Thursday, 20 April 2017

#ClinicSpeak & #ResearchSpeak: Are you a faller?

If you are at risk of falls does increasing the number of steps walked each day reduce the number of falls you have? #ResearchSpeak #ClinicSpeak

The study below suggest that pwMS who fall, or at increased risk of falling, are less mobile and active than those who don't fall. The correlation between reduce activity/mobility (steps per day) was independent of disability (EDSS). The investigators' imply in the conclusion that the link between reduced mobility/activity is causal and that if you increase the number of steps pwMS take this would reduce their risk of falling. I am not sure if this is correct. The association could be reverse causation, i.e. pwMS who have problems with balance and postural righting reflexes, as defined using the Activities-Balance Confidence scale in this study, may reduce mobility (loss of confidence) as well as putting pwMS at risk of falling. If this is the case then increasing the number of steps you take, i.e. exposure time, might increase your risk of falling. This is why we need to test the hypothesis in a randomised trial. 

Question underpinning the hypothesis: In pwMS at increased risk of falling does increasing their mobility/activity reduce their risk of falling compared to a control population?  

It is a common mistake in research to assume that an association is causative. Implementing an intervention based on causation may give you the wrong outcome. PwMS clearly benefit from exercise, but rather than using walking it may be better to design an exercise programme that doesn't expose these people to falling, e.g. swimming. 



Sebastião et al. Lower Physical Activity in Persons with Multiple Sclerosis at Increased Fall Risk: A Cross-sectional Study. Am J Phys Med Rehabil. 2017 May;96(5):357-361.

Background: Persons with multiple sclerosis (MS) often report being afraid of falling, and this may have effects on physical activity (PA) engagement. 

Objective: This study investigated PA levels in persons with MS as a function of fall risk categories. 

Methods: Forty-seven persons with MS participated in the study and were categorized into either increased fall risk (IFR; n = 21; 55.5 ± 9.0 years) or normal fall risk (NFR; n = 26; 51.2 ± 12.9 years) groups based on scores from the Activities-Balance Confidence scale. PA was measured by accelerometer and expressed as average steps per day, and time spent in sedentary behavior, light PA, and moderate to vigorous physical activity over the course of 7 consecutive days. Univariate and covariate analyses were used to compare the differences in PA between fall risk groups. 

Results: The average steps per day of the NFR group was significant higher compared with the IFR group (6024 ± 2533.1 vs. 2599 ± 1622.7 steps; P < 0.001), and the difference remained after controlling for disability level (5351 ± 2298.6 vs. 3432 ± 2363.6 steps; P = 0.016). There were no differences in light PA and moderate to vigorous physical activity between groups after controlling for disability level. Persons with MS at IFR accumulate fewer steps per day compared with those at NFR. 

Conclusion: This underscores the need for well-designed interventions targeting walking in this population who are far from the recommended 10,000 steps, particularly those with IFR.

7 comments:

  1. AS someone with chronic foot drop physical exercise which is anything more than a very slow walk is impossible. A 600 metre walk takes me about 2o0 minutes. Imust always use a rollator or walking frame:-( I use an FES and since starting with that I have less than a fall a month when the fall is totally unexpected and its always when trying to reach something. Before the FES I would have a serious fall a couple of times a week.

    Everyday I do simple balance exercises, standng and looking up, down and rotating body to the left and right I am quite sure that has helped me as well as my confidence.

    I think people with foot drop should be given balance exercises and told to do them as well as walking as much as possible.

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  2. I have RRMS and often fall, trip, lose my balance and walk like a drunk. But I keep walking because I am worried that if I stop, that will be me on the path towards a wheel-chair. So I fall (twice last week) and I get up again. Yes I constantly have bruised knees but that is better than being in a stuck at home or having to use a walking aid.

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  3. This sort of research is so frustrating. It more or less implies pwMS fall for the same reason. Exercise makes us fit, but it doesn't stop the falls.
    There seems to be a blinkered view here, was this research sponsored by a treadmill company? I'm getting more cynical the older I get.

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  4. I think you're right. I have had fixed disability almost from day one post-dx. I honestly don't think my RISK of falling has been altered by anything except by awareness of my environment. That has caused me to safety-proof my house and to bring 100% concentration to how I put one foot in front of another. What does change through keeping fit is how you recover from a fall and indeed HOW you fall. A good core can turn a potential fall into a stumble. I tripped backwards from a low display platform in John Lewis and should have fallen my length, landing on my head. Instead, I jack-knifed and landed softly in a seated position. I suspect that the link between how much you walk and the incidence of falls is down to increased awareness - i.e. the more often you challenge your ability, the better you get at assessing risk. I'm pretty good at that.... but it didn't stop me tripping on an (over-long) pyjama leg and fracturing my arm last year. OVER-familiarity with one's environment is an ever-present danger!

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  5. Well… I fall sometimes, especially when I ride slick mood & rock mountain trails. Falling over the bar full speed ahead into the sharp rocks is the best experience I had in my life!

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  6. Post relapse, falls were daily, and after hurting myself a number of times I lost confidence for a while and avoided being more than arms length from a wall or furniture, resulting in moving around much less at that time.
    I now know how to use my sticks effectively for keeping my balance and to not look up or sideways while walking, and that sometimes it is safer to let myself fall against a wall than to try and correct it and end up falling away from it. (weirdly I still fall sideways when walking through a doorway!) And to check that my feet are where I expect them to be.
    I can't say that walking more made falls less frequent, quite the opposite, and in any case don't people fall for different reasons?

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  7. Needs be more application of studies that look at mitigating disability .vs. locating it. Seem few and far between. Look at what Kessler Foundation does. The focus is making gains not study after study of statistical numbers.

    In my small support group, now 19 strong, 11 have ambulation issues. Seven of those 11 tried my as seen on TV Total Gym and six of the seven have now purchased one "pre-owned."

    All have said its not only helped ambulation but balance, they feel a whole lot better and use it now for numerous forms of exercise.

    The machine is so flexible towards so many forms of exercise, easily used, accessible.

    I've talked and talked and talked for over a year now trying to get someplace to do some real work with this machine w/ patients. I guess $700 or preowned at $100-$200 is more than budgets allow for to try a machine that IMHO is a game-changer in exercise towards MS.

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