MS Speaks

Addressing the High Risk of Falls in People with Multiple Sclerosis

By Gloria Arminio Berlinski, MS

Reviewed by Aaron Miller, MD, Professor of Neurology, Icahn School of Medicine at Mount Sinai and Medical Director at the Corinne Goldsmith Dickinson Center for Multiple Sclerosis, New York, NY


Intervention programs targeting key modifiable risk factors are vital to preventing falls in people with multiple sclerosis (MS). Research in this field is relatively new, however, and much more work is needed to explore, improve and substantiate prevention strategies. Because falls in MS patients may lead to potentially life-changing consequences, from physical injury to a fear of falling, diminished physical activity, and social isolation, they are “a major problem that requires focused attention,” says Marcia Finlayson, PhD, OT Reg (Ont), OTR, Director of the School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada. And “since falls are multifactorial, solutions need to be multifactorial, as well,” she adds.

A significant health concern

“Over the last decade, researchers have gained an improved understanding of fall risk factors in persons with MS,” says Jacob J. Sosnoff, PhD, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL. “Nearly 50 risk factors...have been found to be associated with falls in persons with MS.”

These fall-related variables in MS include, for example, impaired balance, difficulty dual tasking, inconsistent use of mobility devices, reduced strength and sensation, and changes in vision, notes Dr. Finlayson. “One of the most predictive factors for a future fall is having a history of a previous fall in the past year.”

As a result of the numerous mobility challenges and other disease-related issues, people with MS fall at high rates and experience falls substantially more often than community-dwelling older adults, the most studied group in fall prevention programs, Dr. Finlayson says. To illustrate, approximately 33% of older adults fall during a 12-month period, whereas fall rates among people with MS range from 40% over 1 to 2 months to 70% over 12 months, according to both retrospective and prospective reports, she adds.

Strides in intervention research

Most of the research to date has focused on mobility (ie walking and balance) impairments as key fall risk factors, comments Dr. Sosnoff. Results emerging from these studies suggest that targeted exercises in various settings can reduce fall risk and incidence in people with MS.

A range of research findings on why people with MS fall and how falls can be detected and prevented was shared at the Fifth International Symposium on Gait and Balance in MS, held at the end of 2015 in Portland, Oregon. Several conclusions from presented studies that specifically relate to fall prevention in MS are highlighted here:

~Flach et al’s poster (#15) emphasized that speed when walking and making postural transitions should be incorporated into fall prevention strategies.

~Rice et al (#9) found that more than 50% of individuals who utilized a wheelchair fell once during a six-month assessment period, illustrating the need for interventions in this population.

~Wang et al (#10) recommends that people using assistive devices should partake in dual-task training and strengthening/balance exercises, as well as seek out expert advice for device selection, fitting and training.

~Zeeboer et al (#3) suggested that training in postural control may improve gait and balance.

~Bisson et al (#19) stated that the possible effects of comorbidities should be taken into account during exercise interventions.

~Kindred et al’s (#16) research showed that instilling confidence in walking performance to minimize perceived fall risk may be an important element in rehabilitation.

~Garg et al (#20) demonstrated that gaze and postural stabilization training leads to improvements in gaze stability, postural sway, dynamic balance, and self-reported participation measures.

An observational study published in 2016 assessed the effectiveness of a fall prevention group exercise and education program called Free From Falls (FFF) under real-world conditions. A total of 134 MS participants from across the United States were followed for 6 months after completing 8 weekly FFF sessions. The exercise component included balance practice, sensory fine-tuning, functional activities, and strengthening. The educational piece covered such topics as understanding balance; fear of falling; multisensory training; maximizing mobility, gait and flexibility; safety at home and in the community; and recovering from falls. 

Results indicated that the intervention strategy improved balance confidence and performance, as well as functional mobility, and reduced the number of self-reported falls from baseline to follow-up. To confirm clinical benefits of the FFF program observed in their initial study, Hugos and colleagues point out that a randomized, controlled trial design, along with other improved measures such as objective prospective counting of falls, are required.

“There are several areas in which current fall prevention strategies could be improved,” says Dr. Sosnoff. He went on to note that virtually all fall prevention studies have concentrated on individuals who are ambulatory and have not included those who use wheelchairs for mobility. Rehabilitation programs need to be more comprehensive and target such risk factors as bladder function and cognition to further reduce fall incidence. Researchers should also examine how the curtailment of fall risk and incidence affects a person’s quality of life and community participation.

A team approach

Investigators recognize the need to collaborate and share interdisciplinary expertise to maximize efforts in fall prevention.  One group, the International MS Falls Prevention Research Network, composed of researchers from five countries, including Canada, the United States, Ireland, Italy and the United Kingdom, was formed to find the best evidence-based solutions to minimize falls and secondary outcomes, says Dr. Finlayson.

“Together, our previous research as individuals indicates that reducing fall rates among people with MS will require attention to the interactions among personal capacity (physical, cognitive, psychosocial), environmental demand, and activity demand,” says Dr. Finlayson, who helped found the network with Dr. Sosnoff.

The clinician’s role

“Clinicians should regularly inquire about history of falls with each of their MS clients, says Dr. Finlayson, “and ask about the factors surrounding the fall (e.g. was the person walking and talking at the same time; was the person engaging in an activity that challenged his or her physical abilities; was there an environmental barrier that the person encountered?).” People are often reluctant to report falls because they are embarrassed or are afraid of what will happen as a result, she continues. “Clinicians need to make reporting of falls safe so that appropriate supports can be put in place to reduce their frequency and severity.”

 “Fall risk factors are as unique as the individuals with MS,” comments Dr. Sosnoff. Consequently, clinicians should perform a comprehensive fall risk assessment in order to tailor fall prevention techniques to a person’s distinct set of risk factors. For instance, he explains, if there are two people living with balance impairments—although balance training/exercises will benefit both of them—it is possible that other fall-related symptoms are coming into play. One of them may be getting out of bed several times a night due to nocturia and tripping over clutter in the dark. “Simply adding a motion-sensing night light to minimize the risk of falls at night would greatly benefit this individual.”