Are you a potential faller?

A

Barts-MS rose-tinted-odometer: ★★ (A Green & Yellow Friday – Lime Green (#32CC32) & Lemon Glacier (#F4FF00))

The biggest risk of losing your independence is falling and long bone fractures of the lower limbs. PwMS are 6x more likely than the general population to fall and fracture a lower limb long bone. I currently have a patient of mine with PPMS in hospital with bilateral fractures of the femur. She will not walk again. 

In our experience, the best predictor of falling is the need for a walking aid. The study below shows that fallers are more likely to have progressive or advanced MS and are already less mobile.

Please, please, please if you are tripping, having near falls or have fallen please get yourself referred to a falls prevention clinic and to see a physiotherapist. There are a lot of things that can be done to prevent falls.

Another issue is bone health. Faller or near fallers need to have their bone density checked and treated if low. The majority of pwMS have osteopenia and need to be on medication to manage this problem.  The reason why pwMS have thin bones is well known; less vitamin D, less sunlight, less physical activity, higher rate of smoking, intermittent steroids, etc. 

Prevention of falls and fractures is better than treating their consequences. I will do a separate MS-Selfie Newsletter on falls prevention.

Block et al. Identifying falls remotely in people with multiple sclerosis. J Neurol. 2021 Aug 17;1-10. doi: 10.1007/s00415-021-10743-y.

Background: Falling is common in people with multiple sclerosis (MS) but tends to be under-ascertained and under-treated.

Objective: To evaluate fall risk in people with MS.

Methods: Ninety-four people with MS, able to walk > 2 min with or without an assistive device (Expanded Disability Status Scale (EDSS ≤ 6.5) were recruited. Clinic-based measures were recorded at baseline and 1 year. Patient-reported outcomes (PROs), including a fall survey and the MS Walking Scale (MSWS-12), were completed at baseline, 1.5, 3, 6, 9, and 12 months. Average daily step counts (STEPS) were recorded using a wrist-worn accelerometer.

Results: 50/94 participants (53.2%) reported falling at least once. Only 56% of participants who reported a fall on research questionnaires had medical-record documented falls. Fallers had greater disability [median EDSS 5.5 (IQR 4.0-6.0) versus 2.5 (IQR 1.5-4.0), p < 0.001], were more likely to have progressive MS (p = 0.003), and took fewer STEPS (mean difference – 1,979, p = 0.007) than Non-Fallers. Stepwise regression revealed MSWS-12 as a major predictor of future falls.

Conclusions: Falling is common in people with MS, under-reported, and under-ascertained by neurologists in clinic. Multimodal fall screening in clinic and remotely may help improve patient care by identifying those at greatest risk, allowing for timely intervention and referral to specialized physical rehabilitation.

Conflicts of Interest

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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust and are not meant to be interpreted as personal clinical advice.

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.

18 comments

  • What sort of things can physiotherapists and fall prevention clinics do?
    What exactly is a fall prevention clinic?

    I consulted an orthopaedic doctor after a fall and asked about prevention. Didn’t get the impression that anything can be done.

  • Vitamine D + extra Calcium = even more bowel trouble…

    Prednisolone is my reason of less bone density. All them 3 day 1000mg cures…🤯

    A couple of weeks ago I was tested for Osteoporoses. The rate must be between +1 and -1.
    Lucky me, I had -0,9. So probably next time we test I will probably be out of the boundaries.

  • I have a strict policy on the stairs at home, I don’t move my feet without first checking my hand is wrapped around a spindle, I’ve had too many near misses (and a broken ankle) with my feet not picking up and I can’t trust where my hands are without checking on them. It takes ages to get up and down but my deteriorating hip feels like it is dislocating during the night, I don’t think it would withstand a fall now.
    I keep a grabber in most rooms I am always dropping things or knocking them over, and stay close to walls and furniture, rubbish balance . I think it’s a case of looking at our surroundings, recognising where the risks are and minimising them as much as possible.

  • Best decision I made was getting a walking stick a year ago soon after diagnosis. It was a difficult decision but it has saved me many times from falling over. Practicality over my pride.

  • Can only speak personally, have PPMS and use crutches or rollator but do not feel at risk of falling as my physiotherapy builds my core strength.

  • I’m a faller. I tend to trip over my own feet. Most of the time I save it but I’ve taken a few nasty tumbles. Once an ambulance was called. Unfortunately they don’t carry steri strips so they offered to take me to A&E but I had to get on a sleeper train to Inverness so they changed my dressing and dropped me opposite Euston station with a promise to go to urgent care in the morning. I ran Loch Ness Marathon a couple of days later in a PB time of 3:52. I still have the scar on my chin though.

    I fell on the trails during a race when I had nystagmus. Arguably I shouldn’t have been running – I missed one of the signs due to my visual impairment and ended up taking far longer to finish than I should have.

    I tripped on a pavement near home and avoided that side of the road for nearly a year afterwards. There’s another pavement near home that I avoid because it is increasingly broken up by cars parking on it.

    My worst fall was due to lack of care crossing a wooden bridge in trail shoes. So grippy in the mud but when they hit wet wood I skid everywhere. I fell on my coccyx. My spine is out of alignment but because no one ever looked at it before we’re not sure whether it was caused by my fall. My pelvis was probably fractured in the fall too but I didn’t go for an x ray as it wouldn’t have changed the treatment or recovery. My range of motion was affected for several months afterwards. I’m only just approaching my pre-fall fitness and condition and it happened in November 2019.

    It’s been a while since I’ve fallen now although I’ve had some near misses.

    In terms of bone health obviously I do a lot of weight bearing exercise. I take Vitamin D, I’ve never smoked, I eat a healthy plant based plus fish diet – although there is no dairy in my diet I eat plenty of other calcium-containing foods like kale, tofu and almonds. I do Pilates and yoga to help with balance. Running is so important to me I want to do everything in my control to keep being able to run.

  • I apparently had multiple fracture Bilateral superior and inferior pubic rami fracture. Complain for months to gp and he said is sciatica do the physio. I was admitted in hospital I couldn’t stand on my feet and they took xray And ct scan and came back with i got old fracture and new.
    I was giving Adcal-D3 2 a day lots of morphine,baclofen and alendronic acid 70mg 1 a week bit worries for taking this drug because of side effects and taking Natalizumub wich now have 2 new brain lesion and physio. Still concerned I haven’t recovered conpare to the terrible accident you had running and all your fracture.

  • I take the dog out for an early morning walk through the woods which has stoney paths. I bought a wooden hiking pole which is really handy if the path is wet or if you have to walk into the long grass. I’ve got very slight foot drop on my right foot. Sometimes my right walking boot catches one of the protruding stones on the path and I use the pole to steady myself. 2 weeks ago I invested in a Swedish AFO (£30) which goes into my right boot and straps round my right calf. When you place your right heel down it gives it a spring off so I no longer catch any of the protruding stones on the path. My walking speed has really increased as I’m confident that I won’t catch any stones.. Worth looking into if footdrop is the cause of your falls ie your foot keeps catching something and potentially causing a fall

  • Just went on my first holiday with my walking stick. Really postponed the walking aid but I am at a point which I cannot safely go without. I,ve gone from squatting 165kgs 5 times in 2016 to hoping I can get up after a deep squat with no weight at all these days. Morning stiffness is my biggest risk of falling. PPMS has taken so much from me my pride should be my last concern. Still it hurts being 38 and have to live like I am 90 years old

  • A big problem – I feel there should be a better label than ‘falling’ to capture the complexities of why and how it happens. I know it’s not just pwMS who experience this but a fall is a pretty big marker of how MS changes your life forever. After a fall, you have a different relationship with the world around you. You are no longer fully in control of your environment because you cannot trust your body to do all the things you didn’t even realise it did to keep you upright and safe. What that means is that MS is in your head the whole time. I’ve found good solutions, but it’s taken years and enormous effort.

  • Those who can afford it will potentially benefit from seeing a neuro physio.
    I initially had quite a problem with foot drop and was therefore vulnerable to falling forwards, in the manner we here in the UK would respond to with the jokey: ‘enjoy your trip?’ It was very disconcerting and alarming. My physio explained this had resulted in my walking defensively with my torso held very strictly and my arms not swinging loosely, but held close to my body ready to grab on to something. My physio has me do exercises for this and for the foot drop, mainly eversion of the foot on a daily basis, which has been extremely helpful and effective.
    As lots of the Blog readers know – MS Gym and other YouTube vids show exercises for foot drop, but I’d still recommend a neuro physio for those able to see one, because, as for me, they can observe how you walk/move as a result of falls or risk of falls.

By Prof G

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