Apex Balance Shoe References

Footwear and Falls:

Inappropriate footwear has been identified as a contributor of up to 45% of falls. A recent study of people who had suffered a fall-related hip fracture reported that 75% were wearing poor footwear at the time of the injury

  • Gabell A, Simons MA, Nayak US: Falls in the elderly: predisposing causes. Ergonomics 1985;28:965–975.
  • Sherrington C, Menz HB: An evaluation of footwear worn at the time of fall-related hip fracture. Age Ageing 2003;32:310–314.

Poor Shoe Fit = Falls:

Poorly fitting shoes have been linked to falls:

  • Gabell A, Simons M, Nayak U: Falls in the healthy elderly: Pre-disposing causes. Ergonomics 1985, 28:965-975.
  • Frey C: Foot health and shoewear for women. Clin Orthop Relat Res 2000, 372:32-44.
  • Barbieri E: Patient falls are not patient accidents. J Gerontol Nurs 1983, 9:165-173.
  • Finlay A: Footwear management in the elderly care pro- gramme. Physiotherapy 1986, 72:172-178.

Neuropathy, Proprioception and Balance

Evidence demonstrates a strong relationship exists between foot sensation and standing balance performance.

Similarly, a loss of lower limb proprioception, including joint position sense at the ankles and feet, can detrimentally affect gait and standing balance, leading to greater dependence on compensatory motor mechanisms in order to remain upright

An increasing body of literature suggests footwear interventions may be another treatment option to help improve gait performance

Footwear and Seniors

Problems with shoe wear have long been recognized as an endemic issue among the geriatric population with a prevalence rate of nearly 80%.

  • Menz HB and Lord SR. The contribution of foot problems to mobility impairment and falls in community-dwelling older people. J Am Geriatr Soc. 2005; 49(12):1651-1656.
  • romp AM, Pluijm, SM F, Smit JH, et al. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly.  J Clin Epidemiol. 2001;54(8):837-844.

Foot Pathology and Balance

Individuals having foot pathology are often severely physically impaired, making it increasingly difficult to perform activities of daily living. Consequentially, this leads to physical inactivity, which is cited as one of the first signs of deterioration and the overall decrease in quality of life.

  • Warburton DER, Nicol CW, Bredin SSD. Health benefits and physical activity. CMAJ. 2006;174(6):801-809.

Chronic Disease and Falls

Individuals with diabetes, chronic disease, nondiabetic neuropathy, and inflammatory conditions are at a severe disadvantage.

Further complications of foot pathology, which include cellulitis, ulcerations, and difficulty in maintaining balance, have increased the risk of serious injuries and fractures from falls.

  • Warburton DER, Nicol CW, Bredin SSD. Health benefits and physical activity. CMAJ. 2006;174(6):801-809.
  • Win S, Parakh K, Eze-Nliam CM, Gottdiener JS, Kop WJ, Ziegel- stein RC. Depressive symptoms, physical inactivity and risk of cardiovascular mortality in older adults: the Cardiovascular Health Study. Heart. 2011;97(6):500-505.

Falls and Preventative Measures

Studies have shown that adults older than 65 years fall at least once per year on average, some of which are attributed to generalized thinning of skin and fat pad atrophy.

The increased risk of falls may highlight the need to promote preventative measures to combat this issue.

  • Menz HB, Lord SR, Tiebelman A. A physiological approach to falls risk assessment and prevention. J Am Phys Ther. 2003; 83(3):237-252.
  • Koepsell TD, Wolf ME, Buchner DM, et al. Footwear style and
    risk of falls in older adults. J Am Geriatr Soc. 2004;52(9): 1495-1501.

Preventative Measure: Wearing Appropriate Shoes

One of these measures may include wearing appropriate foot-wear.

  • Burns SL, Leese GP, McMurdo MET. Older people and ill fitting shoes. Postgrad Med J. 2002;78(920):344-346.
  • Menant JC, Seele JR, Menz HB, Munro BJ, Lord SR. Optimizing footwear for older people at risk of falls. J Rehabil Res Dev. 2008;45(8):1167-1182.

Footwear can Improve Balance

A prevailing hypothesis is that wearing the appropriate footwear will improve factors such as plantar pressure, thereby mitigating pathology while facilitating balance.

  • Win S, Parakh K, Eze-Nliam CM, Gottdiener JS, Kop WJ, Ziegel- stein RC. Depressive symptoms, physical inactivity and risk of cardiovascular mortality in older adults: the Cardiovascular Health Study. Heart. 2011;97(6):500-505.
  • Menz HB, Lord SR, Tiebelman A. A physiological approach to falls risk assessment and prevention. J Am Phys Ther. 2003; 83(3):237-252.
  • Hijmans JM, Geertzen JH, Dijkstra PU, Postema K. A systematic review of effects of shoes and other ankle or foot appliances on balance in older people with peripheral nervous system disorders. Gait Posture. 2007;25(2):316-323.

Barefoot Walking

Walking barefoot does not appear to provide a safe alternative for older people, as it has been found that walking barefoot or in socks also elevates fall risk.

  • Koepsell TD, Wolf ME, Buchner DM, Kukull WA, LaCroix AZ, Tencer AF, Frankenfeld CL, Tautvydas M, Larson EB: Footwear style and risk of falls in older adults. J Am Geriatr Soc 2004;52:1495–1501.
  •  Menz HB, Morris ME, Lord SR: Footwear characteristics and risk of indoor and out- door falls in older people. Gerontology 2006; 52:174–180.

Finlay, 1986

  • Finlay assessed the footwear of 274 patients attending a geriatric hospital and reported that only half were wearing ‘adequate’ footwear.
  • The most commonly observed inappropriate features were excessively flexible heel counters, high heels and narrow heels.
  • Finlay AE. Footwear management in the elderly care programme. Physiother 1986; 72: 172–8.

Dyer, 1998

50% of shoes worn had heel slippage and unsatisfactory heel counters were evident in 63% of all slippers. A similar investigation by Dyer et al.  found that 58% of 112 older people admitted to a falls clinic were wearing ‘unsatisfactory’ footwear.

  • Dyer CAE, Watkins CL, Gould C, Rowe J. Risk-factor assessment for falls: from a written checklist to the penless clinic. Age Ageing 1998; 27: 569–72.

Footwear and Balance

A number of recent studies have investigated the influence of various shoe features on balance ability in older people.

    1. High heels have been shown to impair balance when standing and responding to perturbation
      • Lord SR, Bashford G. Shoe characteristics and balance in older women. J Am Geriatr Soc 1996; 44: 429–33.
    2. Overly soft-soled shoes impair beam-walking performance.
      • Brecht JS, Chang MW, Price R, Lehmann J. Decreased balance performance in cowboy boots compared with tennis shoes. Arch Phys Med Rehabil 1995; 76: 940–6.
      • Robbins SE, Gouw GJ, McClaran J. Shoe sole thickness and hardness influence balance in older men. J Am Geriatr Soc 1992; 40: 1089–94.
    3. High heel counters have been shown to improve balance compared to standard, low-cut footwear.
      • Lord SR, Bashford G, Howland A, Munro B. Effect of shoe collar height and sole hardness on balance in older women. J Am Geriatr Soc 1999; 47: 1–4.
    4. Inadequate slip resistance of the outersole of the shoe is also thought to increase risk of slipping accidents
      • Menz HB, Lord SR, McIntosh AS. Slip resistance of casual footwear: implications for falls in older adults. Gerontology 2001; 47: 145–9.
    5. Textured insole
      • Menz HB, Lord SR. Footwear and postural stability in older people. J Am Podiatr Med Assoc 1999; 89: 346–57.

The Ideal Shoe

Based on this information, the ‘ideal’ safe shoe for older people is thought to consist of a low sturdy heel, high heel counter, a thin, firm midsole and a textured sole.

  • Menz HB, Lord SR. Footwear and postural stability in older people. J Am Podiatr Med Assoc 1999; 89: 346–57.

Falling and Footwear

The most common type of footwear worn at the time of the fall was slippers (22%), followed by walking shoes (17%) and sandals (8%). Few subjects were wearing high heels when they fell (2%). The majority of subjects (75%) wore shoes with at least one theoretically sub-optimal feature, such as absent fixation (63%), excessively flexible heel counters (43%) and excessively flexible soles (43%). Subjects who tripped were more likely to be wearing shoes with no fixation compared to those who reported other types of falls [x2=4.21, df=1, P=0.033; OR=2.93 (95%CI 1.03–8.38)].

  • Sherrington, Catherine, Menz, Hylton,  An evaluation of footwear worn at the time of fall-related hip fracture. Age and Ageing 2003; 32: 310–314The high prevalence of sub-optimal footwear features reported is consistent with previous studies which have found that older people primarily base their footwear choices on comfort rather than safety.
  • Sherrington, Catherine, Menz, Hylton,  An evaluation of footwear worn at the time of fall-related hip fracture. Age and Ageing 2003; 32: 310–314

Hourihan et al.

Reported that of 107 older people who were admitted to hospital following a fall-related hip fracture, 33% were wearing slippers and 68% wore shoes with flexible heel counters at the time of fracture.

  • Hourihan F, Cumming RG, Taverner-Smith KM, Davidson I. Footwear and hip fracture-related falls in older people. Aust J Ageing 2000; 19: 91–3.

Fixation

Shoes with inadequate fixation tend to promote a shuffling gait, and are more likely to become separated from the foot when walking.  It is therefore plausible that wearing shoes with inadequate fixation, such as soft slippers and other indoor slip-on shoes, may predispose to falls by impairing normal gait and acting as an extrinsic tripping hazard

Low Heeled and Lightweight

Low-heeled footwear is known to reduce the risk of falls, likely due to the associated lowering of the center of gravity.

Athletic and lightweight canvas shoes (sneakers) are associated with the lowest risk of a fall when compared to other types of shoes.10,12

Wide shoes are effective against bunions, and extra-depth shoes are more appropriate if the individual has hammertoes or mid- foot arthrosis.

Slip Resistance

As an extra preventative measure, better fitting footwear with slip-resistant soles is recommended both inside and outside the household to reduce the risk of falls.

  • Brecht JS, Chang MW, Price R, Lehmann J. Decreased balance performance in cowboy boots compared with tennis shoes. Arch Phys Med Rehabil. 1995;76(10):940-946.
  • Van der Zwaard BC,vander Horst HE, Knol DL,Vanwanseele B, Elders P.  Treatment of forefoot problems in older people: a randomized clinical trial comparing podiatric treatment with standardized shoe advice. Ann Fam Med. 2014;12(5):432-440.
  • Corrigan JP, Moore DP, Stephens MM. Effect of heel height on forefoot loading. Foot Ankle. 1993;14(3):148-152.

Summary

  • Taken together, the below three studies seem to support the use of footwear with:
    1. low heels
    2. slip-resistant soles
    3. wider frames to ensure comfort, better balance, and reduced risk of injury
    4. the combination of both extra-depth, wide, and low-heeled footwear to increase foot stability and facilitate balance.
  • Brecht JS, Chang MW, Price R, Lehmann J. Decreased balance performance in cowboy boots compared with tennis shoes. Arch Phys Med Rehabil. 1995;76(10):940-946.
  • Van der Zwaard BC,vander Horst HE, Knol DL,Vanwanseele B, Elders P. Treatment of forefoot problems in older people: a randomized clinical trial comparing podiatric treatment with standardized shoe advice.  Ann Fam Med. 2014;12(5):432-440.
  • Corrigan JP, Moore DP, Stephens MM. Effect of heel height on forefoot loading. Foot Ankle. 1993;14(3):148-152.

Shoefit

One study showed that elderly individuals rarely get ‘‘sized’’ for shoes that fit any more often than once in 5 years. Furthermore, retail stores often do not stock the customized shoes (ie, extra wide) needed for elderly customers, making availability an issue for elderly patients.

  • Soames RW, Evans AA. Female gait patterns: The influence of footwear. Ergonomics. 1987;30(6):893-900.
  • Speksnijder CM, Munckhof R, Moonen S, Walenkamp G. The higher the heel the higher the forefoot-pressure in ten healthy women. Foot. 2005;15(1):17-21.

The Cost of Poor Footwear

The increased expenses may cause elderly patients to abandon the recommendations completely.

The neglect of appropriate footwear in the elderly has been linked to early amputation, and in rare cases, early demise.

  • JessupRL.Footpathologyandinappropriatefootwearasriskfac- tors for falls in a subacute aged-care hospital. J Am Podiatr Med Assoc. 2007;97(3):213-217.
  • Sherrington C, Menz HB. An evaluation of footwear worn at the time of fall-related hip fracture. Age Ageing. 2003; 32(3): 310-314.

Footwear Contributes to Falls

Footwear has been implicated in the incidence or prevalence of some common foot pathologies.

These pathologies, in return, have contributed to the growing risk of even more serious injuries such as falls and fractures.

  • Menz HB and Lord SR. The contribution of foot problems to mobility impairment and falls in community-dwelling older peo- ple. J Am Geriatr Soc. 2005; 49(12):1651-1656.

Footwear and Quality of Life

Ultimately, the noticeable decrease in physical activity in the elderly patients has been linked to depression and an overall decline health and quality of life. Clinically, preventative measures such as appropriate footwear should be continually emphasized to stop or delay the progression of some foot problems.

  • Burns SL, Leese GP, McMurdo MET. Older people and ill fitting shoes. Postgrad Med J. 2002;78(920):344-346.

Choosing the Right Footwear is Cost Effective

While recommending appropriate footwear is a cost-effective approach when compared to other options, it is often hindered by socio- economic obstacles. Nevertheless, studies have shown that it can be a vital step to ensure prolonged musculoskeletal and overall health among the elderly patients.

Textured Insoles?

Textured shoe insoles, designed to enhance plantar sensory information, have been shown to consistently alter gait patterns in the short-term, potentially improving walking stability in a range of clinical populations, including older fallers, adults with Parkinson’s disease and Muscular Sclerosis

  • Hatton AL, Dixon J, Rome K, Newton JL, Martin DJ. Altering gait by way of stimulation of the plantar surface of the foot: the immediate effect of wearing textured insoles in older fallers. J Foot Ankle Res. 2012;5:11.
  • Jenkins ME, Almeida QJ, Spaulding SJ, van Oostveen RB, Holmes JD, Johnson AM, et al. Plantar cutaneous sensory stimulation improves single- limb support time and EMG activation patterns among individuals with Parkinson’s disease. Parkinsonism Relat Disord. 2009;15:697–702.
  • Dixon J, Hatton AL, Robinson J, Gamesby-Iyayi H, Hodgson D, Rome K, et al. Effect of textured insoles on balance and gait in people with multiple sclerosis: an exploratory trial. Physiotherapy. 2014;100:142–9.
  • Kelleher KJ, Spence WD, Solomonidis S, Apatsidis D. The effect of textured insoles on gait patterns of people with multiple sclerosis. Gait Posture. 2010; 32:67–71.

To date, exploratory studies indicate that textured insoles can lead to beneficial alterations in spatiotemporal gait parameters such as:

  1. Reduced mediolateral base of support
  2. Improved gait kinetics and kinematics in MS.
  3. Dixon J, Hatton AL, Robinson J, Gamesby-Iyayi H, Hodgson D, Rome K, et al. Effect of textured insoles on balance and gait in people with multiple sclerosis: an exploratory trial. Physiotherapy. 2014;100:142–9.
  4. Kelleher KJ, Spence WD, Solomonidis S, Apatsidis D. The effect of textured insoles on gait patterns of people with multiple sclerosis. Gait Posture. 2010; 32:67–71.

After wearing textured insoles for 2 weeks, significant increases have also been observed in stride and step length, and significant de- creases in the size of the ML base of support during level-ground walking (interpreted to represent a more confident gait pattern) . These changes were observed independent of wearing the textured insoles, again supporting the theory that a sensory training effect may have occurred during the intervention period

  • Dixon J, Hatton AL, Robinson J, Gamesby-Iyayi H, Hodgson D, Rome K, et al. Effect of textured insoles on balance and gait in people with multiple sclerosis: an exploratory trial. Physiotherapy. 2014;100:142–9.

Joanne Paton, Sam Glasser, Richard Collings, and Jon Marsden, Getting the right balance: insole design alters the static balance of people with diabetes and neuropathy
J Foot Ankle Res. 2016; 9: 40.

  • When the smooth topped low resilient memory insole with arch fill was covered with a textured material static balance improved by a statistically significant amount.
  • Textured Insoles have an effect on static balance.
  • This effect is independent of neuropathy severity.
  • The addition of a textured cover seems to counter the negative effect of an arch fill, even in participants with severe sensation loss.

Alluel E, Olivier I, Nougier V. The lasting effects of spike insoles on postural control in the elderly. Behav Neurosci. 2009;123(5):1141–7. doi: 10.1037/a0017115

  • When the smooth topped low resilient memory insole with arch fill was covered with a textured material,  static balance improved by a statistically significant amount.

Hatton AL, Dixon J, Rome K, Martin D. Standing on textured surfaces: effects on standing balance in healthy older adults. Age Ageing. 2011;40(3):363–8. doi: 10.1093/ageing/afr026.

  • Hatton and colleagues examined the effects of textured insoles in 50 older adults’ quiet standing with eyes closed and open.
  • They found that whilst textured pyramids (with the potential to cause focal points of skin stretch) reduced ML sway with eyes closed.

Annino G1, Palazzo F,  et al, Effects of long term stimulation of textured insoles on postural control in health elderly J Sports Med Phys Fitness. 2016 Sep 15.

  • The results confirm that postural stability improved in healthy elderly individuals, increasing somatosensory information's from feet plantar mechanoreceptors.
  • Long term stimulation with textured insoles decreased CoP,  Vnet and VM/L with eyes closed.

Enhanced Walking Capacity

  • Interventions that effectively preserve or enhance walking capacity are paramount to improving quality of life and maintaining independence.

Healthcare Professionals

  • Due to the relationship between footwear and pathology, health professionals have a responsibility to consider footwear characteristics in the etiology and treatment of various patient presentations.
  • In order for health professionals and researchers to accurately and efficiently critique an individual's footwear, thorough footwear assessment is required.
  • Christian J Barton, Daniel Bonanno and Hylton B Menz, Development and evaluation of a tool for the assessment of footwear characteristics,  Journal of Foot and Ankle Research 2009, 2:10

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