Slippin’ on Slippers…..Effects of footwear on falls at home.
Falls, especially those among older adults, is one of the biggest areas of concern for therapists and nurses, and a leading cause of disability and mortality. Here, we address an often overlooked issue and give some tips as to how to bring it up with your clients! For more blog posts and helpful articles, contact us to sign up for our mailing list!
One thing that we as clinicians often notice in the home care environment is that our patients have VERY specific footwear preferences. As you would guess, they are often not wearing the laced-up sneakers that they train with in the in-patient rehab world. Upon returning home, they’re usually wearing slippers – often standing on the folded over heel so they can easily slide them on. Perhaps they are just wearing regular socks or maybe wandering around barefoot!
But even as we educate/cajole/frankly plead with our older patients to use shoes, or rubberized socks, or even just to tie their laces, is there ever a whisper in the back of your mind…. What IS the best footwear for them to use in the home? I mean, are slippers much worse than bare feet? Are rubber socks a practical option? Should we continue trying to educate on the absolute best-case scenario, even when we know that we… well, we may not get heard?
Luckily for us therapists and nurses, there are some brave clinicians out there who have managed to convince even the most hard-core slipper-wearing older adults to participate in studies that examine the best options and the effectiveness of wearing ‘proper’ footwear at home. Now, if they could only release an article on how they convinced them….!
A study completed by Ng et al in 2010 examined the effects that various types of footwear had on gait and balance in people recovering from stroke. For walking indoors, most participants (53.3%) preferred wearing slippers, 29.7% preferred closed fitting shoes and 13.2% preferred walking barefoot. Menant et al in 2010 in their review of optimal footwear for older adults in the home, corroborated these findings, showing that the majority wore slippers inside their home and less than a third walked barefoot or with socks. These numbers remained consistently high within nursing homes and hospital inpatients, and with increasing age. Other studies cited by Menant hypothesize that deformities of the feet, hypersensitivity, and pain influence the use of slippers inside the home. It follows that those with difficulties donning their shoes would prefer something easier to use, and backless slip on shoes can often fit the bill for these patients.
Indeed, this confirms what we truly knew all along… most of our patients are going to be wearing slippers (usually old and backless ones) when ambling about the house. But really, how detrimental is this on their balance? I mean, I’m sure there are many other influences that contribute to falls more so than what you prefer to wear on your feet.
So how much should we emphasize the importance of this with our clients?
Menz et al. in 2017 had a close look at the effects different footwear has on balance – in this case socks, backless slippers and enclosed slippers. Balance ability- measured through postural sway, limits of stability, and tandem walking; and gait patterns – cadence, walking speed, and step length were all used as outcome measures, as was perceptions of the footwear. Participants in this study were all community-dwelling older women, at risk of falls. The enclosed slipper that the researchers chose was selected to incorporate several features considered beneficial to balance – a low/firm sole, rigid heel, and a Velcro fastening. The overall results of the outcome measures showed a significant improvement in balance ability when wearing the enclosed slipper as opposed to backless slipper or socks. Additionally, gait patterns were optimized in the enclosed slipper, intermediate with the backless and worst with the socks. When asked about their perception of the enclosed slipper (because let’s face it, this is an important one!!) they considered them to be more attractive, both to self and others; and most of the ladies agreed that they would consider wearing this type of slipper to reduce their risk of falls.
Supportive of these findings, Ng’s study demonstrated a significant improvement in gait speed, step length, and stance for individuals wearing shoes, as opposed to those in slippers or barefoot. Of particular concern, a poor awareness of specific footwear advice or education on the topic was a result in this study – clearly, it cannot be taken for granted that our patients will be considering their footwear the same way that we, as objective outsiders are.
Another look at this issue comes from Arnadottir and Mercer in 2000 who examined balance and gait of women 65-93 years old in respect to their footwear. Functional tests like the Functional Reach Test, Timed Up and Go, and 10-meter walk test were used to determine whether dress shoes, walking shoes, or barefooted walking were optimal in balance and gait. In line with previous studies mentioned, the participants performed best across all measures when wearing sensible walking shoes.
So our clinical hunches are confirmed! Those slippers that you can’t get your patient out of are NOT helpful to their balance and gait and are definitely not helping with your therapy sessions and/or safety advice for inside the home. But apart from coming in armed with a bunch of research articles, that your 80-year old patient will likely give you the hairy eyeball for, what’s a home care clinician to do?
Well, it’s easy to make certain assumptions. We can safely assume that many of your patients never have considered changing their footwear. They more than likely have been wearing their indoor footwear of choice for much longer than they have been receiving your services. We shouldn’t assume, however, that they would still opt for a less safe option after being given a gentle and clear education about the dangers that unsafe footwear poses. With your guidance, they may be willing to bring out another pair for consideration. Research bears out that walking shoes with a firm sole and non-slip surfaces are going to be the safest option, but if your patient cannot bear the thought of wearing outdoor shoes inside the home, then talking about safer, enclosed slippers will be a good segue to wearing safer footwear.
We should also pay attention to the ease with which a patient can don their own footwear. IF assessing dressing tasks isn’t commonly something you work on with your patient, it can be an easy thing to overlook. But if putting on enclosed slippers or shoes is difficult for your patient, they may opt for a backless slipper or sock. This is something worth seeing if your intervention can be helpful in – can you work with them on crossing their legs to put on shoes, or contact your friendly neighborhood OT for some adaptive equipment that can increase your patient’s compliance?
Finally, considering the patient’s dignity is something that clinicians, who have their safety core in their hearts, can easily misunderstand. These patients have often had so much control taken from them already, and in turn will be much more likely to stick with a decision they made with your support over one that was ‘forced’ upon them. Showing your patient examples of footwear options that they are happy to choose from or looking at their available choices with them while offering guidance is a decision that will pay dividends in the future. Empower them to make their own safest choice.
So, as initially suspected, footwear has a large influence on the safety and balance of our community dwelling patients. To increase home safety, and provide the best possible outcomes, this is something we should all be including in assessment, education, and intervention.
To learn more about Home Based Safety and Balance interventions, join us for a comprehensive, practical 2.5 hour seminar here. We at ARC seminars teach usable, evidence based information that you can immediately put into practice, to greatly improve your patient outcomes!
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