Reducing Risk of Falls in Older Adults: Shoe-Wear Recommendations, Modifications, and Special Considerations
Erica Ghigliotty, SPT
Background
Those who know me well could confidently tell you that my strongest passions include the following: Working with older adults and preventing falls, bridging the gap between language barriers, and working to ensure underrepresented individuals’ needs are being acknowledged and met. These passions fueled the desire to develop this capstone, which aimed to reduce falls in an underserved Spanish-speaking population during our program’s service learning trip in Guatemala. However, this project provides tools for many others, and is not limited to those in Guatemala.
The decision to focus on shoe-wear for falls prevention was motivated by extremely passionate and knowledgable individuals that have mentored me throughout my educational experience. My third clinical instructor, Andy Blackburn, PT, CLT, once encouraged me to consider the foundation, being the feet of all individuals with balance impairments. As I had previously overlooked this, I realized that I needed to – and wanted to – learn more. I then sought the guidance of Mike Gross, PT, PhD, FAPTA who teaches the foot and ankle unit in the PHYT 734 Musculoskeletal II course. I also requested him to serve as my clinical instructor for the integrated clinical experience elective offered by the school, where I was able to deepen my understanding of interventions in this area. I even learned how to make a pair of orthotics!
I also serve as a research assistant for a study exploring the effect of lighting for postural stability related to falls in individuals with dementia. While reviewing the mechanisms of many falls, I began to notice peculiar shoe-wear choices and combinations. While this study is still in the works, and a relationship between shoe-wear intervention and falls in this population has yet to be identified, it certainly contributed to my decision to focus on shoe-wear-related interventions.
Statement of Need / Purpose
The overwhelming prevalence of falls among older adults often prompts Physical Therapy intervention. In fact, falls within the geriatric population account for the majority of injuries that contribute to morbidity, mortality, and approximately $50 billion in direct medical expenses.1 While there are a number of considerations that any given provider should explore when screening patients for falls risk, shoe-wear concerns and subsequent intervention have been identified, but are often neglected.2 My clinical experience suggests that older adults often ask about shoe-wear – “What is the best?” Alternatively, many patients have reported that they did not know that shoe-wear could contribute to falls, nor that changes to shoe-wear could prevent them.1 Given these reasons, it is increasingly important to identify up-to-date information regarding appropriate shoe-wear for older adults in order to provide the best, evidence-based interventions and recommendations for this growing population.
Older adults with a history of falls are more likely to have pre-existing foot pain and foot deformities and/or impairments.3 As a result, I decided to dig deeper and ask, is it possible to address any combination of these concerns through shoe-wear modifications? If so, is it clinically significant? What are some other special considerations related to shoe-wear? For example, how can we ensure the understanding and implementation of these recommendations amongst those who share different cultures, languages, resources, or have cognitive impairments such as dementia?
Now that I have developed a strong understanding of shoe-wear recommendations for the geriatric population, my goal is to continue educating therapists and patients about these significant, relatively easy-to-implement findings in order to maximize the number of individuals who could benefit from these recommendations.
Products
I made an infographic for shoe-wear recommendations for balance. This was designed for health fairs in Guatemala, but the focus on visual aides allows for a universal understanding of these shoe-wear concepts. Therefore, they can be used with patients, their families, in therapy gyms and clinics, and beyond.
Shoe-Wear Recommendations Health Fair Document English and Spanish
The following attachment was my research plan for Guatemala. The plan was to intervene in Guatemala by providing insole modifications, but the population was surprisingly younger at the health fairs and non-
ambulatory in the long-term care facility in which we volunteered. Additionally, COVID-19 cut our experience short, but that’s another story. Regardless of the limited amount of shoe modifications that I was able to provide, this plan will serve as a skeleton for future research and perhaps as an intervention for the individuals with dementia from the research study I have referenced. Current students, if you are interested in considering this as a capstone, please contact me at erica_ghigliotty@med.unc.edu!
Below is the powerpoint presentation for UNC Home Health, which will take place in May. I believe that sharing my findings with local clinicians is a crucial step in implementing new concepts. My goal was to educate therapists in home health because my recommendations are relatively easy to implement in an “on-the-go” setting. I would be glad to extend my presentation to other clinicians, which includes, but is not limited to coworkers at my final clinical site and future workplace(s).
Shoe-Wear Capstone Presentation
The following evidence document summarizes the findings in the literature related to shoe-wear recommendations. This is mostly for my benefit, but those who would like to dive deeper into this topic should certainly take a look.
Evidence Document – Shoe-Wear Recommendations for Balance
Evaluation
I am always eager to receive feedback so that I can provide meaningful materials and information for my audience. My committee members have received a commitee feedback form to complete, but have also been consulted throughout my third year in order to help make this happen.
Capstone Committee Feedback Form
In Guatemala, I aimed to ask all participants a number of survey questions that can be found in the Guatemala Research Plan also referenced in the Products section above. This would have helped me identify barriers and improve patient receptiveness to the care plans and educational points.
My presentation with UNC Home Health has yet to take place, but all viewers will receive the following feedback form. Upon their responses, I will be able to make specific modifications and adjust teaching strategies as needed.
Self-Assessment and Reflection
Ultimately, I am proud of all that I have learned and the resultant products. I am excited to share my shoe-wear recommendation document with many others, as the visual concepts are universal for those who do not have visual impairments. Right now, my translation of the explanations are only in Spanish and English, but I would be happy to continue finding ways to translate the content into other languages as needed.
My literature search determined that there is limited evidence regarding cultural, socioeconomic, and cognitive barriers related to shoe-wear intervention. This was part of my goal and it was disappointing at first. However, the beautiful thing about this project is that I realized it is only the start of something greater. For example, I am continuing to contribute to the research of falls prevention in those with dementia in order to find answers to my unanswered questions and best serve my future patients. I also plan to return to Guatemala as a leader where I can continue to implement my ideas/findings, and help current students with their projects and clinical skills. In other words, the challenges and unforeseen events that I encountered helped me create career goals and a vision for myself in the future; This was unanticipated, but I am grateful for it.
Acknowledgements
This project was fueled by my interests that have thrived as a result of the following individuals and their contagious energy and passions that worked to help me learn and succeed:
Thank you very, very, (“10 more verys”) much, Dr. Mike Gross. Let’s be honest, a capstone on shoe-wear and feet would simply not be complete without you! My time in the clinic with you was unforgettable and inspired many aspects of this project. In fact, my research plan for the Guatemala service trip was made possible because of you. You have been incredibly resourceful, helped me make a number of “home-made” insole modifications to help Guatemalans, and were patient with me even though it took me a while to get the hang of it. You have certainly helped me build my confidence as a clinician and individual, which is invaluable.
Dr. Lisa Johnston, you are so appreciated! I remember having nothing more than scattered ideas about the Guatemala service trip and my capstone. You were essential in helping me morph my ideas into something much greater and structured. You have always grounded me throughout my education at UNC, and I am forever grateful for your suppport and ability to remind me of my potential. Also, thank you to my other committee member and advisor, Dr. Debbie Thorpe for contributing to my plan, and being eager to serve as my capstone advisor. You have provided wonderful, constructive, and timely feedback.
Thank you Dr. Sarah van der Horst for making my first clinical rotation such an unforgettable and unique experience! In addition to sparking my interest in orthopedics, you granted me the ability to work directly with Spanish-speakers in a patient care setting because of our shared language abilities – this is incredibly important to me as a future clinician! My experience with you prepared me that much more for the Guatemala service trip, where I utilized some of the products that I developed for this capstone. Finally, as a UNC DPT alumna, you highly recommended Mike Gross as a mentor; He has been tremendous in ensuring the success of this capstone.
A huge shout-out to Physical Therapist, Andy Blackburn: You reinforced my love for working with the geriatric population during my clinical rotation at Carol Woods, CCRC. You should know that you are part of the reason that I developed an interest in shoe-wear, feet, and balance – I often transport back to my days in the clinic with you, and remember when you reminded me to look at patients’ foundation: their feet! While I initially did not feel comfortable in this area, I pursued a number of opportunities during my third year to learn more, and now look! My capstone is all about it!
Thank you to the research team that I have been working with over the past year as we are studying the effects of lighting on falls in older adults with dementia: Dr. Sheryl Zimmerman and Kimberly Ward, you both have been eager to accept my ideas and contributions, which includes considering shoe-wear when coding the circumstances of falls. I am excited to explore and discover patterns that will guide my future research and patient care. I have found that this population is largely neglected when considering shoe-wear and balance, and it looks like we may be the first to add some content to the literature – That’s huge! Dr. Carol Giuliani, you are the one that recruited me for this experience, so this is all thanks to you! I am grateful for your wisdom as a leader of geriatric care within our program.
Lastly, I would like to thank my friends (including my lovely classmates), and family for supporting and loving me throughout physical therapy school. A special shout-out to my mom and dad who have utilized their Spanish interpreting and translating experience to help with my products for Guatemala. Among the successes and the challenges that I have faced during grad school, you all have stayed constant. You are my cheerleaders in life!
References
- Neville C, Nguyen H, Ross K, et al. Lower-Limb Factors Associated with Balance and Falls in Older Adults: A Systematic Review and Clinical Synthesis. J Am Podiatr Med Assoc. November 2019. doi:10.7547/19-143
- AlgorithmforFallRiskScreening,Assessment,andIntervention.Centersfor Disease Control and Prevention. https://www.cdc.gov/steadi/pdf/STEADI- Algorithm-508.pdf. Published 2019. Accessed February 29, 2020.
- Menz HB, Auhl M, Spink MJ. Foot problems as a risk factor for falls in community-dwelling older people: A systematic review and meta-analysis. Maturitas. 2018;118:7–14. doi:10.1016/j.maturitas.2018.10.001
12 Responses to “Reducing Risk of Falls in Older Adults: Shoe-wear Recommendations, Modifications, and Special Considerations”
Shelby Miller
Hi Erica,
Congratulations on producing an amazing Capstone! I am so proud of you!! I loved how this project was fueled by unique passions, and it shone through in your work. I am so impressed by the breadth and depth of learning experiences that you used to inform your knowledge on this practice area. You developed some wonderful deliverables that I know will make a difference for many communities.
I especially love the shoe wear recommendations infographic that you created with Spanish included. I think the universal language of visuals makes it an even more effective tool. One point that I noticed was that you mentioned avoiding being barefoot and instead wearing shoes, not slippers, at all times. One series of questions that I have is related to how to effectively influence patient compliance when providing this falls risk education. Did you notice a resistance to this recommendation as a trend among patients? Did you find any useful motivational strategies for convincing patients to wear shoes, not slippers, while in the house?
Additionally, I think that the research plan you developed for the Guatemala service trip could easily be converted into a clinician resource used to guide evaluations and inform clinical practice. It was a great model for that specific setting, but it also looks like a great model for any older adult screening considering shoe wear modification interventions!! One suggestion that I have for the handout would be to eliminate abbreviations and acronyms to ensure wide-spread understanding, especially if it is eventually disseminated as an evaluation tool.
I am so thankful to have gotten the chance to join you on the Guatemala trip!! Another series of questions that I have is related to your perception of international physical therapy practice related to this issue. Did you get the chance to discuss shoe wear with any of the staff at Las Obras, the clinic we visited in Guatemala? If so, did they seem to consider it a relevant issue for their patient population? Did it seem like it was something that physical therapists in Guatemala addressed in their interventions? There is a need for this project to address gaps in practice here, so I imagine your project may have provided very important education for the therapists there too, in addition to benefitting the patients that you treated. Through my experience in Guatemala, I learned that sometimes providing education to the local therapists can be a long-term and sustainable approach to making a difference in their health care system in addition to treating the patients who you see while you are there to serve.
I could also imagine that various social determinants of health could create barriers to accessing proper shoe wear, even if it were recommended. You mention the usefulness of your evaluation tools in assessing potential barriers, and I would love to hear more about that. What were some of the most common barriers that you discovered in your patients? I am sure considering many of the same barriers could benefit patient care anywhere in order to optimize patient success. I would love to hear your thoughts!
Sorry for such a long comment with so many questions!! I am clearly very intrigued by your project and would love to continue the discussion. Perhaps my questions are too lengthy for a comment response. I would love to grab coffee with you sometime post-quarantine, for so this and so many other reasons, because I adore you!
I am so impressed with this project! It is so clear that you put a lot of hard work and effort into this Capstone and it paid off! The research and experience that you contributed to developing this project helped to create something that is truly a great contribution to the profession! I hope to return to Guatemala alongside you in the future! Incredible work on this project! Thank you!!!
Erica Ghigliotty
You are too kind, Shelby! I love that you find my work exciting, and that you have many questions and feedback for me.
To answer your first question, I know that many cultures and common personal preferences may affect the applicability of these findings. Since I have conducted my research, I have not run into any issues. However, like you, I definitely foresee the controversy. This is why falls prevention is/ should be multi-faceted. Shoe-wear should never be the sole area of focus. However, we should always educate patients about the evidence, explain the importance of our intervention, and hope that they will consider it at the very least. It is important to note that there is some controversy in the literature regarding barefoot walking, but this is very important when sensation is impaired.
I love your idea about converting my research plan into a clinican resource guide! Thank you for your suggestion, and I completely agree about the abbreviations – a bad tendency that we as physical therapists sometimes have, and should break.
Unfortunately, I did not speak to any of the staff at Las Obras about shoe-wear recommendations for balance. None of the patients I worked with were ambulatory, and we focused on the patients in front of us. In hindsight, I am sure that the therspists would have appreciated this information regardless, especially since physical therapy students who will be working in other settings were present at the gym that I worked at with LaCorey, Austin, and Lisa. The only mention of shoes during my time at Las Obras was that they have to be big enough to accommodate patients’ feet who have AFOs.
Social determinants of health are very important, which is why the survey questions that I developed include open-ended questions to allow individuals to voice their concerns. My goal was not to provide information that was not helpful or applicable, but it was hard to anticipate the needs of others without asking beforehand. Overall, shoe donations with decent characteristics will be helpful since shoes can be expensive, which is hard to justify sacrificing when priorities are different. I found that many individuals in the communities that we visited obtain shoes in the most convenient fashion, which meant inappropriate fit, and ultimately, the inability to intervene with insole modifications.
Again, I love your clear enthusiasm! I am so happy to have experienced Guatemala with you as well. Even though I have addressed some of your concerns via this comment, a coffee date to further elaborate and just hang out sounds wonderful! We shall see how everything plays out. Thank you again for your feedback. I hope all is well 🙂
Erica
Anjali
Erica,
I had the pleasure of witnessing a portion of your capstone project in Guatemala. I saw you use your infographic to educate community members in Spanish about shoe wear recommendations. I appreciated how you provided basic education regarding important shoe wear features specific to each individual’s feet. Your infographic and talking points were clear and picture-based, which was appropriate for the health literacy level of your target audience. Your research plan contained items that were appropriate and feasible to perform during health fairs in Guatemala. I recognize that it was difficult to know in advance about the population base that would attend the health fairs in Guatemala, but I think this intervention (and my community education capstone component) could have been more impactful if COVID-19 had not derailed our trip, and if we somehow were able to encourage more older adults to attend the health fairs by pre-planning with contacts in Guatemala and/or holding health fairs in areas with a greater geriatric population such as Cabecita de Algodon. I appreciate that you are encouraging other students to consider continuing this capstone project!
Your PowerPoint presentation is informative, clear, clinically useful, and comprehensive. It is clear that a lot of background work and a thorough review of evidence was conducted to construct this presentation. UNC Home Health therapists will be lucky to receive such a useful and detailed presentation from you!
Overall, this was an impressive, multifaceted capstone project that targets multiple audiences in two languages. Well done!
Erica Ghigliotty
Anjali,
Thank you for your feedback. I am grateful that you understand the challenges we faced in Guatemala and have elaborated on it so that others can further understand. I am confident that we both did our best given the circumstances. I do hope to return and suggest visiting Cabecita de Algodon! This would provide students the ability to work with another population, and learn more about their specific needs and typical treatment in Guatemala. I know there are several DPT2s and DPT1s who, like us, are passionate about working with older adults. I am sure they would appreciate this.
Thanks again for your comment,
Erica
Katherine Lewis
Hi Erica,
First of all, I found your capstone deliverables to be absolutely wonderful. I was especially interested in your capstone project as I share your passion for working with the older adult population. Therefore, I am unsurprisingly also interested in continuing to increase my knowledge on evidence-based falls prevention strategies. With regards to your infographic, I loved that you conveyed this information in both Spanish and English. By conveying safe footwear recommendations in multiple languages, you are making this information available to a larger population and therefore have the opportunity to positively impact more patients. Additionally, I believe the first page of your infographic, in which you use only images and universally understood symbols to indicate appropriate footwear, is very helpful as this information may be easily understood by not only individuals who speak different languages but also to individuals with lower levels of health literacy as well. Your Shoe-Wear presentation was well done and very informative as well! I especially appreciated the information you shared regarding different aspects of an individual’s foot which may put them at an increased risk for falls. I will certainly incorporate this information into may typical exam for older adults.
One thought that occurred to me while viewing your presentation materials was, what if an individual does not have the financial means to purchase new shoes? I was wondering you knew of any programs which assist individuals in paying for new footwear for the purposes of falls prevention?
Erica Ghigliotty
Hi Katie,
I gladly welcome your thoughts and find joy knowing that you appreciate these products. My goal was to extend beyond one specific population, and I am happy that you noticed my efforts to do this by translating the information into another language. I hope to find ways to translate my products into more languages depending on the settings to which these products find their way.
You also brought a very important concern to light – shoes are expensive! Addressing this barrier was actually one of the goals of my planned research in Guatemala where over 60% of the population sits at or below the poverty level: Could simple, cost-effective shoe-wear modifications improve balance? I invite you to attend my Zoom presentation in May where I further elaborate on these modifications. Basically, I talk more about the assessment of feet, findings that are associated with falls, and certain ways to intervene. While orthotics are expensive as well, insole posting (much cheaper) could address these issues and potentially reduce falls risk. I wanted to gather data in Guatemala, but their shoes were often too small for their feet to be able to add more materials. Whenever I did provide shoe-wear recommendations, I focused on the features of shoes to focus on rather than types of shoes or good brands. Shoe donations will be important in coming years in order to test the effectiveness of this intervention.
Thank you so much for your insight. There is no doubt in my mind that you will be an effective therapist when you consider numerous patient characteristics such as SES.
Best,
Erica
Debbie Thorpe
Erica
You did a great job on this project! I really like your handouts and evaluation materials for patients. Your presentation looks great and I think will provide a wealth of knowledge to UNC Home Health therapists in May and would definitely be appropriate for therapists in all other settings if you get a chance. You should be very proud of this project and getting it posted on time, despite Guatemala! I would love to keep you involved and present this as a potential research project for next years DPT3s if you might be willing to be on a committee.
Best Wishes
Erica Ghigliotty
Hi Debbie,
Thank you for all that you have assisted me with as an advisor! I am glad that you are proud and satisfied with the products. I am excited to present to UNC Home Health as well. I hope to learn more about barriers within their setting. This will help me determine areas to focus on that could also guide future DPT3s and their capstones. So yes, of course I would be willing to be a committee member in the future! This is not the end, but the beginning of something greater, and I would be honored to continue being a part of it.
Thanks again,
Erica
Austin White
Erica,
As I write this, I have already downloaded and saved all of your materials because they are very thorough, informative, and clinically useful! I too plan to work with the geriatric population and am thrilled to have these resources – thank you! I love how you made your Capstone project so clinically applicable, and it made me smile to see that you found a way to combine your three passions of older adults, Spanish, and underserved individuals.
I would love to hear more about your experience as a research assistant for the study on the effects of lighting for postural stability related falls in individuals with dementia! In the older adults course that I took this past fall through the department of Social Work, we discussed the multifaceted nature of the impairments often associated with dementia. The mechanisms of falls are also multifaceted (as you mentioned here), which is why I was so excited to read that you are diving deeper into two of these mechanisms of falls.
Thank you for choosing shoe-wear as your topic because I enjoyed Mike Gross’ introduction to this topic during MSK II and I really appreciate now having older adult specific materials. I found it so relatable that you brought up the commonly asked question of “what is the best?” because I have been asked this question by older adults as well and now feel better equipped to answer. Even my own grandmother has told me her feet hurt but that her shoes “look good” so she doesn’t need new ones. Now I have evidence to convince her buying a new pair of shoes is worth it!
I love that you provided the material for multiple audiences, including health fairs and home health clinicians. As Helen mentioned, would you be willing to share this information with local senior centers? Or YMCAs (which have many exercise classes dedicated to this population)? Or shoe stores such as Fleet Feet? Or what about geriatric-specialty clinics? As we have learned, older adults tend to have multiple co-morbidities so their physician visits might be focused on other impairments or medications, meaning a brochure with this information would be beneficial to both the physician and the patient.
Amazing job with this project, Erica! I know many patients and clinicians will benefit from it, just like I have. Thank you!
Hope you are staying safe and well -Austin
Erica Ghigliotty
Austin,
I am thrilled that you found my materials useful and saved them! I, too, am happy that I could find a way to marry my passions. My committee members certainly helped me with this, and I am excited to see how it continues.
I love that you mentioned the Geriatric class that you took as the primary investigator of the study I am working on is Dr. Sheryl Zimmerman, a professor at the UNC School of Social Work. Our professions and interests certainly overlap, and I am learning more about that all of the time! I would be happy to update this website and send you the article once our report is published. We need more data regarding effective treatment for those with dementia related to falls! I originally wanted to explore this area in depth, but found limited evidence – especially related to shoe-wear and feet.
Lastly, thank you for your suggestions! I have not thought of sharing these deliverables with shoe stores, but wow – you have such a great point! I am confident that older adults and/or their caregivers ask employees at shoe stores the same question they ask us… “What is best?” I can provide the stores with the up-to-date evidence, and it would benefit everyone. Thank you again for all of your suggestions and your appreciation of this project. I am doing well, and hope you are too!
Best,
Erica
Helen Buchanan
Erica – what a great idea! There is clearly a need for this kind of approach and resources, both for the service trip to Guatemala and here at home. I, too, have had both ends of the spectrum with older adults (or their adult children) asking “what shoes are best” and others looking perplexed when shoe wear is addressed as a contributor to falls. Often it is one of the simplest extrinsic factors we can adjust. Your clinician-aimed presentation breaks down all aspects to inspect on the shoe to ensure we’re providing the best fit in matching the needs of the older adult. Your bilingual client-targeted handout matches multiple learning styles with visual and verbal cues. It’s truly amazing! This handout could also be very helpful to clinicians and community workers/volunteers, acting as a pocket guide with English and Spanish speakers in home health, at community fairs, etc. Have you thought about sharing it at the community Falls Awareness/Prevention Day at the local senior centers, such as when we worked with Carol G for falls screening, in addition to your home health presentation? Regardless, these products are a fantastic springboard into your career and I know this experience has helped you formulate ideas into actions – what great practice for the real world with resources already in your toolkit! Congratulations!
Erica Ghigliotty
Helen,
Thank you for your comment and feedback! It means a lot to have you appreciate this project and find it useful as I know you love working with older adults too. Furthermore, I love your ideas! I have certainly thought about extending this project and sharing it with SHAC, Amigas En Salud, and with therapy gyms at residential facilities and/or senior centers, but being present during Falls Awareness/Prevention Day at senior centers is brilliant! Individuals are in the right mindset going into these events and are eager to learn. I’m sure I could talk to Dr. Carol Giuliani to see if she’ll have me back to present this information – I’m sure she will!
Thanks again,
Erica