Better Balance, Mobility and Falls Prevention

MS Plus acknowledges the traditional custodians of the land this podcast is recorded on, the Wurundjeri people of the Kulin Nation. We pay our respects to their Elders past and present. ​

Nicola: Welcome to the MS Podcast Series. I'm Nicola Graham and this episode is all about better balance, mobility and falls prevention. Just as a bit of a disclosure, I am with absolute irony and sitting here with my moon boot and crutches as I had a fall and broke my ankle at the weekend. So I wish I'd had this conversation with the wonderful Emeritus Professor Sheila Lennon last week.

Anyway, if you're feeling your balance isn't quite what it used to be, if you've taken a tumble, please have a listen. Learn what you can do to improve your balance and to prevent falls, and as you can imagine, I'm very keen to hear the information today. So, as I mentioned, I'm talking to Emeritus Professor Sheila Lennon from Flinders University.

And Professor Lennon joined Flinders University in 2012 as Foundation Chair of Physiotherapy. She's an absolute legend, she's spent over 40 years in neurological physiotherapy, so we're very fortunate to have the benefit of her wisdom and experience today. Sheila's area of research and teaching expertise is neurological rehabilitation, and she frequently runs balance and mobility group classes for falls prevention. I think I might join it by Zoom and we'll give you some more details about these later on in the podcast.

So really warm welcome, Sheila. Thank you for joining me today.

Sheila: Thank you very much Nicola, for that kind introduction.

And as you say, I'm very passionate about giving people with MS access to exercises to improve their balance and mobility and prevent falls. My interest in this area was really generated when I was in charge of neuro rehab at Guy's Hospital and King's College in London, where I worked a lot with people with MS at various stages of their disease and that was the very first time back in, it would have been probably about 1989 that I set up a community exercise classes between the specialist service and the community physio service so I have a long standing interest in this area.

Nicola: Well, Sheila, I'm really keen to pick your brains today and for everybody listening to benefit from all that experience.

So, how common are falls in people who've got MS, Sheila?

Sheila: Look, falls in people with MS are extremely common. They actually fall far more frequently than older people, who are always in the headlines about falls, and health services are always trying to prevent falls, but people with MS, we know from the research studies between 52 to 63% of people with MS fall and 25% of those falls lead to various serious injury like fracture or head injury. So is a big problem for people with MS.

Nicola: That's a lot of falls for a lot of people, Sheila, so let's do what we can to, to prevent that, so listen up, everybody. What is it about MS that makes people susceptible to falls, Sheila?

Sheila: I think the main thing for people with MS is their actual symptoms that they have related to multiple sclerosis. Your balance is controlled by your sensory motor system and your visual system and your vestibular system.

And basically, all those three things can be affected in people with MS. But there are symptoms like weakness, drop foot, sensory loss, and also just disturbances to their postural control and balance and fatigue in particular. And let's not forget about the sort of cognitive brain fog issues that people with MS often have.

So, there's a lot of reasons why people with MS may fall. And that's probably the most important thing I would say to people. First tip is we know from research literature, if you have fallen once in the past year, you are likely to fall again. So, the first thing you need to do is speak to one of your healthcare professionals about your fall and what you can do to try and prevent or minimise falls in the future. And there's lots of things you can do to minimise the risk of falls.

Nicola: Fantastic, and that's what we'll cover today. What is the most common factor, Sheila, that causes people to fall?

Sheila: I would say it's a sort of a tough question that because basically everybody is an individual and it's very important that you do an individual analysis with a person to identify their main risk factors for falls, and that's one of the things I do in my classes. We analyse with them, and we get them to track their falls and analyse their falls and get them to brainstorm why they think they fell. Distraction. I think distraction is the number one thing and probably, the second number one thing, is really rushing, and probably they're common for all of us when we fall. You know, you might have been in a situation yourself, Nicola.

Nicola: Absolutely, Sheila. I would say that my broken ankle was rushing and distraction.

Sheila: Yes, and the second thing for people with MS is the sort of activities, everyday activities that are tricky for them that we don't think about because we never think about when we bend down to get something or we're reaching or we're turning, and those activities, people with MS have to sort of perform them often in a different way to the way you and I would do it. And sometimes they don't always think of the best compensations they can use to try and perform those activities safely.

So that's another factor for people with MS. It's very important to look at those everyday activities, that's the second tip. Look at those everyday activities and get some tips from your health care professionals about how you could make those movements safer or less effortful.

Nicola: Okay. Well, we'll talk a little bit more about that, I think. But let's start with top tips for how our listener can improve their balance, and therefore, prevent falls.

Sheila: Yes, so my real top tip is challenge your balance. Just walking is not enough if you've had falls. What happens with people with MS, quite often they rely, over rely, and often that's the only way they can remain up on their feet, on a rollator or a different type of walking aid to walk, and that changes the way that they posturally adjust, and adjust their balance and they sort of, in a way, lose the idea of what it's like to actually regain balance. So be put out of your comfort zone and then return to your comfort zone. So, it's really important to do challenging exercises for your balance because walking is not really enough.

Nicola: So particularly if you're walking with a walker, that's not going to challenge your balance enough and you're going to lose a bit of function by the sounds of it.

Sheila: And we know people who use walking aids, any type of walking aid, be it a stick or a rollator, are much more susceptible to falls than people who do not rely on walking aids.

Nicola: And so, how do they challenge that balance, Sheila? What do they do? Because it sounds a bit counterintuitive, you know, that you might think.

Sheila: Look, it does sound very counterintuitive, and my balance boost exercises that I found from my series of research studies and also derived from other areas of fall prevention are very simple exercises like, for example, stepping in different directions. So, stepping sideways, stepping forward, stepping backwards, stepping across your body. That's a very important exercise to challenge your balance, standing on one leg is very important.

Nicola: I'm doing a lot of that at the moment, Sheila.

Sheila: I know. And this is something really difficult for my clients. They come in and they're having problems really walking any distance because of fatigue. And some of them have heat sensitivity and all those other issues, and I say, right, the first thing we're going to do now is see what you're like in standing. So, we only work in standing. We work with standing, reaching in different directions, practicing sit to standing to strengthen the muscles in your lower legs because, obviously strength is a factor as well as balance, stepping in different directions, standing on one leg and then walking in different directions. So it's quite an intensive workout and we know from the literature that you have to work at a moderate intensity to produce change. in the structure and function of your brain, that's neuroplasticity.

So, when people come to observe my classes, I think quite often they're astonished about how hard we make people work, and even when I work with my students from Flinders University, I get them to do the class along with the clients and they're young people and they get tired too.

Nicola: So, what does moderate intensity look like and can a person do this on their own, Sheila, or do they need a group?

Sheila: No, they don't need a group, but I think they gain a lot of support and confidence from the group, but these simple exercises are things people have to do every day anyway, but what we get them to do is maybe practice them in chunks of five minutes, maybe starting very slowly at only doing something for a minute and progressing up to that. Moderate intensity for walking, for example, means that you're doing about 120 steps a minute, so you're just walking as if you're a little bit late for a meeting, you can still carry on a conversation, but you're sort of feel that you're working.

So, you have to feel that you're working when you're doing these exercises.

Nicola: Okay, and that's so that the brain gets rewired and can learn a new skill. That's wonderful.

If you could make one strong recommendation to people with MS, what would that be?

Sheila: I have so many recommendations, Nicola. It's really hard to actually choose one.

But I would say the most important thing is introduce some of these key exercises into your everyday routine to make them a habit. So, say you decide that you're going to try practising that stepping or standing on one leg, practice standing on one leg when you're actually at the counter doing something in the kitchen or you're brushing your teeth and build up the repetitions of it.

Because we know we need a lot of repetitions, so the more you can tie the exercise to something you're doing every day anyway, the more you're going to be able to practice. And we know in order to change the wiring in your brain, you're looking at really a minimum of about 400 repetitions. And if you chunk that in small blocks and you perform it safely, you're in the corner of a room or you have a table in front of you, you can actually perform these exercises, really safely.

So that's a good way to practice standing on one leg, for example, and then there’s the stepping in different directions. And there's apps and things that we can recommend to you to try and do that. But I would say the first thing is, if you are falling and concerned about it, rather than restricting your movements, and really isolating yourself, being careful, being fearful of falling, make sure you speak to a health care professional, and even calling the MS assist line will point you in the right direction about resources for falls prevention. So, you can do a lot to prevent falls, but you need knowledge. And then, the need to know the correct exercise to target for you as an individual, because everybody's different.

Nicola: So, people can probably, with, if anybody listening is on an NDIS plan, they might be able to access a physiotherapist or exercise physiologist or join one of our groups, perhaps.

Sheila: Many false prevention classes in the community, but what I would say is quite often they are geared to a different age group, so it'd be important to choose one that works for you, but you certainly get some good, basic knowledge with that, but I am a firm believer in tailoring the exercises specifically towards the symptoms that people with MS experience. So, I think that's the best way to go forward with the exercises.

The other thing that you'll probably find surprising is that I really feel another really key recommendations is get comfortable getting on and off the floor. The more you know that when you, if you do end up on the floor, you know how to get up or you know how to advise someone to help you get up, the more confident you feel when you're out and about doing stuff. So, it's really important to feel confident getting on and off the floor.

Nicola: Is there a particular technique that you'd recommend, Sheila, if somebody is on the floor to get up?

Sheila: Yes, there, look, we as physios say getting on and off the floor is a problem solving activity, and everybody's really different depending on the problems that they have. But the easiest way to get on and off the floor is to make sure you get to a chair or something that you can pull yourself up to, onto that is solid.

Put your stronger leg forward first, so kneel in front of a chair, put your stronger leg forwards first, and then try to push up from standing that way, so go towards something to help steady yourself. But before you do that, always make sure to take time, get your breath, make sure that you haven't got any injury and I guess a really strong recommendation that I know a lot of my clients don't do is make sure you always have a button or a mobile on you so you can call for help if something happens to you.

Nicola: Great advice, Sheila, thank you. And you mentioned a couple of apps that people might be able to use. It sounded like for their exercise routine for balance. Do you have any in mind, Sheila, that you would recommend?

Sheila: An app that I absolutely love, and all my clients love it as well, is an app developed by a Brisbane physiotherapist, Meg Laurie, and it's called Clock Yourself.

So, if you just put that into Google, that app will come up. And the reason that app is good is you can control the pace of it, you can control the duration of it, and it actually gets you to step in different directions in a way that's safe for you to do that. So, I would recommend that you actually look at the Clock Yourself app.

But what I would say to you, is it's quite a lot of knowledge involved in understanding falls prevention. And I think certainly speaking to your health professional is a first step, but I would strongly recommend that people join in some form of class as well, whichever class they can have access to, because we do a class two hours a week for six weeks to get through all the material that's important for people to know. And the wonderful thing about that, Nicola, is quite often I get emails and messages from my client saying they haven't fallen at all since they started doing the class, and they stopped themselves from falling because they were able to take a step and they learn how to do that protective stepping in the class.

There's lots of different exercises we can do, but the ones that I mentioned to you are the simple ones that people can start off doing at home. Always be very careful when you're challenging your balance, so make sure you're safe. You have a chair behind you so you can sit down when you feel tired and make sure you have something you can hold on to in front of you as well.

Nicola: That sounds great, Sheila. So, how do people get access to your classes? How can they get in touch with you for information?

Sheila: Yes, look, I run these classes in collaboration with the MS Society in South Australia, but I also am able to do them by Zoom. So, if anybody is interested in finding out more about the Zoom classes, to access my class they can just contact me on my email, which I think you're going to put in a link.

It's at [email protected]. I'm very happy to answer any queries you may have and give you access to some resources.

Nicola: Thanks so much, Sheila, that's very generous. So just for our listeners, I'll spell that out. That's Sheila, S H E I L A dot Lennon, L E N N O N, [email protected].

Sheila: Yes. And if I could say one more thing, please, Nicola, we have some fantastic physical activity guidelines now, adapting your lifestyle to live well with MS developed by MS Research Australia. And I think I sent you the link to that as well, so it's well worth the listeners having a look at that material too because, fortunately, a lot of the exercises and activities we're recommending in relation to balance are the sort of exercises you have to be doing anyway to reduce the time that you spend in sitting and improve your physical activity.

So, it's well worthwhile having a look at the guidelines and just to encourage everybody, you don't have to be doing 40 minutes of exercise twice a week to be ordered in order to see changes in your balance. We have shown that even just doing five minutes times eight actually makes a big difference to improving your sit to stand, improving your walking, changing your confidence in your balance and mobility and reducing your falls.

Obviously, the more you practice, the better you get, but it's something that is achievable for everybody with MS. So it's, it's really worth their while investigating how they can modify the factors that are causing them to fall, and to keep practicing things in their daily routine to keep them steady and challenge their balance.

Nicola: And Sheila, that's 5 minutes times 8, so is that over a whole week?

Sheila: MS. Yes, yes, you can chunk. The research that I've done, of course, has been testing it in the format of the two-hour session where we have 40 minutes to 50 minutes, depending on who's in the class, of actual exercises. We do eight circuits, used to doing these sorts of exercises I was suggesting to you. But we also do an hour of discussion and education about falls prevention, energy conservation, all those sorts of topics, and I think gaining that knowledge and education and awareness of your movement strategies, they need both elements, the education and the exercises, to actually really work effectively for falls prevention.

Nicola: Any top tips from that education side of things, Sheila? So, you mentioned energy preservation, so people are not exhausting themselves and therefore making themselves vulnerable. Any other tip from that side of things that people can take away with them?

Sheila: Yes, a really key strategy for falls prevention is what we call stop, scan and plan. And that's something that everybody feels is useful for them. So apart from keeping physically active and challenging your balance, just take a few minutes. Say, you're going into an unfamiliar environment or you're going into an outside, into the garage or into the garden. Take a minute. Stop. Look, scan around your environment, identify any potential hazard, hoses, buckets, pets etc and plan your route of least risk. So, if you have that little stop, scan and plan in your mind, whenever you're doing something that you know is a little bit more risky for you, say you have difficulty walking and you know your balance isn't the best.

That's probably my top tip. Stop, scan and plan.

Nicola: That's great advice, Sheila, and it really ties into that being mindful and not being distracted and taking a moment and thinking about what you're doing, doesn't it?

Sheila: Absolutely.

Nicola: And just to give people the physical activity guidelines link, if people head to the MSRA, so, MS Research Australia website, which is msra.org. au, and have a look for the Modifiable Lifestyle Guide, and in that has got the physical activity side of things, which gives you a really great guideline.

That's wonderful, Sheila. Anything else you feel like you'd like to add before we bring our podcast to a close?

People have got some great tips for how to improve their balance immediately with the stepping in different directions, the sit and stand, the planning and the mindfulness side of things, anything else that you would like to suggest. I know you've strongly suggested that people see their healthcare professional as well and we're really asking people to challenge themselves and learn how to get up off the floor safely as well, be careful if they're particularly tired.

Sheila: Yes, that's a really good summary you did for me there, Nicola. I'm glad to hear you were listening well. I think for me a really important factor in this is self-management and self-efficacy. The more our clients can take control of what's happening to them, understand their symptoms, understand the small steps they can take to try and minimise their risk of falls, the better. So that is really important that they be able to understand why they're doing these exercises, how they can adjust them to make them more challenging so they can keep improving. So that's really important.

And the last thing I always joke with the clients about this is: Take your meds!

A lot of people we know who come to see us are on medication and often they will say to me I didn't realise I should be doing so much exercise or moving in that way or physical activity because I thought if I was taking the medication that was all I would need to do.

But when I say take your meds, I mean thinking about all those other factors that influence your ability to exercise and be physically active.

And meds is M for your mood. and your mindfulness. E is for your exercise and physical activity, which we've been talking a lot about today. D is for your diet because you need good energy to be able to move effectively. And if when you look at the lifestyle guide by MSRA, we probably don't have very strong evidence based recommendations as far as anti-inflammatory diets go, but that's a big space and there's a lot of changing information in that space, so just paying attention to good nutrition is really important.

And the last bit of the meds, the S, is have a good sleep pattern, well rested and support from people. Don't be afraid to ask for help.

Nicola: That's beautiful advice, Sheila. Thank you. And just also a gentle reminder for our listeners, if they go to our webinar library, there's some great further information there.

And I'm very fortunate that Sheila and I will be doing a webinar on falls prevention in a bit more depth as well at some point this year. So, please look out for that too.

So, a huge thank you, Sheila, on behalf of our listeners and their families. And a heartfelt thank you to all the work you've done over a number of years for people with MS and falls prevention and rehabilitation.

So, thank you for a career helping to support people in this space.

Sheila: Thank you so much for having me, Nicola. I really enjoy working with people with MS and it's been a pleasure to do this podcast with you.

Nicola: I encourage people to reach out, get in touch with Sheila with the email address that we've given you and maybe hop onto one of the classes.

You might find some local in your MS society or MS Limited locally, or you may have an opportunity to work with Sheila via Zoom, which is great.

So just a gentle reminder to you as well, that if you do have any specific MS concerns or queries, if you'd like to speak to a nurse advisor or a social worker, if you'd like some peer support, if you'd like to chat with somebody in a very similar situation, if you'd like employment support or NDIS, then we'd love to hear from you. We'd love to support you. That's what we're here for.

You can call MS Connect on 1800 042 138. That's the gateway to all of our services.

Thanks again, Sheila, and thanks everyone for listening.

Bye for now.