ClinicSpeak: falls and fractures as an outcome measure

Have you fallen recently? Are you worried about sustaining a fracture? #MSBlog #MSResearch #ClinicSpeak

"Sticking to the holistic management of MS theme; have you had a recent bone health assessment by your family doctor, or GP, or your neurology team? The meta-analysis below (combining many trial results into one) show that MSers are at increased risks of bone fractures. This is not new. For those of us who spend our time treating MS we see a large number of MSers with fractures every year. Why is this issue important? Mainly because it is common trigger for moving into a wheelchair. In an audit done at our hospital the best predictor of falls (the main cause of fractures in MSers) was use of a walking aid. Once someone with a walking aid falls and fractures a long bone on the lower limb (femur, tibia or fibula), by the time they have recovered from being incapacitated by the fracture they are often dependent, or at least partially dependent, on a wheelchair for mobility. Falling and sustaining a fracture also seriously knocks one confidence about getting out and 'doing it'. I have seen too many MSers after a fracture become housebound because of falling again and sustaining another fracture. Therefore it is very important to try and anticipate falls and fractures so they can be prevented. Our neurophysiotherapists run a falls prevention clinic; so if you are concerned about falls please ask to be referred to a physiotherapist for an assessment.

Most falls prevention programmes include a common sense checklist (see NHS Choices): 

Home environment: 
  • mopping up spillages straight away
  • removing clutter, trailing wires and frayed carpet
  • using non-slip mats and rugs
  • using high-wattage light bulbs in lamps and torches so you can see clearly
  • organising your home so that climbing, stretching and bending are kept to a minimum, and to avoid bumping into things
  • getting help to do things that you are unable to do safely on your own
  • not walking on slippery floors in socks or tights
  • not wearing loose-fitting, trailing clothes that might trip you up
  • wearing well-fitting shoes that are in good condition and support the ankle
  • taking care of your feet by trimming toenails regularly, using moisturiser and seeing a GP or chiropodist about any foot problems
Strength and balance training:
  • Doing regular exercises to improve your strength and balance can help reduce your risk of having a fall. This can range from simple activities such as walking and dancing to specialist training programmes. There is also evidence that taking part in regular tai chi sessions can help reduce the risk of falls in the elderly; I am sure this would work for MSers. Tai chi works by improving balance and co-ordination. 
Review your medication: 
  • Drugs that increase sedation increase your risk of falls. 
  • In addition to poor balance and abnormal postural righting reflexes poor vision increases your risk of having a fall. If you have visual problems you may need to been seen by an eye clinic to see if anything can be done to improve vision. 
  • Drinking alcohol exacerbates MS-related inco-ordination and exaggerate the effects of sedatives. A large number of MSers drink excessively. Please try and not drink alcohol, or at least reduce your consumption. If you have an alcohol dependency problem ask for help. 

The other factor is bone health. MSers are more likely to have thin bones due to a number of potential factors; for example physical inactivity, low vitamin D levels, repeated course of steroids, the use of concomitant medication that reduces vD levels and/or thin bones further, smoking, excessive alcohol intake, etc. We routinely request bone density scans or DEXA scans in MSers at risk of falls and treat them if we find them to be osteopenic. Yes, there are many effective therapies available for osteopenia and osteoporosis. We also make sure all our MSers take vitamin D supplements with the aim of keeping them vD replete. The driver behind our routine vD supplementation programme in established MS is bone health rather than disease modification. I am personally not convinced of the evidence that vD modifies the course of MS. 

I suppose the elephant in the room is if we prevented MSers becoming disabled in the first place, they wouldn't have balance and visual problems, nor would they have thin bones and hence won't fall and fracture bones. This brings us back to the argument for early and effective DMTs to prevent, or delay the onset of disability. I know I sound like a stuck record, but using DMTs as a preventive measure is very important. 

Falls and fractures has not passed us by as a crude but important outcome measure. We are currently looking into whether or not DMTs prevent falls and fractures. This could be another metric to prove, or disprove, whether or not DMTs are effective in the long-term. If we can show that early and effective use of DMTs reduces falls and fractures in the future it would be another argument to support adoption of early effective treatment in MS."

Su et al. The association between multiple sclerosis and fracture risk. Int J Clin Exp Med. 2014 Nov 15;7(11):4327-31. eCollection 2014.

Background: Several studies were performed to assess the association between multiple sclerosis (MS) and fracture risk. However, the results were inconsistent and inconclusive. 

Aim: In the present study, the possible association was investigated by a meta-analysis. 

Methods: Eligible articles were identified for the period up to August 2014. Pooled risk ratios (RR) with 95% confidence intervals (CI) were appropriately derived from random-effects models. Nine studies with more than 9,000,000 subjects were eligible. 

Results: We found that MS was significant associated with fracture risk in overall population (OR = 1.58, 95% CI 1.36-1.84, P < 0.01). In terms of subgroup analyses by fracture sites, the associations were significant in femur (RR = 4.57, 95% CI 3.01-6.69, P < 0.01), hip (RR = 3.01, 95% CI 2.72-3.41, P < 0.01), tibia (RR = 2.72, 95% CI 2.22-3.32, P < 0.01), humerus (RR = 1.78, 95% CI 1.12-2.40, P = 0.02), pelvis (RR = 1.34, 95% CI 1.12-1.67, P < 0.01), and vertebrae (RR = 1.30, 95% CI 1.13-1.69, P < 0.01). 

Conclusion: This meta-analysis suggested that MS may be associated with fracture development.

CoI: multiple

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