Wheelchair Safety Fall and Injury Prevention Interventions | Occupational Therapy

Millions of Americans rely on wheelchairs for mobility and function after a physical disability.[1]National Center for Health Statistics. Number of persons using assistive technology devices by age of person and type of device: United States, 1994 [online]. Centers Dis Control. Available at: … Reference List Studies have shown that serious wheelchair-related accidents can result in fractures, concussions, dislocations, amputations, and spinal cord injuries.[2]Kirby RL, Ackroyd-Stolarz SA, Brown MG, Kirkland SA, MacLeod DA. Wheelchair-related accidents caused by tips and falls among noninstitutionalized users of manually propelled wheelchairs in Nova … Reference List It is estimated that an average of over 36,559 wheelchair-related accidents occur that require medical attention.[3] Kirby RL, Ackroyd-Stolarz SA. Wheelchair safetyadverse reports to the United States Food and Drug Administration. Am J Phys Med Rehabil. 1995;74(4): 308–312. While any single part of the body may be injured from a wheelhchair fall or tip-over, the head and neck accounts for 50% of the injuries and is the single largest category of body parts that are injured.[4] Kirby RL, DiPersio M, MacLeod D. Wheelchair safety: effect of locking or grasping rear wheels during a rear tip. Arch Phys Med Rehabil. 1996;77(12):1266–1270.

Mechanisms

While the cause of wheelchair-related injuries can vary, characteristics include the wheelchair state/selection, rider, and riding situation (e.g., the environment). These incidents can occur with a variety of conditions from spinal cord injuries to cerebral palsy to other non-neurological disabilities.[5]Gaal, R. P., Rebholtz, N., Hotchkiss, R. D., & Pfaelzer, P. F. (1997). Wheelchair rider injuries: causes and consequences for wheelchair design and selection. Journal of rehabilitation research … Reference List Situations in which these falls occur can be any activity from transfers to propulsion over uneven terrain, reaching for objects, and maneuvering curbs or stairs.

Mechanical and Physics Mechanisms of Injuries

According to the Department of Veterans Affairs, backwards falls occurred the most with manual wheelchairs, followed by forward-direction falls. Sideways direction falls were more rare. For powered wheelchairs, sideways-related falls were more common in their study, followed by forward falls. Backwards falls were more rare. This may be due to the engineering and the center of gravity of powered whelechairs, e.g., battery and motor being low to the ground.

In terms of component failure, the casters (manual and powered wheelchairs) was the part that failed the most. The frame came in second for manual wheelchairs, but for powered wheelchairs, the second and third most common parts to fail were the electrical control systems and the drive train (mechanical parts that are not present in manual wheelchairs).

By far, the most prevalent mechanism of injury was hitting an immovable (stationary) object. Other mechanisms such as while transport in a vehicle or during lift operation were less common for manual whelechairs. The second most common mechanism of injury for powered wheelchairs were getting hit by a car and transport in a vehicle[6]Gaal, R. P., Rebholtz, N., Hotchkiss, R. D., & Pfaelzer, P. F. (1997). Wheelchair rider injuries: causes and consequences for wheelchair design and selection. Journal of rehabilitation research … Reference List (perhaps due to heavy-powered wheelchairs having a lot of momentum and not being properly secured to the moving vehicle that makes abrupt stops?)

Consequences

Falls from wheelchairs can cause pain and injury to the wheelchair user and also is costly. These costs are often paid by Medicare, Medicaid, or private insurance companies and hospitals. Injuries themselves may require medical attention and can injure costs such as for surgeries, medical attention, and rehabilitation. Complications can occur such as immobility-induced blood clots resulting in a significant mortality rate.[7]Zuckerman JD. Hip fracture. N Engl J Med.
1996;334(23):1519–1525.

Prevention and Intervention Approaches

  1. User safety and precautions
  2. Wheelchair selection
  3. Wheelchair modifications
  4. Environmental modifications and considerations

User Training Interventions

Examples of user interventions include:

  • Keeping the wheelchair in good working condition
  • Turning off powered wheelchairs when not in use.
  • Not pulling backward on a door or object when in a manual wheelchair.
  • Not putting heavy loads on the back of a manual wheelchair.
  • Not removing anti-tippers; installing them if not present.
  • Not going down steep slopes.
  • Not avoiding “caster flutter”.
  • Not riding in wet conditions.
  • Not reading the product operations manual.
  • Not engaging wheel locks and brakes; not maintaining them.

With occupational therapy, important things to consider include personal client contexts, e.g., socioeconomic status, gender, weight, height; habits, roles, and routines; environment (in multiple conditions); and meaningful values and goals.

W/C Selection and Modifications

Improper wheelchair selection can be attributed to either the wheelchair user self-prescribing and selecting an improper-fitting wheelchair or the provider, e.g., a therapist who is inexperienced selecting an ill-fitting wheelchair. Even if the proper wheelchair is selected in the beginning, a wheelchair user’s condition could worsen with progressive conditions such as ALS, resulting in a wheelchair being unsafe.

Selection of suitable wheelchairs and necessary parts is of utmost importance to ensure proper seating safety with a balance of comfort and function to minimize falls.[8]Joanna Briggs Institute for Evidenced Based Nursing. Falls in hospitals. Best Pract. 1998;2(2):1–6 Other recommendations to prevent tips and falls include (1) moving the center of gravity downward (closer to the ground) and (2) moving the center of gravity horizontally – to increase the distance between the center of gravity and the wheels. These two modifications will increase stability. The same concepts also apply for how the wheelchair users load up the wheelchair with temporary transport loads like heavy backpacks, and filled baskets.

Environmental

Environmental considerations are often intuitive, such as avoiding riding in the rain and other unsafe conditions. As the highest incidence of mechanism occurs with collision or navigation over immobile objects, efforts can be made to modify these objects in the home to make them safer. Locations include entryways, bathrooms, hallways, and the kitchen. Overall, the more barrier-free the environment, the safer it will be. Occupational therapists may also consider OT adaptations and modifications such as increasing task-lighting and decreasing visual distractions and barriers such as glare with client-centered modifications and interventions.

Of course, these modifications may not be possible in the public environment, but unsafe conditions should be reported to the proper personnel to ensure the safety of the general public and to prevent future injuries, e.g., cracks in sidewalks.

Conclusion

Overall, “fall prevention initiatives should consider a wheelchair user’s fall risks in a holistic manner, acknowledging that a person’s current situation, as well as anticipating their fall risks and fall prevention needs, will change over time.”[9]Singh, H., Scovil, C. Y., Yoshida, K., Oosman, S., Kaiser, A., Craven, C., … & Musselman, K. E. (2020). Factors that influence the risk of falling after spinal cord injury: a qualitative … Reference List

References

References
1 National Center for Health Statistics. Number of persons using assistive technology devices by age of person and type of device: United States, 1994 [online]. Centers Dis Control. Available at: http://www.cdc.gov/nchs/about/major/nhis dis/ad292tb1.htm. Accessed 2003.
2 Kirby RL, Ackroyd-Stolarz SA, Brown MG, Kirkland SA, MacLeod DA. Wheelchair-related accidents caused by tips and falls among noninstitutionalized users of manually propelled wheelchairs in Nova Scotia. Am J Phys Med Rehabil. 1994;73(5):319–
330.
3 Kirby RL, Ackroyd-Stolarz SA. Wheelchair safetyadverse reports to the United States Food and Drug Administration. Am J Phys Med Rehabil. 1995;74(4): 308–312.
4 Kirby RL, DiPersio M, MacLeod D. Wheelchair safety: effect of locking or grasping rear wheels during a rear tip. Arch Phys Med Rehabil. 1996;77(12):1266–1270.
5, 6 Gaal, R. P., Rebholtz, N., Hotchkiss, R. D., & Pfaelzer, P. F. (1997). Wheelchair rider injuries: causes and consequences for wheelchair design and selection. Journal of rehabilitation research and development, 34(1), 58-71.
7 Zuckerman JD. Hip fracture. N Engl J Med.
1996;334(23):1519–1525.
8 Joanna Briggs Institute for Evidenced Based Nursing. Falls in hospitals. Best Pract. 1998;2(2):1–6
9 Singh, H., Scovil, C. Y., Yoshida, K., Oosman, S., Kaiser, A., Craven, C., … & Musselman, K. E. (2020). 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. BMJ open, 10(2), e034279.
Jeff is a licensed occupational therapist and lead content creator for OT Dude. He covers all things occupational therapy as well as other topics including healthcare, wellness, mental health, technology, science, sociology, and philosophy. Buy me a Coffee on Venmo.