Preventing Falls In The Elderly: Where DPMs Can Have An Impact

Douglas H. Richie, DPM, FACFAS

What One Landmark Study Showed About A Multifaceted Intervention Program To Reduce Falls

Clearly, the proven strategies for reducing falls in the elderly population are multifaceted and many are outside the realm or scope of practice of the podiatric physician. Furthermore, as Tinetti points out, the most complicated component of a strategy to prevent falls involves reduction in the use of medications (benzodiazepines, other sleeping medications, neuroleptics, antidepressants, anticonvulsants, or class IA antiarrhythmics), the vast majority of which are outside the scope of the podiatric physician.28 Yet Tinetti points out in her article (directed to the primary care physician) that evaluation of the feet and referral to a podiatric physician are essential components of the fall prevention program.

   In 2011, our Australian colleagues published a landmark paper that will hopefully put the podiatric profession on the map as a key member of the fall prevention team.29 For the first time, a multifaceted intervention implemented by podiatric physicians showed a significant effect in reducing falls in a community-based elderly population. This randomized, prospective controlled trial studied 305 elderly individuals with disabling foot pain who also had an increased risk of falls. The experimental group received the following interventions: a foam, prefabricated foot orthosis customized to offload painful calluses in the forefoot, advice on footwear, a subsidy for footwear, a home-based program of foot and ankle exercises, a fall prevention education booklet, and routine podiatry care for 12 months. The control group received routine podiatry care for 12 months.

   This multifaceted program resulted in a reduction of falls by 36 percent over a 12-month period. This compared favorably with other previous programs that have included tai chi as well as cataract surgery. Secondary benefits for the intervention group were significant improvement of strength and range of motion of the ankle as well as improvements in balance. The researchers felt that the exercise program was the key component to the multifaceted intervention. This program included ankle joint stretching, ankle strengthening and toe flexor tendon strengthening. It is important to note that isolated balance training and any measure to improve balance were not part of the exercise program.

   Any podiatric physician in this country can implement the components of this multifaceted intervention. Obstacles may be the fact that Medicare does not reimburse footwear and foot orthoses unless the patient has diabetes and qualifies under certain criteria. Also be aware that AFOs were not part of the Australian study and these devices do not function in the same way as the foot orthoses that the authors studied.

   Patients can implement exercise programs focusing on the foot and ankle at home if podiatrists or qualified physical therapists provide the appropriate training. Fall prevention education in the form of a single publication provided in the Australian study is not available here in the United States but programs for fall prevention that include patient education are available at most large hospitals and senior community centers around the country.

In Conclusion

Podiatric physicians are now critical members of the fall prevention team thanks to research provided by our Australian colleagues who have identified and verified certain risk factors peculiar to the foot and ankle. Restricted ankle joint range of motion, foot pain and weakness of the toe flexor muscles are key independent risk factors for falling in the elderly. Recognition of these factors, in combination with previously identified general systemic factors, will allow the podiatric physician to make appropriate referrals while implementing several proven interventions within their own practices that can reliably reduce the risk of falls in elderly patients.

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