Original research| Volume 99, ISSUE 4, P641-651, April 2018

Prediction of Falls in Subjects Suffering From Parkinson Disease, Multiple Sclerosis, and Stroke

Published:November 01, 2017DOI:



      To compare the risk of falls and fall predictors in patients with Parkinson disease (PD), multiple sclerosis (MS), and stroke using the same study design.


      Multicenter prospective cohort study.


      Institutions for physical therapy and rehabilitation.


      Patients (N=299) with PD (n=94), MS (n=111), and stroke (n=94) seen for rehabilitation.


      Not applicable.

      Main Outcome Measures

      Functional scales were applied to investigate balance, disability, daily performance, self-confidence with balance, and social integration. Patients were followed for 6 months. Telephone interviews were organized at 2, 4, and 6 months to record falls and fall-related injuries. Incidence ratios, Kaplan-Meier survival curves, and Cox proportional hazards models were used.


      Of the 299 patients enrolled, 259 had complete follow-up. One hundred and twenty-two patients (47.1%) fell at least once; 82 (31.7%) were recurrent fallers and 44 (17.0%) suffered injuries; and 16%, 32%, and 40% fell at 2, 4, and 6 months. Risk of falls was associated with disease type (PD, MS, and stroke in decreasing order) and confidence with balance (Activities-specific Balance Confidence [ABC] scale). Recurrent fallers were 7%, 15%, and 24% at 2, 4, and 6 months. The risk of recurrent falls was associated with disease type, high educational level, and ABC score. Injured fallers were 3%, 8%, and 12% at 2, 4, and 6 months. The only predictor of falls with injuries was disease type (PD).


      PD, MS, and stroke carry a high risk of falls. Other predictors include perceived balance confidence and high educational level.


      List of abbreviations:

      ABC (Activities-specific Balance Confidence), BBS (Berg Balance Scale), CI (confidence interval), CIQ (Community Integration Questionnaire), DGI (Dynamic Gait Index), IADL (instrumental activities of daily living), IQR (interquartile range), MS (multiple sclerosis), PD (Parkinson disease)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Schenkman M.
        • Morey M.
        • Kuchibhatla M.
        Spinal flexibility and balance control among community-dwelling adults with and without Parkinson's disease.
        J Gerontol A Biol Sci Med Sci. 2000; 55: M441-M445
        • Visser J.E.
        • Bloem B.R.
        Role of the basal ganglia in balance control.
        Neural Plast. 2005; 12: 161-174
        • Canning C.G.
        • Paul S.S.
        • Nieuwboer A.
        Prevention of falls in Parkinson's disease: a review of fall risk factors and the role of physical interventions.
        Neurodegener Dis Manag. 2014; 4: 203-221
        • Kerr G.K.
        • Worringham C.J.
        • Cole M.H.
        • Lacherez P.F.
        • Wood J.M.
        • Silburn P.A.
        Predictors of future falls in Parkinson disease.
        Neurology. 2010; 75: 116-124
        • Duncan R.P.
        • Cavanaugh J.T.
        • Earhart G.M.
        • et al.
        External validation of a simple clinical tool used to predict falls in people with Parkinson disease.
        Parkinsonism Relat Disord. 2015; 21: 960-963
        • Cameron M.H.
        • Bourdette D.
        Imbalance in multiple sclerosis: a result of slowed spinal somatosensory conduction.
        Somatosens Mot Res. 2008; 25: 113-122
        • Prosperini L.
        • Petsas N.
        • Raz E.
        • et al.
        Balance deficit with opened or closed eyes reveals involvement of different structures of the central nervous system in multiple sclerosis.
        Mult Scler. 2014; 20: 81-90
        • Giannì C.
        • Prosperini L.
        • Jonsdottir J.
        • Cattaneo D.
        A systematic review of factors associated with accidental falls in people with multiple sclerosis: a meta-analytic approach.
        Clin Rehabil. 2014; 28: 704-716
        • van Asseldonk E.H.
        • Buurke J.H.
        • Bloem B.R.
        • et al.
        Disentangling the contribution of the paretic and non-paretic ankle to balance control in stroke patients.
        Exp Neurol. 2006; 201: 441-451
        • Roerdink M.
        • Geurts A.C.
        • de Haart M.
        • Beek P.J.
        On the relative contribution of the paretic leg to the control of posture after stroke.
        Neurorehabil Neural Repair. 2009; 23: 267-274
        • Batchelor F.A.
        • Mackintosh S.F.
        • Said C.M.
        • Hill K.D.
        Falls after stroke.
        Int J Stroke. 2012; 7: 482-490
        • Minet L.R.
        • Peterson E.
        • von Koch L.
        • Ytterberg C.
        Occurrence and predictors of falls in people with stroke: six-year prospective study.
        Stroke. 2015; 46: 2688-2690
        • Rudzińska M.
        • Bukowczan S.
        • Stożek J.
        • et al.
        The incidence and risk factors of falls in Parkinson disease: prospective study.
        Neurol Neurochir Pol. 2013; 47: 431-437
        • Nilsagård Y.
        • Gunn H.
        • Freeman J.
        • et al.
        Falls in people with MS–an individual data meta-analysis from studies from Australia, Sweden, United Kingdom and the United States.
        Mult Scler. 2015; 21: 92-100
        • Kerse N.
        • Parag V.
        • Feigin V.L.
        • et al.
        Falls after stroke: results from the Auckland Regional Community Stroke (ARCOS) Study, 2002 to 2003.
        Stroke. 2008; 39: 1890-1893
        • Schmid A.A.
        • Wells C.K.
        • Concato J.
        • et al.
        Prevalence, predictors, and outcomes of poststroke falls in acute hospital setting.
        J Rehabil Res Dev. 2010; 47: 553-562
        • Gazibara T.
        • Pekmezovic T.
        • Kisic-Tepavcevic D.
        • et al.
        Incidence and prediction of falls in Parkinson's disease: a prospective cohort study.
        Eur J Epidemiol. 2015; 30: 349-352
        • Hoang P.D.
        • Cameron M.H.
        • Gandevia S.C.
        • Lord S.R.
        Neuropsychological, balance, and mobility risk factors for falls in people with multiple sclerosis: a prospective cohort study.
        Arch Phys Med Rehabil. 2014; 95: 480-486
        • Schmid A.A.
        • Yaggi H.K.
        • Burrus N.
        • et al.
        Circumstances and consequences of falls among people with chronic stroke.
        J Rehabil Res Dev. 2013; 50: 1277-1286
        • Hughes A.J.
        • Daniel S.E.
        • Kilford L.
        • Lees A.J.
        Accuracy of clinical diagnosis of idiopathic Parkinson's disease: a clinico-pathological study of 100 cases.
        J Neurol Neurosurg Psychiatry. 1992; 55: 181-184
        • McDonald W.I.
        • Compston A.
        • Edan G.
        • et al.
        Recommended diagnostic criteria for multiple sclerosis: guidelines from the international panel on the diagnosis of multiple sclerosis.
        Ann Neurol. 2001; 50: 121-127
        • Herman B.
        • Schulte B.P.
        • van Luijk J.H.
        • Leyten A.C.
        • Frenken C.W.
        Epidemiology of stroke in Tilburg, The Netherlands. The population-based stroke incidence register: 1. Introduction and preliminary results.
        Stroke. 1980; 11: 162-165
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders, fourth ed, text revision.
        American Psychiatric Publishing, Washington (DC)2000
        • Shah S.
        • Vanclay F.
        • Cooper B.
        Improving the sensitivity of the Barthel Index for stroke rehabilitation.
        J Clin Epidemiol. 1989; 42: 703-709
        • Berg K.
        • Wood-Dauphinee S.
        • Williams J.I.
        • Gauton D.
        Measuring balance in the elderly: preliminary development of an instrument.
        Physiother Can. 1989; 41: 304-311
        • Podsiadlo D.
        • Richardson S.
        The timed “Up & Go”: a test of basic functional mobility for frail elderly persons.
        J Am Geriatr Soc. 1991; 39: 142-148
        • Lawton M.P.
        • Brody E.M.
        Assessment of older people: self-maintaining and instrumental activities of daily living.
        Gerontologist. 1969; 9: 179-186
        • Powell L.E.
        • Myers A.M.
        The Activities-specific Balance Confidence (ABC) Scale.
        J Gerontol A Biol Sci Med Sci. 1995; 50: M28-M34
        • Clemson L.
        • Bundy A.C.
        • Cumming R.G.
        • Kay L.
        • Luckett T.
        Validating the Falls Behavioural (FaB) scale for older people: a Rasch analysis.
        Disabil Rehabil. 2008; 30: 498-506
        • Finlayson M.L.
        • Peterson E.W.
        • Fujimoto K.A.
        • Plow M.A.
        Rasch validation of the falls prevention strategies survey.
        Arch Phys Med Rehabil. 2009; 90: 2039-2046
        • Willer B.
        • Ottenbacher K.J.
        • Coad M.L.
        The community integration questionnaire. A comparative examination.
        Am J Phys Med Rehabil. 1994; 73: 103-111
        • World Health Organization
        (Available at:) (Accessed January 1, 2014)
        • Kempen J.C.
        • Knol D.L.
        • Lankhorst G.J.
        • Beckerman H.
        Community walking can be assessed using a 10-metre timed walk test.
        Mult Scler. 2011; 17: 980-990
        • Kornetti D.L.
        • Fritz S.L.
        • Chiu Y.P.
        • Light K.E.
        • Velozo C.A.
        Rating scale analysis of the Berg Balance Scale.
        Arch Phys Med Rehabil. 2004; 85: 1128-1135
        • Wrisley D.M.
        • Kumar N.A.
        Functional gait assessment: concurrent, discriminative, and predictive validity in community-dwelling older adults.
        Phys Ther. 2010; 90: 761-773
        • Huang T.T.
        • Wang W.S.
        Comparison of three established measures of fear of falling in community-dwelling older adults: psychometric testing.
        Int J Nurs Stud. 2009; 46: 1313-1319
        • Cattaneo D.
        • Lamers I.
        • Bertoni R.
        • Feys P.
        • Jonsdottir J.
        Participation restriction in people with multiple sclerosis: prevalence and correlations with cognitive, walking, balance, and upper limb impairments.
        Arch Phys Med Rehabil. 2017; 98: 1308-1315
        • Cattaneo D.
        • Carpinella I.
        • Aprile I.
        • Prosperini L.
        • Montesano A.
        • Jonsdottir J.
        Comparison of upright balance in stroke, Parkinson and multiple sclerosis.
        Acta Neurol Scand. 2016; 133: 346-354
        • Divani A.A.
        • Vazquez G.
        • Barrett A.M.
        • Asadollahi M.
        • Luft A.R.
        Risk factors associated with injury attributable to falling among elderly population with history of stroke.
        Stroke. 2009; 40: 3286-3292
        • Matinolli M.
        • Korpelainen J.T.
        • Sotaniemi K.A.
        • Myllylä V.V.
        • Korpelainen R.
        Recurrent falls and mortality in Parkinson's disease: a prospective two-year follow-up study.
        Acta Neurol Scand. 2011; 123: 193-200
        • Lusardi M.M.
        • Fritz S.
        • Middleton A.
        • et al.
        Determining risk of falls in community dwelling older adults: a systematic review and meta-analysis using posttest probability.
        J Geriatr Phys Ther. 2017; 40: 1-36
        • Pang M.Y.
        • Eng J.J.
        Fall-related self-efficacy, not balance and mobility performance, is related to accidental falls in chronic stroke survivors with low bone mineral density.
        Osteoporos Int. 2008; 19: 919-927
        • Thomas A.A.
        • Rogers J.M.
        • Amick M.M.
        • Friedman J.H.
        Falls and the falls efficacy scale in Parkinson's disease.
        J Neurol. 2010; 257: 1124-1128
        • Allen N.E.
        • Sherrington C.
        • Paul S.S.
        • O'Rourke S.D.
        • Canning C.G.
        Fear of falling and future falls in people with Parkinson's disease.
        Mov Disord. 2012; 27: S299-S300
        • Li Y.H.
        • Song G.X.
        • Yu Y.
        • Zhou de D.
        • Zhang H.W.
        Study on age and education level and their relationship with fall-related injuries in Shanghai, China.
        Biomed Environ Sci. 2013; 26: 79-86
        • Padubidri A.
        • Al Snih S.
        • Samper-Ternent R.
        • Markides K.S.
        • Ottenbacher K.J.
        • Raji M.A.
        Falls and cognitive decline in Mexican Americans 75 years and older.
        Clin Interv Aging. 2014; 9: 719-726
        • Dlugonski D.
        • Pilutti L.A.
        • Sandroff B.M.
        • Suh Y.
        • Balantrapu S.
        • Motl R.W.
        Steps per day among persons with multiple sclerosis: variation by demographic, clinical, and device characteristics.
        Arch Phys Med Rehabil. 2013; 94: 1534-1539
        • Mak M.K.
        • Pang M.Y.
        Parkinsonian single fallers versus recurrent fallers: different fall characteristics and clinical features.
        J Neurol. 2010; 257: 1543-1551
        • Nilsson M.H.
        • Rehncrona S.
        • Jarnlo G.B.
        Fear of falling and falls in people with Parkinson's disease treated with deep brain stimulation in the subthalamic nuclei.
        Acta Neurol Scand. 2011; 123: 424-429
        • Finlayson M.L.
        • Peterson E.W.
        • Cho C.C.
        Risk factors for falling among people aged 45 to 90 years with multiple sclerosis.
        Arch Phys Med Rehabil. 2006; 87 (quiz 1287): 1274-1279
        • Alemdaroğlu E.
        • Uçan H.
        • Topçuoğlu A.M.
        • Sivas F.
        In-hospital predictors of falls in community-dwelling individuals after stroke in the first 6 months after a baseline evaluation: a prospective cohort study.
        Arch Phys Med Rehabil. 2012; 93: 2244-2250
        • Jørgensen L.
        • Engstad T.
        • Jacobsen B.K.
        Higher incidence of falls in long-term stroke survivors than in population controls: depressive symptoms predict falls after stroke.
        Stroke. 2002; 33: 542-547