Walking Distance as a Predictor of Falls in People With Multiple Sclerosis

Nationwide Update on Prevalence of Falls, Injurious Falls, Concerns About Falling, and Fall Prevention in Persons With Multiple Sclerosis

OBJECTIVE

The aim of the study is to estimate the current nationwide prevalence of falls, injurious falls, concerns about falling, and information on fall prevention among people with multiple sclerosis.

DESIGN

This is a cross-sectional national web-based survey that included 965 adult people with multiple sclerosis. Participants self-reported falls and injurious falls experienced in the past 6 months. Participants also provided information on their concerns about falling and information on fall prevention received.

RESULTS

A total of 56% reported falling in the past 6 months. The prevalence of falls at the population level ranges between 53% and 59%. Most falls occur inside of participants' homes (68%). About 30% of fallers reported an injurious fall. Most respondents, 87% expressed being concerned about falling and 68% reported they had cut down on activities due to their concerns about falling. Among participants who received information about falling (64%), only 9% received a formal fall prevention course.

CONCLUSIONS

Despite advances in falls research over the last decades, falling continues to be a highly prevalent problem for people with multiple sclerosis. About one-third of those falls result in injuries. Concerns about falling among fallers and nonfallers affect the performance of daily activities and independence. Few people receive a formal falls prevention education or training.

Self-reported fatigue impact is associated with frequency of falls and injurious falls in people with multiple sclerosis

BACKGROUND

Fatigue is the most common symptom associated with multiple sclerosis (MS). Fatigue as a risk factor for injurious falls and frequency of falls is understudied. Falling recurrently is associated with injurious falls which may lead to reduced functional independence and poor quality of life of people with MS. Identifying contributors of recurrent falls and injurious falls is clinically useful to develop effective interventions.

OBJECTIVE

To investigate the associations between fatigue impact and frequency of falls and injurious falls in people with MS.

METHODS

Fifty-one participants completed the Modified Fatigue Impact Scale (MFIS) and a survey of number of falls and injurious falls during the past year. Logistic regression analyses were conducted to investigate whether scores on the MFIS (Total, Physical, Cognitive, and Psychosocial) predicted odds of being a recurrent faller (> 2 falls) or infrequent faller (1- 2 falls) versus a non-faller, and odds of experiencing an injurious fall (yes/no). The analyses were adjusted for demographic and clinical characteristics and common symptoms of MS (depression, cognition, pain, and sleep disturbance).

RESULTS

Higher MFIS Total score was associated with higher odds of infrequent falls (OR = 1.07, 95% CI, 1.00 - 1.15, p = 0.05) and recurrent falls (OR = 1.10, 95% CI, 1.00 - 1.20, p = 0.04) relative to not falling in the past year. Higher scores on the MFIS Physical subscale were significantly associated with high odds of infrequent falls (OR = 1.15, 95% CI, 1.02 - 1.30, p = 0.03) and recurrent falls (OR = 1.19, 95% CI, 1.02 - 1.39, p = 0.03). MFIS Psychosocial subscale was significantly associated with higher odds of infrequent falls (OR = 2.01, 95% CI, 1.14 - 3.53, p = 0.02). MFIS Total and MFIS Cognitive subscale were significantly associated with higher odds of injurious falls (OR = 1.11, 95% CI, 1.00 - 1.23, p = 0.04) and (OR = 1.28, 95% CI, 1.02 - 1.60, p = 0.04), respectively.

CONCLUSION

The findings indicated self-reported fatigue impact and its specific domains were associated with an increased risk of falling and injurious falls. Further studies using prospective falls assessment and longitudinal evaluation of fatigue are warranted to extend our findings.

Motor Imagery of Walking in People Living with and without Multiple Sclerosis: A Cross-Sectional Comparison of Mental Chronometry

Motor imagery represents the ability to simulate anticipated movements mentally prior to their actual execution and has been proposed as a tool to assess both individuals’ perception of task difficulty as well as their perception of their own abilities. People with multiple sclerosis (pwMS) often present with motor and cognitive dysfunction, which may negatively affect motor imagery. In this cross-sectional study, we explored differences in motor imagery of walking performance between pwMS (n = 20, age = 57.1 (SD = 8.6) years, 55% female) and age- and sex-matched healthy controls (n = 20, age = 58.1 (SD = 7.0) years, 60% female). Participants underwent mental chronometry assessments, a subset of motor imagery, which evaluated the difference between imagined and actual walking times across four walking tasks of increasing difficulty (i.e., large/narrow-width walkway with/without obstacles). Raw and absolute mental chronometry (A-MC) measures were recorded in single- (ST) and dual-task (DT) conditions. In ST conditions, pwMS had higher A-MC scores across all walking conditions (p ≤ 0.031, η² ≥ 0.119), indicating lower motor imagery ability compared to healthy controls. During DT, all participants tended to underestimate their walking ability (3.38 ± 6.72 to 5.63 ± 9.17 s). However, after physical practice, pwMS were less able to adjust their imagined walking performance compared to healthy controls. In pwMS, A-MC scores were correlated with measures of balance confidence (ρ = −0.629, p < 0.01) and the self-reported expanded disability status scale (ρ = 0.747, p < 0.01). While the current study revealed that pwMS have lower motor imagery of walking performance compared to healthy individuals, further work is necessary to examine how the disassociation between mental chronometry and actual performance relates to quality of life and well-being.

Prevalence and determinants of falls in persons with multiple sclerosis without a clinical disability

BACKGROUND

Falls are common in persons with Multiple Sclerosis (pwMS) and lead to destructive results, specifically with increasing disability. However, there is only scarce data investigating prevalence and determinants of falls in pwMS without a clinical disability. Therefore, this study aimed to investigate proportion of fallers and related factors in pwMS without a clinical disability.

METHODS

One hundred and four pwMS with no clinical disability (EDSS≤1.5) were recruited in this cross-sectional study. The outcome measures comprised of the Timed 25-Foot Walk (T25FW), Six Minute Walk Test (6MWT), Timed Up and Go Test (TUG), Multiple Sclerosis Walking Scale (MSWS-12), Single Leg Stance Test (SLS), Activities-Specific Balance Confidence Scale (ABC), Symbol Digit Modalities Test (SDMT), Modified Fatigue Impact Scale (MFIS), and Beck Depression Inventory-II (BDI-II). The number of falls during the last three months was recorded.

RESULTS

Twenty-five percent of the pwMS reported at least one fall in the last three months. The TUG and MSWS-12 scores were significantly greater in the fallers compared to non-fallers (p<0.05). Whereas the fallers had significantly less ABC scores (p<0.05). Increasing TUG and MSWS-12 score and decreasing ABC score was related with increased risk of being classified as a faller adjusting for EDSS score.

CONCLUSION

The present findings highlight that falls are frequent problem for pwMS, even if they do not have a clinical disability. Therefore, falls prevention strategies are also required in the early stages of the disease in clinical practice. The ABC scale, MSWS-12, and TUG test can be used by the clinicians and researchers to predict potential fallers of the pwMS without a clinical disability.

Balance Right in Multiple Sclerosis (BRiMS): a feasibility randomised controlled trial of a falls prevention programme

Background

Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial.

Methods

This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone.

Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries.

Results

Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%).

After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23).

Conclusions

Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible.

Trial registration

ISRCTN13587999

Date of registration: 29 September 2016

A self-management programme to reduce falls and improve safe mobility in people with secondary progressive MS: the BRiMS feasibility RCT

BACKGROUND

Balance, mobility impairments and falls are common problems for people with multiple sclerosis (MS). Our ongoing research has led to the development of Balance Right in MS (BRiMS), a 13-week home- and group-based exercise and education programme intended to improve balance and encourage safer mobility.

OBJECTIVE

This feasibility trial aimed to obtain the necessary data and operational experience to finalise the planning of a future definitive multicentre randomised controlled trial.

DESIGN

Randomised controlled feasibility trial. Participants were block randomised 1 : 1. Researcher-blinded assessments were scheduled at baseline and at 15 and 27 weeks post randomisation. As is appropriate in a feasibility trial, statistical analyses were descriptive rather than involving formal/inferential comparisons. The qualitative elements utilised template analysis as the chosen analytical framework.

SETTING

Four sites across the UK.

PARTICIPANTS

Eligibility criteria included having a diagnosis of secondary progressive MS, an Expanded Disability Status Scale (EDSS) score of between ≥ 4.0 and ≤ 7.0 points and a self-report of two or more falls in the preceding 6 months.

INTERVENTIONS

Intervention - manualised 13-week education and exercise programme (BRiMS) plus usual care. Comparator - usual care alone.

MAIN OUTCOME MEASURES

Trial feasibility, proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls), feasibility of the BRiMS programme (via process evaluation) and economic data.

RESULTS

A total of 56 participants (mean age 59.7 years, standard deviation 9.7 years; 66% female; median EDSS score of 6.0 points, interquartile range 6.0-6.5 points) were recruited in 5 months; 30 were block randomised to the intervention group. The demographic and clinical data were broadly comparable at baseline; however, the intervention group scored worse on the majority of baseline outcome measures. Eleven participants (19.6%) withdrew or were lost to follow-up. Worsening of MS-related symptoms unrelated to the trial was the most common reason (n = 5) for withdrawal. Potential primary and secondary outcomes and economic data had completion rates of > 98% for all those assessed. However, the overall return rate for the patient-reported falls diary was 62%. After adjusting for baseline score, the differences between the groups (intervention compared with usual care) at week 27 for the potential primary outcomes were MS Walking Scale (12-item) version 2 -7.7 [95% confidence interval (CI) -17.2 to 1.8], MS Impact Scale (29-item) version 2 (MSIS-29vs2) physical 0.6 (95% CI -7.8 to 9) and MSIS-29vs2 psychological -0.4 (95% CI -9.9 to 9) (negative score indicates improvement). After the removal of one outlier, a total of 715 falls were self-reported over the 27-week trial period, with substantial variation between individuals (range 0-93 falls). Of these 715 falls, 101 (14%) were reported as injurious. Qualitative feedback indicated that trial processes and participant burden were acceptable, and participants highlighted physical and behavioural changes that they perceived to result from undertaking BRiMS. Engagement varied, influenced by a range of condition- and context-related factors. Suggestions to improve the utility and accessibility of BRiMS were highlighted.

CONCLUSIONS

The results suggest that the trial procedures are feasible and acceptable, and retention, programme engagement and outcome completion rates were sufficient to satisfy the a priori progression criteria. Challenges were experienced in some areas of data collection, such as completion of daily diaries.

FUTURE WORK

Further development of BRiMS is required to address logistical issues and enhance user-satisfaction and adherence. Following this, a definitive trial to assess the clinical effectiveness and cost-effectiveness of the BRiMS intervention is warranted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13587999.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 27. See the NIHR Journals Library website for further project information.

Fall definitions, faller classifications and outcomes used in falls research among people with multiple sclerosis: a systematic review

Purpose: To identify the definitions of a fall, faller classifications and outcomes used in prospectively-recorded falls research among people with Multiple Sclerosis (MS).Methods: A systematic review of peer-reviewed journal articles was conducted using electronic databases. Relevant data were extracted by one reviewer and verified by a second independent reviewer.Results: Twenty-six papers met the inclusion criteria. A relative degree of heterogeneity existed amongst studies for the outcomes of interest to this review. Thirteen different fall definitions were identified. Fourteen different falls outcomes were used across the included studies, with six of these reported by only one study each. Data regarding injurious falls were presented by only eight papers. The majority (n = 17) of papers classified individuals as a faller if they fell at least once.Conclusions: This review highlights the large variation in fall definitions, faller classifications and outcomes used in this research field. This hinders cross-comparison and pooling of data, thereby preventing researchers and clinicians from drawing conclusive findings from existing literature. The creation of an international standard for the definition of a fall, faller classification and falls outcomes would allow for transparent and coordinated falls research for people with MS, facilitating progression in this research field.Implications for rehabilitationFalls are a common occurrence among people with Multiple Sclerosis (MS) resulting in numerous negative consequences.There is large heterogeneity in the definitions, methods and outcomes used in falls research for people with MS.This lack of standardisation prevents the accurate cross-comparison and pooling of data, impeding the identification of falls risk factors and effective falls prevention interventions for people with MS.Consequently, clinicians should interpret the outcomes of falls research for people with MS with caution, particularly when comparing studies regarding falls risk assessments and falls prevention interventions for use in clinical practice.

Identificação de fatores de risco para quedas em indivíduos com esclerose múltipla: uma revisão sistemática de estudos prospectivos

RESUMO O objetivo deste estudo foi identificar, a partir de uma revisão sistemática, variáveis clínicas, instrumentais e demográficas associadas com maior risco de queda em indivíduos com esclerose múltipla (EM), com base em dados prospectivos. A pesquisa foi conduzida nas bases de dados Medline, Web of Science, Bireme e CINAHL, utilizando os descritores “esclerose múltipla”, “quedas”, “quedas acidentais”, “risco de quedas”, “controle postural” e “equilíbrio”, seguido de buscas manuais. Foram considerados elegíveis estudos de coorte prospectivos, com período mínimo de acompanhamento das quedas de três meses, que avaliassem a associação de determinada variável demográfica, clínica ou instrumental em relação a maior risco de queda em indivíduos com EM. A escala de Newcastle-Ottawa modificada foi utilizada para avaliação da qualidade metodológica dos estudos incluídos. Foram identificados 357 estudos, 12 dos quais foram incluídos na revisão sistemática, com total de 1.270 pacientes incluídos. Destes, 740 (58,26%) pacientes apresentaram um ou mais episódios de queda, 396 (31,18%) apresentaram episódios de queda recorrentes (2≥quedas no período estipulado), e 530 (41,74%) não apresentaram nenhum episódio. Com exceção da espasticidade e do impacto da dupla tarefa na velocidade da marcha, todas as variáveis investigadas apresentaram resultados conflitantes quanto às suas associações a maior risco de quedas. São necessários mais estudos que apresentem homogeneidade dos fenótipos clínicos de indivíduos com EM, além da utilização de instrumentos de avaliação validados, a fim de estabelecer uma associação robusta de outras variáveis clínicas, instrumentais e demográficas com maior risco de queda.

A study on nonlinear estimation of submaximal effort tolerance based on the generalized MET concept and the 6MWT in pulmonary rehabilitation

BACKGROUND

The six-minute walk test (6MWT) is considered to be a simple and inexpensive tool for the assessment of functional tolerance of submaximal effort. The aim of this work was 1) to background the nonlinear nature of the energy expenditure process due to physical activity, 2) to compare the results/scores of the submaximal treadmill exercise test and those of 6MWT in pulmonary patients and 3) to develop nonlinear mathematical models relating the two.

METHODS

The study group included patients with the COPD. All patients were subjected to a submaximal exercise test and a 6MWT. To develop an optimal mathematical solution and compare the results of the exercise test and the 6MWT, the least squares and genetic algorithms were employed to estimate parameters of polynomial expansion and piecewise linear models.

RESULTS

Mathematical analysis enabled to construct nonlinear models for estimating the MET result of submaximal exercise test based on average walk velocity (or distance) in the 6MWT.

CONCLUSIONS

Submaximal effort tolerance in COPD patients can be effectively estimated from new, rehabilitation-oriented, nonlinear models based on the generalized MET concept and the 6MWT.

Comparison of trunk impairment scale versions 1.0 and 2.0 in people with multiple sclerosis: A validation study

BACKGROUND

Trunk control impairment often accompanies multiple sclerosis (MS). Trunk stability is necessary for movements of extremities, as are selective trunk movements for normal gait. Measuring trunk function is thus of interest.

METHODS

We examined the relationships between the Trunk Impairment Scale (TIS1.0 and TIS2.0) and the Berg Balance Scale (BBS), 5 sit-to-stand test (5STS), Timed Up and Go test (TUG), 10-m timed walk test (10TW), 2-min walk test (2MWT), Falls Efficacy Scale - International, and 12-item MS Walking Scale (MSWS-12) in 47 outpatients. We determined construct validity by calculating the degree to which the TIS versions produced different scores between known groups: use or nonuse of walking aid, MS disability status, and whether participants experienced a fall or not during 14 weeks.

RESULTS

TIS correlated moderately with BBS and 5STS; moderately (TIS1.0) or weakly (TIS2.0) with TUG, 10TW, and 2MWT; and weakly to moderately with MSWS-12 in subgroups with Expanded Disability Status Scale (EDSS) >6.0. No other clear correlation patterns were found. TIS did not discriminate between known groups.

CONCLUSIONS

TIS1.0 is recommended for individuals with MS (EDSS score 4.0-7.5). Better trunk function correlates with better balance and walking ability. TIS has limited value in fall risk screening.

Walking Distance as a Predictor of Falls in People With Multiple Sclerosis

Background and Purpose

People with multiple sclerosis (PwMS) experience falls, usually when walking and transferring. The aim was to investigate if walking distance and patient overestimate of walking distance are predictors of falls in PwMS.

Methods

A prospective study was conducted, with a single test occasion followed by prospective registration of falls for 3 months. All PwMS in Region Örebro County with a previously registered Expanded Disability Status Scale score between 3.0 and 7.0 in the Swedish MS Registry were invited to participate (n = 149). Altogether, data from 49 PwMS being relapse free for at least 3 months and with a confirmed Expanded Disability Status Scale between 1.5 and 7.0 upon study entry were analysed.

Results

Twenty‐two PwMS (45%) fell during the study period, providing information of 66 falls. Walking distance or overestimate of one's walking distance, as compared with test results, did not predict falls in this MS sample.

Discussion

Walking and standing activities are associated with numerous falls in PwMS. Our data do not clearly support routine measurements of walking distance in assessing individual fall risk. © 2015 The Authors. Physiotherapy Research International published by John Wiley & Sons, Ltd.