A study of wheelchair,movement and environmental factors associated with concerns about falls among wheelchairs users

1. Introduction

By analyzing data about falls in different countries it is possible to argue that it is a public health issue. Falls are a frequent event among the elderly in Brazil [1]. Between 1996 and 2012, the mortality rates of the elderly due to falls increased in all regions of the country. This data points to the importance of monitoring these accidents to assist the planning of technological and human resources to prevent falls [2]. In Canada, falls cost 2 billion dollars per year [3]. Most injuries in Canada occur among the elderly, who are a growing population in the country [3]. Falls can cause complications for public health as a result of injuries [3].

There may be a relationship between the prevalence of falls and the need for assistance for locomotion among the elderly [1]. Falls from wheelchairs are recognized as a concern factor for individuals’ health [4]. Falls during wheelchair use may be influenced by the characteristics of users [7, 4, 8], wheelchair stability [9, 8, 10, 11] and environmental accessibility issues [12, 13, 11]. Chen [9] found that 87.8% of the daily accidents involving wheelchair users (WUs) in three years of study were tumbles or falls. Some causal actions of falls from wheelchairs are moving up or down a slope, transfers, propulsion, front wheel breakage, rocks, potholes, wheel component breakage, fainting and loss of balance [14].

Kittel [5] investigated factors associated with wheel-chair abandonment and dissatisfaction and identified some of them as being lack of experience in use and selection of wheelchairs, and limitations in wheelchair design (inappropriate size and weight). These factors were related to limitations in wheelchair use in daily activities [5]. Medola et al. [6] found low level of satisfaction with the aspects of comfort, mobility, access outside the home and appearance of wheelchairs. The authors pointed out that satisfaction may be influenced by the environment: indoor home environments were associated with higher level of satisfaction than outdoor ones [6].

More effective solutions to improve wheelchair design require the collaboration of users, clinicians, designers and other professionals [16]. Some assistive technologies available in the market are still perceived to be ineffective, especially in supporting transfers between the wheelchair and other surfaces [16]. Transfers are one of the most challenging tasks for WUs [16] and this movement often results in accidents [8, 11, 12]. To be independent in transfer maneuvers is important as it affects the personal, social, and self-image of the WU [16].

A fall can have varied physical and psychosocial factors and consequences. It is important to understand the contexts of falls, beyond hospitalization data. Understanding factors involved in the concern about falls can help provide more confidence for WUs during their daily mobility. The assistive device used, the daily movements, routines and users’ perceptions of this context should also be considered.

Fall experiences are still common in the daily lives of WUs and cause injuries. However, little is known about how wheelchair type, daily movements and environment influence users’ concerns about falls.

The aim of this study was to discuss the relationship between users’ concerns about falls and wheelchair type, daily movements and environmental factors. This knowledge can improve interventions – from an interdisciplinary perspective – to reduce falls and improve WUs’ confidence in using their wheelchairs. Future interventions based on this study can involve rehabilitation, wheelchair design and environments.

2. Materials and methods

3. Results

4. Discussion

This study found that falls are events experienced by most of our sample of WU, and also a factor of concern during daily wheelchair use. Concerns about falls can be influenced by various factors. The consequences of a fall for the user seem to be more psychological than physical, as few serious physical injuries were reported, but concerns about falls increased. The consequences of injuries after falls corroborate the finding by Xiang [17] and Chen [9] that most falls and imbalances in wheelchair operation result in some type of injury.

A fall also seems to affect the future involvement of the individual in activities, as many of the sampled WUs reported feeling insecure about carrying out movements with the type of wheelchair related to the fall and going to places where the fall happened, such as public transport or shops. The results suggest that wheelchair type may have an effect on concerns about falls. The use of a rigid frame wheelchair was associated with higher levels of concerns about falls, mainly when leaning backward. It is possible that this is related to the characteristic of this wheelchair type, which is usually lighter, more compact and more agile.

Also, more than half of the sample reported that they do not perform the wheelie maneuver, which is an important skill for daily activities [23] and user stability [24]. This maneuver was more commonly reported by WUs with a rigid frame wheelchair, due to users of such wheelchairs seems to be more independent. Conversely, rigid frame wheelchairs were more associated with users’ concerns about falls. Thus, it seems that even for users with skills in conducting complex movements, such as wheelies, concerns about falls were still reported when using this type of wheelchair.

An interesting finding is the lack of specialized training on the use of a wheelchair reported by most of the users, as well as that they do not perform the wheelie maneuver. Training on wheelchair skills is important to allow users to gain independence in a variety of mobility situations and environmental/accessibility conditions, but also, for manual WUs, to be able to learn optimal propulsion techniques, taking into account push efficiency and biomechanical loads. In our study, half of the sample reported that they had not received training, which corroborates the study of Kirby [23].

A lack of wheelchair skills has been reported in some studies [25]. A lack of specific training for wheelchair use can generate a worsening of users’ physical condition and autonomy and independence [26]. It also might result in abandonment of the wheelchair [27]. Wheelchair design and rehabilitation interventions should be combined to provide adequate training to users, to improve their confidence in maneuvering their wheelchair [28].

As expected, there is also an influence of the characteristics of WUs on the concern about falls and on fall occurrence. Most of the participants reported using their wheelchair for around 5 to 10 hours in a typical day, and being totally independent. Regardless of users’ experiences with wheelchairs, we found that falls and concerns about falls were frequent, because a large part of the sample reported one or more falls throughout their time using a wheelchair. Indeed, even experienced WUs experience repeated falls during transfers and daily movements [21].

Common environments (sidewalks, streets, squares, and parks, among others) were associated with concerns about falls for most of the participants in this study. Architectural accessibility is still a problem in many urban spaces in Brazil. For this reason, it is common to find irregular sidewalks, squares and establishments with physical barriers that result in difficult access in different environments [22]. Barriers such as lack of accessibility impact perceptions of danger and, consequently, can cause a reduction in social participation. In the current study, even active and experienced users frequently reported concerns about falls and experiencing memorable falls in non-domestic environments.

Other studies also point to the influence of environmental aspects on falls among wheelchair users. In the study of Xiang [17] injuries in adult WUs were more frequent at home and in hospitals and institutions. Forslund [13] found that most of the falls occurred indoors, while the study of Rice [11] found that falls were more frequently reported on sidewalks, surfaces with debris or uneven surfaces, and it was corroborated by Singh [21] that most participants had at least one fall every six months due to uneven surfaces. The literature points out that transfers, especially when there are also environmental restrictions [16], can result in falls [8, 11, 13, 12]. Environment restrictions can be large gaps in height and width, lack of space to safely position the wheelchair and instability of transferring surfaces [16].

In the present study, most participants reported an increase in concerns about falls after the fall described. Concerns about falls may be associated with reduced activity and limited community participation, reduced quality of life, and negative impacts in the domains of physical health, psychological health, and the environment [33]. Indeed, some participants reported that they stopped performing some activities because of a fall, suggesting that there are psychosocial consequences of falls, such as feelings of fear, embarrassment and frustration, in addition to the possible reduction in participation in daily activities, as also reported by Khan [4].

We also found that wheelchair failure or breakage was common in the users’ daily routine, with wheelchair failure being the main factor related to falls. Not every incident of breakage or failure of the wheelchair caused a fall, but the number of falls due to this type of incident was high.

Mobility in non-domestic environments and performing transfers were most associated with reports of WUs’ concerns about falls. The ability to perform transfers independently seems to affect individuals’ perceptions of safety, since transfers with the help of another person were more related to reports of concerns about falls than performing transfers alone. Barbareschi and Holloway [16] state that this movement is extremely important, and affects the individual’s personal, social, and self-image.

The risk of falling increases when the occupant tends to lean forward. Of our sample of wheelchair users who were concerned about falling, the leaning direction most associated with concerns about falls was forward, although this is not the direction in which falls occurred most often.

There was a higher prevalence of concerns about backward falls among rigid frame WUs. In the study of Silva [29] participants pointed to backward propulsion in rigid frame wheelchairs as a generator of perceptions of instability and insecurity, both in users and non-users [29]. In the current study, the concern about falls differed according to the wheelchair type. The front and rear load distribution and inertial properties differ between wheelchair types [30], which can affect the user’s perception of balance.

Stability is more affected by the position of the rear axle [31], the position of the castors [32] and the weight distribution [6]. A shorter length of a wheelchair was a predictor of falls in the study of Nelson [7]. The influence of the position of the rear axle on stability leads to a need to develop dynamically adjustable axles [10]. In the current study, the main change in the wheelchair after a fall was made in the axis, corroborating these studies.

The high number of respondents who had experienced at least one fall corroborates Berg [15], Forslund [13] and Khan [4], who reported that falls are a recurrent event for WUs, and also that serious injuries from falls are uncommon. However, Chen [9] pointed out that any injury has the potential to impact the individual’s social and health function. Indeed, our findings show that falls can increase users’ concern and make them stop doing some activities.

The differences observed between the factors related to falls were also raised by the study of Silveira [14]. There are different predictors and recurrent factors for falls [13, 11, 8]. In Sung [33], powered wheelchair users were six times more likely to have concerns about falls compared to users of manual wheelchairs. Conversely, in the present study, manual WUs reported more concerns about falls than powered WUs.

The study of Chen [9] found that injuries from falls were more frequently located in the upper and lower extremities, while in the present study the head and neck were the body areas most frequently reported as receiving injuries. This finding may be related to the fact that the participants were asked to consider the most important fall, therefore it is possible that the potential for serious injuries in these body areas influenced their reporting on falls.

5. Limitations of the study

Due to the diversity of the study population, the sample was not homogeneous in terms of demographic data, such as age and height. It was also not possible to achieve a numerically equal sample in the wheelchair categories. It is believed that a larger sample of WUs using power wheelchairs would be important for achieving a more accurate comparison. It is also important to evaluate the influence of the type and intensity of training received on concerns about falls among in these individuals.

Participants reflected on their lifetime wheelchair use, which can affect their ability to recollect falls and injuries clearly, so it is possible that details about falls, such as direction and situation, may not be accurate. It could be that patients’ perspectives regarding not being trained to use their wheelchair arise because some have had a wheelchair for a long time.

6. Conclusions

This study found that the characteristics of the wheelchair influence the concerns about falls, alongside with interaction with the environment and the activities and movements performed in daily routine. It is important to consider that the influences are mainly related to wheelchair type (rigid frame, foldable frame or powered), due to the characteristics of the WU, the environment and the specific conditions in which falls occur.

The present study also found a need for evaluation and improvement of training on wheelchair skills, due to the high levels of concern users had when performing backward and forward tilting movements. Additionally, we did not find a high percentage of users who had undergone training. Public places must provide a safe environment for WUs’ to perform their mobility activities, thus promoting better means for their independence and social participation.

Funding

This work was supported by the Coordination for the Improvement of Higher Education Personnel (CAPES) #1 under Grant 88887.597667/2021-00.

Author contributions

CONCEPTION: Paula Conceição Rocha de Oliveira.

PERFORMANCE OF WORK: Paula Conceição Rocha de Oliveira, Fausto Orsi Medola and Luciana Ramos Baleotti.

INTERPRETATION OR ANALYSIS OF DATA: Paula Conceição Rocha de Oliveira and Fausto Orsi Medola.

PREPARATION OF THE MANUSCRIPT: Paula Conceição Rocha de Oliveira, Luciana Ramos Baleotti, Gustavo Christofoletti and Fausto Orsi Medola.

REVISION FOR IMPORTANT INTELLECTUAL CONTENT: Paula Conceição Rocha de Oliveira, Luciana Ramos Baleotti, Gustavo Christofoletti and Fausto Orsi Medola.

SUPERVISION: Fausto Orsi Medola.

Ethical considerations

The research methods were submitted and approved by the Research Ethics Committee of the School of Philosophy and Sciences of São Paulo State University – Campus of Marília – FFC/UNESP/SP – Brazil, Technical Appraisal: (Technical Appraisal 3.550.293). Participants were informed about the objectives and procedures and, after accepting to voluntarily participate, read an Informed Consent Form and indicated their acceptance in an online form.