Falls in the Amputee Population
- 1 Introduction
- 2 Risk Assessment
- 3 Inpatient Falls
- 4 Outpatient Falls
- 5 Reasons for Falling
- 6 Consequences of Falls
- 7 Falls Education
- 8 Rising From a Fall
- 9 Additional Resources
- 10 References
A fall is defined as "an unintentional loss of balance resulting in the individual coming to rest on the ground". People with limb loss have an increased risk of falling when compared to the general population and falls are associated with decreased confidence with balance, balance, and social participation.  Falls in patients with an amputation could be devastating, even more so in the elderly and frail population.  It is important for a patient to be able to fall safely and to be able to lower themselves down to the floor, to reduce fear and in order to do activities on the ground.
Risk Factor Assessment Tools
The causes of falls vary for different age groups and can lead to serious outcomes. Risk factor assessment tools are utilised to identify the issues around the potential of falls for an individual patient.
Examples of gait and balance assessment tools  include:
- Timed up and Go (TUG)
- Timed Up and Go TestBerg Balance Scale (BBS)
- Berg Balance Scale
- Tinetti Performance Oriented Mobility Assessment (POMA)
- Tinetti test
- Dynamic Gait Index
These assessment tools measure a person's ability to balance and to walk in an appropriate way. They determine how long the person can keep their balance during gait, as well as considering a few activities of daily living (ADL) while moving from one point to another.
The ultimate aim of using these tools is to identify issues that can be taken into account in the management of this patient and so reduce their likelihood of experiencing a fall. Potential issues identified could include:
- Mental problems
- Language difficulties
- Short term verbal memory
- Construct ability
- Calculation problems
Falls Risk Assessment and Management Plan (FRAMP)
FRAMP  is a comprehensive tool that evaluates a patient's risk of falls from the early stage of hospitalization. FRAMP uses three similar stages of assessment during a specific period of time which identifies the history of falls, use of walking aids, cognitive impairment and other urinary and fecal problems.
FRAMP includes individualized intervention for specific risks such as:
- Mobility risks
- Functional ability risks
- Medication/ medical condition risks
- Cognitive state risks
- Continence/ elimination risks
Each one of the above risks is assessing the level of a patient's ability to perform the test with appropriate intervention for each problem.
FRAMP also provides a minimum intervention to be applied to all patients which are:
- Provision of information for the patient about their environment (toilet, bed and ward) and the use of the call bell to facilitate their needs.
- Education of patients about mobility aids and to enable them to use it in the proper way.
- Improve their awareness about the conditions that increase their risks of falls in order to prevent it.
- Improve the quality of the surrounding environment to reduce the risk of falls (lighting and remove obstacles).
A study conducted in the UK showed a 32% fall incidence among adult amputee in-patients and in Canada, one study found a fall incidence of 20.5% and another 31%.  The majority of falls were in the following conditions: a patient seated in a wheelchair attempted an unassisted transfer and fell because of balance loss, improper use of the wheelchair, decreased movement, or because the patient did not follow instructions, or reached for something while seated in the wheelchair.  A patient who fell once has a 1 out of 3 change to fall again. 1 out of 5 in-hospital amputee patients fall during their stay and 18% of them sustain an injury.  In a retrospective study at a tertiary rehabilitation center in the United States following 1472 patients over 18 months the researchers found the following: 
- 9.5% of patients fell
- Patients fell mostly during the day (85%)
- Falls occurred in the patient’s own room (90%) when unobserved (74%)
- 50% of falls happened in week 1 of rehabilitation
In hospitals, fall prevention programs can result in the reduction of falls and the cost involved with injuries. 
"Community-dwelling prosthetic users" who fall more are usually younger and has better confidence in their balance, mostly they do not get injured when they fall. 
52% of out-patients fall
In general patients at a higher risk for falls are: 
- Patients between 41 and 50 years of age
- Diagnosis of stroke and amputation
- Patients with a large number of comorbidities (equal or more than 9)
Risk factors for falling among patients with limb loss are: 
- Above knee amputation
- Back or joint pain
- Multiple prosthesis or stump problems
- Patient has cognitive impairment
- More than 70 years old
- Amputation was done less than 4 years ago
- Increase postural sway during walking compared to non-amputees, especially in patients with amputations due to vascular dysfunction
- Score low on the balance confidence scale
- Higher activity levels in community dwelling people older than 50 years reduce the risk of falls in this population
Fear of falling increases: 
- When the patient has to focus on each step taken
- Another fall incident occurred in the last 12 months
- With poor health
Reasons for Falling
- Related to the patient
- Related to prosthesis
- Related to the environment
- Combination of all three
Consequences of Falls
- Fractures to the femur
- Trauma to the stump
- Increase in fear of falling
- Lengthy hospital stay and patient is discharged to a long-term facility
- Mobility and social activity restriction
- Prevent falling
- Know how to minimize injury during a fall
- Know what to do immediately after falling
- If applicable, report falls to the health care professional or get assistance
Inpatient Falls Prevention
- Complete a fall risk assessment
- Teach the patient to do safe transfers and post notices in the ward to remind patients to do safe transfers
Outpatient Falls Prevention
- Fall prevention training and safety education
- Get rid of potential trip hazards like difficult to see objects, clutter on the floor, loose rug, rugs with a height difference that might catch your foot.
- Make sure you have enough room between to furniture to move around a wheelchair or with crutches 
- Pets running around might lead to a fall and the patient should consider ways to prevent that
- Immediately clean up any spills, wet floors, or pet urine
- Change or avoid areas of low lighting, slopes, or slippery floors
- Change inaccessible or difficult to access areas
- Get home assessed by a Physiotherapist or Occupational Therapist
- Strengthen weak muscles
- Optimal prosthetics and adjustments, maintain your prosthesis and follow the instructions from your prosthetist 
- Use of assistive devices, like cane or crutches
- Be careful to change into shoes you are not used to as a heel height change will influence the alignment of the prosthesis and the change in hardness of the sole could influence your walking.
- When walking it is important to look up and observe the terrain to avoid any puddles, or potholes ahead. 
Know How to Minimize Injury During a Fall
- People tend to fall forward, blocking their fall with their hands (reflexively)
- Allow the body to be flexible
- Practice falling with your therapist, if the patient's condition allows this and it is safe to do
- When a patient fall he/she should immediately let go of the assistive devices to prevent injury
- The patient should absorb the fall by falling on their hands with slightly bend elbows and immediately roll over on their side to minimize the fall impact It is important to absorb the impact with the rest of the body and not just the hands to reduce the risk of fractures.
- The patient should try to tuck their chin in when falling to avoid hitting their head. Instead of falling forwards or to the side the patient could attempt to fall backwards if it is safe. 
Know What to Do Immediately After Falling
- People will tend to help you and pull you up. This is not advised especially if you have an injury like a fracture or a dislocation. If you feel disorientated or confused then you might fall again.
- Instruct the patient to stay seated on the floor after a fall and first get over the shock and then re-orient themselves and do a self-assessment to where they are and to feel for any new pain or injury. If the patient wears a prosthesis they should feel if the suspension is still intact and the prosthesis in working order. Gather the walking aids, if any. 
- If someone rushed over to help they should ask the person to wait for a moment while they come to their senses.
- The patient could ask for assistance from the bystander. It is the easiest to go on to their stomach, then go on all fours (if possible), and then arise with assistance.
- If the patient is alone he/she could crawl over to the nearest sturdy seating furniture and transfer into sitting.
- Practice recovery from a fall with your patient so that they are comfortable to stand up on their own, with an assistive device, or transfer into sitting on a chair before standing up.
- If any injury is noted the patient should immediately phone/call for assistance.
- Persons living alone should try to always carry their mobile phone or an alert button/alarm (medical alert pendant) to alert emergency services.
- Teach how to get up from a fall, if able, during rehabilitation using backward-chaining.
When to Report a Fall
- Instruct your patient to report any serious fall or in the following conditions:
- Increase in falls or increase in the level of clumsiness
- When the fall has an innate cause instead of environmental like dizziness
- If the patient wore the prosthesis during the fall it is best to report back to the prosthetist and have the prosthesis checked for safety. 
Rising From a Fall
Many techniques exist and the therapist should practice and work closely with the patient to find the optimal and safe way of getting up from the floor. Optimally the patient should use the assistive devices and the intact leg to rise up.  When getting up from the floor the patient should always take care of their sound knee by avoiding any twisting movements and by using the arms to help with standing up.
- Wong CK, Chihuri ST, Li G. Risk of fall-related injury in people with lower limb amputations: a prospective cohort study. Journal of rehabilitation medicine. 2016 Jan 5;48(1):80-5.
- Engstrom B, Van de Ven C, editors. Therapy for amputees. Elsevier Health Sciences; 1999.
- Gailey RS, Clark CR. Physical Therapy Management of Adult Lower-Limb Amputees. Chapter 23 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Available from: http://www.oandplibrary.org/alp/chap23-01.asp [Accessed 29 Nov 2017]
- (1) Risk Factor Assessment Tools, Minnesota Falls Prevention website: http://www.mnfallsprevention.org/professional/assessmenttools.html
- (2) Falls Risk Assessment and Management Plan (FRAMP) ,Fall Risk Assessment Australia: https://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/falls/PDF/Dev-of-FRAMP.pdf
- Dyer D, Bouman B, Davey M, Ismond KP. An intervention program to reduce falls for adult in-patients following major lower limb amputation. Healthcare quarterly. 2008 Mar 15;11(Sp).
- Lee JE, Stokic DS. Risk factors for falls during inpatient rehabilitation. American journal of physical medicine & rehabilitation. 2008 May 1;87(5):341-53. Available from: https://scholar.google.com/scholar_url?url=https://pdfs.semanticscholar.org/4109/1170671ef4eb6bd6ce38437346524bcf139a.pdf&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=ZNMZWsngBKTAjgTu16bYDg&scisig=AAGBfm1wrbr52FIX89tjWz_CJwX5xddOxQ [Accessed 25 Nov 2017]
- Falls in the Amputee Population: a literature review Presentation. Angela Stark NSW PAR 5th November 2004.
- Miller WC, Speechley M, Deathe B. The prevalence and risk factors of falling and fear of falling among lower extremity amputees. Archives of physical medicine and rehabilitation. 2001 Aug 31;82(8):1031-7.
- Highsmith, J. Amputees & Falling. 360 Orthotics & Prosthetics.
- Ensuring Fall Safety. Kimball, C. Amputee Coalition. Dec 2014
- Guidance for falls prevention in lower limb amputees. Bacpar. Available from: http://www.csp.org.uk/sites/files/csp/secure/falls_prevention_lowerlimb_amputees.pdf [Accessed 26 Nov 2017]
- Cindy Asch-Martin Personal Affects. Getting Up Off The Ground Part 2.
- Cindy Asch-Martin Personal Affects. Getting Up Off the Ground.
- Prosthetika. Bilateral AK Getting Up After Falling.
- Dream Team Prosthetics LLC. Bilateral Above Knee Amputee Getting Up From The Floor Demonstration.