for develop literature review skills Please choose a topic and then select what you believe would be a useful database within which to start

Laura A. Rice, Cherita Ousley & Jacob J. Sosnoff To cite this article: Laura A. Rice, Cherita Ousley & Jacob J. Sosnoff (2015) A systematic review of risk factors associated with accidental falls, outcome measures and interventions to manage fall risk in non-ambulatory adults, Disability and Rehabilitation, 37:19, 1697-1705, DOI: 10.3109/09638288.2014.976718 To link to this article: https://doi.org/10.3109/09638288.2014.9767

A systematic review of risk factors associated with accidental falls, outcome measures and interventions to manage fall risk in non-ambulatory adults Laura A. Rice, Cherita Ousley, and Jacob J. Sosnoff Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Champaign, IL, USA Abstract Purpose: To systematically review peer-reviewed literature pertaining to risk factors, outcome measures and interventions managing fall risk in non-ambulatory adults. Methods: Twenty-one papers were selected for inclusion from databases including PubMed/Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Scopus, Consumer Health Complete and Web of Science. Selected studies involved a description of fall related risk factors, outcomes to assess fall risk and intervention studies describing protocols to manage fall risk in non-ambulatory adults. Studies were selected by two reviewers and consultation provided by a third reviewer. Results: The most frequently cited risk factors/characteristics associated with falls included: wheelchair related characteristics, transfer activities, impaired seated balance and environmental factors. The majority of the outcomes were found to evaluate seated postural control. One intervention study was identified describing a protocol targeting specific problems of individual participants. A global fall prevention program was not identified. Conclusion: Several risk factors associated with falls were identified and must be understood by clinicians to better serve their clients. To improve objective assessment, a comprehensive outcome assessment specific to non-ambulatory adults is needed. Finally, additional research is needed to examine the impact of structured protocols to manage fall risk in non-ambulatory adults. Implications for Rehabilitation Falls are a common health concern for non-ambulatory adults. Risk factors commonly associated with falls include wheelchair related characteristics, transfer activities, impaired seated balance and environmental factors. Limited outcome measures are available to assess fall risk in non-ambulatory adults. Clinicians must be aware of the known risk factors and provide comprehensive education to their clients on the potential for falls. Additional research is needed to develop and evaluate protocols to clinically manage fall risk. Keywords Fall, mobility limitations, wheelchair History Received 14 April 2014 Revised 9 September 2014 Accepted 10 October 2014 Published online 29 October 2014 Introduction Falls are a common health concern among individuals living with a variety of disabilities including those who utilize a wheelchair as their primary means of mobility. There are approximately 2.8 million wheelchair users in the United States and wheelchair use is expected to increase by 5% on a yearly basis [1]. Although fall incidence varies significantly by population, generalized results indicate that between 30% and 60% of non-ambulatory adults are impacted by falls [2–6]. As individuals age, the incidence of falls increases with over 75% of non-ambulatory nursing home residents over the age of 65 reporting at least one fall annually [7]. A fall can lead to a variety of injuries ranging from simple scrapes and bruises to more significant impairments such as fractures or concussions [4,5,8,9]. Approximately 100 000 wheelchair related accidents, many of which are associated with falls, occur every year and are serious enough to require a visit to an Emergency Department [8]. Moreover, 68% of fatal wheelchair related accidents are caused by falls [10]. Aside from physical injury, falls may also lead to the development of a dysfunctional fear of falling [11,12] which often negatively impacts an individual’s quality of life [13]. Fear of falling may result in self-imposed activity curtailment, loss of confidence, difficulty performing typical societal roles, loss of independence, physiological deconditioning [14] and difficulty in performing activities of daily living [15,16]. Ultimately, a reduction in physical activity and participation may be indicative of a disuse–disability cycle resulting in increased risk for falls [14]. Address for correspondence: Dr Laura A. Rice, Department of Kinesiology and Community Health, University of Illinois, Huff Hall, 1206 S. Fourth St., Champaign, IL 61820, USA. E-mail: [email protected] In addition to the impact on health and well-being, falls (experienced by both ambulatory and non-ambulatory adults) are a costly secondary aspect of disability putting a substantial strain on the already fragile United States (US) healthcare system. In 2010, falls cost the US healthcare system 30 billion dollars in direct costs [17] and are projected to exceed 54.9 billion dollars in both direct and indirect costs by 2020 [18]. Although a significant amount of research has examined risk factors for falls in ambulatory adults, a limited amount of work has been focused on non-ambulatory adults who primarily use a wheelchair for mobility. Focused evaluation of non-ambulatory adults is needed, as the cause of falls is significantly different among these populations [7]. Consequently, due to the differences in fall epidemiology between ambulatory and non-ambulatory adults and lack of evidenced based treatment protocols, the purpose of this systematic literature review is three-fold. We are first interested in performing a comprehensive assessment of the literature describing risk factors associated with falls in non-ambulatory adults. This analysis will result in a comprehensive understanding of the activities and characteristics of individuals who frequently fall. Indeed, a comprehensive understanding of risk factors associated with falls in non-ambulatory adults is necessary prior to the design and implementation of a comprehensive intervention program. Next, we are interested in exploring the methodology of how risk factors associated with falls are assessed and highlight outcomes that can be easily implemented in a clinical setting. Many of the established fall risk assessment tools, such as the Berg Balance Test [19] or the Dynamic Gait Index [20] requires the participant to be able to stand and ambulate in order to obtain accurate and valid results. Such outcomes are not appropriate for wheelchair users. This assessment will highlight equivalent outcome assessments appropriate for non-ambulatory adults. Finally, we will examine intervention studies describing effective programs to manage fall risk in non-ambulatory adults and highlight effective programs that can be translated into clinical practice. This comprehensive assessment of falls in nonambulatory individuals is essential to gaining an understanding of a health concern impacting a large portion of the population and the provision of effective evidenced based care. Methods Data sources and searches The Preferred Reporting Items for Systematic Reviews and MetaAnalysis (PRISMA) statement [21] and protocol described by Khan et al [22] were used to guide the systematic review. The review was performed by three reviewers of which two hold advanced degrees in rehabilitation research (L.R. and J.S.) and one holds an undergraduate degree in kinesiology (C.O.). A health science librarian experienced in systematic review development assisted in the selection of databases. To begin the process, two authors (L.R. and C.O.) performed the initial literature search. The search was limited to studies published in English prior to December 2013 and included peerreviewed articles from six electronic databases: PubMed/Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Scopus, Consumer Health Complete and Web of Science. The search included a core set of key terms including, the following medical subject heading (MeSH) terms: ‘‘Accidental Falls’’ and ‘‘Wheelchair’’. Additional key words were included but not limited to: Ataxia, Neuro, Spinal Cord Injury, Multiple Sclerosis, Cerebral Palsy, Brain Injury, Stroke, Mobility Limitations, (Not) Ambulatory, (Not) Walking, Postural Balance, Postural Control. The full search strategy for each database is provided in Appendix. Study inclusion criteria Study inclusion criteria required that the papers were peer reviewed, published in English and assessed fall related characteristics of non-ambulatory adults. A non-ambulatory adult is defined as a person who primarily utilizes a wheeled mobility device in their living environment and community. To capture a broad spectrum of literature and to prevent unnecessary exclusion of a publication, a variety of research designs were included with no restrictions on measurement methods, study environment or specific disabilities limiting ambulation. Exclusion criteria consisted of: (1) nonEnglish language publications and (2) non-peer-reviewed articles, including dissertations or conference proceedings. Study selection Authors (L.R. and C.O.) screened the papers selected and excluded those publications that did not include individuals who primarily used a wheelchair for mobility based on the title, key words and/or abstract. Papers that included a mixed population of participants (both ambulatory and non-ambulatory) were included only if non-ambulatory data was presented separately. An exception was made when evaluating papers describing outcomes to assess fall risk. Papers were included that utilized abled bodied participants in simulated wheelchair experiences. Data extraction and quality assessment Based on established procedures [22], the quality of the literature selected and potential for bias was assessed using a customized checklist developed by the authors. The customized checklist, as shown in Table 1, was based on the format of the National Service Framework (NSF) Typology of Evidence [23]. The inter-rate reliability of this tool was assessed and found to have moderate reliability [23]. Each paper reviewed was assessed on quality and applicability as described in Table 1 by author L.R., who is familiar with the hierarchy of research design. The quality of the papers was further discussed with co-authors J.S. and C.O and consensus was reached. Finally, utilizing the framework established by the NSF [23] and displayed in Table 2, an overall grade ranging from A to C was given to the final group of 21 papers. Data was extracted from the selected studies by one author (L.R.) and findings were discussed with the other authors (J.S. and C.O.) The following items were extracted from the selected studies: study design, study objective, study setting, participant characteristics, outcome measured used, intervention and general findings. Data synthesis and analysis After being critically assessed and findings extracted, the selected studies were divided into three sections: (1) studies that assessed risk factors associated with falls; (2) studies that described outcomes to assess fall risk and (3) intervention studies detailing protocols to manage fall risk. If applicable, a paper could fit into multiple categories. The frequency of each fall risk factor or outcome measure utilized was collected and presented (Tables 3 and 4). The most frequently appearing fall risk factors were categorized into the following categories: wheelchair design/ wheelchair related factors, performance of transfers, poor balance and using a wheelchair on uneven terrain. Due to the low frequency of intervention studies found (n ¼ 1), the intervention was described in narrative form. Results As illustrated in Figure 1, a systematic literature review was performed in which a total of 212 unique studies were identified. After screening the title and abstracts, 167 papers were removed 1698 L. A. Rice et al. Disabil Rehabil, 2015; 37(19): 1697–1705 due to lack of compliance with the inclusion criteria. Two authors (L.R. and C.O.) agreed on 45 papers in which a review of the full text was warranted. An additional 24 papers were further exclude due to failure to comply with the inclusion/exclusion criteria. The third author (J.S.) provided consultation when a disagreement occurred between L.R. and C.O. A final group of 21 papers was selected and agreed upon by all authors. The final group of 21 studies were extensively reviewed and categorized as papers that (1) evaluated risk factors associated with falls (Table 3); (2) outcomes to assess fall risk (Table 4) and (3) intervention studies to manage fall risk (Table 5). Overall, the group of selected studies received a research grade [23] of A indicating that high quality research was utilized in this systematic review. Individualize grades of each paper are presented in Tables 3–5. Of the 21 papers evaluated, 15 (71.4%) received a grade of ‘‘high’’ indicating high research quality and a low potential for bias and 17 (80.9%) received a designation of ‘‘Direct’’ indicating the papers directly evaluated non-ambulatory adults. Risk factors associated with falls A total of 11 out of 21 papers identified (52.4%) evaluated risk factors associated with falls in non-ambulatory adults (Table 3). Risk factors found to be associated with falls were extracted and categorized. The most frequently cited factors included: (1) wheelchair design/related characteristics (n ¼ 7; 63.6 %), (2) performance of transfers (n ¼ 6; 54.5%), (3) poor balance (n ¼ 4; 36.3%) and (4) using a wheelchair on uneven or sloping terrain (n ¼ 4; 36.3%). Thapa et al. [7] found that 87% of falls in non-ambulatory adults occurred with equipment present. Of those falls, 34% were specifically associated with a wheelchair. In Kirby et al. [4], Nelson et al. [13] and Gaal et al. [3], specific wheelchair configurations impacting stability were found to be associated with falls. Kirby et al. [4] found that lighter weight wheelchairs, an adjustable rear-axle position and use of a backpack on the wheelchair increased the risk. Nelson et al. [13] found a shorter wheelchair length to be associated with falls and Gaal et al. [3] found the use of small/hard casters to be associated with falls. Finally, a lack of appropriate wheelchair maintenance was found to be associated with falls in Chen et al. [24], Nelson et al. [5] and Kirby and Smith [25]. Falls during transfer activities were found to be a common occurrence as reported by 6 out of the 11 (54.5%) papers reviewed [4,5,7,24–26]. Chen et al. [24] assessed participant’s selfperceived reasons for tips and falls and found transfers to be one of the top four activities cited by study participants. Kirby et al. [4] found that performance of independent transfers increased the risk for falls and use of an assistant decreased fall risk. The percentage of participants who reported a fall during transfer activities varied significantly with Nelson et al. [5] reporting that 44% of participants fell during transfers compared to 84% reported by Thapa et al. [7]. Thapa et al. [7] also compared fall risk during transfers between ambulatory and non-ambulatory nursing home residents and found fall frequency to be higher in non-ambulatory adults (84%) compared to ambulatory (21%). Finally, a case report described by Kirby and Smith [25] describes, in detail, a fall that occurred during a transfer. Falls that occurred due to a loss of balance or associated with a reaching task were described by Chen et al. [24], Dyer et al. [26], Nelson et al. [5] and Saverino et al. [27]. Chen et al. [24] found reaching to be one of the top four self-perceived reasons for falls. Similarly, of non-ambulatory participants, Saverino et al. [27] found loss of balance or attempts to reach an item outside of an individual’s base of support to be associated with the highest frequency of falls. Dyer et al. [26] found loss of balance was a factor in 64% of falls and reaching tasks were involved in 28.6% of falls. Finally, Nelson et al. [5] reported that loss of balance was associated with 11% of falls. Although Nelson et al. [13] did not find impaired sitting balance to be a factor associated with falls, having intact seating balance was found to be protective against falls. The individual’s environment was also found to have a significant impact on fall incidence. The percentage of individuals who reported a fall as a result of maneuvering a wheelchair on an Table 1. Literature assessment checklist. Part 1: Quality assessment Item: 1. Are the research questions/aims and design clearly stated? 2. Is the research design appropriate for the aims and objectives of the research? 3. Are the methods clearly described? 4. Is the data adequate to support the author’s interpretations/conclusions? 5. Are the results generalizable? Part 1 Scoring: Each above item is scored as follows: Yes ¼ 2; In Part ¼ 1; No ¼ 0 (Max score ¼ 10) Interpretation of score: High Quality: 7/10; Medium Quality: 4–6/10; Low Quality: 3/10 Part 2: Applicability Choose 1: Direct Studies that focus directly on individuals who are non-ambulatory Indirect Extrapolated evidence from population with other conditions Table 2. Research rating. Grade Criteria Research Grade A More than one study of high quality score (47/10) and At least one of these has direct applicability Research Grade B One high quality study or More than on medium quality study (4–6/10) and At least one of these has direct applicability Or More than one study of high quality score (47/10) of indirect applicability One medium quality study (4–6/10) Research Grade C Lower quality (2–3/10) studies or Indirect studies only DOI: 10.3109/09638288.2014.976718 Fall management in non-ambulatory adults 1699 Table 3. Risk factors associated with falls. Author Study design Participants (detailed description, number) Risk factors associated with falls Research quality/ applicabilityb Boswell-Ruys [42] Cross-sectional survey n ¼ 125 Acute or chronic spinal cord injury (SCI) Use of a manual wheelchair for greater than 75% of mobility Unwarranted concerns about falling impact community participation and independence Warranted concerns indicate un-addressed safety issues High/Direct Chen [24] Case-control n ¼ 95 Active manual and powered wheelchair users Diagnoses: SCI, polio, and others Average wheelchair use: 66.5 hours/week Transfers Loss of balance/reaching Operation of wheelchair on level ground or a slope Lack of regular wheelchair maintenance Not using a professional prescribed wheelchair Not using a seat belt High/Direct Dyer [26]a Cross-sectional n ¼ 58 s/p amputation of a major lower limb Falls occurred while/due to: poor balance (64%) transfers (71.4%) reaching (28.6%) Medium/Direct Gaal [3] Cross-sectional n ¼ 109 Wheelchair users who had experienced accidents Propulsion on difficult surfaces (cause of 79% of tips/falls) Small, solid casters High/Direct Kirby [4] Cross-sectional n ¼ 577 Non-institutionalized manual wheelchair users Propulsion on difficult surfaces Younger age Male gender Diagnosis of paraplegia or spina bifida Having had a wheelchair prescribed Lightweight wheelchair Increased camber Adjustable rear-axle positions Use of a backpack Daily use of a wheelchair Propelling the chair with both hands Use of the wheelchair for recreation Sideways transfers (without a transfer board) High/Direct Kirby [25] Case study 54 y.o. female s/p left transtibial amputation Wheelchair design Transfers Medium/Direct Nelson [5] Cross-sectional n ¼ 45 medical records Diagnosis of SCI History of fractures Activities in which falls occurred: Transfers (44%) Propulsion on uneven surfaces (15%) Repositioning in bed (22%) Reaching (11%) Riding or transferring into a vehicle (30%) Showering (7%) Factors Contributing to Falls: Loss of balance Equipment failure Muscle spasms Excessive speed Narcolepsy Not wearing protective straps High/Direct Nelson [13] Prospective cohort study n ¼ 702 US Veterans Community-dwelling Diagnosis of SCI Used a wheelchair as primary means of mobility Pain in previous 6 months Alcohol abuse Greater motor function History of previous fall Fewer SCI years Shorter wheelchair length High/Direct Opalek [43] Cross-sectional n ¼ 30 Wheelchair users Received care in a Level 1 trauma center Older age (465 years old) Medium/Direct Saverino [27]a Cross-sectional n ¼ 320 Diagnosis: s/p CVA, s/p orthopedic surgery, neurological diagnosis, h/o multiple trauma. Poor sitting balance or reaching High/Direct Thapa [7]a Prospective cohort study n ¼ 725 465 years older Involved equipment (87%) Occur while seated or during transferring (82%) High/Direct a Only data for non-ambulatory study participants presented. b Please see Table 1 for a description of how research quality and applicability was determined. 1700 L. A. Rice et al. Disabil Rehabil, 2015; 37(19): 1697–1705 uneven or sloping surface varied greatly despite the relative homogeneity of the populations evaluated. Nelson et al. [5] found that 15% of falls were caused by propulsion over uneven surfaces, however Gaal et al. [3] found that 79% of individuals reported a fall due to uneven surfaces. Kirby et al. [4] found that twice as many wheelchair related falls occurred outside the home versus inside. Finally, Chen et al. [24] reported that propulsion over a sloping surface was one of the top four self-perceived causes of falls. Outcomes to assess fall risk Eleven of the 21 papers (52.4 %) identified evaluated outcomes to assess risk factors associated with falls in non-ambulatory adults (Table 4). The majority (7/11, 63.6%) of the studies assessed seated postural control. As described in the previous section, impaired seated postural control is an attribute frequently associated with falls. Of the seven measures evaluated, five [28–32] (71.4%) utilized equipment that captures precise data best suited for research studies performed in a laboratory setting. Studies by de Abreu et al. [28] and Takara et al. [32] utilized motion capture systems to precisely evaluate body displacement during quite sitting and reaching tasks. Kamper et al. [29]; Okunribido et al. [30] and Petrofsky [31] utilized force platforms to assess postural stability. These papers indicate that precise assessments of postural balance can be made which is essential to fully understanding seated balance but the methodology may not be practical for a clinical setting. Less expensive outcomes potentially better suited for a clinical setting were described by Gorman et al. [33] and Springle et al. [34]. Gorman et al. [33] described the Function In Sitting Test (FIST) that evaluates a participant’s static and dynamic postural stability by asking participants to perform a series of tasks while sitting on a mat table. The tasks are evaluated utilizing a standardized balance assessment rating scale [35]. Sprigle et al. [34] describe a functional reaching test that requires participants to reach in a variety of directions in an unsupported sitting position. Results indicate that a bilateral reaching task is strongly associated with a participant’s ability to perform common Activities of Daily Living (ADLs). Four out of the 11 papers (36.4%) evaluated other risk factors associated with falls in non-ambulatory adults. A study by Boswell-Ruys et al. [11] examined the impact of concerns about falling and developed an outcome measure to assess concerns. While this outcome measure is primarily intended for individuals living with Spinal Cord Injury (SCI) the items assessed are appropriate for many non-ambulatory adults. Gagnon et al. [36] examined positions of instability during transfer activities. Due to the association of transfers with falls and the inherent instability during transfers this data is very important but the outcome assessment requires extensive equipment and complex data analysis to assess instability. A measure that can be easily used Figure 1. PRISMA Flow Diagram. DOI: 10.3109/09638288.2014.976718 Fall management in non-ambulatory adults 1701 as a clinical assessment of transfer quality and skills is described by Tsai et al. [37]. This clinical measure, the Transfer Assessment Instrument (TAI) evaluates subcomponents of transfers and provides clinicians with a detailed summary of individualized areas of concern. Finally, Stapleton et al. [38] describes the Fall Risk Assessment Tool (FRAT), an outcome measure to assess fall risk in a sub-acute and residential care facility. The proportion of non-ambulatory adults evaluated in this study was not fully described, however the items assessed would be appropriate for the population. Intervention study Only one paper was identified that described a fall prevention program (Table 5). While this paper does present the data for wheelchair users independently, the entire trial was performed with both ambulatory and non-ambulatory adults. Dyer et al. [26] describe a study in which individuals with a recent history of a lower extremity amputation underwent an intervention program based on problems identified by nursing staff. Once a fall occurred a customized intervention program was developed to Table 4. Outcomes used to assess fall risk. Author Participants (detailed description, number) Outcomes measures Research quality/ applicabilitya Boswell-Ruys [42] n ¼ 125 Acute or chronic spinal cord injury (SCI) Use of a manual wheelchairs for greater than 75% of mobility Spinal Cord Injury-Falls Concern Scale (SCI-FCS) High/Direct de Abreu [28] n ¼ 11 individuals with SCI ASIA A – C T2-L1 n ¼ 6 people without SCI Description of a forward reaching task Participants were asked to reach 50%, 75% and 90% of their individual maximal forward reach Trunk anterior displacement and the time spent to perform the test was recorded High/Direct Gagnon [36] n ¼ 10 SCI Manual wheelchair users Description of a dynamic equilibrium model to measure the theoretical forces required to move the center of pressure to the limit of the base of support (destabilizing force) and to neutralize the kinetic energy and stop the displacement of the center of mass at the limit of the base of support (stabilizing force) during each phase of a sitting pivot transfer Used to identify the phases of greatest instability during the SPT tasks High/Direct Gorman [33] n ¼ 31 months s/p CVA All participants were rated as moderate, moderately severe or severe disability status on the modified Rankin Scale Function In Sitting Test (FIST) High/Direct Kamper [29] n ¼ 11 Tetraplegia or paraplegia from a complete SCI C5-C7; T2-T9 OR Able Bodied No information provide regarding the distribution between Abled Bodied and individuals with SCI Active males A description of servo-controlled tilt platform was provided that was constructed to provide a lowcost, small, and easily transportable device for generating precise and repeatable perturbations Medium/Indirect Okunribido [30] n ¼ 4 Able bodied participants Described methods of assess: Horizontal distance of the occupied wheelchair center of gravity from the rotational axis of the casters Static forward stability Perception of safety (0–10 scale) Medium/Indirect Petrofsky [31] n ¼ 20 Able Bodied participants Development of a device to measure: Balance: side-to-side, forward-to-back sway and the center of gravity of the body during standing and sitting in a chair or wheelchair Tremor High/Indirect Sprigle [34] n ¼ 20 SCI Development of a complex reach assessment that includes: functional reach (FR), reach area (RA), and bilateral reach (BR) High/Direct Stapleton [38] Reliability Study: n ¼ 28 participants, 6 nurses Predictive Study: n ¼ 291, 4 investigators Participants were associated with age care and rehabilitation programs No specific information provided RE: wheelchair use Fall Risk Assessment Tool High/Indirect Takara [32] n ¼ 11 Paraplegia- T2-L1, ASIA A-C Description of the assessment of static seated balance on different surface types. Medium/Direct Tsai [37] n ¼ 41 Full time wheelchair users who perform a sitting or standing pivot transfer Transfer Assessment Instrument (TAI) High/Direct a Please see Table 1 for a description of how research quality and applicability was determined. 1702 L. A. Rice et al. Disabil Rehabil, 2015; 37(19): 1697–1705 prevent future falls. Results indicated that the program successfully decreased fall incidence by 5%. Discussion Our systematic review of risk factors associated with falls, outcomes to assess falls risk and interventions to manage fall risk is the first comprehensive assessment of the many facets involved in effective fall management. Despite the significant number of non-ambulatory adults living both in the community and institutions, research specific to this population is limited and does not provide well-defined recommendations. Additionally, there are few comprehensive assessment tools available to objectively assess an individual’s risk for falling and only one paper describing a fall risk management protocol was found. Our results are consistent with components of other literature reviews assessing falls in full time wheelchair users/non-ambulatory adults. Mikolajewska’s [39] narrative review examining frequent circumstances associated with wheelchair-related falls concluded that a limited amount of literature exists to provide evidenced based recommendations on management of fall risk. Mikoljweska [39] makes several important recommendations on ways to improve safety, including performing a comprehensive assessment of the individual’s needs, assuring proper wheelchair prescription and continued maintenance and providing extensive training on wheelchair related skills. These recommendations are very important as our analysis found wheelchair related characteristics and lack of proper wheelchair maintenance to be a significant factor associated with falls. In a literature review performed by Gavin-Dreshnack et al. [6], a call was made to develop and refine a fall risk assessment tool specific for wheelchair users due to their unique characteristics and significant differences in fall related risk factors compared to ambulatory individuals. In the almost 10 years that have passed since this publication, a comprehensive tool has not yet been developed. GavinDreshnack et al. [6] also recommended the development of a predictive model for wheelchair related falls and injuries which has also not come to fruition. Our failure to discover a comprehensive fall risk assessment tool or a predictive fall risk model supports the findings of Gavin-Dreshnack and further emphasizes the great need that exists. Risk factors associated with falls A comprehensive assessment of the literature indicates that the majority of risk factors found to be associated with falls are items that can be modified through therapeutic interventions or changes in wheelchair set-up, selection and proper maintenance. Due to the lack of interventions studies published to manage fall risk, clinicians must be aware of the known risk factors associated with falls and primarily rely on their clinical judgment to prevent negative fall-related outcomes. If an individual displays modifiable risk factors such as poor balance, poor transfer performance or a wheelchair set-up consistent with the risk factors described by Kirby et al. [4], Nelson et al. [13] and Gaal et al. [3], clinicians must utilize their clinical skills to manage individualized problems. Care must be taken when modifying wheelchair set up. While many of the wheelchair set up risk factors associated with falls negatively impact the stability of the chair, they positively impact functional mobility and prevention of upper extremity impairments [40]. Wheelchair prescription provided by a knowledgeable clinician is essential to achieve a careful balance between stability and mobility. To improve outcomes, evidenced based research is needed to provide recommendations to clinicians on the most appropriate and effective methodologies to comprehensively manage impairments. Outcome measures to assess fall risk Another difficulty facing effective detection and management of fall risk in non-ambulatory adults is the lack of objective validated outcome measures. Without the ability to effectively assess impairment, it is difficult to fully evaluate individuals at risk and examine if intervention programs are effective. Approximately 63% of the papers identified describing outcomes to assess factors associated with fall risk focused on seated postural control. Although this is an important aspect of fall risk, it only evaluates part of the problem. The FRAT [38] although brief, has good potential to be used as quick screening tools to assess fall risk. Further testing however is needed to examine the validity of the outcome measure in a variety of settings and with a variety of patient populations and to determine if the measure is predictive of falls in various populations and settings. Overall, a comprehensive outcome measures is needed to assess multiple facets of an individual’s risk for falls. Intervention studies to manage fall risk The most critical need identified in this literature review is the lack of intervention studies describing protocols designed to manage risk factors associated with falls in non-ambulatory adults. Due to the lack of intervention studies identified, we were not able to fully achieve our goal of describing effective programs to manage fall risk. The study performed by Dyer et al. [26] shows that a program designed to manage fall risk and decrease the frequency of falls can result in clinical change. Although the change identified by Dyer et al. [26] was modest, the incidence of falls did decrease. It is possible that such a change can make a substantial improvement in the health, well-being and quality of life of non-ambulatory adults. As the population ages, the ability of many individuals to effectively ambulate functional distances will decline and wheelchairs will become the primary source of mobility in a large portion of the population. Being able to effectively manage fall risk will make a significant impact on a rapidly expanding group of individuals. Effective manage will also help to alleviate the economic strain that is currently being placed on the United States healthcare system. Table 5. Intervention study. Author Participants Intervention Conclusion Research quality/applicabilitya Dyer [26] n ¼ 58 s/p amputation of a major lower limb The Falls Assessment to Tool to improve identification of potential fallers When fall occurred, a team of clinicians examined the cause and implemented a customized plan After implementation of the program, fall incidence decreased by 5% No fall related injuries were sustained Medium/Direct a Please see Table 1 for a description of how research quality and applicability was determined. DOI: 10.3109/09638288.2014.976718 Fall management in non-ambulatory adults 1703 Limitations There are several limitations that must be carefully considered when examining this paper. The risk factors we discuss are only those that have been reported in the literature – it is very possible that other fall risk factors remain to be identified. By keeping our inclusion criteria generalized we have attempted to limit this potential bias however, results may be impacted. Therefore, clinicians should be aware of and provide education on a variety of risk factors associated with falls, not just those specific to nonambulatory adults. More work identifying risk factors within this population is necessary. Also, in an attempt to assure a comprehensive assessment of the literature, several studies were included in the analysis that included both community and nonambulatory adults. Although we only utilized data that was presented separately for non-ambulatory adults, some results may be influenced by the mixed population design without our knowledge. These studies however provided an important comparison between ambulatory and non-ambulatory adults, helped to distinguish the risk factors that differ between populations and assure a comprehensive assessment of the literature. In addition, some of the papers included only examined risk factors associated with falls that resulted in accidents substantial enough to be reported to a healthcare provider. Thus, some risk factors may be under-reported and represented. Finally, our systematic review only evaluated papers published in English. Thus, papers published in other language may have been missed. Conclusion/future work In summary, our results indicate that there are several risk factors associated with falls impacting non-ambulatory adults. Many of these factors can be modified through therapeutic interventions and changes in environment. Clinicians must be aware of the risk factors and provide comprehensive education to their clients on the potential for falls. Additional work is needed to examine factors predictive of falls. The majority of papers reviewed were cross-sectional in nature and therefore could only identify factors associated with falls. Predictive studies would improve the strength of the findings presented and provide a solid foundation for the development of a clinical practice guideline. Finally, the assessment of risk factors associated with falls should be expanded and include risk factors found to be associated with falls in other populations. For example, impaired cognition has been found to be associated with falls in ambulatory adults [41] and should be further evaluated in non-ambulatory adults. A significant need exists to develop a comprehensive tool to specifically assess risk factors associated with falls in nonambulatory adults. Due to the differences in fall etiology between ambulatory and non-ambulatory adults, a comprehensive outcome measure specific to the population is essential. Finally, the literature detailing programs to manage fall risk is minimal. Further investigation and publication of effective protocols are necessary to provide clinicians with evidenced based resources. Declaration of interest Funding to perform this systematic review was provided by departmental funding of the Department of Kinesiology and Community that is part of the College of Applied Health Sciences at the University of Illinois, Urbana-Champaign. References 1. LaPlante MP, Kaye HS. Demographics and trends in wheeled mobility equipment use and accessibility in the community. Assist Technol 2010;22:3–17; quiz 19. 2. Berg K, Hines M, Allen S. Wheelchair users at home: few home modifications and many injurious falls. Am J Public Health 2002;92:48. 3. Gaal RP, Rebholtz N, Hotchkiss RD, Pfaelzer PF. Wheelchair rider injuries: causes and consequences for wheelchair design and selection [see comments]. J Rehabil Res Dev 1997;34:58–71. 4. Kirby RL, Ackroyd-Stolarz SA, Brown MG, et al. Wheelchairrelated accidents caused by tips and falls among noninstitutionalized users of manually propelled wheelchairs in Nova Scotia. Am J Phys Med Rehabil 1994;73:319–30. 5. Nelson A, Ahmed S, Harrow J, et al. Fall-related fractures in persons with spinal cord impairment: a descriptive analysis. SCI Nurs 2003; 20:30–7. 6. Gavin-Dreschnack D, Nelson A, Fitzgerald S, et al. Wheelchairrelated falls: current evidence and directions for improved quality care. J Nurs Care Qual 2005;20:119–27. 7. Thapa PB, Brockman KG, Gideon P, et al. Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors. J Am Geriatr Soc 1996; 44:273–8. 8. Xiang H, Chany AM, Smith GA. Wheelchair related injuries treated in US emergency departments. Inj Prev: J Int Soc Child Adoles Inj Prevent 2006;12:8–11. 9. Kirby RL, Ackroyd-Stolarz SA. Wheelchair safety – adverse reports to the United States Food and Drug Administration. Am J Phys Med Rehabil 1995;74:308–12. 10. Calder CJ, Kirby RL. Fatal wheelchair-related accidents in the United States. Am J Phys Med Rehabil 1990;69:184–90. 11. Boswell-Ruys CL, Harvey LA, Delbaere K, Lord SR. A Falls Concern Scale for people with spinal cord injury (SCI-FCS). Spinal Cord 2010;48:704–9. 12. Finlayson ML, Peterson EW. Falls, aging, and disability. Phys Med Rehabil Clin North Am 2010;21:357–73. 13. Nelson AL, Groer S, Palacios P, et al. Wheelchair-related falls in veterans with spinal cord injury residing in the community: a prospective cohort study. Arch Phys Med Rehabil 2010;91:1166–73. 14. Peterson EW, Cho CC, Finlayson ML. Fear of falling and associated activity curtailment among middle aged and older adults with multiple sclerosis. Mult Scler 2007;13:1168–75. 15. Tinetti ME, Baker DI, Dutcher J, et al. Reducing the risk of falls among older adults in the community. Berkeley, CA: Peacable Kingdom Press; 1997. 16. Tinetti ME, Williams CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J Gerontol. Series A, Biol Sci Med Sci 1998;53:M112–19. 17. Costs of Falls Among Older Adults. 2014; Available from: http:// www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html [last accessed 19 Feb 2014]. 18. Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. J Forensic Sci 1996;41:733–46. 19. Berg K, Wood-Dauphinee S, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med 1995;27:27–36. 20. Wrisley DM, Marchetti GF, Kuharsky DK, Whitney SL. Reliability, internal consistency, and validity of data obtained with the functional gait assessment. Phys Ther 2004;84:906–18. 21. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. 22. Khan K, Kunz R, Kleijnen J, Antes G. Systematic reviews to support evidence-based medicine. 2nd ed. London, UK: Hachette; 2011. 23. Turner-Stokes L, Harding R, Sergeant J, et al. Generating the evidence base for the National Service Framework for Long Term Conditions: a new research typology. Clin Med 2006;6:91–7. 24. Chen WY, Jang Y, Wang JD, et al. Wheelchair-related accidents: relationship with wheelchair-using behavior in active community wheelchair users. Arch Phys Med Rehabil 2011;92:892–8. 25. Kirby RL, Smith C. Fall during a wheelchair transfer: a case of mismatched brakes. Am J Phys Med Rehabil 2001;80:302–4. 26. Dyer D, Bouman B, Davey M, Ismond KP. An intervention program to reduce falls for adult in-patients following major lower limb amputation. Healthcare Quart (Toronto, Ont.) 2008;11:117–21. 27. Saverino A, Benevolo E, Ottonello M, et al. Falls in a rehabilitation setting: functional independence and fall risk. Eura Medicophys 2006;42:179–84. 1704 L. A. Rice et al. Disabil Rehabil, 2015; 37(19): 1697–1705 28. de Abreu DC, Takara K, Metring NL, et al. Interference of different types of seats on postural control system during a forward-reaching task in individuals with paraplegia. Int J Rehabil Res 2012;35: 208–13. 29. Kamper DG, Adams TC, Reger SI, et al. A low-cost, portable system for the assessment of the postural response of wheelchair users to perturbations. IEEE Trans Rehabil Eng 1999;7:435–42. 30. Okunribido OO. Patient safety during assistant propelled wheelchair transfers: the effect of the seat cushion on risk of falling. Assist Technol 2013;25:1–8. 31. Petrofsky JS. A device for the evaluation of sitting and reach balance in people in wheelchairs and standing. J Med Eng Technol 2006;30: 358–67. 32. Takara K, Gaspar MI, Metring NL, et al. Evaluation of the influence of different types of seats on postural control in individuals with paraplegia. Spinal Cord 2010;48:825–7. 33. Gorman SL, Radtka S, Melnick ME, et al. Development and validation of the Function In Sitting Test in adults with acute stroke. J Neurol Phys Ther 2010;34:150–60. 34. Sprigle S, Maurer C, Holowka M. Development of valid and reliable measures of postural stability. J Spinal Cord Med 2007;30:40–9. 35. Guccione A, Scalzitti D. Examination of functional status and activity level. In: O’Sullivan S, Schmitz TJ, eds. Physical rehabilitation. 5th ed. Philadelphia, PA: Davis; 2007:373–400. 36. Gagnon D, Duclos C, Desjardins P, et al. Measuring dynamic stability requirements during sitting pivot transfers using stabilizing and destabilizing forces in individuals with complete motor paraplegia. J Biomech 2012;45:1554–8. 37. Tsai CY, Rice LA, Hoelmer C, et al. Basic psychometric properties of the transfer assessment instrument (version 3.0). Arch Phys Med Rehabil 2013;94:2456–64. 38. Stapleton C, Hough P, Oldmeadow L, et al. Four-item fall risk screening tool for subacute and residential aged care: the first step in fall prevention. Aust J Ageing 2009;28:139–43. 39. Mikolajewska E. Wheelchair-related falls: a review. Int J Disabil Hum Dev 2013;12:259–66. 40. Boninger ML, Koontz AM, Sisto SA, et al. Pushrim biomechanics and injury prevention in spinal cord injury: recommendations based on CULP-SCI investigations. J Rehabil Res Dev 2005;42: 9–20. 41. Finlayson ML, Peterson EW, Cho CC. Risk factors for falling among people aged 45 to 90 years with multiple sclerosis. Arch Phys Med Rehabil 2006;87:1274–9; quiz 1287. 42. Boswell-Ruys CL, Harvey LA, Barker JJ, et al. Training unsupported sitting in people with chronic spinal cord injuries: a randomized controlled trial. Spinal Cord 2010;48:138–43. 43. Opalek JM, Graymire VL, Redd D. Wheelchair falls: 5 years of data from a level I trauma center. J Trauma Nurs 2009;16:98–102. Appendix Search strategy Data base Search strategy PubMed/Medline (((((Fall[Title]) OR Postural Balance[Title]) AND (Spinal Cord Injury OR Wheelchair OR Multiple Sclerosis OR Cerebral Palsy OR brain injury OR mobility limitations) NOT Ambulatory))) AND English[Language] CINAHL Accidental fall OR postural balance NOT walking Cochrane Library accidental falls in title abstract keywords or postural balance not ambulation (Word variations have been searched) Scopus TITLE-ABS KEY((accidental falls OR postural balance) not walking) AND (LIMIT-TO(DOCTYPE, ‘‘ar’’) OR LIMIT-TO(DOCTYPE, ‘‘re’’)) AND (EXCLUDE(EXACTKEYWORD, ‘‘Walking’’)) AND(EXCLUDE(EXACTKEYWORD, ‘‘Gait’’)) Consumer Health Complete accidental falls OR postural balance NOT TI walking AND wheelchair AND risk assessment NOT TI ambulation Web of Science ((TS ¼ (accidental falls) and TS ¼ (postural balance)) NOT TS ¼ walk) AND Language ¼ (English)