The Footwear Assessment Form: a reliable clinical tool to assess footwear characteristics of relevance to postural stability in older adults

Identifying the Number of Steps Required for Familiarisation to Athletic Footwear in Healthy Older Adults

INTRODUCTION

Research on athletic footwear familiarisation within an older population is sparse. This is problematic because unfamiliar footwear may act as a new perturbation and modify older adults' walking gait and stability. In addition, while athletic footwear has been suggested to enhance older adults' comfort and support during activities of daily living, the necessary period for familiarisation with athletic footwear is unknown. Therefore, this study aimed to identify the number of steps required for older adults to be familiarised with athletic footwear of different midsole thicknesses.

METHODS

Twenty-six healthy and physically active community-dwelling older adults, 21 females (71.1 ± 4.5 years; 164.5 ± 5.3 cm; 68.4 ± 11.4 kg) and five males (70.6 ± 2.3 years; 175.2 ± 7.8 cm; 72.8 ± 9.7 kg), completed a walking-based protocol. Participants walked two trials of 200 steps at their habitual speed on a 10-m track of an optical measurement system in three footwear conditions: (1) New Balance® REVlite 890v6 (thick midsole); (2) New Balance® REVlite 1400v5 (moderate midsole); and (3) New Balance® Minimus 20v7 (thin midsole). Gait speed (m.s-1) and walking time (min) were analysed for each participant over the 400 steps. Number of required familiarisation steps were established over three analysis phases, consisting of steady-state gait assessment, averaging and analysis of blocks of 40 steps, and sequentially comparing these steps with a predetermined threshold. Footwear familiarisation was assumed when the mean gait speed fell within an acceptable level (±2 SD from 320 to 360 step values) and subsequently maintained.

RESULTS

Most participants were familiarised with all three footwear conditions (thick n = 18; moderate and thin n = 20) after walking 80 steps. For all participants, the moderate midsole had the shortest familiarisation period (160 steps). The highest number of familiarisation steps was found in the thick (320 steps) and thin midsoles (240 steps) for some participants.

CONCLUSION

A minimum of 320 familiarisation steps is recommended to account for both individual differences and midsole thicknesses. Implementing this walking-based footwear familiarisation protocol would improve validity of future studies, ensuring they analyse footwear effects rather than familiarisation with the footwear.

Measurement and reporting of footwear characteristics in running biomechanics: A systematic search and narrative synthesis of contemporary research methods

This review aimed to synthesise the methods for assessing and reporting footwear characteristics among studies evaluating the effect of footwear on running biomechanics. Electronic searches of Scopus®, EBSCO, PubMed®, ScienceDirect®, and Web of Science® were performed to identify original research articles of the effect of running footwear on running biomechanics published from 1^st January 2015 to 7^th October 2020. Risk of bias among included studies was not assessed. Results were presented via narrative synthesis. Eligible studies compared the effect of two or more footwear conditions in adult runners on a biomechanical parameter. Eighty-seven articles were included and data from 242 individual footwear were extracted. Predominantly, studies reported footwear taxonomy (i.e., classification) and manufacturer information, however omitted detail regarding the technical specifications of running footwear and did not use validated footwear reporting tools. There is inconsistency among contemporary studies in the methods by which footwear characteristics are assessed and reported. These findings point towards a need for consensus regarding the reporting of these characteristics within biomechanical studies to facilitate the conduct of systematic reviews and meta-analyses pertaining to the effect of running footwear on running biomechanics.

Activity and footwear characteristics in people with and without plantar heel pain: A matched cross-sectional observational study

BACKGROUND

Activity and footwear may be associated with plantar heel pain (PHP), however both factors have rarely been investigated. The aim of this study was to investigate activity and footwear characteristics in PHP while controlling for important confounders.

METHOD

This cross-sectional observational study compared 50 participants with PHP to 25 participants without PHP who were matched for age, sex and body mass index. Activity was measured using the Stanford Activity Questionnaire, as well as the number of hours per day participants stood for, and whether they stood on hard floors. Footwear characteristics were measured using the footwear domain of the Foot Health Status Questionnaire (FHSQ), as well as the style of shoe, heel height, and the Shore A hardness value of the heel of the shoe most used.

RESULTS

Participants with PHP stood for more than twice as long as participants without PHP (mean difference 3.4 hours, p < 0.001, large effect size). Participants with PHP also reported greater difficulty accessing suitable footwear (FHSQ footwear domain mean difference (MD) 22 points, p = 0.002, large effect size (ES), and they wore harder-heeled shoes (Shore A MD 6.9 units, p = 0.019, medium ES). There were no significant differences for physical activity, whether they stood on hard floors, the style of shoe they wore, or heel height.

CONCLUSIONS

Compared to people without PHP, people with PHP stand for more than twice the amount of time each day, have substantial difficulties accessing suitable footwear, and the primary shoes they wear are harder under the heel.

Repeatability and reliability of the footwear assessment tool in Spanish patients: A transcultural adaptation

BACKGROUND

The footwear assessment tool was designed to advise an appropriate footwear for each situation and patient. Footwear alterations structures can influence in musculoskeletal disorders, developing foot ulcers, increase the peak plantar pressure, bacterial growth, low back pain.

METHODS

To validate the study 101 subjects were recruited. The study was tested by two expert podiatrists using the tool for the assessment of footwear characteristics that is composed by five domains, fit, general features, general structure, motion control properties and cushioning system. Each domain analyzes different shoe items.

RESULTS

An excellent agreement between the test-retest. A suitable Cronbach's α was suggested for the five domains of fit (α = 0.952), general features (α = 0.953), general structure (α = 0.947), motion control properties (α = 0.951), and cushioning system (α = 0.951). Test-retest reliability was excellent for all domains. There were no significant differences between any domain (p > 0.05). There was only statistically significant difference in the item forefoot height (p = 0.011). For all the domains items there were no statistically significant difference (p > 0.05).

CONCLUSIONS

The tool for the assessment European footwear is a suitable repeatability and reliability footwear tool that can be used in Spanish language subjects.

Effects of Footwear on Anterior Cruciate Ligament Forces during Landing in Young Adult Females

Rates of anterior cruciate ligament (ACL) rupture in young people have increased markedly over the past two decades, with females experiencing greater growth in their risk compared to males. In this study, we determined the effects of low- and high-support athletic footwear on ACL loads during a standardized drop-land-lateral jump in 23 late-/post-pubertal females. Each participant performed the task unshod, wearing low- (Zaraca, ASICS) or high- (Kayano, ASICS) support shoes (in random order), and three-dimensional body motions, ground-reaction forces, and surface electromyograms were synchronously acquired. These data were then used in a validated computational model of ACL loading. One-dimensional statistical parametric mapping paired t-tests were used to compare ACL loads between footwear conditions during the stance phase of the task. Participants generated lower ACL forces during push-off when shod (Kayano: 624 N at 71-84% of stance; Zaraca: 616 N at 68-86% of stance) compared to barefoot (770 N and 740 N, respectively). No significant differences in ACL force were observed between the task performed wearing low- compared to high-support shoes. Compared to barefoot, both shoe types significantly lowered push-off phase peak ACL forces, potentially lowering risk of ACL injury during performance of similar tasks in sport and recreation.

Evaluation and optimisation of a footwear assessment tool for use within a clinical environment

Footwear has been documented as a significant factor in the aetiology of foot pain in the general population. Assessing footwear in a clinical setting continues to be practitioner specific and there is limited guidance to direct advice. Health professionals must have access to clinically appropriate and reliable footwear assessment tools to educate patients on healthier footwear choices. The primary aim of this study was to critique what elements should be in a footwear assessment tool with a secondary aim of testing the agreed tool for validity.

A combined Nominal Group Technique and then a Delphi technique from purposively sampled experts of foot health professions were employed to critique elements of footwear assessment. The agreed tool was then tested by practising podiatrists on 5 different shoes to assess the validity and reliability of the measures.

Twelve test evaluation criteria were identified receiving significant ratings to form the final footwear assessment tool consisting of five footwear themes. Application of the tool in a clinical setting validated the themes of footwear characteristics, footwear structure, motion control and wear patterns. However, the assessment of footwear fit was not reliable.

The footwear tool was refined based on the collective consensus achieved from the rounds creating a more clinically appropriate tool. The validity of this tool was assessed as high in some of the themes but for those that were lower, a training need was identified.

Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study

Background

Falls in older people are common and can result in loss of confidence, fear of falling, restriction in activity and loss of independence. Causes of falls are multi-factorial. There is a paucity of research assessing the footwear characteristics among older people who are at high risk of falls, internationally and in the Irish setting. The aim of this study was to examine the proportion of older adults attending a geriatric day hospital in Ireland who were wearing incorrectly sized shoes.

Methods

A consecutive sample of 111 older adults aged 60 years and over attending a geriatric day hospital in a large Irish teaching hospital was recruited. Demographic data including age, mobility, medications, co-habitation status, footwear worn at home and falls history were recorded. Shoe size and foot length were measured in millimetres using an internal shoe gauge and SATRA shoe size stick, respectively. Participants’ self-reported shoe size was recorded. Footwear was assessed using the Footwear Assessment Form (FAF). A Timed Up and Go (TUG) score was recorded. Functional independence was assessed using the Nottingham Extended Activities of Daily Living (NEADL) Scale. The primary outcome of interest in this study was selected as having footwear within the suggested range (10 to 15 mm) on at least one foot. Participants who met this definition were compared to those with ill-fitting footwear on both feet using Chi-square tests, T-tests or Mann–Whitney U tests.

Results

The mean difference between shoe length and foot length was 18.6 mm (SD: 9.6 mm). Overall, 72% of participants were wearing footwear that did not fit correctly on both feet, 90% had shoes with smooth, partly worn or fully worn sole treading and 67% reported wearing slippers at home. Participant age, TUG score and NEADL score were not associated with ill-fitting footwear.

Conclusions

Wearing incorrectly fitting shoes and shoes with unsafe features was common among older adults attending geriatric day services in this study. A large number of participants reported wearing slippers at home.

Important features of retail shoes for women with rheumatoid arthritis: A Delphi consensus survey

OBJECTIVES

Footwear management aims to preserve foot function, reduce the burden of foot pain and maintain joint mobility in women with rheumatoid arthritis (RA). Whilst retail footwear is commonly recommended by health professionals, there is no current consensus on recommended features of retail footwear for women with RA. This study aimed to determine consensus from health professionals about the important features of retail footwear for women with RA.

METHODS

An international Delphi exercise using online survey software was conducted with 39 participants from health care backgrounds. Three iterative rounds were conducted. In the first round, participants listed features of retail footwear that would be important for women with RA. Responses of the first round, combined with results of a scoping review of patient-reported outcome measures used in assessing footwear in arthritis and a qualitative analysis of female patients' perspectives of retail footwear in RA were used to create items for the second round. Items were scored by a 9-point rating scale with consensus defined by the RAND/UCLA disagreement index. The third round consisted of items which did not reach consensus or scored >1 on the RAND/UCLA disagreement index from round two.

RESULTS

Fifty-eight items (n = 58) were generated for rating and at the end of three iterative rounds, there was agreement that thirty-eight items were important, that two were not important, and there was no agreement for a further eighteen items. Item themes reaching consensus included footwear characteristics and acceptability and psychosocial aspects of footwear. Footwear characteristics related to heel height, shape, cushioning, toe box size, adjustable fastening, removable insoles, mid-foot support and soft accommodative uppers. Acceptability and psychosocial aspects included affordability, comfort, aesthetic, style, colour and impact on femininity.

CONCLUSION

This consensus exercise has identified the important features of retail footwear for women with RA.

How Footwear Is Assessed in Patient Reported Measures for People with Arthritis: A Scoping Review

BACKGROUND

In people with arthritis, footwear may influence foot function, pain, and mobility. In order to measure the effectiveness of interventions and patient experience, patient-reported outcome measures (PROMs), and patient-reported experience measures (PREMs) are frequently used. The aim of the scoping review was to identify footwear item content within foot-specific PROMs and PREMs used in people with arthritis.

METHOD

Original studies that developed or validated a footwear-inclusive PROM or PREM for use in people with arthritis affecting the foot were included. A comprehensive search was conducted using AMED, CINAHL, MEDLINE, Scopus, SPORTDiscus, and Ovid Emcare and Embase. A content analysis of extracted footwear content items was performed, by coding item content and grouping into broad themes, then further narrowing down and defining themes under five main categories.

RESULTS

Nineteen articles satisfied inclusion criteria for this scoping exercise. Eleven PROMs met the inclusion criteria, five of which were designed for use in disease-specific populations (rheumatoid arthritis and gout) and six designed for generic populations. Categories of the footwear specific content from the PROMs included pain, impairment and function, shoe-specific characteristics, and psychosocial aspects. None of the included PROMs assessed footwear satisfaction. Eight PREMs relating to footwear experiences were identified. Seven of the PREMs were disease specific (inflammatory arthritis, osteoarthritis, rheumatoid arthritis, and systemic sclerosis) and one was generic. Content of the footwear-related items of the included PREMs were categorized under pain, impairment and function, footwear satisfaction, and shoe-specific characteristics. None of the PREM studies reported on psychosocial aspects of footwear.

CONCLUSIONS

Many different instruments have been used to measure the experience of footwear in patients with arthritis. However, no comprehensive tool that evaluates footwear and its relationship with pain, impairment, and disability; the psychosocial aspects of footwear; specific footwear features; and satisfaction is currently available for use in people with arthritis.

LEVEL OF EVIDENCE

IV.

"How are running shoes assessed? A systematic review of characteristics and measurement tools used to describe running footwear"

Background: Many footwear characteristics are argued as risk factors for running related injuries (RRI). Several footwear assessment tools are available; however, their use in studies of RRI is unknown. Objective: This systematic review evaluated the characteristics and methods of assessing footwear in studies of RRI. Design: Five online databases were searched for studies on adult runners, in running style footwear, who experienced running-related pain or injury. The methodological quality of included articles was independently assessed by two raters using a modified Downs and Black checklist. Study and participant characteristics, footwear assessment tools used, and footwear characteristics reported were extracted for qualitative synthesis. Results: Twenty-four articles were included in the review. Low risk of bias was determined for 11 (44%) of the included studies. Twenty-eight different footwear characteristics were grouped into four categories: nomenclature, measurements, qualitative features, and subjective features. Fifteen different methods for assessing the 28 footwear characteristics were reported among the included studies. Only three methods were described previously, as valid and reliable. Conclusion: Differences in assessing footwear may mask the link between footwear characteristics and injury risk. Systematic footwear assessments and nomenclature are needed to evaluate the effects of footwear characteristics on RRI.

Experience of finding footwear and factors contributing to footwear choice in people with gout: a mixed methods study using a web-based survey

Background

Gout frequently affects the foot, particularly the first metatarsophalangeal joint. People with gout commonly wear ill-fitting footwear that lacks cushioning and support, which may further contribute to foot pain and disability. Footwear with good cushioning and motion control may be an effective non-pharmacological intervention. Currently, there is limited understanding about the footwear experience in people with gout. The aim was to understand footwear characteristics, experience of finding footwear, and factors contributing to footwear choice, in people with gout.

Methods

A web-based survey of people visiting a gout education website. Participants self-reported a diagnosis of gout. The 17-item survey included questions to elicit demographic and clinical characteristics, type of footwear worn, level of difficulty finding appropriate footwear, and factors contributing to choices about footwear. A mixed quantitative and qualitative methodology was used to report survey findings.

Results

Survey respondents (n = 83) were predominately White/Caucasian (84%), male (58%), and aged between 46 and 75 years-old (73%). Thirty-nine percent were newly diagnosed (< 12 months), 43% had gout for 1–10 years, and 19% had disease over 10 years. Gout flares in the feet were reported by 77 (93%) respondents, mostly in the big toe joint (73%). Seventy-six (92%) participants completed questions about footwear. Closed-in athletic shoes (88%), sturdy walking shoes (79%), and casual closed-in slip-on shoes (63%) were most frequently worn. Orthopaedic shoes were worn least often (16%). Comfort, fit, support, and ease to put on/take off were the features most often rated as important or very important when choosing footwear. Over half the respondents (64%) reported difficulty in finding footwear. Three categories, encompassing seven subcategories, were identified from the qualitative analysis to describe experiences of footwear. Categories included difficulty finding suitable shoes; impact of shoes on activity; and preferred footwear.

Conclusions

People with gout need comfortable shoes that conform to the foot, have a wide opening, made from pliable materials with adjustable straps. The main barriers related to footwear include difficulty finding shoes that are wide enough, suitable for work and aesthetically pleasing. These findings provide clinicians with important insights into the priorities and needs of people with gout that should be considered when developing footwear interventions.

Effect of high and low-supportive footwear on female tri-planar knee moments during single limb landing

Background

Higher landing-related external knee joint moments at later stages of female pubertal development likely contribute to a higher incidence of non-contact anterior cruciate ligament (ACL) injury. Athletic footwear may provide a potential strategy to alter higher knee moments.

Methods

Thirty-one late/post-pubertal girls (Tanner stage IV-V, menarche and growth spurt attained) performed a single limb drop lateral jump in three footwear conditions (barefoot, low support shoes and high support shoes), in which peak knee abduction moment (KAbM), flexion moment (KFM) and internal rotation moments (KIRM) were measured. Repeated measures ANOVA and ANCOVA were used to test for a main effect of footwear with and without foot posture index (FPI) as a covariate (p < 0.05) with post-hoc test carried out via Fisher's Least Significant Difference (LSD).

Results

A main effect of footwear condition was observed for peak KFM (p < 0.05), but not KAbM or KIRM, in both unadjusted and adjusted models. Post-hoc analysis demonstrated that both high- and low-support shoes increased peak KFM compared with barefoot (p < 0.001).

Conclusion

Our findings indicate commercially available high- and low-supportive footwear increase peak KFM, but do not effect KAbM or KIRM while landing among late/post-pubertal girls. This suggests that these styles of footwear are inadequate at reducing higher knee moments in an at-risk cohort.

Importance of Footwear for Preventing Xerosis and Hyperkeratosis in Older People with Psychiatric Disorders Living in an Institution

Few studies have focused on the relation between the use and characteristics of footwear and the presence of foot lesions in people with psychiatric disorders. This work analyzes the influence of different footwear habits on the presence of deformities and ungueal and dermal pathologies of the foot of institutionalized people with psychiatric disorders compared to people without these disorders. A transversal and observational study was conducted on 107 participants, divided into two groups who have used different types of shoes throughout their lives. The control group comprised 63 autonomous people who mainly use leather footwear and a study group of 44 institutionalized people with intellectual disabilities and psychiatric disorders who mainly use textile footwear. There were significant differences between populations. The group with psychiatric disorders presented more xerosis and hyperkeratosis. Footwear with inappropriate characteristics is a possible causal agent of skin alterations. Wearing footwear with quality textile uppers, e.g., fabric or felt, could influence the appearance of these alterations. Leather footwear is recommended for institutionalized people to reduce symptoms of xerosis and improve their quality of life.

Podiatry intervention versus usual care to prevent falls in care homes: pilot randomised controlled trial (the PIRFECT study)

Background

Common foot problems are independent risk factors for falls in older people. There is evidence that podiatry can prevent falls in community-dwelling populations. The feasibility of implementing a podiatry intervention and trial in the care home population is unknown. To inform a potential future definitive trial, we performed a pilot randomised controlled trial to assess: (i) the feasibility of a trial of a podiatry intervention to reduce care home falls, and (ii) the potential direction and magnitude of the effect of the intervention in terms of number of falls in care home residents.

Methods

Informed by Medical Research Council guidance on developing and evaluating complex interventions, we conducted a single blind, pilot randomised controlled trial in six care homes in the East of Scotland. Participants were randomised to either: (i) a three month podiatry intervention comprising core podiatry care, foot and ankle exercises, orthoses and footwear provision or (ii) usual care. Falls-related outcomes (number of falls, time to first fall) and feasibility-related outcomes (recruitment, retention, adherence, data collection rates) were collected. Secondary outcomes included: generic health status, balance, mobility, falls efficacy, and ankle joint strength.

Results

474 care home residents were screened. 43 (9.1%) participants were recruited: 23 to the intervention, 20 to control. Nine (21%) participants were lost to follow-up due to declining health or death. It was feasible to deliver the trial elements in the care home setting. 35% of participants completed the exercise programme. 48% reported using the orthoses ‘all or most of the time’. Completion rates of the outcome measures were between 93% and 100%. No adverse events were reported. At the nine month follow-up period, the intervention group per-person fall rate was 0.77 falls vs. 0.83 falls in the control group.

Conclusions

A podiatry intervention to reduce falls can be delivered to care home residents within a pilot randomised controlled trial of the intervention. Although not powered to determine effectiveness, these preliminary data provide justification for a larger trial, incorporating a full process evaluation, to determine whether this intervention can significantly reduce falls in this high-risk population.

Trial registration

ClinicalTrials.gov identifier: NCT02178527; Date of registration: 17 June 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0541-1) contains supplementary material, which is available to authorized users.

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

Background

Ill-fitting shoes have been implicated as a risk factor for falls but research to date has focused on people with arthritis, diabetes and the general older population; little is known about people with neurological conditions. This survey for people with stroke and Parkinson’s explored people’s choice of indoor and outdoor footwear, foot problems and fall history.

Methods

Following ethical approval, 1000 anonymous postal questionnaires were distributed to health professionals, leads of Parkinson’s UK groups and stroke clubs in the wider Southampton area, UK. These collaborators handed out survey packs to people with a confirmed diagnosis of stroke or Parkinson’s.

Results

Three hundred and sixty three completed surveys were returned (218 from people with Parkinson’s and 145 from people with stroke). Most respondents wore slippers indoors and walking shoes outdoors and considered comfort and fit the most important factors when buying footwear. Foot problems were reported by 43 % (95 % confidence intervals 36 to 52 %; stroke) and 53 % (95 % confidence interval 46 to 59 %; Parkinson’s) of respondents; over 50 % had never accessed foot care support. Fifty percent of all respondents reported falls. In comparison to non-fallers, a greater proportion of fallers reported foot problems (57 %), with greater proportions reporting problems impacting on balance and influencing choice of footwear (p < 0.01) in comparison to non-fallers in each case. Forty-seven percent of fallers with foot problems had not accessed foot care support.

Conclusions

Many people with stroke and Parkinson’s wear slippers indoors. A high percentage of these individuals reported both foot problems and falls impacting on footwear habits and choice of footwear; however many did not receive foot care support. These findings highlight that further exploration of footwear and foot problems in these populations is warranted to provide evidence based advice on safe and appropriate footwear to support rehabilitation and fall prevention.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-016-0170-5) contains supplementary material, which is available to authorized users.

Foot and ankle characteristics associated with falls in adults with established rheumatoid arthritis: a cross-sectional study

BACKGROUND

People with rheumatoid arthritis (RA) have an increased risk of falls. The foot is a common site of pathology in RA and foot problems are reported in up to 90% of patients with established disease. The aim of this study was to determine whether foot and ankle characteristics are associated with falls in people with RA.

METHODS

Adults with RA were recruited from rheumatology outpatient clinics in Auckland, New Zealand. Participants reported whether they had fallen in the preceding year, and the number of falls. Clinical characteristics, common fall risk factors, and foot and ankle variables were measured. Univariate parametric and non-parametric analysis compared fallers and non-fallers on all variables to determine significant differences. Logistic regression analysis identified variables independently associated with falls.

RESULTS

Two hundred and one participants were prospectively recruited. At least one fall in the preceding 12-months was reported by 119 (59%) participants. Univariate analysis showed that fallers had significantly longer mean disease duration, more co-morbid conditions, an increase in lower limb tender joints, higher midfoot peak plantar pressures and were more likely to have a history of vascular disease than non-fallers. Fallers also reported greater difficulty with activities of daily living, increased fear of falling and greater self-reported foot impairment. Logistic regression analysis revealed that increased midfoot peak plantar pressures (odds ratio (OR) 1.12 [for each 20 kPa increase], 95% confidence interval (CI) 1.00-1.25), self-reported foot impairment (OR 1.17 [for each three point increase], 95% CI 1.05-1.31) and history of vascular disease (OR 3.22, 95% CI 1.17-8.88) were independently associated with a fall in the preceding 12 months.

CONCLUSIONS

Elevated midfoot peak plantar pressures, self-reported foot impairment and vascular disease are associated with falls in people with RA. Assessment of foot deformity, foot function and self-reported foot impairment may be of benefit when considering falls prevention strategies in people with RA.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry (trial ACTRN12612000597897).

Point prevalence of suboptimal footwear features among ambulant older hospital patients: implications for fall prevention

Objective The aim of the present study was to establish the point prevalence of 'suboptimal' features in footwear reported to have been used by older hospital patients when ambulating, and to explore underpinning factors for their choice of footwear. Method A cross-sectional investigation was undertaken on 95 of 149 eligible in-patients across 22 high fall-risk wards in a large metropolitan hospital in Brisbane, Australia. Results Over 70% of participants experienced an unplanned admission. Although most participants had access to some form of footwear in hospital (92%), nearly all reported ambulating in footwear with 'suboptimal' features (99%). Examples included slippers (27%), backless slippers (16%) or bare feet (27%). For patients who ambulated in bare feet, only one-third reported 'lack of access to footwear' as the primary cause, with others citing foot wounds, pain, oedema and personal choice as the main reason for bare foot ambulation. Conclusions Admitted patients frequently use footwear with 'suboptimal' features for ambulation in hospital. While some footwear options (for example well-fitting slippers) could be suited for limited in-hospital ambulation, others are clearly hazardous and might cause falls. Since footwear choices are influenced by multiple factors in this population, footwear education strategies alone may be insufficient to address the problem of hazardous footwear in at-risk patients. Footwear requirements may be more effectively addressed within a multidisciplinary team approach encompassing foot health, mobility and safety. What is known about the topic? Accidental falls while ambulating are an important health and safety concern for older people. Because certain footwear characteristics have been negatively linked to posture and balance, and specific footwear types linked to falls among seniors, the use of footwear with fewer suboptimal characteristics is generally recommended as a means of reducing the risk of falling. While footwear usage and choices have been explored in older people in the community and in residential care settings, there is little comparable data on acutely unwell older hospital patients. What does this paper add? This paper provides prevalence data on the use of footwear with suboptimal characteristics among ambulant older hospital patients, and identifies concurrent factors that may be relevant to patient footwear choices. What are the implications for practitioners? Pain, foot pathology and a desire to retain independence are important concerns for hospitalised patients and are likely to influence their choice of footwear used to ambulate with. Pragmatic team-based approaches that remain sensitive to key patient concerns may be more successful in optimising patient footwear usage than footwear education strategies alone.

Older people's perceptions of a multifaceted podiatric medical intervention to prevent falls

BACKGROUND

Falls are common in older people and are associated with substantial health-care costs. A recent randomized controlled trial of a multifaceted podiatric medical intervention demonstrated a 36% reduction in the fall rate over 12 months. We evaluated the acceptability of and levels of satisfaction with this intervention in the older people who participated in the trial.

METHODS

Participants allocated to the intervention group (which included a home-based program of foot and ankle exercises, assistance with the purchase of safe footwear when necessary, and provision of prefabricated foot orthoses) completed a structured questionnaire 6 months after they had received the intervention. The questions addressed participants' perceptions of their balance and foot and ankle strength, the perceived difficulty of the exercise program, and the degree of satisfaction with the footwear and orthoses provided.

RESULTS

Of 153 participants, 134 (87.6%) attended the 6-month follow-up assessment and completed the questionnaire. Most participants perceived improvements in balance (62.7%) and foot and ankle strength (74.6%) after 6 months of performing the exercises, and 86.6% considered the difficulty level of the exercises to be "about right." Most participants reported that they were somewhat or very satisfied with the footwear (92.3%) and orthoses (81.6%) provided.

CONCLUSIONS

The multifaceted podiatric medical intervention used in this trial was generally perceived to be beneficial and demonstrated high levels of satisfaction among participants. Further research is now required to evaluate the feasibility of implementing the intervention in a range of clinical practice settings.

An immediate effect of custom-made ankle foot orthoses on postural stability in older adults

BACKGROUND

Foot and ankle problems are highly prevalent fall risks in the elderly. Ankle foot orthoses designed to stabilize the foot and ankles have been studied within specific patient groups, but their efficacy with a less restrictive elderly population is unknown. This study investigated if custom-made ankle foot orthoses improve postural stability in older adults.

METHODS

Thirty ambulatory older adults averaged 73 (standard deviation=6.5) years completed Romberg's balance (eyes-open/eyes-closed), functional reach, and Timed Up and Go tests while wearing validated kinematic sensors. Each test was completed in standardized shoes with and without bilateral orthoses. Additionally, barefoot trials were conducted for the Romberg's and functional reach tests.

FINDINGS

Compared to the barefoot and 'shoes alone' conditions, the orthoses reduced center of mass sway on average by 49.0% (P=0.087) and 40.7% (P=0.005) during eyes-open balance trials. The reduction was amplified during the eyes-closed trials with average reductions of 65.9% (P=0.000) and 47.8% (P=0.004), compared to barefoot and 'shoes alone' conditions. The orthoses did not limit functional reach distance nor timed-up and go completion times. However, the medial-lateral postural coordination while reaching was improved significantly with orthoses compared to barefoot (14.3%; P=0.030) and 'shoes alone' (13.5%; P=0.039) conditions.

INTERPRETATION

Ankle foot orthoses reduced postural sway and improved lower extremity coordination in the elderly participants without limiting their ability to perform a standard activity of daily living. Additional studies are required to determine if these benefits are retained and subsequently translate into fewer falls.

Comparison of the responsiveness of the foot health status questionnaire and the Manchester foot pain and disability index in older people

Background

In recent years, several questionnaires have been developed for the assessment of foot health and its impact on quality of life. In order for these tools to be useful outcome measures in clinical trials, their ability to detect change over time (responsiveness) needs to be determined. Therefore, the aim of this study was to assess the responsiveness of two commonly-used questionnaires in older people with foot pain.

Methods

Participants (n = 59; 24 women and 35 men, mean age [SD] 82.3 [7.8] years) allocated to the intervention arm of a randomised controlled trial assessing the effectiveness of extra-depth footwear compared to usual care completed the Foot Health Status Questionnaire (FHSQ) and Manchester Foot Pain and Disability Index (MFPDI) at baseline and 16 weeks. Responsiveness of the FHSQ subscales (pain, function, footwear and general foot health) and MFPDI subscales (pain, functional limitation and concern about appearance) was determined using (i) paired t-tests, (ii) Cohen’s d, (iii) the standardised response mean (SRM), and (iv) the Guyatt index.

Results

Overall, the FHSQ pain subscale exhibited the highest responsiveness, as evidenced by a highly significant paired t-test (p <0.001), Cohen’s d = 0.63 (medium effect size), SRM = 0.50 (medium effect size) and Guyatt index = 1.70 (huge effect size). The next most responsive measure was the FHSQ function subscale, as evidenced by a borderline paired t-test (p = 0.050), Cohen’s d = 0.37 (small effect size), SRM = 0.26 (small effect size) and GI = 1.22 (very large effect size). The FHSQ footwear, FHSQ general foot health and MFPDI pain, functional limitation and concern about appearance subscales demonstrated lower responsiveness, with negligible to medium effect sizes.

Conclusion

The FHSQ pain and function subscales were most responsive to change in older people with foot pain receiving a footwear intervention. These findings provide useful information to guide researchers in selecting appropriate outcome measures for use in future clinical trials of foot disorders.

The impact of different footwear characteristics, of a ballet flat pump, on centre of pressure progression and perceived comfort

BACKGROUND

Uncomfortable shoes have been attributed to poor fit and the cause of foot pathologies. Assessing and evaluating comfort and fit have proven challenging due to the subjective nature. The aim of this paper is to investigate the relationship between footwear characteristics and perceived comfort.

METHODS

Twenty-seven females assessed three different styles of ballet pump shoe for comfort using a comfort scale whilst walking along a 20 m walkway. The physical characteristics of the shoes and the progression of centre of pressure during walking were assessed.

RESULTS

There were significant physical differences between each style, square shoe being the shortest, widest and stiffest and round shoe having the least volume at the toe box. Centre of pressure progression angle was centralised to the longitudinal axis of the foot when wearing each of the three shoes compared to barefoot. Length, width and cantilever bending stiffness had no impact on perceived comfort.

CONCLUSION

Wearing snug fitting flexible soled round ballet flat pump is perceived to be the most comfortable of the shoe shapes tested producing a faster more efficient gait. Further investigations are required to assess impact/fit and upper material on perceived comfort to aid consumers with painful feet in purchasing shoes.

An evaluation of seasonal variations in footwear worn by adults with inflammatory arthritis: a cross-sectional observational study using a web-based survey

Background

Foot problems are common in adults with inflammatory arthritis and therapeutic footwear can be effective in managing arthritic foot problems. Accessing appropriate footwear has been identified as a major barrier, resulting in poor adherence to treatment plans involving footwear. Indeed, previous New Zealand based studies found that many people with rheumatoid arthritis and gout wore inappropriate footwear. However, these studies were conducted in a single teaching hospital during the New Zealand summer therefore the findings may not be representative of footwear styles worn elsewhere in New Zealand, or reflect the potential influence of seasonal climate changes. The aim of the study was to evaluate seasonal variations in footwear habits of people with inflammatory arthritic conditions in New Zealand.

Methods

A cross-sectional study design using a web-based survey. The survey questions were designed to elicit demographic and clinical information, features of importance when choosing footwear and seasonal footwear habits, including questions related to the provision of therapeutic footwear/orthoses and footwear experiences.

Results

One-hundred and ninety-seven participants responded who were predominantly women of European descent, aged between 46–65 years old, from the North Island of New Zealand. The majority of participants identified with having either rheumatoid arthritis (35%) and/or osteoarthritis (57%) and 68% reported established disease (>5 years duration). 18% of participants had been issued with therapeutic footwear. Walking and athletic shoes were the most frequently reported footwear type worn regardless of the time of year. In the summer, 42% reported wearing sandals most often. Comfort, fit and support were reported most frequently as the footwear features of greatest importance. Many participants reported difficulties with footwear (63%), getting hot feet in the summer (63%) and the need for a sandal which could accommodate a supportive insole (73%).

Conclusions

Athletic and walking shoes were the most popular style of footwear reported regardless of seasonal variation. During the summer season people with inflammatory arthritis may wear sandals more frequently in order to accommodate disease-related foot deformity. Healthcare professionals and researchers should consider seasonal variation when recommending appropriate footwear, or conducting footwear studies in people with inflammatory arthritis, to reduce non-adherence to prescribed footwear.

Footwear suitability in Turkish preschool-aged children

BACKGROUND

Unsuitable footwear worn in childhood may cause some foot problems by interfering normal development of foot.

OBJECTIVES

To compare footwear suitability rate of indoor and outdoor footwear at all points in preschool children and investigate factors which could affect footwear suitability.

STUDY DESIGN

A cross-sectional survey study.

METHODS

A total of 1000 healthy preschool children (4-6 years old) participated in this study. Indoor and outdoor footwear of children were evaluated through Turkish version of Footwear Assessment Score. Effect of factors like age, sex, number of siblings, educational and occupational situation of parents, and behavior of school management about selecting footwear was investigated.

RESULTS

Children got better footwear score for outdoor than indoor ones (p < 0.001). Boys got statistically better footwear score for both indoor and outdoor ones than girls (p < 0.001). Also significant difference in footwear score was found in favor of children who were going to schools that gave guidance about selecting footwear for both indoor and outdoor in comparison to children going to other schools (p < 0.001).

CONCLUSIONS

For healthy foot development, parents need an education about suitable footwear for their children. Performing education programs and investigation of their effect with comprehensive follow-up studies in future is essential.

CLINICAL RELEVANCE

This study reflects footwear habits of Turkish preschool children and factors affecting this issue. Results may give way to education programs about suitable footwear worn in childhood for healthy foot development.

Variation in the location of the shoe sole flexion point influences plantar loading patterns during gait

Background

Several footwear design characteristics are known to have detrimental effects on the foot. However, one characteristic that has received relatively little attention is the point where the sole flexes in the sagittal plane. Several footwear assessment forms assume that this should ideally be located directly under the metarsophalangeal joints (MTPJs), but this has not been directly evaluated. The aim of this study was therefore to assess the influence on plantar loading of different locations of the shoe sole flexion point.

Method

Twenty-one asymptomatic females with normal foot posture participated. Standardised shoes were incised directly underneath the metatarsophalangeal joints, proximal to the MTPJs or underneath the midfoot. The participants walked in a randomised sequence of the three shoes whilst plantar loading patterns were obtained using the Pedar® in-shoe pressure measurement system. The foot was divided into nine anatomically important masks, and peak pressure (PP), contact time (CT) and pressure time integral (PTI) were determined. A ratio of PP and PTI between MTPJ2-3/MTPJ1 was also calculated.

Results

Wearing the shoe with the sole flexion point located proximal to the MTPJs resulted in increased PP under MTPJ 4–5 (6.2%) and decreased PP under the medial midfoot compared to the sub-MTPJ flexion point (−8.4%). Wearing the shoe with the sole flexion point located under the midfoot resulted in decreased PP, CT and PTI in the medial and lateral hindfoot (PP: −4.2% and −5.1%, CT: −3.4% and −6.6%, PTI: −6.9% and −5.7%) and medial midfoot (PP: −5.9% CT: −2.9% PTI: −12.2%) compared to the other two shoes.

Conclusion

The findings of this study indicate that the location of the sole flexion point of the shoe influences plantar loading patterns during gait. Specifically, shoes with a sole flexion point located under the midfoot significantly decrease the magnitude and duration of loading under the midfoot and hindfoot, which may be indicative of an earlier heel lift.

The effects of sandals on postural stability in patients with rheumatoid arthritis: an exploratory study

BACKGROUND

Rheumatoid arthritis results in postural instability, pain and functional limitations. As rheumatoid arthritis progresses, localised forefoot deformities such as hallux valgus and clawing of the lesser toes occur, leading to a high proportion of people with rheumatoid arthritis wearing sandals. Sandals may affect postural stability due to poor motion control. The aim was to assess two different open-toe sandals on postural stability in people with rheumatoid arthritis.

METHODS

Twenty women with rheumatoid arthritis were assessed in quiet standing under four conditions: (1) open-back sandal; (2) closed-back sandal; (3) own footwear and (4) bare feet. Postural stability was assessed as postural sway in the anterior-posterior and medial-lateral directions, with eyes open and eyes closed, using a pressure mat. Repeated measures analysis of variance tested the interaction effect of the footwear and eye conditions on anterior-posterior and medial-lateral sway.

FINDINGS

In eyes-open, there was no significant difference in anterior-posterior sway (P=.169) and medial-lateral sway (P=.325) for footwear conditions. In eyes-closed testing, compared with barefoot conditions, increased anterior-posterior sway was observed with participants' footwear (P<.0001), the open-back sandal (P=.005), and the closed-back sandal (P=.017). With eyes closed, increased anterior-posterior sway was also observed with the participants' footwear compared with the closed-back sandal (P=.041). Increased medial-lateral sway was observed with the closed-back sandal compared with bare feet (P=.014).

INTERPRETATION

Sandals may be detrimental to older women with well-established rheumatoid arthritis when eyes are closed. Further investigation is needed to evaluate the effect of sandals on dynamic tasks.

Evaluation of the accuracy of shoe fitting in older people using three-dimensional foot scanning

Background

Ill-fitting footwear is a common problem in older people. The objective of this study was to determine the accuracy of shoe fitting in older people by comparing the dimensions of allocated shoes to foot dimensions obtained with a three-dimensional (3D) scanner.

Methods

The shoe sizes of 56 older people were determined with the Brannock device^®, and weightbearing foot scans were obtained with the FotoScan 3D scanner (Precision 3D Ltd, Weston-super-mare, UK). Participants were provided with a pair of shoes (Dr Comfort^®, Vista, CA, USA), available in three width fittings (medium, wide and extra wide). The dimensions (length, ball width and ball girth) of the allocated shoes were documented according to the last measurements provided by the manufacturer. Mean differences between last dimensions and foot dimensions obtained with the 3D scanner were calculated to provide an indication of shoe fitting accuracy. Participants were also asked to report their perception of shoe fit and comfort, using 100 mm visual analogue scales (VAS).

Results

Shoe size ranged from US size 7 to 14 for men and 5.5 to 11 for women. The allocated shoes were significantly longer than the foot (mean 23.6 mm, 95% confidence interval [CI] 22.1 to 25.2; t₅₅ = 30.3, p < 0.001), however there were no significant differences in relation to ball width (mean 1.4 mm, 95% CI −0.1 to 2.9 mm; t₅₅ = 1.9, p = 0.066) or ball girth (mean −0.7 mm, 95% CI −6.1 to 4.8 mm; t₅₅ = −0.2, p = 0.810). Participants reported favourable perceptions of shoe fit (mean VAS = 90.7 mm, 95% CI 88.4 to 93.1 mm) and comfort (mean VAS = 88.4 mm, 95% CI 85.0 to 91.8 mm).

Conclusion

Shoe size selection using the Brannock device® resulted in the allocation of shoes with last dimensions that were well matched to the dimensions of the foot. Participants also considered the shoes to be well fitted and comfortable. Older people with disabling foot pain can therefore be dispensed with appropriately-fitted shoes using this technique, provided that the style and materials used are suitable and extra width fittings are available.

Nurses' understandings of suitable footwear for older people

PURPOSE

The purpose of this paper is to gain insight into nurses' understandings of what constitutes suitable footwear for older people in care homes.

DESIGN/METHODOLOGY/APPROACH

An exploratory descriptive qualitative survey was carried out of 20 registered nurses employed in six Scottish care homes for older people. Data were collected using a semi-structured questionnaire that included five open-ended questions. Content analysis was used to theme footwear perceptions.

FINDINGS

Participants had several views about what encompasses safe footwear; some were erroneous. The link between inappropriate footwear and falls was recognised by 80 per cent of respondents, but some were unclear about the features that effect or inhibit safety. No UK or international standardised guidelines were identified that advise nurses about appropriate footwear for older people.

PRACTICAL IMPLICATIONS

It is unknown whether respondents represent the nurse population because findings are restricted by a small sample size. Nonetheless, the group showed variable understanding of what constitutes safe footwear for older people and links with fall prevention. Improved nurse-education about what comprises safe footwear and the links with falls prevention in older people is required. Structured guidelines to direct nurse educators about what to teach student nurses about appropriate footwear for older people may work towards reducing falls.

ORIGINALITY/VALUE

No guidelines to direct nurses about appropriate footwear for older people in care homes have been written. Key points have been developed.

Effectiveness of off-the-shelf footwear in reducing foot pain in Australian Department of Veterans' Affairs recipients not eligible for medical grade footwear: study protocol for a randomized controlled trial

Background

Foot pain is highly prevalent in older people, and in many cases is associated with wearing inadequate footwear. In Australia, the Department of Veterans’ Affairs (DVA) covers the costs of medical grade footwear for veterans who have severe foot deformity. However, there is a high demand for footwear by veterans with foot pain who do not meet this eligibility criterion. Therefore, this article describes the design of a randomized controlled trial to evaluate the effectiveness of low cost, off-the-shelf footwear in reducing foot pain in DVA recipients who are currently not eligible for medical grade footwear.

Methods

One hundred and twenty DVA clients with disabling foot pain residing in Melbourne, Australia, who are not eligible for medical grade footwear will be recruited from the DVA database, and will be randomly allocated to an intervention group or a ‘usual care’ control group. The intervention group will continue to receive their usual DVA-subsidized podiatry care in addition to being provided with low-cost, supportive footwear (Dr Comfort®, Vasyli Medical, Labrador, Queensland, Australia). The control group will also continue to receive DVA-subsidized podiatry care, but will not be provided with the footwear until the completion of the study. The primary outcome measure will be pain subscale on the Foot Health Status Questionnaire (FHSQ), measured at baseline and 4, 8, 12 and 16 weeks. Secondary outcome measures measured at baseline and 16 weeks will include the function subscale of the FHSQ, the Manchester Foot Pain and Disability Index, the number of DVA podiatry treatments required during the study period, general health-related quality of life (using the Short Form 12® Version 2.0), the number of falls experienced during the follow-up period, the Timed Up and Go test, the presence of hyperkeratotic lesions (corns and calluses), the number of participants using co-interventions to relieve foot pain, and participants’ perception of overall treatment effect. Data will be analyzed using the intention-to-treat principle.

Discussion

This study is the first randomized controlled trial to evaluate the effectiveness of off-the-shelf footwear in reducing foot pain in DVA recipients. The intervention has been pragmatically designed to ensure that the study findings can be implemented into policy and clinical practice if found to be effective.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12612000322831

Predictors of adherence to a multifaceted podiatry intervention for the prevention of falls in older people

Background

Despite emerging evidence that foot problems and inappropriate footwear increase the risk of falls, there is little evidence as to whether foot-related intervention strategies can be successfully implemented. The aim of this study was to evaluate adherence rates, barriers to adherence, and the predictors of adherence to a multifaceted podiatry intervention for the prevention of falls in older people.

Methods

The intervention group (n = 153, mean age 74.2 years) of a randomised trial that investigated the effectiveness of a multifaceted podiatry intervention to prevent falls was assessed for adherence to the three components of the intervention: (i) foot orthoses, (ii) footwear advice and footwear cost subsidy, and (iii) a home-based foot and ankle exercise program. Adherence to each component and the barriers to adherence were documented, and separate discriminant function analyses were undertaken to identify factors that were significantly and independently associated with adherence to the three intervention components.

Results

Adherence to the three components of the intervention was as follows: foot orthoses (69%), footwear (54%) and home-based exercise (72%). Discriminant function analyses identified that being younger was the best predictor of orthoses use, higher physical health status and lower fear of falling were independent predictors of footwear adherence, and higher physical health status was the best predictor of exercise adherence. The predictive accuracy of these models was only modest, with 62 to 71% of participants correctly classified.

Conclusions

Adherence to a multifaceted podiatry intervention in this trial ranged from 54 to 72%. People with better physical health, less fear of falling and a younger age exhibited greater adherence, suggesting that strategies need to be developed to enhance adherence in frailer older people who are most at risk of falling.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12608000065392.

Effect of foot orthoses contour on pain perception in individuals with patellofemoral pain

BACKGROUND

foot orthoses have been described as a possible intervention for individuals with patellofemoral joint pain. No study has attempted to quantify the perceived comfort and support of foot orthoses when used as an intervention for patellofemoral joint pain.

METHODS

a randomized case-control trial with crossover between contoured and flat orthoses was conducted on ten individuals with patellofemoral pain and ten healthy participants. All of the participants completed a comfort-support assessment and had in-shoe plantar pressure data collected before and after 3 weeks of wear. A 1-week washout period was used to minimize any continued treatment effect between orthotics testing. The patellofemoral pain group also completed a numeric rating scale to assess pain reduction after using each orthosis.

RESULTS

all of the participants perceived that greater support was provided by the contoured orthoses in the heel and arch regions. Even with a 30% difference in material hardness between the two orthoses, all of the participants rated cushioning as equivalent. Six individuals in the patellofemoral pain group reported a clinically significant reduction in knee pain as a result of wearing foot orthoses.

CONCLUSIONS

a key factor in the selection of contoured foot orthoses versus flat inserts is the amount of support that an individual perceives in the arch and heel regions. In addition, clinicians using foot orthoses as an intervention for patellofemoral pain should expect an individualistic, nonsystematic response.

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

OBJECTIVE

To determine the effectiveness of a multifaceted podiatry intervention in preventing falls in community dwelling older people with disabling foot pain.

DESIGN

Parallel group randomised controlled trial.

SETTING

University health sciences clinic in Melbourne, Australia.

PARTICIPANTS

305 community dwelling men and women (mean age 74 (SD 6) years) with disabling foot pain and an increased risk of falling. 153 were allocated to a multifaceted podiatry intervention and 152 to routine podiatry care, with 12 months' follow-up.

INTERVENTIONS

Multifaceted podiatry intervention consisting of foot orthoses, advice on footwear, subsidy for footwear ($A100 voucher; £65; €74), a home based programme of foot and ankle exercises, a falls prevention education booklet, and routine podiatry care for 12 months. The control group received routine podiatry care for 12 months.

MAIN OUTCOME MEASURES

Proportion of fallers and multiple fallers, falling rate, and injuries resulting from falls during follow-up.

RESULTS

Overall, 264 falls occurred during the study. 296 participants returned all 12 calendars: 147 (96%) in the intervention group and 149 (98%) in the control group. Adherence was good, with 52% of the participants completing 75% or more of the requested three exercise sessions weekly, and 55% of those issued orthoses reporting wearing them most of the time. Participants in the intervention group (n=153) experienced 36% fewer falls than participants in the control group (incidence rate ratio 0.64, 95% confidence interval 0.45 to 0.91, P=0.01). The proportion of fallers and multiple fallers did not differ significantly between the groups (relative risk 0.85, 0.66 to 1.08, P=0.19 and 0.63, 0.38 to 1.04, P=0.07). One fracture occurred in the intervention group and seven in the control group (0.14, 0.02 to 1.15, P=0.07). Significant improvements in the intervention group compared with the control group were found for the domains of strength (ankle eversion), range of motion (ankle dorsiflexion and inversion/eversion), and balance (postural sway on the floor when barefoot and maximum balance range wearing shoes).

CONCLUSIONS

A multifaceted podiatry intervention reduced the rate of falls in community dwelling older people with disabling foot pain. The components of the intervention are inexpensive and relatively simple to implement, suggesting that the programme could be incorporated into routine podiatry practice or multidisciplinary falls prevention clinics.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12608000065392.

Preventing falls and fall-related injuries in hospitals

Falls are a widespread concern in hospitals settings, with whole hospital rates of between 3 and 5 falls per 1000 bed-days representing around a million inpatient falls occurring in the United States each year. Between 1% and 3% of falls in hospitals result in fracture, but even minor injuries can cause distress and delay rehabilitation. Risk factors most consistently found in the inpatient population include a history of falling, muscle weakness, agitation and confusion, urinary incontinence or frequency, sedative medication, and postural hypotension. Based on systematic reviews, recent research, and clinical and ethical considerations, the most appropriate approach to fall prevention in the hospital environment includes multifactorial interventions with multiprofessional input. There is also some evidence that delirium avoidance programs, reducing sedative and hypnotic medication, in-depth patient education, and sustained exercise programs may reduce falls as single interventions. There is no convincing evidence that hip protectors, movement alarms, or low-low beds reduce falls or injury in the hospital setting. International approaches to developing and maintaining a fall prevention program suggest that commitment of management and a range of clinical and support staff is crucial to success.

'Choosing shoes': a preliminary study into the challenges facing clinicians in assessing footwear for rheumatoid patients

Background

Footwear has been accepted as a therapeutic intervention for the foot affected by rheumatoid arthritis (RA). Evidence relating to the objective assessment of footwear in patients with RA is limited. The aims of this study were to identify current footwear styles, footwear characteristics, and factors that influence footwear choice experienced by patients with RA.

Methods

Eighty patients with RA were recruited from rheumatology clinics during the summer months. Clinical characteristics, global function, and foot impairment and disability measures were recorded. Current footwear, footwear characteristics and the factors associated with choice of footwear were identified. Suitability of footwear was recorded using pre-determined criteria for assessing footwear type, based on a previous study of foot pain.

Results

The patients had longstanding RA with moderate-to severe disability and impairment. The foot and ankle assessment demonstrated a low-arch profile with both forefoot and rearfoot structural deformities. Over 50% of shoes worn by patients were open-type footwear. More than 70% of patients' footwear was defined as being poor. Poor footwear characteristics such as heel rigidity and sole hardness were observed. Patients reported comfort (17%) and fit (14%) as important factors in choosing their own footwear. Only five percent (5%) of patients wore therapeutic footwear.

Conclusions

The majority of patients with RA wear footwear that has been previously described as poor. Future work needs to aim to define and justify the specific features of footwear that may be of benefit to foot health for people with RA.

A case-series study to explore the efficacy of foot orthoses in treating first metatarsophalangeal joint pain

Background

First metatarsophalangeal (MTP) joint pain is a common foot complaint which is often considered to be a consequence of altered mechanics. Foot orthoses are often prescribed to reduce 1^st MTP joint pain with the aim of altering dorsiflexion at propulsion. This study explores changes in 1^st MTP joint pain and kinematics following the use of foot orthoses.

Methods

The effect of modified, pre-fabricated foot orthoses (X-line^®) were evaluated in thirty-two patients with 1^st MTP joint pain of mechanical origin. The primary outcome was pain measured at baseline and 24 weeks using the pain subscale of the foot function index (FFI). In a small sub-group of patients (n = 9), the relationship between pain and kinematic variables was explored with and without their orthoses, using an electromagnetic motion tracking (EMT) system.

Results

A significant reduction in pain was observed between baseline (median = 48 mm) and the 24 week endpoint (median = 14.50 mm, z = -4.88, p < 0.001). In the sub-group analysis, we found no relationship between pain reduction and 1^st MTP joint motion, and no significant differences were found between the 1^st MTP joint maximum dorsiflexion or ankle/subtalar complex maximum eversion, with and without the orthoses.

Conclusions

This observational study demonstrated a significant decrease in 1^st MTP joint pain associated with the use of foot orthoses. Change in pain was not shown to be associated with 1^st MTP joint dorsiflexion nor with altered ankle/subtalar complex eversion. Further research into the effect of foot orthoses on foot function is indicated.

The effects of shoe fit on gait in community-dwelling older adults

Shoes have a beneficial function in physical performance, particularly for gait. The purpose of this study was to investigate the association of shoe fit with gait parameters in community-dwelling older people. The fit of habitual shoes (HS) was evaluated in healthy older subjects and subjects were classified into well-fit (n=48) and poorly-fit (n=37) groups. The sizes of their feet were measured using an optical laser scanning system to provide newly-fitted shoes (NFS). Gait experiments were performed while wearing HS and NFS, separately. Trunk linear accelerations were measured along the vertical, anteroposterior and mediolateral axes using a tri-axial accelerometer attached to the L3 spinous process. Measurements were sampled at 200-Hz during a 20-m gait task at a self-selected speed. After signal processing, the gait velocity, stride duration, stride length and gait regularity (Reg) were obtained. Among the poorly-fit group, 86% wore shoes that were too loose. Subjects wearing ill-fitting shoes had a tendency to walk slower, had shorter stride lengths and lower Reg in the vertical direction than those wearing well-fitting shoes. Whereas NFS increased the gait velocity, the stride length and the Reg in the vertical direction, the increases in subjects that previously wore ill-fitting HS was significantly greater than in subjects that originally wore well-fitting HS. In conclusion, our study indicates that a significant proportion of older adults wear ill-fitting shoes and that well-fitting shoes are important to improve gait performance.

Randomized trial of custom orthoses and footwear on foot pain and plantar pressure in diabetic peripheral arterial disease

AIM

Custom-made foot orthoses reduce plantar pressure, ulceration and amputation in patients with diabetes mellitus. There is limited evidence of their effect on foot pain. In a randomized, single-blind, sham-controlled trial, the efficacy of custom orthoses on foot pain and plantar pressure in diabetic patients with peripheral arterial disease was investigated.

METHODS

Sixty-one participants were randomly assigned to either custom foot orthoses (n = 30) or sham insoles (n = 31). Both groups also received standardized walking footwear. Outcomes included foot pain and function, mean pressure, toe-brachial index, average daily steps, disability, comfort, quality of life, adherence and adverse events. A multivariate predictive model was constructed to explore factors contributing to pain relief during the trial.

RESULTS

At 8 weeks, 95% of participants provided follow-up data, adherence was high and there were few adverse events. Foot pain and function scores significantly improved at 8 weeks with both custom orthoses and the sham, but there was no significant difference between groups. Custom orthoses reduced pressure significantly more than the sham. There were no significant differences between groups for toe-brachial index, daily steps, disability, comfort or quality of life. Regression modelling identified inappropriate pre-trial footwear as the strongest predictor of foot pain relief during the trial.

CONCLUSIONS

Custom foot orthoses significantly reduced plantar pressure compared with the sham, but there were no significant differences between groups for pain or function. The high-quality walking footwear provided to both groups may explain this finding. Footwear should have greater emphasis as the clinical intervention.

Clinical audit of foot problems in patients with rheumatoid arthritis treated at Counties Manukau District Health Board, Auckland, New Zealand

Background

At diagnosis, 16% of rheumatoid arthritis (RA) patients may have foot joint involvement, increasing to 90% as disease duration increases. This can lead to joint instability, difficulties in walking and limitation in functional ability that restricts activities of daily living. The podiatrist plays an important role in the multidisciplinary team approach to the management of foot problems. The aim of this study was to undertake a clinical audit of foot problems in patients with RA treated at Counties Manukau District Health Board.

Methods

Patients with RA were identified through rheumatological clinics run within CMDHB. 100 patients were eligible for inclusion. Specific foot outcome tools were used to evaluate pain, disability and function. Observation on foot lesions were noted and previous history of foot assessment, footwear/insoles and foot surgery were evaluated.

Results

The median age of the cohort was 60 (IQR: 51–64) years old with median disease duration of 15 (IQR: 7.3–25) years. Over 85% presented with foot lesions that included corns and callus over the forefoot region and lesser toe deformities. Moderate to high disability was noted. High levels of forefoot structural damage were observed. 76% had not seen a podiatrist and 77% reported no previous formal foot assessment. 40% had been seen at the orthotic centre for specialised footwear and insoles. 27% of RA patients reported previous foot surgery. A large proportion of patients wore inappropriate footwear.

Conclusion

This clinical audit suggests that the majority of RA patients suffer from foot problems. Future recommendations include the provision of a podiatrist within the current CMDHB multidisciplinary rheumatology team to ensure better services for RA patients with foot problems.

Development and evaluation of a tool for the assessment of footwear characteristics

BACKGROUND

Footwear characteristics have been linked to falls in older adults and children, and the development of many musculoskeletal conditions. Due to the relationship between footwear and pathology, health professionals have a responsibility to consider footwear characteristics in the etiology and treatment of various patient presentations. In order for health professionals and researchers to accurately and efficiently critique an individual's footwear, a valid and reliable footwear assessment tool is required. The aim of this study was to develop a simple, efficient, and reliable footwear assessment tool potentially suitable for use in a range of patient populations.

METHODS

Consideration of previously published tools, other footwear related literature, and clinical considerations of three therapists were used to assist in the development of the tool. The tool was developed to cover fit, general features, general structure, motion control properties, cushioning, and wear patterns. A total of 15 participants (who provided two pairs of shoes each) were recruited, and assessment using the scale was completed on two separate occasions (separated by 1 - 3 weeks) by a physiotherapist and a podiatrist on each participant's dominant foot. Intra-rater and inter-rater reliability were evaluated using intra-class correlation coefficients (ICCs) (model 2, 1) and the 95% limits of agreement (95% LOAs) for continuous items, and percentage agreement and kappa (kappa) statistics for categorical items.

RESULTS

All categorical items demonstrated high percentage agreement statistic for intra-rater (83 - 100%) and inter-rater (83 - 100%) comparisons. With the exception of last shape and objective measures used to categorise the adequacy of length, excellent intra-rater (ICC = 0.91 - 1.00) and inter-rater reliability (ICC = 0.90 - 1.00) was indicated for continuous items in the tool, including the motion control properties scale (0.91 - 0.95).

CONCLUSION

A comprehensive footwear assessment tool with good face validity has been developed to assist future research and clinical footwear assessment. Generally good reliability amongst all items indicates that the tool can be used with confidence in research and clinical settings. Further research is now required to determine the clinical validity of each item in various patient populations.

The effects of usual footwear on balance amongst elderly women attending a day hospital

OBJECTIVE

to examine the effects of footwear on balance in a sample of older women attending a day hospital.

DESIGN

this was a crossover trial with a quasi-randomised allocation.

SETTING

assessments took place in the geriatric day hospital.

SUBJECTS

a cohort of 100 older women aged 60 years and over attending a day hospital.

METHODS

demographic data and a brief falls history were recorded. Participant's footwear was assessed using a footwear assessment form. A Berg Balance Scale (BBS) was completed under two conditions--shoes on and shoes off with order counter-balanced.

RESULTS

the mean BBS was 39.07 (SD 9.14) with shoes on and 36.54 (SD 10.39) with shoes off (P < 0.0001). Balance scores were significantly higher with shoes on for 10 of the 14 Berg subcategories. Lower barefoot BBS scores were associated with a greater beneficial effect of footwear on balance (P < 0.001). Shoe characteristics were not associated with change in the BBS score.

CONCLUSIONS

Wearing their own footwear significantly improved participants' balance compared to being barefoot. The greatest benefit of footwear was seen in those with the poorest balance. Further studies should investigate whether particular types of footwear are associated with greater benefit.

Efficacy of a multifaceted podiatry intervention to improve balance and prevent falls in older people: study protocol for a randomised trial

Background

Falls in older people are a major public health problem, with at least one in three people aged over 65 years falling each year. There is increasing evidence that foot problems and inappropriate footwear increase the risk of falls, however no studies have been undertaken to determine whether modifying these risk factors decreases the risk of falling. This article describes the design of a randomised trial to evaluate the efficacy of a multifaceted podiatry intervention to reduce foot pain, improve balance, and reduce falls in older people.

Methods

Three hundred community-dwelling men and women aged 65 years and over with current foot pain and an increased risk of falling will be randomly allocated to a control or intervention group. The "usual cae" control group will receive routine podiatry (i.e. nail care and callus debridement). The intervention group will receive usual care plus a multifaceted podiatry intervention consisting of: (i) prefabricated insoles customised to accommodate plantar lesions; (ii) footwear advice and assistance with the purchase of new footwear if current footwear is inappropriate; (iii) a home-based exercise program to strengthen foot and ankle muscles; and (iv) a falls prevention education booklet. Primary outcome measures will be the number of fallers, number of multiple fallers and the falls rate recorded by a falls diary over a 12 month period. Secondary outcome measures assessed six months after baseline will include the Medical Outcomes Study Short Form 12 (SF-12), the Manchester Foot Pain and Disability Index, the Falls Efficacy Scale International, and a series of balance and functional tests. Data will be analysed using the intention to treat principle.

Discussion

This study is the first randomised trial to evaluate the efficacy of podiatry in improving balance and preventing falls. The trial has been pragmatically designed to ensure that the findings can be generalised to clinical practice. If found to be effective, the multifaceted podiatry intervention will be a unique addition to common falls prevention strategies already in use.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12608000065392