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From Gerontology

Footwear Characteristics and Risk of Indoor and Outdoor Falls in Older People
Hylton B. Menz, Meg E. Morris, Stephen R. Lord

Background: Footwear characteristics have been shown to influence balance in older people; however, the relationship between footwear and falls is unclear. Objective: To determine the relationships between footwear characteristics and the risk of indoor and outdoor falls in older people. Methods: Footwear characteristics (shoe type, heel height, heel counter height, heel width, critical tipping angle, method of fixation, heel counter stiffness, sole rigidity and flexion point, tread pattern and sole hardness) were assessed in 176 people (56 men and 120 women) aged 62-96 (mean age 80.1, SD 6.4) residing in a retirement village. Falls were recorded over a 12-month follow-up period and comparisons made between fallers and non-fallers. Results: 50 participants (29%) fell indoors and 36 (21%) fell outdoors. After controlling for age, gender, demographic characteristics, medication use, physiological falls risk factors and foot problems, those who fell indoors were more likely to go barefoot or wear socks inside the home (OR = 13.74; 95% CI 3.88-48.61, p < 0.01). However, there were no significant differences in indoor or outdoor footwear characteristics between fallers and non-fallers. Five indoor fallers (10%) and three outdoor fallers (8%) stated that their shoes contributed to their fall. Conclusion: Footwear characteristics were not significantly associated with falls either inside or outside the home. Risk of falling indoors was associated with going barefoot or wearing socks. Older people at risk of falling should therefore be advised to wear shoes indoors where possible.

Other recent footwear and falls papers (PubMed links):

Footwear style and risk of falls in older adults

Biomechanical properties of shoes and risk of falls in older adults

Wearing slippers, falls and injury in residential care

An evaluation of footwear worn at the time of fall-related hip fracture

Older patient can have shoe related falls due to poor fit secondary to neurologic(diabetes),orthopedic(arthritis) or even economic factors.

John,

Our most recent study found no relationship between footwear fit and falls, however a previous study of footwear and hip fractures found that older people who suffered a trip-related fracture were more likely to be wearing shoes without any method of fixation (ie: laces, buckles, etc). In that study, two participants specifically blamed their shoes for the fall - one stated that her slipper "got stuck", causing her to trip, and another stated that her moccasin slipped off her foot and she tripped over it.

Cheers,

Hylton

Effects of Footwear Features on Balance and Stepping in Older People.
Menant JC, Steele JR, Menz HB, Munro BJ, Lord SR.
Gerontology. 2008 Feb 4 [Epub ahead of print]

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In what order were the footwear types tested? These elderly patients may have fatigued towards the end of the testing process. Were the heeled shoes tested last? If so that could have skewed the results a little.

I'm also curious at the wording "An elevated heel of only 4.5 cm height significantly impairs balance in older people". Does this suggest that a 4.5cm heel height is not a significant heel? Does this also mean that anything under 4.5cm is safe?

Trent

Hopefully Hylton will stop by and confirm this as I do not have the publication handy, but it is pretty standard methodology in these sorts of studies to randomise the order for each subject, so assume that this was what was done.

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Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
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Hi Trent,

In response to your questions:

1. Yes, the order of testing of the shoes was randomised to account for practice and fatigue effects (see p. 2).

2. The phrase "only 4.5cm" is in reference to previous studies, which have assessed higher heels (5 and 6cm).

There is some evidence that shoes of varying heel heights up to 4cm have no effect on balance (Lindemann et al, 2003) raising the possibility that there may be a critical height above which balance deficits become evident (ie: >4cm).

Ref:

Lindemann U, Scheible S, Sturm E, Eichner B, Ring C, Najafi B, Aminian K, Nikolaus T, Becker C. Elevated heels and adaptation to new shoes in frail elderly women. Z Gerontol Geriatr. 2003 Feb;36(1):29-34. abstract

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Cheers,

Hylton

Hylton B. Menz, PhD
Associate Professor and Reader
NHMRC Australian Clinical Research Fellow
Director, Musculoskeletal Research Centre
La Trobe University

Hi Hilton,

Has there been research assessing how does this critical height compares to other population segments?

Men v women?

'children' v 'young adults' v 'middle aged' v 'old' v 'old old'?

Active v inactive?

Those with Hx foot/lower limb injury?

Those classified with 'flat feet' (FPI?)?

Cheers,

Paul

Hi Hylton,

Thanks for clarifying the randomisation of the tests carried out.

The reason I asked about the heel height was in reference to "critical height" you have mentioned. I'm curious why someone has not collating research in an attempt to standardise acceptable parameters for high heels. It has to be one of the greatest battles out there for Podiatrists. If we could put something out there that says, this is the heel height, width, etc that we have proven correlates to less injuries or even no injuries it would be a great tool to use.

I know you are coming form a different angle, in terms of gerontology, however your research is related. Just a thought.

Trent

Dear Paul and Trent,

Not to my knowledge.

I agree that this would be useful, but again, to my knowledge this hasn't been done.

Given the reasonably strong evidence of the detrimental effects of heel elevation on balance, my personal opinion (and I know Cameron/toeslayer will strongly disagree ) is that heel elevation should be avoided in older people as a general rule unless there are good clinical reasons for using shoes with elevated heels (eg: fixed equinus deformity).

Looking through some previous footwear posts, I'm not sure how toeslayer got away relatively unscathed with this one:

Not true!

__________________
Cheers,

Hylton

Hylton B. Menz, PhD
Associate Professor and Reader
NHMRC Australian Clinical Research Fellow
Director, Musculoskeletal Research Centre
La Trobe University

Menant JC, Steele JR, Menz HB, Munro BJ, Lord SR. Optimizing footwear for older people at risk of falls. J Rehabil Res Dev. 2008;45(8):1167-82.

Footwear influences balance and the subsequent risk of slips, trips, and falls by altering somatosensory feedback to the foot and ankle and modifying frictional conditions at the shoe/floor interface. Walking indoors barefoot or in socks and walking indoors or outdoors in high-heel shoes have been shown to increase the risk of falls in older people. Other footwear characteristics such as heel collar height, sole hardness, and tread and heel geometry also influence measures of balance and gait. Because many older people wear suboptimal shoes, maximizing safe shoe use may offer an effective fall prevention strategy. Based on findings of a systematic literature review, older people should wear shoes with low heels and firm slip-resistant soles both inside and outside the home. Future research should investigate the potential benefits of tread sole shoes for preventing slips and whether shoes with high collars or flared soles can enhance balance when challenging tasks are undertaken.

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Cheers,

Hylton

Hylton B. Menz, PhD
Associate Professor and Reader
NHMRC Australian Clinical Research Fellow
Director, Musculoskeletal Research Centre
La Trobe University

Gait Posture. 2009 Apr 7. [Epub ahead of print]

Rapid gait termination: Effects of age, walking surfaces and footwear characteristics.

Menant JC, Steele JR, Menz HB, Munro BJ, Lord SR.
Prince of Wales Medical Research Institute and University of New South Wales, Randwick, NSW, Australia.

The aim of this study was to systematically investigate the influence of various walking surfaces and footwear characteristics on the ability to terminate gait rapidly in 10 young and 26 older people. Subjects walked at a self-selected speed in eight randomized shoe conditions (standard versus elevated heel, soft sole, hard sole, high-collar, flared sole, bevelled heel and tread sole) on three surfaces: control, irregular and wet. In response to an audible cue, subjects were required to stop as quickly as possible in three out of eight walking trials in each condition. Time to last foot contact, total stopping time, stopping distance, number of steps to stop, step length and step width post-cue and base of support length at total stop were calculated from kinematic data collected using two CODA scanner units. The older subjects took more time and a longer distance to last foot contact and were more frequently classified as using a three or more-steps stopping strategy compared to the young subjects. The wet surface impeded gait termination, as indicated by greater total stopping time and stopping distance. Subjects required more time to terminate gait in the soft sole shoes compared to the standard shoes. In contrast, the high-collar shoes reduced total stopping time on the wet surface. These findings suggest that older adults have more difficulty terminating gait rapidly than their younger counterparts and that footwear is likely to influence whole-body stability during challenging postural tasks on wet surfaces.

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Cheers,

Hylton

Hylton B. Menz, PhD
Associate Professor and Reader
NHMRC Australian Clinical Research Fellow
Director, Musculoskeletal Research Centre
La Trobe University

hi all,
i think slippers is one big factor causing older adults to fall at home. The poor fixation mechanism of slippers would increase risk of falling because older adults need to spend extra energy and concentration to hold the shoes within the foot. This could be considered an secondary task. When older adults performing two or more tasks concurrently, the total capacity is required and therefore one of the tasks will be compromised (Shumway-Cook, 2002). Older adults tend to forcus on postural control as their primary task.

A high heel could increase loading of the forefoot, increased arch height and lead to increased risk of lateral ankle sprain. A high-heel shoes would also increase energy consumption which could be another contributing factor for falling. Many studies found high-heeled footwears are responsible for instability and falling ( Snow and Williams, 1994). Robbin et al 1991 also suggests a thin and hard midsole is the best for older adults in terms of preventing falls because soft materials cause instability due to sensory reduction-less perception.

The think the footwear assessment form by Sherrington and Menz, 1999 which looks at the types footwear, fixation, heel hight, midsole, heel counter stiffness, sole flexion point, sole hardness etc, is a great reliable clinical tool to assess patients' footwear

Jessup 2004 is another good reference to look at the poor mechanisms of footwear that would increase risk of falling, such as


P.S Romberg's test, timed get up and go test are good guideline to check patient's stability


hope all make sense

regards,
Mark

It with interest that i have read your thread, as i have noted that in some rest home situations,residents are often encouraged to wear slippers as it is an'easy'footwear to put on and often does not require caregivers to assist.i recommended that this option was discouraged and replaced with a sports shoe type alternative, often replacing laces with an elastic lace alternative so that footwear could still be slipped on easily by most residents.in some cases i also added a simple arch support to stabilise the foot.falls have slowly decreased and the gait patterns of several residents who used to shuffle in slippers now walk more confidently in their shoes.Regards melpod.

Two thoughts for you

Heel "height" is not the real issue, heel "pitch" is the real issue.

Slippers, your right they are poorly fixed to the foot, but have you ever seen a pair of slippers that actually fit the clients foot correctly? most are too big as one of the ever helpful children have bought them without the parent been there, how many times have l heard........."Thats close enough, she does walk much any way"

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David Sutton
C.Ped.CM
My location
www.bilbyshoes.com

Are non-slip socks really 'non-slip'? An analysis of slip resistance

Satyan Chari, Terrence Haines, Paul Varghese and Alyssia Economidis

BMC Geriatrics 2009, 9:39doi:10.1186/1471-2318-9-39

Abstract (provisional)
Background
Non-slip socks have been suggested as a means of preventing accidental falls due to slips. This study compared the relative slip resistance of commercially available non-slip socks with other foot conditions, namely bare feet, compression stockings and conventional socks, in order to determine any traction benefit.

Methods
Phase one involved slip resistance testing of two commercially available non-slip socks and one compression-stocking sample through an independent blinded materials testing laboratory using a Wet Pendulum Test. Phase two of the study involved in-situ testing among healthy adult subjects (n=3). Subjects stood unsupported on a variable angle, inclined platform topped with hospital grade vinyl, in a range of foot conditions (bare feet, non-slip socks, conventional socks and compression stockings). Inclination was increased incrementally for each condition until slippage of any magnitude was detected. The platform angle was monitored using a spatial orientation tracking sensor and slippage point was recorded on video.

Results
Phase one results generated through Wet Pendulum Test suggested that non-slip socks did not offer better traction than compression stockings. However, in phase two, slippage in compression stockings was detected at the lowest angles across all participants. Amongst the foot conditions tested, barefoot conditions produced the highest slip angles for all participants indicating that this foot condition provided the highest slip resistance.

Conclusions
It is evident that bare feet provide better slip resistance than non-slip socks and therefore might represent a safer foot condition. This study did not explore whether traction provided by bare feet was comparable to 'optimal' footwear such as shoes. However, previous studies have associated barefoot mobilisation with increased falls. Therefore, it is suggested that all patients continue to be encouraged to mobilise in appropriate, well-fitting shoes whilst in hospital. Limitations of this study in relation to the testing method, participant group and sample size are discussed.

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Cheers,

Hylton

Hylton B. Menz, PhD
Associate Professor and Reader
NHMRC Australian Clinical Research Fellow
Director, Musculoskeletal Research Centre
La Trobe University

Hi Hylton

Just doing some research myself for a talk on falls and rereading the tread. Picked up your comments how I got away with so muc - the reason is simple no one pays any attention to what I write. Just like growing older I can now walk through a group of young ladies and be completely unseen. Time was I could turn some heads but no longer, alas. Same with my writing.

On heel heights generally - I suppose it is very difficult to be precise because of individual anatomical variation. Also the type of fall patterns does vary within the demographic ie from community dwelling elderly to geriatric to psycho-geriatric etc. I can certainly see the association between imbalance and falls and anything that would lead to imbalance would be a critical factor. I do not think heels should be mandatory.

I was interested recently to read of the studies from Italy where there seemed to be an arguement that heeled shoes might assist with continuence training in older adults. Have you any comment?

Cheers
toeslayer (the pod formerly known as Cameron)

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I try to notice foot drop issues when I fit older people. They often report carpet giving them trouble and "catching" on the toes of their shoes.

Many times we have ground off the urethane or rubber distal to the sulcus, and replaced it with smooth soling leather. In cases of foot drop, this helps quite a bit, according to reports from my patients. Esp. on carpet.

Of course a leaf spring AFO would solve the problem better. But, in mild cases or where the elderly patient will not wear a brace, it helps.

In my own observations the vast amount of them: target fixate within 4 feet of their on footstep and start to create a self fulfillling prophesy, they are pitched foward using a controlled fall as a gait, they are poorly propulsive, they have become physically weaker due to developing a flacid gait rather than being dynamically active, they do not counter rotate to manage lateral sway and centre their mass, they have inadequate counter balance swing of their arms so they get little propulsive assist nor offset-balance, they wear shoes that stiffle muscle action and inhibit proprioreceptive feedback, and they have set beliefs that they are too old to change which is another self fullfilling prophesy. Foot function is probably the least of the problem

Hamish you make it sound like its a lost battle and its all their fault.
As for "...they have set beliefs that they are too old to change...."
there is no age limitation on being stubborn.
, l have three children one of which proves that often

l understand what you are saying but as far as "..foot function been least of their problems..", we need to start somewhere and getting them/ anyone mobile again is a great achievement.
We start by reminding them to swing their arms rather than hold them tight to their body, to fit them with light weight but structural footwear and often modify them as "gaittec" does to compensate for some of those lost functions within their gait.

Most elderly when they come in do have shoes that are 5-6years old that no longer support them and due to the poor fit offer little proprioceptive feedback as they slop about, there is often a lot we can do to improve their gait and balance.

l must say Hylton and Martin must be pulling their hair out with some of the footwear some of their subject turn up in

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David Sutton
C.Ped.CM
My location
www.bilbyshoes.com

No not blaming them, just observing an attitude that has developed in many. I agree one has to start somewhere, with luck our profession gives us an in. Other professions will start somewhere else. What I have come across on may ocassions is a lack of regard for the other bits from our profession, who can get hung up on small elements and neglect to observe the other "stuff".