Effectiveness of a combination of cognitive behavioral therapy and task-oriented balance training in reducing the fear of falling in patients with chronic stroke: study protocol for a randomized controlled trial

Abstract

Background: The consequences of falls are devastating for patients with stroke. Balance problems and fear of falling are two major challenges, and recent systematic reviews have revealed that habitual physical exercise training alone cannot reduce the occurrence of falls in stroke survivors. However, recent trials with community-dwelling healthy older adults yielded the promising result that interventions with a cognitive behavioral therapy (CBT) component can simultaneously promote balance and reduce the fear of falling. Therefore, the aim of the proposed clinical trial is to evaluate the effectiveness of a combination of CBT and task-oriented balance training (TOBT) in promoting subjective balance confidence, and thereby reducing fear-avoidance behavior, improving balance ability, reducing fall risk, and promoting independent living, community reintegration, and health-related quality of life of patients with stroke.

Methods: The study will constitute a placebo-controlled single-blind parallel-group randomized controlled trial in which patients are assessed immediately, at 3 months, and at 12 months. The selected participants will be randomly allocated into one of two parallel groups (the experimental group and the control group) with a 1:1 ratio. Both groups will receive 45 min of TOBT twice per week for 8 weeks. In addition, the experimental group will receive a 45-min CBT-based group intervention, and the control group will receive 45 min of general health education (GHE) twice per week for 8 weeks. The primary outcome measure is subjective balance confidence. The secondary outcome measures are fear-avoidance behavior, balance ability, fall risk, level of activities of daily living, community reintegration, and health-related quality of life.

Discussion: The proposed clinical trial will compare the effectiveness of CBT combined with TOBT and GHE combined with TOBT in promoting subjective balance confidence among chronic stroke patients. We hope our results will provide evidence of a safe, cost-effective, and readily transferrable therapeutic approach to clinical practice that reduces fear-avoidance behavior, improves balance ability, reduces fall risk, promotes independence and community reintegration, and enhances health-related quality of life.

Trial registration: ClinicalTrials.gov, NCT02937532 . Registered on 17 October 2016.

Keywords: Balance self-efficacy; Cognitive behavioral therapy; Fall risk; Fear of falling; Stroke rehabilitation; Subjective balance confidence.

Fig. 1

Schedule of enrollment, interventions, and assessments. ABC-C Activities-specific Balance Confidence Scale (Chinese version), BBS Berg Balance Scale, CBT cognitive behavioral therapy, CIM-C Community Integration Measure (Chinese version), GHE general health education, IADL-C Lawton Instrumental Activities of Daily Living (Chinese version), SAFFE-C Survey of Activities and Fear of Falling in the Elderly (Chinese version), SF36-C MCS mental component of the Chinese version of the Short Form General Health Questionnaire, SF36-C PCS physical component of the Chinese version of the Short Form General Health Questionnaire, S-PPA Short-form Physiological Profile Assessment, TOBT task-oriented balance training

Fig. 2

Flow diagram for clinical trial