#013: How to prevent falls caused by MS. Interview with Laurits Taul Madsen

Today I’m talking with Laurits Taul Madsen about how falls can be prevented for people living with MS. What reasons increase the risk of falls and what effective countermeasures you can take? The better shape you are in and the healthier your bones are, the less serious falls are and they also occur less often. For sure a very important topic as falls happen very often for people with MS.

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Nele Handwerker: Hello, Laurits. It’s a pleasure to have you on the show today, and a warm welcome to our hosts in Denmark. #00:00:05#

Laurits Taul Madsen: Thank you, Nele. It’s nice to be on the show and thank you for the invite. #00:00:09#

Nele Handwerker: Before we start with the questionnaire, I would like to ask you to introduce yourself a little bit so that the people know who is here on the show with me today. #00:00:20#

Introduction - Who is Laurits Taul Madsen?

Laurits Taul Madsen: Yes, of course. My name is Laurits. I’m from Denmark, a PhD student in Aarhus, working with Professor Ulrik Dalgas. I’ve studied sports science and was done in 2018 with my master’s. And afterwards I was hired as a scientific research assistant on the COGEX project, the cognition and exercise, big project on progressive MS and cognition. And in 2021, I started my PhD, which is an exercise. And we try to look at these booster sessions, so how can we keep people active over time? And when I’m not doing research, I live in the countryside with my wife and little daughter, Gertrude. And I like to play golf when there’s time for that. But it’s not a lot of time with both work and kid. #00:01:23#

Nele Handwerker: Yes, absolutely. I can totally understand that. I have to go back to a sport group myself, not fitting in right now. So I have to do it on my own.

What was your personal motivation for your career choice?

Laurits Taul Madsen: Yeah, as I said, I studied sports science. And at least here in Denmark, people typically go either in the sports direction and look at how can we get the jumpers to jump one centimeter higher, or how to get the football player to sprint a little bit faster. And I did find that interesting. So I spoke to Ulrik again. He kind of took me under his wings. And he had done a lot with MS before, and I found it quite interesting that with my background, I could do something I say useful. And that sounds negative to the ones working with sports. But in my opinion, it’s very useful and makes sense for me that we can work with things that really matters for people and we can help people get a better everyday life. #00:02:32#

Nele Handwerker: Absolutely, yes. Becoming active can be so hard depending on what your life is and what your issues are.

Severity of falls caused by MS

How often do people with MS slip or fall?

Laurits Taul Madsen: Yeah. There’s actually a study showing that when they ask people, how many times have you fallen the last three or six months? Over half of the people asked answer that they have fallen. So that’s quite a high number. I think actually was a bit surprising to me to read. But again, it depends. There are some people falling a lot and some people luckily not falling at all. But in a general term, it’s approximately half of the people. #00:03:26#

Nele Handwerker: That’s really a lot.

What are the effects of falls caused by MS on health status and quality of life?

Laurits Taul Madsen: Well, of course, it again depends on the fall. If you fall on grass and you perhaps need to dust a little dirt off. And if you fall down the stairs, you can break your bones and that will have serious effects on your everyday life. And it’s also known that people with MS can affect in a way that you have a higher probability of getting osteoporosis. So if you fall, there’s a higher risk of breaking bones. And of course, breaking bones is a major health issue and can really, really be a setback in your everyday life that you need to have your arm in… what do you call it? #00:04:19#

Nele Handwerker: Yes, that arm sling, that goes around your neck. #00:04:24#

Laurits Taul Madsen: Exactly. Or you need to have your leg seated for a couple of months. So it can have a serious issues. #00:04:31#

How long does it take the fallen to recover?

Laurits Taul Madsen: I’m not familiar with any specific numbers. But again, it would depend on both the fall and the person who’s falling. If you are in a bad situation before the fall and you fall, then it’ll probably take longer to recover after the fall. On the other hand, if you are well-functioning and in good shape and quite strong, then you would recover faster after the fall. #00:05:14#

Nele Handwerker: Yeah. I mean, of course, that’s the same for healthy people. If you’re in good shape and your muscles work, you can prevent yourself a bit from severe injuries. #00:05:27#

Laurits Taul Madsen: But the important part about falling is the bones. So if you have strengthened your bones before and are in a good situation with your bones, then you are a higher likely to recover good from a potential fall and perhaps not breaking anything. #00:05:45#

Nele Handwerker: Yeah, makes totally sense.

Reason for falling MS

What are the common neuromuscular impairments that contribute to falls in individuals with multiple sclerosis?

Laurits Taul Madsen: That’s a good question. And we did a study a couple of months ago. And when we talk about neuromuscular impairments, the neuromuscular is the brain sending signals down to the muscle. So we both have the brain and the muscle working in a neuromuscular way. When we typically measure this, we measure the force. So if you have a person seated and you ask the person to push with his or her leg as strong as possible, then we typically just measure how strong is this person? But another way to measure it is to measure how quickly can the person produce this force. And that’s where the brain is really important. And MS is in the central nervous system, so the brain is impaired. So this is a really important part to look at, and that’s what we call the rate of force development.

So how quickly can a person produce force. And when you’re about to fall, you’re not interested in how strong you are. You’re interested in how quickly you can produce enough force to counteract this balanced perturbation and avoid the fall. So the most important thing, the neuromuscular things, is the rate of force development. And we saw in our study that it was very, very high numbers when we looked at rate of force development compared to the muscle strength. That the rate of force development was markedly more important than the muscle strength. #00:07:41#

Nele Handwerker: Okay. And that’s something that we are measuring with EMP, don’t we? With Electro Physical Motoric? #00:07:48#

Laurits Taul Madsen: No. It’s actually quite a simple measure. And that’s good because then we can easily go out and use it in the everyday world. We just look at…if you imagine that you kick to a monitor that measures your strength, then we get a curve when strength goes up over time. And then at some point after two, three seconds you reach your maximum strength. But then we look at the first part of the curve, how quickly does the force go up, or how rapid is this increase. And then if you’re really impaired in the central nervous system, the curve will not be steep. It’ll go slow, slow, slow, then you reach your force. And on the other hand, if the central nervous system is working quite okay, then you’ll get a steep curve and you’ll quickly be able to produce force. #00:08:42#

Nele Handwerker: Okay. Thanks for explaining. #00:08:44#

Laurits Taul Madsen: Yeah, no worries. #00:08:46#

How do changes in muscle strength and coordination impact balance and stability in individuals with MS?

Laurits Taul Madsen: Yeah. We see that muscle strength is good when we try to improve our balance. But it’s very important to say that muscle strength is not the only thing improving balance and coordination. I think these are two very important and very complex aspects. When you talk about balance, you have so many things that interact. You have the vision, you have the strength and so on, the coordination. And it’s very, very complex thing to improve. But muscle strength is one of the things that we, from our point of view, know how to improve. And we know that we can improve muscle strength and thereby improving balance from that side. And that can reduce the risk of falls. But when we talk about falls as well, it’s important to remember that this neuromuscular thing is only a pixel of the picture. We have the balance and walking aids and potentially fatigue. And so there are many, many aspects affecting the risk of falling. #00:10:14#

Nele Handwerker: Yeah, absolutely.

Can psychologically factors, such as anxiety or fear of falling increase the risk of falling?

Laurits Taul Madsen: They’re both known to be risk factors of falling. So if you have anxiety or if you have a fear of falling, then you are at a high risk of falling. And is it the hen or the egg? We don’t know about this because, of course, if you’re falling many times, then you have a higher fear of falling and then the fear of falling will affect when you measure falls. And we saw that in our study as well, that fear of falling was correlated with the number of falls. But actually not a lot of studies are done, at least with neuromuscular impairments as a focus on falls in MS. This is, to our knowledge, one of the first studies. #00:11:13#

How does fatigue affect neuromuscular function and contribute to fall risk?

Laurits Taul Madsen: Yeah. That’s the same that we know that it’s a well-known factor that increases the risk of falling. So if you are fatigued, then it increases the risk of falling. We actually didn’t see that in our study, but it is in a general point of view, what we see. And fatigue is something that pops up every time we talk on any issue fatigue has some role to play. So that’s a key factor that we get to understand how we can reduce fatigue. I think that would reduce a lot of other…yeah. What do you call it? #00:12:14#

Nele Handwerker: Issues that we have with MS. MS symptoms reduce them in severity. Absolutely. And sport is so important, but unfortunately so many people don’t feel like sport when they are so fatigued. That’s an issue, but okay. Now let’s come to the part how we can prevent falling.

How to prevent falling

Are there specific tests or measures, like gait analysis, that can help identify individuals with MS who are at a higher risk of falling?

Nele Handwerker: I know in Dresden we do, for example, some jumping on a plate where you can measure, and we have a walking mat where you do the gait analysis. But, of course, that’s not common in the normal field for neurologists. #00:12:56#

Laurits Taul Madsen: It sounds like a luxury. #00:12:56#

Nele Handwerker: Absolutely. #00:12:58#

Laurits Taul Madsen: That’s some of the tests that you can do. And there are tests for postural stability as well. If you have poor postural stability, you’ll have a higher risk of falling. And when we look at the neuromuscular measurements, this rate of force development could be a assist that could be used for further. Because it’s quite easily done and you don’t need a lot of equipment and you can quickly see how the result is, then you can flag the person. If the rate of force development is good, you go green. If there’s something to work on, you go yellow. And if it’s extremely poor, then you need to really focus on this neuromuscular function and improve that in order to decrease the risk of falls. #00:13:50#

Can improvements in neuromuscular function through targeted interventions or therapies help reduce the risk of falls for people with MS?

Laurits Taul Madsen: I would say I hope they can because we actually don’t know. #00:14:07#

Nele Handwerker: Okay. We don’t know for sure. #00:14:08#

Laurits Taul Madsen: No, it’s not investigated yet. But I would be quite confident that it can be reduced if you…when you need to improve this neuromuscular function, you have to do resistance training. And you have to do it with quite a lot of weight. Or you have to do what we call power training where, for example, if you jump, that would be a power exercise where you really work on producing force quickly. But we actually don’t know yet because it’s not investigated in people with MS. But it will be in a short matter of time. I’m quite positive that we will set up a study to investigate this. #00:14:59#

Nele Handwerker: Nele Handwerker: Very good. I mean, I’m totally fine. So I have the luxury, for example, when I’m doing sports in front of the computer, then the burpees are on. But my sports program and the burpees I do quite often in the evening, our poor neighbors below us. I don’t manage many burpees either but I’m getting better, and my analysis on the power plate in the MS center here in Dresden has also shown this improvement. #00:15:27#

Laurits Taul Madsen: That’s good. That’s my hate, hate exercise purpose. It’s so tough. #00:15:33#

Nele Handwerker: Absolutely. No, I can’t do many. But I know I have to work on them. They’re good for my strength.

What role does the awareness of body position play in neuromuscular function and fall risk?

Laurits Taul Madsen: It plays an important role and it’s a bit tricky this body position how to measure this. But it is important obviously that you are aware of your body. That you’re not only strong, but you are aware of where you have your limbs, and so in falls. But I don’t have any specific numbers to give you on this, unfortunately. It would’ve been nice though. #00:16:19#

Nele Handwerker: Yeah. Well, let’s see. Maybe they will come in the future.

Are there any early warning signs or symptoms that individuals with MS should be aware of as potential indicators of fall risk?

Laurits Taul Madsen: Well, for example, walking. But that can be difficult as a person with MS to note if you’re walking worse than you did half a year ago. If it’s just a small decrease. Of course, if you start to…your legs start to drop also you are aware. But the neurologist and therapist need to observe early walking deficits. So, that’s things that can’t be seen with the eye, but can be measured. For example, we use this test called the six-spot step test. I don’t know if you’re familiar with that. We need to kick blocks. And there was a study done a couple of months ago, I think it came out, where they looked at newly diagnosed patients. So they were diagnosed within two years and compared to healthy individuals. And at the six-spot step test, I think they performed around 40 or 45% worse than the healthy individuals. And when you saw them walking, they seemed to be walking fine. So that’s a test that can pick up these deficits at an early point. #00:17:56#

Nele Handwerker: Okay. But can you maybe explain to the audience what the test is all about? #00:17:59#

Laurits Taul Madsen:  Yes, of course. You walk five meters, and you need to kick five wooden blocks out. So the first two trials, you kick them out with your right feet.  And the next two trials, you kick them out with your left foot. And then you get time from the four attempts. And if you walk, if you don’t have any walking impairments, it’s typically around five seconds or so. And then of course it can go up to 20-25 if you have a poor walking ability. #00:18:33#

Nele Handwerker: I think I would equally good or bad with both feet. #00:18:36#

Laurits Taul Madsen: Yeah. That could be a way to look at early warning signs. #00:18:42#

Nele Handwerker: Yeah, that’s good. #00:18:43#

Laurits Taul Madsen: Also, the rate of force development could be a way to look at it. Because it’s such a simple measure that you can. And it’s around five minutes or so and then you can see if a person is in risk of falling. #00:18:59#

Nele Handwerker: Yeah. Simple is key. I mean, especially when we are maybe out of the, let’s say, western European countries or western world where the healthcare systems are way tighter on money. It’s absolutely key to have several tests. #00:19:16#

Laurits Taul Madsen: Also, here in the west we are short of time. #00:19:20#

Nele Handwerker: Yeah. True. #00:19:20#

Laurits Taul Madsen: At least in Denmark, I know that a lot of…#00:19:23#

Nele Handwerker: Same here in Germany. #00:19:25#

Laurits Taul Madsen: Neurologists are short of time and the therapists are short of time, so we need to figure out how we can quickly and efficiently measure these things. #00:19:35#

Nele Handwerker: Absolutely.

Can rehabilitation programs focused on neuromuscular function and balance provide long-term benefits for individuals with MS in terms of fall prevention?

Laurits Taul Madsen: Again, I hope. And I think we actually don’t know yet. But it is a theme that is coming up and it’s getting more attention in the world of rehabilitation that we should focus on preventing falls. The study that we have done is with retrospective fall histories. So, we’ve asked them how many times they have fallen within the last year. So, the next thing is that we set up a rehabilitation program, and then we have some people do the rehabilitation program, some people living their normal life over a year. Then we see if the people in the rehabilitation program fall less than the people living their normal life. #00:20:36#

Nele Handwerker: Yeah, that sounds good. #00:20:38#

Laurits Taul Madsen: But it’s not investigated yet. #00:20:40#

Nele Handwerker: Yeah. So many things to do. #00:20:43#

Laurits Taul Madsen: Exactly. But we know from other populations that among others, the elderly, that rate of force development and improving the rate of force development is effective in terms of reducing the falls. #00:21:00#

Nele Handwerker: Makes totally sense.

Are there specific neuromuscular exercises or training programs that can enhance balance and reduce falls?

Laurits Taul Madsen: Yeah. I think the part of enhancing the balance is, as I mentioned, complex. And it’s not only about neuromuscular exercises, but also about specific balance exercises. I think if you want to improve your balance, you should do balance exercises. If you want to improve your walking, you should do walking exercises. And if you want to improve your neuromuscular function, you could do neuromuscular exercises. And a side effect of improving your neuromuscular function is improving your balance. But as I mentioned, resistance training with heavy weight puts a lot of pressure on the central nervous system and thereby improves neuromuscular function. #00:22:00#

Nele Handwerker: Yeah. And to everybody out there who has kids going to the playground and playing with your kid on the playground and maybe using the balance stuff there can help us well. I think. Right? #00:22:12#

Laurits Taul Madsen: Yeah, exactly. Go with your kid on the playground and take a squat, go up, lift them up on the playground. Yeah. #00:22:23#

Nele Handwerker: Yeah. We have here a funny song we always do in the morning. And it’s by lifting my daughter up, and I think my arm muscles already improved a bit. And yeah, you can do so many things with your kids, with little ones or with your grandchildren depending on what your situation is. #00:22:40#

Laurits Taul Madsen: And that depends on where you are. If you are in bad shape, there’s not a lot that needs to be done to improve this. Actually, it could be everyday things such as taking the stairs instead of the elevator if you’re able to, of course, yes. Or doing sit and standing from a chair five times every day or 10 times every day. That’s a start if you don’t have the time. #00:23:14#

Nele Handwerker: Absolutely.

Can people at risk do any lifestyle modifications or adaptations to improve their neuromuscular function and reduce fall risk?

Laurits Taul Madsen: I think the main lifestyle modification in order to improve their neuromuscular function is to stay active. If they are active and if they’re not active, start to be active in the way that it’s possible for everyone. We have only looked at people who are ambulatory and a lot of the research done is with people who are ambulatory. And, of course, if you’re not able to walk that well, it can be difficult to be active. So if you want to be active, it should be done in a safe way. And I think in the research world, we should have a bit more focus on this patient group, because these are probably the persons that are falling the most when they’re going to the bathroom, for example, also. But it’s also from a research perspective, a difficult group to work with because it’s limited what you can do with the exercise programs. #00:24:42#

Nele Handwerker: Yeah. It’s way harder when you are already have quite some issues with the MS symptoms and can’t move that much, of course. It’s way harder.

Do you have any specific nutritional or dietary advice to support optimal neuromuscular function?

Laurits Taul Madsen: Eat your veggies. I don’t have any. I’m not an expert on the nutritional part. So, I would just recommend that you eat your greenies and perhaps low-fat meat. And I don’t have any specific advice for this other than just staying regularly healthy. #00:25:27#

Nele Handwerker: Lots of fiber, right? That’s the green part. #00:25:33#

Laurits Taul Madsen: Some people have success with some things and other people have success with other things. But I’m not an expert on the nutritional part. #00:25:46#

Nele Handwerker: Healthy diet would be good. Not too much crappy food. Just a little for the fun.

Are there any assistive devices or equipment that can aid individuals with MS in improving their neuromuscular function and avoiding falls?

Laurits Taul Madsen: I don’t think I’m familiar with any specific assistive devices. You can have the stimulator on your legs. You’re probably familiar with that. If you have a drop foot. #00:26:22#

Nele Handwerker: So, the one that is just below your knee, or at your knee more or less. #00:26:25#

Laurits Taul Madsen: Yeah. That can help if you are in a situation with a drop foot. Otherwise, if you want to improve your neuromuscular function, it’s hard work. There’s no shortcut for that, unfortunately. #00:26:44#

Nele Handwerker: Unfortunately. Yeah. #00:26:45#

Laurits Taul Madsen: We don’t have the pill yet. Perhaps it will come. But be a lot of…#00:26:51#

Nele Handwerker: You have to exercise. That’s it. #00:26:54#

Laurits Taul Madsen: Yeah, you have to. #00:26:55#

How might this knowledge impact future interventions and treatments for fall prevention?

Laurits Taul Madsen: As this is the first study that has investigated the neuromuscular function and falls. And we have seen a large deficit visit in those falling compared to those not falling. We have the knowledge now that the people who fall have a lower neuromuscular function. So, the next part is, okay, if we improve the neuromuscular function in this part of the population will then reduce the risk of falling. So, it’s always in reasons that we built upon the previous research. Now we must take the next step and investigate this. #00:27:48#

Nele Handwerker: Yes. And then there will be new questions to be answered afterwards. After you receive answers it’s not over. There are new questions and that’s good.

What are the potential effects of disease-modifying therapies for MS on neuromuscular function and fall risk?

Laurits Taul Madsen: To my knowledge, I don’t think that disease modifying therapies have a concrete effect on neuromuscular function. Of course, it does in a way that it preserves the central nervous system in a better way and thus making better opportunity to have a better neuromuscular function, but it’s not directly targeted neuromuscular function. And we don’t have any therapies targeting neuromuscular function. #00:28:43#

Nele Handwerker: Of course, that’s just prevention, right? #00:28:46#

Laurits Taul Madsen: Yeah, exactly. We have Fampyra which can help for walking, but that’s not about neuromuscular function. #00:28:59#

Nele Handwerker: And as far as I know, it helps some people, and it doesn’t help for other people. #00:29:02#

Laurits Taul Madsen: Yeah, exactly. But if you are in a situation where your walking is decreased, then perhaps Fampyra can help and your walking can improve a little, and then reducing the risk of falls a little. #00:29:22#

Nele Handwerker: Okay. Now, there might be a few people who want to follow you on all your research you are doing in the future.


How and where can interested people follow your research activities?

Laurits Taul Madsen: I think if they follow on LinkedIn there, we usually put most of our research up on LinkedIn. And if they want to dig even deeper, the research gate is a good place. Researchgate.net, here you can find all your favorite experts and follow their latest research. #00:30:00#

Laurits Taul Madsen on:

Is there anything else you would like to share with the listeners?

Laurits Taul Madsen: Do exercise. No, I don’t think I have any specifics. But it’s important to say that when we talk about, we have a tendency to track our own theme or topic up and perhaps forget a bit about other things. Now we look at falls and neuromuscular function, but fall is one symptom. There are a lot of other symptoms and neuromuscular function is only one part of the risks in falling. So there are a lot of other symptoms important for this as well. So, we need to be open. I think that’s my advice to other researchers and general people with MS, that there are a lot of symptoms and a lot of different ways to improve the different symptoms. #00:31:00#

Nele Handwerker: Absolutely. #00:31:01#

Laurits Taul Madsen: But exercise for sure can a lower many symptoms such as fatigue and risk of falling and improving walking capacity and so on. #00:31:12#

Nele Handwerker: Absolutely. It can make symptoms better and it can help with preventing disease progression. Right? #00:31:20#

Laurits Taul Madsen: Exactly. #00:31:20#

Nele Handwerker: It’s a very important part of lifestyle. #00:31:23#

Laurits Taul Madsen: Yeah. An important point as well is to preserve function and be at a better place if something happens like an attack, for example. #00:31:31#

Nele Handwerker: Laurits, thank you very much. Thank you very much for all your research you have done so far with your colleagues. And I will follow the things you are doing on LinkedIn and maybe you are coming at another point back to the podcast. #00:31:47#

Laurits Taul Madsen: I would be happy to. #00:31:49#

Nele Handwerker: Kind regards to beautiful Denmark. And thanks. Bye-Bye. #00:31:53#

Laurits Taul Madsen: Thank you. Bye. #00:31:55#

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