Changes of Functional Ability in Patients With Spinal Cord Injury With and Without Falls During 6 Months After Discharge Jirabhorn Wannapakhe, Preeda Arayawichanon, Jiamjit Saengsuwan and Sugalya Amatachaya PHYS THER. 2014; 94:675-681. Originally published online March 6, 2014 doi: 10.2522/ptj.20130260
The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/94/5/675 Collections
This article, along with others on similar topics, appears in the following collection(s): Balance Diagnosis/Prognosis: Other Falls and Falls Prevention Spinal Cord Injuries
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Research Report Changes of Functional Ability in Patients With Spinal Cord Injury With and Without Falls During 6 Months After Discharge Jirabhorn Wannapakhe, Preeda Arayawichanon, Jiamjit Saengsuwan, Sugalya Amatachaya
Background. Ambulatory patients with spinal cord injury (SCI) encounter a high risk of falls. However, most of the fall data in the literature were subjectively reported, without evidence to confirm the functional ability of those with and without falls.
Objectives. The purpose of this study was to prospectively evaluate changes in functional ability relating to falls in participants with SCI who fell and those who did not fall during the 6-month period after discharge.
Design. A 6-month prospective design was used in the study. Method. Fifty independent ambulatory participants with SCI were assessed for their functional ability using the Timed “Up & Go” Test, 10-Meter Walk Test, Berg Balance Scale, and Six-Minute Walk Test (6MWT) prior to discharge and 6 months afterward. After discharge, the participants’ fall data were monitored monthly to categorize them into faller (ⱖ1 fall in 6 months) and nonfaller (no fall) groups.
Results. Twenty-seven participants (54%) fell, and their baseline functional abilities were obviously lower than those who did not fall. After 6 months, the functional ability of these participants showed significant improvement for every test, whereas those who did not fall demonstrated a significant improvement only for the 6MWT. After adjusting for the baseline data, the functional ability at 6 months showed no significant differences between the groups.
Limitations. The study did not monitor physical activities of the participants during the follow-up period. The findings on fear of falling were subjectively reported by the participants.
J. Wannapakhe, PT, PhD, School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand. P. Arayawichanon, MD, School of Rehabilitation Medicine, Faculty of Medicine, Khon Kaen University. J. Saengsuwan, NU, PhD, Faculty of Public Health, Khon Kaen University. S. Amatachaya, PT, PhD, School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, 40002 Thailand. Address all correspondence to Dr Amatachaya at: [email protected]. [Wannapakhe J, Arayawichanon P, Saengsuwan J, Amatachaya S. Changes of functional ability in patients with spinal cord injury with and without falls during 6 months after discharge. Phys Ther. 2014;94:675– 681.] © 2014 American Physical Therapy Association Published Ahead of Print: March 6, 2014 Accepted: February 26, 2014 Submitted: June 25, 2013
Conclusions. Participants with SCI are commonly characterized as being active and enthusiastic, which may drive their physical activities. However, sensorimotor impairments following SCI hinder their ability to move safely, particularly in those with more functional deterioration. Therefore, greater functional improvement is accompanied by a higher risk of falls. Because falls can induce serious consequences, rehabilitation professionals may need to seek strategies to improve safety issues during movement for these patients, particularly in their own environments. Post a Rapid Response to this article at: ptjournal.apta.org May 2014
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atients with spinal cord injury (SCI) have intact integrative capability of the brain, and the condition is most likely to occur in young men.1 Thus, these patients are commonly characterized as being active, having high degrees of energy, and being enthusiastic.2,3 However, sensorimotor impairments following SCI affect balance and walking ability; therefore, the patients encounter a high risk of falls and subsequent injury, particularly those with incomplete lesions.4 Currently, there is a trend toward a decrease in rehabilitation time for patients with SCI (from 115 days in 1974 to 36 days in 2005).5– 8 This trend may further affect the ability of patients to achieve an optimal level of ability at the time of discharge and have an increased risk of falls after discharge. Many community-dwelling individuals with SCI have experienced at least 1 fall during a 6- to 12-month period, both when data were gathered prospectively (39% and 74%)7,9 and when data were gathered retro-
spectively (34% and 75%).10,11 After falls, some patients encounter physical and psychological consequences, such as fractures, muscular pain, and fear of future falls, that further limit their mobility.7,9 –12 However, most of these data were subjectively reported by the patients. There are only 2 studies that have reported functional ability relating to falls in ambulatory participants with SCI.7,11 Phonthee et al11 found that independent ambulatory participants with SCI who had a history of falls during the previous 6 months had significantly better functional ability than those without a history of falls. Subsequently, Phonthee et al7 contrarily found in a prospective investigation that participants who fell had significantly poorer functional ability than those who did not fall. The different findings may be associated with the study designs in which the measurements of functional ability were done before (for a prospective study)7 and after (for a retrospective study)11 falls. Thus, the existing evidence may not clearly direct clinical impli-
The Bottom Line What do we already know about this topic? Falls are a major problem in ambulatory patients with spinal cord injury (SCI).
What new information does this study offer? The findings of this study suggest that falls are positively correlated with increased long-term gains in functional ambulatory motor skills rather than reflective of worsening skills. Therefore, the number of falls should not be taken as the sole measure of ambulatory function or balance ability in people with SCI.
If you’re a patient, what might these findings mean for you? Falls could induce serious consequences (eg, fracture, unconsciousness) in patients with SCI. Therefore, your physical therapist may use strategies to improve your safety as you move, particularly in your own environments.
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cations for fall prevention. A further study that investigated functional abilities before and after falls would clearly indicate the levels and change of functional ability relating to falls in these individuals. Therefore, this study prospectively monitored the fall data and investigated the change in functional ability in independent ambulatory participants with SCI who fell and those who did not fall during a 6-month period after discharge.
Method Participants The study was conducted in independent ambulatory participants with SCI who were consecutively admitted to a tertiary rehabilitation center in Thailand from June 2010 to April 2012. From a sample size calculation for within-group comparison using the data from an unpublished pilot study (N⫽10), this study required at least 20 participants per group. The inclusion criteria were an age of at least 18 years and the ability of independent walking for a minimum of 10 m. All of the participants had SCI due to traumatic causes or nonprogressive diseases and were at the subacute (postinjury time [PIT] ⬍12 months) or chronic (PITⱖ12 months) stage of injury. The patients were excluded if they had an SCI from a progressive disease or presented signs and symptoms that might affect mobility such as deformity in the joints of the lower extremities, leg-length discrepancy, musculoskeletal pain greater than 5 out of 10 on a visual analog scale, and brain function disorders. Every participant gave written informed consent before the start of the study. Protocol Two to 3 days prior to discharge, patients were assessed for their eligibility according to the criteria of the study. The eligible participants then were evaluated for their baseline demographics (including age
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Functional Ability in Patients With Spinal Cord Injury and sex), SCI characteristics (including cause, severity, stage, and level of SCI), baseline walking ability (ability of independent walking over at least 10 m), and types of ambulatory devices required for daily walking. Thereafter, the participants were assessed for their baseline functional ability using the Timed “Up & Go” Test (TUG), the 10-Meter Walk Test (10MWT), the Berg Balance Scale (BBS), and the Six-Minute Walk Test (6MWT). Prior to discharge, the participants received a routine home program from their physical therapists without any special instructions from the researchers. In addition, the participants received a fall diary to record fall data at home daily. Every month, the researcher ( J.W.) telephoned the participants to interview them and summarize the fall data of the month for a total of 6 months. After 6 months, the participants were reassessed for their functional ability using the 4 functional tests. Details of the functional tests and fall assessments are as follows. TUG. The TUG incorporates many complex tasks (eg, changing from sitting to standing, walking, turning around, and sitting down) that reflect mobility and dynamic balance control. Participants were instructed to stand up from a chair with armrests, walk 3 m, turn around a traffic cone, and walk back to sit down in the chair at a maximum and safe speed with or without a customary walking device. The test recorded the time taken from the command “go” until the participant’s back was against the backrest of the chair. Then, the average findings of 3 trials were recorded (in seconds).7,11,13–16 10MWT. The 10MWT measures walking speed, the results of which correlate with motor function and overall quality of gait.14,15 Participants walked at a comfortable pace along a 10-m walkway without any May 2014
Independent ambulatory patients with spinal cord injury interested in participating in the study (N=54) 4 patients were excluded due to: — having spine tumor — loss of follow-up in the sixth month
50 participants (men=37, women=13) completed the study
Nonfaller Group n=23 (46%)
Faller Group n=27 (54%)
Figure. Flowchart of study participants.
break to the endpoint with or without a walking device for 3 trials. Then, the average time required over the 4 m in the middle of the walkway was converted to gait speed (in meters per second).14,16 BBS. The BBS assesses balance ability while performing 14 sitting and standing activities.2,17 Ability to perform the tasks was rated using a 5-point ordinal scale ranging from 0 to 4 based on time and ability to execute the activities. Thus, the total possible scores range from 0 to 56.2,17–19 6MWT. The 6MWT is widely used to measure functional endurance.15 Participants were required to walk along a smooth rectangular walkway for as long as possible in 6 minutes with or without a walking device. During the test, participants were allowed to rest as needed without stopping the timer and continue walking as soon as they could. Every 1 minute during the test, participants were informed about the time left and offered verbal encouragement. The distance covered after 6 minutes was recorded.7,15,20 –22
These tests were executed by the same examiner ( J.W.) for both assessment periods on a flat, smooth, nonslippery surface without any disturbing factors (eg, noise or obstacles on the floor). During the tests, participants needed to fasten a lightweight safety belt with the tester walking or being aside the participants to ensure their safety and the accuracy of the measurements. The participants did not wear any shoes or socks to minimize effects of improper or different types of shoes on the outcomes and risk of injury that might occur when the participants performed the tests at their fastest speed. Fall surveillance. A fall was defined as an unexpected event that resulted in the participant coming to rest on the ground, floor, or other lower level.7,9 –11 If there was a fall, other data relating to the fall (such as time, place, and consequences of the fall)7 also were gathered via telephone interview. To ensure the data accuracy, the findings were confirmed by caregivers or relatives. If there was any conflicting information between the participants and
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Functional Ability in Patients With Spinal Cord Injury Table 1. Baseline Demographics and Spinal Cord Injury Characteristics of the Participantsa Variable Age (y)
b
Postinjury time (mo)b Sex: male/female
Faller Group (nⴝ27)
Nonfaller Group (nⴝ23)
P
48.00 (13.19) [47.78 to 53.22]
47.39 (14.38) [41.17 to 53.61]
.41
39.41 (41.24) [23.10 to 55.72]
34.26 (38.49) [17.62 to 50.91]
.76
22/5
15/8
.19
3/24
5/18
.44
7/20
6/17
.99
8/19
9/14
.48
14/13
11/12
.78
c
Severity of injury: AIS C/Dc Stage of injury: subacute/chronic
c
Level of injury: tetraplegia/paraplegiac Walking device used: yes/no
c
a
AIS⫽American Spinal Injury Association (ASIA) Impairment Scale; AIS C⫽incomplete spinal injury: motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3; AIS D⫽incomplete spinal injury: motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of ⱖ3. b The data are reported as mean (standard deviation) [95% confidence interval], and the findings between the groups were compared using an independent-sample t test. c The data are reported as number of participants, and the findings between the groups were compared using the chi-square test.
caregiver, the researcher relied on the data that were consistent with those in the fall diary. Then, the fall data after 6 months were used to
categorize the participants into faller (at least 1 fall in 6 months) and nonfaller (no fall) groups.
Table 2. Factors Inducing Falls as Perceived by the Participants and Consequences of the Fall Variable
No. of Falls (%)a
Factors inducing falls as perceived by the participants Environmental hazard
33 (40)
Loss of balance
33 (40)
Lower limb muscle weakness
9 (11)
Spasticity
4 (5)
Less attention during movement
2 (2)
Dizziness
1 (1)
Rapid movement
1 (1)
Data Analysis Descriptive statistics were applied to explain the baseline demographics, SCI characteristics, and findings of the study. The chi-square test and independent-sample t test were used to compare the differences in baseline demographics and SCI characteristics between the groups for the continuous and categorical variables, respectively. Then, the dependentsample t test was utilized to compare functional changes within the groups. In addition, an analysis of covariance (ANCOVA) was applied to analyze the differences in functional changes between the groups. The level of significant difference was set at P⬍.05.
Consequences of fallsb Physical consequences None
59 (71)
Skin abrasion and bruise
22 (27)
Muscle pain or tear
1 (1)
Unconsciousness
1 (1)
Fracture
0
Psychological consequences None
82 (99)
Fear of falling
1 (1)
Functional consequences None
78 (94)
Reduced mobility and social communication a
The total number of falls was 83. b The data were gathered using a questionnaire.7
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5 (6)
Role of the Funding Source The research was supported by funding from the KKU-Integrated Multidisciplinary Research Cluster, the Postgraduate School, Faculty of Associated Medical Sciences, and the Improvement of Physical Performance and Quality of Life (IPQ) research groups, Khon Kaen University.
Results During the period of data collection, 54 independent ambulatory participants with SCI were eligible to the criteria and agreed to participate in the study. However, 4 participants were
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Functional Ability in Patients With Spinal Cord Injury Table 3. Functional Abilities in Participants Who Fell and Those Who Did Not Fall at Discharge and 6 Months Thereaftera Faller Group (nⴝ27)
Nonfaller Group (nⴝ23) b
At Discharge
At 6 Months
Pb
.01c
25.78 (18.49) [17.78 to 33.77]
24.77 (17.74) [17.10 to 32.44]
.65
0.57 (0.37) [0.42 to 0.73]
0.65 (0.37) [0.49 to 0.81]
.10
Variable
At Discharge
At 6 Months
P
Timed “Up & Go” Test (s)
35.32 (17.27) [28.49 to 42.15]
27.30 (15.92) [21.00 to 33.60]
0.38 (0.26) [0.27 to 0.48]
0.50 (0.28) [0.39 to 0.61]
0.52 (0.35) [0.39–0.66]
0.79 (0.58) [0.56–1.02]
.01c
0.71 (0.43) [0.53–0.90]
0.80 (0.46) [0.60–1.00]
.08
Berg Balance Scale score
34.92 (15.30) [28.87 to 40.98]
40.41 (12.82) [35.34 to 45.48]
.01c
36.26 (15.62) [29.51 to 43.02]
38.13 (17.12) [30.73 to 45.54]
.32
Six-Minute Walk Test (m)
123.63 (88.68) [88.55 to 158.71]
169.13 (90.51) [133.33 to 204.94]
159.18 (94.43) [118.35 to 200.01]
191.91 (115.01) [142.18 to 241.65]
.03c
10-Meter Walk Test (m/s) Preferred speed Fastest speed
a b c
⬍.01c
⬍.01c
The data are reported as mean (standard deviation) [95% confidence interval]. The findings between discharge and 6 months after discharge were compared using the paired-samples t test. Significant difference.
lost during the follow-up period because of changing their address (n⫽2) and having a serious inadvertent event (n⫽2). Therefore, 50 independent ambulatory participants with SCI (37 men and 13 women) completed the study (Figure), and their baseline data are presented in Table 1. The findings on falls and functional ability are as follows. Fall Data Twenty-seven participants experienced at least 1 fall over 6 months (range⫽1–24 times/participant, and the total number of falls was 83) (Tab. 2). There were no significant differences in baseline demograph-
ics and SCI characteristics between the faller and nonfaller groups (P⬎.05) (Tab. 1). The falls occurred every month (range⫽10 –15 times/ month) in the house during daytime (5:00 am– 6:59 pm), were mostly due to stumbling over an obstacle on the floor (n⫽65), and mostly occurred while changing postures (ie, changing from sitting to standing) (n⫽18). Although most falls introduced no or mild physical consequences, 1 participant became unconscious after a fall (Tab. 2). Functional Ability of Faller and Nonfaller Groups Table 3 presents functional abilities
of participants who fell and those who did not fall during 6 months after discharge. The findings demonstrate that at discharge, participants who fell had obviously lower functional ability than those who did not fall. After 6 months, the functional ability of these participants demonstrated significant improvement from their baseline ability for every test (Pⱕ.01) (Tab. 3), whereas only the data of the 6MWT for participants who did not fall showed significant improvement (P⬍.05) (Tab. 3). However, when adjusted for the baseline data, the functional ability of the participants after the follow-up period showed no signifi-
Table 4. Functional Ability After the Follow-up Period of the Participants Who Fell and Those Who Did Not Fall When Adjusted for the Baseline Dataa Variable
Faller Group (nⴝ27)
Nonfaller Group (nⴝ23)
Difference (95% CI)b
Timed “Up & Go” Test (s)
24.23 (2.22)
28.37 (2.41)
⫺4.14 (⫺10.84 to 2.56)
.22
0.57 (0.04)
0.56 (0.04)
0.01 (⫺0.10 to 0.13)
.81
Pc
10-Meter Walk Test (m/s) Preferred speed
0.87 (0.07)
0.71 (0.08)
0.17 (⫺0.06 to 0.39)
.14
Berg Balance Scale score
Fastest speed
40.90 (1.64)
37.55 (1.78)
3.34 (⫺1.53 to 8.21)
.17
Six-Minute Walk Test (m)
182.69 (13.54)
176.00 (14.70)
6.69 (⫺33.90 to 47.27)
.74
a
The data are reported as mean (standard error). b 95% CI⫽95% confidence interval. c The findings between faller and nonfaller groups were compared using an analysis of covariance.
May 2014
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Functional Ability in Patients With Spinal Cord Injury cant differences between the groups (P⬎.05) (Tab. 4). Therefore, the findings in Table 3 might be prone to type 1 error due to multiple t tests. The data from the ANCOVA also indicated no significant interaction between groups and time (P⬎.05).
Discussion This study prospectively evaluated the change of functional ability in independent ambulatory participants with SCI who fell and those who did not fall during the 6 months after discharge. The results demonstrated that 54% of the participants experienced at least 1 fall in the 6 months after discharge. These participants had obviously lower baseline functional ability than those who did not fall. After the follow-up period, participants who fell showed significant improvement for all functional tests (Pⱕ.01), whereas only the data of 6MWT for participants who did not fall showed significant improvement (P⬍.05) (Tab. 3). After adjusting for the baseline differences, functional abilities after the follow-up period for participants who fell and those who did not fall showed no significant differences (P⬎.05) (Tab. 4). The incidence of falls found in this study was in the range of previous reports (between 34% and 75%).7,9 –11 Nevertheless, most of these studies reported retrospective fall data.10,11 For the prospective studies,7,9 Amatachaya and colleagues found that 74% of participants fell at least once during 6 months after discharge. However, the study recruited only 23 independent ambulatory participants with SCI, which may have reduced the strength of the findings. Phonthee et al7 reported that 35 of 89 community-dwelling ambulatory participants with SCI (39%) experienced at least 1 fall in 6 months. The different findings may relate to the frequency of follow-up periods for the fall data. Phonthee et al7 moni680
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tored the fall data weekly, and the frequent prospective follow-up periods may lead to the “Hawthorne effect,” a phenomenon in which individuals realize that they are being observed and temporarily increase attention to their movements, which reduces the incidence of falls. Nevertheless, the findings of the present study confirmed the high incidence of falls in independent ambulatory participants with SCI and that the falls were likely to occur while walking and changing posture, and they could introduce serious consequences (ie, unconsciousness). This study applied the TUG, 10MWT, BBS, and 6MWT because these tests are valid and reliable for assessing functional ability relating to falls in individuals with SCI.14,15,17,19 The BBS and TUG quantify static and dynamic balance while sitting, standing, and walking.7,11,13,14,17 The TUG also incorporates many complex tasks other than just walking, and thus the results may clearly reflect activities of daily living.7,11,15 The 10MWT measures walking speed in which the result is considered a surrogate for the overall quality of gait and motor function.15,20,23 The 6MWT is a thorough assessment tool, the results of which reflect functional endurance.15,24 Van Hedel et al24 indicated that the 10MWT may face a plateau when testing participants with good walking ability; thus, the 6MWT may better indicate the improvement due to an increase in speed and endurance.15,20,24 Therefore, we believe that using these tests may thoroughly quantify the change in functional ability relating to fall risk in these individuals. The results of the present study indicate that participants who fell had obviously lower baseline functional ability than those who did not fall (Tab. 3). The findings are in line with those reported by Phonthee et al,7 who found that independent ambu-
latory participants who fell had significantly lower functional ability than those who did not fall. The intact integrative capability of the brain with common characteristics of being active, having a high degree of energy, and being enthusiastic may increase the attempts of participants at performing physical activities, particularly in those with low levels of functioning.2,3 However, the inadequate levels of ability may have reduced the safety of the participants while moving, and thus they had a high risk of falls. On the contrary, a better level of functional ability may afford safety while moving for the participants who did not fall (Tab. 3). Nevertheless, the higher functional gain after 6 months of participants who fell also may be associated with a higher level of physical (risk-taking) activity. As most of the falls had no serious consequences, these participants could significantly increase their functional ability to a level that was not significantly different from those who did not fall (Tab. 4). The findings of the current study suggested that falls were positively correlated with increased long-term gains (6 months) in functional ambulatory motor skills rather than reflective of worsening skills. Hence, the number of falls should not be taken as the sole measure of ambulatory function or balance ability in this population. However, the existing evidence also suggests that a fall can induce serious consequences (eg, fracture, unconsciousness).7,9 –11 Rehabilitation professionals may need to seek strategies to improve safety issues while moving for these patients, particularly in their own environments. Nonetheless, the findings of the present study contain some limitations. First, the study did not monitor physical activities of the participants during the follow-up time. The higher
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Functional Ability in Patients With Spinal Cord Injury levels of physical activities in participants who fell were implied from the findings that the participants showed a greater level of functional improvement (Tab. 3). A risk of falls may relate to other factors such as daily lifestyle, level of risk-taking activities, home adaptation, and environmental hazards. Second, the functional tests were applied to indicate levels of ability relating to participants’ falls, and thus they did not wear shoes and socks in order to minimize effects of improper or different types of shoes on the outcome and risk of injuries that might occur when the participants performed the tests at a maximum speed. Nevertheless, testing without shoes may have a crucial influence on the outcomes of functional tests and may not relate to participants’ falls. Finally, the findings on fear of falling were subjectively indicated by the participants.7,10,11 A further study that applies a standard measure for a level of fear of falling (eg, fall efficacy scale) and takes all these factors into account may strengthen the findings. All authors provided concept/idea/research design. Dr Wannapakhe and Dr Amatachaya provided writing and project management. Dr Wannapakhe provided data collection and study participants. Dr Wannapakhe, Dr Saengsuwan, and Dr Amatachaya provided data analysis. Dr Amatachaya provided fund procurement and clerical support. Dr Wannapakhe, Dr Arayawichanon, and Dr Amatachaya provided facilities/equipment. Dr Saengsuwan provided consultation (including review of manuscript before submission). The authors thank Mr Ian Thomas for his help in preparing the manuscript. The research was supported by funding from the KKU-Integrated Multidisciplinary Research Cluster, the Postgraduate School, Faculty of Associated Medical Sciences, and the Improvement of Physical Performance and Quality of Life (IPQ) research groups, Khon Kaen University.
May 2014
The study protocol was approved by the Office of the Khon Kaen University Ethics Committee in Human Research. DOI: 10.2522/ptj.20130260
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12 Krause JS. Factors associated with risk for subsequent injuries after traumatic spinal cord injury. Arch Phys Med Rehabil. 2004; 85:1503–1508. 13 Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148. 14 Poncumhak P, Saeingsuwan J, Kamruecha W, Amatachaya S. Reliability and validity of three functional tests in ambulatory patients with spinal cord injury. Spinal Cord. 2013;51:214 –217. 15 van Hedel HJ, Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests. Arch Phys Med Rehabil. 2005;86: 190 –196. 16 Saensook W, Poncumhak P, Saeingsuwan J, et al. Discriminative ability of the three functional tests in independent ambulatory patients with spinal cord injury who walked with and without ambulatory assistive devices. J Spinal Cord Med. 2014;37; 212–217. 17 Wirz M, Mu ¨ ller R, Bastiaenen C. Falls in persons with spinal cord injury: validity and reliability of the Berg Balance Scale. Neurorehabil Neural Repair. 2010;24: 70 –77. 18 Berg K, Wood-Dauphine´e S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can. 1989;41:304 –311. 19 Datta S, Lorenz DJ, Morrison S, et al. A multivariate examination of temporal changes in Berg Balance Scale items for patients with ASIA Impairment Scale C and D spinal cord injuries. Arch Phys Med Rehabil. 2009;90:1208 –1217. 20 Jackson AB, Carnel CT, Ditunno JF, et al. Outcome measures for gait and ambulation in the spinal cord injury population. J Spinal Cord Med. 2008;31:487– 499. 21 Schmidt-Read M, Sisto SA, Ditunno JF. Standardized ambulation assessments following spinal cord injury. Top Spinal Cord Inj Rehabil. 2008;14:39 – 60. 22 van Hedel HJ, Wirz M, Dietz V. Standardized assessment of walking capacity after spinal cord injury: the European network approach. Neurol Res. 2008;30:61–73. 23 van Hedel HJ; EMSCI Study Group. Gait speed in relation to categories of functional ambulation after spinal cord injury. Neurorehabil Neural Repair. 2009;23: 343–350. 24 van Hedel HJ, Dietz V, Curt A. Assessment of walking speed and distance in subjects with an incomplete spinal cord injury. Neurorehabil Neural Repair. 2007;21: 295–301.
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Changes of Functional Ability in Patients With Spinal Cord Injury With and Without Falls During 6 Months After Discharge Jirabhorn Wannapakhe, Preeda Arayawichanon, Jiamjit Saengsuwan and Sugalya Amatachaya PHYS THER. 2014; 94:675-681. Originally published online March 6, 2014 doi: 10.2522/ptj.20130260
References
This article cites 23 articles, 4 of which you can access for free at: http://ptjournal.apta.org/content/94/5/675#BIBL
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This article, along with others on similar topics, appears in the following collection(s): Balance Diagnosis/Prognosis: Other Falls and Falls Prevention Spinal Cord Injuries
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Research Report Changes of Functional Ability in Patients With Spinal Cord Injury With and Without Falls During 6 Months After Discharge Jirabhorn Wannapakhe, Preeda Arayawichanon, Jiamjit Saengsuwan, Sugalya Amatachaya
Background. Ambulatory patients with spinal cord injury (SCI) encounter a high risk of falls. However, most of the fall data in the literature were subjectively reported, without evidence to confirm the functional ability of those with and without falls.
Objectives. The purpose of this study was to prospectively evaluate changes in functional ability relating to falls in participants with SCI who fell and those who did not fall during the 6-month period after discharge.
Design. A 6-month prospective design was used in the study. Method. Fifty independent ambulatory participants with SCI were assessed for their functional ability using the Timed “Up & Go” Test, 10-Meter Walk Test, Berg Balance Scale, and Six-Minute Walk Test (6MWT) prior to discharge and 6 months afterward. After discharge, the participants’ fall data were monitored monthly to categorize them into faller (ⱖ1 fall in 6 months) and nonfaller (no fall) groups.
Results. Twenty-seven participants (54%) fell, and their baseline functional abilities were obviously lower than those who did not fall. After 6 months, the functional ability of these participants showed significant improvement for every test, whereas those who did not fall demonstrated a significant improvement only for the 6MWT. After adjusting for the baseline data, the functional ability at 6 months showed no significant differences between the groups.
Limitations. The study did not monitor physical activities of the participants during the follow-up period. The findings on fear of falling were subjectively reported by the participants.
J. Wannapakhe, PT, PhD, School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand. P. Arayawichanon, MD, School of Rehabilitation Medicine, Faculty of Medicine, Khon Kaen University. J. Saengsuwan, NU, PhD, Faculty of Public Health, Khon Kaen University. S. Amatachaya, PT, PhD, School of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, 40002 Thailand. Address all correspondence to Dr Amatachaya at: [email protected]. [Wannapakhe J, Arayawichanon P, Saengsuwan J, Amatachaya S. Changes of functional ability in patients with spinal cord injury with and without falls during 6 months after discharge. Phys Ther. 2014;94:675– 681.] © 2014 American Physical Therapy Association Published Ahead of Print: March 6, 2014 Accepted: February 26, 2014 Submitted: June 25, 2013
Conclusions. Participants with SCI are commonly characterized as being active and enthusiastic, which may drive their physical activities. However, sensorimotor impairments following SCI hinder their ability to move safely, particularly in those with more functional deterioration. Therefore, greater functional improvement is accompanied by a higher risk of falls. Because falls can induce serious consequences, rehabilitation professionals may need to seek strategies to improve safety issues during movement for these patients, particularly in their own environments. Post a Rapid Response to this article at: ptjournal.apta.org May 2014
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atients with spinal cord injury (SCI) have intact integrative capability of the brain, and the condition is most likely to occur in young men.1 Thus, these patients are commonly characterized as being active, having high degrees of energy, and being enthusiastic.2,3 However, sensorimotor impairments following SCI affect balance and walking ability; therefore, the patients encounter a high risk of falls and subsequent injury, particularly those with incomplete lesions.4 Currently, there is a trend toward a decrease in rehabilitation time for patients with SCI (from 115 days in 1974 to 36 days in 2005).5– 8 This trend may further affect the ability of patients to achieve an optimal level of ability at the time of discharge and have an increased risk of falls after discharge. Many community-dwelling individuals with SCI have experienced at least 1 fall during a 6- to 12-month period, both when data were gathered prospectively (39% and 74%)7,9 and when data were gathered retro-
spectively (34% and 75%).10,11 After falls, some patients encounter physical and psychological consequences, such as fractures, muscular pain, and fear of future falls, that further limit their mobility.7,9 –12 However, most of these data were subjectively reported by the patients. There are only 2 studies that have reported functional ability relating to falls in ambulatory participants with SCI.7,11 Phonthee et al11 found that independent ambulatory participants with SCI who had a history of falls during the previous 6 months had significantly better functional ability than those without a history of falls. Subsequently, Phonthee et al7 contrarily found in a prospective investigation that participants who fell had significantly poorer functional ability than those who did not fall. The different findings may be associated with the study designs in which the measurements of functional ability were done before (for a prospective study)7 and after (for a retrospective study)11 falls. Thus, the existing evidence may not clearly direct clinical impli-
The Bottom Line What do we already know about this topic? Falls are a major problem in ambulatory patients with spinal cord injury (SCI).
What new information does this study offer? The findings of this study suggest that falls are positively correlated with increased long-term gains in functional ambulatory motor skills rather than reflective of worsening skills. Therefore, the number of falls should not be taken as the sole measure of ambulatory function or balance ability in people with SCI.
If you’re a patient, what might these findings mean for you? Falls could induce serious consequences (eg, fracture, unconsciousness) in patients with SCI. Therefore, your physical therapist may use strategies to improve your safety as you move, particularly in your own environments.
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cations for fall prevention. A further study that investigated functional abilities before and after falls would clearly indicate the levels and change of functional ability relating to falls in these individuals. Therefore, this study prospectively monitored the fall data and investigated the change in functional ability in independent ambulatory participants with SCI who fell and those who did not fall during a 6-month period after discharge.
Method Participants The study was conducted in independent ambulatory participants with SCI who were consecutively admitted to a tertiary rehabilitation center in Thailand from June 2010 to April 2012. From a sample size calculation for within-group comparison using the data from an unpublished pilot study (N⫽10), this study required at least 20 participants per group. The inclusion criteria were an age of at least 18 years and the ability of independent walking for a minimum of 10 m. All of the participants had SCI due to traumatic causes or nonprogressive diseases and were at the subacute (postinjury time [PIT] ⬍12 months) or chronic (PITⱖ12 months) stage of injury. The patients were excluded if they had an SCI from a progressive disease or presented signs and symptoms that might affect mobility such as deformity in the joints of the lower extremities, leg-length discrepancy, musculoskeletal pain greater than 5 out of 10 on a visual analog scale, and brain function disorders. Every participant gave written informed consent before the start of the study. Protocol Two to 3 days prior to discharge, patients were assessed for their eligibility according to the criteria of the study. The eligible participants then were evaluated for their baseline demographics (including age
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Functional Ability in Patients With Spinal Cord Injury and sex), SCI characteristics (including cause, severity, stage, and level of SCI), baseline walking ability (ability of independent walking over at least 10 m), and types of ambulatory devices required for daily walking. Thereafter, the participants were assessed for their baseline functional ability using the Timed “Up & Go” Test (TUG), the 10-Meter Walk Test (10MWT), the Berg Balance Scale (BBS), and the Six-Minute Walk Test (6MWT). Prior to discharge, the participants received a routine home program from their physical therapists without any special instructions from the researchers. In addition, the participants received a fall diary to record fall data at home daily. Every month, the researcher ( J.W.) telephoned the participants to interview them and summarize the fall data of the month for a total of 6 months. After 6 months, the participants were reassessed for their functional ability using the 4 functional tests. Details of the functional tests and fall assessments are as follows. TUG. The TUG incorporates many complex tasks (eg, changing from sitting to standing, walking, turning around, and sitting down) that reflect mobility and dynamic balance control. Participants were instructed to stand up from a chair with armrests, walk 3 m, turn around a traffic cone, and walk back to sit down in the chair at a maximum and safe speed with or without a customary walking device. The test recorded the time taken from the command “go” until the participant’s back was against the backrest of the chair. Then, the average findings of 3 trials were recorded (in seconds).7,11,13–16 10MWT. The 10MWT measures walking speed, the results of which correlate with motor function and overall quality of gait.14,15 Participants walked at a comfortable pace along a 10-m walkway without any May 2014
Independent ambulatory patients with spinal cord injury interested in participating in the study (N=54) 4 patients were excluded due to: — having spine tumor — loss of follow-up in the sixth month
50 participants (men=37, women=13) completed the study
Nonfaller Group n=23 (46%)
Faller Group n=27 (54%)
Figure. Flowchart of study participants.
break to the endpoint with or without a walking device for 3 trials. Then, the average time required over the 4 m in the middle of the walkway was converted to gait speed (in meters per second).14,16 BBS. The BBS assesses balance ability while performing 14 sitting and standing activities.2,17 Ability to perform the tasks was rated using a 5-point ordinal scale ranging from 0 to 4 based on time and ability to execute the activities. Thus, the total possible scores range from 0 to 56.2,17–19 6MWT. The 6MWT is widely used to measure functional endurance.15 Participants were required to walk along a smooth rectangular walkway for as long as possible in 6 minutes with or without a walking device. During the test, participants were allowed to rest as needed without stopping the timer and continue walking as soon as they could. Every 1 minute during the test, participants were informed about the time left and offered verbal encouragement. The distance covered after 6 minutes was recorded.7,15,20 –22
These tests were executed by the same examiner ( J.W.) for both assessment periods on a flat, smooth, nonslippery surface without any disturbing factors (eg, noise or obstacles on the floor). During the tests, participants needed to fasten a lightweight safety belt with the tester walking or being aside the participants to ensure their safety and the accuracy of the measurements. The participants did not wear any shoes or socks to minimize effects of improper or different types of shoes on the outcomes and risk of injury that might occur when the participants performed the tests at their fastest speed. Fall surveillance. A fall was defined as an unexpected event that resulted in the participant coming to rest on the ground, floor, or other lower level.7,9 –11 If there was a fall, other data relating to the fall (such as time, place, and consequences of the fall)7 also were gathered via telephone interview. To ensure the data accuracy, the findings were confirmed by caregivers or relatives. If there was any conflicting information between the participants and
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Functional Ability in Patients With Spinal Cord Injury Table 1. Baseline Demographics and Spinal Cord Injury Characteristics of the Participantsa Variable Age (y)
b
Postinjury time (mo)b Sex: male/female
Faller Group (nⴝ27)
Nonfaller Group (nⴝ23)
P
48.00 (13.19) [47.78 to 53.22]
47.39 (14.38) [41.17 to 53.61]
.41
39.41 (41.24) [23.10 to 55.72]
34.26 (38.49) [17.62 to 50.91]
.76
22/5
15/8
.19
3/24
5/18
.44
7/20
6/17
.99
8/19
9/14
.48
14/13
11/12
.78
c
Severity of injury: AIS C/Dc Stage of injury: subacute/chronic
c
Level of injury: tetraplegia/paraplegiac Walking device used: yes/no
c
a
AIS⫽American Spinal Injury Association (ASIA) Impairment Scale; AIS C⫽incomplete spinal injury: motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3; AIS D⫽incomplete spinal injury: motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of ⱖ3. b The data are reported as mean (standard deviation) [95% confidence interval], and the findings between the groups were compared using an independent-sample t test. c The data are reported as number of participants, and the findings between the groups were compared using the chi-square test.
caregiver, the researcher relied on the data that were consistent with those in the fall diary. Then, the fall data after 6 months were used to
categorize the participants into faller (at least 1 fall in 6 months) and nonfaller (no fall) groups.
Table 2. Factors Inducing Falls as Perceived by the Participants and Consequences of the Fall Variable
No. of Falls (%)a
Factors inducing falls as perceived by the participants Environmental hazard
33 (40)
Loss of balance
33 (40)
Lower limb muscle weakness
9 (11)
Spasticity
4 (5)
Less attention during movement
2 (2)
Dizziness
1 (1)
Rapid movement
1 (1)
Data Analysis Descriptive statistics were applied to explain the baseline demographics, SCI characteristics, and findings of the study. The chi-square test and independent-sample t test were used to compare the differences in baseline demographics and SCI characteristics between the groups for the continuous and categorical variables, respectively. Then, the dependentsample t test was utilized to compare functional changes within the groups. In addition, an analysis of covariance (ANCOVA) was applied to analyze the differences in functional changes between the groups. The level of significant difference was set at P⬍.05.
Consequences of fallsb Physical consequences None
59 (71)
Skin abrasion and bruise
22 (27)
Muscle pain or tear
1 (1)
Unconsciousness
1 (1)
Fracture
0
Psychological consequences None
82 (99)
Fear of falling
1 (1)
Functional consequences None
78 (94)
Reduced mobility and social communication a
The total number of falls was 83. b The data were gathered using a questionnaire.7
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5 (6)
Role of the Funding Source The research was supported by funding from the KKU-Integrated Multidisciplinary Research Cluster, the Postgraduate School, Faculty of Associated Medical Sciences, and the Improvement of Physical Performance and Quality of Life (IPQ) research groups, Khon Kaen University.
Results During the period of data collection, 54 independent ambulatory participants with SCI were eligible to the criteria and agreed to participate in the study. However, 4 participants were
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Functional Ability in Patients With Spinal Cord Injury Table 3. Functional Abilities in Participants Who Fell and Those Who Did Not Fall at Discharge and 6 Months Thereaftera Faller Group (nⴝ27)
Nonfaller Group (nⴝ23) b
At Discharge
At 6 Months
Pb
.01c
25.78 (18.49) [17.78 to 33.77]
24.77 (17.74) [17.10 to 32.44]
.65
0.57 (0.37) [0.42 to 0.73]
0.65 (0.37) [0.49 to 0.81]
.10
Variable
At Discharge
At 6 Months
P
Timed “Up & Go” Test (s)
35.32 (17.27) [28.49 to 42.15]
27.30 (15.92) [21.00 to 33.60]
0.38 (0.26) [0.27 to 0.48]
0.50 (0.28) [0.39 to 0.61]
0.52 (0.35) [0.39–0.66]
0.79 (0.58) [0.56–1.02]
.01c
0.71 (0.43) [0.53–0.90]
0.80 (0.46) [0.60–1.00]
.08
Berg Balance Scale score
34.92 (15.30) [28.87 to 40.98]
40.41 (12.82) [35.34 to 45.48]
.01c
36.26 (15.62) [29.51 to 43.02]
38.13 (17.12) [30.73 to 45.54]
.32
Six-Minute Walk Test (m)
123.63 (88.68) [88.55 to 158.71]
169.13 (90.51) [133.33 to 204.94]
159.18 (94.43) [118.35 to 200.01]
191.91 (115.01) [142.18 to 241.65]
.03c
10-Meter Walk Test (m/s) Preferred speed Fastest speed
a b c
⬍.01c
⬍.01c
The data are reported as mean (standard deviation) [95% confidence interval]. The findings between discharge and 6 months after discharge were compared using the paired-samples t test. Significant difference.
lost during the follow-up period because of changing their address (n⫽2) and having a serious inadvertent event (n⫽2). Therefore, 50 independent ambulatory participants with SCI (37 men and 13 women) completed the study (Figure), and their baseline data are presented in Table 1. The findings on falls and functional ability are as follows. Fall Data Twenty-seven participants experienced at least 1 fall over 6 months (range⫽1–24 times/participant, and the total number of falls was 83) (Tab. 2). There were no significant differences in baseline demograph-
ics and SCI characteristics between the faller and nonfaller groups (P⬎.05) (Tab. 1). The falls occurred every month (range⫽10 –15 times/ month) in the house during daytime (5:00 am– 6:59 pm), were mostly due to stumbling over an obstacle on the floor (n⫽65), and mostly occurred while changing postures (ie, changing from sitting to standing) (n⫽18). Although most falls introduced no or mild physical consequences, 1 participant became unconscious after a fall (Tab. 2). Functional Ability of Faller and Nonfaller Groups Table 3 presents functional abilities
of participants who fell and those who did not fall during 6 months after discharge. The findings demonstrate that at discharge, participants who fell had obviously lower functional ability than those who did not fall. After 6 months, the functional ability of these participants demonstrated significant improvement from their baseline ability for every test (Pⱕ.01) (Tab. 3), whereas only the data of the 6MWT for participants who did not fall showed significant improvement (P⬍.05) (Tab. 3). However, when adjusted for the baseline data, the functional ability of the participants after the follow-up period showed no signifi-
Table 4. Functional Ability After the Follow-up Period of the Participants Who Fell and Those Who Did Not Fall When Adjusted for the Baseline Dataa Variable
Faller Group (nⴝ27)
Nonfaller Group (nⴝ23)
Difference (95% CI)b
Timed “Up & Go” Test (s)
24.23 (2.22)
28.37 (2.41)
⫺4.14 (⫺10.84 to 2.56)
.22
0.57 (0.04)
0.56 (0.04)
0.01 (⫺0.10 to 0.13)
.81
Pc
10-Meter Walk Test (m/s) Preferred speed
0.87 (0.07)
0.71 (0.08)
0.17 (⫺0.06 to 0.39)
.14
Berg Balance Scale score
Fastest speed
40.90 (1.64)
37.55 (1.78)
3.34 (⫺1.53 to 8.21)
.17
Six-Minute Walk Test (m)
182.69 (13.54)
176.00 (14.70)
6.69 (⫺33.90 to 47.27)
.74
a
The data are reported as mean (standard error). b 95% CI⫽95% confidence interval. c The findings between faller and nonfaller groups were compared using an analysis of covariance.
May 2014
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Functional Ability in Patients With Spinal Cord Injury cant differences between the groups (P⬎.05) (Tab. 4). Therefore, the findings in Table 3 might be prone to type 1 error due to multiple t tests. The data from the ANCOVA also indicated no significant interaction between groups and time (P⬎.05).
Discussion This study prospectively evaluated the change of functional ability in independent ambulatory participants with SCI who fell and those who did not fall during the 6 months after discharge. The results demonstrated that 54% of the participants experienced at least 1 fall in the 6 months after discharge. These participants had obviously lower baseline functional ability than those who did not fall. After the follow-up period, participants who fell showed significant improvement for all functional tests (Pⱕ.01), whereas only the data of 6MWT for participants who did not fall showed significant improvement (P⬍.05) (Tab. 3). After adjusting for the baseline differences, functional abilities after the follow-up period for participants who fell and those who did not fall showed no significant differences (P⬎.05) (Tab. 4). The incidence of falls found in this study was in the range of previous reports (between 34% and 75%).7,9 –11 Nevertheless, most of these studies reported retrospective fall data.10,11 For the prospective studies,7,9 Amatachaya and colleagues found that 74% of participants fell at least once during 6 months after discharge. However, the study recruited only 23 independent ambulatory participants with SCI, which may have reduced the strength of the findings. Phonthee et al7 reported that 35 of 89 community-dwelling ambulatory participants with SCI (39%) experienced at least 1 fall in 6 months. The different findings may relate to the frequency of follow-up periods for the fall data. Phonthee et al7 moni680
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tored the fall data weekly, and the frequent prospective follow-up periods may lead to the “Hawthorne effect,” a phenomenon in which individuals realize that they are being observed and temporarily increase attention to their movements, which reduces the incidence of falls. Nevertheless, the findings of the present study confirmed the high incidence of falls in independent ambulatory participants with SCI and that the falls were likely to occur while walking and changing posture, and they could introduce serious consequences (ie, unconsciousness). This study applied the TUG, 10MWT, BBS, and 6MWT because these tests are valid and reliable for assessing functional ability relating to falls in individuals with SCI.14,15,17,19 The BBS and TUG quantify static and dynamic balance while sitting, standing, and walking.7,11,13,14,17 The TUG also incorporates many complex tasks other than just walking, and thus the results may clearly reflect activities of daily living.7,11,15 The 10MWT measures walking speed in which the result is considered a surrogate for the overall quality of gait and motor function.15,20,23 The 6MWT is a thorough assessment tool, the results of which reflect functional endurance.15,24 Van Hedel et al24 indicated that the 10MWT may face a plateau when testing participants with good walking ability; thus, the 6MWT may better indicate the improvement due to an increase in speed and endurance.15,20,24 Therefore, we believe that using these tests may thoroughly quantify the change in functional ability relating to fall risk in these individuals. The results of the present study indicate that participants who fell had obviously lower baseline functional ability than those who did not fall (Tab. 3). The findings are in line with those reported by Phonthee et al,7 who found that independent ambu-
latory participants who fell had significantly lower functional ability than those who did not fall. The intact integrative capability of the brain with common characteristics of being active, having a high degree of energy, and being enthusiastic may increase the attempts of participants at performing physical activities, particularly in those with low levels of functioning.2,3 However, the inadequate levels of ability may have reduced the safety of the participants while moving, and thus they had a high risk of falls. On the contrary, a better level of functional ability may afford safety while moving for the participants who did not fall (Tab. 3). Nevertheless, the higher functional gain after 6 months of participants who fell also may be associated with a higher level of physical (risk-taking) activity. As most of the falls had no serious consequences, these participants could significantly increase their functional ability to a level that was not significantly different from those who did not fall (Tab. 4). The findings of the current study suggested that falls were positively correlated with increased long-term gains (6 months) in functional ambulatory motor skills rather than reflective of worsening skills. Hence, the number of falls should not be taken as the sole measure of ambulatory function or balance ability in this population. However, the existing evidence also suggests that a fall can induce serious consequences (eg, fracture, unconsciousness).7,9 –11 Rehabilitation professionals may need to seek strategies to improve safety issues while moving for these patients, particularly in their own environments. Nonetheless, the findings of the present study contain some limitations. First, the study did not monitor physical activities of the participants during the follow-up time. The higher
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Functional Ability in Patients With Spinal Cord Injury levels of physical activities in participants who fell were implied from the findings that the participants showed a greater level of functional improvement (Tab. 3). A risk of falls may relate to other factors such as daily lifestyle, level of risk-taking activities, home adaptation, and environmental hazards. Second, the functional tests were applied to indicate levels of ability relating to participants’ falls, and thus they did not wear shoes and socks in order to minimize effects of improper or different types of shoes on the outcome and risk of injuries that might occur when the participants performed the tests at a maximum speed. Nevertheless, testing without shoes may have a crucial influence on the outcomes of functional tests and may not relate to participants’ falls. Finally, the findings on fear of falling were subjectively indicated by the participants.7,10,11 A further study that applies a standard measure for a level of fear of falling (eg, fall efficacy scale) and takes all these factors into account may strengthen the findings. All authors provided concept/idea/research design. Dr Wannapakhe and Dr Amatachaya provided writing and project management. Dr Wannapakhe provided data collection and study participants. Dr Wannapakhe, Dr Saengsuwan, and Dr Amatachaya provided data analysis. Dr Amatachaya provided fund procurement and clerical support. Dr Wannapakhe, Dr Arayawichanon, and Dr Amatachaya provided facilities/equipment. Dr Saengsuwan provided consultation (including review of manuscript before submission). The authors thank Mr Ian Thomas for his help in preparing the manuscript. The research was supported by funding from the KKU-Integrated Multidisciplinary Research Cluster, the Postgraduate School, Faculty of Associated Medical Sciences, and the Improvement of Physical Performance and Quality of Life (IPQ) research groups, Khon Kaen University.
May 2014
The study protocol was approved by the Office of the Khon Kaen University Ethics Committee in Human Research. DOI: 10.2522/ptj.20130260
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Changes of Functional Ability in Patients With Spinal Cord Injury With and Without Falls During 6 Months After Discharge Jirabhorn Wannapakhe, Preeda Arayawichanon, Jiamjit Saengsuwan and Sugalya Amatachaya PHYS THER. 2014; 94:675-681. Originally published online March 6, 2014 doi: 10.2522/ptj.20130260
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