Determining the Causes and Mechanisms of Falls in Children with Cerebral Palsy

Walker, B (2025) Determining the Causes and Mechanisms of Falls in Children with Cerebral Palsy. Doctoral thesis, Liverpool John Moores University.

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Abstract

Background: Falls are a common problem for children with cerebral palsy (CP). Falls lead to negative psychosocial consequences such as embarrassment and reduced activity participation, which negatively impacts daily wellbeing. However, causes of falls, particularly in the real-world are under investigated. To identify children with CP at high fall risk and develop effective interventions to reduce falls, we must first establish the mechanisms of falls that require prevention and thus must determine causes of falls in the real-world.
Research Question: What are the causes and mechanisms of falls in children with CP?
Study 1 (Chapter 2): A systematic review was undertaken that highlighted an understudied link between challenging environments and falls in children with CP. This work synthesised key gait characteristics that children with CP adopt when walking on surfaces other than level ground. However, a gap in knowledge was identified when trying to understand if gait characteristics were enough to prevent real-world falls and only three papers reported occurrence of falls in challenging environments. The understudied link evidenced within this review is likely due to a lack of investigation in challenging environments that reflects those in the real-world, as informed by children’s lived experiences.
Study 2 (Chapter 3): Patient and public involvement and engagement (PPIE) with children with CP and their parents revealed more about causes of real-world falls to meaningfully contribute to the development of participatory informed methods. This work used child-centred consultations and creative activities to develop The Walk-Along Project; a method tailored for children with CP, for exploring lived experiences of falls using walk-along interviews. A critical reflection on the impacts, strengths and challenges of conducting PPIE with children with CP and their parents is reported.
Study 3 (Chapter 4): The Walk-Along Project was carried out with children with CP and their parents in their local walking places, to reveal novel insights into places that falls occur in the real-world. This study evidenced that the places children with CP find most challenging and experience falls are uneven surfaces, e.g. grass potholes, and with distractions, e.g. dogs barking. Outcomes of this study highlighted the causes of real-world falls, which led directly into the design of a bespoke laboratory protocol for investigating the mechanisms of falls in replica real-world environments that had not been considered previously.
Study 4 (Chapter 5): This study captured incidents of instability using a bespoke laboratory protocol that offered novel insight into how children with CP negotiate replica real-world challenging environments. Outcomes from this study revealed several mechanisms of potential falls and demonstrated individualised fall risk factors. This included novel evidence that children with CP demonstrate suboptimal stepping strategies (e.g. a late change in foot placement) to avoid challenging features of the environment (e.g. potholes), that reduce stability, even when exhibiting compensatory mechanisms (e.g. reduced walking speed). Identification and understanding of these potential mechanisms of falls is vital for informing future fall prevention programmes.
Conclusion: This PhD generates novel insight about the causes and mechanisms of falls in children with CP. Mixed methods approaches used in this work went beyond typical stability assessments by understanding why and how falls occur in real-world environments. Early PPIE (Chapter 3), highlighted the importance of children with CP and their parents to produce more meaningful research outcomes. The Walk-Along Project (Chapter 4) was the first of its kind to conduct walk-along interviews with children with CP and their parents for exploring experiences of real-world falls. The bespoke walkway (Chapter 5) presents the first evidence of mechanisms of potential falls and high fall risk in replica real-world environments known to be most challenging. The outcomes of this PhD provide evidence that children with CP experience falls in uneven environments, with distractions, likely due to destabilizing interactions with an environmental feature e.g. trip over a pavement edge, or an avoidance of a feature e.g. step around a pothole. This novel knowledge paves the way for designing future diagnostic tools and fall prevention interventions, which previously were underinformed or not considered in treatment plans for children with CP.

Item Type:	Thesis (Doctoral)
Uncontrolled Keywords:	Cerebral Palsy; Falls; Lived Experiences; Stability
Subjects:	R Medicine > RC Internal medicine > RC1200 Sports Medicine
Divisions:	Sport and Exercise Sciences
Date of acceptance:	2 June 2025
Date of first compliant Open Access:	25 June 2025
Date Deposited:	25 Jun 2025 09:41
Last Modified:	25 Jun 2025 09:41
DOI or ID number:	10.24377/LJMU.t.00026534
Supervisors:	Foster, RJ, O'Brien, TD, Barton, GJ, Carter, B and Wright, DM
URI:	https://researchonline.ljmu.ac.uk/id/eprint/26534

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