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Foot and Ankle Characteristics Associated With Impaired Balance and Functional Ability in Older People
Hylton B. Menz, Meg E. Morris, and Stephen R. Lord
J Gerontol A Biol Sci Med Sci 2005 60: 1546-1552
Background. Ageing is associated with changes to the structure and function of the foot and ankle, and there is preliminary evidence that foot problems impair balance and increase the risk of falls. To explore this in more detail, we conducted a study to determine the relative contribution of several foot and ankle characteristics to performance on a range of balance and functional tests.
Methods. One hundred seventy-six people (56 men and 120 women, mean age 80.1 years, standard deviation 6.4 years) residing in a retirement village underwent tests of foot and ankle characteristics (including foot posture, range of motion, strength, and deformity), sensorimotor function (including vision, sensation, strength, and reaction time), and balance and functional ability (including tests of standing balance, leaning balance, stepping, sit-to-stand, and walking speed).
Results. Many foot and ankle characteristics and sensorimotor measures were associated with performance on the balance and functional tests in univariate analyses. Multiple regression analysis consistently revealed that ankle flexibility, plantar tactile sensitivity, and toe plantarflexor strength were significant and independent predictors of balance and functional test performance, explaining up to 59% of the variance in these test scores.
Conclusions. Foot and ankle characteristics, particularly ankle flexibility, plantar tactile sensation, and strength of toe plantarflexor muscles, are significant independent predictors of balance and functional ability in older people. Programs to improve the strength and flexibility of the foot and interventions to augment plantar sensation may be beneficial in improving mobility and reducing the risk of falls.
One of the surprising results of this study was that foot posture (measured using the FPI, arch index and navicular height) was not associated with balance ability in older people.
The 12-month follow-up of this study has been completed, and confirms that foot problems are a falls risk factor:
Foot and Ankle Risk Factors for Falls in Older People: A Prospective Study
Hylton B. Menz, Meg E. Morris and Stephen R. Lord
The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 61:866-870 (2006) - link
Background. Foot problems are common in older people and are associated with impaired balance and functional ability. Few prospective studies, however, have been undertaken to determine whether foot problems are a risk factor for falls.
Methods. One hundred seventy-six people (56 men and 120 women, mean age 80.1, standard deviation 6.4 years) residing in a retirement village underwent tests of foot and ankle characteristics (including foot posture, range of motion, strength, and deformity) and physiological falls risk factors (including vision, sensation, strength, reaction time, and balance) and were followed for 12 months to determine the incidence of falls.
Results. Seventy-one participants (41%) reported falling during the follow-up period. Compared to those who did not fall, fallers exhibited decreased ankle flexibility, more severe hallux valgus deformity, decreased plantar tactile sensitivity, and decreased toe plantarflexor strength; they were also more likely to have disabling foot pain. Discriminant function analysis revealed that decreased toe plantarflexor strength and disabling foot pain were significantly and independently associated with falls after accounting for physiological falls risk factors and age.
Conclusions. Foot and ankle problems increase the risk of falls in older people. Interventions to address these factors may hold some promise as a falls prevention strategy.
I am curious, as gentle mobilisations (even a long time after injury) of the ankle and other foot joints appear to improve joint and muscle function in a good number of people, possibly including awareness of where the feet are, have studies been done to show any efficacy of this as part of treatment for the aging population. Or indeed as a profilactic approach?
To my knowledge there are no published studies that have addressed this. However, at the ISPGR conference in 2003, a paper was presented by a British osteopath (Mark Goss-Sampson) in which postural sway parameters were measured before and after manual ankle manipulations were applied to young and elderly women. The results indicated that a greater "dynamic safety margin" was evident in both groups following the intervention. I've been unable to track down a published manuscript on the study.
Could be an interesting study for a pod to do using mobilsation techniques (based around Maitlands approach) as opposed to possible osteopathic manipulation techniques.
A Multivariate Fall Risk Assessment Model for VHA Nursing Homes Using the Minimum Data Set. J Am Med Dir Assoc. 2007 Feb;8(2):115-22
French DD, Werner DC, Campbell RR, Powell-Cope GM, Nelson AL, Rubenstein LZ, Bulat T, Spehar AM
Quote:
OBJECTIVES: The purpose of this study was to develop a multivariate fall risk assessment model beyond the current fall Resident Assessment Protocol (RAP) triggers for nursing home residents using the Minimum Data Set (MDS).
DESIGN: Retrospective, clustered secondary data analysis. Setting: National Veterans Health Administration (VHA) long-term care nursing homes (N = 136).
PARTICIPANTS: The study population consisted of 6577 national VHA nursing home residents who had an annual assessment during FY 2005, identified from the MDS, as well as an earlier annual or admission assessment within a 1-year look-back period.
MEASUREMENT: A dichotomous multivariate model of nursing home residents coded with a fall on selected fall risk characteristics from the MDS, estimated with general estimation equations (GEE).
RESULTS: There were 17 170 assessments corresponding to 6577 long-term care nursing home residents. The increased odds ratio (OR) of being classified as a faller relative to the omitted "dependent" category of activities of daily living (ADL) ranged from OR = 1.35 for "limited" ADL category up to OR = 1.57 for "extensive-2" ADL (P < .0001). Unsteady gait more than doubles the odds of being a faller (OR = 2.63, P < .0001). The use of assistive devices such as canes, walkers, or crutches, or the use of wheelchairs increases the odds of being a faller (OR = 1.17, P < .0005) or (OR = 1.19, P < .0002), respectively. Foot problems may also increase the odds of being a faller (OR = 1.26, P < .0016). Alzheimer's or other dementias also increase the odds of being classified as a faller (OR = 1.18, P < .0219) or (OR=1.22, P < .0001), respectively. In addition, anger (OR = 1.19, P < .0065); wandering (OR = 1.53, P < .0001); or use of antipsychotic medications (OR = 1.15, P < .0039), antianxiety medications (OR = 1.13, P < .0323), or antidepressant medications (OR = 1.39, P < .0001) was also associated with the odds of being a faller.
CONCLUSIONS: This national study in one of the largest managed healthcare systems in the United States has empirically confirmed the relative importance of certain risk factors for falls in long-term care settings. The model incorporated an ADL index and adjusted for case mix by including only long-term care nursing home residents. The study offers clinicians practical estimates by combining multiple univariate MDS elements in an empirically based, multivariate fall risk assessment model.
I recognize that balance is very complicated as a component of "fitness" and see a direct relationship between gastroc/soleous flexibility and ankle dorsiflexion. If yuo don't have adequate ankle dorsiflexion when moving forward one is more inclined to compensate in frontal and transverse planes. The more birthdays a person spends having short calves, the greater the effects of frontal and transverse compensation will have on balance through muscular imbalance.
I am also very curious, as a pedorthist, as to the effects of poor fitting footwear on balance. I would guess that about 80% of the population will have some significant error in sizing and fitting them,selves with footwear suitable for their daily activities. I would say that msot pople will short fit themselves. However, the concern I have with fitting elderly people in footwear too large, or in a sloppy manner is that they are not getting enough sensory [u]info from sloppy fitting and would be at a greater risk for falling. This also applies to footwear which is unstable and distorted.
Greater toe grip and gentler heel strike are the strategies to adapt to slippery surface.
Fong DT, Mao DW, Li JX, Hong Y.
Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong, China.
This study investigated the plantar pressure distribution during gait on wooden surface with different slipperiness in the presence of contaminants. Fifteen Chinese males performed 10 walking trials on a 5-m wooden walkway wearing cloth shoe in four contaminated conditions (dry, sand, water, oil). A pressure insole system was employed to record the plantar pressure data at 50Hz. Peak pressure and time-normalized pressure-time integral were evaluated in nine regions. In comparing walking on slippery to non-slippery surfaces, results showed a 30% increase of peak pressure beneath the hallux (from 195.6 to 254.1kPa), with a dramatic 79% increase in the pressure time integral beneath the hallux (from 63.8 to 114.3kPa) and a 34% increase beneath the lateral toes (from 35.1 to 47.2kPa). In addition, the peak pressure beneath the medial and lateral heel showed significant 20-24% reductions, respectively (from 233.6-253.5 to 204.0-219.0kPa). These findings suggested that greater toe grip and gentler heel strike are the strategies to adapt to slippery surface. Such strategies plantarflexed the ankle and the metatarsals to achieve a flat foot contact with the ground, especially at heel strike, in order to shift the ground reaction force to a more vertical direction. As the vertical ground reaction force component increased, the available ground friction increased and the floor became less slippery. Therefore, human could walk without slip on slippery surfaces with greater toe grip and gentler heel strike as adaptation strategies.
The Following User Says Thank You to Hylton Menz For This Useful Post:
The effects of usual footwear on balance amongst elderly women attending a day hospital.
Horgan NF, Crehan F, Bartlett E, Keogan F, O'Grady AM, Moore AR, Donegan CF, Curran M. Age Ageing. 2008 Nov 11. [Epub ahead of print]
Quote:
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.
BACKGROUND: Hallux valgus and lesser toe deformities are highly prevalent foot problems in older people. One factor contributing to the development of these toe deformities is reduced toe flexor strength. As adequate toe flexor strength is also crucial in maintaining balance, it was hypothesised that poor toe flexor strength and toe deformities would increase the risk of falls in community-dwelling older people.
METHOD: The feet of 312 men and women aged 60-90years were assessed for the presence of lesser toe deformities and hallux valgus. Hallux and lesser toe flexor strength were assessed using an emed AT-4 pressure platform and novel test protocol. Participants were then followed prospectively to determine their falls incidence over 12months.
FINDINGS: During the 12month follow-up, 107 (35%) participants experienced a fall. Compared to non-fallers, fallers displayed significantly less strength of the hallux (11.6 (SD 6.9) versus 14.8 (SD 7.8)% BW, P<0.01) and lesser toes (8.7 (SD 4.7) versus 10.8 (SD 4.5)% BW, P<0.01), and were more likely to have hallux valgus (relative risk [RR]=2.36; 95% CI=1.03-5.45; P<0.01) and lesser toe deformity (RR=1.32; 95% CI=1.04-1.69; P<0.01).
INTERPRETATION: Reduced toe flexor strength and the presence of toe deformities increase the risk of falling in older people. To reduce this risk, interventions designed to increase strength of the toe flexor muscles combined with treatment of those older individuals with toe deformities may be beneficial
Objective
The aim of the study was to find the correlation between foot and ankle characteristics with functional abilities and balance among south Indian geriatrics.
Methodology
Sixty elderly people residing in an old age home were taken for test of Foot & Ankle characteristics, Balance and functional ability. Foot & Ankle characteristics were tested across five domains: Foot posture was tested by foot posture index, ankle flexibility was measured by modified version of Lunge test, foot deformity was tested by the grading exercised by the photographs, foot strength was measured by Paper grip test and foot sensation was tested by Semmens- weinsten aesthesiometer.. Balance and Functional ability were tested by standing balance test, sit to stand, 8foot and go test and walking speed.
Results
The correlation value between Foot posture with standing balance test, sit to stand test, 8-foot up and go test, gait speed are -0.027, -0.097, 0.048, 0.05 respectively.The correlation value between Ankle flexibility with Standing balance test, Sit to stand test, 8-foot up and go test, Gait speed are -0.023, -0.134, -0.169, -0.261 respectively. The correlation value between Hallux valgus deformity (HVD)with Standing balance test, Sit to stand test, 8-foot up and go test, Gait speed are -0.153, 0.011, -0.075, -0.099 respectively.The correlation value between Paper grip test1 (PGT1)with Standing balance test, Sit to stand test, 8-foot up and go test, Gait speed are 0.735, -0.367, 1.374, 1.133 respectively.The correlation value between Foot sensation(FS) with Standing balance test, Sit to stand test, 8-foot up and go test, Gait speed are -0.007, 0.052, -0.272, -0.206 respectively.
Conclusion
This study proves that Foot and Ankle characteristics strongly correlate with the Balance and Functional ability in geriatric population.
Foot characteristics and balance
Linear Mode
