Hilary Gunn

Identification of Risk Factors for Falls in Multiple Sclerosis: A Systematic Review and Meta-Analysis

Background Falls are a significant issue in people with multiple sclerosis (MS), with research demonstrating fall rates of more than 50%. Purpose The purpose of this study was to evaluate the risk factors associated with falling in people with MS. Data Sources Mixed search methods were used, including computer-based and manual searches. Additionally, hand searches of reference lists and conference abstracts were performed. All literature published from the sources earliest date to January 2012 was included; only full-text English-language sources (or those where a translation was available) were included. Study Selection Eligibility criteria specified articles evaluating any aspect of fall risk in adults with a confirmed MS diagnosis, where the incidence of falling as determined by prospective or retrospective participant report was included. Data Extraction Data were extracted independently by 2 reviewers using a written protocol and standardized extraction documentation. Detailed assessment of each article was independently undertaken by both reviewers, including assessment of study quality using an adaptation of the Newcastle Ottawa Scale plus extraction of key data (participant characteristics, fall incidence, and outcomes). Data Synthesis The final review comprised 8 articles with a total of 1,929 participants; 1,037 (53.75%) were classified as fallers. Eighteen different risk factors were assessed within the included studies. Meta-analysis demonstrated an increase in fall risk associated with impairments of balance and cognition, progressive MS, and use of a mobility aid. Narrative review of the qualitative articles and those factors where meta-analysis was not possible also was undertaken. Limitations Variation in assessment, analysis, and reporting methods allowed meta-analysis for only 4 factors. Conclusion There is limited evidence of the factors associated with fall risk in people with MS. Further methodologically robust studies are needed.

Risk factors for falls in multiple sclerosis: an observational study.

Background: People with multiple sclerosis (MS) experience frequent falls, which are associated with impairments and limitations to activities and participations. Objective: The objective of this paper is to evaluate falls risk factors using robust clinical measures. Methods: A total of 150 individuals (confirmed MS diagnosis, Expanded Disability Status Scale (EDSS) 3.5–6.5) were recruited, with 148 participants included in the final analysis. Demographic data were collected and performance assessed in eight predictor measures (Physiological Profile Assessment (PPA), Brief Ataxia Rating scale, Ashworth scale (Ashworth), Modified Falls Efficacy scale, Symbol Digit Modalities Test, dual-task interference, lying/standing blood pressure, static/dynamic visual acuity). Participants prospectively recorded falls over three months using a daily diary. People were classified as “fallers” based on reports of ≥ two falls. Results: A total of 104 participants recorded 672 falls; 78 (52.7%) reported ≥ two falls. Continence issues, previous falls history and use of prescribed medications were each associated with increased risk of being a “faller”. Ashworth and PPA risk score contributed significantly to a logistic regression model predicting faller/non-faller classification. The reduced model (Ashworth, PPA, EDSS) showed fair-to-good predictive ability (ROC c-statistic 0.73, sensitivity 70%, specificity 69%). Conclusion: This study confirms the high prevalence of falls in ambulant people with MS. Important potentially modifiable risk factors are identified, suggesting aspects to target in falls interventions.

Falls in people with MS—an individual data meta-analysis from studies from Australia, Sweden, United Kingdom and the United States

Background: Falls are common in people with multiple sclerosis (PwMS). Previous studies have generally included small samples and had varied methods. Objectives: The objectives of this paper are to compile fall rates across a broad range of ages and disease severity and to definitively assess the extent to which MS-associated and demographic factors influence fall rates. Methods: Individual data from studies in four countries that prospectively measured falls for three months were analyzed. We determined fall rates, prevalence of fallers (≥1 falls) and frequent fallers (≥2 falls), location and timing of falls, and fall-related demographic factors. Results: A total of 537 participants reported 1721 falls: 56% were fallers and 37% frequent fallers. Most falls occurred indoors (65%) between 6 a.m. and 6 p.m. (75%). Primary progressive MS was associated with significantly increased odds of being a faller (odds ratio (OR) 2.02; CI 1.08–3.78). Fall risk peaked at EDSS levels of 4.0 and 6.0 with significant ORs between 5.30 (2.23–12.64) and 5.10 (2.08–12.47). The fall rate was lower in women than men (relative risk (RR) 0.80; CI 0.67–0.94) and decreased with increasing age (RR 0.97 for each year, CI 0.95–0.98). Conclusion: PwMS are at high risk of falls and there are important associations between falls and MS-associated disability, gender and age.

Fall Incidence as the Primary Outcome in Multiple Sclerosis Falls-Prevention Trials Recommendation from the International MS Falls Prevention Research Network

The aim of this article is to provide recommendations on behalf of the International MS Falls Prevention Research Network (IMSFPRN) for the primary outcome measure for multiple sclerosis (MS) falls-prevention interventions. The article will consider the definition of a fall, methods of measuring falls, and the elements of falls that should be recorded, as well as how these elements should be presented and analyzed. While this information can be used to inform the content of falls-prevention programs, the primary aim of the article is to make recommendations on how the outcome of these programs should be captured.

Problem Based Learning in physiotherapy education: a practice perspective

BACKGROUND Problem Based Learning (PBL) has been integrated into a range of health education curricula; however there is limited research evaluating the application of skills developed through PBL in clinical practice. AIM This study aimed to provide evidence of how skills gained through PBL are applied in practice by student physiotherapists, from the perspective of their placement supervisors. METHOD A qualitative one-to-one semi-structured interview methodology was used, purposively recruiting a sample of 10 qualified physiotherapists with experience of placement supervision of students studying on a PBL physiotherapy undergraduate degree. RESULTS The supervisors felt that PBL offered positive benefits for both student education and clinical practice. There was evidence of the application of skills and attributes associated with PBL, including positive learning behaviours and a high level of motivation and self-direction. Supervisors felt that proactive students were able to apply transferable skills inherent in the PBL approach to clinical practice, including a holistic, problem-solving approach and effective team-working but that there was considerable variation between students. CONCLUSIONS There is evidence of variable application of skills associated with PBL in clinical practice in this study group. Further research would be useful to explore the factors that enable students to successfully apply the attributes developed using a PBL approach into practice.

Fall risk in people with MS: A Physiological Profile Assessment study

Introduction The Physiological Profile Assessment (PPA) is used in research and clinical practice for assessing fall risk. We compared PPA test performance between people with multiple sclerosis (MS) and healthy controls, determined the fall-risk profile for people with MS and developed a reference database for people with MS. Methods For this study, 416 ambulant people with MS (51.5 ± 12.0 years) and 352 controls (52.8 ± 12.2 years) underwent the PPA (tests of contrast sensitivity, proprioception, quadriceps strength, reaction time and sway) with composite fall-risk scores computed from these measures. MS participants were followed prospectively for falls for 3 months. Results The MS participants performed significantly worse than controls in each PPA test. The average composite fall-risk score was also significantly elevated, indicating a “marked” fall risk when compared with controls. In total, 155 MS participants (37.3%) reported 2 + falls in the follow-up period. Frequent fallers performed significantly worse than non-frequent fallers in the contrast sensitivity, reaction time and sway tests and had higher PPA composite scores. Conclusions In line with poor PPA test performances, falls incidence in people with MS was high. This study provides comprehensive reference data for the PPA measures for people with MS that could be used to inform future research and clinical practice.

Relationship Between Physiological and Perceived Fall Risk in People With Multiple Sclerosis: Implications for Assessment and Management

OBJECTIVE This study evaluated the relationship between physiological and perceived fall risk in people with multiple sclerosis (MS). DESIGN Secondary analysis of data from prospective cohort studies undertaken in Australia, the United Kingdom, and the United States. SETTING Community. PARTICIPANTS Ambulatory people with MS (N=416) (age 51.5±12.0 years; 73% female; 62% relapsing-remitting MS; 13.7±9.9 years disease duration). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES All participants completed measures of physiological (Physiological Profile Assessment [PPA]) and perceived (Falls Efficacy Scale-international [FESi]) fall risk and prospectively recorded falls for 3 months. RESULTS 155 (37%) of the participants were recurrent fallers (≥2 falls). Mean PPA and FESi scores were high (PPA 2.14±1.87, FESi 34.27±11.18). The PPA and the FESi independently predicted faller classification in logistic regression, which indicated that the odds of being classified as a recurrent faller significantly increased with increasing scores (PPA odds ratio [OR] 1.30 [95% CI 1.17-1.46], FESi OR 1.05 [95% CI 1.03-1.07]). Classification and regression tree analysis divided the sample into four groups based on cutoff values for the PPA: (1) low physiological/low perceived risk (PPA <2.83, FESi <27.5), (2) low physiological/high perceived risk (PPA <2.83, FESi >27.5), (3) high physiological/low perceived risk (PPA >2.83, FESi <35.5), and (4) high physiological/high perceived risk (PPA <2.83, FESi >35.5). Over 50% of participants had a disparity between perceived and physiological fall risk; most were in group 2. It is possible that physiological risk factors not detected by the PPA may also be influential. CONCLUSIONS This study highlights the importance of considering both physiological and perceived fall risk in MS and the need for further research to explore the complex interrelationships of perceptual and physiological risk factors in this population. This study also supports the importance of developing behavioral and physical interventions that can be tailored to the individuals needs.

Experiences of people with Parkinson's disease and their views of physical activity interventions: a qualitative systematic review protocol.

REVIEW QUESTION/OBJECTIVES This review aims to explore the experiences of people with Parkinsons disease (pwPD) participation in physical activity and their views of interventions designed to engage and sustain engagement. Synthesis of the best available evidence will be used to determine any gaps in the research literature and make recommendations on approaches to increase and maintain engagement in physical activity in pwPD living in a community setting. The specific objectives are to.

Development of a balance, safe mobility and falls management programme for people with multiple sclerosis

Abstract Purpose: To utilise stakeholder input to inform the structure, format and approach of a multiple sclerosis (MS) balance, safe mobility and falls management programme. Materials and methods: Using a three-round nominal group technique, participants individually rated their agreement with 20 trigger statements, followed by a facilitated group discussion and re-rating. Three mixed groups included service users (n = 15) and providers (n = 19). Quantitative analysis determined agreement, whilst qualitative responses were analysed thematically. Results: Median scores for each of the 20 trigger statements did not change significantly over sequential rounds, however, deviations around the medians indicated more agreement amongst participants over time. Key recommendations were: Aims and approach: The programme should be tailored to the needs of people with MS. Falls and participation-based outcomes are equally important. Structure and format: The programme should balance expected burden and anticipated benefit, moving away from models requiring weekly attendance and promoting and supporting self-efficacy. Optimising engagement: Support to maintain engagement and intensity of practice over the long term is essential. Sustainability: Adequate funding is necessary. Staff should have MS specific knowledge and experience. Conclusions: Participants collaboratively identified critical components of a MS balance, safe mobility and falls management programme. They also highlighted the importance of a collaborative, user-centred, MS-specific approach. Implications for Rehabilitation People with multiple sclerosis need condition-specific interventions focussed on maximising balance and safe mobility and reducing falls. Programme design should support self-efficacy and flexible engagement. Adequate support and funding are seen as essential by both service users and providers.