Investigation of the Feasibility of an Intervention to Manage Fall Risk in Wheeled Mobility Device Users with Multiple Sclerosis

A mixed-methods study examining perceptions of fear of falling among community-dwelling people who use wheelchairs full-time

Objective: There is growing evidence that fear of falling (FOF) is common in people who use wheelchairs full-time and negatively influence their performance of daily activities and quality of life. The purpose of this study was to gain an in-depth understanding of perceptions related to FOF among people who use wheelchairs full-time.Methods: Mixed-method analysis was conducted using semi-structured interviews and surveys to gain insight into FOF. Surveys included demographic information; Spinal Cord Injury-Fall Concerns Scale (SCI-FCS); a questionnaire that directly assesses FOF and associated activity curtailment; and Fall Control Scale (FCS).Results: Among 39 participants (age = 43.1 ± 15.6 years, disability duration = 21.2 ± 11.1 years), 27 participants (69%) reported FOF. Participants with less perceived ability to control falls indexed by FCS reported higher SCI-FCS scores, indicating greater FOF (rs = -0.384, p = 0.016). Qualitative findings revealed that participants felt that FOF developed due to sustaining fall-related injuries or limited ability to recover from a fall. Some participants perceived falling as a part of their lives. They believed that it was not the cause of developing FOF.Conclusions: Among people who use wheelchairs full-time, FOF is prevalent and may develop due to fears of sustaining injuries or being unable to get up after falling. Developing an evidenced-based education protocol aimed at managing falls (e.g., establishing a fall recovery strategy and education on techniques to reduce injury during falls) is needed to minimize FOF people who use wheelchairs full-time.

The differences in demographics, fear of falling, transfer quality and participation enfranchisement between manual and power wheelchair users with multiple sclerosis and spinal cord injury

PURPOSE

To examine the differences in demographics, fear of falling (FOF), transfer quality and participation enfranchisement between manual and power wheelchair users with multiple sclerosis (MS) and spinal cord injury (SCI).

MATERIALS AND METHODS

Secondary data analysis including 126 manual or power wheelchair users with MS and SCI (median age, 53.00 years, IQR = 24.00). Demographic information including age, gender, height, weight and disability duration was collected. Body mass index (BMI) was calculated for all participants. Participation enfranchisement was examined using both subscales (Importance and Control) of the enfranchisement scale of the Community Participation Indicator (CPI). FOF was assessed using the Spinal Cord Injury-Falls Concern Scale (SCI-FCS) and transfer quality was assessed using the Transfer Assessment Instrument (TAI) 3.0 and 4.0. Mann-Whitney's U-tests or independent samples t-tests and chi-square were used to analyse the differences between continuous variables and categorical variables, respectively.

RESULTS

Fifty-seven percent of participants were manual wheelchair users. There were significant differences in most demographic information except for weight and disability duration. Significant differences were also found for BMI (t = 1.06, p = 0.04), CPI-Importance (U = 1282.50, p < 0.01), CPI-Control (U = 1165.50, p < 0.01) and SCI-FCS (t = 4.08, p < 0.01). Manual wheelchair users outperformed power wheelchair users in all outcomes analysed except the TAI (p = 0.18).

CONCLUSIONS

Power wheelchairs users presented with a higher BMI, reported lower participation enfranchisement, and reported higher levels of FOF compared to manual wheelchair users. The findings may help clinicians to develop targeted rehabilitation goals specific for power and manual wheelchair users with MS and SCI.

Online Delivery of the Individualized Reduction of Falls Intervention for Persons With Multiple Sclerosis Who Use a Wheelchair or Scooter Full-time: A Pilot Study

BACKGROUND

People with multiple sclerosis (MS) who use a wheelchair or scooter full-time fall frequently; however, fall prevention programming that meets the unique needs of this population is limited. This study examined the preliminary efficacy of a group-based online fall prevention and management intervention designed specifically for people with MS.

METHODS

This pre/post intervention, mixed-methods study included people with MS who used a wheelchair or scooter full-time, experienced at least 1 fall within the past year, and transferred independently or with minimal or moderate assistance. Participants engaged in a 6-week, online, individualized, multicomponent fall prevention and management intervention: Individualized Reduction of Falls-Online (iROLL-O).

RESULTS

No statistically significant change in fall incidence occurred after iROLL-O. However, fear of falling significantly decreased (P < .01) and knowledge related to fall management (P = .04) and fall prevention and management (P = .03) significantly improved. Qualitative results indicated that participants valued the opportunity for peer learning and iROLL-O's attention to diverse influences on fall risk.

CONCLUSIONS

This study is the first to examine the preliminary efficacy of an online fall prevention and management intervention for people with MS who use a wheelchair or scooter full-time. iROLL-O has promise, and participants found it valuable. Further efforts are needed to retain iROLL-O participants with lower confidence and functional mobility, and more research is needed to investigate the impact of the intervention on key outcomes over time.

Process evaluation findings of a fall prevention and management program for wheelchair and scooter users with multiple sclerosis

Objective

To describe process evaluation findings of a clinical trial to evaluate the Individualized Reduction of Falls (iROLL) program, a 6-session, group-based intervention designed to reduce fall incidence among people living with multiple sclerosis (MS) who use a wheelchair or scooter full-time.

Methods

A mixed-methods process evaluation focusing on implementation and mechanisms of impact (MOI) was conducted. Both iROLL participants and trainers (licensed occupational or physical therapists) provided input.

Results

Seventeen iROLL participants and nine trainers participated. The overall session attendance rate was 93%. Content and logistics fidelity were 95% and 90%, respectively and average overall participant satisfaction rating was 4.7/5.0. Five MOI themes emerged: group dynamic, comprehensive nature of the program, strong program development, role of a skilled interventionist, and motivated participants. Recruitment challenged program reach.

Conclusion

iROLL is acceptable to the target audience, can be delivered with high fidelity and has diverse and interacting mechanisms of impact operating. Remote delivery may improve reach.

Innovation

Effective iROLL delivery requires trainers with strong group management skills who can also individualize material while maintaining program fidelity. Comprehensive training and on-going support of the occupational and physical therapists delivering iROLL bolsters program effectiveness. Program access may improve with online delivery.

Pilot Study of a Fall Prevention and Management Intervention Program for People With Multiple Sclerosis Who Use a Wheelchair or Scooter Full-Time

Objective

To examine the efficacy of a fall prevention/management intervention among persons with multiple sclerosis (PwMS) who use a wheelchair (WC) or scooter full-time.

Design

Pre-post/follow-up trial.

Setting

Community and research laboratory.

Participants

Twenty-one PwMS who used a WC or scooter full-time, self-reported at least 1 fall/12 months, and could transfer independently or with minimal/moderate assistance (N=21).

Intervention

Six-week, group and community-based fall prevention and management intervention. The intervention included six 2-hour in-person weekly sessions led by a physical or occupational therapist featuring interactive group discussions, skill practice, and action planning opportunities.

Main Outcome Measures

Fall frequency tracked 12 weeks pre- and 24 weeks post intervention. Outcomes were assessed pre- and post intervention and 12 weeks post intervention. Measures included surveys to examine fear of falling (FOF), fall prevention/management, quality of life, community participation, and assessment of functional mobility skills. Semistructured interviews were administered post intervention to ascertain overall experiences with the program and effect on daily life. A Friedman test with signed-rank post hoc analysis was run to determine differences across the 3 study visits.

Results

After the intervention, fall incidence did not significantly change, but fall management strategies (P=.01-0.05), importance of community participation (P=.01), and transfer quality (P=.02) significantly improved. Moderate effect sizes were noted among concerns about falling, activity curtailment because of to FOF, and WC skills. Qualitative results indicate that participants found the intervention beneficial and applied intervention content in their daily lives.

Conclusions

This study is the first to describe the effect of a multicomponent fall prevention/management intervention designed specifically for PwMS who use a WC or scooter full-time. Results indicate the program has potential to reduce fall risk; however, further testing is needed to fully examine the effect of the program.

Online self-management fall prevention intervention for people with multiple sclerosis: a feasibility study protocol of a parallel group randomised trial

INTRODUCTION

Falls among people with multiple sclerosis (PwMS) are common and associated with injuries, fear of falling and low health-related quality of life. Considerations of behavioural, environmental, psychological and physical influences (including ambulation status) are needed to meet fall prevention needs for PwMS. Thus, using a codesign process involving key stakeholders a novel online self-management fall prevention intervention was created specifically for ambulatory and non-ambulatory PwMS. The feasibility, acceptability, fidelity and outcome of this complex intervention will be explored. Findings will inform a future full-scale randomised controlled trial.

METHODS AND ANALYSIS

A mixed-method design will be used. Forty-eight PwMS, stratified for ambulation level, will be randomised to control (n=24) or intervention (n=24). Both groups will receive a brochure about fall risk factors and fall prevention. The intervention is group-based (eight PwMS in each group); will be delivered online; and involve six, 2-hour weekly sessions and a booster session 8 weeks after the sixth session. Each intervention group will be led by a trained facilitator. Data collection will be performed at baseline, and after seven and 18 weeks. Outcome measures will capture data on fall prevention behaviours, fear of falling, falls self-efficacy, social and everyday activities, perceived impact of MS and number of falls. Feasibility of recruitment process, data collection procedures, outcome measures, and delivery, and intervention acceptability, fidelity and outcomes will be evaluated. Both quantitative and qualitative methods will be used.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Swedish Ethical Review Authority (registration number 2021-04817). Results will be disseminated in peer-review journals, at conferences, research meetings, in social media and through the patient organisation Neuro Sweden.

TRIAL REGISTRATION NUMBER

NCT04317716.

Prediction of future falls among full-time wheelchair and scooter users with multiple sclerosis: A prospective study

BACKGROUND

Seventy-five percent (75%) of full-time wheelchair or scooter users with multiple sclerosis (MS) experience at least one fall in a period of 6 months. Falls are detrimental for the independence, quality of life, and community participation. No previous prospective study has evaluated fall risk factors in this segment of MS community.

OBJECTIVE

To develop a multivariable falls risk prediction model for people with MS (PwMS) who use a wheelchair or scooter full-time.

METHODS

This prospective cohort study is a secondary data analysis that recruited PwMS from the community across the US. Forty-eight adults with MS who use a wheelchair or scooter as their main form of mobility were included. Dependent variable was fall incidence over 3-month recorded through diaries. Dependent variable was categorized as fallers (≥ 1 fall) and non-fallers (0 fall). Predictors were demographics, history of falls in the past 6 months, measures of fear of falling, Spinal Cord Injury- Falls Concern Scale, California Verbal Learning Test II, and Multiple Sclerosis Quality of Life- mental health. Multivariable logistic regression analyses were conducted to identity predictors of future falls.

RESULTS

In total, 63 falls (range 0 - 8) were reported over the 3-month period from a total of 26 fallers (54%). Multivariate logistic regression analyses indicated that the risk factor with the best predictive ability of future falls included history of falls in the past 6 months (sensitivity 77%, specificity 54%, and area under the receiving operating curve statistic = 0.76, 95% CI 0.62 to 0.89).

CONCLUSION

Findings highlight the importance of asking full-time wheelchair and scooter users with MS if they have fallen in the past 6 months to quickly identify those who are at increased fall risk and in need of follow up assessment and intervention to identify and address modifiable risk factors. More attention to fall risks among full-time wheelchair or scooter users with MS is suggested to increase the understanding among clinicians and researchers of modifiable risk factors.

Fear of Falling, Community Participation, and Quality of Life Among Community-Dwelling People Who Use Wheelchairs Full Time

OBJECTIVES

To examine the differences in community participation and quality of life (QOL) among individuals who use wheelchairs full time with and without fear of falling (FOF).

DESIGN

Cross-sectional study design.

SETTING

University research laboratory.

PARTICIPANTS

Individuals (N=85) who use a manual or power wheelchair full time who are living with various health conditions and have a history of at least 1 fall in the past 12 months (age, 45.4±15.8y; disability duration, 21.5±13.6y) were included. Forty-six (54%) were manual wheelchair users.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

To quantify FOF, participants responded (yes/no) to the question: "Are you worried or concerned that you might fall?" Community participation and QOL were indexed by the Community Participation Indicator (CPI) and the World Health Organization Quality of Life-Brief version (WHOQOL-BREF), respectively. A multivariate analysis of variance (MANOVA) was performed to examine the differences in CPI and WHOQOL-BREF scores among wheelchair users who reported FOF and no FOF.

RESULTS

A total of 54 participants (63.5%) reported that they were worried or concerned about falling. The MANOVA revealed significant differences in overall CPI (F_2,82=4.714; P=.012; Wilks' λ=0.897) and WHOQOL-BREF (F_4,63=3.32; P=.016; Wilks' λ=.826) scores. Participants who reported FOF demonstrated significantly lower CPI and WHOQOL-BREF scores compared with those who did not report FOF.

CONCLUSIONS

FOF and associated activity curtailment are prevalent and may be a factor influencing full time wheelchair users' community participation and QOL. Prospective research is needed to better understand how FOF influences community participation and QOL among individuals who use wheelchairs full time. Findings would support the development of interventions, specifically for individuals who use wheelchairs full time, to reduce FOF and improve community participation and QOL.

Fear of falling and falls in people with multiple sclerosis: A literature review

INTRODUCTION

Fear of falling (FOF) is a widespread problem affecting about 60% of people with multiple sclerosis (pwMS). Inflammatory lesions in the brain that are caused by the disease result in gait deficits and increase the risk of fall. Falls induce fear of falling and trigger a vicious circle, which in turn increases the likelihood of falling. Objective of this review was to provide an overview of existing research on the effects of FOF and therapy options in multiple sclerosis.

METHODS

A systematic search at Web of Science and PubMed was conducted. The search included the terms (fear of falling) OR (concern about falling) OR (fall anxiety) AND (multiple sclerosis).

RESULTS

In included studies, FOF was measured by different instruments. The Falls Efficacy Scale-International (FES-I) was the most frequently used instrument for pwMS. Patients with a higher FOF score fell more frequently, had lower walking speed, shorter stride length, larger ellipse sway area and a more severe disability. At present, therapeutic offers exist mainly in the field of physiotherapy. For reducing FOF, assisted vibration (d_z = 0.68), VR (d_z =0.87) and bicycle training (d_z = 1.23) were the most effective methods.

CONCLUSION

It is advisable to develop therapies that incorporate both physical and psychological aspects in neurorehabilitation, like in a cognitive behavioral therapy. Moreover, FOF monitoring should be integrated into the clinical routine.

A brief fall prevention intervention for manual wheelchair users with spinal cord injuries: A pilot study

Objective: To conduct a pilot study of an intervention to decrease fall incidence and concerns about falling among individuals living with Spinal Cord Injury who use manual wheelchairs full-time. Design: Pre/post. After a baseline assessment, a structured intervention was implemented. The assessment protocol was repeated 12 weeks after the baseline assessment. Setting: Research laboratory and community. Participants: 18 individuals living with SCI who use a manual wheelchair full-time with an average age of 35.78 ± 13.89 years, lived with SCI for 17.06 ± 14.6 years; 61.1% were female. Intervention: A 1:1, 45 minute, in-person intervention focused on factors associated with falls and concerns about falling: transfers skills and seated postural control. Outcome measures: Participants reported fall incidence and completed the Spinal Cord Injury Fall Concerns Scale, Community Participation Indicators and the World Health Organization Quality of Life - short version (WHOQOL-BREF). Transfer quality was assessed with the Transfer Assessment Instrument (TAI) and seated postural control with the Function In Seating Test (FIST). Results: Recruitment, assessment and delivery of the intervention were successfully completed. After exposure to the intervention, fall incidence significantly decreased, (P = 0.047, d_z= 0.507) and FIST scores improved (P = 0.035, d_z = 0.54). Significant improvements were also found in the WHOQOL-BREF Physical (P = 0.05, d_z= 1.566) and Psychological (P = 0.040, d_z= 0.760) domains. Conclusion: The feasibility of the structured intervention was established and the intervention has the potential to reduce fall incidence and improve quality of life among individuals living with SCI who use a wheelchair. Appropriately powered randomized controlled trials of the program are warranted.

Validation of an individualized reduction of falls intervention program among wheelchair and scooter users with multiple sclerosis

INTRODUCTION

Falls are a serious concern for wheelchair and scooter users with multiple sclerosis (MS). Approximately, 75% of the population reports at least one fall in a 6-month period and nearly half report frequent falls. Falls can result in physical injuries and contribute to activity curtailment. Despite the negative consequences, limited evidenced-based fall prevention programs designed specifically for wheelchair and scooter users with MS exist.

PURPOSE

Recognizing the threat falls pose to health and well-being and the dearth of fall prevention programs, the purpose of this study is to perform a structured process evaluation and examine the feasibility and efficacy of a community-based intervention specifically designed to reduce fall incidence among wheelchair and scooter users with MS. Secondary aims of the intervention are to improve functional mobility skills associated with fall risk (e.g., transfer and wheelchair skills, balance), increase knowledge of fall risk factors, decrease fear of falling, and enhance quality of life and community participation.

METHODS

To evaluate our specific aims, a clinical trial will be performed with 160 wheelchair and scooter users with MS. (ClinicalTrials.gov Identifier: NCT03705364). Participants will be recruited to participate in a small group-style community-based program. The content of the program will be based on factors found to be associated with falls among wheelchair and scooter users with MS. These factors include but are not limited to, wheelchair/scooter related characteristics, transfer activities, impaired seated balance, and environmental factors. A physical or occupational therapist, will implement the intervention, which is comprised of 6 sessions that occur once weekly. The incidence of falls, along with an examination of wheelchair/scooter and transfer skills, seated postural control and knowledge of fall related risk factors will be compared between intervention and control participants, with assessment periods occurring prior to the intervention, 1 to 2 weeks after completion of the 6-week intervention session, and 12 weeks after the intervention period is complete.

CONCLUSION

Results from this study will guide the refinement of the intervention program and inform future research among a large and diverse group of wheelchair and scooter users living with MS.

Falls among full-time wheelchair users with spinal cord injury and multiple sclerosis: a comparison of characteristics of fallers and circumstances of falls

PURPOSE

The purpose of this study is to (1) explore and (2) compare circumstances of falls among full-time wheelchair users with spinal cord injury (SCI) and multiple sclerosis (MS).

METHODS

A mixed method approach was used to explore and compare the circumstances of falls of 41 full-time wheelchair users with SCI (n = 23) and MS (n = 18). In addition to collecting participants' demographic information (age, gender, type of wheelchair used, duration of wheelchair use, and duration of disability), self-reported fall frequency in the past 6 months, self-reported restriction in activity due to fear of falling and the Spinal Cord Injury-Fall Concerns Scale (SCI-FCS) was collected. Qualitative data in the form of participants' responses to an open-ended question yielding information regarding the circumstances of the most recent fall were also collected. To examine differences in survey outcomes and demographic characteristics between participants with SCI and MS, independent t-tests and Pearson's Chi-square tests were used. Qualitative data were analyzed with a thematic analysis.

RESULTS

Statistical analysis revealed that individuals with MS (mean =3.3) had significantly higher average SCI-FCS than individuals with SCI (mean =2.4). The analysis of the participants' descriptions of the circumstances of their most recent falls resulted in three main categories: action-related fall contributors (e.g., transfer), (2) location of falls (e.g., bathroom), and (3) fall attributions (e.g., surface condition).

CONCLUSIONS

The results from this study helped to understand fall circumstances among full-time wheelchair users with MS and SCI. Findings from this study can inform the development of evidenced-based interventions to improve the effectiveness of clinically based treatment protocols. Implications for rehabilitation Falls are a common health concern in full-time wheelchair users living with multiple sclerosis and spinal cord injury. The circumstances surrounding falls reported by full-time wheelchair users living with multiple sclerosis and spinal cord injuries were found to be multifactorial. The complex nature of falls must be taken into consideration in the development of fall prevention programs. Findings from this study can inform the development of comprehensive evidence-based, population-specific interventions to manage falls among full-time wheelchair users living with multiple sclerosis and spinal cord injury.

Falls Among Wheelchair and Scooter Users with Multiple Sclerosis—A Review

Falls are increasingly recognized as a threat to the safety, health and well-being of people with multiple sclerosis (MS), and emerging evidence suggests that full time wheelchair and scooter users with MS have unique fall prevention needs. This review is comprised of three parts. Part 1 summarizes findings describing influences on falls among full time wheelchair and scooter users with MS and associated clinical implications. Although further studies are needed, early findings regarding influences on fall risk operating in this specific population highlight the importance of addressing falls that occur during activities of daily living, the high frequency of falls occurring in the bathroom, and both extrinsic (e.g., wet/slippery surfaces) and intrinsic (e.g., muscle spasticity/weakness) contributors to falls. Part 2 of this review describes available evidence regarding interventions to prevent falls in full time wheelchair and scooter users with MS. Because intervention work in this area is limited to one pilot study, Part 3 presents priorities for future research and identifies the need for randomized trials evaluating fall prevention programs that address diverse fall risk factors and allow for development and attainment of individualized fall prevention goals.