The effects of a multi-dimension rehabilitation programme for reducing fear of falling in patients with chronic stroke : a randomized, controlled trial

Abstract

Stroke is a chronic and disabling age-related disease worldwide. Current projections estimate that the global number of people with stroke will reach 77 million by 2030 as a consequence of increased life expectancy and decreased mortality rates. Falling is a major complication after stroke, and the fear of falling is a major psychological contributor to an increased risk of falling. Studies have suggested that physical training, including functional and task-oriented balance training (TOBT) and gait rehabilitation, can effectively reduce the fear of falling in people with stroke. Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that aims to redirect an individual's maladaptive thoughts and behaviors. CBT has shown promising results with various health issues, such as depression and chronic back pain, and clinical trials have demonstrated its ability to reduce the fear of falling in healthy older adults. TOBT is a form of physical training that has been clinically proven to improve the recovery of motor function after stroke. A meta-analysis revealed that a 2- to 6-week course of TOBT could improve upper and lower limb motor function and balance performance in people with stroke, which could reduce fear of falling. Given the evidence available, one could reasonably hypothesize that the addition of CBT would augment the benefits of TOBT in reducing fear of falling in people with stroke. Therefore, this study aimed to compare the combination of CBT or general health education (GHE) with TOBT (CBT + TOBT or GHE + TOBT, respectively) to determine whether the former would more rapidly and effectively improve the fear of falling in people with stroke. We further anticipated that the combination of CBT and TOBT would induce earlier and greater improvements in fear avoidance behaviors exhibited by people with stroke and in related health variables such as balance performance, fall risk, independent daily living, community integration, and health-related quality of life. This thesis begins with a systematic review and meta-analysis (study 1) of the effects of CBT with respect to reducing the fear of falling and improving balance performance in older adults. The positive findings of our systematic review and meta-analysis suggest that CBT may effectively reduce the fear of falling in older adults. In study 2, we investigated the abilities of subjective balance confidence, walking endurance, and fear avoidance behavior to predict the level of community reintegration in community-dwelling people with stroke. Notably, we identified fear avoidance behavior as the most potent predictor of the level of community reintegration in this population. This finding was consistent with our hypothesis that an improved fear of falling could enhance the level of community reintegration in people with stroke. In addition to determining an intervention to effectively reduce the fear of falling, it is also important to identify outcome measures that reflect its effectiveness. After reviewing the evidence in support of CBT's ability to reduce the fear of falling and investigating the predictive role of fear avoidance behavior in community reintegration of people with stroke, we conducted three cross-sectional studies to identify reliable and valid outcome measures for the main study which investigated the effectiveness of combined CBT with TOBT in improving fear of falling in people with stroke. We then examined the psychometric properties of three potential assessment tools in cross-sectional studies 3 through 5. In studies 3 and 4, we examined the psychometric properties of the Chinese version of the Survey of Activities and Fear of Falling in the Elderly (SAFE-C) and the Short-form Physiological Profile Assessment (S-PPA), respectively. Both measures proved valid and reliable for assessment of fear avoidance behavior and fall risk, respectively, in people with stroke. In study 5, we translated and validated the Community Integration Measure (CIM) and demonstrated that the Chinese version of CIM is a valid and reliable tool for assessment of the level of community reintegration in Hong Kong Chinese people with stroke. To facilitate replication and create an impactful clinical application, we developed a detailed protocol for the main study in study 6. In study 7, our main study, we examined whether the combination of CBT + TOBT would be more effective than the combination of GHE + TOBT for reducing the fear of falling and fear avoidance behavior and improving balance performance, fall risk, independent living, health-related quality of life, and community reintegration in community-dwelling people with stroke. In our main study, we compared the effectiveness of CBT + TOBT (experimental group) and GHE + TOBT (control group) in reducing the fear of falling and thus reducing fear avoidance behavior and improving balance performance, fall risk, independent living, health-related quality of life, and community reintegration after a stroke. Eighty-nine subjects were randomized into either the experimental group or the control group and participated in 90-minute interventions 2 days per week for 8 weeks. The outcomes were assessed at baseline, after 4 and 8 weeks of intervention, and 3 and 12 months after the intervention ended. In summary, our findings reveal that the participants in the CBT + TOBT group reported greater improvements than those in the control group regarding fear of falling, fear avoidance behavior, balance performance, independent daily living, and community reintegration over time from the end of the intervention to the 12-month follow-up visit and greater improvement in physical function at the 12-month follow-up visit. The CBT + TOBT and GHE + TOBT groups both demonstrated significant reductions from baseline in the fear of falling and significant improvements in balance performance and physical function from mid-intervention (4 weeks) to the 12-month follow-up visit and significant reductions in fear avoidance behavior over time from the end of the intervention to the 12-month follow-up visit. However, only the CBT + TOBT group exhibited significant improvements in independent daily living and community reintegration from the end of the intervention to the 12-month follow-up visit.