The experience of falls and fall risk during the subacute phase of spinal cord injury: a mixed methods study

Figures & data

Table 1. Focus group agenda and questions.

1) Introductions and meeting overview
2) Overview of findings from fall survey
Phase 1 data presented^a 23/60 participants fell, 48 falls in total. Most falls occurred in the afternoon, followed by morning and nighttime. Most falls occurred inside or just outside the home. The most common activities being performed at the time of a fall were (in decreasing order): walking, changing positions, getting into/out of bed, standing, and climbing stairs. The most common causes of a fall were (in decreasing order): weakness in legs, slipped, poor balance, and legs gave out. 23 falls resulted in injury (i.e. pain, cuts, bruises, bumped head, broken bone), 2 falls required medical attention. Fear of falling changed over the first six months post-injury. Some participants developed a fear while others lost the fear.	Questions asked What are your thoughts on these findings? [Probe: Higher/lower numbers than you expected?] What are your thoughts on these findings? [Probe: Why do you think most falls happened in the afternoon and morning?] What are your thoughts on these findings? [Probe: Why do you think most falls happened at home?] What are your thoughts on these findings? [Probe: Why do you think these activities were linked to falls?] What are your thoughts on these findings? [Probe: Do any of these causes surprise you? Have you experienced a fall for any of these reasons?] What are your thoughts on these findings? [Probe: Have you experienced an injury from a fall? Do you think there are other consequences of falling, beside injury?] What are your thoughts on these findings? [Probe: Why do you think the fear of falling can change?]
3) Sharing of photographs
Each participant shared 1 photograph taken for the photo-assignment [20]	Questions asked What are your thoughts on the situation described by [participant name]? [Probe: Have you experienced something similar?]
4) Discussion about fall prevention initiatives
Questions Asked Can you describe the advice or training to prevent falls you received while you were in the rehabilitation hospital, if any? [Probe: Who provided the advice/training? Did the advice/training differ for those using wheelchairs compared to those who ambulated?] Did you receive advice/training when your assistive device changed (e.g., wheelchair to walker)? Please describe/elaborate. How do you decide which assistive device or gait aid to use?
5) Designing a fall prevention program
Participants were asked to consider what an ideal fall prevention program would include.	Questions asked What would the fall prevention program focus on? Why? When would be the best time after spinal cord injury to administer a fall prevention program? Why? Where would be the best place to deliver a fall prevention program? Why? Who would be the best person to deliver this program? Why?
6) Discussion about knowledge translation
Questions Asked Do you think there needs to be more awareness of falls after SCI? Why or why not? If yes, how could this awareness be implemented? Who should be targeted? How do you think the information gained from the fall survey should be shared? Who should we share the information with?

^aData presented graphically and in text.

Table 2. Participant characteristics Phase I.

	All participants (n = 71)	Included participants (n = 60)	Fallers (n = 23)	Non-fallers (n = 37)
Biological sex (F, M)	16 (22.5%), 55 (77.5%)	13 (21.7%), 47 (78.3%)	3 (13.0 %), 20 (87.0%)	10 (27.0%), 27 (73.0%)
Age (years)	57.8 (15.3)	58.4 (14.6)	53.5 (16.0)	61.5 (13.0)
Time post-injury at discharge (days)	108.3 (68.6)	99.0 (60.3)	86.4 (39.6)	106.9 (69.6)
Injury mechanism (trauma, non-trauma, unknown)	32 (45.1%), 37 (52.1%), 2 (2.8%)	29 (48.3%), 31 (51.7%)	11 (47.8%), 12 (52.5%)	18 (48.6%), 19 (51.4%)
Neurological level of injury	C2 – L5	C2 – L5	C2 – L5	C2 – L2
AIS A	10 (14.1%)	9 (15.0%)	4 (17.4%)	5 (13.5%)
AIS B	5 (7.0%)	3 (5.0%)	1 (4.3%)	2 (5.4%)
AIS C	7 (9.9%)	7 (11.7%)	3 (13.0%)	4 (10.8%)
AIS D	43 (60.6%)	37 (61.7%)	14 (60.9%)	23 (62.2%)
AIS C or D	3 (4.2%)	3 (5.0%)	1 (4.3%)	2 (5.4%)
Unknown AIS	3 (4.2%)	1 (1.7%)	0 (0%)	1 (2.7%)
Ambulates	--	30 (50.0%)	11 (47.8%)	19 (51.4%)
Uses Wheelchair	--	20 (33.3%)	6 (26.1%)	14 (37.8%)
Wheelchair → Ambulates^	--	10 (16.7%)	6 (26.1%)	4 (10.8%)

Demographic and injury-related data of the total sample (n = 71), participants included in the analysis (n = 60), fallers (n = 23) and non-fallers (n = 37). Values are expressed as mean (SD) or count (%), as appropriate. AIS, American Spinal Injury Association Impairment Scale. ^Used a wheelchair at discharge from inpatient rehabilitation, but ambulated at 6-months post-discharge.

Table 3. Fall circumstances, causes and consequences.

	n (%)
Time of fall
Afternoon	23 (47.9%)
Morning	14 (29.2%)
Night	8 (16.7%)
Evening	3 (6.3%)
Location of fall
Home Indoors	25 (52.1%)
Home Outdoors	12 (25.0%)
Community Outdoors	6 (12.5%)
Community Indoors	4 (8.3%)
Work Outdoors	1 (2.1%)
Work Indoors	0 (0%)
Activity at time of fall
Walking	17 (35.4%)
Other^	9 (18.8%)
Changing positions	6 (12.5%)
Getting into/out of bed	6 (12.5%)
Standing	5 (10.4%)
Climbing stairs	5 (10.4%)
Opening/closing a door	0 (0%)
Getting into/out of a vehicle	0 (0%)
Perceived causes of fall*
Weakness in legs	9 (18.8%)
Slipped	9 (18.8%)
Poor balance	7 (14.6%)
Legs gave out	6 (12.5%)
Other†	5 (10.4%)
Tripped	3 (6.3%)
Moving quickly/rushing	3 (6.3%)
Was distracted	2 (4.2%)
Tired	1 (2.1%)
Don’t know	1 (2.1%)
Spasms in my legs	1 (2.1%)
Weather	1 (2.1%)
Doing more than one thing	0 (0%)
Alcohol/drug consumption	0 (0%)
Dark/poorly lit environment	0 (0%)
Not using my walker/cane/brace	0 (0%)
Type of injury*
Pain	8 (44.4%)
Cuts/scrapes	4 (22.2%)
Bruises	2 (11.1%)
Bumped head	2 (11.1%)
Broken bone	1 (5.6%)
Muscle strain (back)	1 (5.6%)
Medical attention required
No	46 (95.8%)
Yes	2 (4.2%)
Recent change in medication
No	41 (85.4%)
Yes	7 (14.6%)

* More than 1 response option could be selected.

^{^} Slipping off bed while sitting, trying new exercises in physical therapy sessions, dancing, wheeling, using wheelchair on a decline, changing medical equipment while unsecured in the wheelchair.

^† Going down a ramp in the wrong direction while in a wheelchair, not using the seatbelt on wheelchair, not having anti-tippers on chair while getting stuck in the snow, low blood pressure, forgetting to perform stretches, sitting in the same position for too long, poor positioning of a transfer board, obscured vision.

Table 4. Participant characteristics Phase II.

Participant Code	Age (years)	Sex	Mobility status	Time post-injury at discharge (days)	Neurological level of injury	AIS
F09	57	M	Ambulatory	47	L5	C
F20	70	M	Ambulatory	33	L1	B
F30	53	M	Ambulatory	92	C6	D
F44	72	M	Non-ambulatory	109	C4	D
F56	59	F	Non-ambulatory	135	L1	A

AIS, American Spinal Injury Association Impairment Scale. Mobility status at the time of the focus group.

Table 5. Theme, subthemes, and supporting quotes.

Overarching theme: Individuals with SCI encounter many challenges and an increased fall risk during the transition home from inpatient rehabilitation
Subtheme 1: Lack of preparedness to manage fall risk upon returning home from inpatient rehabilitation
(i) “I wish they had dealt directly with me because I never had any training as to if I fall, how do I get up. If I’m about to fall and I realize it, what things could I do to minimize the fall? Nothing like that. And, so I would’ve found that extremely helpful.” – F20 (ii) “I think it’d be good to train us how to get up, which isn’t really fall prevention, it’s fall recovery, and how you can become a coach for yourself and for others.” – F09 (iii) “I really didn’t think about all the effort that I was going to have put in in different areas. And, I didn’t articulate that with my therapist. So when I left here, I was just like, ‘Oh my God, you know, okay, this is it’.” – F30
Subtheme 2: Adjusting to increased fall risk following discharge from inpatient rehabilitation
(i) “When I’m out in the community, I have 1 or 2 sticks and my walker and it’s almost always flat. And, I find that I gravitate toward certain things. Certain shops I don’t go to because I know it’s going to be, you know a bit of a hill or you know where I’m a little bit dodgy.” – F09 (ii) “You might be somewhere where it looks smooth and it’s not slippery, but some places could be very slippery and looking the other way, you know. So, it’s a matter of being aware of your environment and your surfaces, I would think.” – F44 (iii) “Lyrica makes me extremely dizzy and throws me completely off balance. And, when I’m fatigued between 2:00 and 4:00, if I don’t lie down, I’m going to fall down.” – F20
Subtheme 3: Psychological impact of the transition to living at home with an increased fall risk
(i) “I had a spinal cord issue, but also brand new hardware. So falls could actually damage the hardware to all the bones are set. So I think sometimes [we] get so protective of ourselves that we can’t start to move on, to start to walk away from rollator or move and transition.” – F09 (ii) “The whole transition, I mean there was so much fear, so many unknowns really. A peer support worker would’ve [helped] me, I think more than a physiotherapist.” – F30 (iii) “The peer support worker’s a good idea, but I don’t want us to lose focus on the fact that this whole education around falling needs to be integrated into the program with the physiotherapists that we’re dealing with.” – F20

Forslund E, Jørgensen V, Franzén E, et al. 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(2):144–151.

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