#T4TD falls and fractures

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Did you know that people with MS have a six times higher risk than age-matched controls of having a long bone fracture of the lower limb?

The reason for this is that pwMS often have balance problems, unsteadiness of gait (ataxia), lower limb weakness (dropped foot) and are maybe excessively sedated from their medications. All these factors increase your chances of falling. In addition, pwMS are at high risk of poor bone health (osteopaenia or osteoporosis) due to inactivity, reduced outdoor activity, low vitamin D levels, steroid treatment and comorbidities such as smoking. 

falls + poor bone health = increased long bone fractures

Why is this so important? A lower limb long bone fracture is one of the events that can tip someone with MS from being independent into becoming dependent and is often the trigger for needing a wheelchair. In addition, people with advanced MS don’t rehabilitate very well because they have reduced reserve and are usually quite disabled. 

How do you know if you are at risk of falls and fractures? We have shown that the best predictor of falls is the need for a walking aid (splint, stick, crutch, frame, functional electrical stimulator, etc.). If you are using a walking aid and are having falls, or near falls, you need to see a physiotherapist to be enrolled in a falls prevention programme and you will also need to have your bone density checked. This latter can be assessed via several methods, but the commonest is called a DEXA scan (dual-energy X-ray absorptiometry scan). If you are found to be osteopaenic or osteoporotic you may need treatment. 

Falls and fracture prevention is another self-management task; please don’t ignore it!

Prevention is better than treating the consequences of falls and fractures. For example, one of my patients with MS tragically fell going to the toilet at night. She crashed into a mirror that shattered and lacerated her arm and severed her brachial artery. She tragically bled to death as she lived alone, did not have an alert dongle around her neck and was unable to get herself up off the floor. Ever since she died I have taken falls prevention very seriously. Can you please do the same? You never know it may even save your life. 

Long bones of the lower limbs = femur, tibia and fibula

#T4TD = Thought for the Day

CoI: none for this post

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

6 comments

  • This is so important. I’ve written about this before . I was diagnosed with MS in 2004 and fell and broke my hip in 2018 at 58 and was subsequently diagnosed with osteoporosis. Bone health had never been discussed with me by any of my medical professionals ( MS or otherwise). I would like to see standard DXA scanning for all women with MS at the time of the menopause or at the very least education in bone health. I’m fortunate in that I have an excellent physio and rehab programme but the fall and fracture has permanently affected my walking and quality of life.

  • Prof G,

    Many thanks for your efforts on the T4TD posts. They will certainly resonate with anyone living with MS. On their own, they are informative and helpful. However, when one draws them together it highlights how devastating MS is – affecting every bodily function in one way or another. It’s a tough disease to live with coupled with the knowledge that it can only get worse.

    If you get time, could you do a T4TD on why the research / medical still can’t identify an approach (treatment + lifestyle factors) which would halt the progression of this vile disease. I know that some may be cured because they were given an IRT early on, but there are hundreds of thousands who have missed that boat and are facing a future of pain, bowel issues, falls…..until the grim reaper puts them out of their misery. A T4TD on what might be round the corner would bring a little bit of hope (we wouldn’t hold you to anything as we know the past has been littered with promising areas which have turned out to be damp squibs).

  • Hi Prof G, I also feel pwMS might suffer hypermobility in their joints. Joints that are over flexible, ankles especially – which also cause problems with stability & movement. For me – you upper body turns to do something & slow signals to your lower limbs to turn cause, pain twinges & over flexible movements. Thus resulting in moments of extra shooting pain and unsteadiness and then toppling over. It could be just me though 🙁 the time of life & those blasted hormonal challenges!

    I definitely feel my ankle joints have changed & albeit depending on your weight – might also cause pwMS to have problems with mobility. Using aids to help negotiate the undulating pavements around my village are also a reason to succumb to walking support. Feet/foot care too – needs to be addressed and comfort in your choice of footwear too! My stilettos and high wedges, gather dust in my closet and although I do like to think that one day I might wear them again – I have to look more to a sensible pair of trainers or walk shoes, along with a good walking aid – with a strong sense of positivity, that will get me walking and not to be put off, even if pwMS need plan their route and put in place various supports around their home. Any bone break or osteoarthritis/osteoporosis (replacing joints) are a challenge to us all – especially as we age.

    Lots of falls happen when people need to go the bathroom! Is this because of the urgency and the brain is so focused on this! My dear late Mother – fell trying to get to the toilet and broke her hip severely in doing so, which led to her death as she developed pneumonia (possible that she already had a low lingering infection) – but the reason why she fell was she needed to go! This appears to happen a lot in the elderly folk. Strangely it also happened to my Ma-in law too – in her home, needed the bathroom – fell attempting to get there and broke her hip. She survived (God Bless her) the replacement hip but a traumatic experience for all!

  • I’ve been disappointed by falls classification rubrics and tools for assessing fracture risk. They seem to be of limited use in guiding individual treatment decisions.

    I’m 70yo, SPMS, Dx @55yo, no current DMT, non-ambulatory except in physiotherapy, which I’ve done 2-3x/wk for 10 years. Resistance exercise and weight training have helped maintain & recover leg, trunk & upper-body strength. Botulinum toxin injections for lower-limb spasticity judiciously reduce muscle tone, allowing greater range of motion in exercise and significantly improving its results. I’ve built upper-body strength & maintained ability to perform stand-and-pivot transfers from my manual wheelchair & mobility scooter. In occasional failed transfers I can control descent & reach the floor without impact or injury. My last fall with impact was +5yrs ago, I see a neurologist & 2 physiatrists regularly (1 for botox).

    In annual BMD scans I was judged low risk for fracture. Then, 20 months ago, while riding the subway I was thrown out of my scooter when the train braked hard after entering a station at higher-than-usual speed. Femoral neck fracture, hemiarthroplasty, 1mo acute-care + 1mo post-acute, intensive rehab to recover from injury & deconditioning. I regained nearly all strength. Post-fracture BMD scan was nearly identical to the last pre-fracture scan (1.5 yrs between the two).

    However, regardless of scan results, ability and details of individual falls history, a fracture of any origin automatically causes assessment tools to jump risk of a subsequent fracture from low to high. There’s no allowance for fracture circumstances – in this case, 100% externally applied force causing unusually strong (although not measured) impact. As a result, in post-fracture clinic, surgeon & 2 specialists strongly recommend beginning anti-resorptive therapy (bisphosphonates) for osteopenia. I question the need for this, since studies show my bone strength unchanged and population-derived tools ignore fracture origin. In my view the real-life risk of another fracture remains low. Because they suppress bone turnover, bisphosphonates over the long term (7-10y) can actually weaken bone integrity and induce unusual types of fracture. This risk is considered to be outweighed by the drugs’ efficacy in preventing more common types, but if the risk of the latter is low to begin with then the therapeutic proposition becomes less attractive. I’m wary of polypharmacy & have worked to reduce my Rx load to the minimum needed for effective symptom management (overactive bladder, sciatic nerve pain, mood stability).

    I submit this account for the consideration of all, and to poke gently at one of many familiar generic portraits of MS symptoms, associated risk and mitigation strategy. Symptom management, the focus of treatment for many older MS patients, is a complex, multi-factorial affair. It suffers from want of robust research, attention to measurement, sophisticated assessment tools and published clinician insight. It’s gratifying to see an eminent neurologist share his knowledge and clinical experience in this area. If you could work up a T4TD on spasticity – perhaps the most troublesome MS symptom, after fatigue – I and surely many others would read it with great interest.

  • I have had ‘mystery falls’ twice – just fell while walking on even ground in sensible footwear.
    One caused an ankle sprain, it healed in some days.
    The second one caused an ankle fracture, lower leg was in a cast for over a month

    It’s a mystery because I don’t otherwise have any walking problems .

    Could there be an MS-related cause why the falls happened?
    Or is this something that can happen to anyone?

    • It rarely happens to people for no reason unless you are much older with age-related fall-out in neurological function. The most common cause of MS-related falls if you are not ataxic or weak is that it has affected your balance or postural righting system. This means if you tip the reflexes that right you are not working and hence you fall. The latter happens in other neurodegenerative diseases as well, for example in Parkinson’s disease.

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