Falls in ambulatory individuals with spinal cord injury : incidence, risk factors and perceptions of falls

Abstract: Background: Falls in ambulatory individuals with chronic spinal cord injury (SCI) are common and may have adverse consequences. Little and inconclusive research has been done in this population, and there is a need for more knowledge in order to develop prevention strategies appropriate for this population. Aim: The overall aim of this thesis was to study the incidence of and identify the risk factors for recurrent (>2) and injurious falls in ambulatory individuals with SCI. Method: A consecutive sample of 224 individuals with chronic (≥ 1 year) traumatic SCI and at least 18 years old attending regular follow-up programs at two rehabilitation centres located in Norway and Sweden, were included. Individuals with complete motor lesions above C5 (AIS A and B) or lesions below were excluded. At baseline data believed to be important for falls and fallrisk were collected through interviews, clinical tests, questionnaires including fall history the previous year. The following 12 months falls were monitored using an automatic short message service (SMS) posted every second week. The participants answered „yes‟ or „no‟ to the question: „Have you been falling the past two weeks? A positive answer was followed by a structured telephone interview. The number of falls, fall-related injuries and severity of the injuries as well as the perceived causes of the falls were registered. Results: Study 1, a cross-sectional study (n=224) including both wheelchair users and ambulatory individuals, found that 73 per cent of the participants reported falling and 51 per cent reported recurrent falls (>2) the previous year. Ambulatory, younger and active individuals had higher risks of recurrent falls, and different factors were associated with recurrent falls in ambulatory individuals and wheelchair users. Study II, a longitudinal observational study, included the ambulatory subgroup (n=68). Fifty-six (82%) of the participants reported falling and 33(48%) reported recurrent falls. Of 272 reported falls, 41per cent were injurious. Four per cent, all women, experienced serious injuries. Reporting recurrent falls the previous year and fear of falling could predict recurrent and injurious falls. Reduced maximal walking speed was also a predictor of recurrent falls. Study III included a purposeful sample of 15 ambulatory individuals who shared their experiences and perceptions on falls, risk of falling and fall-related consequences. The participants considered falls to be part of life and took precautions, but were also willing to take risks if important for self-image. However, falls in every-day situations interfered with their selfimage as healthy and well-functioning. A few expressed inexpedient concerns about falling. Study IV, a methodological study, validated and compared the psychometric properties of two balance scales; the Berg Balance Scale and the Mini-BESTest in 46 individuals able to walk 10 metres. Both scales were valid, but the Mini-BESTest seemed to be preferable in ambulatory individuals with SCI due to lack of ceiling effect, better responsiveness and better scaling properties. Conclusion: Falls and injurious falls were common in ambulatory individuals with SCI. A history of recurrent falls and fear of falling could predict recurrent and injurious falls. In addition slower maximal walking speed was a predictor of recurrent falls. Participants considered falls to be a part of life, but falls affected self-identity as „normal‟ and well-functioning. Mini-BESTest was the best scale for measuring balance control in this group. The studies show that there is a need for fall prevention measures adapted for the ambulatory SCI population.