDCS (risk ratio 0.30, 95% CI 0.14 to 0.63; 60 participants). AUTHORS' CONCLUSIONS: At present there exists very little evidence about interventions other than exercises to reduce falling post stroke. Low to very low quality evidence exists that this population benefits from exercises to prevent falls, but not to reduce number of fallers.Fall research does not in general or consistently follow methodological gold standards, especially with regard to fall definition and time post stroke. More well-reported, adequately-powered research should further establish the value of exercises in reducing falling, in particular per phase, post stroke.

Exercise- and strategy-based physiotherapy-delivered intervention for preventing repeat falls in people with Parkinson's: the PDSAFE RCT.

BACKGROUND: People with Parkinson's disease are twice as likely to experience a fall as a healthy older person, often leading to debilitating effects on confidence, activity levels and quality of life. OBJECTIVE: To estimate the effect of a physiotherapy programme for fall prevention among people with Parkinson's disease. DESIGN: A multicentre, pragmatic, investigator-masked, individually randomised controlled trial (RCT) with prespecified subgroup analyses. SETTING: Recruitment from NHS hospitals and clinics and community and social services in eight English regions with home-based interventions. PARTICIPANTS: A total of 474 people with Parkinson's disease (i.e. Hoehn and Yahr scale stages 1-4) were recruited: 238 were assigned to a physiotherapy programme and 236 were assigned to usual care. Random allocation was 50 : 50. INTERVENTIONS: All participants received routine care; the usual-care group received an information digital versatile disc (DVD) and a single advice session at trial completion. The intervention group had an individually tailored, progressive, home-based fall avoidance strategy training programme with balance and strengthening exercises: PDSAFE. MAIN OUTCOME MEASURES: The primary outcome was the risk of repeat falling, collected by self-report monthly diaries between 0 and 6 months after randomisation. Secondary outcomes included near-falls, falls efficacy, freezing of gait (FoG), health-related quality of life, and measurements taken using the Mini-Balance Evaluation Systems Test (Mini-BESTest), the Chair Stand Test (CST), the Geriatric Depression Scale, the Physical Activity Scale for the Elderly and the Parkinson's Disease Questionnaire. RESULTS: PDSAFE is the largest RCT of falls management among people with Parkinson's disease: 541 patients were screened for eligibility. The average age was 72 years, and 266 out of 474 (56%) participants were men. Of the 474 randomised participants, 238 were randomised to the intervention group and 236 were randomised to the control group. No difference in repeat falling within 6 months of randomisation was found [PDSAFE group to control group odds ratio (OR) 1.21, 95% confidence interval (CI) 0.74 to 1.98; p = 0.447]. An analysis of secondary outcomes demonstrated better balance (Mini-BESTest: mean difference 0.95, 95% CI 0.24 to 1.67; p = 0.009), functional strength (CST: p = 0.041) and falls efficacy (Falls Efficacy Scale - International: mean difference 1.6, 95% CI -3.0 to -0.19; p = 0.026) with near-falling significantly reduced with PDSAFE (OR 0.67, 95% CI 0.53 to 0.86; p = 0.001) at 6 months. Prespecified subgroup analysis (i.e. disease severity and FoG) revealed a PDSAFE differing effect; the intervention may be of benefit for people with moderate disease but may increase falling for those in the more severe category, especially those with FoG. LIMITATIONS: All participants were assessed at primary outcome; only 73% were assessed at 12 months owing to restricted funding. CONCLUSIONS: PDSAFE was not effective in reducing repeat falling across the range of people with Parkinson's disease in the trial. Secondary analysis demonstrated that other functional tasks and self-efficacy improved and demonstrated differential patterns of intervention impact in accordance with disease severity and FoG, which supports previous secondary research findings and merits further primary evaluation. FUTURE WORK: Further trials of falls prevention on targeted groups of people with Parkinson's disease are recommended. TRIAL REGISTRATION: Current Controlled Trials ISRCTN48152791. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 36. See the NIHR Journals Library website for further project information. Sarah E Lamb is funded by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) at Oxford Health NHS Foundation Trust, the NIHR Oxford Biomedical Research Centre at the Oxford University Hospitals NHS Foundation Trust and CLAHRC Oxford. Victoria A Goodwin is supported by the NIHR Collaborations for Leadership in Applied Health Research and Care in the South West Peninsula (PenCLAHRC). Lynn Rochester is supported by the NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University. The research was also supported by the NIHR Newcastle Clinical Research Facility Infrastructure funding. Helen C Roberts is supported by CLAHRC Wessex and the NIHR Southampton Biomedical Research Centre.

People with Parkinson's disease fall often. Falls are scary and make moving about harder. The PDSAFE trial tested a new 'home physiotherapy' programme for reducing falls. People with Parkinson's disease were allocated to one of two groups by chance: they either received the PDSAFE exercises or just normal care. The costs were looked at and people were asked for their views of the PDSAFE exercises. To take part, people had to have Parkinson's disease, live in their own home, be able to walk, have had at least one fall in the previous year and pass a memory test. PDSAFE was taught by physiotherapists and included exercises and fall avoidance strategies. Everyone had to record falls on a monthly calendar, and balance, strength and walking were tested. To our knowledge, this was the largest falls trial looking at people with Parkinson's disease in the world: 541 people took part. The number of falls an individual reported differed a lot between people. When all people with Parkinson's disease in the trial were considered, the physiotherapy programme did not reduce falls in the first 6 months. However, it was found that some people had fewer falls after taking part in the exercises, whereas others did not. Those with more severe Parkinson's disease (i.e. problems with movement, memory and freezing of gait) fell more often after the PDSAFE intervention, even though their balance and confidence improved. Those with good memory, moderate disease and two or three falls in the previous year reacted well to PDSAFE and had fewer falls. It was found that PDSAFE reduced near-falls (about to fall but managed to save themselves) and improved balance and confidence. The physiotherapists and those who took part liked the programme and felt that it helped, but it was expensive to run. In conclusion, a falls prevention programme should be based on each person's needs and a different treatment should be used for those with more severe Parkinson's disease.

Multicentre, randomised controlled trial of PDSAFE, a physiotherapist-delivered fall prevention programme for people with Parkinson's.

OBJECTIVE: To estimate the effect of a physiotherapist-delivered fall prevention programme for people with Parkinson's (PwP). METHODS: People at risk of falls with confirmed Parkinson's were recruited to this multicentre, pragmatic, investigator blind, individually randomised controlled trial with prespecified subgroup analyses. 474 PwP (Hoehn and Yahr 1-4) were randomised: 238 allocated to a physiotherapy programme and 236 to control. All participants had routine care; the control group received a DVD about Parkinson's and single advice session at trial completion. The intervention group (PDSAFE) had an individually tailored, progressive home-based fall avoidance strategy training programme with balance and strengthening exercises. The primary outcome was risk of repeat falling, collected by self-report monthly diaries, 0-6 months after randomisation. Secondary outcomes included Mini-BESTest for balance, chair stand test, falls efficacy, freezing of gait, health-related quality of life (EuroQol EQ-5D), Geriatric Depression Scale, Physical Activity Scale for the Elderly and Parkinson's Disease Questionnaire, fractures and rate of near falling. RESULTS: Average age is 72 years and 266 (56%) were men. By 6 months, 116 (55%) of the control group and 125 (61.5%) of the intervention group reported repeat falls (controlled OR 1.21, 95% CI 0.74 to 1.98, p=0.447). Secondary subgroup analyses suggested a different response to the intervention between moderate and severe disease severity groups. Balance, falls efficacy and chair stand time improved with near falls reduced in the intervention arm. CONCLUSION: PDSAFE did not reduce falling in this pragmatic trial of PwP. Other functional tasks improved and reduced fall rates were apparent among those with moderate disease. TRIAL REGISTRATION NUMBER: ISRCTN48152791.

Identifying balance impairments in people with Parkinson's disease using video and wearable sensors.

BACKGROUND: Falls and near falls are common among people with Parkinson's (PwP). To date, most wearable sensor research focussed on fall detection, few studies explored if wearable sensors can detect instability. RESEARCH QUESTION: Can instability (caution or near-falls) be detected using wearable sensors in comparison to video analysis? METHODS: Twenty-four people (aged 60-86) with and without Parkinson's were recruited from community groups. Movements (e.g. walking, turning, transfers and reaching) were observed in the gait laboratory and/or at home; recorded using clinical measures, video and five wearable sensors (attached on the waist, ankles and wrists). After defining 'caution' and 'instability', two researchers evaluated video data and a third the raw wearable sensor data; blinded to each other's evaluations. Agreement between video and sensor data was calculated on stability, timing, step count and strategy. RESULTS: Data was available for 117 performances: 82 (70%) appeared stable on video. Ratings agreed in 86/117 cases (74%). Highest agreement was noted for chair transfer, timed up and go test and 3 m walks. Video analysts noted caution (slow, contained movements, safety-enhancing postures and concentration) and/or instability (saving reactions, stopping after stumbling or veering) in 40/134 performances (30%): raw wearable sensor data identified 16/35 performances rated cautious or unstable (sensitivity 46%) and 70/82 rated stable (specificity 85%). There was a 54% chance that a performance identified from wearable sensors as cautious/unstable was so; rising to 80% for stable movements. SIGNIFICANCE: Agreement between wearable sensor and video data suggested that wearable sensors can detect subtle instability and near-falls. Caution and instability were observed in nearly a third of performances, suggesting that simple, mildly challenging actions, with clearly defined start- and end-points, may be most amenable to monitoring during free-living at home. Using the genuine near-falls recorded, work continues to automatically detect subtle instability using algorithms.

It takes two: the influence of dance partners on the perceived enjoyment and benefits during participation in partnered ballroom dance classes for people with Parkinson's.

PURPOSE: To explore the views of people with Parkinson's and their dance partners on the influence and issues surrounding dancing with an able-bodied dance partner during partnered ball room dance classes. METHODS: In depth, semi-structured interviews explored purposively selected participants' experiences and views about dance classes. Fourteen people with Parkinson's and their dance partners (six spouses, two friends/relatives, five volunteers) were interviewed within a month of completing the 10-week dance class program. Data were analyzed thematically. RESULTS: Generally, those partnered with a spouse or an experienced dancer, or when dance couples were able to develop good rapport, gained greater enjoyment and sense of achievement from dance classes in comparison to couples who did not enjoy dancing together or had clashing approaches to dance. Managing and negotiating who would "lead" in a dance was challenging for dance couples particularly among male people with Parkinson's. CONCLUSIONS: People with Parkinson's experience of the dance classes were influenced by the relationship and compatibility with their dance partner. Dance partnerships may impact on recruitment, enjoyment, outcome and continued participation in dance classes. Potential effects of partnerships should be analyzed and reported in studies evaluating the outcomes of dance classes. Implications for rehabilitation We recommend that health professionals consider involving spouses in Parkinson's dance classes as this may improve recruitment, adherence, enjoyment and overall outcome of the dance classes. If volunteers are needed, aim to recruit those who already have good dancing ability, convey a love of dancing and have the sensitivity and social skills to interact positively with the person with Parkinson's. Consider dance partnership issues when advertising and promoting dance classes. Address partnership issues through open communication and by changing partners if the dance partnership is not working well.

A survey to explore what information, advice and support community-dwelling people with stroke currently receive to manage instability and falls.

PURPOSE: To describe and determine the benefits of the information and support services currently offered to people with stroke experiencing instability and falls. METHODS: A cross-sectional survey study. Two hundred and fifty-six surveys were sent out to community stroke groups in Hampshire and the Isle of Wight, as well as to people with stroke on a patient register. RESULTS: One hundred and twenty-five surveys were returned. A total of 107 participants (86%) reported instability and 62 (50%) had experienced a fall in the preceding year; 29 (28%) had reportedly received information on falls prevention. Forty-four participants (43%) sought help from health professionals following instability and falls; just over half reported that the information they received was useful. One quarter (n = 11) of those seeking help were referred on to falls clinics; all attended and 86% felt attending had been beneficial. However, only one participant was followed up by these clinics. CONCLUSIONS: Findings suggest that the majority of people with stroke who have experienced instability and falls did not receive any information and support, with very few referred on to falls clinics. Health professionals play a key role in information provision and facilitating access to falls prevention programs. Further research is required to determine the most effective ways to implement current guidelines to manage instability and falls in this high-risk group. Implications for rehabilitation: Many community-dwelling people with stroke did not receive any information, help or support after experiencing instability and falls. Clinicians must stress that falls are a complication, not an expectation, post-stroke. Information on falls prevention and available support services should be offered to individuals prior to discharge from hospital, in GP practices and in rehabilitation settings. All individuals with stroke seeking health professional help following instability and falls should be referred on to falls clinics for individualized multifactorial assessment and intervention to comply with current guidelines.

A cross-sectional observational study comparing foot and ankle characteristics in people with stroke and healthy controls.

PURPOSE: The purpose of this study was to explore and compare foot and ankle characteristics in people with stroke and healthy controls; and between stroke fallers and non-fallers. METHODS: Participants were recruited from community groups and completed standardized tests assessing sensation, foot posture, foot function, ankle dorsiflexion and first metatarsal phalangeal joint range of motion (1st MPJ ROM), hallux valgus presence and severity. RESULTS: Twenty-three stroke participants (mean age 75.09 ± 7.57 years; 12 fallers) and 16 controls (mean age 73.44 ± 8.35 years) took part. Within the stroke group, reduced 1st MPJ sensation (p = 0.016) and 1st MPJ ROM (p = 0.025) were observed in the affected foot in comparison to the non-affected foot; no other differences were apparent. Pooled data (for both feet) was used to explore between stroke/control (n = 78 feet) and stroke faller/non-faller (n = 46 feet) group differences. In comparison to the control group, stroke participants exhibited reduced sensation of the 1st MPJ (p = 0.020), higher Foot Posture Index scores (indicating greater foot pronation, p = 0.008) and reduced foot function (p = 0.003). Stroke fallers exhibited significantly greater foot pronation in comparison to non-fallers (p = 0.027). CONCLUSIONS: Results indicated differences in foot and ankle characteristics post stroke in comparison to healthy controls. These changes may negatively impact functional ability and the ability to preserve balance. Further research is warranted to explore the influence of foot problems on balance ability and falls in people with stroke. Implications for Rehabilitation Foot problems are common post stroke. As foot problems have been linked to increased fall risk among the general population we recommend that it would be beneficial to include foot and ankle assessments or a referral to a podiatrist for people with stroke who report foot problems. Further research is needed to explore if we can improve functional performance post stroke and reduce fall risk if treatment or prevention of foot problems can be included in stroke rehabilitation.

A survey exploring self-reported indoor and outdoor footwear habits, foot problems and fall status in people with stroke and Parkinson's.

BACKGROUND: Ill-fitting shoes have been implicated as a risk factor for falls but research to date has focused on people with arthritis, diabetes and the general older population; little is known about people with neurological conditions. This survey for people with stroke and Parkinson's explored people's choice of indoor and outdoor footwear, foot problems and fall history. METHODS: Following ethical approval, 1000 anonymous postal questionnaires were distributed to health professionals, leads of Parkinson's UK groups and stroke clubs in the wider Southampton area, UK. These collaborators handed out survey packs to people with a confirmed diagnosis of stroke or Parkinson's. RESULTS: Three hundred and sixty three completed surveys were returned (218 from people with Parkinson's and 145 from people with stroke). Most respondents wore slippers indoors and walking shoes outdoors and considered comfort and fit the most important factors when buying footwear. Foot problems were reported by 43 % (95 % confidence intervals 36 to 52 %; stroke) and 53 % (95 % confidence interval 46 to 59 %; Parkinson's) of respondents; over 50 % had never accessed foot care support. Fifty percent of all respondents reported falls. In comparison to non-fallers, a greater proportion of fallers reported foot problems (57 %), with greater proportions reporting problems impacting on balance and influencing choice of footwear (p < 0.01) in comparison to non-fallers in each case. Forty-seven percent of fallers with foot problems had not accessed foot care support. CONCLUSIONS: Many people with stroke and Parkinson's wear slippers indoors. A high percentage of these individuals reported both foot problems and falls impacting on footwear habits and choice of footwear; however many did not receive foot care support. These findings highlight that further exploration of footwear and foot problems in these populations is warranted to provide evidence based advice on safe and appropriate footwear to support rehabilitation and fall prevention.

Physical inactivity post-stroke: a 3-year longitudinal study.

PURPOSE: To explore change in activity levels post-stroke. METHODS: We measured activity levels using the activPAL™ in hospital and at 1, 2 and 3 years' post-stroke onset. RESULTS: Of the 74 participants (mean age 76 (SD 11), 39 men), 61 were assessed in hospital: 94% of time was spent in sitting/lying, 4% standing and 2% walking. Activity levels improved over time (complete cases n = 15); time spent sitting/lying decreased (p = 0.001); time spent standing, walking and number of steps increased (p = 0.001, p = 0.028 and p = 0.03, respectively). At year 3, 18% of time was spent in standing and 9% walking. Time spent upright correlated significantly with Barthel (r = 0.69 on admission, r = 0.68 on discharge, both p < 0.01) and functional ambulation category scores (r = 0.55 on admission, 0.63 on discharge, both p < 0.05); correlations remained significant at all assessment points. Depression (in hospital), left hemisphere infarction (Years 1-2), visual neglect (Year 2), poor mobility and balance (Years 1-3) correlated with poorer activity levels. CONCLUSION: People with stroke were inactive for the majority of time. Time spent upright improved significantly by 1 year post-stroke; improvements slowed down thereafter. Poor activity levels correlated with physical and psychological measures. Larger studies are indicated to identify predictors of activity levels. Implications for Rehabilitation Activity levels (measured using activPAL™ activity monitor), increased significantly by 1 year post-stroke but improvements slowed down at 2 and 3 years. People with stroke were inactive for the majority of their day in hospital and in the community. Poor activity levels correlated with physical and psychological measures. Larger studies are indicated to identify the most important predictors of activity levels.

A design to investigate the feasibility and effects of partnered ballroom dancing on people with Parkinson disease: randomized controlled trial protocol.

BACKGROUND: Self-help and physical leisure activities has become increasingly important in the maintenance of safe and functional mobility among an increasingly elderly population. Preventing the cycle of deterioration, falling, inactivity, dependency, and secondary complications in people with Parkinson disease (PD) is a priority. Research has shown that people with PD are interested in dance and although the few existing trials are small, initial proof of principle trials from the United States have demonstrated beneficial effects on balance control, gait, and activity levels. To our knowledge, there has been no research into long-term effects, cost effectiveness, the influence on spinal posture and turning, or the personal insights of dance participants. OBJECTIVE: The purpose of this study was to determine the methodological feasibility of conducting a definitive phase III trial to evaluate the benefits of dance in people with PD. We will build on the proof of principle trials by addressing gaps in knowledge, focusing on areas of greatest methodological uncertainty; the choice of dances and intensity of the program; for the main trial, the availability of partners, the suitability of the currently envisaged primary outcomes, balance and spinal posture; and the key costs of delivering and participating in a dance program to inform economic evaluation. METHODS: Fifty participants (mild-to-moderate condition) will be randomized to the control (usual care) or experimental (dance plus usual care) groups at a ratio of 15:35. Dance will be taught by professional teachers in a dance center in the South of England. Each participant in the experimental group will dance with his or her spouse, a friend, or a partner from a bank of volunteers. A blinded assessor will complete clinical measures and self-reported ability at baseline, and at 3 and 6 months after randomization. A qualitative study of a subgroup of participants and partners will examine user's views about the appropriateness and acceptability of the intervention, assessment protocol, and general trial procedures. Procedures for an economic evaluation of dance for health care will be developed for the main trial. RESULTS: Recruitment began in January 2013 and the last participant is expected to complete the trial follow-up in June 2014. CONCLUSIONS: Findings from our study may provide novel insights into the way people with PD become involved in dance, their views and opinions, and the suitability of our primary and secondary outcomes. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 63088686; http://www.controlled-trials.com/ISRCTN63088686/63088686 (Archived by WebCite at http://www.webcitation.org/6QYyjehP7).

Interventions for preventing falls in people after stroke.

BACKGROUND: Falls are one of the most common medical complications after stroke with a reported incidence of 7% in the first week after stroke onset. Studies investigating falls in the later phase after stroke report an incidence of up to 73% in the first year post-stroke. OBJECTIVES: To evaluate the effectiveness of interventions aimed at preventing falls in people after stroke. SEARCH METHODS: We searched the trials registers of the Cochrane Stroke Group (November 2012) and the Cochrane Bone, Joint and Muscle Trauma Group (May 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2012, Issue 5, MEDLINE (1950 to May 2012), EMBASE (1980 to May 2012), CINAHL (1982 to May 2012), PsycINFO (1806 to May 2012), AMED (1985 to May 2012) and PEDro (May 2012). We also searched trials registers, checked reference lists and contacted authors. SELECTION CRITERIA: Randomised controlled trials of interventions where the primary or secondary aim was to prevent falls in people after stroke. DATA COLLECTION AND ANALYSIS: Review authors independently selected studies for inclusion, assessed trial quality, and extracted data. We used a rate ratio and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling we used a risk ratio and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate. MAIN RESULTS: We included 10 studies with a total of 1004 participants. One study evaluated the effect of exercises in the acute and subacute phase after stroke but found no significant difference in rate of falls (rate ratio 0.92, 95% CI 0.45 to 1.90, 95 participants). The pooled result of four studies investigating the effect of exercises on preventing falls in the chronic phase also found no significant difference for rate of falls (rate ratio 0.75, 95% CI 0.41 to 1.38, 412 participants).For number of fallers, one study examined the effect of exercises in the acute and subacute phase after stroke but found no significant difference between the intervention and control group (risk ratio 1.19, 95% CI 0.83 to 1.71, 95 participants). The pooled result of six studies examining the effect of exercises in the chronic phase also found no significant difference in number of fallers between the intervention and control groups (risk ratio 1.02, 95% CI 0.83 to 1.24, 616 participants).The rate of falls and the number of fallers was significantly reduced in two studies evaluating the effect of medication on preventing falls; one study (85 participants) compared vitamin D versus placebo in institutionalised women after stroke with low vitamin D levels, and the other study (79 participants) evaluated alendronate versus alphacalcidol in hospitalised people after stroke.One study provided single lens distance glasses to regular wearers of multifocal glasses. In a subgroup of 46 participants post-stroke there was no significant difference in the rate of falls (rate ratio 1.08, 95% CI 0.52 to 2.25) or the number of fallers between both groups (risk ratio 0.74, 95% CI 0.47 to 1.18). AUTHORS' CONCLUSIONS: There is currently insufficient evidence that exercises or prescription of single lens glasses to multifocal users prevent falls or decrease the number of people falling after being discharged from rehabilitation following their stroke. Two studies testing vitamin D versus placebo and alendronate versus alphacalcidol found a significant reduction in falls and the number of people falling. However, these findings should be replicated before the results are implemented in clinical practice.

Functional electrical stimulation with exercises for standing balance and weight transfer in acute stroke patients: a feasibility randomized controlled trial.

OBJECTIVES: To test parameters needed for the design of a larger trial including the following: 1) identifying eligible participants, recruitment, and retention rates; 2) the feasibility and acceptability of delivering functional electrical stimulation (FES) to the gluteus maximus and quadriceps femoris for acute stroke patients in a hospital rehabilitation setting; 3) the outcome measures; 4) obtaining initial estimates of effect size; and 5) clarifying the relevant control group. MATERIALS AND METHODS: Twenty-one people with acute stroke-mean age = 68 (min to max: 33-87) years; weeks postonset = 4.6 (min to max: 1-14)-were randomized to three groups to receive two weeks of balance training with FES, balance training alone, or usual care. Symmetry in normal standing, weight transfer onto the affected limb, balance, mobility, and speed of walking were assessed before, shortly after the end of training, and two weeks later by a blinded assessor. RESULTS: 1) FES was successfully delivered but not with the planned eight sessions; 2) no trends in favor of FES were found; and 3) 4% of those screened took part but approaching 20% might be recruited in the future, no single outcome measure was suitable for all participants, and more routine physiotherapy was delivered to the control group. CONCLUSIONS: FES is feasible in this patient group but further feasibility and definitive trials are required.

Impact of stroke-associated infection on long-term survival: a cohort study.

BACKGROUND AND OBJECTIVE: The effects of stroke-associated infection (SAI) on long-term survival are unclear. We performed a prospective evaluation to explore risk factors of SAI, and compared survival status over the 3 years following stroke onset between those who experienced SAI and those who did not. METHODS: Consecutive patients with acute stroke admitted to a stroke unit between April 2005 and December 2006 were invited to participate. We prospectively collected data on demographics, pathological and clinical stroke subtype, stroke severity, and neurological and functional consequences, and abstracted additional data on occurrence and timing of SAI in hospital from medical notes. Survival status 3 years after stroke onset was obtained. RESULTS: We recruited 413 acute stroke patients, 161 (39%) experienced SAI. After excluding patients with infection at onset, patients with intracerebral haemorrhage (p=0.014), dysphagia (p=0.003) and urinary incontinence/catheterisation (p=0.000) were at higher risk of infection after controlling for case mix. The risk of death in hospital was greater following an SAI (HR 3.56; 95% CI 1.94 to 6.53; p=0.000), as was risk of death calculated over the whole 3-year follow-up period among those acquiring SAI within 2 weeks of onset (HR 1.66; 95% CI 1.14 to 2.40; p=0.031). CONCLUSIONS: SAIs have long-lasting effects on patient survival. This serves to emphasise the importance of immediate access to organised stroke unit care for people with acute stroke, with active physiological monitoring and protocols for early detection and treatment of SAIs.

Investigating head and trunk rotation in sitting: a pilot study comparing people after stroke and healthy controls.

BACKGROUND AND PURPOSE: Healthy individuals have a top-down coordination pattern when turning while walking; they first rotate the head, then the shoulders, the pelvis and, finally, the feet. The aim of this study was to compare spatial and temporal characteristics of head and trunk rotation in sitting between people early after stroke and healthy participants, and investigate change over time. METHODS: This was a pilot, quantitative, longitudinal study. We recruited participants from stroke wards and local groups. People with stroke were assessed at 3, 6 and 12 weeks after stroke. Healthy participants were examined with the same weekly intervals. Participants were in a seated position and were asked verbally to rotate their head and look at a visual signal placed at 90° to the left and to the right of the subject. CODAmotion (Charnwood Dynamics Ltd, Rothley, UK) was used for 3-D motion recording and analysis. RESULTS: Healthy participants (two women and four men; mean age 66 years) showed significant rotation of the head before rotation of the shoulders at all three time points; people with stroke (one woman and five men; mean age 71 years) did not show this top-down pattern of movement. There was no significant difference between start times of head and shoulder rotation at 3 (p = 0.167), 6 (p = 0.084) and 12 weeks after stroke (p = 0.062). Conclusions. The results of our pilot study warrant further investigation into the recovery and pattern of axial coordination after stroke. Future studies could provide insight into the mechanisms behind impaired postural control in people after stroke.