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Monthly Archives: July 2012

Putting the Right Foot Forward-Falls Prevention

Falls are a common and complex problem amongst the ageing population, causing considerable mortality, morbidity, reduced functioning and premature nursing home admissions. In fact, falls are the leading cause of injury deaths in people aged 65 years and over. Further, one in three people aged 65 years and over fall each year.

Several published clinical guidelines review the evidence for fall prevention strategies and provide recommendations for assessment and intervention. Most falls experienced by elderly individuals result from multi-factorial and interacting precipitating and predisposing causes. Thus, their diagnoses, treatment and prevention create a difficult clinical challenge. A fall may be the first indicator of an acute problem, may stem from a chronic disease or simply a sign of the progression of typical age related changes in vision, gait and strength. The following intrinsic and extrinsic factors may precipitate events and falls.

Intrinsic

  • Gait and balance impairment/foot problems
  • Peripheral neuropathy
  • Vestibular dysfunction
  • Muscle weaknession impairment                                                           
  • Medical illness
  • Advanced age
  • Dementia
  • Drugs

Extrinsic

  • Environmental hazards
  • Poor footwear

Amongst these intrinsic and extrinsic risk factors, gait and balance impairment, with underlying foot problems, along with footwear, are in the midst of the most consistently proven predictors of a falls risk. Indeed, the role of the lower limb, feet and footwear in falls prevention is important, given that over half of reported falls occur from an individual’s base of support. As we age our feet can change shape and lose some feeling and flexibility. This changes the way we walk and affects balance. More specifically, these changes relate to muscle weakness, decreased joint range of motion and somatosensory changes. With muscle weakness, there may be a decrease in the strength of muscles in the calf and back of ankle. Therefore, the person’s ability to create a stabilizing axis around the ankle joint is reduced. Osteoarthritis can play a significant role in decreased range of motion. Especially around the ankle, there may be limited range of motion, leading to a rigid foot type, which in turn, causes postural instability as the body moves over the foot. A rigid foot is also less likely to handle rough terrain and less able to absorb shock.  Somatosensory changes relate to light touch, pressure and vibration and proprioception. Conditions such as peripheral neuropathy or a stroke can have a detrimental effect on a person’s awareness of these, making it difficult to adjust to changes in environment and knowing where their placement of foot is.

As many older people are less capable of providing self care to their feet, it is the responsibility of nursing staff, carers and certain health professions, to employ strategies as a means of reducing an elderly persons falls risk. Of particular significance, if nursing staff become aware of foot problems such as swelling, arthritis, toe deformities, skin and nails problems (corns and calluses) or other abnormalities such as collapsed arch/flat feet, the resident should be referred to a podiatrist for further assessment. In addition, individuals with known diabetes, peripheral neuropathy or peripheral vascular disease, which can affect balance and proprioception, require a detailed podiatric assessment. Podiatrists are skilled in the assessment of feet and footwear, which should be implemented upon admission and continually on a regular basis. Specifically, safe footwear can potentially improve postural stability in residents and therefore reduce falls risk. A detailed assessment by a podiatrist for a fall specific feet and footwear examination will include:

  • Fall history: pain and footwear
  • Dermatological assessment: skin and nail problems
  • Vascular assessment: peripheral vascular status
  • Neurological assessment: propriception; balance and stability; sensory, motor and autonomic function
  • Biomechanical:  posture, foot and lower limb range of motion, foot deformity, gait analysis
  • Footwear assessment: stability and balance features, prescription of footwear and footwear modifications, or orthoses
  • Education: foot care and footwear, and the link between footwear and falls.

 

The key features that every safe shoe should have are identified on the illustration below.

                                                                                                                                                                                                              

 What makes a shoe unsafe?

  • Soft or stretched uppers make the foot slide around in shoe
  • High heels impair stability when walking
  • Narrow heels make the foot unstable     
  • Lack of laces means the foot can slide out of shoe
  • Slippery or worn soles are a balance hazard, particularly on wet floor                                                                      

All health care professions can play an important role in further improving foot conditions and footwear by: ensuring shoes are cleaned and repaired when necessary; ensuring residents with urinary incontinence have dry, clean footwear; ensuring residents have more than one pair of shoes in case shoes are damaged or soiled; discouraging walking while wearing slippery socks and stockings; discouraging use of talcum powder, which makes floors slippery; educating residents and carers about basic foot care. Further, exercise programs target strength, balance and flexibility.

Overall, most falls are amenable to change and thus can be prevented through a multidisciplinary approach.  Falls result from the interaction of medical, psychological, environmental and age related changes. Gait and balance impairment with underlying foot problems, are one of the most consistently proven predictors of falls risk. Further, footwear plays an integral part in improving postural instability, by the use of a safe shoe checklist. Best practice in fall and injury prevention involves implementing the aforementioned strategies, identifying fall risk and implementing individualised strategies related to gait, foot problems and footwear, which must be monitored and reviewed regularly.

Written by Ashlee Finch

Senior Foot Care Podiatrist

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