Given the frequency of falls among senior citizens, this author offers a thorough review of the literature and provides pertinent insights on key podiatric risk factors for falls, testing tips to assess fall risk and interventions that may be beneficial in this patient population.
Over the past two decades, podiatric medicine has become a vital member of the healthcare team treating important health issues around the world. For example, the role of the podiatric physician in the team approach to treating the diabetic foot has elevated our profession to a level of esteem where we are on a par with any medical specialty.1
At the same time, there is an equally important public health issue that has the same potential for podiatric physicians to make a significant impact but has yet to become part of mainstream podiatric practice. This issue is fall prevention in the elderly.
One in three adults over the age of 65 falls each year and half of these people fall multiple times.2,3 The Centers for Disease Control and Prevention report that falls are the leading cause of injury-related deaths in people over the age of 65.4 In 2000, the cost of treating non-fatal fall related injuries was $19 billion and is expected to double by 2020.5,6
The importance of fall prevention is underscored by the volume of research published on this subject by a wide range of medical specialists and scientists. Systematic reviews of the subject of fall prevention reveal over 5,000 articles that cover all aspects of epidemiology, pathophysiology, biomechanics and intervention.7 Despite the impressive amount of published research, there are many unanswered questions about identifying and treating elderly patients at risk of sustaining a traumatic fall.
The ability of a human to remain upright during stance and gait requires an intricate, fascinating system of neuromuscular control, which operates at multiple levels in the body. Sensory input is derived primarily from three levels: the visual system, the vestibular system and the somatosensory system of the extremities, which include the muscle stretch receptors, the joint mechanoreceptors and pressure receptors on the plantar surface of the foot. Processing of the sensory input occurs centrally at the brain stem and cerebral cortex to coordinate muscular activation for ambulation and maintenance of upright stance. The “feed forward” mechanism to recover from slipping or tripping requires proper muscle reaction time, muscle strength and adequate joint range of motion of the extremities.
With multiple levels of input and output from the central nervous system to provide us with proper muscular activation to respond to unexpected hazards, it is easy to see how numerous risk factors associated with aging can predispose people to traumatic falls. The medical literature has identified many independent risk factors for falling. Listed in descending order of strength of scientific evidence, the risk factors include: previous falls, balance impairment, decreased muscle strength, visual impairment, polypharmacy (more than four medications) or psychoactive drugs, gait impairment and walking difficulty, depression, dizziness or orthostasis, functional limitations, age older than 80 years, female sex, incontinence, cognitive impairment, arthritis, diabetes and pain.8
More than one risk factor increases the risk of falling. With no risk factors, the risk of falling is 8 percent and grows to 78 percent with four risk factors.3 More alarming is the finding that the risk of falling quadruples for a patient within two weeks of discharge from the hospital.9
Medications that physicians commonly prescribe for elderly patients can negatively affect all aspects of neuromuscular control of the body during gait. While the use of four or more medications from any category of drugs will increase the risk of falling, identifying certain drugs that can independently increase the risk is more difficult. In general, an increased risk of falling is associated with the following medications: serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic agents, benzodiazepines, anticonvulsants and class IA antiarrhythmic medications.10 Withdrawal of these medications becomes a complicated issue when considering fall prevention. Many times, the condition patients are taking the medication for is itself a risk factor for falling.
Most of our elderly patients experience a decline in balance and muscle strength. The combination of this decline with visual and vestibular compromise increases the risk of falling. What, if anything, can we as podiatric physicians do about this?
Helfand voiced a call to attention for podiatric physicians to realize their role in fall prevention in 1966.11 Few paid notice, especially outside the podiatric profession. Beginning in 1991, the emergence of significant research conducted by a group of Australian podiatrists started a movement that has now placed podiatry in an esteemed position in the role of fall prevention in the elderly.12 As a profession, American podiatric physicians owe a debt of gratitude to Lord and Menz as well as all of their students and collaborators for their monumental contributions to our understanding of foot health and fall prevention in the elderly. Their findings have elucidated four general areas of podiatric risk factors.
Toe deformity. While previous studies have reported an association of “foot problems” with an increased risk of falls in the elderly, Menz and Lord were the first to attempt to measure the effects of specific foot deformities on balance and functional abilities in older people.12-14 Then these researchers were able to make a connection between foot health and fall risk by showing that people with a history of multiple falls had a significantly higher foot problem score than those who had not fallen.15 These foot problems included (in order of prevalence): hallux valgus, lesser toe deformities, plantar calluses and corns on the toes. The presence of foot problems was associated with decreased performance on functional ability tests such as stair ascent and alternate stepping. This suggested that certain forefoot deformities could compromise balance in elderly patients during dynamic gait.
Range of motion and toe flexion strength. A series of studies have demonstrated certain physiologic or clinical markers from a foot examination that could be clues to fall risk in the elderly. The first paper on this subject showed 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 percent of the variance in these measures.16
Expanding on these findings, Menz and co-workers developed a series of standardized tests for foot problems and then correlated the results with the risk of falling in elderly patients in a prospective study.17 This was the most important study at that time because it validated that the previously identified risk factors of reduced ankle flexibility, more severe hallux valgus deformity and reduced plantar tactile sensitivity were associated with a significantly increased risk of falling among elderly patients. Two of these foot and ankle characteristics, toe plantarflexor weakness and disabling foot pain, were significantly and independently associated with fall risk. This important study validated previous notions about the importance of adequate ankle joint range of motion and the ability to grasp with the toes to maintain balance.
A prospective study by Mickle and colleagues further validated the importance of toe flexor strength.18 This study of 312 older individuals showed that the presence of hallux valgus, lesser toe deformity and reduced plantarflexion strength of the hallux and lesser toes increases the risk of falling in older people. In particular, hallux strength and the presence of lesser toe deformities were independent predictors of falls. Furthermore, individuals with hallux valgus and lesser toe deformities had weaker flexor muscles of the associated toes. The authors suggested that interventions focusing on exercises that strengthen the toe flexor muscles may be of benefit to prevent falls in elderly patients. This led to the development of a multifaceted podiatric fall prevention program, which has been a monumental contribution to the medical community. I will discuss the study of this program later in the article (see “What One Landmark Study Showed About A Multifaceted Intervention Program To Reduce Falls” below).
Foot pain. Previous studies have shown that foot pain is associated with a risk of falling in men and women residing in a retirement village.17 Since foot pain occurs in up to 54 percent of community dwelling elderly people, the relationship between foot pain and risk of falling can be significant.19
Mickle and colleagues correlated foot pain, plantar pressure and fall risk in a prospective study of 162 community dwelling older adults.20 In this study, those who had fallen generated higher plantar pressures during gait and reported greater foot pain than those who had not fallen. The authors speculated that providing interventions for older individuals with foot pain and high plantar pressures may result in a reduced risk of falling. These interventions could include footwear with better cushioning under areas of high pressure as well as podiatric care, which includes lesion debridement or orthotic treatment.
Footwear. The role of shoes in the risk of falls is the subject of extensive study. Some of the findings have been surprising based upon our understanding of proprioception and sensory feedback from the feet to provide balance and postural control. While most would expect that the barefoot condition would provide better balance in comparison to wearing shoes, research has indicated the opposite result when looking at the frequency of falls in the elderly.
A study by Koepsell and co-workers showed that walking barefoot or simply wearing socks indoors resulted in an 11-fold increased risk of falling in comparison to wearing shoes.21 Other studies have validated this finding that slippers, in comparison to shoes, lead to an increased risk of falling.22 Not all shoes are protective for falls in the home. Menz and others have identified the following characteristics of shoes that are associated with increased risk of falling: wearing shoes with inadequate fixation (no laces, straps, or buckles); increased heel height (greater than 4.5 cm); narrow heel (less than 20 percent width of the heel); and a reduced contact area of the sole and smooth tread.23
In 2008, Menant and co-workers published a systematic review of the literature to provide a comprehensive understanding of the role of footwear and traumatic falls.24 This review again concluded that elderly people should wear properly fitted shoes inside the home. Wearing slippers, socks or being barefoot has consistently been associated with an increased risk of falling indoors. The authors recommended shoes with firm, thin soles, citing evidence that softer shoes have been associated with balance problems. Finally, the authors recommended a tread sole with beveled heels to prevent slip-induced falls.
Combining the current knowledge from the general scientific literature as well as the large number of papers published by podiatric researchers, there are key risk factors that are most relevant to the patient presenting to the podiatric physician. These risk factors include: history of a previous fall, diabetes, gait impairment, arthritis, reduced ankle joint range of motion, weakness of toe flexors, reduced plantar sensation, hallux valgus, claw toe, plantar calluses and foot pain. Recognizing any or all of these findings in the history or examination of any patient in podiatric practice should be a tip-off that intervention(s) may be necessary, much of which the podiatric physician can implement.
For those podiatric physicians who want to get more involved with the screening of all of their patients for a fall risk assessment, many clinical tests are available. Often, these tests are time consuming and one could question whether they actually fall within the scope of podiatric practice.
There is one protocol developed by our Australian colleagues as a screening for fall risk in primary care. One may modify this protocol and apply it to podiatric practice. Tiedemann and co-workers have developed a fall risk assessment tool, which an external study validated and proved reliable.2 This tool can provide a feasible fall risk assessment that can accurately predict multiple falls and assist with guiding interventions in community-living older people. This assessment discriminates between those who have had multiple falls and those who have not had multiple falls with an accuracy of 72 percent. This compares well with other similar assessments for identifying those with multiple falls and exceeds the predictive ability of other popular tests including the Timed Up and Go test and the Functional Reach test. The QuickScreen® Clinical Assessment Form illustrates the test. Here are the key points of the assessment.
1. There is a test of low (10 percent) contrast visual acuity measured at a distance of 3 m.8
2. The assessment has a tactile sensitivity test at the ankle using a single Semmes–Weinstein-type pressure monofilament.
3. For the near tandem stand test, the participant stands with his or her eyes closed and with bare feet in a near tandem position. The feet are parallel and separated laterally by 2.5 cm. The heel of the front foot is 2.5 cm anterior to the great toe of the back foot.
4. In the sit-to-stand test, participants rise from a standard height (43 cm) chair five times as fast as possible with their arms folded.
5. The alternate step test involves placing the whole foot (shoes removed) onto a step that is 18 cm high and 40 cm deep. Patients alternate with the right and left feet for a total of eight repetitions as quickly as possible.
The medical literature contains thousands of articles relevant to fall prevention. Various researchers have developed and tested interventions to address any and all of the aforementioned risk factors. What is perplexing is the fact that treating individual risk factors does not reliably lead to any significant reduction of fall risk in elderly patients. Clearly the prevention of falls is far more complicated than simply identifying risk.
For example, a recent trend in podiatric medicine has been the dispensing of bilateral solid shell ankle-foot orthoses (AFOs) to prevent the risk of falls in elderly patients (see my Podiatry Today DPM Blog at http://goo.gl/7r7dG  ). Training sessions and webinars promoting the sale of these braces justify the medical necessity of this intervention because the treatment focuses on musculoskeletal or neuromuscular disorders that have previously been identified to be risk factors for falling. The problem is that treating balance problems, muscle weakness, neuropathy or ankle arthritis with AFOs has never proven to prevent falls in the elderly. In short, AFOs have never been included in any credible published study of an independent or multifaceted fall prevention program.
The most recent Cochrane review of community-based fall prevention trials was published in 2008.26 This 254-page document surveyed over 4,000 references and selected 111 randomized controlled trials of 53,000 participants. This review paper made the following conclusions about fall prevention programs.
• Exercise programs may target strength, balance, flexibility or endurance. Programs that contain two or more of these components reduce the rate of falls and number of people falling. Exercising in supervised groups, participating in tai chi and carrying out individually prescribed exercise programs at home are all effective.
• Multifactorial interventions assess an individual person’s risk of falling and then carry out or arrange referral for treatment to reduce the risk. Some studies have shown multifactorial interventions to be effective but other studies have shown such interventions to be ineffective.
• Taking vitamin D supplements probably does not reduce falls, except in people who have a low level of vitamin D in the blood. Interventions to improve home safety do not seem to be effective, except in people at high risk for falling, such as those with severe visual impairment.
• Wearing an anti-slip shoe device in icy conditions can reduce falls.
• Some medications increase the risk of falling. Ensuring that medications are reviewed and adjusted may be effective in reducing falls. Gradual withdrawal from some types of drugs for improving sleep, reducing anxiety and treating depression may reduce falls.
• Cataract surgery reduces falls in people having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition that may result in changes in heart rate and blood pressure.
Costello and colleagues also observed that multifactorial fall prevention programs are not always successful.27 These authors reviewed 781 published studies and concluded that only such programs that target individuals with a previous fall are successful. Researchers also noted that an exercise program combined with balance training was the single treatment intervention that had a benefit for patients with and without a previous history of falling. Costello and co-workers also recommended that a medication and vision assessment with appropriate health practitioner referral should be included in a fall screening examination.
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.
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.
At the same time, podiatric physicians should be cautious about using any recently marketed “devices” that purport to prevent falls in elderly patients. Using bilateral AFOs to treat musculoskeletal risk factors in elderly patients who have been identified at risk for falling has never been tested for safety and efficacy in preventing falls. Until this treatment has had testing via rigorous randomized clinical trials, our focus should be on implementing other interventions that peer-reviewed research has already validated.
It is important for the podiatric physician to recognize his or her role as a member of a healthcare team in treating this vital public health issue. By following sound, scientifically proven guidelines, there is significant opportunity for podiatric physicians to become key players on the fall prevention team, which will improve the quality of life of their elderly patients.
Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is in private practice in Seal Beach, Calif.
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18. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. Toe weakness and deformity increase the risk of falls in older people. Clinical Biomechanics. 2009; 24(10):787–791.
19. Munro BJ, Steele JR. Foot-care awareness. A survey of persons aged 65 years and older. J Am Podiatr Med Assoc 1998; 88(5):242–248.
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21. Koepsell TD, Wolf ME, Buchner DM, et al. Footwear style and risk of falls in older adults. J Am Geriatr Soc. 2004; 52(9):1495–1501.
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29. Spink MJ, Menz HB, Fotoohabadi MRf, E Wee, Landorf KB, Hill KD, Lord SR. Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomized controlled trial. BMJ 2011; 342:d3411.
For further reading, see Dr. Richie’s DPM Blogs “How Can DPMs Prevent Falls In The Elderly?” at http://tinyurl.com/6238jq9  , “The Truth About AFOs And Fall Prevention” at http://goo.gl/7r7dG  or “Still Looking For Documentation That AFOs Effectively Prevent Falls” at http://tinyurl.com/cjjcvko  .