Fear of Falling, Community Participation, and Quality of Life Among Community-Dwelling People Who Use Wheelchairs Full Time

Published:December 17, 2020DOI:



      To examine the differences in community participation and quality of life (QOL) among individuals who use wheelchairs full time with and without fear of falling (FOF).


      Cross-sectional study design.


      University research laboratory.


      Individuals (N=85) who use a manual or power wheelchair full time who are living with various health conditions and have a history of at least 1 fall in the past 12 months (age, 45.4±15.8y; disability duration, 21.5±13.6y) were included. Forty-six (54%) were manual wheelchair users.


      Not applicable.

      Main Outcome Measures

      To quantify FOF, participants responded (yes/no) to the question: “Are you worried or concerned that you might fall?” Community participation and QOL were indexed by the Community Participation Indicator (CPI) and the World Health Organization Quality of Life-Brief version (WHOQOL-BREF), respectively. A multivariate analysis of variance (MANOVA) was performed to examine the differences in CPI and WHOQOL-BREF scores among wheelchair users who reported FOF and no FOF.


      A total of 54 participants (63.5%) reported that they were worried or concerned about falling. The MANOVA revealed significant differences in overall CPI (F2,82=4.714; P=.012; Wilks’ λ=0.897) and WHOQOL-BREF (F4,63=3.32; P=.016; Wilks’ λ=.826) scores. Participants who reported FOF demonstrated significantly lower CPI and WHOQOL-BREF scores compared with those who did not report FOF.


      FOF and associated activity curtailment are prevalent and may be a factor influencing full time wheelchair users’ community participation and QOL. Prospective research is needed to better understand how FOF influences community participation and QOL among individuals who use wheelchairs full time. Findings would support the development of interventions, specifically for individuals who use wheelchairs full time, to reduce FOF and improve community participation and QOL.


      List of abbreviations:

      ANOVA (univariate analysis of variance), CPI (community participation indicator), FOF (fear of falling), MS (multiple sclerosis), POR (prevalence odds ratio), QOL (quality of life), SCI (spinal cord injury), WHOQOL-BREF (World Health Organization Quality of Life Brief version)
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        • Routhier F.
        • Vincent C.
        • Desrosiers J.
        • Nadeau S.
        Mobility of wheelchair users: a proposed performance assessment framework.
        Disabil Rehabil. 2003; 25: 19-34
        • Brault M.W.
        Americans with disabilities: 2010.
        Washington, DC: US Department of Commerce, Economics and Statistics Administration, US Census Bureau, 2012
        • Nelson A.
        • Ahmed S.
        • Harrow J.
        • Fitzgerald S.
        • Sanchez-Anguiano A.
        • Gavin-Dreschnack D.
        Fall-related fractures in persons with spinal cord impairment: a descriptive analysis.
        SCI Nurs. 2003; 20: 30-37
        • Kirby R.L.
        • Ackroyd-Stolarz S.A.
        • Brown M.G.
        • Kirkland S.A.
        • MacLeod D.A.
        Wheelchair-related accidents caused by tips and falls among noninstitutionalized users of manually propelled wheelchairs in Nova Scotia.
        Am J Phys Med Rehabil. 1994; 73: 319-330
        • Opalek J.M.
        • Graymire V.L.
        • Redd D.
        Wheelchair falls: 5 years of data from a level I trauma center.
        J Trauma Nurs. 2009; 16: 98-102
        • Gaal R.P.
        • Rebholtz N.
        • Hotchkiss R.D.
        • Pfaelzer P.F.
        Wheelchair rider injuries: causes and consequences for wheelchair design and selection.
        J Rehabil Res Dev. 1997; 34: 58-71
        • Forslund E.B.
        • Granstrom A.
        • Levi R.
        • Westgren N.
        • Hirschfeld H.
        Transfer from table to wheelchair in men and women with spinal cord injury: coordination of body movement and arm forces.
        Spinal Cord. 2007; 45: 41-48
        • Rice L.
        • Kalron A.
        • Berkowitz S.H.
        • Backus D.
        • Sosnoff J.J.
        Fall prevalence in people with multiple sclerosis who use wheelchairs and scooters.
        Medicine. 2017; 96e7860
        • Tinetti M.E.
        • Powell L.
        Fear of falling and low self-efficacy: a case of dependence in elderly persons.
        J Gerontol. 1993; 48: 35-38
        • Rice L.A.
        • Sung J.
        • Peters J.
        • Bartlo W.D.
        • Sosnoff J.J.
        Perceptions of fall circumstances, injuries and recovery techniques among power wheelchair users: a qualitative study.
        Clin Rehabil. 2018; 32: 985-993
        • Sung J.
        • Trace Y.
        • Peterson E.W.
        • Sosnoff J.J.
        • Rice L.A.
        Falls among full-time wheelchair users with spinal cord injury and multiple sclerosis: a comparison of characteristics of fallers and circumstances of falls.
        Disabil Rehabil. 2019; 41: 389-395
        • Butler Forslund E.
        • Roaldsen K.S.
        • Hultling C.
        • Wahman K.
        • Franzén E.
        Concerns about falling in wheelchair users with spinal cord injury--validation of the Swedish version of the spinal cord injury falls concern scale.
        Spinal Cord. 2016; 54: 115-119
        • Liu T.W.
        • Ng S.S.
        • Kwong P.W.
        • Ng G.Y.
        Fear avoidance behavior, not walking endurance, predicts the community reintegration of community-dwelling stroke survivors.
        Arch Phys Med Rehabil. 2015; 96: 1684-1690
        • Allison L.K.
        • Painter J.A.
        • Emory A.
        • Whitehurst P.
        • Raby A.
        Participation restriction, not fear of falling, predicts actual balance and mobility abilities in rural community-dwelling older adults.
        J Geriatr Phys Ther. 2013; 36: 13-23
        • Rosenbaum P.
        • Stewart D.
        The World Health Organization International Classification of Functioning, Disability, and Health: a model to guide clinical thinking, practice and research in the field of cerebral palsy.
        Semin Pediatr Neurol. 2004; 11: 5-10
        • Noel C.
        • Elizabeth S.
        • John U.
        Social exclusion, mobility and access.
        Sociol Rev. 2005; 53: 539-555
        • Mollenkopf H.
        • Marcellini F.
        • Ruoppila I.
        • Flaschenträger P.
        • Gagliardi C.
        • Spazzafumo L.
        Outdoor mobility and social relationships of elderly people.
        Arch Gerontol Geriatr. 1997; 24: 295-310
        • Ravenek K.E.
        • Ravenek M.J.
        • Hitzig S.L.
        • Wolfe D.L.
        Assessing quality of life in relation to physical activity participation in persons with spinal cord injury: a systematic review.
        Disabil Health J. 2012; 5: 213-223
        • Akosile C.O.
        • Anukam G.O.
        • Johnson O.E.
        • et al.
        Fear of falling and quality of life of apparently-healthy elderly individuals from a Nigerian population.
        J Cross Cult Gerontol. 2014; 29: 201-209
        • Chang N.T.
        • Chi L.Y.
        • Yang N.P.
        • Chou P.
        The impact of falls and fear of falling on health-related quality of life in Taiwanese elderly.
        J Community Health Nurs. 2010; 27: 84-95
        • Schoene D.
        • Heller C.
        • Aung Y.N.
        • Sieber C.C.
        • Kemmler W.
        • Freiberger E.
        A systematic review on the influence of fear of falling on quality of life in older people: is there a role for falls?.
        Clin Interv Aging. 2019; 14: 701-719
        • Zijlstra G.A.
        • van Haastregt J.C.
        • van Rossum E.
        • van Eijk J.T.
        • Yardley L.
        • Kempen G.I.
        Interventions to reduce fear of falling in community-living older people: a systematic review.
        J Am Geriatr Soc. 2007; 55: 603-615
        • Lin M.R.
        • Wolf S.L.
        • Hwang H.F.
        • Gong S.Y.
        • Chen C.Y.
        A randomized, controlled trial of fall prevention programs and quality of life in older fallers.
        J Am Geriatr Soc. 2007; 55: 499-506
        • Gallagher E.M.
        • Brunt H.
        Head over heels: impact of a health promotion program to reduce falls in the elderly.
        Can J Aging. 1996; 15: 84-96
        • Rice L.A.
        • Peters J.
        • Sung J.
        • Bartlo W.D.
        • Sosnoff J.J.
        Perceptions of fall circumstances, recovery methods, and community participation in manual wheelchair users.
        Am J Phys Med Rehabil. 2019; 98: 649-656
        • Zijlstra G.A.
        • van Haastregt J.C.
        • van Eijk J.T.
        • van Rossum E.
        • Stalenhoef P.A.
        • Kempen G.I.
        Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people.
        Age Ageing. 2007; 36: 304-309
        • Rice L.A.
        • Sung J.H.
        • Keane K.
        • Peterson E.
        • Sosnoff J.J.
        A brief fall prevention intervention for manual wheelchair users with spinal cord injuries: a pilot study.
        J Spinal Cord Med. 2020; 43: 607-615
        • Rice L.A.
        • Peterson E.W.
        • Backus D.
        • et al.
        Validation of an individualized reduction of falls intervention program among wheelchair and scooter users with multiple sclerosis.
        Medicine. 2019; 98: e15418
        • Tennstedt S.
        • Howland J.
        • Lachman M.
        • Peterson E.
        • Kasten L.
        • Jette A.
        A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults.
        J Gerontol B Psychol Sci Soc Sci. 1998; 53: P384-P392
        • Heinemann A.W.
        • Magasi S.
        • Bode R.K.
        • et al.
        Measuring enfranchisement: importance of and control over participation by people with disabilities.
        Arch Phys Med Rehabil. 2013; 94: 2157-2165
        • Skevington S.M.
        • Lotfy M.
        • O'Connell K.A.
        The World Health Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group.
        Qual Life Res. 2004; 13: 299-310
        • Setia M.S.
        Methodology series module 3: cross-sectional studies.
        Indian J Dermatol. 2016; 61: 261-264
        • Tabachnick B.G.
        • Fidell L.S.
        • Ullman J.B.
        Using multivariate statistics. 5. Pearson, Boston2007
        • Lakens D.
        Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs.
        Front Psychol. 2013; 4: 863
        • Rice L.A.
        • Ousley C.
        • Sosnoff J.J.
        A systematic review of risk factors associated with accidental falls, outcome measures and interventions to manage fall risk in non-ambulatory adults.
        Disabil Rehabil. 2015; 37: 1697-1705
        • Rice L.A.
        • Isaacs Z.
        • Ousley C.
        • Sosnoff J.
        Investigation of the feasibility of an intervention to manage fall risk in wheeled mobility device users with multiple sclerosis.
        Int J MS Care. 2018; 20: 121-128
        • Finlayson M.
        • Peterson E.W.
        • Cho C.
        Pilot study of a fall risk management program for middle aged and older adults with MS.
        NeuroRehabilitation. 2009; 25: 107-115
        • Suzuki M.
        • Ohyama N.
        • Yamada K.
        • Kanamori M.
        The relationship between fear of falling, activities of daily living and quality of life among elderly individuals.
        Nurs Health Sci. 2002; 4: 155-161
        • Manns P.J.
        • Chad K.E.
        Components of quality of life for persons with a quadriplegic and paraplegic spinal cord injury.
        Qual Health Res. 2001; 11: 795-811
        • Amato M.
        • Ponziani G.
        • Rossi F.
        • Liedl C.
        • Stefanile C.
        • Rossi L.
        Quality of life in multiple sclerosis: the impact of depression, fatigue and disability.
        Mult Scler. 2001; 7: 340-344
        • Groff D.G.
        • Lundberg N.R.
        • Zabriskie R.B.
        Influence of adapted sport on quality of life: perceptions of athletes with cerebral palsy.
        Disabil Rehabil. 2009; 31: 318-326
        • Hoenig H.
        • Landerman L.R.
        • Shipp K.M.
        • George L.
        Activity restriction among wheelchair users.
        J Am Geriatr Soc. 2003; 51: 1244-1251
        • Delbaere K.
        • Crombez G.
        • Vanderstraeten G.
        • Willems T.
        • Cambier D.
        Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study.
        Age Ageing. 2004; 33: 368-373
        • Friedman S.M.
        • Munoz B.
        • West S.K.
        • Rubin G.S.
        • Fried L.P.
        Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention.
        J Am Geriatr Soc. 2002; 50: 1329-1335
        • Kempen G.I.
        • van Haastregt J.C.
        • McKee K.J.
        • Delbaere K.
        • Zijlstra G.A.
        Socio-demographic, health-related and psychosocial correlates of fear of falling and avoidance of activity in community-living older persons who avoid activity due to fear of falling.
        BMC Public Health. 2009; 9: 170
        • Painter J.A.
        • Allison L.
        • Dhingra P.
        • Daughtery J.
        • Cogdill K.
        • Trujillo L.G.
        Fear of falling and its relationship with anxiety, depression, and activity engagement among community-dwelling older adults.
        Am J Occup Ther. 2012; 66: 169-176
        • Lee S.
        • Oh E.
        • Hong G.-R.S.
        Comparison of factors associated with fear of falling between older adults with and without a fall history.
        Int J Environ Res Public Health. 2018; 15: 982
        • Kumar A.
        • Carpenter H.
        • Morris R.
        • Iliffe S.
        • Kendrick D.
        Which factors are associated with fear of falling in community-dwelling older people?.
        Age Ageing. 2014; 43: 76-84
        • Hawthorne G.
        • Herrman H.
        • Murphy B.
        Interpreting the WHOQOL-BREF: preliminary population norms and effect sizes.
        Soc Indic Res. 2006; 77: 37-59
        • Hicks A.L.
        • Martin K.A.
        • Ditor D.S.
        • et al.
        Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being.
        Spinal Cord. 2003; 41: 34-43
        • Qi Y.
        • Zhang X.
        • Zhao Y.
        • et al.
        The effect of wheelchair Tai Chi on balance control and quality of life among survivors of spinal cord injuries: a randomized controlled trial.
        Complement Ther Clin Pract. 2018; 33: 7-11
        • Cote-Leclerc F.
        • Boileau Duchesne G.
        • Bolduc P.
        • et al.
        How does playing adapted sports affect quality of life of people with mobility limitations? Results from a mixed-method sequential explanatory study.
        Health Qual Life Outcomes. 2017; 15: 22
        • Hastings J.
        • Robins H.
        • Griffiths Y.
        • Hamilton C.
        The differences in self-esteem, function, and participation between adults with low cervical motor tetraplegia who use power or manual wheelchairs.
        Arch Phys Med Rehabil. 2011; 92: 1785-1788
        • Lord S.R.
        • Sherrington C.
        • Menz H.B.
        • Close J.C.
        Falls in older people: risk factors and strategies for prevention.
        Cambridge University Press, New York2007
        • Bloch F.
        Critical falls: why remaining on the ground after a fall can be dangerous, whatever the fall.
        J Am Geriatr Soc. 2012; 60: 1375-1376
        • Tinetti M.E.
        • Liu W.L.
        • Claus E.B.
        Predictors and prognosis of inability to get up after falls among elderly persons.
        JAMA. 1993; 269: 65-70
        • Tischler L.
        • Hobson S.
        Fear of falling: a qualitative study among community-dwelling older adults.
        Phys Occup Ther Geriatr. 2005; 23: 37-53
        • Peterson E.W.
        • Kielhofner G.
        • Tham K.
        • von Koch L.
        Falls self-efficacy among adults with multiple sclerosis: a phenomenological study.
        OTJR. 2010; 30: 148-157
        • Forslund E.B.
        • Jørgensen V.
        • Franzén E.
        • et al.
        High incidence of falls and fall-related injuries in wheelchair users with spinal cord injury: A prospective study of risk indicators.
        J Rehabil Med. 2017; 49: 144-151
        • Khan A.
        • Pujol C.
        • Laylor M.
        • et al.
        Falls after spinal cord injury: a systematic review and meta-analysis of incidence proportion and contributing factors.
        Spinal Cord. 2019; 57: 526-539