List of abbreviations
10-MWT
10-Meter walking test
6-MWT
6-Minute Walking Test
ADL
activities of daily living
BBS
Berg balance scale
CHIEF
Craig Hospital Inventory of Environmental Factors
FIST
function in sitting test
FOF
fear of falling
FES I
The Falls Efficacy Scale International
mFRT
modified functional reach test
PEI
photo-elicitation interviews
SCI
spinal cord injury
SCI-FCS
Spinal Cord Injury-Fall Concerns Scale
SCIM III
Spinal Cord Independence Measure III
TAI
transfer assessment instrument
TUG
timed up and go
WISCI II
Walking Index for SCI
WST
Wheelchair Skills Test
Introduction
Falls are a common scenario, among other impairments and conditions, experienced by individuals living with a spinal cord injury (SCI) (see Table 1 ). Between 31% and 82% of individuals living with SCI will experience at least one fall in a year ( ). This chapter examines the frequency of falls, circumstances associated with falls, consequences of falls, methods to evaluate fall risk, and intervention programs to manage fall risk.
| Spinal shock |
| Paralytic ileus |
| Deep venous thrombosis and pulmonary embolus |
| Autonomic dysreflexia |
| Falls |
| Pressure ulcers |
| Spasticity |
| Postural hypotension |
| Bladder, bowel, and sexual function |
| Osteoporosis |
Fall frequency
Falls are common among people living with SCI who are nonambulatory (use a wheelchair or scooter full time) and those who ambulate. A fall is defined as an event in which an individual unexpectedly makes contact with the ground, floor, or some other lower level ( ). Due to differences in functional abilities, it is important to consider differences in fall frequency between those who ambulate and those who do not.
A systematic review and meta-analysis performed by found that 34% to 82% of individuals living with SCI who are able to ambulate fell at least once over a 6- to 12-month period, and 31% to 73% of individuals living with SCI who are nonambulatory fell at least once in the same time span ( ) (see Table 2 ).
| Frequency | % of Ambulatory individuals with SCI | % of Nonambulatory individuals with SCI |
|---|---|---|
| At least 1 fall | 34%–82% | 31%–73% |
| Recurrent falls (more than 1 fall) | 28%–68% | 30%–41% |
Ambulatory individuals are more likely to fall compared to individuals who do not ambulate ( ). The odds of falling for individuals who ambulate are more than 29 times higher compared to individuals who do not ambulate. Jorgensen et al. proposed that falls are less frequent among nonambulatory individuals due to the larger base of support provided by the wheelchair.
Recurrent falls
Among nonambulatory individuals with SCI, Jorgensen et al. reported that men experienced recurrent falls (more than one fall) 3.1 times more often than women within a year. This finding could be explained by the difference in how men and women manage risk. As age increases, the odds of falling more than once among nonambulatory individuals with SCI decreased. The increased odds of falling among younger adults may be due to activity level and involvement in activities in the workplace that increase exposure to more potential fall situations than older adults ( ).
Between 30% and 41% of nonambulatory individuals had recurrent falls within a 6- to 12-month period ( ). Recurrent falls were also reported 14% more often among individuals with greater functional mobility independence, likely because more mobile individuals can engage in more intense physical activity and are therefore more likely to fall ( ).
Most ambulatory individuals with SCI report falling more than once ( ). Within a 6- to 12-month period, 28%–68% of ambulatory individuals with SCI experienced multiple falls ( ). Jorgensen et al. reported that individuals who could recover by themselves following a fall experienced 4.7 times more recurrent falls than those who could not get up by themselves. The increased frequency could be related to increased confidence in the ability to recover from a fall among those who are able to recover independently. Increased confidence may result in taking greater risks and exposure to more situations that lead to a fall ( ).
Fall circumstances
The circumstances in which individuals living with SCI are likely to encounter a fall vary widely. Compared with other populations, including older adults, much less is known about fall risk factors among individuals living with SCI ( ). Further research is needed to comprehensively understand risk factors associated with falls.
To systematically examine the known risk factors associated with falls, the Biological, Behavioral, Social & Economic, and Environmental (BBSE) Model is used to classify fall risk factors and highlight the multi-factorial nature of falls ( ). Fig. 1 displays a visual representation of the BBSE.
Biological risk factors
Biological contributors of falls among both ambulatory and nonambulatory individuals living with SCI include many factors. The most common contributors include muscle weakness, loss of balance, spasticity, and muscle spasms ( ; ; ; ). Lower levels of functional mobility have also been linked to an increased risk of falling ( ). However, Nelson et al. found that persons with more function are also at greater risk because they have a greater exposure to situations where falls may occur, making them more likely to engage in risk-taking behaviors ( ). Other biological factors that may increase the risk of falls summarized by Khan et al. include: male sex (wheelchair users only), an increased number of comorbidities, trunk weakness, fatigue, walking asymmetry, shorter duration since sustaining SCI, narcolepsy, and reduced sensation ( ). Age can also be a risk factor. Among 94 participants, individuals who reported a high frequency of falls were significantly younger. This may be because these individuals are more active and have greater levels of enthusiasm and energy ( ). In addition, reports of pain in the 2 months prior to the fall can affect the performance of activities of daily living and increase fall risk ( ). Studies have also revealed that individuals living with incomplete spinal cord injury, injuries in which partial sensation and/or motor function persists below the level of injury, experience significantly more falls than individuals with complete injuries ( ).
Behavioral risk factors
In a systematic review and meta-analysis, Khan et al. found that the most commonly reported behavioral attributions associated with falls included inattention or distraction, ambulation, fear of falling, a history of previous falls, and not using the safety features of a wheelchair or walking aid ( ). Risk-taking behaviors are also associated with falls ( ), which is theorized to be the reason why men are three times more likely to fall than women ( ). Nelson et al. also found alcohol abuse increased the risk of falls as well as the use of a shorter wheelchair. A shorter wheelchair allows for greater maneuverability; however, the design makes the chair less stable overall ( ). Finally, individuals with a lower quality of life were found to fall more frequently ( ).
Environmental risk factors
Environmental contributors to falls exist both within and outside the home. Hazards such as railings, stairs, heavy doors, and slippery floors are identified as increasing the risk of falls ( ). Among nonambulatory individuals, Sung et al. reported that the bathroom was the most common location for falls to occur, and 43% of falls were associated with pushing or driving the wheelchair on rough surfaces ( ). Forslund et al. found that 65% of falls occurred indoors, and 47% of falls occurred between the hours of 9 AM and 6 PM ( ).
Social and economic
Social and economic factors were also identified as fall contributors. Nelson et al. found that a higher level of education was associated with falls ( ). In addition, lack of fall prevention training ( ) and caregiver error ( ) were also found to contribute to falls. Table 3 summarizes fall risk factors according to the BBSE.
| Biological | Behavioral | Environmental | Social and economic factors |
|---|---|---|---|
|
|
|
|
Consequences of falls
Falls experienced by individuals living with SCI can result in a variety of physical and psychosocial consequences for the faller, as well as high costs to society at large (see Table 4 ).
| Physical injuries consequences | Bruises, cuts, abrasions, bone fractures, concussions, death |
| Psychosocial consequences | Fear of falling, feelings of embarrassment or frustration; deconditioning, decreased community participation |
| Societal consequences | Cost to health-care systems, increased dependence on caregivers |
Physical consequences of falls
A systematic review and meta-analysis conducted by revealed that the frequency of reported falls which resulted in injuries ranged from 6% to 62% in ambulatory individuals with SCI and 13%–38% in nonambulatory individuals with SCI, though the frequency of total falls experienced (both injurious and noninjurious) appears to be similar between ambulatory and nonambulatory individuals with SCI (see Table 5 ).
| Population | Frequency of injuries |
|---|---|
| Ambulatory individuals | 6%–62% |
| Nonambulatory individuals | 13%–38% |
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