Wheelchair use can be limited by falls and accidents resulting in injury and/or by repairs and maintenance issues. All these factors have potential to affect wheelchair use, to decrease confidence in the equipment or user’s skill in operation, impact functional and social activities and, place the person at risk of injury. Falls risk is an important factor to assess for people who use wheeled mobility devices.
Summarized Level 5 Evidence Studies
The following level 5 evidence studies have been reviewed, and the overarching findings from the studies are highlighted in this section. As noted at the start of this chapter, these types of studies are not included in the discussion or in the conclusions but their contribution to the research evidence is of value. In the following observational studies, the authors surveyed large numbers of people related to falls, fall-related injuries and need for wheelchair repairs to explore the frequency and severity of these incidences.
Saunders and Krause (2015) surveyed 759 people with traumatic SCI asking them to recall the incidence of falls and/or injuries they incurred over the previous year related to wheelchair use. Almost 20% reported a fall with 10.4% reporting a resultant injury and 22.8% having at least one hospitalization due to a fall or injury sustained. Similarly, Chen et al. (2011) asked participants to recall accidents in the previous three years (response rate was 79.2%) during telephone interviews. A lack of regular maintenance and the w/c not being professionally prescribed were found to be associated with increased risk of wheelchair accidents. A lack of regular maintenance and not using seat belts were significant predictors of the cumulative number of accidents. In a secondary analysis, Hogaboom et al. (2018) explored the data from 610 participants with SCI.
They found that wheelchair breakdowns that resulted in an immediate consequence such as being stranded, injured, or missing work or an appointment, were associated with reported worse pain and lower self-perceived health. Worobey et al. (2014) retrospectively asked 945 people who used power wheelchairs the frequency of repairs in the previous 6 months. More than 25% of participants reported experiencing at least one repair in the previous six months. Toro et al. (2016) also surveyed people with spinal cord injury to explore the frequency of repairs and resultant adverse outcomes as well as the types of repairs needed, if they were completed and by whom (n=591). 63.8% of respondents reported needing one repair in the past 6 months, (mean =1.5 =/- 2.1), and 27.6% needed more than 1 repair; 21% of participants reported adverse consequences and 30% being stranded. Wheelchairs and casters were the most frequently required repair for manual wheelchairs and to the electronics and power systems systems for power wheelchairs.
In their 2017 study, Butler Forslund et al interviewed and monitored via text messaging, 149 people with an SCI who reported a total 448 falls in a two-week period. Of this number of falls, 70 resulted in an injury of some type; 67% were minor injury (bruises, scratches, etc.), 23% were moderate injuries (strains and sprains) and 10% were severe (fractures of concussion). The most frequent situations where falls occurred were wheelchair transfers and pushing the wheelchair (18 falls on flat ground, 37 on uneven surfaces and 24 going over gutters or curbs).
These authors suggest asking about wheelchar related falls, especially recurrent falls, is critical to identify increased risk for falls. The authors suggest that since most falls are related to pushing the wheelchair, that wheelchair skills training play a key role in falls prevention during intital rehabilitation and when there are changes in functional status.
Based on the large number of participants in all of these studies, and the consistency of high falls frequencies with varying degrees of health outocmes, it is suggested that falls risk identification is an important component of a full wheelchair and seating assessment. Additionally, the impact of wheelchair skills training on falls prevention needs to be researched to determine its viability as a means for reducing falls risk.
Nelson et al. (2010) completed monthly monitoring with participants over a one year period to collect data related to wheelchair related falls and injuries for the purpose of identifying 1) the incidence of falls and related injuries, 2) the epidemiology of wheelchair related falls, 3) the severity of injury and 4) identifying associated risk factors that best predict wheelchair related falls and related injuries. The variables collected were compared and contrasted to the groups of no fall, fall and injurious fall to address these purposes. 82% of variances for wheelchair related falls were explained by the predictive factors of: increased pain in previous 2 months, positive for alcohol abuse, high FIM score for motor function; history of fall in past year; fewer years with SCI and; a shorter length of w/c (distance measured between front caster and centre of rear axle). 81% of the variance in wheelchair related falls with injuries was explained by four variables: increased pain in past two months, higher FIM score on motor subscales, history of falls in past year, and lack of accessibility at home entrance. Incidence rates found in this study, 31% reported falls with 14% reporting injurious falls, is reported by the authors to be slightly higher than the national (USA) estimate. The authors suggest that most of the predictive risk factors are modifiable, particularly the shorter wheelchair frame and the lack of accessibility to the home entrance. Therefore, they suggest that recommendations for preventing falls should be incorporated into rehabilitation and as part of all new wheelchair fittings.
Worobey et al. (2012) surveyed 723 participants who used their wheelchair for more than 40 hours per week, to report the incidence of wheelchair repairs, breakdowns and the resultant consequences over a six-month time period. Overall, 52.6% of participants experienced at least one wheelchair repair in the past 6 months with 32.2% experiencing at least one consequence because of the repair/breakdown. Unfortunately, the authors did not differentiate in the data between repair and breakdown, which potentially could hold different meaning and affects for the participants. 31% of participants reported experiencing the consequence of missing work or school and 32% of participants reported and injury. In this study, participants who used power wheelchairs reported more repairs and adverse consequences compared to reports for manual wheelchair use. Of all consequences reported, 65% were accounted for by participants who used power wheelchairs. Wheelchairs with power seat functions also reported significantly higher consequences of being stranded, being injured and missing appointments. The authors also compared results of this study (2006-2011) to historical results (2004-2006), finding that there has been an increase in the incidence of repairs/breakdowns and resultant consequences. The authors suggest that the increasing incidence may be related to a decrease in wheelchair quality due to a lack of standards enforcement and the funding structure in the author’s country, for which further investigation is required. It is questioned whether the separation of repairs versus breakdowns and if regular maintenance was completed would provide additional valuable data for this issue.
There is level 4 evidence (from one cohort study: Neslon et al. 2010) which suggests that tipping or falling from the wheelchair is the most frequently experienced wheelchair-use related accident.
There is level 4 evidence (from one cohort study: Nelson et al. 2010) to suggest that there are a variety of predictive factors for wheelchair related falls and injuries including a recent increase in pain, recent history of falls, not using seat belts, lack of regular maintenance, the w/c not being professionally prescribed, high FIM scores on the motor subscale combined with a shorter w/c frame length and, a lack of accessibility at home entrance.
There is level 3 evidence (from one cohort study: Worobey et al. 2012; one case series study by McClure et al. 2009) to suggest that in a six month time period between one quarter and one half of wheelchairs will require a repair and that of these repairs up to one third will result in an adverse effect.