Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2013;94:616-21

ORIGINAL ARTICLE

Falls in People With Multiple Sclerosis Who Use a Walking Aid:

Prevalence, Factors, and Effect of Strength and Balance
Interventions
Susan Coote, PhD, Neasa Hogan, PhD, Sue Franklin, PhD
From the Department of Clinical Therapies & Centre for Physical Activity and Health Research, University of Limerick, Limerick, Ireland.

Abstract
Objectives: To investigate falls prevalence, factors associated with falling, and the effects of balance and strengthening interventions on falls in
persons with multiple sclerosis (MS).
Design: Baseline and posttreatment data from a randomized controlled trial.
Setting: Community.
Participants: People with MS (NZ111) who use bilateral support for gait.
Interventions: Group and one-on-one physiotherapy.
Main Outcome Measures: Falls prevalence was assessed using retrospective recall. Demographic information was collected, impairments of body
function were assessed, and results from the Berg Balance Scale, 6-minute walk test (6MWT), Multiple Sclerosis Impact Scale-29 version 2
physical and psychological scores, and the Modified Fatigue Impact Scale (MFIS) were obtained.
Results: The prevalence of falls in a 3-month period was 50.5% among participants with MS, of whom 28% had more than 1 fall. Fallers had
a greater physical (mean difference,
3.9; PZ.048) and psychological (median difference,
4.5; PZ.001) impact of MS and a greater impact of
fatigue (mean difference,
9.4; PZ.002). A logistic regression analysis found that the MFIS score made a unique, significant contribution to the
model (odds ratioZ1.04; 95% confidence interval, 1.018e1.079), correctly identifying 68% of fallers. A 10-week group physiotherapy intervention significantly reduced both the number of fallers (58.3% before to 22.9% after intervention, PZ.005) and the number of falls (63 before to
25 after intervention, PZ.001).
Conclusions: The prevalence of falls is high in this population of persons with MS, and the impact of MS and of fatigue is greater in fallers.
Development and evaluation of interventions to reduce falls risk and the transition to faller or multiple faller status are required.
Archives of Physical Medicine and Rehabilitation 2013;94:616-21
2013 by the American Congress of Rehabilitation Medicine

Falls are a significant problem for both the person who falls and
the health care system. At a personal level, falls can lead to pain,
injury, or fracture. This can lead to increased reliance on others for
assistance, fear of falling, and activity curtailment. At a societal
level, the medical costs of falls and fractures are great, as are the
costs incurred because of loss of income and increased care needs.
For people with multiple sclerosis (MS), the prevalence of
falls is estimated to be between 52% and 55% in retrospective
Presented to the European Committee for Treatment and Research in Multiple Sclerosis,
October 1316, 2010, Gothenburg, Sweden.
Supported by Multiple Sclerosis Ireland through the Getting the Balance Right Project.
No commercial party having a direct financial interest in the results of the research supporting
this article has or will confer a benefit on the authors or on any organization with which the authors
are associated.
Clinical Trial Registration Number: ISRCTN77610415.

studies1-3 considering self-reported falls in the last 2 to 12 months.

Prospective reports suggest similar proportions, with between
48%4 and 63%5 of people falling. This is significantly greater than
the prevalence in elderly populations where a large epidemiologic6 study suggested that 15.9% of elderly people fell in
a 3-month period.
In addition to a higher incidence of falling, people with MS
have an increased fracture risk because of a reduction in bone
mineral density as a result of decreased mobility, vitamin D
deficiency, and the use of glucocorticoids and antidepressants.7
Recent studies in the United Kingdom8 and the Netherlands9
found that the risk of hip fracture in people with MS was higher
than in the general population, and that people with MS with
a history of falling had double the risk of osteoporotic fracture.8
The incidence of falls was significantly greater in people with

0003-9993/13/$36 - see front matter 2013 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2012.10.020

Falls in people with multiple sclerosis who use a walking aid

MS10 than in healthy controls, even in those in the early course of
MS. The risk of an injurious fall was 3 times higher for women
veterans with MS than for women veterans without MS after
controlling for age and number of clinic visits.11
Several studies have investigated the factors relating to falls in
people with MS. The factors that are most common are deficits of
balance (7 studies),1,2,4,12-15 walking aid use and lower mobility
status (6 studies2,5,12,14,16,17), and a higher Expanded Disability
Status Score (6 studies4,5,10,13,14,17). Other authors have found that
impairments of muscle tone and proprioception,5 continence,1
brainstem and middle cerebellar peduncal lesions,13 and
increasing numbers of symptoms16 are associated with falls. Fear
of falling and activity curtailment,18 and cognitive deficits17 are
also associated with falls in people with MS. There are a variety of
symptoms that predict falling. The fact that these symptoms can
occur in various combinations highlights the complexity of this
problem and its management.
Despite the increased prevalence of falls and related injuries,
and the ever-increasing body of work to investigate the factors
associated with falls in people with MS, there are very few studies
with the aim of reducing fall risk or that evaluate falls as an
outcome. Although several studies19-21 have reported positive
outcomes on balance, only 2 studies were found that have
considered number of falls as an outcome. Cattaneo et al19 evaluated balance programs based on sensory and motor strategies,
and motor strategies alone and found a significant difference
between groups in the number of falls that was not present
preintervention. Esnouf et al22 found that those people using
a drop-foot stimulator had significantly fewer falls than those
participating in an exercise program focusing on core stability.
While both studies suggest positive outcomes on number of falls,
the small number of studies highlights the need for development
and evaluation of interventions to reduce both fall risk and the
number of falls.
The aim of this article is to present the falls data for a cohort
of people with MS who were assessed as part of a randomized
controlled trial of interventions for people with MS who use
bilateral assistance to walk outdoors. The article presents data on
falls prevalence over a 3-month period before intervention, the
factors associated with falls, and the effect of 2 physiotherapy
interventions and yoga on number of fallers and number of falls in
the sample.

Methods
These data were part of the baseline assessments of 1 arm of an
exercise trial, the methods of which have been published previously.23 Participants were stratified according to their mobility, and
these data include people with MS who scored 3 or 4 on the Guys
Neurological Disability Rating Scale (GNDS) mobility section
(indicating use of bilateral aids for gait and/or occasional wheelchair use for longer distances). Ethical approval was obtained for all
the testing sites, and patients gave written informed consent.

617

Measures
A fall was defined as an unexpected contact of any part of the
body with the ground. Falls status was established by asking
2 questions: (1) Have you ever fallen? and (2) Have you fallen in
the last 3 months? If participants responded yes to the second
question, they were asked how many times they had fallen in the
last 3 months. Participants were asked retrospectively about the
number of falls in the 3 months before the baseline assessment.
They then received the interventions for a 10-week period and
were reassessed at week 12, during which they were asked about
the number of falls in the 3 months before that assessment.
At impairment level, lower limb sensation was evaluated using
a simple verbal numerical rating scale, with 0 indicating no feeling
at all and 10 indicating normal sensation. Three areas of the lower
limb were tested bilaterally; thus a total of 60 indicated normal
sensation. Proprioception was assessed by placing participants
big toe in an up or down position and asking participants to
identify where their toe was. It was scored as either normal
or abnormal.
At activities level, balance was assessed using the Berg Balance
Scale (BBS), a 14-item clinical scale that evaluates balance in
sitting and standing and rates performance from 0 (cannot
perform) to 4 (normal performance). It has been demonstrated to
have good reliability24 and validity25 for people with MS. Walking
endurance was measured using the 6-minute walk test (6MWT).
This measures walking distance over a 6-minute period and is
a good predictor of habitual walking.26 Studies have suggested that
it is valid27 and reliable28 for people with MS. Subjects were
instructed to walk as fast and as safely as possible.29
At participation level, the Multiple Sclerosis Impact Scale-29
version 230 (MSIS-29v2) physical and psychological components
were used. The impact of fatigue was measured using the Modified Fatigue Impact Scale31 (MFIS).
The data from the baseline assessments in week 1 were used in
this analysis.

Interventions
Participants were randomly assigned to take part in group physiotherapy, one-to-one physiotherapy, or yoga. All interventions
were for 1 hour per week for 10 weeks. The median number of
sessions attended was 8, 9, and 8 for group physiotherapy, one-toone physiotherapy, and yoga, respectively. The group physiotherapy intervention focused on a standardized program of
6 exercises designed to target both balance and strength, and is
outlined in the study protocol.23 One-to-one physiotherapy was at
the discretion of the treating therapist, but data gathered from the
treating therapists revealed that they also focused on exercises to
improve balance and strength. Data from the yoga instructors
suggested that they focused on relaxation exercises, meditation,
breathing techniques, stretching, and maintaining different yogic
postures and poses.

List of abbreviations:
BBS
GNDS
MFIS
MS
MSIS-29v2
6MWT

Berg Balance Scale

Guys Neurological Disability Rating Scale
Modified Fatigue Impact Scale
multiple sclerosis
Multiple Sclerosis Impact Scale-29 version 2
6-minute walk test

www.archives-pmr.org

Analysis
Data were coded and entered into an Excela spreadsheet and
imported into SPSSb for analysis. Descriptive statistics were used
to identify the prevalence of falls in the cohort. To assess any
significant differences between fallers and nonfallers for the

618

S. Coote et al

potential risk factors, independent t tests were used for continuous

data that were normally distributed, Mann-Whitney U tests were
performed on data that were abnormally distributed, and chisquare tests for independence were used for categorical data.
Based on the existing literature for falls prediction, the
hypothesis was that sex, age, time since diagnosis, lower limb
sensation, proprioception, BBS score, GNDS score (disability),
and 6MWT distance (mobility) would predict falling. Based on
the finding that Multiple Sclerosis Impact Scale-29 version 2
(MSIS-29v2) and MFIS scores were greater for fallers, the impact
of fatigue (MFIS) and impact of MS (MSIS-29v2 physical and
psychological scores) were also added to the model. The dependent variable for the analysis was the number of falls in the last 3
months, coded as 0 for no falls or 1 for one or more falls. Given
the dichotomous nature of the variable, a bivariate logistic
regression was used.
To ensure that multicollinearity was not an issue, variables with
a Spearman correlation coefficient greater than 0.6 were omitted
from the model. On this basis, the MSIS-29v2-psychological
component was omitted because it was significantly correlated
with both the MSIS-29v2-physical (.60, P<.001) and MFIS (.64,
P<.001) variables. Model selection was performed on the final set
of 10 potential covariates by using 3 different model selection
methods: enter, backward conditional, and forward conditional.
For all models, a P value of .05 was used for both entry into and
remaining in the model. The models obtained from the 3 methods
were then compared to assess whether there were discrepancies.
To assess the effect of the intervention on the proportion of
fallers (people who reported 1 or more falls in the last 3 months),
the McNemar test was used to analyze the data. The Wilcoxon
signed-rank test was used to analyze the difference in number of
falls pre- and postintervention.

reporting more than 1 fall in the previous 3 months (nZ31) made

up 27.9% of the total sample. The number of falls in the previous
3 months ranged from 1 to 18, with a mean of 3 falls per faller
during that time. When considering only those participants with
more than 1 fall, they had a mean of 4.5 falls each in the previous
3 months.
Table 1 presents the differences between fallers and nonfallers
for a number of symptoms and outcome measures. Fallers reported a significantly greater physical and psychological impact of
MS and a significantly greater impact of fatigue.
There was agreement in all 3 regression models in terms of the
significant variables in the model. The forward and backward
conditional models concurred and were significant (P<.001,
c21Z11.762, nZ94), indicating the model was able to distinguish
between fallers and nonfallers. The model as a whole explained
between 11.8% (Cox & Snell r2) and 15.7% (Nagelkerke r2) of
the variance in fall status, correctly classifying 68.1% of fallers.
Only 1 variable made a unique, statistically significant contribution
to the model. A higher MFIS score (PZ.002), indicating greater
impact of fatigue, recorded an odds ratio of 1.048 (95% confidence
interval, 1.018e1.079). The P value for the Hosmer and Lemeshow
goodness-of-fit test suggested no evidence of lack of fit (PZ.400).
Table 2 presents the number and percent of fallers and number
of falls in each group before and after the interventions. There was
a significant reduction in both the number of fallers and the
number of falls after the group physiotherapy intervention.

Discussion
The results indicate that 50.5% of participants reported a fall in
the last 3 months. This suggests a similar prevalence to population
studies in the United States that also found prevalences of 52% to
55%.1,3 Because our sample considered only those who use
walking aids, and since walking aid use in itself has been found to
be associated with falls in previous studies,2,5,14 this prevalence is
somewhat lower than expected. It is possible that the shorter
period in the falls question (3mo in this study as opposed to 6 or
12mo in previous studies) may account for this. We found that

Results
Of the 111 participants assessed at baseline, 81.1% (nZ90)
answered yes to the question have you ever fallen, and 50.5%
(nZ56) reported 1 or more falls in the last 3 months. Those

Table 1

Differences between participants who reported a fall in the last 3 months and those who did not at baseline

Characteristic

Fallers (nZ56)

Nonfallers (nZ55)

Mean Difference (95% CI)

Age (y)
Sex (M/F)
GNDS mobility score 3/4
Time since diagnosis (y)
LL sensation (normal/abnormal)
Proprioception (normal/abnormal)
MSIS-29v2ephysical
MSIS-29v2epsychological
BBS
6MWT distance (m)
MFIS

55.610.4
17/38
33/23
16.65
27/25
34/20
549.5
19.5 (5.5)x
28.210
78 (41.5)x
46.714.1

54.711.1
23/32
33/21
14.13
31/23
37/15
50.310.8
15 (4)x
29.511
92.5 (49.5)x
3816.9

1.1 (
5.1 to 2.9)

.586*
.116y
.858y
.561*
.452y
.551y
.048*{
.001z{
.879*
.174z
.002*{

3.9 (
7.8 to
0.3)

4.5jj
1.2 (
3.9 to 4.5)
14.5jj

9.4 (
15.5 to
3.5)

NOTE. Values are mean  SD, n, or as otherwise indicated.

Abbreviations: CI, confidence interval; F, female; LL, lower limb; M, male.
* Independent t tests.
y
c2 test for independence.
z
Mann-Whitney U test.
x
Median (interquartile range).
jj
Median difference.
{
Statistically significant.

www.archives-pmr.org

Falls in people with multiple sclerosis who use a walking aid

Table 2

619

Number of fallers and falls pre- and postintervention

Intervention

Fallers Preintervention

Fallers Postintervention

P*

Total No. of Falls

Preintervention

Total No. of Falls

Postintervention

Py

Group physiotherapy (nZ48)

1-to-1 Physiotherapy (nZ35)
Yoga (nZ13)
Control (nZ15)

28
16
7
5

11
9
3
2

.005*
.118
.125
.375

63
61
25
14

25
21
8
2

.001z
.088
.091
.131

(58.3)
(45.7)
(53.8)
(33.3)

(22.9)
(25.7)
(23.1)
(13.3)

NOTE. Values are n (%) or as otherwise indicated.

* McNemar test.
y
Wilcoxon signed-rank test.
z
Statistically significant.

28% of the sample, which equates to 56% of fallers, reported more

than 1 fall in the last 3 months; this is similar to other studies
which reported that 45%15 of fallers reported multiple falls. These
data confirm that falls are a significant problem for people with
MS. The fall prevalence for this population (50%)2,3 is much
greater than that for the aging population (15%),6 which has been
the focus of a great deal of research to date. Given the increased
risk of fracture for people with MS,8 it is essential that greater
efforts are made to develop and evaluate falls prevention programs
for this population.
Of note is that fallers had a greater physical and psychological
impact of MS, represented by significantly higher scores on both
subsections of the MSIS-29v2. This finding provides further
compelling evidence for the need to address this issue, to improve
the quality of life for people with MS. Interestingly, the BBS
scores were not different between fallers and nonfallers. This
finding is in conflict with that of Cattaneo et al,12 who found
a significant difference between fallers and nonfallers on this
variable. While their mean BBS scores were 44 and 52, respectively, our population had much lower scores (28 and 29,
respectively), and all used walking aids. It is possible that walking
aid use in itself is the predictor of falls, and that other domains not
measured in this study are more greatly associated with fall status
for this more disabled subgroup of people with MS.
These data also suggest that fallers had a greater impact of
fatigue and that fatigue is the only significant predictor of falls
status among the variables considered in this study. Previously,
only Finlayson et al1 have considered fatigue as a variable and
found a difference between fallers and nonfallers in self-reported
fatigue, but fatigue did not remain in the final regression model of
falls status. The variables in this analysis considered demographics (sex, age, time since diagnosis), impairments of body
functions (proprioceptive deficit, sensory deficit), activity
(balance, walking endurance), disability (GNDS mobility score),
and participation (impact of MS and impact of fatigue) measures.
Despite the fact that variables such as age,1,14 balance,2,4 walking
aid use,2,14 and disability4,10 have been found to be significantly
associated with fallers in other studies, the only variable to emerge
as a unique and significant predictor of falls is the MFIS score.
The data suggest that for every 10-point increase in MFIS score,
there is a 10-fold increased likelihood of reporting a fall, and that
68% of fallers can be predicted by their MFIS score alone.
This new finding suggests that fatigue management strategies
may be an important element of falls prevention programs for people
with MS who use walking aids. The cause or effect relationship
between fatigue and falls requires further evaluation. Is a history of
falls and activity curtailment because of a fear of falling contributing
www.archives-pmr.org

to a lack of fitness and weakness caused by inactivity and hence

contributing to fatigue impact? Or is the peripheral element of
fatigue that affects muscle latencies and muscle endurance properties preventing normal balance responses and causing falls? These
complex relationships require further investigation.
These preliminary data from our exercise trial suggest that
a 10-week group physiotherapy intervention consisting of exercises to improve balance and strength can significantly reduce
both the proportion of fallers and the number of falls. This concurs
with the findings of Cattaneo,19 who also found reductions in falls
status after their balance interventions.
Interestingly, and similar to the findings of Cattaneo,19 the
control group also demonstrated a reduction (though nonsignificant in both studies) in falls. The simple act of asking about falls
may have made the participants more aware that they were falling
and led to a change in behavior as a result. Matsuda et al15 found
that only 50% of fallers talked to a health care professional about
falls. It may be important, therefore, to educate health care
professionals about the need to ask about falls in people with MS.
After a comprehensive search of the literature, only 2 studies
that considered the number of falls as an outcome for people with
MS were found. This is in contrast to the 111 studies included in
a Cochrane review of falls interventions in the elderly population,
whose falls prevalence is far less than that for persons with MS.
Studies with the primary aim of falls prevention for people with
MS, and with larger sample sizes and matched control groups are
urgently required.

Study limitations
Our data were obtained from people who volunteered for a clinical
trial of exercise interventions, rather than from a population study, as
is the case in the aforementioned studies. It is therefore possible that
our relatively small sample is biased toward those more predisposed
to exercise, possibly excluding those with significant activity
curtailment because of falls. Additionally, falls status was collected
using retrospective methods relying on patient recall over a 3-month
period rather than the more common 6-month time interval.
Prospective, diary-based methods with a minimum of monthly
reporting as recommended by the PROFANE network32 are recommended for future studies. Furthermore, we did not consider all
the factors that have been associated with fall statusdthere was no
measure of strength, spasticity, or of fear of falling, which may be
important. Nonetheless, the MFIS score alone correctly identified
68% of fallers. While group intervention reduced the number of falls
and fallers, it must be noted that our yoga and control groups had

620
low numbers because some participants were not treated as
randomized. Participants expressed a need for physiotherapy and
refused to be in the yoga or control groups. They were subsequently
randomly assigned to either group or one-to-one physiotherapy. This
introduces selection bias to the study, and it is therefore important
that this finding be confirmed by a larger study with a matched
control group. Additionally, a longer follow-up of the effect of
intervention on falls status is required.

Conclusions
Data from this study confirm the high prevalence of falls among
people with MS. Fallers report a significantly greater impact of
MS on their lives than nonfallers, reinforcing the importance of
addressing this complex issue. When considering the factors
associated with falls status, the impact of fatigue (MFIS score)
was the only variable in the final model correctly classifying 68%
of fallers. The odds ratios suggest that for every 10-point increase
in the MFIS score, there is a 10-fold increase in the likelihood of
reporting a fall for this population of people with MS who have
significant disability and use bilateral assistance to walk. The
relationship between fatigue and falls status warrants further
investigation. Preliminary data suggest that a group physiotherapy
intervention consisting of a 10-week balance and strengthening
exercise program can significantly reduce the number of fallers
and falls. This finding needs to be confirmed in studies with
a larger sample size powered to detect a reduction in falls, and
with a matched control group.
There is an urgent need for intervention trials that have the
primary aim of reducing falls, falls risk, and the transition to
becoming a faller. To appropriately design and evaluate programs, it
is essential that we fully understand the relationships between the
many factors that contribute to falls. To do this, prospective studies
incorporating a wide range of measures are required. Interventions
should then be developed based on those key factors and using the
perspectives of people with MS, clinicians, and health care providers.

Suppliers
a. Microsoft Excel; Microsoft, One Microsoft Way, Redmond,
WA 98052.
b. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

Keywords
Accidental falls; Clinical trial; Multiple sclerosis; Prevalence;
Rehabilitation

Corresponding author
Susan Coote, PhD, Health Sciences Bldg, University of Limerick,
Castletroy, Limerick, Ireland. E-mail address: susan.coote@ul.ie.

Acknowledgments
We thank the Multiple Sclerosis Society of Ireland for their
support in recruiting subjects for the study.

S. Coote et al

References
1. 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;87:1274-9.
2. Cattaneo D, De Nuzzo C, Fascia T, Macalli M, Pisoni I, Cardini R.
Risks of falls in subjects with multiple sclerosis. Arch Phys Med
Rehabil 2002;83:864-7.
3. Marrie RA, Cutter G, Tyry T, Vollmer T. A cross-sectional study of
bone health in multiple sclerosis. Neurology 2009;73:1394-8.
4. Kasser SL, Jacobs JV, Foley JT, Cardinal BJ, Maddalozzo GF.
A prospective evaluation of balance, gait, and strength to predict
falling in women with multiple sclerosis. Arch Phys Med Rehabil
2011;92:1840-6.
5. Nilsagard Y, Lundholm C, Denison E, Gunnarsson LG. Predicting
accidental falls in people with multiple sclerosisda longitudinal
study. Clin Rehabil 2009;23:259-69.
6. Stevens JA, Mack KA, Paulozzi LJ, Ballesteros MF. Self-reported falls
and fall-related injuries among persons aged 65 yearseUnited
States, 2006. J Safety Res 2008;39:345-9.
7. Gibson J, Summers G. Bone health in multiple sclerosis. Osteoporos
Int 2011;22:2935-49.
8. Bazelier MT, van Staa T, Uitdehaag BMJ, et al. The risk of fracture in
patients with multiple sclerosis: the UK general practice research
database. J Bone Miner Res 2011;26:2271-9.
9. Bazelier MT, Bentzen J, Vestergaard P, et al. The risk of fracture in
incident multiple sclerosis patients: The Danish National Health
Registers. Mult Scler 2012;18:1609-16.
10. Moen SM, Celius EG, Nordsletten L, Holmy T. Fractures and falls in
patients with newly diagnosed clinically isolated syndrome and multiple
sclerosis. Acta Neurol Scand Suppl 2011;124(Suppl 191):72-82.
11. Cameron MH, Poel AJ, Haselkorn JK, Linke A, Bourdette D. Falls
requiring medical attention among veterans with multiple sclerosis:
a cohort study. J Rehabil Res Dev 2011;48:13-20.
12. Cattaneo D, Ferrarin M, Jonsdottir J, Montesano A, Bove M. The
virtual time to contact in the evaluation of balance disorders and
prediction of falls in people with multiple sclerosis. Disabil Rehabil
2012;34:470-7.
13. 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;304:55-60.
14. Sosnoff JJ, Socie MJ, Boes MK, et al. Mobility, balance and falls in
persons with multiple sclerosis. PLoS One 2011;6:1-5.
15. Matsuda PN, Shumway-Cook A, Bamer AM, Johnson SL, Amtmann D,
Kraft GH. Falls in multiple sclerosis. PM R 2011;3:624-32.
16. Matsuda PN, Shumway-Cook A, Ciol MA, Bombardier CH,
Kartin DA. Understanding falls in multiple sclerosis: association of
mobility status, concerns about falling, and accumulated impairments.
Phys Ther 2012;92:407-15.
17. DOrio VL, Foley FW, Armentano F, Picone MA, Kim S, Holtzer R.
Cognitive and motor functioning in patients with multiple sclerosis:
neuropsychological predictors of walking speed and falls. J Neurol Sci
2012;316:42-6.
18. 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;13:1168-75.
19. Cattaneo D, Jonsdottir J, Zocchi M, Regola A. Effects of balance
exercises on people with multiple sclerosis: a pilot study. Clin Rehabil
2007;21:771-81.
20. Smedal T, Lygren H, Myhr K, et al. Balance and gait improved in
patients with MS after physiotherapy based on the Bobath concept.
Physiother Res Int 2006;11:104-16.
21. Lord S, Wade D, Halligan P. A comparison of two physiotherapy
treatment approaches to improve walking in multiple sclerosis: a pilot
randomized controlled study. Clin Rehabil 1998;12:477.
22. Esnouf JE, Taylor PN, Mann GE, Barrett CL. Impact on activities of daily
living using a functional electrical stimulation device to improve dropped

www.archives-pmr.org

Falls in people with multiple sclerosis who use a walking aid

23.

24.

25.
26.

27.

foot in people with multiple sclerosis, measured by the Canadian

Occupational Performance Measure. Mult Scler 2010;16:1141-7.
Coote S, Garrett M, Hogan N, Larkin A, Saunders J. Getting the
balance right: a randomised controlled trial of physiotherapy and
exercise interventions for ambulatory people with multiple sclerosis.
BMC Neurol 2009;9:34.
Cattaneo D, Jonsdottir J, Repetti S. Reliability of four scales on
balance disorders in persons with multiple sclerosis. Disabil Rehabil
2007;29:1920-5.
Cattaneo D, Regola A, Meotti M. Validity of six balance disorders scales
in persons with multiple sclerosis. Disabil Rehabil 2006;28:789-95.
Gijbels D, Alders G, Van Hoof E, et al. Predicting habitual walking
performance in multiple sclerosis: relevance of capacity and selfreport measures. Mult Scler 2010;16:618-26.
Goldman MD, Marrie RA, Cohen JA. Evaluation of the six-minute
walk in multiple sclerosis subjects and healthy controls. Mult Scler
2008;14:383-90.

www.archives-pmr.org

621
28. Paltamaa J, West H, Sarasoja T, Wikstrom J, Malkia E. Reliability of
physical functioning measures in ambulatory subjects with MS.
Physiother Res Int 2005;10:93-109.
29. Fry DK, Pfalzer LA. Reliability of four functional tests and rating of
perceived exertion in persons with multiple sclerosis. Physiother Can
2006;58:212-20.
30. Hobart J, Cano S. Improving the evaluation of therapeutic interventions in multiple sclerosis: the role of new psychometric methods.
Health Technol Assess 2009;13(12):1-200.
31. Fisk JD, Ritvo PG, Ross L, Haase DA, Marrie TJ, Schlech WF.
Measuring the functional impact of fatigue: initial validation
of the Fatigue Impact Scale. Clin Infect Dis 1994;18(Suppl 1):
S79-83.
32. Lamb SE, Jorstad-Stein EC, Hauer K, Becker C. Development of
a common outcome data set for fall injury prevention trials: the
Prevention of Falls Network Europe consensus. J Am Geriatr Soc
2005;53:1618-22.