Avoiding Slips and Falls

Posted by Nurse Linda in Life After Paralysis on December 02, 2020 # Health

Falls are a major cause of spinal cord injury. More than 30% of spinal cord injuries (SCIs) are due to a slip or fall, making this cause second only to motor vehicle accidents. In those over 65 years, slips and falls are the number one cause of SCI. After SCI, individuals with incomplete injury have a higher number of slips and falls. However, individuals with complete SCI injury have fallen from a variety of incidences as well. A slip or a fall can lead to spinal cord injury, but they are significant safety issues after SCI. Thought should be given to preventing further injury once a spinal cord injury has taken place.

Falling is not often thought about for those who use wheelchairs but happens often. Getting bumped out of your chair, having spasms, equipment failure or a missed intention by a caregiver can be some of the sources of slips and falls. Individuals who ambulate with or without devices are generally in the high-risk fall category; however, issues with spinal cord injury or paralysis from any cause can affect anyone.spine xray

Slips or falls can lead to broken bones, hyperextended joints, bruising, and cuts. After a slip or fall, symptoms that can be affected can include an increase in spasticity or autonomic dysreflexia. Neurogenic pain can develop or increase.

Balance is an issue for falls. Regardless of the level of the spinal cord injury, balance, and the center of gravity for the human body is affected by SCI. For those with higher-level injuries, balance can be more of an issue as it is difficult to know your position in space when you are challenged with getting input from the part of your body below the level of injury. But for those with lower-level injuries, balance is affected in a different way. Positioning in space is still an issue below the level of injury, but accommodation of sensory input can also be overestimated in lower injuries.

Strengthening your body above and below the level of injury is imperative to help your balance. It is a benefit if you can activate your muscles above the level of injury to help position your body upright. If your level of injury is high, there might not be enough power in the available muscles to reach this goal. At a lower level of injury, you might think you are well balanced but could have positioning errors. Strength on either side of the body can vary. None of us are entirely symmetrical, especially after SCI.

Being aware of your body position can be helped by visual cues. Use your line of sight to assess the horizon of your view to see if you are tilting. Just looking around will give some indication if you are upright or tilting. You might need to look at your feet if ambulatory to make sure they are squarely on the ground before looking out into the world when moving about.

Learning to trust your adaptive equipment can take some time. Using the tilt function on your chair can make your body go into a flat position or even a position with your head slightly below your body. This change in gravity can be quite an adaption. It takes time to get used to it. In addition, you might be a little dizzy at first or even get a headache. Some individuals report a stuffy nose. If using braces, positioning should be placed with the feet squarely on the ground and then you need to look forward to stepping. You need to learn to trust your equipment in that your feet will not veer out of position.

All these activities take time for adaptation. Allow yourself time to get there. Some individuals, even with lower-level injuries, will need to use compression garments to maintain blood pressure such as abdominal binders and elastic hose. Increasing fluids as your bladder program can tolerate will also help avoid that blood pressure drop.

Tone or spasms is another fall alert. Tone generally occurs in individuals with higher-level injuries in the cervical or thoracic areas of the spinal cord. It can be a hazard for injury because the muscles tighten, which takes away some of the ‘give’ the body can use during a fall to avoid serious injury such as a bone fracture.

Sometimes, tone becomes so strong that you can be tossed from your chair just by a significant spasm. An individual cannot predict when this strong force of tone will happen, but you can almost guarantee that it will occur at the least opportune time. Some people will use a safety belt on their chairs or safety belts for their legs or arms. Use of healthcare treatment, either by exercise, medication, injections, or intrathecal implants, can be used to control severe tone.

Individuals with lower-level injury in the lumbar and sacral area generally do not have tone, although this is not a rule. SCI can produce a mixed injury type at a lower level, which might include tone. Generally, those with a lower level injury will have a more flaccid muscle type. The protective reflexes that are used in an injury situation are not present. Muscles become smaller in lower-level injuries, which does not protect the bones. Fractures are easier with this level of injury. Ambulation with splints or braces does put weight through the bones, providing some strength in the bone.

A slip of an extremity with sensation issues can lead to fractures if your foot, leg, hand, or arm slips off a positioning device. The extremity can be caught in a wheel or hooked onto some other part of your mobility device. If the sensation is an issue, the extremity can be significantly damaged before you are aware of the situation. The positioning of extremities, feet and legs, hands, and arms, is essential to maintaining body integrity. Complications of SCI such as diabetes can further reduce sensation in the extremities.

Be sure to use your positioning equipment to ensure the safety of your limbs. If you have supports to hold your limb in place, be sure to apply them. They not only keep your extremities safe but also help hold your body in the correct position for the most benefit of your functional ability. If you have a higher-level injury, do not overlook a trunk positioning belt or forehead support.

If you are ambulatory, be careful to observe for hazards in your environment. In the home, throw rugs are a significant cause of falls because a toe can get stuck under the rug leading to a fall. Issues with sensation will not provide the input that your toe is caught. The rug can become further dislodged, making the fall significantly worse. A step with a small lip overhang is another quick way for your foot to be caught in an instant. Spills that are not mopped up, poorly fitting footwear, loose boards and weak handrails are others.

For everyone, the outdoors can present challenges. Uneven sidewalks can be difficult, if not impossible, to navigate in a chair or when walking. Be sure to look for curbs that have cut-outs so you can easily maneuver across them. Some individuals have learned to ‘pop a wheelie’ to access a curb or even a step. Don’t try this on your own. Enlist the help of a physical therapist to teach you this technique. If your regular route has uneven walks or no cut-outs, but sure to notify your local streets division. They might not be aware of the dangerous situation and are usually eager to have the area fixed.

Weather is another effect for slips and falls for everyone. Wet walks and streets make rolling and walking slippery. It can be impossible to move over snow and ice. Wait until the area is cleared before going out. Notifying the city streets department that you use mobility equipment of any kind might put your street on the list for earlier cleaning. Your own walks and drive will need to be cleaned by someone at your expense.

Should you slip or fall, you will need to know how to right yourself or tell someone what you need to have done for you. A physical or occupational therapist or a nurse is the person to enlist in your education in case you fall. It is difficult to describe how to right yourself after a fall. You really need to have the hands-on experience and the muscle-building education to be successful in re-entering your chair from the ground.

For those who have lower-level injuries, you can learn how to right yourself while still in your chair if it tips back by changing your center of gravity by leaning forward and by holding the wheel steady as you pull up on it. This sounds quite complicated, and it is! But it is manageable with strength. You do need hands on education as it is hard to explain in type. If you fall out of the chair in front of it, roll your body up into the chair. Again, hard to envision. There are videos and educational programs online to learn about these techniques. Learn about them but be sure you have a professional with you when you learn to do them. Being risky in these activities can lead to more dangerous and disastrous slips and falls.

If you have a higher-level injury, you will need help in getting back into your chair. Many people will want to help you, but they usually lack the experience in how to do so. You do not want someone pulling on your arm or leg to lift your body. It is best to have someone call 911 for assistance. After a fall, you could have broken a bone, have a significant bruise/bleeding, or even another spinal cord injury. The EMTs know how to assess for injury, how to move your body and how to lift you correctly.

Slips and falls can lead to spinal cord injury but are an additional catastrophe after a spinal cord injury. Knowing how to get help is knowing how to help yourself. Nurse Linda

Pediatric Consideration:

Small children are easier to move around, so a slip out of the chair or a fall with braces can be easy to correct just by picking up the child. Older children’s falls should be treated like adults. But before intervening by picking up any aged child, check for injury or if a body part is out of alignment or overstretched. Call for help even with small children. Hidden injuries can be present.

Children’s bones are different from adult bones. Their bones are not as hard until the child reaches puberty. Children can have broken bones, just like adults. Often children’s bones are broken like a young tree branch. This is called a ‘green stick’ fracture. The bone breaks in what looks more like shredding, just like a young tree branch. These can be harder to detect as there is no displacement of the bone as in an adult. You might notice a fracture due to swelling or an increase in spasticity or autonomic dysreflexia (AD). If you are wondering about a bone break or fracture, be sure to consult your healthcare professional. Imaging by use of an x-ray, CT or MRI scan is the only way to find some bone fractures. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.