Development of a falls management intervention for people with Multiple Sclerosis

Background

Up to 70 per cent of people with MS fall annually. The importance of developing a suitable falls management intervention has been identified by people with MS and professionals.

Aims

This project aimed to inform the development of a falls management intervention for people with MS. The project involved a systematic review to inform the content for the programme, and a nominal group study to develop consensus on the most appropriate format and structure of the programme.

Systematic review

Aim/ Methods

The systematic review aimed to evaluate the effectiveness of exercise and education programmes on falls and/or balance outcomes in adults with Multiple Sclerosis. Data were extracted using computer based and manual searches and reviewed against the selection criteria. Two reviewers independently extracted data and assessed methodological quality using the Cochrane risk of bias tool

Results

Random-effects meta-analysis indicated a small decrease in falls risk with the use of exercise (risk ratio 0.74), although the 95 per cent confidence interval (CI) crossed 1 (95 per cent CI, .12-4.38). The pooled standardized mean difference (SMD) for the effect of exercise on balance outcomes was 0.55 (95 per cent CI, 0.35-0.74). SMD varied significantly between exercise subgroupings; gait, balance, and functional training interventions yielded the greatest pooled effect size (ES) (SMD 0.82; 95 per cent CI, 0.55-1.10). There was a moderate positive correlation between program volume (minutes/week) and ES (Cohen’s d )(r 0.70, P.009), and a moderate negative correlation between program duration in weeks and ES (r 0.62, P 0.03). Variations in interventions and outcomes and methodological limitations mean that results must be viewed with caution.

Nominal Group study

Aim/ Methods

The nominal group study aimed to explore service users’ and providers’ views regarding the formats of delivery for the proposed falls programme. The process used three sequential rounds of individual rating, group discussion and re-rating focussed around 20 trigger statements relating to programme structure, format and delivery methods. Three separate groups brought together service users (n=15) and a range of relevant professionals (n=21). Quantitative analysis defined consensus, whilst participants’ qualitative responses were analysed thematically.

Results

While consensus was achieved in only three statements, significant changes in the level of agreement within the groups developed with successive rounds (p<0.05). Three overarching qualitative themes were developed summarising the main issues and recommendations.  

1. Make it specific: The programme content, format and approach should be tailored specifically to the unique needs of people with MS.

2. Find the balance: Falls outcomes are important but should be considered alongside participation-based outcomes. A collaborative approach should be used - balancing support for participants whilst also ensuring they achieve the required intensity and duration of challenging balance activities.

3. Do it right: Small issues may be pivotal to engagement; therefore the programme should enable participants to engage flexibly according to individual needs and preferences. Adequate funding is necessary, and staff should have MS specific knowledge and experience.

Conclusions from this project

The systematic review suggests that balance may improve through exercise interventions, but that the magnitude of the improvements achieved in existing programs may not be sufficient to impact falls outcomes. Supporting participants to achieve an appropriate intensity of practice of highly challenging balance activities appears to be critical to maximizing effectiveness.

The nominal group study identified aspects of structure, format and approach for an MS falls programme potentially critical to its success and sustainability. Crucially the programme needs to be MS specific, to employ a collaborative approach and to move away from the group-based, weekly format common to many generic falls programmes.

Funding

This study was supported by the Multiple Sclerosis Society in the UK (Grant ref: 990) £15,388

Dissemination

Poster presentations related to this project

1. Gunn, H., Endacott. R., Haas, B., Marsden, J. F., & Freeman, J. (2015). Developing a falls management intervention for people with MS: A nominal group study. RIMS annual conference, Milan, Italy

Publications relating to this project

1.  Gunn, H., Markevics, S., Haas, B., Marsden, J., & Freeman, J. (2015). Systematic Review: The Effectiveness of Interventions to Reduce Falls and Improve Balance in Adults With Multiple Sclerosis. Archives of Physical Medicine and Rehabilitation, 96(10), 1898–1912. http://doi.org/10.1016/j.apmr.2015.05.018

Research Team

External members of the research team

Sophie Markevics, Physiotherapy Team Lead, Tiverton and Cullompton Cluster, Royal Devon and Exeter NHS Foundation Trust