Falls in the amputee population

Original Editor - Tarina van der Stockt

Top Contributors - Tarina van der Stockt

A fall is defined as "an unintentional loss of balance resulting in the individual coming to rest on the ground"[1]. People with limb loss has an increased risk of falling when compared to the general population and falls are associated with decreased confidence with balance, balance, and social participation. [1] Falls in patients with an amputation could be devastating, even more so in the elderly and frail population. [2] 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.[3]

In-patient falls

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%. [4] 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. [4] 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. [5] In a retrospective study at a tertiary rehabilitation center in the United States following 1472 patients over 18 months the researchers found the following: [6]

  • 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 hospital fall prevention programs can result in reduction falls and the cost involved with injury. [1]

Out-patient falls

"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. [1]

52% of out-patients fall[6]

In general patients at a higher risk for falls are: [5]

  • 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: [5]

  • Above knee amputation
  • Back or joint pain
  • Multiple prosthesis or stump problems
  • Patient has cognitive impairment
  • More than 70 years old
  • Deaf
  • Amputation was done less than 4 years ago
  • Increase postural sway during walking compared to non-amputees, esp 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[1]

Fear of falling increases: [7]

  • 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 [6]

  • Related to patient
  • Related to prosthesis
  • Related to environment
  • Combination of all 3

Consequences of falls [6]

  • 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

Fall education [8]

  1. Prevent falling
  2. Know how to minimize injury during a fall
  3. Know what to do immediately after falling
  4. If applicable, report fall to health care professional or get assistance

In-patient fall prevention[6]

Out-patient fall prevention[8]

  • 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 [9]
  • 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 [9]
  • 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. [3]

Know how to minimize injury during a fall

  • People tend to fall forward, blocking their fall with their hands (reflexively)[8]
  • Allow the body to be flexible[8]
  • Practice falling with your therapist[8], if the patient's condition allow this and it is safe to do
  • When a patient fall he/she should immediately let go of the assistive devices to prevent injury[3]
  • 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[3] 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. [10]

Know what to do immediately after falling[8]

  • 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. [8][4]
  • 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 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

When to report a fall

  • Instruct your patient to report any serious fall or in the following conditions:[7]
    • Increase in falls or increase in 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. [2]

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. [3] 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.

Resources

Guidance for falls prevention in lower limb amputees. Bacpar

References

  1. 1.0 1.1 1.2 1.3 1.4 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.  Available from: https://scholar.google.com/scholar_url?url=http://www.ingentaconnect.com/content/mjl/sreh/2016/00000048/00000001/art00012%3Fcrawler%3Dtrue&hl=en&sa=T&oi=gsb-gga&ct=res&cd=0&ei=HK0ZWoDmIM-CjgS_6KPwCQ&scisig=AAGBfm0D75zcrbR2XEvjdVqDCzL-4HCHLA [Accessed 25 Nov 2017]
  2. 2.0 2.1 Engstrom B, Van de Ven C, editors. Therapy for amputees. Elsevier Health Sciences; 1999.
  3. 3.0 3.1 3.2 3.3 3.4 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]
  4. 4.0 4.1 4.2 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). Available from: https://www.researchgate.net/profile/Kathleen_Ismond/publication/5470876_An_Intervention_Program_to_Reduce_Falls_for_Adult_In-Patients_Following_Major_Lower_Limb_Amputation/links/57acee5a08ae0932c974cd91.pdf [Accessed 25 Nov 2017]
  5. 5.0 5.1 5.2 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]
  6. 6.0 6.1 6.2 6.3 6.4 Falls in the Amputee Population: a literature review Presentation. Angela Stark NSW PAR 5th November 2004. Available from https://www.physio-pedia.com/images/4/44/Falls_in_Amputees.pdf [Accessed 25 Nov 2017]
  7. 7.0 7.1 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. Available from: http://www.archives-pmr.org/article/S0003-9993(01)27659-X/fulltext [Accessed 25 Nov 2017]
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Highsmith, J. Amputees & Falling. 360 Orthotics & Prosthetics. Available from: http://www.360oandp.com/Health--Wellness-Amputees--Falling.aspx [Accessed 25 Nov 2017]
  9. 9.0 9.1 Ensuring Fall Safety. Kimball, C. Amputee Coalition. Dec 2014 https://www.amputee-coalition.org/ensuring-fall-safety/
  10. 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]
  11. Cindy Asch-Martin Personal Affects. Getting Up Off The Ground Part 2. Available from: https://youtu.be/F5zw_q6Gpl4 [last accessed 30 Nov 2017]
  12. Cindy Asch-Martin Personal Affects. Getting Up Off the Ground. Available from: https://youtu.be/GadBl4EuWI4[last accessed 30 Nov 2017]
  13. Prosthetika. Bilateral AK Getting Up After Falling. Available from: https://youtu.be/n9PNpCzVXzE[last accessed 30 Nov 2017]
  14. Dream Team Prosthetics LLC. Bilateral Above Knee Amputee Getting Up From The Floor Demonstration. Available from: https://youtu.be/7KILUvJuP-Y[last accessed 30 Nov 2017]
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