Risk of Fall-Related Injuries among Ambulatory Participants with Spinal Cord Injury.

Spinal cord injury (SCI) results in permanent motor and sensory deficits and can elevate the risk of secondary health conditions1 and mortality.2,3 As the proportion of neurologically complete injuries has decreased,4 and with advances in medical and rehabilitation care, many persons are able to regain or maintain ambulation. However, recent studies have identified that ambulation is associated with an increased risk of falls after SCI5 and is sometimes associated with negative health outcomes, including pain and depression.6,7 Many ambulatory persons with SCI use assistive devices to help with walking.8 Even though these devices can aid with ambulation, there is evidence that certain devices may impede balance and increase risk of falls.9 Brotherton et al10 identified risk of falls (an unplanned, unexpected contact with the supporting surface) among persons with ambulatory SCI, finding that 75% reported at least 1 fall in the previous year. Among persons who are able to walk at least 10 m, it has been found that worse health (as measured by number of medical conditions), arthritis, and dizziness resulted in increased odds of a fall in the previous year.11 Persons who used a cane were more likely to fall than those who did not, and those who used a walker were less likely to fall than those who did not.11 A recent study of falls in ambulatory individuals with SCI reported higher functional ability among persons classified as “fallers” compared to “non-fallers.”5 Although those studies were able to assess some predictors in relation to falls, they lacked the power to assess predictors in a multivariable model or assess multiple predictors simultaneously. Other research on falls among persons with SCI has been limited to falls among wheelchair users, excluding persons who are ambulatory. Falls in persons who are ambulatory could result in negative health outcomes, including fractures or further disability, but studies of predictive factors of those falls have been limited by sample size and scope of measurement. In addition to the increased risk of falls with the use of some assistive devices, Saunders et al8 found that the use of 1 cane and the use of a wheelchair less than half the time for locomotion were associated with increased odds of greater pain intensity, pain interference, and fatigue. These results suggest that persons who are only partially ambulatory or who use certain devices for ambulation are at increased risk for negative health outcomes. In addition, the consequences of a fall after SCI may be severe and result in added disability, as SCI is associated with bone density loss12 and osteoporosis,13 which increases the risk of fracture.14 Behavioral and personality factors contribute to the events leading to SCI. Alcohol or drug use has been found to be a contributing factor to injury in 39% of SCIs.15 Furthermore, these behaviors have been shown to have an effect on postinjury outcomes and subsequent injuries as a result of an event or mishap, including falls.16,17 Brotherton et al10 found that participants did not perceive alcohol or prescription medication use to be related to falls; however, a larger study has yet to be completed to examine this relationship or to link these behaviors with falls resulting in injuries (FRI). Exercise has also been examined as a behavioral factor related to fall risk. Exercise frequency (days/week) has been shown to decrease the odds of falling in ambulatory individuals with SCI.11 The purpose of this study was to assess the relationships between walking devices and behaviors, including alcohol use, prescription medication use, and exercise, with FRI among participants with SCI who are ambulatory.