A Novel Strategy to Decrease Fall Incidence Post-Stroke (BLAST)

March 28, 2022 updated by: VA Office of Research and Development
Approximately 15,000 Veterans are hospitalized for stroke each year with new cases costing an estimated $111 million for acute inpatient, $75 million for post-acute inpatient, and $88 million for follow-up care over 6 months post-stroke. Contributing to these costs is the incidence of falls. Falls are a costly complication for Veterans with stroke as they lead to an increased incidence of fractures, depression, and mortality. New strategies are needed to help Veterans post-stroke regain their ability to safely walk without increasing their risk of falling as well as readily identify those who are a fall risk. This study addresses both of these needs as it will 1) investigate a new treatment approach, backward walking training, to determine if it will decrease fall incidence in the first year post-stroke and 2) determine if backward walking speed early after a stroke can identify those that are at risk for future falls.

Study Overview

Status

Completed

Conditions

Detailed Description

Approximately 15,000 Veterans are hospitalized for stroke each year. Persistent walking and balance deficits contribute to long-term disability and a high incidence of falls. Falls are a common and costly complication of stroke; between 40% and 70% of affected individuals fall within the first year. Falls lead to fear of falling, limitations in self-care and increased dependence. Of greater concern, they lead to serious adverse events, including fractures, depression and mortality. A primary goal of stroke rehabilitation is to improve mobility despite persistent motor, balance and visual-spatial deficits. However, this goal has a down side since it increases fall risks. Here, the investigators propose a novel therapeutic strategy to improve ambulation while decreasing the risk of falls: Backward Walking Training (BWTraining).

The investigators' central hypothesis is that a 6-week BWTraining program at 2-months post-stroke is superior to standard care in reducing falls within the 1st year post-stroke. Identification of those at risk for falling is a necessary component of post-stroke rehabilitation to implement pro-active measures to decrease risk once individuals rejoin community living. Recent research in a cohort of elderly adults determined that maximal Backward Walking Speed (BWSpeed) (not forward) identified individuals that had experienced a fall in the previous six months,6 suggesting that BWSpeed could be a simple, inexpensive screening tool to identify individuals at risk of falling. With a randomized, blinded design, the investigators propose to prospectively assess the value of BWSpeed as a tool to predict future falls.

A notable post-stroke conundrum is that increased mobility may increase fall risk.5 On the other hand, limiting mobility leads to a multitude of inactivity-associated deficits, including recurrent stroke.

To date, no intervention has demonstrated efficacy for improving walking while minimizing fall risk. BWTraining may be a simple and effective intervention to achieve both goals. In the investigators' recent randomized controlled pilot trial (RCT), individuals with sub-acute stroke who participated in a BWTraining demonstrated 3-fold improvement in backward and forward walking speed and fall self-efficacy. Further, BWTraining caused 75% greater improvement in balance versus those in a dose-matched balance training group. At the 3-month follow-up assessment, BWSpeed of the BWTraining group averaged 0.63 m/s, exceeding the threshold for fall risk in elderly adults.

Given the success of the investigators' pilot intervention, a larger and more rigorous trial is needed to demonstrate reduced fall incidence over an extended follow-up period. The investigators designed this RCT to address three specific aims:

Aim #1: Test the hypothesis that 1-year fall incidence is decreased for participants randomized to BWTraining administered at 2-months post-stroke (versus usual care comparison group).

Hypothesis #1a: BWTraining at 2-months post-stroke reduces the number of falls over the next year.

Hypothesis #1b: BWTraining at 2-months post-stroke increases gait speed, improves balance and increases balance confidence over the next year.

Aim #2: Test the hypothesis that BWTraining at 2 months (immediate) vs. 1-year (delayed) post-stroke is more effective at improving BWSpeed.

Hypothesis #2a: BWSpeed improvement from 2- to 14-months post-stroke is greater when BWTraining is delivered at 2 months versus 1 year post-stroke.

Hypothesis #2b: Improvements in forward gait speed, Functional Gait Assessment and Activities-Balance Confidence Scale from 2- to 14-months post-stroke are greater when BWTraining is delivered at 2 months versus 1 year post-stroke.

Aim #3: This exploratory aim will test the hypothesis that BWSpeed at 2-months post-stroke is a significant predictor of fall incidence over the next year 1 year period, after adjusting for other covariates.

Hypothesis #3: BWSpeed at 2-months will be a significant predictor of fall incidence during the first year post-stroke, after adjusting for other covariates.

This study is significant since it concerns a novel strategy to improve ambulation while minimizing the risk of falling after a stroke. BWTraining is highly novel, is easy to administer and exciting preliminary data suggest that is has major potential as a therapeutic tool. In addition, the investigators will determine the potential of BWSpeed (a simple, clinically relevant screening tool) to identify those at risk for future falls.

Study Type

Interventional

Enrollment (Actual)

62

Phase

  • Phase 2
  • Phase 1

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

    • Florida
      • Gainesville, Florida, United States, 32608
        • North Florida/South Georgia Veterans Health System, Gainesville, FL

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years to 90 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Berg Balance Scale < 42
  • Self-selected 10 meter gait speed < 0.8 m/s
  • Diagnosis of unilateral stroke
  • > 2 months < 4 months post-stroke
  • Able to ambulate at least 10 feet with maximum 1 person assist
  • Medically stable
  • 18-85 years of age
  • Physician approval for patient participation

Exclusion Criteria:

  • Presence of neurological condition other than stroke
  • Serious cardiac conditions

    • hospitalization for myocardial infarction or heart surgery within 3 months
    • history of congestive heart failure
    • documented serious and unstable cardiac arrhythmias
    • hypertrophic cardiomyopathy
    • severe aortic stenosis
    • angina or dyspnea at rest or during activities of daily living
  • Anyone meeting New York Heart Association criteria for Class 3 or Class 4 heart disease will be excluded
  • Severe arthritis or orthopedic problems that limit passive ranges of motion of lower extremity

    • knee flexion contracture of -10
    • knee flexion ROM < 90
    • hip flexion contracture > 25
    • ankle plantar flexion contracture > 15
  • Severe hypertension with systolic greater than 200 mmHg and diastolic greater than 110 mmHg at rest, that cannot be medically controlled into the resting range of 180/100 mmHg
  • Pain upon ambulation
  • Receiving physical therapy services for mobility and/or gait
  • Living in a skilled nursing facility
  • Unable to ambulate at least 150 feet prior to stroke, or experienced intermittent claudication while walking less than 200 meters
  • History of serious chronic obstructive pulmonary disease or oxygen independence
  • Non-healing ulcers on the lower extremity
  • Uncontrollable diabetes with recent weight loss, diabetic coma or frequent insulin reactions
  • On renal dialysis or presence of end stage liver disease
  • Pulmonary embolism within previous 6 months
  • History of major head trauma
  • History of sustained alcoholism or drug abuse in the last six months
  • Intracranial hemorrhage related to aneurysmal rupture or an arteriovenous malformation
  • Current enrollment in a clinical trial to enhance stroke motor recovery

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Immediate Backward Walking Training
Individuals will participate in 18 sessions of Backward Walking training immediately following baseline assessment.
Backward Walking Training will occur both on a treadmill and overground. In brief, BWTraining will consist of 20-30 minutes of step training with a Body Weight Support and Treadmill system (BWST), rest periods provided as warranted, with manual assistance provided by trainers, followed by 15 minutes of overground gait training. A 20-30 min period of actual stepping is the goal for the intervention sessions on the treadmill with rest periods as needed. Each training session may last up to 1 hour and 30 minutes including time for warm-up, stretching, and cool down. Participants will be fitted with a harness around their hips and torso, which will be attached to an overhead support system directly above the treadmill. From a stationary position, the treadmill belt will gradually be increased in speed with intervention trainers assisting participant to step backward with their paretic leg, their non-paretic leg (if needed) and at the hips for weight-shift.
Active Comparator: Delayed Backward Walking Training
Individuals will participate in 18 sessions of Backward Walking training at 1-year post-strokeD
Backward Walking Training will occur both on a treadmill and overground. In brief, BWTraining will consist of 20-30 minutes of step training with a Body Weight Support and Treadmill system (BWST), rest periods provided as warranted, with manual assistance provided by trainers, followed by 15 minutes of overground gait training. A 20-30 min period of actual stepping is the goal for the intervention sessions on the treadmill with rest periods as needed. Each training session may last up to 1 hour and 30 minutes including time for warm-up, stretching, and cool down. Participants will be fitted with a harness around their hips and torso, which will be attached to an overhead support system directly above the treadmill. From a stationary position, the treadmill belt will gradually be increased in speed with intervention trainers assisting participant to step backward with their paretic leg, their non-paretic leg (if needed) and at the hips for weight-shift.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Fall incidence (number of falls)
Time Frame: Change between baseline and 1-year post-stroke
Fall incidence will be monitored using the international standards for defining and reporting falls,60 including the following definition for a fall: "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." This explanation will be provided to participants and caregivers and printed on monthly calendars issued at randomization.
Change between baseline and 1-year post-stroke

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
10 Meter Walk Test
Time Frame: Change between baseline and 1-year post-stroke
Individuals will be given a 2 meter warm-up distance for walking, preceding the 10 meter distance and 2 meters beyond the 10 meters to continue walking. The time that it takes to traverse the 10 meters at the subject's usual pace will be recorded.
Change between baseline and 1-year post-stroke
3-Meter Backward Walk test
Time Frame: Change between baseline and 1-year post-stroke
The test consists of a 1 meter warm-up distance, a timed 3 meter distance, followed by an additional 1 meter to continue walking An average of two trials will be recorded.
Change between baseline and 1-year post-stroke
Functional Gait Assessment
Time Frame: Change between baseline and 1-year post-stroke
A 10-item clinical gait and balance test during which participants perform the following activities: walk at normal speeds, at fast and slow speeds, with vertical and horizontal head turns, with eyes closed, over obstacles, in tandem, backward and while ascending and descending stairs.
Change between baseline and 1-year post-stroke
Activities-Specific Balance Confidence Scale
Time Frame: Change between baseline and 1-year post-stroke
This 16-item self-report measure is used to assess perceived efficacy (self-reported confidence) in maintaining balance while performing a number of activities common in community-dwelling older adults.
Change between baseline and 1-year post-stroke
Berg Balance Scale
Time Frame: Change between baseline and 1-year post-stroke
This tool consists of 14 items that assesses static and dynamic standing balance, ability to sit, stand up and transfer.
Change between baseline and 1-year post-stroke
Lower-Extremity Fugl-Meyer Motor Score
Time Frame: Change between baseline and 1-year post-stroke
This tool consists of 17 items that assess motor control of the lower extremity as participants move their hip, knee and ankle in lying, sitting and standing
Change between baseline and 1-year post-stroke
Four-Step Square Test
Time Frame: Change between baseline and 1-year post-stroke
This clinical test of dynamic standing balance examines the ability to step over small objects, change direction and includes taking a backwards step.
Change between baseline and 1-year post-stroke
Stride time
Time Frame: Change between baseline and 1-year post-stroke
Stride time will be captured during forward and backward walking across a GAITRite instrumented walkway.
Change between baseline and 1-year post-stroke
Stride length
Time Frame: Change between baseline and 1-year post-stroke
Stride length will be captured during forward and backward walking across a GAITRite instrumented walkway.
Change between baseline and 1-year post-stroke
Step time
Time Frame: Change between baseline and 1-year post-stroke
Step time will be captured during forward and backward walking across a GAITRite instrumented walkway.
Change between baseline and 1-year post-stroke
Step length
Time Frame: Change between baseline and 1-year post-stroke
Step length will be captured during forward and backward walking across a GAITRite instrumented walkway.
Change between baseline and 1-year post-stroke
Step width
Time Frame: Change between baseline and 1-year post-stroke
Step width will be captured during forward and backward walking across a GAITRite instrumented walkway.
Change between baseline and 1-year post-stroke
Kinesiologic assessment of walking
Time Frame: Change between baseline and 1-year post-stroke
While walking, three-dimensional ground reaction forces will be acquired under each foot. Hip, knee and ankle angle data from the LE's will be acquired by placing reflective markers on the participant using a modified Helen Hayes marker set with rigid clusters on the pelvis and each thigh, shank and foot segments and recording the movement of these markers at 100 Hz using a 12 camera motion capture system.
Change between baseline and 1-year post-stroke

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Investigators

  • Principal Investigator: Dorian Kay Rose, PhD MS BS, North Florida/South Georgia Veterans Health System, Gainesville, FL

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

August 14, 2017

Primary Completion (Actual)

September 30, 2021

Study Completion (Actual)

February 11, 2022

Study Registration Dates

First Submitted

February 17, 2016

First Submitted That Met QC Criteria

February 17, 2016

First Posted (Estimate)

February 23, 2016

Study Record Updates

Last Update Posted (Actual)

March 29, 2022

Last Update Submitted That Met QC Criteria

March 28, 2022

Last Verified

March 1, 2022

More Information

Terms related to this study

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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