submit to the journals

Multiple Sclerosis and Falls—An Evolving Tale

US Neurology 2013;9(1):30–4 DOI:


Falls are a common health concern in the multiple sclerosis (MS) community with one out of two individuals with MS reporting a fall in the previous 6 months. Falls often lead to physical injury and have been found to be associated with reduced participation and quality of life. These adverse consequences underscore the importance of identifying risk factors for falls in MS so that appropriate interventions can be designed and tested. Ongoing research has suggested that clinical disability, balance, and gait impairment are related to past and future falls. The data also suggest that cognitive impairment is related to falls. Fortunately, it appears that these fall risk factors and falls per se can be reduced with targeted interventions in persons with MS. However, the most effective fall-prevention strategy in persons with MS has yet to be elucidated. Ultimately, the reduction of falls in persons with MS has the potential to improve participation and quality of life.
Keywords: Falls, multiple sclerosis, rehabilitation, balance, gait, cognition, participation
Disclosure: The authors have no conflicts of interest to declare.
Received: May 21, 2013 Accepted: June 25, 2013
Correspondence: Jacob J Sosnoff, PhD, University of Illinois at Urbana-Champaign, Department of Kinesiology and Community Health, 301 Freer Hall, 906 South Goodwin Ave, Urbana, IL, US. E:
An erratum to this article can be found below.

Multiple sclerosis (MS) is a chronic, often disabling, neurologic disease, common among adults worldwide and in the US.1 It has a heterogeneous geographical prevalence with higher rates reported in Central and Northern Europe, North America, and Australia than for Asia, Africa, and South America.2 There are believed to be over 400,000 persons with MS in the US and 2.1 million worldwide. The majority of people with MS are typically diagnosed between 20 and 50 years of age, and women are affected two to three times more often than men. The exact cause of MS is not clear, but it is believed to result from a combination of genetic and environmental factors.3

This disease process involves intermittent bursts of focal inflammation across the central nervous system (CNS).4 The inflammatory process results in the demyelination and transection of axons throughout the CNS. The resulting damage leads to conduction delays and blockage of action potentials along nerve axons.4 This interference with neuronal conduction throughout the nervous system is associated with a heterogeneous array of functional impairments and symptoms including (but not limited to) muscle weakness, cognitive impairment, sensory disturbances, and a decline in postural control and gait function.1

Given these symptoms it is not at all surprising that falls are common in persons with MS. Indeed, over 50 % of persons with MS report falling over a 6-month period.5–8 Perhaps more alarming, the majority of those who do fall require medical attention for injuries.9,6,10 For example, persons with MS are four times more likely to suffer a hip fracture brought about by a fall than age- and gender-matched peers without MS.11 This elevated fracture risk stems from low bone mineral density and osteoporosis in persons with MS.12,13 Lastly, persons with MS who have previously fallen report worse physical and psychologic health status (i.e. health-related quality of life [QoL]) compared with nonfallers with MS.7

Falls can further have an adverse impact on fear of falling and falls selfefficacy and contribute to activity curtailment, physiologic deconditioning, loss of independence, and institutionalization.14,15 For instance, approximately 64 % of persons with MS have an increased fear of falling and, of those individuals, 83 % reported activity curtailment.16 Another study documented that approximately 75 % of community-dwelling persons with MS who have fallen in the last 6 months self-reported activity restriction due to concerns about falling.15 Recently, these self-reports of activity curtailment in persons with MS who have fallen were confirmed with objectively measured ambulatory physical activity (e.g. accelerometry). Specifically, persons with MS who had fallen in the last year had lower amounts of physical activity than persons with MS who had not fallen.17

One caveat to consider when reviewing the majority of research concerning consequences of falls in persons with MS is that all of the studies that support this disability-disuse cycle are cross-sectional in nature. Consequently, it is unclear whether falls truly lead to decreased activity and physiologic deconditioning as proposed or rather falls are unrelated to activity, physiologic deconditioning, and QoL. Ideally, the best way to determine whether there is a strong relation between these variables in persons with MS would be to conduct longitudinal investigations. If such an association is noted, we would further propose that it is worthwhile to explore the possibility that physical activity promotion18 can counteract the fall-related decline in physical activity and potentially minimize physiologic deconditioning and reductions in QoL.

There is sufficient evidence to conclude that persons with MS are at elevated risk for falls compared with healthy individuals of a similar age and that falls seemingly have significant negative effect on QoL stemming from physical injury and reduction in participation. Such observations underscore the importance of identifying risk factors for falls in MS. The main risk factors, if modifiable, can become the focus of targeted interventions designed for reducing falls and the life-altering effects on secondary outcomes such as compromised QoL and/or participation.

Fall Risk Factors in Persons with Multiple Sclerosis
The first step to fall risk prevention in any given clinical population involves an understanding of those factors that can contribute to such occurrences. This is necessary for both identifying individuals at risk for future falls and also for providing information that can be used to design appropriate therapeutic interventions that target a reduction in fall occurrence. Such an approach has been widely adopted in the gerontology literature that serves as a backdrop for the discussion of falls risk and prevention in persons with MS.19

Accordingly, we highlight major observations from the well-developed and characterized falls literature among older adults, another population that has considerable risk for falls. One of the most important observations is that falls are preventable with interventions designed to target specific risk factors.19,20 While previous studies have reported upward of over 400 potential fall risk factors for older adults,21 the primary risk factors include sensorimotor function, general balance, and walking ability.22,23 Linked to these factors is the evidence that highlights that impairments in muscle strength and coordination are also strong predictors of falls in older adults.21,24–27 Not surprisingly, interventions that target these specific factors have been the most widely developed and implemented. Overall, these interventions have been found to effectively reduced physiologic falls risk and fall incidence in older adults.19,20,24,27

It is important to note that although the geriatric literature offers important insights in terms of falls in the older adult, there are notable differences between persons with MS and healthy older adults regarding specific risk factors leading to falls. For instance, assessment of falls risk using standard tools developed for geriatric populations such as the physiologic profile assessment (PPA) illustrate that the overall risk for a future fall is greater for persons with MS than older adults (see Figure 1). Indeed, persons with MS without a fall history have a higher risk for falls even than older adults who have not fallen. This observation highlights the need to develop disease/patient specific falls risk models.

  1. Noseworthy JH, Lucchinetti C, Rodriguez M, Weinshenker BG, Multiple sclerosis, N Engl J Med, 2000;343(13):938–52.
  2. Koch-Henriksen N, Sorensen PS, The changing demographic pattern of multiple sclerosis epidemiology, Lancet Neurol, 2010;9(5):520–32.
  3. Lassmann H, Bruck W, Lucchinetti CF, The immunopathology of multiple sclerosis: an overview, Brain Pathol, 2007;17(2):210–18.
  4. Bjartmar C, Trapp BD, Axonal and neuronal degeneration in multiple sclerosis: mechanisms and functional consequences, Curr Opin Neurol, 2001;14(3):271–8.
  5. Cattaneo D, De Nuzzo C, Fascia T, et al., Risks of falls in subjects with multiple sclerosis, Arch Phys Med Rehabil, 2002;83(6):864–7.
  6. Matsuda PN, Shumway-Cook A, Bamer AM, et al., Falls in multiple sclerosis, PM R, 2011;3(7):624–32; quiz 632.
  7. Coote S, Hogan N, Franklin S, Falls in people with MS who use a walking aid: Prevalence, factors and effect of balance and strengthening interventions, Arch Phys Med Rehabil, 2013;94(4):616–21.
  8. Finlayson ML, Peterson EW, Cho CC, Risk factors for falling among people aged 45 to 90 years with multiple sclerosis, Arch Phys Med Rehabil, 2006;87(9):1274–9; quiz 1287.
  9. Peterson EW, Cho CC, von Koch L, Finlayson ML, Injurious falls among middle aged and older adults with multiple sclerosis, Arch Phys Med Rehabil, 2008;89(6):1031–7.
  10. Cameron MH, Poel AJ, Haselkorn JK, et al., Falls requiring medical attention among veterans with multiple sclerosis: a cohort study, J Rehabil Res Dev, 2011;48(1):13–20.
  11. Bazelier MT, van Staa T, Uitdehaag BM, et al., The risk of fracture in patients with multiple sclerosis: the UK general practice research database, J Bone Miner Res, 2011;26(9):2271–9.
  12. Dobson R, Ramagopalan S, Giovannoni G, et al., Risk of fractures in patients with multiple sclerosis: a populationbased cohort study, Neurology, 2012;79(18):1934–5.
  13. Dobson R, Ramagopalan S, Giovannoni G, Bone health and multiple sclerosis, Mult Scler, 2012;18(11):1522–8.
  14. Finlayson ML, Peterson EW, Falls, aging, and disability, Phys Med Rehabil Clin N Am, 2010;21(2):357–73.
  15. Matsuda PN, Shumway-Cook A, Ciol MA, et al., Understanding falls in multiple sclerosis: association of mobility status, concerns about falling, and accumulated impairments, Phys Ther Mar, 2012;92(3):407–15.
  16. Peterson EW, Cho CC, Finlayson ML, Fear of falling and associated activity curtailment among middle aged and older adults with multiple sclerosis, Mult Scler, 2007;13(9):1168–75.
  17. Sosnoff JJ, Sandroff BM, Pula JH, et al., Falls and physical activity in persons with multiple sclerosis, Mult Scler Int, 2012;2012:315620.
  18. Motl RW, Dlugonski D, Wojcicki TR, et al., Internet intervention for increasing physical activity in persons with multiple sclerosis, Mult Scler, 2011;17(1):116–28.
  19. Gillespie LD, Robertson MC, Gillespie WJ, et al., Interventions for preventing falls in older people living in the community, Cochrane Database Syst Rev, 2012;9:CD007146.
  20. Stel VS, Smit JH, Pluijm SM, Lips P, Balance and mobility performance as treatable risk factors for recurrent falling in older persons, J Clin Epidemiol, 2003;56(7):659–68.
  21. Clark RD, Lord SR, Webster IW, Clinical parameters associated with falls in an elderly population, Gerontology, 1993;39(2):117–23.
  22. Lord SR, Ward JA, Age-associated differences in sensori-motor function and balance in community dwelling women, Age Ageing, 1994;23(6):452–60.
  23. Fasano A, Plotnik M, Bove F, Berardelli A, The neurobiology of falls, Neurol Sci, 2012;33(6):1215–23.
  24. Lord SR, Falls in older people: risk factors and strategies for prevention, 2nd ed, Cambridge/New York: Cambridge University Press, 2007.
  25. Lord SR, Menz HB, Tiedemann A, A physiological profile approach to falls risk assessment and prevention, Phys Ther, 2003;83(3):237–52.
  26. Horak FB, Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls?, Age Ageing, 2006;35(Suppl. 2):ii7–ii11.
  27. Nutt JG, Horak FB, Bloem BR, Milestones in gait, balance, and falling, Mov Disord, 2011;26(6):1166–74.
  28. Gunn HJ, Newell P, Haas B, et al., Identification of Risk Factors for Falls in Multiple Sclerosis: A Systematic Review and Meta- Analysis, Phys Ther, 2013;93(4):504–13.
  29. Sosnoff JJ, Socie MJ, Boes MK, et al., Mobility, balance and falls in persons with multiple sclerosis, PLoS One, 2011;6(11):e28021.
  30. Socie MJ, Sandroff BM, Pula JH, et al., Footfall Placement Variability and Falls in Multiple Sclerosis, Ann Biomed Eng, 2013;41(8):1740–47.
  31. Prosperini L, Kouleridou A, Petsas N, et al., The relationship between infratentorial lesions, balance deficit and accidental falls in multiple sclerosis, J Neurol Sci, 2011;304(1–2):55–60.
  32. Prosperini L, Sbardella E, Raz E, et al., Multiple Sclerosis: White and Gray Matter Damage Associated with Balance Deficit Detected at Static Posturography, Radiology, 2013;268(1):181–9.
  33. D’Orio VL, Foley FW, Armentano F, et al., Cognitive and motor functioning in patients with multiple sclerosis: neuropsychological predictors of walking speed and falls, J Neurol Sci, 2012;316(1–2):42–6.
  34. Sosnoff JJ, Balantrapu S, Pilutti LA, et al., Cognitive Processing Speed Is Related to Fall Frequency in Older Adults With Multiple Sclerosis, Arch Phys Med Rehabil, 2013; [Epub ahead of print].
  35. Nilsagard Y, Lundholm C, Denison E, Gunnarsson LG, Predicting accidental falls in people with multiple sclerosis—a longitudinal study, Clin Rehabil, 2009;23(3):259–69.
  36. Kasser SL, Jacobs JV, Foley JT, et al., A prospective evaluation of balance, gait, and strength to predict falling in women with multiple sclerosis, Arch Phys Med Rehabil, 2011;92(11):1840– 46.
  37. Prosperini L, Fortuna D, Gianni C, et al., The diagnostic accuracy of static posturography in predicting accidental falls in people with multiple sclerosis, Neurorehabil Neural Repair, 2013;27(1):45–52.
  38. Mirelman A, Herman T, Brozgol M, et al., Executive function and falls in older adults: new findings from a five-year prospective study link fall risk to cognition, PLoS One, 2012;7(6):e40297.
  39. Segev-Jacubovski O, Herman T, Yogev-Seligmann G, et al., The interplay between gait, falls and cognition: can cognitive therapy reduce fall risk?, Expert Rev Neurother, 2011;11(7):1057–75.
  40. Hayes HA, Gappmaier E, LaStayo PC, Effects of high-intensity resistance training on strength, mobility, balance, and fatigue in individuals with multiple sclerosis: a randomized controlled trial, J Neurol Phys Ther, 2011;35(1):2–10.
  41. Motl RW, Pilutti LA, The benefits of exercise training in multiple sclerosis, Nat Rev Neurol, 2012;8(9):487–97.
  42. Motl RW, Smith DC, Elliott J, et al., Combined training improves walking mobility in persons with significant disability from multiple sclerosis: a pilot study, J Neurol Phys Ther, 2012;36(1):32–7.
  43. Snook EM, Motl RW, Effect of exercise training on walking mobility in multiple sclerosis: a meta-analysis, Neurorehabil Neural Repair, 2009;23(2):108–16.
  44. Coote S, Hogan N, Franklin S, Falls in People With Multiple Sclerosis Who Use a Walking Aid: Prevalence, Factors, and Effect of Strength and Balance Interventions, Arch Phys Med Rehabil, 2013;94(4):616–21.
  45. Michael YL, Lin JS, Whitlock EP, et al., Interventions to Prevent Falls in Older Adults: An Updated Systematic Review, US Preventive Services Task Force Evidence Syntheses, 2010.
  46. Tinetti ME, Brach JS, Translating the fall prevention recommendations into a covered service: can it be done, and who should do it?, Ann Int Med, 2012;157(3):213–14.
  47. Tinetti ME, Making prevention recommendations relevant for an aging population, Ann Int Med, 2010;153(12):843–4.
  48. Thurman DJ, Stevens JA, Rao JK, Practice parameter: Assessing patients in a neurology practice for risk of falls (an evidencebased review): report of the Quality Standards Subcommittee of the American Academy of Neurology, Neurology, 2008;70(6):473–9.
  49. Gunn H, Creanor S, Haas B, et al., Risk factors for falls in multiple sclerosis: an observational study, Mult Scler, 2013; [Epub ahead of print].
  50. Cattaneo D, Jonsdottir J, Zocchi M, Regola A, Effects of balance exercises on people with multiple sclerosis: a pilot study, Clin Rehabil, 2007;21(9):771–81.
  51. Gunn HJ, Newell P, Haas B, et al., Identification of risk factors for falls in multiple sclerosis: a systematic review and metaanalysis, Phys Ther, 2013;93(4):504–13.
  52. Day LM, Fall prevention programs for community-dwelling older people should primarily target a multifactorial intervention rather than exercise as a single intervention, J Am Geriatr Soc, 2013;61(2):284–5; discussion 285–6.
  53. Finlayson M, Peterson EW, Cho C, Pilot study of a fall risk management program for middle aged and older adults with MS, NeuroRehabilitation, 2009;25(2):107–15.
  54. Coote S, McKeown G, Shannon M, A profiling study of people with multiple sclerosis who access physiotherapy services in Ireland, Int J MS Car, 2010;12(3):115–21.
  55. Einarsson U, Gottberg K, Fredrikson S, et al., Activities of daily living and social activities in people with multiple sclerosis in Stockholm County, Clin Rehabil, 2006;20(6):543–51.
  56. Kirby RL, Ackroyd-Stolarz SA, Brown MG, et al., Wheelchairrelated accidents caused by tips and falls among noninstitutionalized users of manually propelled wheelchairs in Nova Scotia, Am J Phys Med Rehabil, 1994;73(5):319–30.
  57. Nelson AL, Groer S, Palacios P, et al., Wheelchair-related falls in veterans with spinal cord injury residing in the community: a prospective cohort study, Arch Phys Med Rehabil, 2010;91(8):1166–73.
  58. Gavin-Dreschnack D, Nelson A, Fitzgerald S, et al., Wheelchairrelated falls: current evidence and directions for improved quality care, J Nurs Care Qual, 2005;20(2):119–27.
Keywords: Falls, multiple sclerosis, rehabilitation, balance, gait, cognition, participation
pdf icon Errata pdf