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

Abstract

Purpose: To understand the circumstances, causes and consequences of falls experienced by individuals with subacute SCI, and to explore their perspectives on how falls/fall risk impacted their transition to community living.

Materials and methods: Sixty adults with subacute SCI participated. A sequential explanatory mixed methods design was adopted. In Phase I, falls were monitored for six months post-inpatient rehabilitation discharge through a survey. In Phase II, a qualitative focus group (n = 5) was held to discuss participants’ perspectives on Phase I results and falls/fall risk. Descriptive statistics and thematic analysis were used to analyze Phase I and II data, respectively.

Results: Falls commonly occurred in the daytime, at home and about half resulted in minor injury. Three themes reflecting participants’ perspectives were identified in Phase II. 1) Lack of preparedness to manage fall risk upon returning home from inpatient rehabilitation. 2) Adjusting to increased fall risk following discharge from inpatient rehabilitation. 3) Psychological impact of the transition to living at home with an increased fall risk.

Conclusions: The findings highlight the need for fall prevention initiatives during subacute SCI, when individuals are learning to manage their increased fall risk.

IMPLICATIONS FOR REHABILITATION

• Falls are common in the subacute phase of spinal cord injury (SCI), with falls commonly occurring in the daytime at home while walking or changing positions and resulting in minor injury.

• Individuals living with SCI feel unprepared to manage the increased fall risk experienced after discharge from inpatient rehabilitation, and the possibility of falling can cause anxiety and fear.

• Following the transition from inpatient rehabilitation to living at home, individuals with SCI would like continued support from health professionals and/or peers to prevent falls and adjust to living independently with SCI.

Keywords:

• Spinal cord injury
• subacute
• falls
• fall prevention
• mixed methods

Introduction

The majority of people with spinal cord injury (SCI) live with the ongoing threat of losing their balance and falling. Falls are known to be prevalent among community-dwelling individuals with chronic SCI (i.e. >1 year post-injury) with approximately 69–78% of these individuals experiencing at least one fall each year [1,2]. In contrast, 7–23% of inpatients with SCI are reported to have fallen during their hospital stay [3–6]. The occurrence of falls begins to increase shortly after discharge from inpatient rehabilitation, as 38% of individuals with SCI reported falling one or more times during the first six months after discharge [7].

Experiencing falls and living with a high risk of falling has detrimental physical (i.e. injury) and psychosocial (i.e. embarrassment, reduced independence and participation) consequences for people living with SCI [1,7,8]. As a result, fall prevention initiatives are a priority for SCI rehabilitation [9]. Yet healthcare administrators [10], physical and occupational therapists [11] and individuals with SCI [10,12] have suggested there is a lack of evidence-based fall prevention initiatives relevant to people with SCI. After reflecting on their time in rehabilitation, individuals with chronic SCI indicated they would have benefited from fall prevention education that was specific to SCI rather than the generic fall prevention initiatives commonly employed at rehabilitation hospitals [8,13]. However, developing SCI-specific fall prevention initiatives is a challenge since our understanding of the circumstances, causes and consequences of falls that people with SCI experience early after injury is limited. Indeed, physical and occupational therapists have expressed a need for greater insight into the circumstances of falls following SCI [11]. The majority of falls-related research to date has focused on the chronic SCI population [1,14]. Having a greater understanding of the circumstances, causes and consequences of falls during the subacute phase of SCI, when individuals transition from inpatient rehabilitation to community living, may facilitate the creation of fall prevention initiatives for SCI rehabilitation that are more relevant to people living with SCI.

Information about falls may be collected through quantitative means, such as surveys, calendars/dairies or wearable sensors. Prior quantitative research involving the chronic SCI population has revealed that the majority of falls occur during the daytime and at home [15,16]. Individuals with chronic SCI who ambulate as their primary means of mobility tend to fall while walking, standing or changing positions (e.g. moving from sitting to standing) [13,17,18]. In contrast, individuals with chronic SCI who use wheelchairs tend to fall when transferring, reaching, showering, wheeling on uneven surfaces, and moving in bed [8,16,19–22]. Clinicians can use this information to tailor fall prevention education and training to higher-risk environments and activities. However, it is not known whether individuals with subacute SCI demonstrate similar trends in the circumstances of their falls as those with chronic injuries.

More recently, qualitative approaches to data collection have been used to provide deeper insight into the contributing factors and impacts of falls [8,13,23–26]. For example, we have used photography-based approaches, such as photo-elicitation interviewing and photovoice, to learn about falls from individuals with chronic SCI [12,13,24,25]. In these studies, photographs were used as a medium of communication between the participant and researcher, enabling participants to share their stories and deepen our understanding of the social and contextual issues related to falls [27]. For example, individuals with SCI who use a wheelchair explained that falls were the result of multiple interacting factors (i.e. biological, behavioral, social, economic, environmental and wheelchair-related) that were unique to each individual and changed over time [23]. They also explained that by experiencing falls or near falls, they learned behavioral strategies to prevent falls, such as moving more slowly when walking, wheeling and transferring, and being more aware of the environment and their body (e.g. fatigue, spasticity) when moving.[8–10] This detailed insight into the complexity of falls would be difficult to achieve through quantitative research methods alone, but the relatively small sample sizes of qualitative research mean the findings may not generalize beyond the study participants [28].

A mixed methods approach to data collection makes use of the strengths of both quantitative and qualitative methods to enable a more comprehensive understanding of falls after SCI. This knowledge may in turn inform the development of SCI-specific fall prevention initiatives. Hence, the aims of this study were to: 1) understand the circumstances, causes and consequences of falls experienced by individuals with SCI during the first six months following discharge from inpatient rehabilitation, and 2) explore the perspectives of individuals with subacute SCI on why falls occurred and how the risk of falling impacted their transition from inpatient rehabilitation to community living.

Methods

Study design

This study used a sequential explanatory mixed methods design involving two phases (QUANT-QUAL) [28]. In Phase I, a quantitative fall survey was used to prospectively monitor the circumstances, causes and consequences of falls experienced by participants during the first six months post-inpatient rehabilitation. In Phase II, a qualitative focus group was held with a subset of participants to discuss the quantitative results from Phase I, as well as their experiences with falls and the risk of falling during the transition to community living. This study was part of a larger study that investigated the occurrence and impacts of falls in the subacute phase of SCI [7,24]. Ethical approval was obtained from the Research Ethics Board of the University Health Network (UHN, protocol 17-5723).

Participants

Participants were recruited through the Central Recruitment service at the Lyndhurst Centre, Toronto Rehabilitation Institute-UHN [29]. The central recruiter met with inpatients who previously consented to be approached about research and connected interested individuals with the research team. Participants were eligible to participate in Phase I based on the following inclusion criteria: 1) ≥18 years of age; 2) sustained a SCI due to a traumatic or non-traumatic, non-progressive cause; 3) inpatient at the Lyndhurst Centre at the time of enrollment; and 4) had no other co-morbid condition(s) that impacted balance control (e.g. stroke). The sample size justification for Phase I (n = 64) is described in Chan et al. [7]. Following Phase I, up to 10 Phase I participants who lived within 100 km of the Lyndhurst Centre were recruited to complete a photo-assignment [24] (described below). Eight participants completed the photo-assignment and were then invited to participate in Phase II.

Phase I

Initial meeting

An initial meeting lasting about 30 min was conducted by a researcher (OHP, KC, AMB). Initial meetings occurred within the week prior to discharge from inpatient rehabilitation. Demographic (e.g. month and year of birth, sex) and injury-related information (e.g. month and year of injury, mechanism of injury, American Spinal Injury Association Impairment Scale (AIS) rating [30], ambulatory status) were collected from each participant and confirmed in the participant’s health records. Participants who walked as their primary means of mobility were considered ambulatory and those who used a wheelchair as their primary means of mobility (i.e. at least four hours/day) [31] were considered non-ambulatory. Participants were also asked if they fell during inpatient rehabilitation, and if they had a fear of falling, defined as “a lasting concern about falling causing them to avoid or curtail activities they felt they were capable of doing” [32]. At this time, the researcher reviewed the instructions for the fall survey. Participants were instructed to complete the survey within 24 h of experiencing a fall during the six months following discharge from inpatient rehabilitation. The purpose of the fall survey was to document the circumstances surrounding the fall, the perceived cause(s) of the fall, and the consequences of the fall (i.e. injuries, medical assistance). The survey was based on a previous survey that consisted of closed-ended questions and one open-ended question that queried the perceived cause of the fall (see Appendix). Participants were given the World Health Organization’s definition of a fall (i.e. “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level”) [33] as a reference for determining whether they experienced a fall. The survey could be completed online (Qualtrics XM), on paper, or by phoning a researcher (OHP, KC, AMB) and completing the online survey with their assistance.

Monthly meetings

Every 3–4 weeks, a researcher (OHP, KC, AMB) phoned each participant to ensure the fall surveys were being completed, resulting in 6–7 monthly meetings during Phase I. If a participant completed a survey on paper, the research team member entered the survey responses into the online platform for the participant. Any changes in health, medication or ambulatory status were also documented. This follow-up protocol was successfully administered in previous studies [8,13,34]. After the final monthly meeting, participants were classified as “faller” or “non-faller” based on whether or not they experienced one or more falls in the six months since hospital discharge.

Phase II

Phase II involved an in-person focus group meeting with a subset of participants who had recently completed Phase I of the study. Prior to the focus group meeting, eight of the Phase I participants completed a photo-assignment and individual interview, both of which are described in detail elsewhere [24], but will be outlined briefly here. For the photo-assignment, participants used photographs to answer the following questions: 1) What increases your likelihood of falling?; 2) What decreases your likelihood of falling?; and 3) How does the risk of falling affect your ability to participate in recreational activities and/or work (paid or volunteer) [24]? Participants then discussed their photographs with a researcher (OHP) during a semi-structured interview. The in-person focus group meeting for the current study was scheduled once all semi-structured interviews [24] were completed. The focus group discussion lasted one hour and 45 min and was facilitated by OHP (post-doctoral fellow and kinesiologist with a PhD in Rehabilitation Sciences and qualitative research experience) and HS (post-doctoral fellow and occupational therapist with a PhD in Rehabilitation Sciences and extensive qualitative research experience). The goals of the focus group meeting were to: 1) discuss the Phase I results to provide possible explanations for the trends observed; 2) identify commonalities in the falls-related issues raised by the participants; and 3) discuss ways in which these issues could be addressed at the individual, program and societal levels. Open-ended questions were used throughout the meeting to stimulate discussion. The dialogue was digitally recorded and transcribed verbatim offline. See Table 1 for the focus group meeting agenda and questions.

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.

Data analysis

Demographic and injury-related data are reported as mean (± one standard deviation (SD)), median (interquartile range (IQR)), or frequency counts, as appropriate. Data are reported for the whole sample, as well as for fallers and non-fallers separately. Independent t-tests were used to compare age and time since injury between fallers and non-fallers, while a chi-square test was used to compare the distribution of sex, traumatic/non-traumatic cause of injury and mobility status between the two groups. IBM SPSS Statistics 27 was used to conduct the statistical tests. Alpha was set to 0.05.

Fall survey responses were exported to Microsoft Excel for data cleaning and analysis. Survey responses were combined across participants to describe the circumstances, causes and consequences of falls. The incidence proportion of falls was calculated and reported elsewhere [24]. To summarize the circumstances (e.g. time of day, location, etc.), causes and consequences of the falls, frequency tables were created.

Transcription of the focus group dialogue was completed by a researcher (KC). An inductive thematic approach [35,36] was taken to analyze the transcript. The coding process involved three researchers who had qualitative research experience (SM, a physical therapist; KC, a kinesiologist with an MSc in Rehabilitation Sciences; and KEM, a physical therapist and scientist). They independently reviewed the transcript several times and created marginal notes on key ideas and the relationships between them. The three researchers then met to compare and discuss the findings. The marginal notes were used to generate preliminary codes, which were then shared and discussed with two additional researchers (OHP, HS). Together, the researchers identified how the codes could fit into larger categories and themes. Microsoft Excel and Word were used for data management.

Results

Participants

Seventy-one participants with SCI/D were enrolled in this study from February 2018 to December 2019. Eleven participants (15.5%) were lost to attrition (i.e. failure to respond to monthly meetings); therefore, the data of 60 participants were used for the analyses. Participant demographics and injury-related data are reported in Table 2. The majority of participants were male (78.3%) with motor incomplete SCI (i.e. AIS C or D) (78.4%). Their mean age and time post-injury were 58.4 (14.6) years and 99.0 (60.3) days, respectively. Half of the participants were ambulating throughout the duration of Phase I, while one-third used a wheelchair and ten participants (16.7%) transitioned from using a wheelchair to ambulating.

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.

Fall survey data

Of the 60 participants, 23 (38.3%) participants experienced at least one fall during the first six months following inpatient discharge. Demographic and injury-related data for fallers and non-fallers are presented in Table 2. Fallers were significantly younger than non-fallers (p = 0.040), but no significant differences in time post-injury (p = 0.21), sex distribution (p = 0.56), cause of SCI (traumatic versus non-traumatic) (p = 0.43) or mobility status (p = 0.43) were found between fallers and non-fallers. One participant, 22 years of age, who reported 31 falls, was considered an outlier and was excluded from the remaining analyses. This participant experienced the majority of her falls during a daytime hike on uneven terrain. The remaining 22 individuals reported 48 falls in total. The median number of falls per participant was 2 (IQR 2) and the median time to first fall was 51 (IQR 95) days post-discharge from inpatient rehabilitation.

The circumstances of the falls experienced by participants are summarized in Table 3. Almost half (47.9%) of falls were experienced in the afternoon, while 29.2% and 16.7% occurred in the morning and night, respectively. Approximately three quarters of the falls occurred at home; 52.1% inside the home and 25.0% in the outdoor home environment. Over one third of falls were experienced while walking (35.4%) followed by other activities (18.8%), which included slipping off the bed while sitting, trying new exercises in physical therapy sessions, dancing, wheeling, using wheelchair on a decline, and changing medical equipment while unsecured in the wheelchair. Changing positions (12.5%), getting into/out of bed (12.5%), standing (10.4%) and climbing stairs (10.4%) were also reported as being performed at the time of the fall.

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.

The most common causes of falling as perceived by participants were weakness in legs (18.8%), slipped (18.8%), poor balance (14.6%), legs gave out (12.5%) and other causes (10.4%), which included 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, and obscured vision.

Twenty-three falls (47.9%) resulted in injury; the most common injuries were pain (44.4%), cuts/scrapes (22.2%), bruises (11.1%) and a bumped head (11.1%) (Table 3). One participant fractured a toe during a fall. Two participants sought medical attention after a fall; however, there were no hospitalizations. Seven participants reported a change in medication prior to a fall; more specifically, six participants reported a change in pain medication and one participant had started taking antibiotics before experiencing a fall.

Focus group data

Five of the eight eligible participants chose to participate in Phase II. All five participants had a non-traumatic SCI. See Table 4 for their additional demographic and injury-related characteristics. One overarching theme was identified through the thematic analysis of the focus group transcript: Individuals with SCI encounter many challenges and an increased fall risk during the transition home from inpatient rehabilitation. Three subthemes were also revealed: (1) Lack of preparedness to manage fall risk upon returning home from inpatient rehabilitation; (2) Adjusting to increased fall risk following discharge from inpatient rehabilitation; (3) Psychological impact of the transition to living at home with an increased fall risk. See Table 5 for supporting quotes by subtheme.

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

Subtheme 1: Lack of preparedness to manage fall risk upon returning home from inpatient rehabilitation

Participants described feeling unprepared for the “reality” (F30) of the transition home and their increased fall risk. Participants described this transition as “overwhelming” (F30) and “difficult” (F09). F30 explained, “you had the physiotherapist while you were [in inpatient rehabilitation] and then all of a sudden, there was just nothing.” Participants agreed that although a lot of the therapy during their inpatient stay helped to prevent falls, it wasn’t always explicitly stated as fall prevention training: “I mean, I worked with a [physiotherapist] while I was here…did stairs, did a whole bunch of stuff, but I never really heard the word fall prevention while I was doing that.” (F30). One participant suggested that avoiding use of the word “fall” in rehabilitation may be beneficial: “Do you think if they use the word “fall” though, that it puts a big negative on your development?” (F56). However, other participants indicated that preventing, experiencing and managing falls were an inevitable part of their rehabilitation. F20 shared his perspective, comparing falls to surgery: “I don’t see the word fall as being negative…it’s like the term operation. I don’t want to have one. I hate them, but it’s an operation. It’s something you have to go through. I think it’s the same with falls.”

Participants described situations where they felt unprepared to manage their increased risk of falling and the immediate consequences of a fall. For example, F20 shared the following experience:

I remember the first time I fell and I was on the street and I did not know how to get up…and what flashed through my mind was, how do I stand up? But secondly, why wasn’t I trained for this? I mean, if they can train you to go up and down stairs, then they can certainly train you to recover from a fall, which wasn’t part of my therapy.

Other participants agreed on the importance of including training on fall recovery: “I would have liked to have known if I was to fall in a wheelchair how to get myself [up], I was not taught that.” (F56) Several participants discussed other aspects of fall prevention they wish they had learnt while in rehabilitation. For example, F20 shared: “I really didn’t have practice in doing stairs, not to the extent that I felt that you need.” F09 suggested practicing in a simulated home environment would be helpful, “The one thing that wasn’t utilized that I know is [in the rehabilitation centre] is the patient apartment…’cause we don’t live in gyms, but we do live in bedrooms and living rooms and kitchens and of course, bathrooms.” Some participants felt they had to “self-advocate” (F09) to receive appropriate fall prevention training.

Subtheme 2: Adjusting to increased fall risk following discharge from inpatient rehabilitation

Participants discussed the transition home from inpatient rehabilitation and the adjustment to a life where many daily activities involve an increased fall risk. F20 explained:

Now, doing something for the first time since rehabilitation, for instance, getting up in the middle of the night, going to the washroom and coming back to bed. I never used to turn on the lights because I knew where to walk… but the first time I did it and did not turn on the light…I misjudged where the bed was and I leant forward to go on the bed, but the bed wasn’t there.

Participants described learning how to manage their fall risk through experience after discharge from inpatient rehabilitation. During this challenging time, many participants were learning new strategies to decrease their risk of falling. F09 shared his strategy of installing motion-sensitive night lights to decrease fall risk when getting up in the dark. He further explained: “And, now I have Google all through my house. So, I just say, ‘Hey Google, turn on the hall light.’” A strategy used by several participants was to be extra careful when in a higher risk environment, described by F30 as, “Slowing down, being more aware.” Participants also described planning ahead for outings to unknown or unpredictable environments. F09 shared: “I usually take everything, walking sticks and walker, if I don’t know the situation. Or if I think I’m going to be there for a while…I often check things such as weather.” Participants also sought help from others to decrease their fall risk. F09 explained how his wife helped him become independent with getting up and down from the floor:

At first, she’d help me out a little bit with that transition, but I quickly [became more independent], and it was very life giving, because first of all it made it much easier for my wife. So, she knew that with no help or very little help, if I fall, I could get out of that.

Participants demonstrated their growing knowledge about fall risk through discussion of the Phase I findings. For example, when the location of falls identified through the fall survey was reviewed with participants, they offered insight into why these trends were observed. Participants reasoned that most falls occurred inside the home because they were “spending more time at home.” (F30). F56 added that people are more likely to take risks when in their own home: “you spend a lot of time at home, and you’re going up and down the stairs and you’re using the washroom…you’re moving around, like I move around in a walker at home so it’s a little less stable for me than the chair.” In contrast, participants tended to exercise more caution when out in the community, because “there are a lot of obstacles out there…so it’s easier just to avoid them.” (F20). Similarly, F56 explained: “When I’m out, I’m usually with somebody, but I tend to just do flat areas with my wheelchair, or a slight incline, so I’m not doing anything that puts me at risk.”

Similarly, over the first six months post-inpatient discharge, participants became familiar with factors that increased their likelihood of falling. For example, F09 explained, “I find most falls are precipitated after I’ve kind of lost focus,” whereas F56 described being “overconfident” on the day she went home from inpatient rehabilitation as the likely cause of her fall. Winter weather conditions were also discussed as a risk factor. When participants were asked why they thought most falls happened in the afternoon, F09 explained that he became fatigued at around 2:00pm, increasing his fall risk, and F20 agreed: “I do as well. It’s almost on the dot, 2:00. It’s just like fatigue sets in and that’s when I have my nap. If I don’t take my nap, then I’m wonky.” F20 also acknowledged that “people are probably out more or more active [in the afternoon], and so there’s probably a linkage there between the two.” Participants also discussed side effects of medications, such as Lyrica and Baclofen, and other physical symptoms as increasing their fall risk. For example, F44 described his legs as feeling like “a heavy plank of wood” which caused them to “give out” and increased his fall risk.

Subtheme 3: Psychological impact of the transition to living at home with an increased fall risk

Fear, anxiety, and avoidance of activities due to fall risk were discussed by several participants. For example, as described by F30: “It’s just an incredibly hard thing for me to get from the floor to standing up and it’s caused a lot of anxiety, like I said, and the fear. And, it makes me unable or I just don’t want to do some things just because of that.” Similarly, F44 shared: “Well, I’m living in a low-rise apartment on the second floor and I have 12 sets of stairs to get me upstairs to that apartment and it’s very, very difficult and very scary trying to do those stairs.” Several participants brought up their fear of experiencing severe consequences from a fall. This fear may have been instilled in them from discussions with members of their healthcare team, such as this experience shared by F20:

I had a neurosurgeon who told me that if I got a severe bang in the head or if I fell and banged my head that the rods that he implanted in my neck could come lose, the screws could pop and I’d have to go back and I’d have to have another operation. Well, when you hear something like that, you know, you’re terrified about falling.

A significant fear of falling could also result from overhearing stories from peers about falls that led to a traumatic SCI: “You wouldn’t believe the stories of the people [in the rehabilitation centre]. It took very little for them to have a spinal cord injury.” (F56).

Although the Phase I survey data revealed that only one fall resulted in serious physical injury, participants indicated that falls without injuries can still have a negative impact. F20 commented:

Even though only one had a major injury, I don’t think that you can discount the psychological effect that the fall had because that can change your entire life. You know, it limits where you think you can go, what you can do. You live with fear…so even though you haven’t taken a major fall and injured yourself, it still can impact you.

F09 added: “Well, when I fall, it takes a while to get up. It’s emotionally hard and it’s kind of all the positive that’s built up gets totally deflated.” Yet, some participants were reassured to know that only one serious injury was reported in Phase 1: “I thought it was really positive that most [participants] ended up with a few bruises and that. So, it’s not something to be so afraid of.” (F09)

Participants identified a need for greater support throughout the transition from inpatient rehabilitation to independent living at home. As described by F30, this could be “one single person…that you start with while you’re at [rehabilitation centre] and they sort of help you throughout the whole sort of transition or whatever. That person would’ve been a huge help for me. Somebody to guide me a little bit…your whole life has changed…” While participants agreed that a physiotherapist could provide support about fall prevention and management, several participants indicated a preference to have the continued support of a peer with SCI during the transition home: “I think some peer coaching and just going through it or even connecting with somebody…at least once or twice a week would be very helpful.” (F09)

Discussion

In this study, a mixed methods approach was used to increase our understanding of the circumstances, causes and consequences of falls during the first six months post-inpatient rehabilitation. This is one of the first studies to describe, in detail, falls during the subacute phase of SCI. This time of transition from hospital to community living was described by participants as a time of overwhelming change with inadequate supports. Participants felt unprepared to manage the increased fall risk experienced once they were discharged from inpatient rehabilitation, and the possibility of falling caused anxiety and fear. The study findings stress the importance of continuing to provide fall prevention education and training after individuals with SCI have been discharged from inpatient rehabilitation. The findings will help clinicians design SCI-specific fall prevention initiatives that target the locations and activities commonly associated with falls in the subacute phase of SCI.

There are similarities in the circumstances, causes and consequences of falls experienced by individuals with subacute and chronic SCI. This finding suggests that much of the content of SCI-specific fall prevention initiatives could apply to both the subacute and chronic SCI populations. For example, both groups tend to fall during the daytime and at home [8,13,15–17,34,37]. Like the participants in the current study, those with chronic SCI in other studies explained that they tended to be less cautious at home; they were more likely to be careless or multi-task [8]. The activities being performed when a fall occurred were similar for the subacute and chronic populations; walking, wheeling activities, changing positions and standing were most common [8,13,15,17,34,37]. Those who fall are younger than those who do not fall, regardless of time post-SCI [8,34,38,39]. This may reflect a greater willingness to take risks among younger individuals, as some individuals living with SCI, especially those who are younger and male, are willing to risk falling in order to maximize their functional abilities [26]. Lastly, just under half of the falls reported in this study resulted in minor physical injury, which is consistent with the literature studying falls in the chronic SCI population [1].

Despite these similarities, this study also highlighted some unique findings in individuals with subacute SCI. The median time to first fall during the subacute phase of SCI (i.e. 51 (IQR 95) days) was notably shorter than that documented in the chronic SCI population. For example, Jørgensen reported a mean time to first fall of 138 days (95% confidence interval: 107–169 days) among ambulatory individuals with chronic SCI [40]. Similarly, Singh and colleagues reported median times of 97 (IQR: 148) days and 182 (IQR: 116) days for individuals with chronic SCI who ambulate and use a wheelchair, respectively [37]. This difference further highlights the importance of fall prevention initiatives as individuals with SCI transition from hospital to community living. Additional differences in research findings between the subacute and chronic populations suggest a need to tailor some content of inpatient fall prevention initiatives to the subacute population. For example, overconfidence was perceived to contribute to falls shortly after hospital discharge. Indeed, individuals may still be gaining insight into their physical abilities during the subacute phase of SCI [41]. Furthermore, rehabilitation hospitals are accessible environments adapted for wheelchairs. While this environment helps those with newly acquired SCI adjust to their physical changes, it may also hinder the transfer of some physical skills learned in the hospital to home and community environments [42]. The importance of practicing physical skills in simulated home environments was also highlighted by participants in the current study.

Most individuals living with SCI will return directly home following inpatient rehabilitation [43,44]. Participants of the current study described the transition to community living as overwhelming; a word that has been used to describe this transition in prior research [42]. More specifically, when individuals with SCI transition home, they experience the loss of physical abilities, function and independence, while simultaneously reconsidering their familial and social relationships [42]. Further, individuals in the subacute phase of SCI may be dealing with unfamiliar medical complications, such as pressure injuries, neuropathic pain and urinary tract infections [17]. Hence, it is not surprising that 17–25% of individuals with SCI experience some psychosocial distress after transitioning to community living [45,46].

Our findings suggest that a concern about falling contributes to the psychological distress experienced in the subacute phase of SCI. Participants reported feeling anxious and fearful about the consequences of falling. This fear may exist even if they have not yet experienced a fall [7], but have heard about injurious falls from family and friends [24], or a member of their healthcare team. Participants also felt unprepared to manage a fall should one occur, further contributing to their anxiety and fear. To reduce this distress, future fall prevention initiatives could include accurate information about the frequency and minor nature of injuries resulting from falls in the SCI population, as well as implement strategies to improve falls self-efficacy. Although the construct of falls self-efficacy has traditionally focused on the ability to complete activities without falling, more recent research recognizes that falls self-efficacy encompasses a range of abilities related to preventing and managing falls [47]. The Falls-related Self-efficacy Continuum Model identifies four stages in the fall continuum: 1) pre-fall (i.e. perceived ability to perform daily activities without losing one’s balance), 2) near-fall (i.e. perceived ability to recover stability after balance has been lost), 3) fall-landing (i.e. perceived ability to fall safely onto the ground) and 4) completed fall (i.e. perceived ability to recover after a fall) [47,48]. Participants of our study expressed a desire to improve their skills at the two ends of this fall continuum. They discussed needing more practice with daily activities, like stair-climbing, before being discharged home (i.e. pre-fall efficacy) and requiring more practice getting themselves up from the ground after a fall (i.e. completed fall efficacy). Needing to improve efficacy related to near-falls and fall-landing was not explicitly stated by participants, but the importance of these skills have been highlighted by individuals living with chronic SCI [49]. Individuals with chronic, motor incomplete SCI reported that their participation in perturbation-based balance training (i.e. repetitive exposure to near-falls) increased their confidence when taking balance risks in their daily lives [49]. Wheelchair users have highlighted the importance of learning to fall in a way that minimizes injury in a safe and controlled setting (i.e. practice landing falls) [8]. The Falls-related Self-efficacy Continuum Model, along with input from individuals with SCI, may help clinicians to create comprehensive fall prevention initiatives that reduce the anxiety and fear associated with falls/fall risk after SCI.

Our study has several limitations. First, the demographic and injury-related characteristics of Phase I participants differed from national averages in several regards. Our sample was 78% male. Males are 3–5 times more likely to sustain a traumatic SCI than females [50], whereas the male to female ratio is about equal for non-traumatic injuries [51]. In Canada, it is estimated that the prevalences of non-traumatic and traumatic injuries are approximately equal [52]. Hence, taken together the data would suggest the proportion of males in our study was higher than that of the Canadian SCI population. The higher proportion of males in our study may have impacted our findings related to falls, as there is conflicting evidence for an association between the male sex and an increased occurrence of falls [1,20,38]. In addition, 78% of Phase I participants had a motor incomplete SCI (i.e. AIS C or D). This is a higher proportion than that seen across Canadians with SCI; approximately 74% have incomplete injuries (i.e. AIS B, C or D) [53]. Other sample characteristics, such as their mean age and the proportion of traumatic versus non-traumatic injuries, were similar to Canada-wide data [53]. Second, we did not examine the fall data of Phase I participants according to mobility status (i.e. those who ambulate versus those who use a wheelchair). Mobility status is known to influence the causes and circumstances of falls in the chronic SCI population [37,38]. It proved difficult to categorize all participants of this longitudinal study as either wheelchair users or ambulators as their mobility status tended to change throughout the subacute period. A third study limitation was the small number of individuals who participated in Phase II. Although eight participants from Phase I were eligible to participate in Phase II, only five participants did. As highlighted in this study’s results, the subacute phase of SCI is an overwhelming time of adjustment and participants may have limited time for research participation.

In conclusion, the study findings highlight the importance of providing fall prevention initiatives during the subacute phase of SCI, when individuals are learning to manage their increased fall risk. Our increased understanding of the circumstances, causes and consequences of falls during the early phase of community living after SCI will lead to the creation of fall prevention education and training that is relevant to the subacute SCI population.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was funded by the Canadian Institutes of Health Research (Grant # PJT 153017 to KEM).