Description
Age and Ageing 2019; 48: 327?336
? The Author(s) 2019. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi: 10.1093/ageing/afy189
This is an Open Access article distributed under the terms of the Creative Commons Attribution NonPublished electronically 7 January 2019 Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial
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SYSTEMATIC REVIEWS
Podiatry interventions to prevent falls in older
people: a systematic review and meta-analysis
1
School of Nursing and Health Sciences, Section of Ageing and Health, and NHS Tayside Allied Health Professions Directoriate,
University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, UK
2
Nursing Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, Pathfoot, FK9 4LA, UK
3
Nursing Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Cowcaddens Road, Glasgow,
G4 OBA, UK
4
School of Health and Social Care, Edinburgh Napier University, 9 Sighthill Court, Edinburgh, EH11 4BN, UK
5
Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road,
Derby, DE22 3DT, UK
6
Musculoskeletal Reseach Centre, School of Physiotherapy, La Trobe University, Bundoora, Victoria 3086, Australia
7
Institute of Applied Health Research, School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road,
Glasgow, G4 0BA, UK
8
Division of Population and Behavioural Science, Department of Medicine, University of St Andrews, St Andrews, KY16 9TF, UK
9
Section of Ageing and Health, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
10
School of Nursing and Health Sciences, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, UK
Address correspondence to: Gavin Wylie. Tel: +44(0) 1382 388543; Email: [email protected]
Abstract
Background: foot problems are independent risk factors for falls in older people. Podiatrists diagnose and treat a wide
range of problems affecting the feet, ankles and lower limbs. However, the effectiveness of podiatry interventions to prevent
falls in older people is unknown. This systematic review examined podiatry interventions for falls prevention delivered in
the community and in care homes.
Methods: systematic review and meta-analysis. We searched multiple electronic databases with no language restrictions.
Randomised or quasi-randomised-controlled trials documenting podiatry interventions in older people (aged 60+) were
included. Two reviewers independently applied selection criteria and assessed methodological quality using the Cochrane
Risk of Bias tool. TiDieR guidelines guided data extraction and where suitable statistical summary data were available, we
combined the selected outcome data in pooled meta-analyses.
Results: from 35,857 titles and 5,201 screened abstracts, nine studies involving 6,502 participants (range 40?3,727) met the
inclusion criteria. Interventions were single component podiatry (two studies), multifaceted podiatry (three studies), or multifactorial involving other components and referral to podiatry component (four studies). Seven studies were conducted in
the community and two in care homes. Quality assessment showed overall low risk for selection bias, but unclear or high
risk of detection bias in 4/9 studies. Combining falls rate data showed signi?cant effects for multifaceted podiatry interventions compared to usual care (falls rate ratio 0.77 [95% CI 0.61, 0.99]); and multifactorial interventions including podiatry
(falls rate ratio: 0.73 [95% CI 0.54, 0.98]). Single component podiatry interventions demonstrated no signi?cant effects on
falls rate.
Conclusions: multifaceted podiatry interventions and multifactorial interventions involving referral to podiatry produce signi?cant reductions in falls rate. The effect of multi-component podiatry interventions and of podiatry within multifactorial
interventions in care homes is unknown and requires further trial data.
PROSPERO registration number: CRD42017068300.
327
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GAVIN WYLIE1, CLAIRE TORRENS2, PAULINE CAMPBELL3, HELEN FROST4, ADAM LEE GORDON5,
HYLTON B. MENZ6, DAWN A. SKELTON7, FRANK SULLIVAN8, MILES D. WITHAM9, JACQUI MORRIS10
G. Wylie et al.
Keywords
falls, podiatry, care homes, community dwelling, older people, systematic review
Key points
?
?
?
?
Podiatry interventions reduce falls in older people who live in their own homes.
Evidence is less clear for older people living in care homes.
Referral to podiatry services provides reductions in falls.
There is a strong case for trials of podiatry interventions to reduce falls in care homes.
Falls are common among older people in both community
and care home settings, leading to injury, fear, hospitalisation, loss of function and death [1, 2]. Annually, falls cost
the National Health Service (NHS) in the UK more than
?2 billion and in the USA, this ?gure is as high as $100 billion [3, 4]. To date, preventative interventions have typically
included strengthening and balance exercises, medication
review, physiotherapy, occupational therapy, and detecting
and treating visual impairment [5].
More recently, foot problems in older people [6, 7] have
been shown to be associated with falls [8, 9]. Foot-related
risk factors include foot pain, reduced ankle joint range of
motion, hallux valgus deformity (bunion), and reduced toe
plantar ?exor muscle strength, while footwear-related risk
factors include increased heel height, the absence of a strap,
lace or other retaining medium and reduced sole contact
area [8?11]. These factors have led to the development of
podiatry interventions to reduce falls [12, 13]. Podiatrists
improve mobility for patients by providing assessment, diagnosis and treatment of common and complex lower-limb
pathology using a wide range of treatment modalities (manual debridement, surgical techniques, exercises, footwear and
orthoses provision) [14].
Previous systematic reviews have shown encouraging
effects of foot and ankle exercises alone on balance and
falls. Furthermore, footwear and orthoses interventions
have been shown to have a bene?cial effect on balance only
in community-dwelling older people [15, 16]. A systematic
evaluation of multifaceted podiatry intervention packages
(callus debridement, exercise, footwear, orthoses) on falls or
falls rate has not been undertaken.
Older people living in care homes are around three times
more likely to fall compared with those living in the community, therefore understanding effective ways to reduce falls in
care homes is important [17]. Evidence for reducing care
home falls remains equivocal [18] and other than footwear
assessment, the effects of podiatry interventions on falls have
not been evaluated in this setting.
328
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Introduction
The aim of this systematic review is to determine the
effectiveness of podiatry interventions for falls reduction
in older adults residing in the community and in care
homes.
Methods
The review was conducted according to the Cochrane Handbook
for Systematic Reviews (v 5.10) [19] and reported using
PRISMA statement guidance [20]. Methods with an explicit
PICOS (Population, Intervention, Comparison, Outcome,
Study-type) statement were pre-speci?ed and documented
in a protocol registered with PROSPERO, registration
number CRD42017068300 [21].
Search strategy and selection criteria
Ten electronic databases (Medline, AMED, PeDRO, CINAHL,
Embase, Cochrane Central Register of Controlled Trials, CDSR,
DARE, HTA and ZETOC) were searched for randomisedcontrolled trials (RCTs) and quasi-RCTs published between
inception and 18 July 2018.
No date or language restrictions were employed. An
example search string is shown Appendix 1. Clinical trial
registries (e.g. WHO ICTRP), grey literature (Google scholar, EThOS), podiatry-speci?c journals and reference lists
of included studies were also searched. Forward citation
tracking using Google Scholar was also employed to identify other potential studies.
RCTs or quasi-RCTs conducted with ambulatory adults
(=60 years), living in the community or in care home settings of any type were included. Interventions had to be
delivered by podiatrists or staff trained in delivering podiatry interventions (for example, footwear provision, foot
orthoses, toe exercises) to reduce pain, improve balance or
preserve or improve foot health. Internationally, podiatry
encompasses a wide range of techniques that could potentially be delivered by non-podiatrists so we were inclusive in
our de?nition of podiatry-delivered interventions to include
podiatry referral, footwear provision and orthosis provision.
Foot and ankle exercises were included only in the context
of a podiatry intervention, not as a primary falls prevention
intervention [22].
Podiatry interventions to prevent falls in older people: a systematic review and meta-analysis
Data collection and extraction
One reviewer (P.C.) examined searches and eliminated
irrelevant titles. Two reviewers (C.T. and G.W.) independently screened remaining abstracts and full texts that met
selection criteria. Disagreements were resolved through discussion, and a third reviewer (P.C. or H.F.) if required. Data
was extracted to a standardised, pre-piloted form based on
TIDieR reporting guidelines [23]. One reviewer extracted
data (C.T.), another independently checked all data extraction (P.C. and G.W.). Missing information was requested
from study authors.
Risk of bias was independently assessed by two reviewers (P.
C. and C.T.). Studies were judged as either as ?low risk?,
?unclear? or ?high risk? according to the Cochrane Handbook
for Systematic Reviews of Interventions [19]. We considered
the methodological quality for each study on the basis of the
following categories: selection bias, performance bias, detection bias, potential for attrition bias, potential for reporting
bias and other potential bias [24]. Disagreements were resolved
by discussion, with involvement of a third review author where
necessary.
Statistical analysis
Where suitable statistical summary data were available, we
combined selected outcome data in pooled meta-analyses
using the Cochrane statistical package RevMan [25]. Rate
ratios and 95% con?dence intervals were used to examine
falls rate. We assessed heterogeneity using the I2 statistic
with a value of greater than 50% indicating substantial heterogeneity. Where we observed substantial heterogeneity,
we used a random-effects model to pool the data and investigated the source of the heterogeneity. Where the value of
the I2 statistic was less than 50% the data were pooled using
a ?xed-effect model.
Results
Our systematic search identi?ed 35,857 records, of which
35,838 were excluded. Reasons for exclusion were due to the
study design not meeting the selection criteria or the intervention was not a podiatry intervention. A list of excluded
studies can be found in Appendix 7. Nine studies (18
reports) were eligible for inclusion [12, 13, 26?32]. Two studies had insuf?cient detail to include in analyses and further
details have been sought from the authors (see Appendix 8).
Results of the study ?ow are displayed in Figure 1.
Participants
The number of randomised participants (n = 6,502) ranged
from 40 to 3,727 in each trial. The age of participants ranged between 69 and 87 years. Both sexes participated in
each trial, the percentage of women (65.2%) taking part in
the trials was higher than men. Six studies were conducted
with people who had fallen or were at risk of falls, and
three were conducted with participants who had existing
health conditions such as peripheral sensory loss [26] and
foot pain [13, 32] (Table 1).
Interventions
Three types of intervention were identi?ed based on the
falls taxonomy developed by Lamb et al. [33]:
(i) Single component podiatry interventions (two studies,
167 participants) [26, 32], using insoles [26] or off-theshelf footwear in addition to routine podiatry care [32].
(ii) Multifaceted podiatry interventions (three studies,
1,358 participants) [12, 13, 31]. A package of podiatry
interventions was given to every participant and
included routine podiatry, the provision of advice and
information, footwear and/or orthoses if required and
home-based foot and ankle exercises.
(iii) Multifactorial interventions (four studies, 4,984 participants) [27?30]. These were assessment and referral
based and carried out by a multi-disciplinary team
(MDT), all included a podiatry risk assessment and
referral to podiatry. It is unclear if referral led to podiatry treatment or not.
Intervention details pro?led using the TiDieR guidelines
[23] are summarised in Appendix 3.
Of the nine studies, eight compared an ?active? intervention with usual care [12, 13, 27?32], and one with a sham
insole [26]. The interventions were typically delivered by a
podiatrist. In four trials, a podiatrist facilitated the intervention as part of a wider MDT delivering the intervention
(Appendix 3). There was limited information about intervention content, dose or frequency. The length of the intervention period ranged from 12 weeks [26, 30, 31] to 104
weeks [28] (Table 1). Assessment of intervention ?delity
regarding referral, participant attendance at podiatry and
adoption of recommendations was conducted in four studies [12, 13, 27, 28].
Included studies
Studies employed a number of different designs including:
quasi-experimental (two studies), RCT (six studies) and
cluster-RCT (one study). Table 1 summarises the key characteristics of the included studies. Additional details are
Study quality and risk of bias
Risk of bias is summarised for individual trials in Figure 2 and
Appendix 4. The majority of included studies had balanced
groups at baseline. Allocation concealment and methods
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Assessing methodological quality of included studies
available in Appendix 2. Studies were conducted in
Australia, the USA, Canada, Spain, the UK and Ireland
(Table 1). Seven trials were conducted in the community
and in participants? homes [12, 13, 26?29, 32]; two trials
took place in care homes [30, 31].
Identification
G. Wylie et al.
Records identified through database
searching
(n = 34800)
Additional records identified
through other sources
(n = 1057)
Abstracts screened
(n = 5201)
Full-text articles assessed
for eligibility
(n = 303)
Included
Studies included in
narrative synthesis
(n = 9, reported across 18
publications)
Records excluded
(n = 4898)
Full-text articles excluded (n = 281)
Studies awaiting assessment (n = 2,
reported across 4 publications)
(see Suppl Table 7)
Reasons for exclusion: study design
did not meet criteria; no podiatry
component in the intervention; no
falls outcome data reported;
intervention not delivered in
community/care home setting;
population outwith age range (see
Suppl Table 8 for complete list of
studies)
Studies included in
quantitative synthesis
(meta-analysis)
(n = 7)
Figure 1. PRISMA ?ow chart.
of randomisation sequence generation were adequately
reported 7/9 studies. Only ?ve studies reported blinding of
outcome assessors [13, 27, 29?31]. Due to the nature of the
intervention, blinding was not possible in 6/10 studies [12,
13, 28, 29, 31, 32].
Studies reported a low level of withdrawals. Overall,
~89% of participants were retained over the follow-up period, which was similar in both intervention and control
groups. One study did not report the number of withdrawals [28].
Synthesis of results and effectiveness for podiatry
interventions
The included trials used a large number of heterogeneous
validated and non-validated outcome measures and were
recorded at multiple time points during and after the intervention period (Appendix 2).
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Eligibility
Screening
Records after duplicates (n = 10008) removed
(n = 25849)
multiple fallers. This diversity of assessment methods made
comparison across the studies challenging. Two trials
reported lateral balance [26] and foot pain [32] as the primary outcome with falls as a secondary or exploratory outcome. However, it was possible to calculate rate ratios for
falls across multiple component podiatry interventions
(three studies), multifactorial multi-disciplinary interventions
(three studies) and for one single component podiatry intervention. Findings are reported below with the forest plot in
Figure 3. Falls rates for individual studies and absolute differences are reported separately in Appendix 5.
Single component podiatry interventions
Falls rate data were available only for one trial (n = 121 participants) for a single component podiatry intervention [32],
and showed no signi?cant effect on falls rate (RaR 1.58
[95% CI 0.69, 3.60]) (Figure 3) (Appendix 5).
Primary outcome: falls rate
Falls rate, that is, number of falls over a de?ned period, was
the primary outcome in seven studies (Table 1) [12, 13, 27?
31]. Self-report methods using monthly falls calendars or
diaries were used to report on falls rate, number of falls,
time to ?rst fall, proportion of fallers and proportion of
330
Multifaceted podiatry interventions
Pooling data from the three multifaceted podiatry interventions [12, 13, 31], (n = 1,339 participants) demonstrated a
signi?cant bene?t for falls rate (RaR 0.77 [95% CI 0.61,
0.99]). The absolute difference in falls rate ranged from
Podiatry interventions to prevent falls in older people: a systematic review and meta-analysis
Table 1. Summary of key characteristics of included studies
Study
1. First
author
2. Year
3. Study
design
4. Country
Participants and setting
? Study population (N)
? Total number
? Age (x(SD), years)
? Gender (F/M)
? Falls risk at study
entry
Intervention (I)a
1. Name of intervention
2. Regimen
3. Duration of intervention
Comparison (C)
Primary outcomesb
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Podiatry treatment only
Foot Pain and Function (Foot Health
Status?Pain Questionnaire)
Conventional insole
Lateral stability (gait perubation
protocol)
Routine podiatry care
incl. treatment of
pathological nails and
skin lesions
Falls Rate (Falls Calendar)
Routine podiatry care
incl. treatment of
pathological nails and
skin lesions
Proportion of fallers/ Multiple fallers;
Falls rate; Time to ?rst fall (Falls
Calendar)
Routine podiatry care
incl. treatment of
pathological nails and
skin lesions
No. of falls; Time to ?rst fall
(Accident Records); Feasibility
(Recruitment, retention, adherence
and missing data)
None
Falls Rate/Recurrent Falls Rate (Falls
Calendar)
In-home assessment
Falls Rate (Falls diary/calendar)
Continued
331
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SINGLE COMPONENT PODIATRY INTERVENTIONS
? Menz [32] ? Community dwelling
1. Podiatry treatment plus off-the-shelf extra depth
? 2015
(ambulatory older
footwear
? RCT
adults with disabling
2. NR
? Australia
foot pain)
3. 16 weeks
? 120
? Whole group: 82 (8)
? 48/72
? NR
? Balance enhancing facilitatory insole
? Perry [26] ? Community dwelling
(older adults,
? NR
? 2008
moderate loss foot
? 12 weeks
? QuasiRCT
sole sensation)
? Canada
? 40
? I: 69 (3.6); C: 69 (3.1)
? 19/21
? NR
MULTIFACETED PODIATRY INTERVENTIONS
? Cockayne ? Community dwelling
? ?Multifaceted Podiatry intervention?
[12]
? 2 podiatry appointments; Foot and ankle exercise
(aged >65+)
30 min/day, three x/week
? 1,010 (996 analysis)
? 2014
? 12 months
? I: 78.1 (7.2); C:77.7
? RCT
(7.0)
? The UK;
? 610/400
Ireland
? =1 fall in previous 12
months: 657 (65%)
? Spink [13] ? Community dwelling
? Routine podiatry plus multifaceted podiatry
? 2008
(older adults with
intervention
? RCT
disabling foot-pain)
? Home-based exercise Programme: 30 minutes 3x per
? Australia ? 305
week
? Whole group: 73.9
? 6 months
(5.9)
? 211/94
? =2 falls in previous 12
months: I: 48; C: 45
? Multifaceted podiatry intervention
? Wylie [31] ? Care home residents
? 2017
? 43
? Ankle exercises: 30 repetitions 3x per week; toe
? RCT
? I: 86.9 (6.2); C: 85.9
exercise: 20 repetitions each foot 3x per week
? The UK
(7.8)
? 3 months
? 35/8
? NR
MULTIFACTORIAL INTERVENTIONS
? Dyer [30] ? Residential care (aged ? ?Multifactorial Risk Factor Modi?cation Programme?
60 years+)
? 2004
? Group exercise 40 min, 3x/week for 12?14 weeks.
? Cluster
? 196 (20 Residential
Individual home visits and/ or assessments within
RCT
homes)
12?14 weeks: Optician assessment; Podiatry
? The UK ? I: 87.2 (SD: 6.9); C:
assessment (foot condition a concern at baseline
87.4 (SD: 6.9)
assessment); one OT visit.
? 153/43
? 3 months
? Tinetti gait and
balance score: I: 15.43
(SD: 6.8); C: 16 (SD:
6.9)
? Intermediate-intensity, individual multifactorial
? Mahoney ? Community dwelling
(older adults)
intervention
[29]
? 2007
? 349
G. Wylie et al.
Table 1. Continued
Study
1. First
author
2. Year
3. Study
design
4. Country
Participants and setting
? Study population (N)
? Total number
? Age (x(SD), years)
? Gender (F/M)
? Falls risk at study
entry
Intervention (I)a
1. Name of intervention
2. Regimen
3. Duration of intervention
? RCT
? The USA
? I: 79.6 (7.2); C: 80.3
(7.7)
? 274/75
? Mean no. falls in
previous 12 months:
I: 2.4 (SD: 2.6); C: 2.4
(SD: 2.6)
? Community dwelling
(older adults aged
>70 years)
? 3,727 (707 analysis)
? NR
? 418/283
? NR
? Community dwelling
(older adults)
? 712 (698 analysis)
? I: 74.9 (7.9); C: 75.8
(8.6)
? 500/112
? Median no. falls/
person/12 months: 2
(IQR 1?3)
? Assessment visit 2x ?rst three weeks after
enrollment then 11 monthly TC; Review of
recommendations with primary physician within one
month. Longer term exercise?walking =4?5 days/
week; Standing balance exercises 2?3 days/week
? 12 months
Comparison (C)
Primary outcomesb
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
? Program for the prevention of falls in the elderly
? NR
? 2 years
Routine healthcare
? Standard care plus targeted multifactorial falls
prevention programme
? NR
? 12 months
Standard care as
Falls Rate; Falls Injuries (Falls
organised by ED staff
Calendar)
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? Pujiula
Blanch
[28]
? 2000
? QuasiRCT
? Spain
? Russell
[27]
? 2010
? RCT
? Australia
Falls Rate; Mean no. falls/year; No.
multiple fallers
Abbreviations: C?Control/ Comparator; ED?Emergency Department; F?female; I?Intervention; M?male; NR?not reported; SD?Standard Deviation;
TC?telephone contact.
Key: aFurther intervention details pro?led using TiDIER reporting guidelines [23] are shown in Supplementary Table S3, available at Age and Ageing online;
b
Additional outcomes reported in Supplementary Table S2, available at Age and Ageing online. Explanation of falls outcomes: Number of fallers?Number of participants sustaining a fall; Falls incidence?number of falls; Falls rate?expressed as either the number of falls per person or with an additional time denominator;
Time to ?rst fall?falls free survival time.
0.13 [34] to 0.39 [13] (Appendix 5). Overall heterogeneity
was low (I2 = 31%).
Multifactorial interventions
Data for falls rates were also pooled from the three multifactorial trials which included podiatry referral as an intervention component [27, 29, 30] and showed a signi?cantly
bene?cial effect when compared to usual care on falls rate
(RaR 0.73 [95% CI 0.54, 0.98]) (Figure 3). The absolute
falls rate difference ranged from 0.43 to 1.85 (Appendix 5).
Heterogeneity was high (I2 = 60%), and it is also possible
that podiatry interventions were not received by those participants who were referred.
Falls prevention in care homes
Two studies examined podiatry interventions for falls
prevention in care homes [30, 31]. Data could not be
pooled due to heterogeneity of interventions and outcomes. One study involved a multifactorial intervention
including podiatry referral [30] and although study ?ndings signi?cantly favoured the intervention, there was no
332
detail about the actual podiatry treatment received. The
other was a small pilot study examining a multifaceted
podiatry intervention [31]. Although showing a small
effect on falls rate, small sample size and high variability
of scores meant no de?nitive conclusions about effectiveness could be drawn.
Time to ?rst fall
Time to ?rst fall was only measured in multifaceted podiatry
interventions. None showed statistically-signi?cant differences
between intervention and control groups [12, 13, 31].
Injury data
Six studies reported injury data [13, 27?29, 31, 34]. Two
studies reported rate ratios. Where reported, rate ratios for
injury at the end of the intervention ranged from 0.87 [31]
to 1.11 [27], suggesting no effect on falls with harm.
Secondary outcomes
There was a diverse range of secondary outcomes therefore
meta-analysis was not appropriate. Studies examining number
Podiatry interventions to prevent falls in older people: a systematic review and meta-analysis
of fractures [12, 13, 27, 28], functional ability [13, 21, 32], activities of daily living [12, 13, 29] and health-related quality of life
did not demonstrate any signi?cant differences [12, 13, 31, 32].
However, signi?cant positive effects on a range of balance
measures were demonstrated in some single component podiatry interventions [26] and multifactorial interventions [30].
Although one multifaceted intervention demonstrated some
between-group differences in balance, these were inconclusive
[13]. Signi?cant effects of single component interventions on
foot pain and function were found using the Foot Health Status
Questionnaire [32], but not the Manchester Foot Pain and
Disability Index used in both single and multifaceted podiatry
intervention studies [13, 32].
Economic analysis
One trial reported economic data [12]. The study used the
EQ-5D, demonstrating 0.0129 enhancement of quality
333
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Figure 2. Risk of bias summary. A. Review authors? judgements about each risk of bias item presented as percentages across all
included studies. B. Risk of bias summary: review authors? judgements about each risk of bias item for each study.
G. Wylie et al.
adjusted life years (QALYs) over 12 months. The cost per
QALY ranged between ?19,494 and ?20,593. The cost per
fall averted was ?1,254 [34].
Adverse events
Five studies examined adverse events [12, 13, 26, 31, 32].
In single component interventions, bruising, ankle pain and
blisters [26, 32] were experienced by participants wearing
insoles and off-the-shelf shoes, which diminished over time.
One multifaceted podiatry intervention study [12] reported
greater foot pain at 12 months in intervention participants.
Adherence
Intervention adherence and reporting of adherence was
suboptimal across the trials. Six trials reported adherence
using self-report methods [12, 26, 27, 29, 31, 32].
Participants in these trials reported wearing foot orthoses
or footwear most or all of the time (between 37% and
56%) [13, 31]. Similarly, a third of participants reported
completing exercises at the prescribed frequency of three
times per day [12, 31]. Podiatry referral rates varied signi?cantly within multifactorial interventions: the highest in one
trial, at 59% of intervention group participants [30] and
lowest at 32% [29]. Data for actual uptake of the podiatry
intervention in the multifactorial trials were not reported.
Completion rate
The odds ratio for drop out rate was no higher in intervention than control groups, indicating that participants tolerate
the podiatry interventions well as well as control group participants receiving usual care (Appendix 6).
334
Discussion
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Figure 3. Forest plot: pooled results of single, multifaceted, and multifactorial interventions versus usual care: falls rate.
To our knowledge, this is the ?rst systematic review and
meta-analysis to speci?cally examine the role of podiatry in
falls prevention. The falls rate ratio size was broadly in line
with effects of other similar interventions identi?ed in a
Cochrane Review of falls prevention interventions in
community-dwelling older people [35]. In considering the
role of podiatry alongside other interventions, the effect
size for multifacteted podiatry interventions compared to
group exercise was similar, suggesting that within multifaceted podiatry interventions, foot and ankle exercises may
confer a strong protective effect against falls. This may also
explain why the multifactorial effect is similar to the effect
seen in multifaceted podiatry interventions. Only two studies were conducted in care homes, and study heterogeneity
prevented any conclusions being drawn about effectiveness
in this setting.
Study quality was moderate. Lack of participant and
intervention provider blinding was a source of bias, a common issue in studies where care providers deliver interventions. Blinding of outcome assessors was undertaken in
most included studies, thus detection bias was likely to be
low. Seven studies recorded falls and timescales over which
falls were recorded; these ranged from 1 to 12 months.
This heterogeneity meant data pooling was possible for
three multifaceted podiatry interventions, and three multifactorial interventions at 6 months only. Statisticallysigni?cant effects were found for both multifacteted and
multifactorial interventions, but the diverse care home and
community settings mean that conclusions relevant to each
setting are limited.
Recommendations for standardisation of outcome and
intervention reporting in falls trials are well established [33, 36].
Podiatry interventions to prevent falls in older people: a systematic review and meta-analysis
from analyses proposed in the registered PROSPERO protocol and therefore represent a protocol deviation.
Conclusion
Multifaceted podiatry interventions can prevent falls in
community-dwelling older people. However, evidence to
support podiatry interventions in care homes is scant. Future
studies should address this gap in knowledge, but also de?ne
the degree of disability and cognitive status of the population
and follow recommended guidelines for measuring and
reporting falls prevention trials.
Supplementary data mentioned in the text are available to
subscribers in Age and Ageing online.
Declarations of Con?icts of Interest: None.
Declarations of Sources of Funding: Funded by the Chief
Scientist Of?ce of the Scottish Government, award number
CGA/16/40. The ?nancial sponsor played no role in the
design, execution, analysis and interpretation of data or writing
of the study.
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