Tag: fractures

#T4TD falls and fractures

Did you know that people with MS have a six times higher risk than age-matched controls of having a long bone fracture of the lower limb?

The reason for this is that pwMS often have balance problems, unsteadiness of gait (ataxia), lower limb weakness (dropped foot) and are maybe excessively sedated from their medications. All these factors increase your chances of falling. In addition, pwMS are at high risk of poor bone health (osteopaenia or osteoporosis) due to inactivity, reduced outdoor activity, low vitamin D levels, steroid treatment and comorbidities such as smoking. 

falls + poor bone health = increased long bone fractures

Why is this so important? A lower limb long bone fracture is one of the events that can tip someone with MS from being independent into becoming dependent and is often the trigger for needing a wheelchair. In addition, people with advanced MS don’t rehabilitate very well because they have reduced reserve and are usually quite disabled. 

How do you know if you are at risk of falls and fractures? We have shown that the best predictor of falls is the need for a walking aid (splint, stick, crutch, frame, functional electrical stimulator, etc.). If you are using a walking aid and are having falls, or near falls, you need to see a physiotherapist to be enrolled in a falls prevention programme and you will also need to have your bone density checked. This latter can be assessed via several methods, but the commonest is called a DEXA scan (dual-energy X-ray absorptiometry scan). If you are found to be osteopaenic or osteoporotic you may need treatment. 

Falls and fracture prevention is another self-management task; please don’t ignore it!

Prevention is better than treating the consequences of falls and fractures. For example, one of my patients with MS tragically fell going to the toilet at night. She crashed into a mirror that shattered and lacerated her arm and severed her brachial artery. She tragically bled to death as she lived alone, did not have an alert dongle around her neck and was unable to get herself up off the floor. Ever since she died I have taken falls prevention very seriously. Can you please do the same? You never know it may even save your life. 

Long bones of the lower limbs = femur, tibia and fibula

#T4TD = Thought for the Day

CoI: none for this post

Foot drop

The study below tried to compare the clinical effectiveness of ankle-foot orthoses (AFOs) and functional electrical stimulation (FES) and whether or not they were cost effective. The high drop-out rate (38%) made the study inconclusive.

When we, at Barts-MS, did a clinical audit a few years ago we showed that the best predictor of falls was the need to use a walking aid; e.g. walking stick, chair, AFO or FES. Falls in MSers are a major cause of morbidity and in fact mortality and are the 3rd or 4th most common reason why MSers need urgent, or unplanned, hospital admissions. Falls lead to head injuries and frequently cause fractures. For example, in the last 4 weeks, I have seen three patients who sustained fractures as a result of falls; one a fractured scaphoid bone in the wrist, another a fractured ankle and the third a fractured humerus and clavicle.

AFO

If you are tripping and/or falling please ask your neurologist or MS nurse to assess you to see if you need a physio assessment to reduce your risk of falls. Prevention is better than having to deal with the consequences of falls.

When it comes to ankle-foot orthoses (AFOs) or functional electrical stimulation (FES) they both do the job equally well. Some people can’t tolerate AFOs (too bulky and unsightly) and others can’t tolerate FES devices (too finicky and/or painful). In addition, to these two options, there is a multitude of other options for MS-related foot drop that are available to you. If you don’t ask you won’t find out.

FES

If you are at risk of falls you need to look into your bone health. This requires a bone density or DEXA scan. MSers are at high risk of having thin bones (osteopaenia or osteoporosis) and may need medication to try and reverse this.

Renfrew et al. The clinical- and cost-effectiveness of functional electrical stimulation and ankle-foot orthoses for foot drop in Multiple Sclerosis: a multicentre randomized trial. Clin Rehabil. 2019 Apr 11:269215519842254. doi: 10.1177/0269215519842254.

OBJECTIVE: To compare the clinical- and cost-effectiveness of ankle-foot orthoses (AFOs) and functional electrical stimulation (FES) over 12 months in people with Multiple Sclerosis with foot drop.

DESIGN: Multicentre, powered, non-blinded, randomized trial.

SETTING: Seven Multiple Sclerosis outpatient centres across Scotland.

SUBJECTS: Eighty-five treatment-naïve people with Multiple Sclerosis with persistent (>three months) foot drop.

INTERVENTIONS: Participants randomized to receive a custom-made, AFO ( n = 43) or FES device ( n = 42).

OUTCOME MEASURES: Assessed at 0, 3, 6 and 12 months; 5-minute self-selected walk test (primary), Timed 25 Foot Walk, oxygen cost of walking, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, Modified Fatigue Impact Scale, Euroqol five-dimension five-level questionnaire, Activities-specific Balance and Confidence Scale, Psychological Impact of Assistive Devices Score, and equipment and National Health Service staff time costs of interventions.

RESULTS: Groups were similar for age (AFO, 51.4 (11.2); FES, 50.4(10.4) years) and baseline walking speed (AFO, 0.62 (0.21); FES 0.73 (0.27) m/s). In all, 38% dropped out by 12 months (AFO, n = 21; FES, n = 11). Both groups walked faster at 12 months with device ( P < 0.001; AFO, 0.73 (0.24); FES, 0.79 (0.24) m/s) but no difference between groups. Significantly higher Psychological Impact of Assistive Devices Scores were found for FES for Competence ( P = 0.016; AFO, 0.85(1.05); FES, 1.53(1.05)), Adaptability ( P = 0.001; AFO, 0.38(0.97); FES 1.53 (0.98)) and Self-Esteem ( P = 0.006; AFO, 0.45 (0.67); FES 1 (0.68)). Effects were comparable for other measures. FES may offer value for money alternative to usual care.

CONCLUSION: AFOs and FES have comparable effects on walking performance and patient-reported outcomes; however, high drop-outs introduces uncertainty.

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