By Annette M. Boyle
PORTLAND, OR—Many people with multiple sclerosis (MS) experience both falls and bladder dysfunction. In the past, those were generally considered common – but probably unrelated – issues.
Now, research conducted by the VA Multiple Sclerosis Center of Excellence—West at the VA Portland, OR, Healthcare indicates that that treating bladder symptoms may provide unexpected benefits, including reducing falls.
“We now think that in some people these symptoms may be related,” explained Michelle Cameron, MD, PT, a neurologist at VA Center of Excellence—West in an article in the VA’s spring MS Veteran newsletter.
Previous studies have shown that up to half of MS patients fall in a six-month period. Falls—and the fear of falls—reduce patient confidence and quality of life and are associated with increased risk of both injury and death.
At the same time, bladder dysfunction affects at least 80% of MS patients, according to the National Multiple Sclerosis Society. Past research has indicated that MS lesions could interfere with the proper transmission of nerve signals that control the bladder, leading to increased frequency and urgency, incontinence, nocturia and difficulty voiding completely.
Cameron and her colleagues probed the relationship between the bladder issues and falls in veterans with relapsing-remitting MS in a study published in the International Journal of MS Care.1 They found that MS patients “who had both urinary urgency with incontinence had almost a 60-times greater odds of recurrent falls compared to those people who did not have these bladder symptoms,” she said.
Notably, recurrent falls were not related to other bladder issues, including urgency without incontinence or frequency. The study identified no association between any bladder symptoms and the risk of falling once.
“Physically and practically, I think that many people with MS fall once in a three-month period, for a range of reasons that may not show any distinct pattern, but once they fall multiple times, distinct contributors may start to become apparent,” Cameron told U.S. Medicine.
The study enrolled 51 patients with physician-confirmed relapsing-remitting MS from the Portland VAMC and Portland-area MS clinics. All participants had mild to moderate disability and had experienced no relapse in the 30 days before the study started. The researchers restricted participants to those ages 18 to 50 years of age to minimize confounding by other potential causes of falls. Patients with other gait or balance issues or who were unable to walk 100 m were also excluded.
At the start of the study, researchers asked all participants whether they currently experienced urinary incontinence, urinary frequency or urinary urgency. Of the 51 participants, 29% said they had urinary urgency, 25% confirmed urinary frequency and 16% reported urinary incontinence.
Patients then received calendars on which they were to record falls, which were defined as “any unexpected event that results in ending up on the ground, floor, or any lower surface.” Participants mailed the calendars back to the researchers each month. Those who did not submit their calendars within a week received phone call reminders.
To provide additional insight into the association between falls and bladder issues and to clarify the conflicting results of previous studies, the researchers sliced the fall data two ways. One analysis classified patients who fell two or more times in the three-month period as recurrent fallers, while those who fell just once or not at all were nonrecurrent fallers. While 15 participants fell at least twice during the study; 36 fell once or never.
The second analysis classified patients who fell at least once as fallers and those who did not as non-fallers. Of the 51 participants, 32 fell at some point in the three months. There were no significant differences in age, gender or disability scores between recurrent and nonrecurrent fallers or between fallers and non-fallers.
After adjusting for age, gender, and disability, only urinary urgency with incontinence had a significant association with recurrent falls. Power analyses found the association between urinary urgency with incontinence and falling at least twice had a post hoc power of 96%. In comparison, recurrent falls and urinary urgency or urinary urgency had post hoc power of 36% and 42%, respectively. The researchers found no association between any of the bladder symptoms studied and falling at least once.
“We think that bladder problems might cause falls in people with MS because, if you have urinary urgency and incontinence, you are likely to often rush to the bathroom,” Cameron noted. “It is also possible that people with bladder problems avoid drinking water and become dehydrated, which can then make them dizzy when walking.”
The strong association between urgency with incontinence and falls, regardless of Expanded Disability Status Scale score, challenges a common assumption that both result from spinal cord lesions, the authors wrote.
“Even people with MS with relatively low levels of clinically assessed disability fall and have bladder problems. Thus, our research alerts clinicians to ask about and address falls and bladder problems early in the disease when they previously might not have thought to do so,” Cameron said.
The results were consistent with and explained the divergent results of previous studies, one of which found an association between urinary incontinence and recurrent falls, while the other did not find an association with urinary incontinence and one or more falls.2,3
The authors pointed out that several participants reported urinary urgency without incontinence, but none had incontinence without urgency. This may indicate that urgency with incontinence develops subsequent to urgency without incontinence, they said.
Patients may not think to mention falls and bladder issues in their conversations with their physicians as they may believe them to be related to aging or untreatable results of their disease, so physicians should take the initiative, wrote the authors.
“Bladder problems, including urgency and incontinence, can often be successfully addressed with medications as well as physical or behavioral interventions. We suggest that people with MS who report falling should be asked about bladder problems and these problems should be addressed by their MS provider, with referral to a urologist, if needed,” Cameron said. “Addressing bladder problems may not only help directly, but also indirectly by preventing falls.”
- Zelaya JE, Murchison C, Cameron M. Associations between bladder dysfunction and falls in people with relapsing-remitting multiple sclerosis. Int J MS Care. 2016 DOI: 10.7224/1537-2073.2016-049
- Nilsagård Y, Lundholm C, Denison E, Gunnarsson LG. Predicting accidental falls in people with multiple sclerosis — a longitudinal study. Clin Rehabil. 2009 Mar;23(3):259-69. doi: 10.1177/0269215508095087.
- Gunn HJ, Newell P, Haas B, Marsden JF, Freeman JA. Identification of risk factors for falls in multiple sclerosis: a systematic review and meta-analysis. Phys Ther. 2013 Apr;93(4):504-13. doi: 10.2522/ptj.20120231. Epub 2012 Dec 13. Review.