Accidental falls in MS; problems practicalities and possibilities

Hilary Gunn, PhD

Background

Plan for session

• Examine the context, prevalence and incidence of falls in people with MS

• Identify the risk factors for falls• Highlight potential

opportunities (and challenges) for intervention

Issues with exploring falls

• Awareness

• Definitions

• Recall accuracy

Awareness of falls in neurological conditions

• Do you ask your patient about falls?

• Do you define falls for your patient?

• How do you think your patient(s) defines a fall?

Definition of a Fall

• Many different definitions exist in the literature– As many as 8 in the MS literature alone

• Commonly used:– “Unexpected event in which a participant

comes to rest on ground, floor, or lower level”

Definition of Recurrent falls

• Experiencing 2 or more falls– “Multiple” – Different time frames are used

• 2 to 12 months– Frequent falls

• Experiencing more than occasional falls – Three+ or unable to recall

Recall accuracy- prospective vs retrospective recall

No Falls One Fall 2 or more Grand Total0

10

20

30

40

50

60

70

80

90

100

3/12 prior to assessment N=3/12 following assessment N=

Falls Rates in MS (3 months)• Total number of falls: 672

• N reporting at least 1 fall: 104 (70.3%)

• Median number of falls: 3 (IQR 1-7)

• Range of reported falls: 1-63

• N reporting 2 or more falls: 78 (52.7%)

Gunn et al 2013

Consequences to the Individual• Injury and hospitalization

• Loss of independence

• Fear and loss of confidence

• Limiting your activity– Reduced strength– Reduced balance– Reduced stamina– Increases your chance of

falling

Fear of fallingRestricted Activity

DecreasedStrength Balance

Gait

Fall

Why are falls so common…?

Possible risk factors in the ICF Framework

Personal Environmental

Neurological Condition

Body Structure & Function(Impairments)

Functional Activities (Limitations)

Participation(Disability)

StrengthFlexibilitySensationPerceptionCognitionBalanceGait

SittingStandingWalkingTransfersReaching

ADLs/IADLsWorkRecreationMobility (Community)

Fear/Self-confidenceHistory of falls Home/Work/Community

Analysis of falls risk/ intervention efficacy

Awareness of odds/ risk ratios is important• Risk ratios

• Odds ratios

• Confidence Intervals (eg. OR 1.75 95%CI 0.3-2.4)

1<1

>1

Less likely More likelyNo difference

1<1

>1

Favours treatment Favours ControlNo difference

Risk factors in Multiple Sclerosis: systematic review

Risk Factor Balance Impairment

Use of a mobility aid

Cognition Progressive MS

Number of studies

4 4 3 3

Number of subjects

1412 1576 1239 596

Pooled OR 1.07 2.5 1.28 1.98

95% CI 1.04- 1.1 2.21- 2.83 1.2- 1.36 1.39-2.80

Heterogeneity (X2)

0.01 (p= 0.9998)

0.28 (p= 0.9638)

0 (p= 0.9992) 1.22 (p=0.54)

(Gunn et al, Physical Therapy 2013)

Is that the whole story?

• Observational study (N=150)• Prospective falls data collection• Later combining of data with 3 other

prospective studies

Our work: Key MS issues associated with falls

• Previous falls history: – OR 10.6 (4.6-24.2)

• Urinary continence issues: – OR 2.77 (1.4-5.4)

• Medication use – Prescription meds: OR 1.12 (0.99 to 1.26)– OTC meds: OR 0.79 (0.64 to 0.97)

Our work: Key MS impairments associated with falls

Fallers worse than non fallers in all measures, however:

• Spasticity:– Ashworth 1: OR 7.88 (2.16 to 28.8)– Ashworth 2+: OR 2.51 (0.91 to 6.95)

• ‘Balance’ and falls risk measures….

Falls risk Assessment

PPA risk factors….

• PPA Score: OR: 1.9 (1.34 to 2.69)– PPA Key Elements:

• Sway• Reaction Time

• Other measures within the PPA not significant

MS Severity as a predictor of falls

Other potential risk factors from prospective cohort studies

• Poor leaning balance, coordinated stability, choice stepping reaction time and ‘complex’ executive function (Hoang et al 2014)

Other Potential Risk FactorsQualitative Studies

• Participation– Divided attention– Walking in crowds (Community mobility)– Taking care of the home– Driving

• Environment– Unsuitable physical environment

• Carpets, slippery surfaces, doorsteps– Climate

• Snow, ice, heat

• Personal– Stress Nilsagard et al., 2009, Peterson et al., 2010

So… what does this mean?

• Unpredictability and change may be key factors

• ‘Indirect’ issues (e.g. continence/ medication) could be important

• Balance is a key problem• ….but strength, visual and ‘simple’

sensory problems may be less so

Proposed relationship

ImmobileMobile

and unstable

high

low

Fall

Ris

k

Mobile and stable

High mobility Low mobility

Matsuda et al., 2012

Developing falls interventions for

people with MS

What do you advise to manage falls?

Falls interventions in older people (Gillespie 2012)

Falls management in MS

– People with MS have very separate needs to ‘average’ users of falls services (e.g. over 65’s) NG3P17 Verbal comment

– By the nature of it it will tend to be older people who go [to the falls service], and then if you’re someone young with say progressive MS, you may be grieving for your former self anyway without having it thrust in your face that you are falling around like your Gran. NG3MS16 Verbal comment

Falls interventions in stroke

• Verheyden et al 2015 (systematic review)– 10 trials n=1004– Exercise – acute/subacute, chronic – no effect

on fall rate OR number of fallers• Noted High intensity functional exercises & Agility

programmes warrant further investigation– Medication – 2 studies, Vit D, Alendronate –

rate and number reduced– Single lens glasses – no effect

Falls interventions in Parkinsons disease

• Goodwin et al 2011 RCT– 10 week group exercise programme plus

home exercises– Significant increase in balance scores. – No difference in falls rate or number of fallers

• Ashburn et al 2007 RCT– 6 week home exercise programme– Improvement in balance outcomes– No significant difference in falls

Sources of evidence in MS

• Systematic review (n=16) • Nominal Group study (n=36)• Research and experience from

international expert group (IMSFPRN)• Research from related areas

(Gunn et al 2015, 2015a)

Evidence in MS…

• Systematic review (Gunn et al 2015)– Falls outcomes

– Other studies (single group n=4) show varied results

So what do we know in MS….?

• Falls education programmes can increase confidence, awareness of (and possibly use of) management strategies

• Exercise programmes can improve balance…..

Gunn et al 2015

So, exercise and education is the way to go?

Type of exercise is likely to be important

Work in other groups suggests exercise….• Needs to be challenging to balance• Needs to include movement in 3

dimensions• Needs to minimise upper limb support• Needs to be tailored to individual needs

Sherrington 2008

Undertaking ‘challenging’ balance exercise

I think sometimes you have to push yourself to know what you can and can’t do physically and mentally. NG3MS20… ……You might try those [difficult] exercises with a little ‘prodding’... NG3MS16…………I think I might need a little bit more than ‘prodding’… NG3MS17

Discussion excerpt

Maximising outcome: does duration and intensity matter in MS?

Volume:Positive correlation between intensity (documented mins/ wk) and effect size r = 0.70 (p=0.009).

Duration:Negative correlation between programme duration (in weeks) and effect size r = -0.62 (p=0.03)

Gunn et al 2015

Maximising outcome: Education programmes

What are the key issues with behaviour change programmes?

E.g. Van der Bij 2002, Van Sluijs 2007, Motl 2014

Time

Act

ivity

leve

l

Recruitment, retention and adherence to exercise

programmes in MS• Recruitment: 50-80%• Adherence:

– Attended programmes- 70-100%– Home programmes- 60-70%

• Attrition: median rate of 18% (range 0-33%)

Gunn et al 2015

So, what should a programme look like?

Key elements we need to get right

• Choosing to participate- making it attractive

• Attending• Participation during sessions• Undertaking practice outside ‘formal’

sessions

Programme approach:Don’t mention the ‘F’ word….

– If I was commissioning a group and everyone in the group had fallen 3 times before they joined and no times afterwards, but they had spent 6 weeks being miserable, or living lesser lives because they were taking less risks as a result, then that’s not an outcome I would be particularly interested in.

(service commissioner)

Programme Approach

– Referral makes it sound like it’s a patient being referred, you know I don’t “refer” myself to the gym, you choose and you just go. NG3P14 Verbal comment

Attending: Programme setting

– I wouldn’t want sessions to be in a hospital… We’re not ill as in ill, we are finding it difficult to cope but nevertheless not needing hospitals. NG3MS18 Verbal comment

– The idea of a hospital setting for me gives it some validity. I’ve got MS, I don’t want to just turn up to a random place not knowing…… I’d like to think that somebody is a professional, and you know, has got a plan in mind. NG2MS12 Verbal comment

Programme setting

Programme structure: Groups are viewed positively….– With regard to exercise groups that I’ve been a

participant in, somehow there is some kind of, um, ‘group energy’ that comes about ….there definitely is something there in the group. NG3MS15 Verbal comment

However…..

• I met a lady last week, she is terrified, she hates seeing people who are struggling…she just gets so upset; she says it’s not worth it. And I can’t argue, what can I say? NG2MS12 Verbal comment

Frequency may be significant

– If you’re an MS person there is no guarantee you can be there one week and the next week, it’s a day on day thing…. You would like to be there for that time, but there’s no guarantee you will be. NG2MS10 Verbal comment

Achieving success in home practice

…” In our falls and balance group I always say ‘now, who’s done the exercises since last week? And I’ll get about 2 hands out of 8…..” (Falls programme lead)

Success in home practice: a matter of format?

• Daily, in the form of exercises at home-if you want me to do two hours of exercise you can forget it……. NG3MS14 Verbal comment

Supporting engagement

– The input needs to be given in such a way that we enjoy it; we remember it or we have prompts to remember it, and we go away and we do it. So that is, whether it’s a group or individual, those rules must apply because the only way it’s going to work is with the time, motivation and energy that we find to put into it. NG3MS16 Verbal comment

Supporting engagementStudy N Attrition Intervention OutcomeHale 2013 28 4% Personalised activity prescription with

motivational interviewing

Paul2014 30 3% Web based physiotherapy with weekly

telephone support

Finklestein 2008 12 0

Individualised exercise programme delivered via telerehabilitation

McAuley 2007 26 58%

Efficacy enhancement sessions vs 'standard care'

Plow 2013 30 0

Customised pamphlets to support a prescribed exercise programme

Smith2012 13 8%

Effect of MI or personal coaching on adherence to an 8 week exercise programme.

Programme support- facilitation

• The leader is pivotal to the success of the programme

– I think the relationship between the therapist, the enabler, whatever we want to call this wonderful being who is leading this group, and the people of the programme is utterly paramount. NG3MS16

Role of the leader/ facilitator

Funding and ongoing support

• You need to do it properly…– It needs to have its own resources because you get

fed up trying to run everything on a shoestring and rushing in and doing a group and then rushing off again to the next thing. NG2P8 Verbal comment

– There’s just not enough time to do anything properly. It would just be depressing if we spent a lot of time developing a really lovely quality service to start off, and they wouldn’t have the time anyway…. NG2P13 Verbal comment

So, what should a programme look like?

Key messages for people with MS….

• Don’t accept falls as inevitable• Adapt and plan- don’t avoid. Think ‘safe

mobility’• Exercise can help balance … BUT….• Intensity of practice and maintaining

engagement is critical to effectiveness- this is a long term commitment

• Use support networks….Going it alone is hard!

Key messages for professionals….

• Intensity of practice and maintaining engagement is likely to be critical

• Participants need support and facilitation delivered by skilled and experienced staff

• Programme needs to support self-efficacy/ lifestyle/ behaviour change

• Individual flexibility within evidence-based limits is important

• We need to do this right!

Our plans

• We have developed BRiMS- balance and safe mobility programme for people with MS

• Grant application pending for feasibility study (South West England and Glasgow initially)

• All comments and feedback welcome!

Thank you for listening

• Acknowledgements:– Funders– PhD supervisors:

• Jenny Freeman• Jon Marsden• Bernhard Haas

– Participants

Hilary.gunn100@plymouth.ac.uk