Polio Survivors and Falls

Authors: Julie K. Silver, MD Dorothy D. Aiello, PT

Falls

Affiliations: From the Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, the Department of Physiatry, Massachusetts General Hospital, and the SpauldingFramingham Outpatient Center, Spaulding Rehabilitation Hospital, Boston, Massachusetts (JKS); and the Department of Physical Therapy, Spaulding-Framingham Outpatient Center, Framingham, Massachusetts (DDA).

Research Article

Polio Survivors Falls and Subsequent Injuries

Correspondence: All correspondence and requests for reprints should be addressed to Julie K. Silver, MD, Harvard Medical School, Physical Medicine and Rehabilitation, 570 Worcester Road, Framingham, MA 01702-8921.

0894-9115/02/8108-0567/0 American Journal of Physical Medicine & Rehabilitation Copyright Š 2002 by Lippincott Williams & Wilkins

ABSTRACT Silver JK, Aiello DD: Polio survivors: Falls and subsequent injuries.

Am J Phys Med Rehabil 2002;81:567–570.

Objective: This study examines the frequency of falls in polio survivors and their resulting morbidity.

Design: Two groups, fallers vs. nonfallers, were investigated in this descriptive study. A total of 233 polio survivors volunteered to complete a structured questionnaire on fall history and sequelae.

Results: Of the study participants, 64% had fallen within the previous year, and 61% had falls for which they received medical attention, including 35% who had at least one fracture. There was not a correlation between age and falling, but there was a strong correlation between tripping and falling.

Conclusions: Falls with resultant injuries are a significant issue for polio survivors that warrants further study. Because tripping was predictive of falling in this sample, bracing should be considered as a treatment or preventative measure.

Key Words: Polio, Polio Survivors, Falls, Fracture

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A

ment received for falls and to address attitudes regarding falls, including the fear of falling. A fall was defined as any uncontrolled episode of contact with the floor. Frequency of tripping was coded as “frequently” (more than twice a week, up to once a day or more), “occasionally” (more than twice each month, up to once or twice a week), “rarely” (once or twice each month), “never,” and “not applicable.”

ccording to the National Center for Injury Prevention and Control, falls rank first as the cause of injuryrelated death for people over 65.1 Fractures in individuals with osteoporosis are often fall related and are associated with high healthcare costs, increased morbidity, and mortality.2– 6 Recently, more attention has been given to the risk of falling and fall prevention in older people.

Risk factors for falls may include poor balance, medication side effects, poor cane or crutch fitting, inclement weather conditions, and hazards in the home.7–13 Trips and slips have also been implicated in falls in older people.14 Current literature generally focuses on frail older subjects and is rather sparse when it comes to identifying at-risk individuals with specific disabilities who may neither be “frail” nor “older,” such as polio survivors. This study was conducted to assess falls and subsequent injuries in polio survivors.

Data Analysis. Subjects were separated into those who did and did not have falls. Descriptive statistics (mean, median, and standard deviation) were done for age. Frequencies were done for all data. A t test was used to compare the two groups for age. The ␹2 test was used to compare the two groups for fear of falling, lifestyle changes caused by the fear of falling, scooter use, and wheelchair use. Spearman’s rho test was used to examine the relationship between falling and tripping.

METHODS

RESULTS

Subjects. A total of 233 polio survivors volunteered to complete a falls questionnaire; they were recruited through various polio support groups’ newsletters and Web sites.

The majority of the respondents were women (60%). The mean age was 58 yr old. The median age was 56 yr old, and the range was 39 –91 yr. Of the 233 respondents, 6% were nonambulatory, 42% reported using braces, and 55% reported use of assistive devices.

Of the 233 subjects surveyed, 183 (79%) had fallen within the previous 5 yr, 148 (64%) within the previous year, and 67 (29%) within the previous month. Sixty-one percent reported falls with injuries for which they required medical attention, and 35% reported falls with at least one resultant bony fracture. Several subjects had multiple fractures from different fall episodes. Fracture was the most common injury, followed by bruising and soft-tissue trauma.

For the falls group, the age range was 43– 89 yr, with a mean of 57 ⫾ 10.4 yr and a median of 55 yr. For nonfallers, the range was 39 –91 yr, with a mean of 59 ⫾ 11.8 yr and a median of 58 yr. There was no statistically significant difference in age between the two groups.

Subjects reported tripping frequently (20% of fallers, 0% of nonfallers), occasionally (39% of fallers,

Data Acquisition. The data collected was based on the subjects’ self-report for objective questions and is thought to be reliable because the reliability and validity of self-report for functional tasks has been shown to be high.15 A structured form was used to obtain demographic data, frequency of tripping, fall frequency, a fall history, a record of subsequent treat-

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TABLE 1 Frequency of fear of falling Yes Fallers Nonfallers

a

159 20

No 24 30

a

Significant difference between groups at P ⱕ 0.05.

13% of nonfallers), rarely (30% of fallers, 30% of nonfallers), never (9% of fallers, 28% of nonfallers), not applicable (2% of fallers, 13% of nonfallers), and blank (0% of fallers, 15% of nonfallers). There was a statistically significant positive correlation between frequency of tripping and falling (r ⫽ 0.455). Regression analysis showed that tripping was predictive of falling in this sample of polio survivors (r2 ⫽ 0.258).

Of those who had fallen, 87% were fearful about falling vs. 40% of those who had not fallen. Those who had fallen were significantly more fearful about falling than those who had not fallen (␹2 ⫽ 48.5, P ⬍ 0.05) (Table 1).

Of those who had fallen, 72% made lifestyle changes because of the fear of falling vs. 28% of those who had not fallen who made changes.

This was a significant difference (␹2 ⫽ 31.74, P ⬍ 0.05) (Table 2).

Using a wheelchair or a scooter was not significantly related to the reported frequency of falls. Wheel-

TABLE 2 Frequency of lifestyle changes because of fear of falling Fallers Nonfallers

Yes

No

131a 14

52 36

a

Significant difference between groups at P ⱕ 0.05.

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TABLE 3 Frequency of wheelchair use Fallers Nonfallers

Yes

No

62 18

121 32

chair use was 34% for fallers and 36% for nonfallers (␹2 ⫽ 0.0004, P ⬍ 0.05) (Table 3). Scooter use was 19% for fallers and 12% for nonfallers (␹2 ⫽ 0.002, P ⬍ 0.05) (Table 4).

DISCUSSION This data shows that falls are a danger for polio survivors. The frequency of falling in the polio survivors surveyed was high; 64% had reported at least one fall within the previous year, with 35% reporting at least one resultant bony fracture. A previous community-based study of fractures in polio survivors noted a significant increased risk of distal femoral and proximal humeral fractures; 80% of these were caused by falls. Because the majority of these fractures were in atrophic limbs, the researchers thought that the increased risk may have been caused by weakness and disuse osteoporosis of involved limbs.16 Their research did not show an unusual risk of fracture except in affected limbs.16 Another survey documented that 21% of polio survivors surveyed had sustained long-bone fractures secondary to falls.17 The fear of falling is also a significant problem in this sample. In older people, fear of falling has been

TABLE 4 Frequency of scooter use Fallers Nonfallers

August 2002

Yes

No

34 6

149 44

associated with increased risk of falling.18,19 However, falls were not correlated with age in polio survivors as it is in the literature on falls in frail older people.20 Tripping was significantly correlated with falls, which is understandable in polio survivors because foot drop is a common sequelae of polio21 and is a common late-onset problem.17,22 Tripping is a risk factor for falling. Depending on its cause, interventions to minimize tripping could include an ankle-foot orthosis, stretching to increase dorsiflexion range, and assistive device use such as a cane or crutches.22,23 Also, as appropriate, strengthening to increase ankle dorsiflexor and hip flexor strength to assist swing phase could be used to minimize tripping.

The significance of tripping and falling is also an important finding because certain clinical tests, such as eyes closed–feet together and tandem stance are not sensitive to tripping.

In this population, a test such as the timed up and go test or the 6-min walk test would be more sensitive to tripping. A recent study showed the timed up and go test to be predictive of falling in community-dwelling older people.24 Polio survivors who have experienced falls are more than twice as likely to be concerned about future falls than polio survivors who have not fallen. Fallers were much more likely to have initiated measures to reduce the likelihood of future falls than nonfallers. Of note is that many subjects reported avoiding tasks (e.g., avoiding stairs or walking on uneven or slippery ground) to help reduce fall risk. Treatment of polio survivors should include increasing safety by recommending appropriate assistive devices and having a home evaluation. Home modifications have been shown to markedly decrease the risk of falling in older people by more than 50%.25–27 Home modifications should minimize trip hazards, for example, by removing throw rugs and

leveling thresholds; proper lighting at night is also important.

CONCLUSION In this study, there was a significant frequency of reported falls and subsequent injury in polio survivors.

Falls with resultant injuries are a significant problem for this population that warrants further study (e.g., evaluation of falls prevention programs). Because some polio survivors may minimize the repercussions from falls and have anecdotally reported that they “know how to fall” or are “experts in the art of falling,” the frequency of falls and injuries caused by falling should be included in patient education.

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Clin Geriatr Med 1996:4:745–59 21. Sharrard WJ: Muscle recovery in poliomyelitis. J Bone Joint Surg (Br) 1955; 37:63–79

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