Podiatry based interventions to prevents falls in the elderly

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It looks pretty certain that the intrinsic foot muscles play an important role in static and dynamic balance and we also know that these muscles are weak in the average individual and even weaker in older people.

But does strengthening these muscles help to prevent falls? Well, we don't really know. Some large scale trials have been carried out to see if podiatry based interventions can help to prevent falls, but the results were not encouraging . However, the foot exercises used in these large scale trials would do little if anything to strengthen the intrinsic since the only "toe exercises" used where grabbing/curling activities.

Recent research has shown that if you want to target the intrinsics then you need to create torque around the MTPJs whist the joints between the bones of the toes remain straight. This has previously been demonstrated for the abductor hallucis and now very recently for the flexor digitorum brevis, and likely applies to all the plantar intrinsics other than the quadratus plantae, a curling muscle.

So where does that leave us in terms of exercises to strengthen the intrinsic foot muscles.

Calf raises -no ,shown to be ineffective.
Toe curls - no an extrinsic foot muscle exercise ( towel curls ,marble pickups).
Strict short foot exercise - no, if the toes are not being pressed down then the plantar intrinsics are not firing.
Doming exercise or less strict short foot exercise where the toes press down - will activate the intrinsics but low dosage
Functional exercises -this is where we started ,targeted exercises is required.
Banded toe flexion - will work to a degree . Karen Mickle used this exercise to strengthen the toe flexors of older people and was successful. I remember heaping praise on her a bit but I did this because she got it right when practically everyone else was getting it wrong.
Novabow toe press - In my opinion, a game changing exercise option that is planned to be launched later this month (my company holds patents in a number of countries). It allows the toe press action that targets the intrinsics in particular and resistance levels are easy to control. Also, people report enjoying using the device.

 

The first paper that I am aware of, concerning any patient group, that shows foot strengthening reduces falls. As the first paper to show that a podiatry/foot strengthening based intervention can significantly reduce falls in a patient group, this has to make it big news.

With regard to knee replacements, apparently the procedure can lead to falls in the elderly . A paper has just been published demonstrating that foot strengthening ( they measured it as toe grip strength ) can reduce falls and improve walking up to 1 year post op .
Below is a quote from the paper and a link .

"Toe grip training was useful in improving walking ability and preventing falls in postoperative TKA patients. The advantage of TGS training is that it is an unoperated muscle function, so the intervention can be conducted safely without specialist supervision unless the toes are impaired. "

Abstract

Falls after total knee arthroplasty (TKA) are common in knee osteoarthritis patients due to advanced age and implant-induced sensory function changes. We reported the influence of toe grip strength (TGS) on falls in knee osteoarthritis patients. This study aimed to determine whether TGS training after TKA is related to the screening assessment and incidence of falls. Elderly patients undergoing unilateral TKA were divided into TGS training (T-group) and control groups (C-group). Six types of training were conducted on bilateral toes. The primary outcomes were changes (Δ) in TGS and Timed up and go test (TUG) time from preintervention to 12 weeks post-intervention. Secondary outcomes involved several factors, including the occurrence of falls. T-group had a shorter TUG and stronger bilateral TGS than C-group. ΔTUG time was significantly correlated with ΔTGS on the affected side. There were significantly fewer falls in T-group than in C-group between 3 and 12 months after TKA. TGS training was useful in improving walking ability and preventing falls in postoperative TKA patients. The advantage of TGS training is that it is an unoperated muscle function, so the intervention can be conducted safely without specialist supervision unless the toes are impaired.

Toe grip strength training improves gait performance and prevents falls in patients after total knee arthroplasty

• January 2024

DOI:10.21203/rs.3.rs-3862787/v1

 

In my clinical years of practice, the number 1 case of balance issues in the older population was gravity drive pronation. Balance and frequency of falls dramatically decreased when abnormal pronation was attenuated.

 

"Balance and frequency of falls dramatically decreased when abnormal pronation was attenuated. " Do you mean via your insoles? Any evidence ?

 

As I said, in my clinical experience which has spanned over 50 years.

The insole/orthotic intervention depends on the etiology of the gravity drive pronation. If it is due to either the PreClinical Clubfoot deformity or Rothbarts foot, I use the specific insoles I designed to stabilize those structural abnormalities.

 

Morton's extension can help with pain from adult acquired flat foot. You yourself have said that a Morton's extension does the same job as your insoles but does not require a clinician make a distinction between the subcategories you conjured.

I am not aware of any studies on Morton's extensions that says they help prevent falls. No evidence from you either re your insoles , Brian.

 

Morton's foot is another foot deformation, not to be confused with Rothbarts foot, is treated using an extension pad. I have had little clinical experience using extension pads to comment on its' efficacious in preventing falls in the elderly population.

Using an extension pad, which is a two dimensional insole, to treat Rothbarts foot, which is a three dimensional deformation, will lead to disappointing results.

It appears you are confusing these two distinct foot aberrations as being the same structure. They are not. For a quick description as to the difference between Morton's foot and Rothbarts foot, I suggest you read the attached paper:

 

Adult acquired flat foot (ACFF) is a objective symptom not a diagnosis. One of the most common causes is the PreClinical Clubfoot Deformity. But ACFF also be a result trauma, infection, acquired tarsal coalition, just to name a few.

In fact, any foot structure that forces the foot into severe gravity drive pronation, visibly collapses the inner medial longitudinal arch (e.g., acquired flat foot).

Using a Morton's extension pad to treat the pain resulting from any of these etiologies, just simply makes no sense.

 

"I have frequently written about this link between talar torsion and the PreClinical Clubfoot Deformity (In Europe termed Progressive Collapsing Foot Deformity)"BR

 

The PreClinical Clubfoot Deformity etiology has been described in several of my previous publications, all available on Researchgate. Clinically, a collapsing ILA is one of its' objective signs.

The term Progressive Collapsing Foot Deformity is used in the European community to describe a foot whose ILA is collapsing.

 

"PreClinical Clubfoot Deformity (In Europe termed Progressive Collapsing Foot Deformity)" Brian Rothbart.

 

"Romero et al (2023), using a 3mm shim underneath the 1st metatarsal head (see attached photo) decreases (in Newtons) pronation and increases supination (in Newtons).

Their findings are almost identical to my research findings using Proprioceptive Insoles to treat RFS and PCFD." Brian Rothbart


Brian A. Rothbart, Feb 28, 2023Report
#1Reply

 

I have attached a photo of the Proprioceptive Insole I designed to treat Rothbarts Foot. Comparing the two insoles, you can see the similarities and differences.

• Romero et al used an insole that applied vertical lift directly underneath the 1st metatarsal. My generic insoles place a vertical lift underneath the hallux to the base of the 1st metatarsal (3.5, 6, or 9mm).

 

Sure but the result is the same, according to you . Actually, your insoles are worse if they require your foot typing.

 

Understood, but disagree.