A survey exploring self-reported indoor and outdoor footwear habits, foot problems and fall status in people with stroke and Parkinson's

Foot Problems in Older Adults Presenting to a Falls and Balance Clinic

INTRODUCTION

Foot problems, including musculoskeletal problems, peripheral neuropathy, peripheral arterial disease and dermatologic pathology are common in older adults and are associated with an increased risk of falling. Multicomponent podiatry interventions have been shown to reduce the incidence of falls. This paper aimed to identify older adults requiring podiatry input in a Falls and Balance clinic; to describe the model of foot health care they receive; to explore cross-sectional associations between foot problems and function and ultimately demonstrate the role of podiatry input in the multidisciplinary management of falls risk.

METHODS

Cohort study of patients attending a Falls and Balance Clinic for Comprehensive Geriatric Assessment. Demographic information was collected and functional independence, mobility, foot problems, and footwear were assessed in the clinic.

RESULTS

One-hundred and two patients were included; median age 79.3 (73-84.3) years, 68.6% female, 93.1% residing independently, 62.7% used a gait aid. Podiatry referrals were made in 80.4% of cases, with muscle weakness being the most common problem identified (90.2%); 74.8% were found to be wearing inappropriate footwear. Most patients received footwear education and half were prescribed foot and ankle strengthening exercises. Hallux and lesser toe weakness were associated with lower Short Physical Performance Battery scores (p < 0.001).

CONCLUSION

The majority of older adults in the Falls and Balance Clinic required podiatry input, with foot weakness and inappropriate footwear being common reasons for referral. Those with weakness of the hallux and lesser toes had poorer balance and mobility, which is known to be associated with greater falls risk. This highlights the need for podiatry assessment and interventions as part of the multidisciplinary approach to the management of falls risk in older adults.

Footwear characteristics and foot problems in community dwelling people with stroke: a cross-sectional observational study

PURPOSE

To explore footwear characteristics and foot problems in community dwelling people with stroke as most research to date focused on the general elderly population.

METHODS

Thirty people with mild to moderate stroke (nine men, mean age 68, mean time since onset 67 months) attended a single session to assess footwear and foot problems using established podiatry foot (wear) and ankle assessments.

RESULTS

Most participants wore slippers indoors (n = 17, 57%) and walking shoes outdoors (n = 11, 37%). Over half wore unsupportive ill-fitting shoes indoors and 47% of outdoor shoes fitted badly. All participants had foot problems (mean 6.5 (3.1), 95% CI: 5.4-7.7), including impaired single limb heel raise (93%), reduced range of movement (77%), sensation (47%), and muscle strength (43%). Many had foot-pain, hallux valgus (both 50%), or swollen feet (40%). Foot problems were associated with reduced balance confidence, activity, and community participation (all p < 0.05). A greater proportion of fallers (13/16) than non-fallers (4/14) reported foot problems (p = 0.029).

CONCLUSIONS

Many community-dwelling people with stroke wore poorly fitting shoes; all had foot problems. Foot problems were linked to reduced mobility. Finding more effective pathways to support people with stroke to select supportive, well-fitting indoor and outdoor footwear is indicated.Implications for rehabilitationPeople with stroke often wear unsupportive ill-fitting shoes and experience foot problems.Assessment of foot problems and footwear advice should be considered during stroke rehabilitation particularly when interventions target fall prevention or improvements in balance and mobility.Information on appropriate footwear and signposting that new shoe purchases should include measuring feet to ensure a good fit is recommended.

The implications of the foot health status in Parkinson patients: A case-control study

Parkinson's disease (PD) is a neurodegenerative disorder that affects both health of the feet, as to gait patterns. This study aimed to find out about foot problems and their impact on self-perceived quality of life and related to foot health in Parkinson's patients compared to a group of healthy subjects and to measure it with Spanish Podiatry Health Questionnaire (PHQ-S). It is about a case-control study in a sample of Parkinson's patients n = 62, healthy controls n = 62. The PHQ-S was reported, it describes perception the subject has in each of podiatric 6 dimensions consulted, assessing appreciation of health status of interviewee's feet and a self-rated the foot health score on the visual analog scale (VAS). There were statistically significant differences (P < 0.05) in the dimensions that assessed problems with walking and moving, nail trimming, concern feet state, and affectation of quality of life related foot health. Regarding the self-perception of state of their feet, Parkinson's patients perceive a worse state of health of their feet than healthy subjects. The mean value was 4.8 (SD 2.2) for Parkinson's patients and 3.8 (SD 2.3) for healthy subjects. In conclusion, patients with PD have problems in walking or moving, foot pain, difficulties in foot hygiene and in cutting for their nails, as well as the concern they suffer from deterioration in state of their feet affect them and decrease their quality of life. Podiatric problems in Parkinson's patients have a great impact in reducing quality of life related to foot health.

Effect of foot health and quality of life in patients with Parkinson disease: A prospective case-control investigation

BACKGROUND

Parkinson's disease (PD) is a common neurodegenerative disorder, characterised by the presence of motor disturbances. Therefore, it can be related to musculoskeletal and orthopaedic problems, particularly in the foot status, that are linked to a negative effect on overall health, mobility and social function.

OBJECTIVE

The aim was to analyse the impact of foot health and quality of life in patients with Parkinson's disease and people without Parkinson's disease, with normalised reference scores, in the light of the values recorded with regard to foot health status and overall health.

MATERIAL AND METHODS

This is a prospective case-control investigation. A sample of Parkinson's patients (n = 62) including 24 men and 38 women was recruited, and foot HQoL was measured using the Foot Health Status Questionnaire Spanish (Sp_FHSQ).

RESULTS

The PD group recorded lower levels of foot health quality of life (HQoL) with lower scores on the Sp_FHSQ in general foot health, general health, physical activity, social capacity and vigour sub-scales. Regarding the rest of the sub-scales of the Sp_FHSQ, foot pain showed higher values in the PD group. Differences between the cases and control groups were analysed by means of a Mann-Whitney U test, showing statistical significance (P < 0.05).

CONCLUSIONS

PD presents an increased negative impact on foot health and quality of life which appears to be related to the chronic neurodegenerative disease.

Impact of Footwear and Foot Deformities in patients with Parkinson's disease: A Case-Series Study

Background: Parkinson's disease (PD) is a common and complex neurological problem. Gait abnormalities are frequent in PD patients, and this increases the risk of falls. However, little is known about foot deformities and footwear in this vulnerable population. Here we investigate whether patients with PD use an appropriate shoe size and know if they have foot deformities or alterations. Methodology: A study of a series of observational descriptive cases in a convenience sample (n = 53 patients) diagnosed with Parkinson's disease. One trained investigator evaluated foot and ankle health. The footwear and foot measurements were obtained using a Brannock device. Results: The podiatric examination and footwear examination detected a high presence of podiatric pathologies and inappropriate footwear. This has a negative impact on the quality of life of these patients. Conclusions: This research detected an elevated number of people with foot deformities or alterations. Moreover, a high proportion of participants with PD wear inadequate footwear (in length, width, or both).

Repeatability of plantar pressure assessment during barefoot walking in people with stroke

Purpose

Stroke-related changes in foot structure and function affect balance and mobility and quantifying foot function following stroke could offer clinically useful information to inform rehabilitation. The aim of this work was to explore the feasibility of undertaking plantar pressure assessment during barefoot walking in people with stroke, and evaluate the repeatability of the assessment protocol and regional footprint analysis as a measure of dynamic foot characteristics.

Materials & methods

Plantar pressure analysis was undertaken using a pressure platform (Tekscan HR Mat) on two test sessions, approximately two weeks apart (mean = 15.64 ± 11.64 days). Peak plantar pressure (kPa) and contact area (cm²) for foot regions were extracted and repeatability analysis undertaken. Descriptive evaluation of field notes and experiences of the participants was undertaken to inform the feasibility of the data collection protocol.

Results

Twenty-one participants (61.8 ± 9.2 years; 11 male, 10 female; 8 right-sided, 13 left-sided stroke) were recruited and 18 returned for retesting. Full data capture was achieved from 14 participants. Peak pressure and contact area demonstrated moderate to good repeatability for at the toes (ICC 0.76 and 0.58 respectively) and good to excellent repeatability for the other foot regions (ICC ≥ 0.82).

Conclusion

The protocol adopted in this study was feasible and yielded good to excellent repeatability for the foot regions, except the toes. The challenges with data collection in our study cohort could help inform future studies adopting similar protocols. This work also has relevance for use of pressure technology in clinical practice for assessing and monitoring foot function following stroke.

The Role of the Podiatrist in Assessing and Reducing Fall Risk: An Updated Review

Falls present a tremendous challenge to health care systems. This article reviews the literature from the previous 5 years (2014-2019) in terms of methods to assess fall risk and potential steps that can be taken to reduce fall risk for patients visiting podiatric clinics. With regard to assessing fall risk, we discuss the role of a thorough medical history and podiatric assessments of foot problems and deformities that can be performed in the clinic. With regard to fall prevention we consider the role of shoe modification, exercise, pain relief, surgical interventions, and referrals.

Factors associated with type of footwear worn inside the house: a cross-sectional study

Background

In specific populations, including those at risk of falls or foot ulcers, indoor footwear is an important aspect of preventative care. This study aims to describe the indoor footwear worn most over the previous year in a sample representative of the Australian inpatient population, and to explore the sociodemographic, medical, foot condition and foot treatment history factors associated with the indoor footwear worn.

Methods

This was a secondary analysis of data collected from inpatients admitted to five hospitals across Queensland, Australia. Sociodemographic information, medical history, foot conditions and foot treatment history were collected as explanatory variables. Outcomes included the self-reported type of indoor footwear (from 16 standard footwear types) worn most in the year prior to hospitalisation, and the category in which the self-reported footwear type was defined according to its features: 'protective', 'non-protective' and 'no footwear'. Multivariate analyses determined explanatory variables independently associated with each type and category.

Results

Protective footwear was worn by 11% of participants (including 4% walking shoes, 4% running shoes, 2% oxford shoes), and was independently associated with education above year 10 level (OR 1.78, p = 0.028) and having had foot treatment by a specialist physician (5.06, p = 0.003). Most participants (55%) wore non-protective footwear (including 21% slippers, 15% thongs/flip flops, 7% backless slippers), which was associated with older age (1.03, p < 0.001). No footwear was worn by 34% of participants (30% barefoot, 3% socks only). Those of older age (0.97, p < 0.001) and those in the most disadvantaged socioeconomic group (0.55, p = 0.019) were less likely to wear no footwear (socks or barefoot).

Conclusions

Only one in nine people in a large representative inpatient population wore a protective indoor footwear most of the time in the previous year. Whilst having education levels above year 10 and having received previous foot treatment by a specialist physician were associated with wearing protective footwear indoors, the presence of a range of other medical and foot conditions were not. These findings provide information to enable clinicians, researchers and policymakers to develop interventions aimed at improving indoor footwear habits that may help prevent significant health burdens such as falls and foot ulcers.

Assessing Plantar Sensation in the Foot Using the Foot Roughness Discrimination Test (FoRDT): A Reliability and Validity Study in Stroke

BACKGROUND

The plantar foot represents a sensory dynamometric map and is essential for balance and gait control. Sensory impairments are common, yet often difficult to quantify in neurological conditions, particularly stroke. A functionally oriented and quantifiable assessment, the Foot Roughness Discrimination Test (FoRDT), was developed to address these shortcomings.

OBJECTIVE

To evaluate inter- and intrarater reliability, convergent and discriminant validity of the FoRDT.

DESIGN

Test-retest design.

SETTING

Hospital outpatient.

PARTICIPANTS

Thirty-two people with stroke (mean age 70 years) at least 3 months after stroke, and 32 healthy, age-matched controls (mean age 70).

MAIN OUTCOME MEASURES

Roughness discrimination thresholds were quantified utilizing acrylic foot plates, laser cut to produce graded spatial gratings. Stroke participants were tested on three occasions, and by two different raters. Inter- and intrarater reliability and agreement were evaluated with Intraclass Correlation Coefficients and Bland-Altman plots. Convergent validity was evaluated through Spearman rank correlation coefficients (rho) between the FoRDT and the Erasmus modified Nottingham Sensory Assessment (EmNSA).

RESULTS

Intra- and interrater reliability and agreement were excellent (ICC =0.86 [95% CI 0.72-0.92] and 0.90 [95% CI 0.76-0.96]). Discriminant validity was demonstrated through significant differences in FoRDT between stroke and control participants (P < .001). Stroke fallers had statistically significant higher FoRDT scores compared with nonfallers (P = .01). Convergent validity was demonstrated through significant and strong correlations (rho) with the Erasmus MC Nottingham Sensory Assessment (r = .69, P < .01). Receiver operator characteristic curve analysis indicated the novel test to have excellent sensitivity and specificity in predicting the presence of self-reported sensory impairments. Functional Reach test significantly correlated with FoRDT (r = .62, P < .01) whereas measures of postural sway and gait speed did not (r = .16-.26, P > .05).

CONCLUSIONS

This simple and functionally oriented test of plantar sensation is reliable, valid, and clinically feasible for use in an ambulatory, chronic stroke and older population. It offers clinicians and researchers a sensitive and robust sensory measure and may further support the evaluation of rehabilitation targeting foot sensation.

LEVEL OF EVIDENCE

III.

Falls, Footwear, and Podiatric Interventions in Older Adults

Footwear is a modifiable risk factor for falls in older adults, including populations with metabolic disease, inflammatory arthritis, and neurodegenerative disease. Ill-fitting footwear, and specific design features, such as elevated heels and backless styles, can impair balance control and heighten the risk of falling. Although foot care is routine practice for some older adults to prevent ulceration (eg, diabetes) or relieve symptoms (eg, foot pain), new footwear interventions are emerging with the potential to ameliorate balance and walking impairments. Multifaceted podiatric interventions, which include appropriate footwear and importantly patient education, may have the capacity to reduce falls in older adults.

Assessing lower limb position sense in stroke using the gradient discrimination test (GradDT™) and step-height discrimination test (StepDT™): a reliability and validity study

Purpose: To evaluate the psychometric properties of two novel tests of lower limb position sense.Methods: Our newly developed tests assess the discrimination thresholds of under-foot slope and step height perception using a two alternative forced choice approach. Stroke participants (n = 32) and age matched controls (n = 32) were tested. Inter- and intra-rater reliability and agreement, sensitivity and specificity, discriminant and convergent validity were evaluated.Results: Intra-rater reliability for both variants of the gradient discrimination test was excellent; intraclass correlation coefficients (ICC) =0.91 and 0.89. The step height discrimination test had excellent intra-rater reliability and agreement: ICC =0.95. Inter-rater reliability was also excellent in both tests (ICC= 0.85-0.93). Discriminant validity was demonstrated with significant differences in test performance between stroke and control participants (p < 0.001). Our novel tests did not significantly correlate with the proprioceptive component of the Erasmus modified Nottingham Sensory Assessment. Receiver Operating Characteristic curve analysis indicated both novel tests to have greater sensitivity and specificity than the proprioceptive component of the Erasmus modified Nottingham Sensory Assessment in predicting the presence of self-reported sensory impairments. Functional reach test, 10 meter walk test, centre of pressure measurement and reported falls showed significant and moderate to strong correlations with novel test performance (r = 0.40-0.60); the Erasmus modified Nottingham Sensory Assessment did not.Conclusions: Our novel, functionally oriented tests of lower limb position sense are reliable, valid and feasible for use in an ambulatory chronic stroke and elderly population.Implications for rehabilitationThe GradDT™ and StepDT are two novel tests of lower limb position sense which are reliable and valid in a chronic stroke sample.They offer clinicians and researchers sensitive, accurate and clinically usable measures of lower limb position sense.

Incorrectly fitted footwear, foot pain and foot disorders: a systematic search and narrative review of the literature

Background

Correct footwear fitting is acknowledged as being vitally important, as incorrectly fitted footwear has been linked to foot pathology. The aim of this narrative review was to determine the prevalence of incorrectly fitted footwear and to examine the association between incorrectly fitted footwear, foot pain and foot disorders.

Methods

A database search of Ovid MEDLINE and CINAHL yielded 1,681 citations for title and abstract review. Eighteen articles were included. Findings were summarised under the categories of (i) children, (ii) adults, (ii) older people, (iii) people with diabetes and (iii) occupation- or activity-specific footwear. Differences in footwear fitting between sexes were also explored.

Results

Between 63 and 72% of participants were wearing shoes that did not accommodate either width or length dimensions of their feet. There was also evidence that incorrect footwear fitting was associated with foot pain and foot disorders such as lesser toe deformity, corns and calluses. Specific participant groups, such as children with Down syndrome and older people and people with diabetes were more likely to wear shoes that were too narrow (between 46 and 81%).

Conclusion

A large proportion of the population wear incorrectly sized footwear, which is associated with foot pain and foot disorders. Greater emphasis should be placed on both footwear fitting education and the provision of an appropriately large selection of shoes that can accommodate the variation in foot morphology among the population, particularly in relation to foot width.

Independent factors associated with wearing different types of outdoor footwear in a representative inpatient population: a cross-sectional study

Background

Footwear can have both a positive and negative impact on lower limb health and mobility across the lifespan, influencing the risk of foot pain, ulceration, and falls in those at risk. Choice of footwear can be influenced by disease as well as sociocultural factors, yet few studies have investigated the types of footwear people wear and the profiles of those who wear them. The aim of this study was to investigate the prevalence and factors associated with outdoor footwear type worn most often in a representative inpatient population.

Methods

This study was a secondary data analysis of a cohort of 733 inpatients that is highly representative of developed nations’ hospitalised populations; 62 ± 19 years, 55.8% male, and 23.5% diabetes. Socio-demographic, medical history, peripheral arterial disease, peripheral neuropathy, foot deformity, foot ulcer history, amputation history and past foot treatment variables were collected. Participants selected the footwear type they mostly wore outside the house in the previous year from 16 types of footwear. Multivariate logistic regression identified independent factors associated with outdoor footwear types selected.

Results

The most common outdoor footwear types were: running shoes (20%), thongs/flip flops (14%), walking shoes (14%), sandals (13%) and boots (11%). Several socio-demographic, medical history and foot-related factors were independently associated (Odds Ratio; 95% Confidence Interval)) with different types of footwear. Running shoes were associated with male sex (2.7; 1.8–4.1); thongs with younger age (0.95 for each year; 0.94–0.97), being female (2.0; 1.2–3.1) and socio-economic status (3.1; 1.2–7.6); walking shoes with arthritis (1.9; 1.2–3.0); sandals with female sex (3.8; 2.3–6.2); boots with male sex (9.7; 4.3–21.6) and inner regional (2.6; 1.3–5.1) and remote (3.4; 1.2–9.5) residence (all, p < 0.05).

Conclusions

We profiled the types of outdoor footwear worn most in a large diverse inpatient population and the factors associated with wearing them. Sex was the most consistent factor associated with outdoor footwear type. Females were more likely to wear thongs and sandals and males boots and running shoes. Overall, this data gives insights into the socio-demographic, medical and other health factors that are related to footwear choice in a large diverse population primarily of older age.

Electronic supplementary material

The online version of this article (10.1186/s13047-018-0260-7) contains supplementary material, which is available to authorized users.

The prevalence, distribution, and functional importance of lower limb somatosensory impairments in chronic stroke survivors: a cross sectional observational study

Purpose: To investigate the prevalence and distribution of lower limb somatosensory impairments in community dwelling chronic stroke survivors and examine the association between somatosensory impairments and walking, balance, and falls. Methods: Using a cross sectional observational design, measures of somatosensation (Erasmus MC modifications to the (revised) Nottingham Sensory Assessment), walking ability (10 m walk test, Walking Impact Scale, Timed "Get up and go"), balance (Functional Reach Test and Centre of Force velocity), and falls (reported incidence and Falls Efficacy Scale-International), were obtained. Results: Complete somatosensory data was obtained for 163 ambulatory chronic stroke survivors with a mean (SD) age 67(12) years and mean (SD) time since stroke 29 (46) months. Overall, 56% (n = 92/163) were impaired in the most affected lower limb in one or more sensory modality; 18% (n = 30/163) had impairment of exteroceptive sensation (light touch, pressure, and pin-prick), 55% (n = 90/163) had impairment of sharp-blunt discrimination, and 19% (n = 31/163) proprioceptive impairment. Distal regions of toes and foot were more frequently impaired than proximal regions (shin and thigh). Distal proprioception was significantly correlated with falls incidence (r = 0.25; p < 0.01), and centre of force velocity (r = 0.22, p < 0.01). The Walking Impact Scale was the only variable that significantly contributed to a predictive model of falls accounting for 15-20% of the variance. Conclusion: Lower limb somatosensory impairments are present in the majority of chronic stroke survivors and differ widely across modalities. Deficits of foot and ankle proprioception are most strongly associated with, but not predictive, of reported falls. The relative contribution of lower limb somatosensory impairments to mobility in chronic stroke survivors appears limited. Further investigation, particularly with regard to community mobility and falls, is warranted. Implications for Rehabilitation Somatosensory impairments in the lower limb were present in approximately half of this cohort of chronic stroke survivors. Tactile discrimination is commonly impaired; clinicians should include an assessment of discriminative ability. Deficits of foot and ankle proprioception are most strongly associated with reported falls. Understanding post-stroke lower limb somatosensory impairments may help inform therapeutic strategies that aim to maximise long-term participation, minimise disability, and reduce falls.

A survey to explore what information, advice and support community-dwelling people with stroke currently receive to manage instability and falls

PURPOSE

To describe and determine the benefits of the information and support services currently offered to people with stroke experiencing instability and falls.

METHODS

A cross-sectional survey study. Two hundred and fifty-six surveys were sent out to community stroke groups in Hampshire and the Isle of Wight, as well as to people with stroke on a patient register.

RESULTS

One hundred and twenty-five surveys were returned. A total of 107 participants (86%) reported instability and 62 (50%) had experienced a fall in the preceding year; 29 (28%) had reportedly received information on falls prevention. Forty-four participants (43%) sought help from health professionals following instability and falls; just over half reported that the information they received was useful. One quarter (n = 11) of those seeking help were referred on to falls clinics; all attended and 86% felt attending had been beneficial. However, only one participant was followed up by these clinics.

CONCLUSIONS

Findings suggest that the majority of people with stroke who have experienced instability and falls did not receive any information and support, with very few referred on to falls clinics. Health professionals play a key role in information provision and facilitating access to falls prevention programs. Further research is required to determine the most effective ways to implement current guidelines to manage instability and falls in this high-risk group. Implications for rehabilitation: Many community-dwelling people with stroke did not receive any information, help or support after experiencing instability and falls. Clinicians must stress that falls are a complication, not an expectation, post-stroke. Information on falls prevention and available support services should be offered to individuals prior to discharge from hospital, in GP practices and in rehabilitation settings. All individuals with stroke seeking health professional help following instability and falls should be referred on to falls clinics for individualized multifactorial assessment and intervention to comply with current guidelines.