Factors Affecting Falls in Spinal Cord Injuries - Is Accompaniment Important in Falls?

Factors Affecting Falls in Spinal Cord Injuries - Is Accompaniment Important in Falls? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factors Affecting Falls in Spinal Cord Injuries - Is Accompaniment Important in Falls? fatma kumbara, aslı turan, berna orhan, özge tezen, zuhal özişler, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6589454/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective : This study aims to evaluate falls occurring during inpatient rehabilitation after spinal cord injury and the impact of caregiver presence on fall risk. Materials and Methods: Patients with spinal cord injury who underwent inpatient rehabilitation at Ankara Bilkent City Hospital’s Physical Medicine and Rehabilitation Clinic between 2020 and 2023 were included in this study. Patients were divided into two groups: those with a history of falls (Group 1) and those without a history of falls (Group 2). Variables assessed included demographic data, etiology, ASIA score, functional status, caregiver presence, and fall timing. Statistical analyses were conducted using the Chi-Square test and the Mann-Whitney U test. Results: A total of 98 patients were included in the study. No significant relationship was found between falls and gender, caregiver presence, etiology, or functional status (p > 0.05). However, a statistically significant association was identified between ASIA scores and falls (p = 0.048). Patients with ASIA C classification were found to have the highest fall risk. According to the Mann-Whitney U test results, no significant differences were observed between the groups in terms of age and SCIM scores, whereas a borderline significant difference was noted in WISCI scores (p = 0.058). Conclusion: Factors such as gender and etiology do not appear to significantly affect fall risk in individuals with spinal cord injuries. Moreover, no statistically significant evidence was found indicating that caregiver presence reduces fall risk. Disease severity is directly related to functional independence (SCIM) and walking ability (WISCI). These findings highlight the need for developing individualized fall prevention strategies during the rehabilitation process. Spinal cord injury falls caregiver ASIA score functional independence Figures Figure 1 Figure 2 Introduction Spinal cord injury (SCI) is a condition that significantly affects individuals’ functional independence and can lead to long-term physical, psychological, and social consequences. Globally, it is estimated to affect approximately 500,000 people annually, often resulting in permanent disability. The rehabilitation of individuals with SCI requires a multidisciplinary approach involving nursing, physiotherapy, occupational therapy, and psychology. The characteristic sensorimotor deficits of SCI—such as lower extremity muscle paresis and impaired proprioception—contribute to balance impairments and consequently increase the risk of falls. Falls are a common complication in individuals with SCI, negatively impacting both patient safety and the success of the rehabilitation process. In-hospital falls and their consequences place an additional burden on healthcare services for this population ( 1 , 2 ). The literature indicates that the incidence of falls in individuals with SCI is high, often resulting in serious injuries, hospital readmissions, and prolonged rehabilitation ( 3 ). In rehabilitation settings that include patients with stroke, amputation, SCI, multisystem trauma, and other neuromuscular disorders, reported fall rates range between 13–14% ( 4 ). On the other hand, systematic reviews on post-SCI falls indicate a continued lack of knowledge regarding the causes and prevention strategies of falls, particularly compared to other neurological populations. Hospital-related fall risk factors include impaired motor function, a history of previous falls, medication use, incontinence, and advanced age ( 3 ). Additionally, approximately 68% of recorded falls in hospitals occur unwitnessed, mostly during daytime hours when ward activity is at its peak ( 4 ). Increased mobility during the rehabilitation process has also been linked to a higher risk of falling. Several strategies have been developed to prevent falls, including the presence of caregivers or attendants. In a study by Giles et al., it was emphasized that attendants may reduce falls by improving patient observation ( 5 ). Another study showed that fall prevention programs can reduce fall rates in hospitals, although the direct effect of attendants remains unclear. Research highlights two main approaches to fall prevention: redesigning the physical environment of the ward and ensuring the presence of additional staff or attendants during high-risk periods. An alternative strategy involves enhancing patient monitoring, especially in high-risk areas such as patient rooms, bathrooms, toilets, and hallways ( 5 ). However, the workload of nursing staff and ward design may hinder continuous supervision of at-risk patients. Therefore, understanding the role of attendants in fall prevention has become a critical area of investigation. Although attendants have been recommended in palliative care and rehabilitation guidelines, the literature regarding their impact on falls in SCI patients remains limited. To date, no randomized controlled trials have examined the effect of attendants on in-hospital fall rates. While such trials would provide high-level evidence, preliminary feasibility studies are necessary. Another underexplored factor is the timing of falls. While falls can occur at any time of day, they are more frequently observed during peak hospital activity periods, such as mealtimes. Additionally, 68% of in-hospital falls have been reported to occur when the patient is alone ( 2 ). This study aims to identify the factors associated with falls in individuals with SCI and to investigate the role of attendants in fall prevention. The study will compare two groups: those who experienced a fall (Group 1, GR1) and those who did not (Group 2, GR2), examining variables such as demographic characteristics, functional independence levels (SCIM), walking index (WISCI), and presence of an attendant. The findings are expected to contribute to the development of effective strategies for fall prevention in individuals with SCI. Recent studies in this field have also emphasized the influence of patient experiences and rehabilitation programs on fall outcomes ( 6 , 7 , 8 ). The specific objectives of this study in hospitalized patients with SCI undergoing rehabilitation are to: Identify the causes, conditions, and locations of falls, and determine whether an attendant was present at the time of the fall, Analyze fall timing and examine patterns based on patient characteristics (e.g., age, sex, type of injury), Compare the clinical and demographic characteristics of patients who experienced falls with those who did not, Evaluate the effectiveness of attendants in fall prevention and develop protective strategies accordingly. Materials and Methods This study was designed as a retrospective, single-center investigation. The study included patients diagnosed with spinal cord injury (SCI) who were hospitalized for rehabilitation and subsequently discharged from the 2B Spinal Cord Injury Unit of Ankara Bilkent City Hospital between January 2020 and December 2023. Medical records of the patients were reviewed retrospectively. Data collected included demographic characteristics (age, sex, marital status, education level, presence of an attendant), date, level and etiology of the injury, length of hospital stay, functional status, and fall-related information. For functional assessment, the Spinal Cord Independence Measure (SCIM) and the Walking Index for Spinal Cord Injury (WISCI) were used. Fall history (presence or absence), number of falls, time of fall (day/night), location of fall (bathroom, during transfer, during exercise, other), and the presence of an attendant at the time of the fall were evaluated from individual patient files. Patients included in the study were 18 years or older, hospitalized between January 2020 and September 2023, and diagnosed with SCI classified as level A, B, C, or D according to the American Spinal Injury Association (ASIA) impairment scale. Patients with significant cognitive impairments, congenital spinal cord injuries, or progressive/neurodegenerative diseases (e.g., multiple sclerosis, amyotrophic lateral sclerosis, Guillain-Barré syndrome) were excluded from the study. The control group consisted of individuals with similar SCI diagnoses who were hospitalized during the same study period but did not have a history of falls. Statistical Analysis To assess the differences between groups, appropriate statistical tests were applied based on the type and distribution of the variables. For continuous variables, the Independent Samples t-test was used when the distribution was normal, while the Mann–Whitney U test was employed for non-normally distributed data. For categorical variables, the Chi-square test or Fisher’s Exact Test was used when appropriate. To identify independent risk factors associated with falls, logistic regression analysis was performed. A p-value of less than 0.05 was considered statistically significant in all analyses. Results A total of 98 patients were included in this study. The patients were divided into two groups: those with a history of falls (Group 1, GR1; n = 49) and those without a history of falls (Group 2, GR2; n = 49). Table 1. Demographic and Clinical Characteristics Variable Fallers (GR1) n = 49 Non-fallers (GR2) n = 49 p -value Age (mean ± SD) 52.1 ± 20.4 45.7 ± 16.3 0.089 Gender (Male) 37 28 0.087 Presence of caregiver 40 38 0.802 Etiology (Traumatic/Non-traumatic) 17 / 32 26 / 23 0.103 Severity (Complete/Incomplete) 5 / 44 7 / 42 0.759 Functional status (Dependent/Independent) 41 / 8 37 / 12 0.453 SCIM (mean ± SD) 65.0 ± 17.1 68.7 ± 12.4 0.223 WISCI (mean ± SD) 7.57 ± 4.82 6.00 ± 5.40 0.132 No statistically significant differences were observed between the fallers (GR1) and non-fallers (GR2) in terms of gender distribution (male/female), presence of a caregiver, mean age, SCIM and WISCI scores, etiology (traumatic/non-traumatic), severity of injury (complete/incomplete), or functional independence status ( p > 0.05) (Table 1). This figure illustrates the distribution of falls among patients based on the time of the fall (day/night), location of the fall (bathroom, during transfer, during exercise, other), and the presence of a caregiver at the time of the fall. It can be observed that most falls occurred during daytime hours, particularly during transfers or in unspecified 'other' locations. Although the presence of a caregiver was frequently noted during the fall events, it does not appear to be a decisive factor in preventing falls. This figure demonstrates the distribution of variables such as gender, presence of caregiver, ASIA score, functional ambulation level, and etiology among patients who experienced falls and those who did not. Blue bars represent fallers, while orange bars represent non-fallers. A notably higher rate of falls is observed among individuals classified as ASIA C and those ambulating within the home environment. Although the etiological distribution does not show a direct association with falls, variations are observed across certain subgroups. Logistic regression analysis was conducted to examine the independent variables influencing falls. According to the analysis results, age was identified as a significant variable associated with falls (p = 0.0119). As age increases, the risk of falling also rises. Gender was identified as a significant factor influencing the risk of falls, with male patients exhibiting a higher risk compared to females (p = 0.0244). No significant association was found between the presence of a caregiver and falls (p = 0.8943). A statistically significant negative correlation was observed between the SCIM score and falls (p = 0.0048), indicating that as the SCIM score increases, the risk of falling decreases. In contrast, a significant positive correlation was found between the WISCI score and falls (p = 0.0078), suggesting that patients with higher WISCI scores have a greater risk of falling. In the comparisons between groups, gender showed a statistically significant difference (p = 0.0387), with male patients demonstrating a higher risk of falling compared to females. Age was found to be near the threshold of significance (p = 0.0641), indicating a trend toward increased fall risk with advancing age, although the difference was not statistically significant. Variables such as caregiver presence, etiology, and ASIA score were not found to be significantly associated with falls (p = 0.616, p = 0.175, and p > 0.05, respectively). However, when ASIA subgroups were analyzed, individuals in the ASIA C group were observed to be at higher risk of falling (p = 0.048). No statistically significant association was found between functional status and the occurrence of falls (p = 0.288). Conclusion In this study, fall-related factors among individuals with spinal cord injury (SCI) were evaluated through a multidimensional approach. According to the findings, while gender, ASIA score, functional status, and certain etiological factors appeared to be associated with falls, no statistically significant differences were found in terms of caregiver presence, age, SCIM, and WISCI scores. Patients classified as ASIA C demonstrated a significantly higher incidence of falls (p = 0.048). The increased fall rate among individuals ambulating within the home suggests a potential relationship between functional level and fall risk. The observation that most falls occurred during daytime hours and particularly during transfers implies that environmental factors may also play a critical role. The presence of a caregiver was not identified as a significant factor in fall prevention (p = 0.616). In conclusion, fall risk assessment should consider not only individual clinical characteristics but also functional capacity, time of day, and environmental conditions. These findings highlight the importance of developing personalized fall prevention strategies during the rehabilitation process. Discussion This study aimed to examine the incidence of falls, associated risk factors, and the potential impact of caregiver presence in individuals undergoing inpatient rehabilitation following spinal cord injury (SCI). The findings are generally consistent with the existing literature, although some discrepancies were also noted. Functional assessment tools such as the SCIM and WISCI have been associated with fall risk. Previous studies have demonstrated a significant relationship between lower SCIM scores and increased fall risk ( 3 , 9 ). In our study, although individuals who experienced falls had lower SCIM and WISCI scores, the differences were not statistically significant. However, the WISCI score approached statistical significance, suggesting that walking ability may have an influence on fall risk. This finding is consistent with the observations reported by Marshall et al. Studies that more clearly demonstrate the relationship between functional independence and falls have reported that lower SCIM scores are directly associated with an increased risk of falling ( 3 , 9 ). Although a similar trend was observed in our study, statistical significance was not achieved. WISCI scores, however, may serve as a potential indicator of fall risk. With respect to the ASIA score, individuals classified as ASIA C were observed to be more prone to falling. The tendency of individuals with partially preserved motor and sensory functions to move more independently may contribute to an increased risk ( 3 ). Wilson et al. reported that falls occurring particularly during transfers are associated with more severe injuries, which aligns with the fall patterns observed in our study. In our study, age was found to have a borderline significant association with falls, whereas male individuals appeared to be more prone to falling. Although the effect of age on fall risk remains a debated topic in the literature, several studies suggest that advanced age may be a contributing risk factor ( 10 ). To better understand the impact of age on fall risk, large-scale and long-term follow-up studies are needed. Previous research has emphasized that individuals with lower functional status are at higher risk of falling and require additional precautions ( 4 ). Similarly, our study revealed a notably higher fall rate among individuals who ambulated indoors. Interestingly, fall rates among wheelchair users were found to be comparable, suggesting that not only walking ability but also environmental factors and individual awareness of safety play significant roles in fall occurrence. The presence of a caregiver did not significantly reduce the risk of falling. Although previous studies have reported a reduction in fall rates through volunteer caregiver programs ( 2 , 5 ), this effectiveness was not confirmed in our study. This suggests that caregivers may not be sufficiently effective as a standalone fall-prevention measure. To enhance their effectiveness, caregivers should be included in educational programs and made more aware of patient safety practices ( 4 , 5 ). In our study, no significant association was found between etiology and falls. However, further large-scale comparative studies are needed to better understand the impact of traumatic versus non-traumatic spinal cord injuries on fall risk. Although the literature suggests that individuals with non-traumatic SCI may have a higher risk of falling, further research is required to draw definitive conclusions ( 3 ). Environmental factors, along with the timing of falls, are among the key determinants of fall risk. The finding that 67% of falls occurred during daytime hours highlights the impact of hospital activity and staff mobility on fall risk. García-Rudolph et al. also emphasized that falls tend to cluster at certain times of the day, underscoring the need to consider environmental factors in prevention efforts ( 11 ). Environmental modifications, technological supports, and educational programs have been proposed in the literature as effective strategies for reducing fall risk ( 12 , 13 ). In particular, insufficient lighting and lack of supervision in areas such as transfer zones, bathrooms, and hallways significantly increase fall risk ( 14 ). These findings clearly demonstrate the importance of incorporating environmental considerations into fall risk assessments. From a psychosocial perspective, the impact of falling on individuals is also a significant finding. Falls have been reported to affect not only physical health but also psychological and social well-being, leading to fear, loss of confidence, and diminished perceptions of independence ( 7 , 8 ). Therefore, when developing fall prevention strategies, patients' personal experiences and awareness should also be taken into account. Khan et al. reported a notably high incidence of falls among individuals with spinal cord injury (SCI), with impairments in transfer ability, balance, and muscle strength being major risk factors ( 10 ). These findings align with the risk factors observed in our study population. Similarly, Abou and Rice found that wheelchair users are particularly prone to falls in home settings, especially during transfers, and such falls can result in serious injuries ( 15 ). These findings clearly highlight the importance of personalized educational strategies. In the literature, it has been reported that the risk of multiple falls in individuals with spinal cord injury (SCI) can be predicted in advance, allowing for the development of targeted prevention strategies ( 16 ). In this context, the functional assessment tools used in our study appear to have potential as screening instruments prior to the occurrence of falls. These tools can be integrated not only into scientific analyses but also into routine clinical practice. In conclusion, this study provides a comprehensive analysis of the multifactorial causes of falls in individuals with SCI. A range of variables, including gender, age, ASIA level, functional status, and the presence of a caregiver, were examined. However, walking ability and functional capacity emerged as the strongest predictors of fall risk. The findings suggest that fall risk is closely associated not only with an individual’s physical condition but also with environmental factors and social support systems. The strengths of this study include the comprehensive evaluation of numerous clinical variables and its foundation on real-world data. However, several limitations must be acknowledged, such as its retrospective design, limited sample size, and reliance on self-reported fall events. Future large-scale prospective studies are needed to validate these findings. In conclusion, individualized, multifactorial, and time-sensitive fall prevention strategies should be integrated into the rehabilitation process for individuals with spinal cord injury (SCI). Specifically, tailored programs should be developed for patients classified as ASIA C, those who are ambulatory within the home environment, and those who are active during daytime hours. Furthermore, it is recommended that structured training programs be implemented to enhance caregiver effectiveness, along with environmental safety modifications. Declarations This study was approved by the Ethics Committee of Ankara Bilkent City Hospital (Approval No: [1-24-151], Date: [2024]). All patient data were analyzed retrospectively and anonymized to ensure confidentiality. References Ash KL, MacLeod P, Clark L. A case control study of falls in the hospital setting. Journal of Gerontological Nursing. 1998;24:7–15. Donoghue J, Graham J, Mitten-Lewis S, Murphy M, Gibbs J. A volunteer companion-observer intervention reduces falls on an acute aged care ward. International Journal of Health Care Quality Assurance. 2005;18:24–31. Wilson A, Kurban D, Noonan VK, Krassioukov A.: Falls during inpatient rehabilitation in spinal cord injury, acquired brain injury, and neurologmusculoskeletal disease programs. Spinal Cord 2020; 58: pp. 334-340. Schwendimann R, Bühler H, Geest S, Milisen K. Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program. BMC Health Serv Res. 2006 Jun 7;6:69. Giles L, Bolch D, Rouvray R, McErlean B,Whitehead H, Phillips P, Crotty M, Can volunteer companions prevent falls among inpatients? A feasibility study using a pre-post comparative design. BMC Geriatr. 2006; 6: 11. Rahimi, S., Khankeh, H. R., Ebadi, A., Mohammadian, B., Eghbali, M., & Habibzadeh, F. (2024). Developing a fall prevention program in an inpatient spinal cord injury rehabilitation unit: A participatory action research study. PLoS ONE , 19(7), e0304320. Habib Perez, O., Chan, K., Martin, S., Marinho-Buzelli, A., Singh, H., & Musselman, K. E. (2024). The experience of falls and fall risk during the subacute phase of spinal cord injury: a mixed methods study. Disability and Rehabilitation , 46(17), 3937–3945. Singh, H., Scovil, C. Y., Bostick, G., Kaiser, A., Craven, B. C., Jaglal, S. B., & Musselman, K. E. (2020). Perspectives of wheelchair users with spinal cord injury on fall circumstances and fall prevention: A mixed methods approach using photovoice. PLoS ONE , 15(8), e0238116. Marshall K, Gustafsson L, McKittrick A, Fleming J, Falls Occurring After a Spinal Cord Injury: A Scoping Review. J.Am J Occup Ther. 2021 May 1;75(3):7503205010 Khan A, Pujol C, Laylor M, et. al.: Falls after spinal cord injury: a systematic review and meta-analysis of incidence proportion and contributing factors. Spinal Cord 2019; 57: pp. 526-539. García-Rudolph A, Wright MA, Devilleneuve EA, Castillo E, Hernandez-Pena E, Opisso E, Tormos JM, Falls During Inpatient Rehabilitation After Spinal Cord Injury: Characterization, Clock-Hour Visualization, and Time to Event Predictors. Arch Phys Med Rehabil. 2023 Aug;104(8):1209-1218. Qin, H., Diao, Y., Hao, M., Wang, Z., Xie, M., Hu, X., & Zhu, T. (2025). Analysis and comparison of the trends in burden of spinal cord injury in China and worldwide from 1990 to 2021: an analysis of the global burden of disease study 2021. Frontiers in Public Health , 12, 1517871. Varghese, R. J., Tong, M.-Y., Szczech, I., Bryan, P., Aronson-Arminoff, M., Farina, D., & Burdet, E. (2024). Design and Preliminary Evaluation of a Torso Stabiliser for Individuals with Spinal Cord Injury. arXiv preprint arXiv:2403.17531 . Donoghue J, Graham J, Gibbs J, Mitten-Lewis S. Who, where and why: situational and environmental factors contributing to patient falls in the hospital setting. Australian Health Review. 2003;26:79–87. Abou L, Rice LA.: Risk factors associated with falls and fall-related injuries among wheelchair users with spinal cord injury. Arch Rehabil Res Clin Transl 2022; 4: Srisim K, Saengsuwan J, Amatachaya S.: Functional assessments for predicting a risk of multiple falls in independent ambulatory patients with spinal cord injury. J Spinal Cord Med 2015; 38: pp. 439-445. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6589454","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451700951,"identity":"03371091-0be2-4077-ad20-3511fe9adb64","order_by":0,"name":"fatma kumbara","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBAC9gYQeYCBwQBEfwBiNnYCWngOMCO0MM4AaWEmRQszD0iIoBb280c3/DhzONqc/ezDzza/tsnzMTMwfviYg0cLTzLbzZ4bh3N39qQbS+f23TZsY2Zglpy5DbcWe4Zkths8Hw7nbjiQxiCd23ObEaiFjZkXjxYe/sdsN/+AtJx/xvzbsue2PWEtEslst3mADttwI41NmuHH7UQitDw2uy1zJj1354xnbJa9DbeT25gZm/H6hYc/8dnNN8esc7fzpzHf+PHntu389uaDHz7i0YIKGNvAZAOx6kHgDymKR8EoGAWjYKQAAP+LVi66CjA2AAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"fatma","middleName":"","lastName":"kumbara","suffix":""},{"id":451700952,"identity":"a9653877-643e-41f0-aee9-3ec6ddc1b16f","order_by":1,"name":"aslı turan","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"aslı","middleName":"","lastName":"turan","suffix":""},{"id":451700953,"identity":"417f9550-9316-40b1-b670-1ae88ab8a70b","order_by":2,"name":"berna orhan","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"berna","middleName":"","lastName":"orhan","suffix":""},{"id":451700954,"identity":"c91b3a9b-714b-4e24-8cfa-b88cd0abb7ca","order_by":3,"name":"özge tezen","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"özge","middleName":"","lastName":"tezen","suffix":""},{"id":451700955,"identity":"26a2f504-68fd-4455-a082-ca09e3a5649d","order_by":4,"name":"zuhal özişler","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"zuhal","middleName":"","lastName":"özişler","suffix":""},{"id":451700956,"identity":"022e4c7b-46fb-49ed-bb25-5b46f1c7898d","order_by":5,"name":"elif yalçın","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"elif","middleName":"","lastName":"yalçın","suffix":""}],"badges":[],"createdAt":"2025-05-04 16:38:20","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6589454/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6589454/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82166915,"identity":"8f3a62e4-8014-4162-b093-a20f2ec02f75","added_by":"auto","created_at":"2025-05-07 09:17:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":113138,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Fall Time, Fall Location, and Presence of Caregiver Among Patients Who Experienced Falls\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6589454/v1/61a85538683a386b63adb271.png"},{"id":82166917,"identity":"ff65d2da-3b19-4733-8627-bde4db42c1d2","added_by":"auto","created_at":"2025-05-07 09:17:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":212818,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Categorical Variables Among Fallers and Non-Fallers\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6589454/v1/8fc7537d7d5f52f5ecee70fc.png"},{"id":82169580,"identity":"04412817-e74a-49f1-b660-66c95ae86422","added_by":"auto","created_at":"2025-05-07 09:41:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":948691,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6589454/v1/f1086c2c-7f3a-42a2-b347-3aad2adfd761.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eFactors Affecting Falls in Spinal Cord Injuries - Is Accompaniment Important in Falls?\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSpinal cord injury (SCI) is a condition that significantly affects individuals\u0026rsquo; functional independence and can lead to long-term physical, psychological, and social consequences. Globally, it is estimated to affect approximately 500,000 people annually, often resulting in permanent disability. The rehabilitation of individuals with SCI requires a multidisciplinary approach involving nursing, physiotherapy, occupational therapy, and psychology. The characteristic sensorimotor deficits of SCI\u0026mdash;such as lower extremity muscle paresis and impaired proprioception\u0026mdash;contribute to balance impairments and consequently increase the risk of falls.\u003c/p\u003e \u003cp\u003eFalls are a common complication in individuals with SCI, negatively impacting both patient safety and the success of the rehabilitation process. In-hospital falls and their consequences place an additional burden on healthcare services for this population (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe literature indicates that the incidence of falls in individuals with SCI is high, often resulting in serious injuries, hospital readmissions, and prolonged rehabilitation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In rehabilitation settings that include patients with stroke, amputation, SCI, multisystem trauma, and other neuromuscular disorders, reported fall rates range between 13\u0026ndash;14% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn the other hand, systematic reviews on post-SCI falls indicate a continued lack of knowledge regarding the causes and prevention strategies of falls, particularly compared to other neurological populations. Hospital-related fall risk factors include impaired motor function, a history of previous falls, medication use, incontinence, and advanced age (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Additionally, approximately 68% of recorded falls in hospitals occur unwitnessed, mostly during daytime hours when ward activity is at its peak (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Increased mobility during the rehabilitation process has also been linked to a higher risk of falling.\u003c/p\u003e \u003cp\u003eSeveral strategies have been developed to prevent falls, including the presence of caregivers or attendants. In a study by Giles et al., it was emphasized that attendants may reduce falls by improving patient observation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Another study showed that fall prevention programs can reduce fall rates in hospitals, although the direct effect of attendants remains unclear.\u003c/p\u003e \u003cp\u003eResearch highlights two main approaches to fall prevention: redesigning the physical environment of the ward and ensuring the presence of additional staff or attendants during high-risk periods. An alternative strategy involves enhancing patient monitoring, especially in high-risk areas such as patient rooms, bathrooms, toilets, and hallways (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, the workload of nursing staff and ward design may hinder continuous supervision of at-risk patients. Therefore, understanding the role of attendants in fall prevention has become a critical area of investigation. Although attendants have been recommended in palliative care and rehabilitation guidelines, the literature regarding their impact on falls in SCI patients remains limited. To date, no randomized controlled trials have examined the effect of attendants on in-hospital fall rates. While such trials would provide high-level evidence, preliminary feasibility studies are necessary.\u003c/p\u003e \u003cp\u003eAnother underexplored factor is the timing of falls. While falls can occur at any time of day, they are more frequently observed during peak hospital activity periods, such as mealtimes. Additionally, 68% of in-hospital falls have been reported to occur when the patient is alone (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aims to identify the factors associated with falls in individuals with SCI and to investigate the role of attendants in fall prevention. The study will compare two groups: those who experienced a fall (Group 1, GR1) and those who did not (Group 2, GR2), examining variables such as demographic characteristics, functional independence levels (SCIM), walking index (WISCI), and presence of an attendant. The findings are expected to contribute to the development of effective strategies for fall prevention in individuals with SCI. Recent studies in this field have also emphasized the influence of patient experiences and rehabilitation programs on fall outcomes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe specific objectives of this study in hospitalized patients with SCI undergoing rehabilitation are to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIdentify the causes, conditions, and locations of falls, and determine whether an attendant was present at the time of the fall,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAnalyze fall timing and examine patterns based on patient characteristics (e.g., age, sex, type of injury),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCompare the clinical and demographic characteristics of patients who experienced falls with those who did not,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEvaluate the effectiveness of attendants in fall prevention and develop protective strategies accordingly.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study was designed as a retrospective, single-center investigation. The study included patients diagnosed with spinal cord injury (SCI) who were hospitalized for rehabilitation and subsequently discharged from the 2B Spinal Cord Injury Unit of Ankara Bilkent City Hospital between January 2020 and December 2023.\u003c/p\u003e \u003cp\u003eMedical records of the patients were reviewed retrospectively. Data collected included demographic characteristics (age, sex, marital status, education level, presence of an attendant), date, level and etiology of the injury, length of hospital stay, functional status, and fall-related information.\u003c/p\u003e \u003cp\u003eFor functional assessment, the Spinal Cord Independence Measure (SCIM) and the Walking Index for Spinal Cord Injury (WISCI) were used. Fall history (presence or absence), number of falls, time of fall (day/night), location of fall (bathroom, during transfer, during exercise, other), and the presence of an attendant at the time of the fall were evaluated from individual patient files.\u003c/p\u003e \u003cp\u003ePatients included in the study were 18 years or older, hospitalized between January 2020 and September 2023, and diagnosed with SCI classified as level A, B, C, or D according to the American Spinal Injury Association (ASIA) impairment scale. Patients with significant cognitive impairments, congenital spinal cord injuries, or progressive/neurodegenerative diseases (e.g., multiple sclerosis, amyotrophic lateral sclerosis, Guillain-Barr\u0026eacute; syndrome) were excluded from the study. The control group consisted of individuals with similar SCI diagnoses who were hospitalized during the same study period but did not have a history of falls.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eTo assess the differences between groups, appropriate statistical tests were applied based on the type and distribution of the variables. For continuous variables, the Independent Samples t-test was used when the distribution was normal, while the Mann\u0026ndash;Whitney U test was employed for non-normally distributed data. For categorical variables, the Chi-square test or Fisher\u0026rsquo;s Exact Test was used when appropriate. To identify independent risk factors associated with falls, logistic regression analysis was performed. A p-value of less than 0.05 was considered statistically significant in all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 98 patients were included in this study. The patients were divided into two groups: those with a history of falls (Group 1, GR1; n = 49) and those without a history of falls (Group 2, GR2; n = 49).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eTable 1. Demographic and Clinical Characteristics\u003c/strong\u003e\u003c/h3\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFallers (GR1) n = 49\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-fallers (GR2) n = 49\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (mean \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e52.1 \u0026plusmn; 20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e45.7 \u0026plusmn; 16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender (Male)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.087\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresence of caregiver\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.802\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEtiology (Traumatic/Non-traumatic)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e17 / 32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e26 / 23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.103\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity (Complete/Incomplete)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e5 / 44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e7 / 42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.759\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunctional status (Dependent/Independent)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e41 / 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e37 / 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCIM (mean \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e65.0 \u0026plusmn; 17.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e68.7 \u0026plusmn; 12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.223\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 237px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWISCI (mean \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003e7.57 \u0026plusmn; 4.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e6.00 \u0026plusmn; 5.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.132\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNo statistically significant differences were observed between the fallers (GR1) and non-fallers (GR2) in terms of gender distribution (male/female), presence of a caregiver, mean age, SCIM and WISCI scores, etiology (traumatic/non-traumatic), severity of injury (complete/incomplete), or functional independence status (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.05) (Table 1).\u003c/p\u003e\n\u003cp\u003eThis figure illustrates the distribution of falls among patients based on the time of the fall (day/night), location of the fall (bathroom, during transfer, during exercise, other), and the presence of a caregiver at the time of the fall. It can be observed that most falls occurred during daytime hours, particularly during transfers or in unspecified \u0026apos;other\u0026apos; locations. Although the presence of a caregiver was frequently noted during the fall events, it does not appear to be a decisive factor in preventing falls.\u003c/p\u003e\n\u003cp\u003eThis figure demonstrates the distribution of variables such as gender, presence of caregiver, ASIA score, functional ambulation level, and etiology among patients who experienced falls and those who did not. Blue bars represent fallers, while orange bars represent non-fallers. A notably higher rate of falls is observed among individuals classified as ASIA C and those ambulating within the home environment. Although the etiological distribution does not show a direct association with falls, variations are observed across certain subgroups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLogistic regression analysis was conducted to examine the independent variables influencing falls. According to the analysis results, age was identified as a significant variable associated with falls (p = 0.0119). As age increases, the risk of falling also rises.\u003c/p\u003e\n\u003cp\u003eGender was identified as a significant factor influencing the risk of falls, with male patients exhibiting a higher risk compared to females (p = 0.0244). No significant association was found between the presence of a caregiver and falls (p = 0.8943). A statistically significant negative correlation was observed between the SCIM score and falls (p = 0.0048), indicating that as the SCIM score increases, the risk of falling decreases. In contrast, a significant positive correlation was found between the WISCI score and falls (p = 0.0078), suggesting that patients with higher WISCI scores have a greater risk of falling.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the comparisons between groups, gender showed a statistically significant difference (p = 0.0387), with male patients demonstrating a higher risk of falling compared to females. Age was found to be near the threshold of significance (p = 0.0641), indicating a trend toward increased fall risk with advancing age, although the difference was not statistically significant. Variables such as caregiver presence, etiology, and ASIA score were not found to be significantly associated with falls (p = 0.616, p = 0.175, and p \u0026gt; 0.05, respectively). However, when ASIA subgroups were analyzed, individuals in the ASIA C group were observed to be at higher risk of falling (p = 0.048). No statistically significant association was found between functional status and the occurrence of falls (p = 0.288).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, fall-related factors among individuals with spinal cord injury (SCI) were evaluated through a multidimensional approach. According to the findings, while gender, ASIA score, functional status, and certain etiological factors appeared to be associated with falls, no statistically significant differences were found in terms of caregiver presence, age, SCIM, and WISCI scores.\u003c/p\u003e \u003cp\u003ePatients classified as ASIA C demonstrated a significantly higher incidence of falls (p\u0026thinsp;=\u0026thinsp;0.048). The increased fall rate among individuals ambulating within the home suggests a potential relationship between functional level and fall risk. The observation that most falls occurred during daytime hours and particularly during transfers implies that environmental factors may also play a critical role. The presence of a caregiver was not identified as a significant factor in fall prevention (p\u0026thinsp;=\u0026thinsp;0.616).\u003c/p\u003e \u003cp\u003eIn conclusion, fall risk assessment should consider not only individual clinical characteristics but also functional capacity, time of day, and environmental conditions. These findings highlight the importance of developing personalized fall prevention strategies during the rehabilitation process.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to examine the incidence of falls, associated risk factors, and the potential impact of caregiver presence in individuals undergoing inpatient rehabilitation following spinal cord injury (SCI). The findings are generally consistent with the existing literature, although some discrepancies were also noted.\u003c/p\u003e \u003cp\u003eFunctional assessment tools such as the SCIM and WISCI have been associated with fall risk. Previous studies have demonstrated a significant relationship between lower SCIM scores and increased fall risk (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In our study, although individuals who experienced falls had lower SCIM and WISCI scores, the differences were not statistically significant. However, the WISCI score approached statistical significance, suggesting that walking ability may have an influence on fall risk. This finding is consistent with the observations reported by Marshall et al.\u003c/p\u003e \u003cp\u003eStudies that more clearly demonstrate the relationship between functional independence and falls have reported that lower SCIM scores are directly associated with an increased risk of falling (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Although a similar trend was observed in our study, statistical significance was not achieved. WISCI scores, however, may serve as a potential indicator of fall risk.\u003c/p\u003e \u003cp\u003eWith respect to the ASIA score, individuals classified as ASIA C were observed to be more prone to falling. The tendency of individuals with partially preserved motor and sensory functions to move more independently may contribute to an increased risk (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Wilson et al. reported that falls occurring particularly during transfers are associated with more severe injuries, which aligns with the fall patterns observed in our study.\u003c/p\u003e \u003cp\u003eIn our study, age was found to have a borderline significant association with falls, whereas male individuals appeared to be more prone to falling. Although the effect of age on fall risk remains a debated topic in the literature, several studies suggest that advanced age may be a contributing risk factor (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). To better understand the impact of age on fall risk, large-scale and long-term follow-up studies are needed.\u003c/p\u003e \u003cp\u003ePrevious research has emphasized that individuals with lower functional status are at higher risk of falling and require additional precautions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Similarly, our study revealed a notably higher fall rate among individuals who ambulated indoors. Interestingly, fall rates among wheelchair users were found to be comparable, suggesting that not only walking ability but also environmental factors and individual awareness of safety play significant roles in fall occurrence.\u003c/p\u003e \u003cp\u003eThe presence of a caregiver did not significantly reduce the risk of falling. Although previous studies have reported a reduction in fall rates through volunteer caregiver programs (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), this effectiveness was not confirmed in our study. This suggests that caregivers may not be sufficiently effective as a standalone fall-prevention measure. To enhance their effectiveness, caregivers should be included in educational programs and made more aware of patient safety practices (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, no significant association was found between etiology and falls. However, further large-scale comparative studies are needed to better understand the impact of traumatic versus non-traumatic spinal cord injuries on fall risk. Although the literature suggests that individuals with non-traumatic SCI may have a higher risk of falling, further research is required to draw definitive conclusions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEnvironmental factors, along with the timing of falls, are among the key determinants of fall risk. The finding that 67% of falls occurred during daytime hours highlights the impact of hospital activity and staff mobility on fall risk. Garc\u0026iacute;a-Rudolph et al. also emphasized that falls tend to cluster at certain times of the day, underscoring the need to consider environmental factors in prevention efforts (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEnvironmental modifications, technological supports, and educational programs have been proposed in the literature as effective strategies for reducing fall risk (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In particular, insufficient lighting and lack of supervision in areas such as transfer zones, bathrooms, and hallways significantly increase fall risk (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These findings clearly demonstrate the importance of incorporating environmental considerations into fall risk assessments.\u003c/p\u003e \u003cp\u003eFrom a psychosocial perspective, the impact of falling on individuals is also a significant finding. Falls have been reported to affect not only physical health but also psychological and social well-being, leading to fear, loss of confidence, and diminished perceptions of independence (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Therefore, when developing fall prevention strategies, patients' personal experiences and awareness should also be taken into account.\u003c/p\u003e \u003cp\u003eKhan et al. reported a notably high incidence of falls among individuals with spinal cord injury (SCI), with impairments in transfer ability, balance, and muscle strength being major risk factors (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These findings align with the risk factors observed in our study population. Similarly, Abou and Rice found that wheelchair users are particularly prone to falls in home settings, especially during transfers, and such falls can result in serious injuries (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These findings clearly highlight the importance of personalized educational strategies.\u003c/p\u003e \u003cp\u003eIn the literature, it has been reported that the risk of multiple falls in individuals with spinal cord injury (SCI) can be predicted in advance, allowing for the development of targeted prevention strategies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In this context, the functional assessment tools used in our study appear to have potential as screening instruments prior to the occurrence of falls. These tools can be integrated not only into scientific analyses but also into routine clinical practice.\u003c/p\u003e \u003cp\u003eIn conclusion, this study provides a comprehensive analysis of the multifactorial causes of falls in individuals with SCI. A range of variables, including gender, age, ASIA level, functional status, and the presence of a caregiver, were examined. However, walking ability and functional capacity emerged as the strongest predictors of fall risk. The findings suggest that fall risk is closely associated not only with an individual\u0026rsquo;s physical condition but also with environmental factors and social support systems.\u003c/p\u003e \u003cp\u003eThe strengths of this study include the comprehensive evaluation of numerous clinical variables and its foundation on real-world data. However, several limitations must be acknowledged, such as its retrospective design, limited sample size, and reliance on self-reported fall events. Future large-scale prospective studies are needed to validate these findings.\u003c/p\u003e \u003cp\u003eIn conclusion, individualized, multifactorial, and time-sensitive fall prevention strategies should be integrated into the rehabilitation process for individuals with spinal cord injury (SCI). Specifically, tailored programs should be developed for patients classified as ASIA C, those who are ambulatory within the home environment, and those who are active during daytime hours. Furthermore, it is recommended that structured training programs be implemented to enhance caregiver effectiveness, along with environmental safety modifications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eThis study was approved by the Ethics Committee of Ankara Bilkent City Hospital (Approval No: [1-24-151], Date: [2024]). All patient data were analyzed retrospectively and anonymized to ensure confidentiality.\u003c/span\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAsh KL, MacLeod P, Clark L. A case control study of falls in the hospital setting. Journal of Gerontological Nursing. 1998;24:7\u0026ndash;15.\u003c/li\u003e\n \u003cli\u003eDonoghue J, Graham J, Mitten-Lewis S, Murphy M, Gibbs J. A volunteer companion-observer intervention reduces falls on an acute aged care ward. International Journal of Health Care Quality Assurance. 2005;18:24\u0026ndash;31.\u003c/li\u003e\n \u003cli\u003eWilson A, Kurban D, Noonan VK, Krassioukov A.: Falls during inpatient rehabilitation in spinal cord injury, acquired brain injury, and neurologmusculoskeletal disease programs. Spinal Cord 2020; 58: pp. 334-340.\u003c/li\u003e\n \u003cli\u003eSchwendimann R, B\u0026uuml;hler H, Geest S, Milisen K. Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program. BMC Health Serv Res. 2006 Jun 7;6:69.\u003c/li\u003e\n \u003cli\u003eGiles L, Bolch D, Rouvray R, McErlean B,Whitehead H, Phillips P, Crotty M, Can volunteer companions prevent falls among inpatients? A feasibility study using a pre-post comparative design. BMC Geriatr. 2006; 6: 11.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRahimi, S., Khankeh, H. R., Ebadi, A., Mohammadian, B., Eghbali, M., \u0026amp; Habibzadeh, F. (2024).\u003c/strong\u003e Developing a fall prevention program in an inpatient spinal cord injury rehabilitation unit: A participatory action research study. \u003cem\u003ePLoS ONE\u003c/em\u003e, 19(7), e0304320.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHabib Perez, O., Chan, K., Martin, S., Marinho-Buzelli, A., Singh, H., \u0026amp; Musselman, K. E. (2024).\u003c/strong\u003e The experience of falls and fall risk during the subacute phase of spinal cord injury: a mixed methods study. \u003cem\u003eDisability and Rehabilitation\u003c/em\u003e, 46(17), 3937\u0026ndash;3945.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSingh, H., Scovil, C. Y., Bostick, G., Kaiser, A., Craven, B. C., Jaglal, S. B., \u0026amp; Musselman, K. E. (2020).\u003c/strong\u003e Perspectives of wheelchair users with spinal cord injury on fall circumstances and fall prevention: A mixed methods approach using photovoice. \u003cem\u003ePLoS ONE\u003c/em\u003e, 15(8), e0238116.\u003c/li\u003e\n \u003cli\u003eMarshall K, Gustafsson L, McKittrick A, Fleming J, Falls Occurring After a Spinal Cord Injury: A Scoping Review. J.Am J Occup Ther. 2021 May 1;75(3):7503205010\u003c/li\u003e\n \u003cli\u003eKhan A, Pujol C, Laylor M, et. al.: Falls after spinal cord injury: a systematic review and meta-analysis of incidence proportion and contributing factors. Spinal Cord 2019; 57: pp. 526-539.\u003c/li\u003e\n \u003cli\u003eGarc\u0026iacute;a-Rudolph A, Wright MA, Devilleneuve EA, Castillo E, Hernandez-Pena E, Opisso E, Tormos JM, Falls During Inpatient Rehabilitation After Spinal Cord Injury: Characterization, Clock-Hour Visualization, and Time to Event Predictors. Arch Phys Med Rehabil. 2023 Aug;104(8):1209-1218.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eQin, H., Diao, Y., Hao, M., Wang, Z., Xie, M., Hu, X., \u0026amp; Zhu, T. (2025).\u003c/strong\u003e Analysis and comparison of the trends in burden of spinal cord injury in China and worldwide from 1990 to 2021: an analysis of the global burden of disease study 2021. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e, 12, 1517871.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVarghese, R. J., Tong, M.-Y., Szczech, I., Bryan, P., Aronson-Arminoff, M., Farina, D., \u0026amp; Burdet, E. (2024).\u003c/strong\u003e Design and Preliminary Evaluation of a Torso Stabiliser for Individuals with Spinal Cord Injury. \u003cem\u003earXiv preprint arXiv:2403.17531\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eDonoghue J, Graham J, Gibbs J, Mitten-Lewis S. Who, where and why: situational and environmental factors contributing to patient falls in the hospital setting. Australian Health Review. 2003;26:79\u0026ndash;87.\u003c/li\u003e\n \u003cli\u003eAbou L, Rice LA.: Risk factors associated with falls and fall-related injuries among wheelchair users with spinal cord injury. Arch Rehabil Res Clin Transl 2022; 4:\u003c/li\u003e\n \u003cli\u003eSrisim K, Saengsuwan J, Amatachaya S.: Functional assessments for predicting a risk of multiple falls in independent ambulatory patients with spinal cord injury. J Spinal Cord Med 2015; 38: pp. 439-445.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"ankara bilkent city hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Spinal cord injury, falls, caregiver, ASIA score, functional independence","lastPublishedDoi":"10.21203/rs.3.rs-6589454/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6589454/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: This study aims to evaluate falls occurring during inpatient rehabilitation after spinal cord injury and the impact of caregiver presence on fall risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods:\u003c/strong\u003ePatients with spinal cord injury who underwent inpatient rehabilitation at Ankara Bilkent City Hospital’s Physical Medicine and Rehabilitation Clinic between 2020 and 2023 were included in this study. Patients were divided into two groups: those with a history of falls (Group 1) and those without a history of falls (Group 2). Variables assessed included demographic data, etiology, ASIA score, functional status, caregiver presence, and fall timing. Statistical analyses were conducted using the Chi-Square test and the Mann-Whitney U test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 98 patients were included in the study. No significant relationship was found between falls and gender, caregiver presence, etiology, or functional status (p \u0026gt; 0.05). However, a statistically significant association was identified between ASIA scores and falls (p = 0.048). Patients with ASIA C classification were found to have the highest fall risk. According to the Mann-Whitney U test results, no significant differences were observed between the groups in terms of age and SCIM scores, whereas a borderline significant difference was noted in WISCI scores (p = 0.058).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Factors such as gender and etiology do not appear to significantly affect fall risk in individuals with spinal cord injuries. Moreover, no statistically significant evidence was found indicating that caregiver presence reduces fall risk. Disease severity is directly related to functional independence (SCIM) and walking ability (WISCI). These findings highlight the need for developing individualized fall prevention strategies during the rehabilitation process.\u003c/p\u003e","manuscriptTitle":"Factors Affecting Falls in Spinal Cord Injuries - Is Accompaniment Important in Falls?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 09:17:46","doi":"10.21203/rs.3.rs-6589454/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4fba1a4-2ac2-4061-98c3-7a3ed3f887ee","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-07T09:17:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 09:17:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6589454","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6589454","identity":"rs-6589454","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}