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Introduction: Community-dwelling, ambulatory stroke survivors fall at very high rates in the first 3-6 months. Current inpatient clinical assessments for fall risk have inadequate predictive accuracy. We found that a pre-discharge obstacle-crossing test has excellent specificity (83%) but lacks acceptable sensitivity (67%) for identifying would-be fallers and non-fallers post discharge. Hypothesis: We assessed the hypothesis that combining the obstacle-crossing test with other highly discriminatory fall risk factors would compensate for the obstacle test’s fair sensitivity and yield an instrument with superior prediction accuracy. Methods: 45 ambulatory stroke survivors (60±11 years old, 15±11 days post stroke) being discharged home completed a battery of physical performance-based and self-reported measures 1-5 days prior to discharge. After discharge, participants were prospectively followed and classified as fallers (≥1 fall) or non-fallers at 3 months. Pre-discharge measures with the largest effect sizes for differentiating fallers and non-fallers were combined into a composite index. Several variations of the composite index were examined to optimize accuracy. Results: A 4-item discharge composite index significantly predicted fall status at 3-months. The goodness of fit of the regression model was significantly better than the obstacle-crossing test alone, χ2(1) = 6.036, p=0.014. Furthermore, whereas the obstacle-crossing test had acceptable overall accuracy (AUC 0.78, 95% CI 0.60-0.90), the composite index had excellent accuracy (AUC 0.85, 95% CI 0.74-0.96). Combining the obstacle-crossing test with only the step test produced a model of equivalent accuracy (AUC 0.85, 95% CI 0.73-0.96) and with better symmetry between sensitivity and specificity (0.71, 0.83) than the 4-item composite index (0.86, 0.67). This 2-item index was validated in an independent sample of n=30 and with bootstrapping 1000 samples from the pooled cohorts. The 4-item index was internally validated with bootstrapping 1000 samples from the derivation cohort plus n=9 additional participants. Conclusion: This study provides convincing proof-of-concept that strategic aggregation of performance-based and self-reported mobility measures, including a novel and demanding obstacle-crossing test, can predict post-discharge fallers with excellent accuracy. Further instrument development is warranted to construct a brief aggregate tool that will be pragmatic for inpatient use and improve identification of future post-stroke fallers before the first fall.

Benjamin Curtis Ramger,1 Kimberly Anne Bader,1 Samantha Pauline Davies,1 David Andrew Stewart,1 Leila Snow Ledbetter,2 Corey Brae Simon,1 Jody Ann Feld1 1Physical Therapy Division, Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA; 2Research and Education, Duke University Medical Center Library, Durham, NC, USACorrespondence: Jody Ann FeldPhysical Therapy Division, Department of Orthopedic Surgery, Duke University School of Medicine, DUMC 104002, Durham, NC 27710, USATel +1 919-681-1979Email jody.feld@dm.duke.eduPurpose: Central post-stroke pain (CPSP) is a neuropathic disorder resulting in pain and disability. An emerging treatment for CPSP is non-invasive brain stimulation including direct current stimulation [tDCS] and repetitive transcranial magnetic stimulation [rTMS]. This systematic review analyzes the efficacy and quality of non-invasive brain stimulation intervention studies for CPSP.Methods: Studies were sought from three research databases published between 2007 and 2017. Studies were included if the sole intervention was non-invasive brain stimulation and the primary outcome either clinical or experimental pain intensity. Studies were qualitatively assessed for risk of bias.Results: Of 1107 articles extracted, six met eligibility criteria. Five studies found a decrease in pain intensity (p

Introduction: Community-dwelling stroke survivors are extremely inactive, leading to a possible cascade of secondary health problems such as obesity and depression and risk for second stroke and mortality. Falls are also a common and serious adverse event, especially prevalent in the first few months after hospital discharge. Customary clinical gait assessments do not adequately predict falls or inactivity after hospital discharge. Objective: To examine whether community-relevant mobility tasks (obstacle crossing and dual-task walking) assessed at hospital discharge can predict fall risk and daily walking activity, respectively, in the first 3 months post discharge. Participants: 47 participants with a mean age of 59.8 (SD=11.7) years and median of 14 (IQR=7-21) days post stroke who were being discharged home from acute care or acute inpatient rehabilitation. Methods: In addition to traditional clinical assessments, participants completed 2 single-task and 2 dual-task walking trials, followed by 4 obstacle-crossing trials (height: 10% of leg length) at their self-selected walking speed, all over an instrumented walkway. Following discharge, participants completed a prospective falls diary and at 3 months post discharge wore an activity monitor to assess daily walking activity. Binary logistic regressions were used to examine the relationship between pre-discharge obstacle-crossing performance and fall status at 3-months post discharge and pre-discharge dual-task gait speed at discharge and walking activity at 3 months post discharge. Results: Participants who failed the obstacle-crossing task at hospital discharge had a significantly higher odds of falling (OR=10.00, 95% CI 2.45, 40.78) in the first 3 months post discharge than those who passed the obstacle-crossing task. A 1-unit change in dual-task gait (DTG) speed resulted in significantly higher odds (OR=23.25, CI 2.46, 219.38) of being a community ambulator at 3 months post hospital discharge. Therefore, for a 0.10 m/s increase in DTG speed, we would expect a 37% increase in the odds of being a community ambulator. Conclusions: Obstacle-crossing appears to be a useful discharge risk-assessment tool for identifying future fallers. The clinical significance of dual-task walking in predicting ambulatory activity after discharge is unclear due to imprecision of the effect estimate, but the present findings suggest that further investigation is warranted.