All Podiatrists have patients who are at risk of falling. Diabetic patients are at a higher risk than the general population due to the gradual onset of peripheral neuropathy, wound management and/or deconditioning. The risk becomes exponentially higher when the patient is both elderly and diabetic. The purpose of this article and presentation is to talk about the role of early detection as well as how to improve postural stability with 3D printed custom insoles and footwear.

Healthcare professionals working with the elderly and diabetic population acknowledge the high risk of these patients falling. However, no single group has taken a position of leadership. Podiatry is perfectly positioned to lead this area of medicine because they are seeing these patients for other problems and have the tools to mitigate risk once it is identified.

The number of people at risk of falling related to age and/or diabetes is extremely large. In 2000, within New York State alone, there were 10,300 fatal falls reported in the elderly.

• If they were over 65, and had diabetes, the chance of falling was 39%. 
• If they were over 55, the chance of falling was 35%. 

The New York Department of Health reported that not only are New Yorkers falling, they are being hospitalized and dying from the falls or from complications related to the falls. The societal cost of the morbidity, mortality, and lost quality of life is staggering, because these falls are often preventable.

The New York State Podiatric Medical Association hired a consulting group as part of a larger effort to examine the use of healthcare dollars within their state, the health of the population, and areas for improvement. The group published a paper that recommended three areas where Podiatry can take leadership, one of which is fall risk.

In fact, the authors of the paper stated that if patients at risk of falling received podiatric intervention, the rate of falls would be reduced by 36%. This statistic should make fall risk assessment and management a priority in every podiatric office.

One of the criteria for performing a fall risk assessment is history of a fall, which means that the risk is already elevated before any action has been taken to protect the patient. The goal should be early detection, to identify and help these people before they fall in the first place. A fall risk assessment should be a simple, mandatory add-on when these patients are seeing the Podiatrist or their staff for foot care, foot pain or wound care. Therefore, devising a comprehensive, time-effective, easy-to-perform fall risk assessment is mandatory in order to effectively integrate a fall prevention program into a busy clinical practice.

I would like to emphasize the importance of integrating a fall risk assessment into wound care clinics, which should be performed when a wound heals, the patient can wear shoes, and is ready for discharge. The importance of placing these patients in properly fitting shoes and getting them active can’t be overstated as part of a wholistic plan to prevent wound recurrence.

A Fall Risk Assessment needs to consider many factors including, but not limited to, medication review, environment hazard assessment, visual, and vestibular health. This article is focused on the somatosensory contribution during static and dynamic balance, as researchers are finding its role more important than visual or vestibular input.

The elderly and the diabetic populations are at a higher fall risk than the general population due to the gradual physiological changes that decrease the sensitivity on the plantar surface of the foot. Decreased sensation impacts the somatosensory feedback loop and the patients’ ability to maintain postural stability. These changes are so gradual that the patient, and their Podiatrist may not be aware of the effect it is having on postural stability.

Another factor correlated to fall risk is foot pain, which can arise from many aetiologies in elderly and diabetic patients. A study conducted in Australia found that within community dwelling older people, 20 to 54 percent of the residents, with foot pain were at risk to fall. They also found a statistically significant difference between the people with and without foot pain. As a Podiatrist, consider the number of elderly and/or diabetic patients you see with foot pain and how many of those are at risk of falling but have no mitigation plan.

Since each of these factors increases fall risk, implementing an early detection protocol is essential in every podiatric clinic and the next step is to select one or more tests to perform.

When determining which tools to use in your clinic, consider these points:

• Is the test valid? 
• Does it test static or dynamic stability, or both? 
• How objective or subjective is the test? 
• How much of the test is self-reporting? 
• Has the reliability been tested? 
• Does it have clinically relevant thresholds? 
• Does it require a lot of training? 
• Does it require a lot of equipment? 
• Does it require a lot of space? 
• Is the test/equipment affordable? 
• Is the outcome something that you can share with other professionals? 

In addition to commonly used tests like the TUG test and the Berg Balance Scale, postural sway performed on a pressure plate has many additional benefits:

• Takes a small amount of space 
• Cost effective 
• Data-driven graphics impress the patient, provide feedback, and motivation to comply with recommendations 
• Extremely sensitive to change 
• Each patient is their own baseline 
• Objective data with no subjectivity 
• Easy to execute, little training required 

These patients are often in denial, and non-compliant. To avoid a loss of independence, they may not be accurate on self-reporting tools. Therefore, you may consider not using a self-reporting tool on its own.

Once a patient has been identified as having some degree of fall risk, there are many mitigation tools available to a Podiatrist, including the introduction of custom insoles and custom footwear.

• 3D printed custom insoles are currently available to Podiatrists, validated by many research papers as an essential part of a postural stability/fall risk program for the elderly and diabetic. 
• Customized footwear prescribed through a Podiatrist, using multi-section injection technology, is coming in the next 12 months. These shoes will address foot deformities and pain while allowing patients to look stylish. The goal is to provide properly fitting custom shoes that everyday people can access through a Podiatrist. Your patient will have a size MARY, instead of ill-fitting size 10. 

Properly fitting shoes are a key component to postural stability, avoiding lesions/wounds, and a return to activity for leg and core strength. Historically, this population has a very difficult time finding footwear that fits due to structural deformities like claw toes, hallux valgus, arthritis or fibrotic tissue. Even if a custom-made shoe were available to these patients, compliance becomes an issue because the shoes are generally not attractive, emphasizing that they have a condition that they are in denial about.

The elderly and diabetic population have specific and immediate needs to maintain an active lifestyle. Early detection of fall risk, and effective tools to improve postural stability, can mitigate morbidity and mortality rates, improve quality of life and save millions of healthcare dollars.

Regards,

Lori Yarrow, BPE, DC, PMP

Chief Customer Officer, Go 4-D