A multifaceted podiatry intervention was successful in decreasing the rate of falls in community dwelling older adults with disabling foot pain.

Institution:

Wake Forest University School of Medicine

Article Citation

Article Link:

Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomised controlled trial.

Clinical Bottom Lines

Compared with usual podiatric care, a multifaceted podiatry intervention reduced the number of falls over one year in community dwelling older adults with disabling foot pain (103 vs 161, P=0.01) without decreasing the number of single or recurrent fallers.

Disclaimer:

This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.

Methods

Type of Study:

Therapy / Prevention

Follow-up Period:

12 months.

Patient Population:

305 community dwelling participants, aged 65-93 with a mean age of 73.9 years, cognitively intact with disabling foot pain, defined as foot pain lasting for at least a day within the last month and a positive response of “some days” or “most/every days” to at least one item on the Manchester foot pain and disability index. Participants included 94 men and 211 women and an average duration of foot pain of 6.9 years. Approximately 1/3rd of participants were living alone. Around 60% were using ≥ 4 drugs, over 50% had fallen in the last year, and 30% had ≥2 falls in the previous year. Approximately 65% of participants had osteoarthritis, 22% had heart disease, 7% had a history of stroke, and 17% had a history of diabetes.

Significant Exclusions:

Participants were excluded if they had neurodegenerative disorders, leg amputation, inability to walk household distances (10 m) without the use of a walking aid, limited English language skills, and leg surgery three months before the initial assessment or planned leg surgery within three months of the planned initial assessment.

Intervention/Exposure:

Control: ‘usual’ podiatric care
Intervention:
1. Foot orthotics: Prefabricated and then heated and molded to participant’s foot shape and customized to redistribute weight away from plantar lesions.
2. Advice/provision of footwear: Footwear assessment forms to assess outdoor footwear. If inappropriate, participants were counseled on hazardous features and given a voucher to buy new footwear.
3. Home based foot and ankle exercise program: Standardized 30 min program 3x’s/wk for 6 months aimed at stretching and strengthening muscles of the foot and ankle. Instructed to increase the number of repetitions or resistance at a self paced rate if no pain and no soreness the next day. Podiatrist telephoned them at 1, 4, 12, and 20 weeks to promote adherence.
4. Falls prevention education: Booklet produced by the Australian Dept of Health and Ageing.

Outcome Measures:

Primary outcomes: proportion of fallers, proportion of multiple fallers, and falling rate (# of falls/participant) in 12 months. Data collected was from monthly falls calendar.
Secondary outcomes: measured at baseline and at 6 months included tests of foot and ankle strength and ROM, balance, functional ability, total physiological profile assessment falls risk score, pain and function subscales of the Manchester foot pain and disability index, short falls efficacy scale international, and mental and physical component summary scores of the short form health survey. 6 month outcomes used (considered a significant time for interventions to be implemented and effects to be apparent).

Results

264 falls total: 103 in the intervention vs 161 in the control. Falls risk ratio 0.64 (0.45-0.91), 95% CI, p=0.01. This corresponds to a 36% reduction in the falls rate during the trial.
The proportion of fallers did not differ significantly between the groups (RR 0.85, 95% CI 0.66 to 1.08, p=0.19).
The number of multiple fallers did not differ significantly (RR 0.63, 0.38 to 1.04, p=0.07).
8 participants had falls resulting in fractures: 1 in the intervention and 7 in the control, p=0.07.
Secondary outcomes: Significant improvements in the intervention group were found for the domains of strength in ankle eversion, range of motion in ankle dorsiflexion and inversion/eversion, and balance.
None of the participants reported any adverse events during the trial.

Methodological Issues…

Unable to blind due to the nature of the study.
One podiatrist in the study could be a limitation if there is significant variation between providers.
195 initially expressed interest but then declined, so potential for volunteer bias.
Intervention did not target all relevant ankle and foot risk factors.
Unable to generalize these findings to residents in long term care.
Unable to determine if one specific intervention was more important than the others.
Generalizability limited due to payer structure in United States.

Other Information

Created By:

Valerie Wilson, MD, Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest University

CAP Topics:

Falls [1]

Geriatric Education [2]

Musculoskeletal Disorders [3]