Prevention of falls through podiatry care

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Jose Oto/SPL

In the linked randomised controlled trial (doi:10.1136/bmj.d3411), Spink and colleagues report a parallel group randomised controlled trial with 12 months of follow-up in 305 older people. The trial assessed the effectiveness of a multifaceted podiatry intervention for preventing falls.1 The intervention included the use of foot orthoses, footwear advice supported by a voucher scheme, a foot and ankle exercise programme, falls prevention education, and routine podiatry care. The intervention significantly reduced the incidence of falls compared with routine care (incidence rate ratio 0.64, 95% confidence interval 0.45 to 0.91). No significant differences were seen between the groups in the proportion of fallers or multiple fallers⇑.

Because the intervention reduced the incidence of falls in people with foot pain and should be inexpensive and simple to implement, the authors concluded that the programme could be used in routine podiatry practice and falls prevention clinics.

The causes of falls are multifactorial and include intrinsic and environmental risk factors.2 Falls commonly occur in older people,3 who often have problems with balance, walking, and mobility, and a third of older people also have foot pain.4 The association between foot pathologies, decreased foot function, foot pain, and falls is established.5 6 7 8

Podiatrists treat people of all ages, but their work tends to focus on older people. Although older people have the same foot disorders as the general population, disorders are more common and cause more problems with advancing age and reduced mobility. Conditions that place the foot at greater risk, such as diabetes, are also more common in older people. Research into the effectiveness of podiatry interventions across all population groups has shown that they reduce pain in foot lesions9; that simple orthotic treatment also reduces foot pain10; and that screening, education, and podiatric interventions can prevent more serious disorders.11

Although foot pain is known to be related to falls in older people, Spink and colleagues show for the first time that standard podiatry interventions can reduce falls in older people with foot pain. The findings of the study could affect the assessment and referral of people with foot pain and provide the basis for evidence based guidelines, where none currently exist.

Despite the promising results, several considerations remain. The research looked at one form of orthoses only (prefabricated, full length, dual density orthoses with a firm density base and soft density top cover). A variety of orthoses are available, and the findings cannot necessarily be applied to other forms. The specific role of footwear in preventing falls is less clear and should be explored further. Similarly, the study looked at people with foot pain only, and many foot conditions are not painful but may still contribute to falls. A full economic evaluation is also needed to determine whether the authors’ assertion about cost effectiveness is true.

What do the results mean in practice? Although the interventions studied are routine to podiatrists, they have had little previous use in the context of falls. The study therefore confirms that podiatrists could potentially help reduce falls in older people, and that when assessing patients at risk of falling, primary care doctors should consider whether the patient has foot pain, foot and ankle weakness, and reduced range of motion. Balance and functional ability should also be taken into account, and whether the patient is already wearing orthoses and for what reason. The doctor should also look at whether the patient avoids walking barefoot and whether their footwear provides adequate stability, correct fit, an acceptably low heel height, a reasonable sole-ground contact area, and slip resistance. If any of these risk factors is identified, referral to a podiatrist is warranted. Future research should focus on patients residing in alternative settings, such as residential homes and hospitals; those at risk of falling because of other risk factors not considered here, such as the presence of toe deformities; and those who have risk factors but no foot pain.