Increased Risk of Fracture in MS Patients

Patient Expert

A recent study confirms that patients with multiple sclerosis have an increased risk of fractures and broken bones.   Researchers analyzed hospital records and death certificates using an English national linked Hospital Episode Statistics (HES) database covering the population of England of about 50 million people during the years 1999-2010.

In this English study, patients with MS had an overall 99% increased risk of fracture as compared to the reference group (Ramagopalan, 2012).   This exceeds the results of previously published studies which investigated the risk of fracture in patients with MS.

A study using the Danish MS register found a 40% increased risk of fracture in MS patients (Bazelier, April 2012).   However, another study by the same authors and using the same database came to a different conclusion and said that "patients with MS had no overall increased risk of fracture" (Bazelier, October 2012).   A study from the United Kingdom (UK) using the General Practice Research Database (GPRD) observed a 20% elevated risk for all fractures (Bazelier, 2011).

Authors note that patients with MS may be at risk of fracture due to low bone mineral density (Gibson, 2011) and an elevated risk of falling (Finlayson, 2006). Osteoporosis occurs more frequently among patients with MS, possibly as a result of immobility, imbalance, progressive disability or other undetermined yet factors (Hearn, 2010; Dobson, 2012). An increased risk of falling may arise from imbalance or disability (Finlayson, 2006).

In the present study, overall risk for all types of fractures was increased in patients with MS by 99%.   The relative risk of all fractures was almost double (RR = 1.99) for MS patients.   Data was analyzed by type of fracture (location).   A significant increased risk of femoral fracture - the femur is the thigh bone - of the femoral neck (RR = 2.79) and femoral shaft (RR = 6.69) was seen.   A femoral neck fracture is commonly known as a "hip fracture."   Increased fractures of the tibia (shinbone) or ankle were also evident (RR = 2.81).

Data was further analyzed by the time of fracture in reference to MS diagnosis (within the first year post-diagnosis or later).   The greatest increased risk of fracture was seen in the femoral shaft (thigh bone) of patients who had been diagnosed with MS for more than one year (RR = 7.00).   The lowest (reduced) risk of fracture was seen in the wrists/hands of patients within their first year post-diagnosis (RR = 0.78).   Reduced risks of fractures were also seen in the ribs, clavicle, and forearm of patients newly diagnosed with MS (less than one year).

Combining the results of this study and several similar studies, an association between MS and and the risk of fractures is quite evident.   Potential explanations for this include an increased risk of osteoporosis in MS patients (perhaps due to immobility, steroid use, or low vitamin D levels) (Dobson, 2012; Gibson, 2011; Hearn, 2010) and/or low bone mineral density (BMD) which can be seen with increased disability and immobility (Kampman, 2011).   However, lower than expected BMD has been reported in patients newly diagnosed with MS or with clinically isolated syndromes as compared to controls (Moen, 2011, 2012).

Regardless of why MS patients may be at increased risk for osteoporosis, low bone mineral density, and fracture, it is important to optimize our bone health and to protect ourselves from falling.   The National MS Society has an excellent brochure - "Minimizing your risk of falls" - which provides concrete recommendations to protect yourself.   The National MS Society also offers a popular eight-week in-person course - Free from Falls: A Comprehensive Fall Prevention Program for People with MS.   Call your local chapter for more information.

What do you do to protect yourself from osteoporosis, falling, and broken bones?

Bazelier MT, et al.   Incidence of fractures in patients with multiple sclerosis: the Danish National Health Registers.   Mult Scler 2012;18(5):622-627.   Epub 2011 Oct 21.

Bazelier MT, et al. The risk of fracture in incident multiple sclerosis patients: The Danish National Health Registers.   Mult Scler 2012;18(11):1609-1616. Epub 2012 April 3.

Bazelier MT, et al.   The risk of fracture in patients with multiple sclerosis: the UK
general practice research database
.   J Bone Miner Res 2011;26(9):2271-2279.

Bazelier MT, et al.   Risk of fractures in patients with multiple sclerosis: a population-based cohort study.   Neurology 2012 Jun 12;78(24):1967-73. Epub 2012 May 16.

Dobson R, Ramagopalan S, Giovannoni G.   Bone health and multiple sclerosis.   Mult Scler 2012 Nov;18(11):1522-8.   Epub 2012 Jun 27.

Finlayson ML, Peterson EW, Cho CC.   Risk factors for falling among people aged 45 to 90 years with multiple sclerosis.   Arch Phys Med Rehabil 2006 Sep;87(9):1274-9; quiz 1287.

Gibson JC, Summers GD.   Bone health in multiple sclerosis.   Osteoporos Int 2011 Dec;22(12):2935-49. Epub 2011 May 21.

Hearn AP, Silber E.   Osteoporosis in multiple sclerosis.   Mult Scler 2010 Sep;16(9):1031-43. Epub 2010 Jun 15.

Kampman MT, Eriksen EF, Holmøy T.   Multiple sclerosis, a cause of secondary
osteoporosis? What is the evidence and what are the clinical implications?
Acta Neurol Scand 2011;(191):44-9. doi: 10.1111/j.1600-0404.2011.01543.x.

Moen SM, et al.   Bone Turnover and Metabolism in Patients with Early Multiple Sclerosis and Prevalent Bone Mass Deficit: A Population-Based Case-Control Study.   PLoS ONE 2012;7(9): e45703. doi:10.1371/journal.pone.0045703

Moen SM, et al.   Low bone mass in newly diagnosed multiple sclerosis and clinically isolated syndrome.   Neurology 2011;77:151-157.

Ramagopalan SV, et al.   Risk of fractures in patients with multiple sclerosis: record-linkage study.   BMC Neurology 2012;12:135 doi:10.1186/1471-2377-12-135.

"Minimizing your risk of falls" (pdf) by Debra Frankel, MS, OTR with Diana M Schneider, PhD. National MS Society, 2011.   Accessed November 12, 2012.