Effectiveness of a multifaceted podiatry intervention to prevent

Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomised controlled trial Ambulatory Journal Club Pamela Sebastian

Case presentation u My patient – 69 year old male, lives alone at home. u History of HTN, HLD and DM type 2, gout u Known peripheral neuropathy (bilateral foot pain) due to diabetes, recurrent gout attacks u Now here for ER f/u after a mechanical fall few days ago

Clinical Question In my patient with foot pain, how can I reduce the recurrence of falls?

Background 1 in 3 people aged 65 and over fall each year u Falls result from interaction between environmental hazards and physiological risk factors u Foot problems affect 1 in 3 older people u Falls result in morbidity and mortality in elderly u Role of multifaceted podiatry in preventing falls u

Journal Article BMJ 2011. 342. d 3411

Methods u Recruitment carried out between July 2008 and Sept 2009 u Participants recruited by post using a database of people who were accessing podiatry services at La Trobe University and by advertisements

Methods (cont) u Eligibility - Community dwelling Age 65 and over Cognitively intact Reported disabling foot pain Increased risk of falling

Methods (cont) u - Exclusion criteria: Neurodegenerative disorders Leg amputation Inability to walk household distances (10 m) without the use of a walking aid Limited English language skills Leg surgery three months before the initial assessment or planned leg surgery

Trial design Parallel group randomized controlled trial u 12 month follow up u 286 participants u Randomized to either the control group or the multifaceted podiatry intervention u Two assessors (physiotherapists), one podiatrist who administered intervention u Participants were provided with a falls calendar to record falls u

Baseline characteristics

Interventions u Both groups continued with podiatry treatment they were currently receiving Intervention group was additionally provided with multifaceted intervention package consisting of: -Foot orthoses -Advise and provision of footwear -Home-based foot and ankle exercise program -Education on falls prevention u

Outcomes u Primary outcome: proportion of fallers, proportion of multiple fallers and the falling rate (number of falls per participant) u Secondary outcome: foot and ankle strength, range of motion, balance and functional ability, falls risk, foot pain and disability, fear of falling and health related quality of life

Statistical Analysis u Intention to treat principle u Used relative risks to compare proportion of fallers and multiple fallers

Results u Primary outcome:

Secondary Outcomes

Strengths u Randomized control trial u High completion rate u Large sample size u Blinding of assessors

Limitations u Not possible to blind participants u Biased towards volunteers with heightened interest and commitment to intervention u Intervention did not target all relevant risk factors u One podiatrist administering intervention u Did not take into account cost effectiveness u Had to have good English proficiency

Conclusion u Multifaceted podiatry intervention is effective in falls prevention in older people with disabling foot pain and increased fall risk u Reduction in falls likely related to significant improvement in foot and ankle strength and ROM, balance and functional ability

Implications u Education of fall prevention and foot/ankle exercises inexpensive and simple to implement u Reduction in falls can reduce morbidity and mortality in elderly and reduce healthcare costs through preventive strategies

What we can do u Refer to podiatry u Advise on footwear u Education material on fall prevention u Leg and foot exercise advice

Questions?