Falls in wheelchair users with spinal cord injury : incidence, risks and concerns

Background: Knowledge about falls and related injuries in persons with spinal cord injuries (SCI) is limited, especially concerning wheelchair users. Further research is required in order to develop future prevention programs, as falls seem to be common and may have serious consequences for persons with SCI.

Aims: to identify the incidence of falls and recurrent falls (>2 falls), and the incidence and severity of fall-related injuries in wheelchair users with SCI. Further, to investigate the validity of instruments for concerns about falling -SCI Falls Concern Scale (FCS), and fall risk prediction during one year with Downton Fall Risk Index and a question of falls the previous year.

Method: 224 persons with traumatic SCI were consecutively recruited at regular follow-up at Rehab Station Stockholm / Spinalis, Sweden and Sunnaas Rehabilitation Hospital, Norway. Inclusion criteria: ≥ 18 years old, ≥ 1 year post SCI. Exclusion criteria: persons with motor complete injuries above C5. Independent variables: demographic data, previous falls, quality of life, risk willingness, functional independence, and exercise habits. Falls were prospectively reported by text messages every second week for one year and were followed-up by telephone interviews. Outcomes: incidence of falls and related injuries, risk indicators for recurrent falls and injuries. SCI-FCS was translated to Swedish and tested for validity.

Results: The Swedish version of SCI-FCS showed, in general, similar psychometric properties as the original version supporting the validity of the scale. The wheelchair users reported overall low levels of concerns about falling. Pushing wheelchair in difficult situations caused most concerns. Ambulatory persons reported more retrospective falls than wheelchair users, and mode of mobility had the highest odds ratio (OR) (2.9), for reporting recurrent falls. Ability to get up from the ground (OR=2.2) and performing regular exercise (OR=1.9) increased the OR of recurrent falls for the total sample, while higher age (OR=0.96 per increasing year of age) decreased the OR of recurrent falls. Associated factors differed between wheelchair users and ambulatory persons. Sixty-four percent fell and 32% fell recurrently, when the wheelchair users reported falls prospectively during one year. Recurrent falls previous year increased the OR of recurrent falls the following year (OR=10.2), and higher quality of life reduced the OR of fall-related injuries. In total, 70 fall-related injuries were registered, of which 47 (67%) were minor, 16 (23%) moderate and 7 (10%) were severe, and 34% reported at least one injury. Most falls occurred during transfers. Downton Fall Risk Index had low accuracy for predicting falls in wheelchair users while the question of falls the previous year was more accurate (sensitivity 37 and 86%, respectively).

Conclusion: Falls were common, and ambulatory persons fell more than wheelchair users. In spite of a broad perspective on contributory factors, previous falls was the only significant risk indicator for recurrent falls in the wheelchair users. SCI-FCS showed promising validity. Downton Fall Risk Index could not predict those who fell, while the question of falls previous year was more accurate.

List of scientific papers

I. Butler Forslund E, Roaldsen KS, Hultling C, Wahman K, Franzén E. Concerns about falling in wheelchair users with spinal cord injury—validation of the Swedish version of the spinal cord injury falls concern scale. Spinal Cord. 2016 Feb;54(2):115-119.
https://doi.org/10.1038/sc.2015.125

II. Jørgensen V, Butler Forslund E, Franzén E, Opheim A, Seiger Å, Ståhle A, Hultling C, Stanghelle JK, Wahman K, Skavberg Roaldsen K. Factors associated with recurrent falls in individuals with traumatic spinal cord injury: a multicenter study. Arch Phys Med Rehabil. 2016 Nov;97(11):1908-1916.
https://doi.org/10.1016/j.apmr.2016.04.024

III. Butler Forslund E, Jørgensen V, Franzén E, Opheim A, Seiger Å, Ståhle A, Hultling C, Stanghelle JK, Roaldsen KS and Wahman K. High incidence of falls and fall-related injuries in wheelchair users with spinal cord injury: A prospective study of risk indicators. J Rehabil Med. 2017; 49.
https://doi.org/10.2340/16501977-2177

IV. Butler Forslund E, Skavberg Roaldsen K, Hultling C, Wahman K, Franzén E. Predictors of falls in wheelchair users with spinal cord injury – a prospective study using the Downton Fall Risk Index and a single question of previous falls. [Manuscript]