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Factors That Influence the Risk of Falling After Spinal Cord Injury

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Factors That Influence the Risk of Falling After Spinal Cord Injury Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-034279 on 25 February 2020. Downloaded from Factors that influence the risk of falling after spinal cord injury: a qualitative photo- elicitation study with individuals that use a wheelchair as their primary means of mobility Hardeep Singh ,1,2 Carol Y Scovil,2,3 Karen Yoshida,1,4 Sarah Oosman,5 Anita Kaiser,1,2,6 Catharine Craven,1,2,7,8 Susan Jaglal,1,2,4,8 Kristin E Musselman1,2,4,5 To cite: Singh H, Scovil CY, ABSTRACT Strengths and limitations of this study Yoshida K, et al. Factors that Introduction Falls are a concern for wheelchair users influence the risk of falling with spinal cord injury (SCI). Falls can negatively impact ► Photo- elicitation allowed detailed visual and verbal after spinal cord injury: a the physical and psychological well- being of fallers. To qualitative photo- elicitation insights into the factors that influence falls experi- date, the perspectives of wheelchair users with lived study with individuals that use enced by wheelchair users with spinal cord injury. experiences of SCI on the contributors to falls has been a wheelchair as their primary ► Telephone interviews may have reduced the depth/ understudied. Information about factors that influence means of mobility. BMJ Open detail of information collected. 2020;10:e034279. doi:10.1136/ fall risk would guide the development of effective fall ► Photographs captured by caregivers may have influ- prevention strategies. bmjopen-2019-034279 enced the content of the photographs. Objectives To gain a comprehensive understanding of the ► Prepublication history for ► Photo- assignment instructions provided to partici- factors that influenced the risk of falling as perceived by this paper is available online. pants prior to taking photographs may have influ- wheelchair users with SCI. To view these files, please visit enced the photographs captured by participants. Design A qualitative study using photo- elicitation interviews. the journal online (http:// dx. doi. ► As the sample is from an urban Canadian environ- Setting A Canadian SCI rehabilitation hospital and the org/ 10. 1136/ bmjopen- 2019- ment, the transferability of findings to other environ- participants’ home/community environments. 034279). ments/contexts is limited. Participants Twelve wheelchair users living in the Received 13 September 2019 community with chronic SCI. http://bmjopen.bmj.com/ Revised 26 November 2019 Methods Participants captured photographs of situations, Accepted 18 December 2019 places or things that they perceived increased and decreased a negative impact on an individual’s psycho- their risk of falling. Semistructured photo- elicitation logical and emotional health.1–3 Falls pose interviews were conducted to discuss the content of the a significant complication for community- photographs and explore perceptions of fall risk factors. A dwelling wheelchair users with spinal cord hybrid thematic analysis and the Biological, Behavioural, injury (SCI) as 69% (95% CI 60% to 76%) Social, Economic, and Environmental model were used as a will experience at least one fall within a year.4 framework to organise/synthesise the data. Wheelchair users commonly experience on September 28, 2021 by guest. Protected copyright. Results Overall, the findings indicated that the risk of falling falls during transfers, reaching, propelling was individualised, complex and dynamic to each person’s on an uneven surface, moving in bed and life situation. Four main themes were revealed in our 1 2 5 6 analysis: (1) Falls and fall risk caused by multiple interacting showering. Depending on the level factors; (2) Dynamic nature of fall risk; (3) Single factors were and severity of their SCI, some individuals targeted to reduce falls and fall- related injuries; and (4) Fall primarily use a wheelchair for mobility but prevention experiences and priorities. can also walk short distances.7 As such, some Conclusions Each wheelchair user encountered numerous wheelchair users may experience falls while © Author(s) (or their fall risk factors in their everyday lives. Information from this standing and walking.1 8 The majority of prior employer(s)) 2020. Re- use study can be used to set priorities for fall prevention. Fall studies examining falls among wheelchair permitted under CC BY-NC. No prevention initiatives should consider a wheelchair user’s users with SCI used quantitative surveys to commercial re- use. See rights fall risks in a holistic manner, acknowledging that a person’s and permissions. Published by gather information on falls, which limits the BMJ. current situation, as well as anticipating their fall risks and 4 fall prevention needs, will change over time. breadth of information collected. There For numbered affiliations see remains a need to gain a more detailed under- end of article. standing of the nature of falls in regard to 2 4 Correspondence to INTRODUCTION this particular population. Few studies have Dr Kristin E Musselman; Falls can have significant adverse conse- used qualitative or mixed methods to explore Kristin. Musselman@ uhn. ca quences such as fractures, head injuries and the perspectives of wheelchair users with SCI Singh H, et al. BMJ Open 2020;10:e034279. doi:10.1136/bmjopen-2019-034279 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-034279 on 25 February 2020. Downloaded from concerning the causes and the impacts of falls.1 3 9 An was used to select participants based on the following in- depth exploration from the perspectives of wheelchair predefined traits: (1) used a manual or power wheel- users can provide insight into priorities and potential chair for ≥4 hours per day15 and (2) had ≥1 fall in the past strategies for fall prevention.3 4 6 months. Based on previous studies using PEI,3 16–18 it was In order to deliver effective fall prevention interven- determined that 10–12 participants who met the above tions and minimise the impact of falls and fall risk on indi- criteria were needed. Thus, the first 15 participants that viduals living with SCI, a comprehensive understanding completed the larger study and met the current study’s of their fall prevention needs and priorities is needed.10 inclusion criteria were invited to participate; 12 partici- One qualitative methodology that enables detailed insight pants agreed. into the perspectives of participants on a particular issue All participants provided informed consent (verbal and is photo- elicitation interviewing (PEI), which involves the written) to participate in this study. Ethical issues related incorporation of photographs into an interview.11 12 In a to photography were reviewed with each participant at previous study, PEI was used to examine the perceived study outset.19 causes of falls and impact of fall risk on the mobility and physical activity levels of individuals with incomplete SCI.3 Patient and public involvement However, since the study sample was limited to individ- Patients or the public were not involved in the design, uals with motor incomplete SCI (ie, American Spinal reporting or dissemination of our research. Cord Injury Association Impairment Scale (AIS) grades C and D), more research is needed to understand the Data collection factors that contribute to falls in individuals with motor As part of the larger study participants had seven to complete SCI (ie, AIS grades A and B). Photo-elicitation nine telephone interactions with HS. Participants were is suited for addressing this knowledge gap. Through provided with verbal instructions to capture photographs photo- elicitation, we can obtain a visual display of the of things, places or situations they perceived increased or participants’ experiences, situations and environments, decreased their risk of falling. Participants were provided as well as a verbal account of their experiences with falls/ with the following written photo-assignment instruc- fall risk factors.3 As the perspectives of wheelchair users tions. ‘Please take at least 2 photographs for each of the with SCI regarding the factors that increase and decrease following questions: (1) What increases your likelihood their risk of falling remain understudied, here we used of falling? and (2) What decreases your likelihood of PEI to gain a more detailed understanding of: (A) the falling?’. Participants were also instructed to refrain from various risk factors associated with falls and (B) the strat- taking pictures of people under the age of 18 years. They egies that can reduce their fall risk. were asked to complete this photo- assignment over seven consecutive days. If participants had difficulty holding and/or manipulating the camera, they could ask a care- http://bmjopen.bmj.com/ METHODS giver for assistance. Following photo-taking participants Settings and participants completed an audio recorded interview (face to face This interpretive qualitative study was conducted at the (n=9) or telephone (n=3)) with a researcher (HS) who Lyndhurst Centre, Toronto Rehab – University Health is a female PhD candidate and an occupational thera- Network. This study is part of a larger research study in pist with experience in SCI rehabilitation and qualitative which we tracked falls for 6 months in 65 participants research. Photographs were used as a point of reference with SCI (32 wheelchair users and 33 ambulators).8 to facilitate these discussions.20 Participants with the following traits were eligible for the The SHOWeD framework—a set of five open-ended on September 28, 2021 by guest. Protected copyright. larger study: (1) chronic (≥1 year postinjury), traumatic questions—was used to explore the issues presented in SCI with a neurological level between C1 and L1 (AIS the photographs.21 The framework effectively facilitates grades A–D); (2) community- dwelling for ≥1 month; and interviews because it moves the discussion about the issue (3) ≥18 years of age. To recruit participants for the larger from a superficial to deeper level.22 Additional semi- study, HS contacted individuals from the central recruit- structured questions were asked during the interviews to ment database at the Lyndhurst Centre.
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