Could a New Clinical Prediction Model Help Podiatrists Prevent Falls?

Fall risk assessment and prevention are an important service that podiatrists can provide. A recent study published in Gerontology took a closer look at a model specifically developed in the Netherlands to evaluate its effectiveness in predicting falls in community-dwelling older adults with foot-related issues. The authors contend that existing fall risk tools have limitations in their predictive value and poor implementation.

Researchers evaluated 407 community-dwelling participants aged greater or equal to 65 years that visited podiatric practices over a 12-month follow-up period. They examined frequency of falls, along with general fall risk factors and those related to foot health and overall function. Subjects experienced a 33.4 percent rate of falls during the study period. The developed clinical prediction model included identifying a history of falls within the previous year, unsteadiness while standing and walking, reduced speed of walking and decreased lesser toe plantarflexion strength.

The authors concluded that their model based on those four metrics had acceptable predictive accuracy in their population sample. They additionally found it easily applicable in the podiatric practice setting, adding that external validation in a future study was in order.

Janet Simon, DPM says that “good” screenings in public health need to detect a condition at a stage when treatment can be more effective, rather than after the onset of the condition. She feels that fall risk is a prime example of this.

“To also be ‘good,’ the screening needs to accurately identify contributing and modifiable risk factors,” she adds. “Research demonstrates the roles that foot and ankle pathologies have on fall risks, mainly from Australian experts. But the translation of these smaller participant studies are not reproduced in larger sample sizes nor are they modifiable for easy real time clinical usage.”

The Stopping Elderly Accidents, Deaths and Injuries (STEADI) screening,¹ while including evaluation of feet/footwear as a category, does not have clear guidelines for completing this portion of the screening, says Dr. Simon. Thus this study fills in a large gap by providing an easily applicable clinical framework.

Rachel Albright, DPM, MPH explains that podiatrists, as a common care provider for those over 65, are essential players in the falls prevention algorithm. Yet, she adds that many don’t know exactly how to identify someone who is at risk for falls and additionally, mitigate those risks.

“It is clear that patients who present to clinic with obvious gait instability warrant a referral to physical therapy for gait/balance training, however, this study helps identify other, possibly not as obvious, risk factors that podiatrists can mitigate,” she says.

Pointing out that many of the risk factors noted in the study are well-known, both commenters didn’t find their identification surprising. Instead, they convey that this indicated how important podiatrists are to reducing poor outcomes. Dr. Simon was surprised, however, that this study felt that pharmaceuticals did not contribute to fall risk, given the importance of polypharmacy (especially psychoactive medications) in the STEADI protocols.¹

When considering important take-home messaging from this study, Dr. Simon feels that patients identified with one or more contributors to potential falls should receive further education about modifying these risk factors.

“For instance, providing exercise guidance for digital strength to patients is straightforward and appreciated since many of these patients are aware of these deficits and have not been advised of how to address them,” she explains.

Dr. Albright continues by saying that there are aspects of the physical exam that podiatrists routinely perform that can have a big impact on reducing falls. For instance, realizing that the four risk factors identified in this study are red flags could shift a visit from “routine” to lifesaving with no additional time spent.

“Including discussions about community exercise/balance programs and assistive devices such as canes, walking poles and walkers often reinforces what primary care providers and loved ones previously recommended,” says Dr. Simon, the Executive Director of the New Mexico Podiatric Medical Association. “The ‘nudge’ that many patients need to decrease their fall risk can often be from their DPM.”

Dr. Albright, a former Public Health Fellow of the American Podiatric Medical Association, wants podiatrists to know how integral they are in preventing falls and perform an assessment for all patients over the age of 65 annually. She adds that the STEADI algorithm also provides a quick, three-question screening assessment that may help.

“If a patient is deemed a fall risk, the physical exam should focus to identify ailments in gait/balance, sensory impairment, and decreased range-of-motion and then treated accordingly,” she says.

Might a Smart Offloading Boot System Have an Impact for DFUs?

A recent article in the Journal of Diabetes Science and Technology studied a smart offloading boot system to evaluate multiple factors surrounding the use of such a modality as a potential option for patients with diabetic foot ulcers (DFUs). The authors cite patient adherence to offloading as a challenge to wound healing, and tested a smart offloading boot (SmartBoot) with a cloud-based dashboard and smartwatch app. They additionally sought information on how this system impacted gait and balance, along with the overall user experience.

Researchers studied 14 volunteer individuals while performing activities like sitting, standing, and walking for 30-minute periods both with and without the smart offloading boot. Sixty-four percent of subjects were female and the average age was around 32 years. They evaluated balance tests, various paces of 10-meter walking tests and a questionnaire about user experience. Additionally, they conducted inquiry into real-time adherence reporting, center of mass sway and step counts.

The study found that most participants felt that the smart offloading boot system was easy to use, relatively comfortable to wear, and not intrusive. They reported regarding adherence versus non-adherence to the system with an average sensitivity, specificity and accuracy at 90.6, 88.0 and 89.3 percent, respectively. Step count error for slow, normal, and fast walking was 4.4, 36.2 and 16.0 percent, respectively. The study results also revealed that the center of mass sway, regardless of test condition, was significantly smaller with the smart boot offloading system than without.

The authors conclude that they feel this is the first smart offloading system with remote patient monitoring and activity and adherence reporting in real time. They feel that, likely due to somatosensory feedback, the system enhanced balance, and that the questionnaire points to the system’s clinical potential. They do acknowledge that more research is necessary to validate the real-time adherence alerting to possibly improve wound healing for those with DFUs.

Jason R. Hanft, DPM, FACFAS shares that he feels the greatest challenge that clinicians face in the offloading space is adherence and that adding a “smart” sensor to offloading devices is the beginning of a paradigm shift within that space.

“For decades, we have demanded adherence with casts and non-removable devices,” he says. “These devices, although excellent at offloading, face significant resistance from patients and lack of utilization by professionals.”

He goes on to say that a modern offloading device is aesthetically appealing to patients, easy to use, and should have advanced force-reducing technology. Adding a “smart” system engages the patient in their care, improves utilization and increases overall adherence, adds Dr. Hanft, the Founder and CEO of Defender.

“To have a successful outcome, all members of the care team must be on the same page, including the patient,” he says. “The ‘smart’ devices provide the conduit to connect the patient to the medical team, thereby working cooperatively with the patient rather than attempting to force adherence on the patient, as was done in the past.”

Dr. Hanft shares that he feels that smart systems and remote monitoring, as studied in this paper, could indeed have a positive effect on clinical outcomes and medical treatments.

1. Centers for Disease Control and Prevention. STEADI – Older Adult Fall Prevention. Available at: https://www.cdc.gov/steadi/index.html . Accessed February 4, 2022.