Most stroke patients receive some form of physiotherapy and most stroke specialists would agree that physiotherapeutic interventions are key to restoring mobility and balance. After a stroke, ways of coping with deficits have to be learnt, and it is unquestionable that in many patients supervised practice of physical skills will provide benefits. Physiotherapy helps to identify impairments in dynamic function as well as the ways in which patients physically compensate for the deficits. Sometimes falls may result from the deficits themselves and sometimes from the compensatory mechanisms (e.g., over-reliance on unaffected limbs to the extent that balance is affected, known as “pusher syndrome”). Physiotherapists can help teach patients adaptive and balanced ways of mobilizing so that they can reduce their falls risk.

Physiotherapists and occupational therapists both have an important role to play in determining what patients can and cannot do safely. This is vital to prevent falls in both inpatient and community settings. By setting guidelines about what patients should be doing on their own, and what they should be doing with supervision, what aids they should be using, and what mobilisation techniques they should employ, therapists can help ensure that the falls risk is minimized as long as patients are operating on a day-to-day basis within their recommended safe levels of function. Of course, if falls do occur it is mandatory to determine whether patients were operating within these recommended safe levels, or whether they were doing something over and above what had been recommended. In the case of a patient who falls despite following recommendations, further assessments may be warranted to determine if there was another unrecognized cause of the fall. In some cases, discussion may need to take place about whether the previously agreed safe levels of function are actually still safe. Sometimes new, lower levels may need to be set, but of course this may compromise the independence of patient. The decision to do this would have to take place as part of a wider analysis of the patients’ goals and wishes as well as the overall direction of rehabilitation. Conversely, the management of a patient who falls after “giving it a go” with a risky and unrecommended manoeuvre is very different. The reasons that the patient has for taking the risk need to be sought in order to determine the approach to take. On the one hand, the patient may not be aware of the risk and require an explanation; alternatively, they might acknowledge the risk but go ahead anyway because of an urge for independence. In all these cases, an individualized approach needs to be taken, in order that the management plans can be tailor-made for each patient. In many cases, there is also a difficult balance to be struck between independence and safety.

A number of randomized controlled trials have addressed the question of whether falls can be reduced in stroke patients undergoing specific physiotherapeutic or exercise regimens. A small trial on early rehabilitation after stroke randomized 56 patients to normal care or an intervention group that were mobilized in the first 24 h post-stroke [37]. This intervention proved no less safe than normal care, but the rates of falls over the following year were no different. As previously discussed, falls are commonly seen while transferring. A study of 48 patients compared usual inpatient rehabilitation with a group who received extra sit-to-stand practice [38]. Although the intervention group’s sit-to-stand performance and quality of life improved, their falls rate remained unchanged. Another research group [39] gave patients a rehabilitation programme that included sit-to-stand training as well as training with a biofeedback device aimed at improving postural symmetry. Out of their 54 participants, they found that the intervention group suffered significantly fewer falls than the controls who underwent a conventional rehabilitation programme (42 % vs. 17 %, p < 0.05).

A larger study [40] randomized 146 patients with mobility problems over a year after a stroke to receive either community physiotherapy or no intervention. At 6 and 9 months, the intervention group had slightly better mobility and gait speed than the control group, but around 20 % of patients in both groups had fallen by these time points. Another community study [41] randomly assigned 61 patients to receiving either supervised agility training or Tai-Chi like stretching and weight-shifting practice. Even though the agility group fell less than the stretching/weight-shifting group (25 falls vs. 75 falls), this difference did not reach significance (p = 0.2). The agility group, whose training involved experimenter-induced standing perturbations, suffered significantly fewer falls on an unexpectedly moving platform. Yelnik et al. and Duncan et al. independently showed that falls were not reduced by a multi-sensorial approach to rehabilitation that included visual deprivation during exercise or by employing body-weight supported treadmill practice in place of home exercise including balance training [42, 43]. The latter study did, however, find significantly fewer falls in severely slow walkers who had balance training at home.

As previously discussed, commonly prescribed medications such as antihypertensives, antidepressants, sedatives, and other psychoactive drugs can predispose to falls. Some medications, however, may actually help decrease risk. Studies have demonstrated reduced falls rate and risk with vitamin D provision to patients with low vitamin D levels [44]. This may be mediated by the effect that vitamin D has on increasing muscle protein synthesis and thereby enhancing muscle strength. A further study showed an even greater reduction in falling from alendronate therapy compared with vitamin D therapy [45]. These findings have not however been replicated, and the putative mechanisms of a falls risk reduction with bisphosphonates are not clear [46, 47].

Whilst randomized controlled trial data is lacking, there are a range of possible interventions for patients with visual field defects, diplopia, or other eye movement abnormalities after stroke [48]. Some are proposed to work by restoring the visual field (restitution); these aim to take advantage of the fact that patients with so-called cortical blindness can sometimes see moving objects in their affected field. Other strategies compensate for the deficit by changing behaviour, such as by training patients to scan across the visual field. Others still aim to substitute for the visual field defect by using a device or extraneous modification such as a prism. Finally, eye patches may be useful in patients who have diplopia.

A number of different environmental interventions are possible to try to help reduce falls risk with stroke patients. In the inpatient setting, chair alarms are sometimes used to alert nurses to patients getting up who may not be very safe to mobilize independently. Other strategies involve identifying patients at risk using alert badges at “board rounds” or alert wristbands. Inpatient environments should be well-lit with non-slippery floors and handrails that are easy to see.

Meanwhile at home, occupational therapy assessments are a key intervention in optimizing the environment to minimize falls risk. People’s homes may be messy with potential obstacles strewn on the floor. There may be slippery carpets or mats. The route to the toilet may be circuitous with bulky furniture in the way. These are things that are usually straightforward to fix. At the same time, balance may be improved with the provision of hand rails in opportune locations. Devices such as stair or bath lifts may help people who might otherwise fall at these locations. A convenient commode may also reduce long and risky trips to the bathroom. A range of other pieces of equipment usually recommended by physiotherapists may also help people’s balance after stroke. Some, such as sticks or orthoses, aid mobility and increase the physical area of people’s support base. The evidence-base for these therapy-directed interventions is extrapolated from interventions to prevent falls in older people in the absence of stroke-specific data [35, 49].

People who are at risk of falls may have the risk attenuated to some extent by the presence of other people to help them. For example, a common time for falls to occur is during transferring. If people have the right help and supervision at these times, whether from friends and family or formal carers, falls can be avoided.

Since urinary incontinence is associated with falls, and the relationship may be partly causal, it follows that managing the incontinence can help manage the falls risk. This will firstly involve assessments to uncover the precipitating factors leading to incontinence and, secondly, specific management strategies aimed at ameliorating or removing those factors. Of course, the management of incontinence, as much as the management of falls, is multidisciplinary, and very often physiotherapists and occupational therapists are invaluable in devising and practising toileting regimens to avoid incontinence after stroke.

A comprehensive evidence base from which to recommend particular interventions to reduce falls risk after stroke is lacking. It may be, however, that the evidence-based approach to falls reduction in the general older population can also be applied, to an extent, to stroke patients. This seems especially true of multifactorial interventions that are based on multifactorial risk assessments. However, not all strokes occur in older age and the stroke population has specific, separate problems and deficits that should be assessed and managed differently.

It is, however, fair to say that the first step in the management of falls risk after stroke is to identify the antecedent factors that contribute to the falls risk in that particular patient. There are many such factors and especially in stroke, different members of the multidisciplinary team have complementary roles in bringing these factors to light, according to their specialty. Just as the assessment of risk is multidisciplinary, so is its management. Patients at risk of falls after stroke will benefit from a coordinated approach to determine the most appropriate individualized interventions which can be applied by members of the different disciplines.

Fear of falling is increasingly recognized as an important determinant of morbidity after falling. It refers to anxiety about falling that may have been caused by a fall that actually occurred, or may just be a result of a general sense of imbalance. It affects people in a number of different ways. Firstly, there is the psychological burden of the anxiety. However, the mental state itself can also cause physical problems. If someone is afraid of falling they are less likely to attempt to mobilize; their mobility and balance then deteriorates, and, as a consequence, their fear of falling increases and becomes more justified.

Fear of falling often has functional consequences as well. People with fear of falling (or indeed with falls regardless of their emotional response) may try to do less around the house, with a resulting loss of independence. They may go out less and give up previously enjoyed activities or lose touch with their social network. These changes may have a profound impact on a patient’s quality of life. There is a possibility this could lead to poorer mental health and depression (although studies have only established a correlation and not a causal link between fear of falling and depression).

In stroke research, studies have shown correlations (again, not causal relationships) between fear of falling and indices of quality of life, depression, and anxiety [50]. Fear of falling can also hamper rehabilitation. Patients with anxieties about balance and falling may be less willing to try new compensatory mechanisms or practise recovering their mobility. This mandates an approach to stroke rehabilitation that includes consideration of patients’ psychological states, particularly with regard to their physical function. Cognitive behavioural therapy may be an invaluable tool to allow patients to learn to tackle their fear and has been shown to be effective in non-stroke patients who have fear of falling [51]. Meanwhile, exercise may have the dual benefit of increasing mobility and improving psychological health [52].

A number of injuries can result from falling and, depending on the mechanism of the fall, bleeding may result. Such bleeding will be potentiated by the antithrombotic medications commonly prescribed to patients after ischaemic stroke. Many patients are prescribed anticoagulants for secondary stroke prevention but, despite the benefit, clinicians may be reluctant to prescribe them in patients at risk of falling because of worries about contributing to bleeding, including traumatic subdural or intracerebral haemorrhage. A number of key studies have addressed this clinical dilemma. Man-Song-Hing et al. [53] analysed data from 49 different studies examining falls, anticoagulation, and intracranial haemorrhage in non-stroke patients and calculated that a person with atrial fibrillation (AF) on warfarin would have to fall 295 or more times a year to make warfarin more risky than beneficial. This probably cannot be usefully extrapolated to stroke patients, however, as it relies on assumptions about the rates of falls which are based on non-stroke patients, and the authors only used traumatic subdural haemorrhage in their analysis of factors that would count against warfarin. Gage et al. [54] retrospectively analysed records of 1,245 Medicare beneficiaries with AF and found that patients treated with warfarin (around half) were no more likely to suffer intracranial haemorrhage, but if they did, it was more likely to be fatal. However, because of the reduction in stroke rates in the warfarin group, warfarin protected patients overall from a composite endpoint of stroke, intracranial haemorrhage, myocardial infarction, and death. It is difficult, however, to draw robust conclusions about the efficacy and safety of warfarin in fallers from this study as there is a selection bias in that patients in the study were only on warfarin because their physician thought that it would be safe and beneficial enough to prescribe and there was no standardized way of assessing falls risk; whether patients were at risk of falls or not was taken from remarks written in the notes. The BAFTA trial [55] randomized 973 over-75-year-olds with AF to either warfarin or aspirin. Patients were recruited from 200 English GP practices, but excluded if their GP found, there were clinical reasons to chose warfarin over aspirin, or vice versa. There were 24 primary events (21 strokes, two other intracranial haemorrhages, and one systemic embolus) in people assigned to warfarin and 48 primary events (44 strokes, one other intracranial haemorrhage, and three systemic emboli) in people assigned to aspirin. These data support the notion that warfarin is not associated with a high excess bleeding risk in the elderly. It should be noted that the sample in the BAFTA study is likely to have excluded some patients at high risk of falls, if their GPs used these patients’ falls risk as a reason to prefer aspirin. Donze et al. [56] studied 515 patients discharged home on warfarin for AF and found that while patients at high risk of falls (determined using a screening questionnaire) had a higher annual rate of major bleeding than those at lower risk (8 % vs. 6.8 %), this was not significant. These studies perhaps argue that extra major bleeding rates with warfarin are overestimated.