•This systematic review identified 15 eligible manuscripts.•A meta-analysis identified foot pain, hallux valgus and lesser toe deformity as risk factors for falling.•Documentation of foot problems ...and referral to foot care specialists should be a routine component of falls prevention.
Foot problems are common in older people. The objective of this systematic review was to determine whether foot problems increase the risk of falling in community-dwelling older people.
Electronic databases were searched from inception to May 2018. To be eligible for inclusion, papers needed to (i) include community-dwelling older participants, (ii) document falls either retrospectively or prospectively, and (iii) document or assess the presence of foot problems. Screening and data extraction were performed by two independent assessors, with disagreements resolved by consensus.
A total of 146 papers were screened by title and abstract, and nine met the inclusion criteria. An additional six eligible papers were identified by searching the reference lists of included papers, resulting in a total of 15 papers. Quantitative synthesis indicated that older people who fell were more likely to have foot pain, hallux valgus, lesser toe deformity, plantar fasciitis, reduced ankle dorsiflexion range of motion, reduced toe plantarflexion strength, impaired tactile sensitivity and increased plantar pressures when walking. Meta-analysis indicated that fallers were more likely to have foot pain (pooled odds ratio OR 1.95, 95% CI 1.38–2.76, p < 0.001), hallux valgus (pooled OR 1.89, 95% CI 1.19–3.00, p = 0.007) and lesser toe deformity (pooled OR 1.67, 95% CI 1.07–2.59, p = 0.020).
Foot problems, particularly foot pain, hallux valgus and lesser toe deformity, are associated with falls in older people. Documentation of foot problems and referral to foot care specialists should therefore be a routine component of falls risk assessment and prevention.
Low back pain (LBP) is an increasingly common condition worldwide with significant costs associated with its management. Identification of musculoskeletal risk factors that can be treated clinically ...before the development of LBP could reduce costs and improve the quality of life of individuals. Therefore the aim was to systematically review prospective cohort studies investigating lower back and / or lower limb musculoskeletal risk factors in the development of LBP.
MEDLINE, EMBASE, AMED, CINAHL, SPORTDiscus, and the Cochrane Library were searched from inception to February 2016. No age, gender or occupational restrictions of participants were applied. Articles had to be published in English and have a 12 month follow-up period. Musculoskeletal risk factors were defined as any osseous, ligamentous, or muscular structure that was quantifiably measured at baseline. Studies were excluded if participants were pregnant, diagnosed with cancer, or had previous low back surgery. Two authors independently reviewed and selected relevant articles. Methodological quality was evaluated independently by two reviewers using a generic tool for observational studies.
Twelve articles which evaluated musculoskeletal risk factors for the development of low back pain in 5459 participants were included. Individual meta-analyses were conducted based on risk factors common between studies. Meta-analysis revealed that reduced lateral flexion range of motion (OR = 0.41, 95% CI 0.24-0.73, p = 0.002), limited lumbar lordosis (OR = 0.73, 95% CI 0.55-0.98, p = 0.034), and restricted hamstring range of motion (OR = 0.96, 95% CI 0.94-0.98, p = 0.001) were significantly associated with the development of low back pain. Meta-analyses on lumbar extension range of motion, quadriceps flexibility, fingertip to floor distance, lumbar flexion range of motion, back muscle strength, back muscle endurance, abdominal strength, erector spinae cross sectional area, and quadratus lumborum cross sectional area showed non-significant results.
In summary, we found that a restriction in lateral flexion and hamstring range of motion as well as limited lumbar lordosis were associated with an increased risk of developing LBP. Future research should aim to measure additional lower limb musculoskeletal risk factors, have follow up periods of 6-12 months, adopt a standardised definition of LBP, and only include participants who have no history of LBP.
To determine the extent to which measures of foot and ankle strength, range of motion, posture, and deformity are associated with performance in a battery of balance and functional ability tests in ...older adults.
Cross-sectional study of people over 65 years.
Community.
Participants (N=305; age range, 65-93y) recruited for a randomized trial investigating the efficacy of a podiatry intervention to prevent falls.
Not applicable.
Clinical measures of foot and ankle strength (using hand-held dynamometry), range of motion, posture, and deformity, and a battery of balance tests (postural sway, maximum balance range, lateral stability, coordinated stability) and functional ability tests (alternate step test, sit-to-stand, timed 6-m walk).
Most (67/88) of the correlations between the foot and ankle tests and performance on the balance and functional tests were statistically significant. Hierarchic linear regression analysis identified hallux plantar flexion strength and ankle inversion-eversion range of motion to be the most consistent significant and independent predictors of balance and functional test performance, explaining up to 25% of the variance in the test scores.
Foot and ankle characteristics, particularly plantar flexor strength of the hallux and ankle inversion-eversion range of motion, are important determinants of balance and functional ability in older people. Further research is required to establish whether intervention programs that include strengthening and stretching exercises for the foot and ankle may achieve improvements in balance and functional ability and reduce the risk of falls in older people.
Background
High plantar pressures are associated with increased foot ulcer risk in people with diabetes. Identification of high plantar pressures in people with diabetes is clinically challenging due ...to time and cost constraints of plantar pressure testing. Factors affecting foot biomechanics, including reduced joint range of motion and foot deformity, are implicated in the development of high plantar pressures and may provide a method to clinically identify those at risk of pressure related complications. The aim of this study was to investigate the contribution of joint range of motion and foot deformity measures on plantar pressures in a community dwelling group with diabetes.
Methods
Barefoot (Tekscan HR Mat™) and in‐shoe (Novel Pedar‐X®) plantar pressure variables, weight bearing ankle dorsiflexion, hallux range of motion, lesser toe deformities and hallux abductus (HAV) scale were assessed in 136 adults with diabetes (52.2% male; mean age 68.4 years). Multivariate multiple linear regression was used to assess the effect of the four biomechanical factors plus neuropathy and body mass index on plantar pressure variables. Non‐parametric bootstrapping was employed to determine the difference in plantar pressure variables for participants with two or more foot biomechanical pathologies compared to those with less than two pathologies.
Results
Almost one third (32%) of the cohort had two or more foot biomechanical pathologies. Participants with two or more foot biomechanical pathologies displayed significant increases in all barefoot plantar pressure regions (except forefoot), compared to those with less than two pathologies. No significant changes were found for the in‐shoe plantar pressure variables. The regression model explains between 9.9% (95%CI: 8.4 to 11.4%) and 29.6% (95% CI: 28.2 to 31%), and between 2.5% (1.0 to 4.0%) and 43.8% (95% CI: 42.5–44.9%), of the variance in the barefoot and in‐shoe plantar pressure variables respectively.
Conclusions
Participants presenting with two or more factors affecting foot biomechanics displayed higher peak pressures and pressure time integrals in all foot regions compared to those with less than two factors. The tests used in this study could help clinicians detect elevated plantar pressures in people with diabetes and present an opportunity for early preventative interventions.
Age-related reduction in lower limb muscle strength has been shown to be related to disability, falls and loss of independence. While there have been a number of studies on age-related changes in ...muscle strength, they have concentrated on more proximal muscle groups with little research into how ageing affects the muscles of the foot and ankle.
To evaluate the intra- and interrater reliability of hand-held dynamometry for the assessment of foot and ankle strength, and to compare the values obtained between young and older people.
The muscle groups which perform ankle dorsiflexion, plantar flexion, inversion, eversion and plantar flexion of the hallux and lesser digits were recorded for 36 young participants (17 males, 19 females, mean age 23.2 ± 4.3 years) and 36 older people (17 males, 19 females, mean age 77.1 ± 5.7 years) using a Citec hand-held dynamometer. Differences in muscle strength between the groups as well as intrarater and interrater reliability of two assessors were determined.
The reliability of the hand-held dynamometry procedure was excellent for both intrarater (ICC(3,1) = 0.78-0.94) and interrater (ICC(3,1) = 0.77-0.88) comparisons. There were significant differences between the muscle strength of the young and older participants for all muscle groups tested (p < 0.001) with older participants being weaker than the young participants by a magnitude of between 24 and 37%.
Hand-held dynamometry is a reliable instrument to measure the foot and ankle strength of young and older adults. Ageing is associated with a reduction in strength of between 24 and 37% for the muscles responsible for movement of the foot and ankle.
Limited ankle dorsiflexion, or equinus, is associated with elevated plantar pressures, which have been implicated in the development and non-healing of foot ulcer. A stretching intervention may ...increase ankle dorsiflexion and reduce plantar pressures in people with diabetes.
Two arm parallel randomised controlled trial from September 2016 to October 2017. Adults with diabetes and ankle equinus (≤5° dorsiflexion) were randomly allocated to receive an 8 week static calf stretching intervention or continue with their normal activities. Primary outcome measures were change in weight bearing and non-weight bearing ankle dorsiflexion and forefoot peak plantar pressure. Secondary outcome measures were forefoot pressure time integrals and adherence to the stretching intervention.
68 adults (mean (standard deviation) age and diabetes duration 67.4 (10.9) years and 14.0 (10.8) years, 64.7% male) were randomised to stretch (n = 34) or usual activity (n = 34). At follow up, no significant differences were seen between groups (adjusted mean difference) for non-weight (+1.3°, 95% CI:−0.3 to 2.9, p = 0.101) and weight bearing ankle dorsiflexion (+0.5°, 95% CI:−2.6 to 3.6, p = 0.743) or forefoot in-shoe (+1.5 kPa, 95% CI:−10.0 to 12.9, p = 0.803) or barefoot peak pressures (−19.1 kPa, 95% CI:−96.4 to 58.1, p = 0.628). Seven of the intervention group and two of the control group were lost to follow up.
Our data failed to show a statistically significant or clinically meaningful effect of static calf muscle stretching on ankle range of motion, or plantar pressures, in people with diabetes and ankle equinus.
•Ankle equinus is associated with increased plantar pressure in people with diabetes.•Adults with diabetes and ankle equinus undertook 8 weeks of static calf stretching.•No significant increase in ankle dorsiflexion was seen following the intervention.•Additionally no significant reduction in plantar pressures was noted.
Hallux valgus (HV) is a common condition involving the progressive subluxation of the first metatarsophalangeal joint due to lateral deviation of the hallux and medial deviation of the first ...metatarsal. The objective of this study was to evaluate the re-test reliability and validity of self-assessment of HV using a simple clinical screening tool involving four standardised photographs (the Manchester scale), in order to determine whether this tool could be used for postal surveys of the condition.
HV was assessed with the Manchester scale in 138 people aged 65 to 93 years of age (102 women and 36 men) as part of a larger randomised controlled trial. At the six month follow-up assessment, HV was reassessed to determine re-test reliability, and participants were asked to self-assess their degree of HV independent of the examiners. Associations between (i) baseline and follow-up assessments of the examiners and (ii) participant and examiner assessments were performed using weighted kappa statistics. Analyses were then repeated after HV was dichotomised as present or absent using unweighted kappa, and sensitivity and specificity of self-assessment of HV was determined.
Re-test reliability of the examiners was substantial to almost perfect (weighted kappa = 0.78 to 0.90), and there was a substantial level of agreement between observations of the participants and the examiners (weighted kappa = 0.71 to 0.80). Overall, there was a slight tendency for participants to rate their HV as less severe than the examiners. When the Manchester scale scores were dichotomised, agreement was substantial to almost perfect for both re-test comparisons (kappa = 0.80 to 0.89) and substantial for comparisons between participants and examiners (kappa = 0.64 to 0.76). The sensitivity and specificity of self-assessment of HV using the dichotomous scale were 85 and 88%, respectively.
The Manchester scale demonstrates high re-test reliability, and self-assessment scores obtained by participants are strongly associated with scores obtained by examiners. These findings indicate that the tool can be used with confidence in postal surveys to document the presence and severity of HV.
ACTRN12608000065392.
Background
Foot posture is considered to be an important component of musculoskeletal assessment in clinical practice and research. However, many measurement approaches are not suitable for routine ...use as they are time‐consuming or require specialised equipment and/or clinical expertise. The objective of this study was therefore to develop and evaluate a simple visual tool for foot posture assessment based on the Arch Index (AI) that could be used in clinical and research settings.
Methods
Fully weightbearing footprints from 602 people aged 62 to 96 years were obtained using a carbon paper imprint material, and cut‐off AI scores dividing participants into three categories (high, normal and low) were determined using the central limit theorem (i.e. normal = +/− 1 standard deviation from the mean). A visual tool was then created using representative examples for the boundaries of each category. Two examiners were then asked to use the tool to independently grade the footprints of 60 participants (20 for each of the three categories, randomly presented), and then repeat the process two weeks later. Inter‐ and intra‐tester reliability was determined using Spearman's rho, percentage agreement and weighted kappa statistics. The validity of the examiner's assessments was evaluated by comparing their categorisations to the actual AI score using Spearman's rho and analysis of variance (ANOVA), and to the actual AI category using percentage agreement, Spearman's rho and weighted kappa.
Results
Inter‐ and intra‐tester reliability of the examiners was almost perfect (percentage agreement = 93 to 97%; Spearman's rho = 0.91 to 0.95, and weighted kappas = 0.85 to 0.93). Examiner's scores were strongly correlated with actual AI values (Spearman's rho = 0.91 to 0.94 and significant differences between all categories with ANOVA; p < 0.001) and AI categories (percentage agreement = 95 to 98%; Spearman's rho = 0.89 to 0.94, and weighted kappas = 0.87 to 0.94). There was a slight tendency for examiners to categorise participants as having higher arches than their AI scores indicated.
Conclusions
Foot posture can be quickly and reliably categorised as high, normal or low in older people using a simplified visual categorisation tool based on the AI.
A weight bearing ankle equinus has adverse effects on forefoot plantar pressure variables in older adults with diabetes, but it is unclear if this is also the case in older adults without diabetes.
...40 older adults with diabetes (88% type 2, mean diabetes duration 17.6 ± 14.8 years) and 40 older adults without diabetes, matched for age (±3 years), sex and BMI (±2 BMI units) were included (63% female, mean age 72 ± 4 years, BMI 30 ± 4 kg/m2). Primary outcomes were prevalence of a weight bearing equinus and evaluation of barefoot forefoot plantar pressures in older adults with and without diabetes.
A weight bearing equinus was present in 37.5% and 27.5% of the diabetes and non-diabetes group respectively with no significant difference between groups (p = 0.470). People with diabetes and equinus displayed higher peak pressure (808 versus 540 kPa, p = 0.065) and significantly higher pressure-time integral (86 versus 68 kPa/s, p = 0.030) than people with diabetes and no equinus group. The non-diabetes equinus group had significantly higher peak pressure (665 versus 567 kPa, p = 0.035) than those with no diabetes and no equinus, but no difference in pressure-time integral.
A high prevalence of a weight bearing equinus was detected in older adults with and without diabetes, with associated increases in plantar pressures. As an equinus has been associated with many foot pathologies this study's findings suggest that clinicians should check for the presence of a weight bearing ankle equinus in all older adults.
•We matched older adults with and without diabetes.•A high prevalence of ankle equinus was detected with no difference between groups.•Equinus significantly increased plantar pressure in both groups.•Clinicians should screen for equinus in older adults regardless of diabetes status.
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