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Using Multivariate Statistics

Lincoln, Yvonna, and Egon Guba, "Postpositivism and the Naturalist Paradigm," pp. 14-46 in Yvonna Lincoln and Egon Guba, Naturalistic Inquiry . Beverly Hills, CA: Sage, 1985.*

25. Multiple Imputation for Nonresponse in Surveys. By D. B. Rubin. ISBN 0 471 08705 X. Wiley, Chichester, 1987. 258 pp. £30.25.

Multiple Imputation for Nonresponse in Surveys

As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture.
This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants.  
Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures.
Multifactorial interventions assess an individual's risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.  
Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls.
Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment.  
Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls.
Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure.
In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling.
The evidence relating to the provision of educational materials alone for preventing falls is inconclusive.

Interventions for preventing falls in older people living in the community

The Pharmacological Basis of Therapeutics A Textbook of Pharmacology, Toxicology and Therapeutics for Physicians and Medical Students. By Prof. Louis Goodman and Prof. Alfred Gilman. Pp. xiii + 1383. (New York: The Macmillan Company, 1941.) 50s. net.

The Pharmacological Basis of Therapeutics

Background: Slips are a common cause of falls, and nonslip socks have been marketed to prevent slips in older people. However, few studies have investigated the biomechanical and clinical effects of walking in nonslip socks. This study aimed to examine gait parameters in older people walking on a slippery surface wearing nonslip socks compared with standard sock and barefoot conditions. Methods: Fifteen older people completed five trials of the fast-paced Timed Up and Go test while barefoot and while wearing standard socks and nonslip socks. Kinematic data (step length, heel horizontal velocity at heel strike, and foot-floor angle at heel strike) and clinical data (total Timed Up and Go test time, total number of steps, number of steps in turn, and observed slips, trips, or falls) were collected. Results: Performance on the Timed Up and Go test did not differ between the barefoot and nonslip sock conditions; however, participants walked more slowly and took shorter steps when wearing standard socks. Participants rated nonslip socks to feel less slippery than barefoot and standard socks. Conclusions: Compared with wearing standard socks, wearing nonslip socks improves gait performance and may be beneficial in reducing the risk of slipping in older people. (J Am Podiatr Med Assoc 103(6): 471-479, 2013)

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Effects of Nonslip Socks on the Gait Patterns of Older People When Walking on a Slippery Surface

In this chapter, we examine the epidemiology of falls in older people. We review the major studies that have described the incidence of falls, the locations where falls occur and falls sequelae. We also examine the costs and services required to treat and manage falls and fall-related injuries. Before addressing these issues, however, it is helpful to briefly discuss four important methodological considerations that are pertinent to all research studies of falls in older people: how falls are defined, how falls are counted, how injurious falls are defined and what constitutes an older person. The definition of a fall In 1987, the Kellogg International Working Group on the Prevention of Falls in the Elderly defined a fall as ‘unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure’. Since then, many researchers have used this or very similar definitions of a fall. The Kellogg definition is appropriate for studies aimed at identifying factors that impair sensorimotor function and balance control, whereas broader definitions that include dizziness and loss of consciousness are appropriate for studies that also address cardiovascular and neurological causes of falls such as syncope, postural hypotension and transient ischaemic attacks.

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Falls in Older People: Epidemiology of falls and fall-related injuries

Objective To describe the management of hallux valgus by general practitioners (GPs) in Australia. Methods We analyzed data from the Bettering the Evaluation and Care of Health program from April 2000 to March 2016. Patient and GP encounter characteristics were extracted. Hallux valgus encounters were identified using the International Classification of Primary Care, Version 2 Plus terms hallux valgus and bunion. Data were summarized using descriptive statistics and 95% confidence intervals around point estimates. Results The data set included 1,568,100 patient-encounter records among which hallux valgus was managed 658 times (4.2 management occasions per 10,000 encounters). This management rate extrapolates to an estimated 60,000 GP-patient encounters across Australia in the most recent year data were available (from 2015 to 2016). The management rate was 3 times higher in female compared to male patients and was most frequent among patients ages 45-64 years. Hallux valgus was most frequently managed by referral to orthopedic surgeons (28 per 100 management occasions), counseling or advice (25 per 100), and referral to podiatrists (16 per 100). Pharmacologic management was also frequently used (20 per 100) and primarily involved prescription of nonsteroidal antiinflammatory drugs (7 per 100). Conclusion Hallux valgus is a commonly encountered problem in Australian general practice and is mostly managed by provision of advice and referral to orthopedic surgeons and podiatrists. Further research is required to examine the factors that influence the selection of surgical and nonsurgical treatment pathways by GPs and their comparative effectiveness.

Management of Hallux Valgus in General Practice in Australia.

Foot orthoses are widely used in the prevention and treatment of foot disorders. The aim of this study was to describe characteristics of custom-made foot orthosis prescriptions from a Australian podiatric orthotic laboratory. One thousand consecutive foot orthosis prescription forms were obtained from a commercial prescription foot orthosis laboratory located in Melbourne, Victoria, Australia (Footwork Podiatric Laboratory). Each item from the prescription form was documented in relation to orthosis type, cast correction, arch fill technique, cast modifications, shell material, shell modifications and cover material. Cluster analysis and discriminant function analysis were applied to identify patterns in the prescription data. Prescriptions were obtained from 178 clinical practices across Australia and Hong Kong, with patients ranging in age from 5 to 92 years. Three broad categories (‘clusters’) were observed that were indicative of increasing ‘control’ of rearfoot pronation. A combination of five variables (rearfoot cast correction, cover shape, orthosis type, forefoot cast correction and plantar fascial accommodation) was able to identify these clusters with an accuracy of 70%. Significant differences between clusters were observed in relation to age and sex of the patient and the geographic location of the prescribing clinician. Foot orthosis prescriptions are complex, but can be broadly classified into three categories. Selection of these prescription subtypes appears to be influenced by both patient factors (age and sex) and clinician factors (clinic location).

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Custom-made foot orthoses: an analysis of prescription characteristics from an Australian commercial orthotic laboratory.

This article describes the design of a parallel-group, participant- and assessor-blinded randomised controlled trial comparing the effectiveness of shoe-stiffening inserts versus sham shoe insert(s) for reducing pain associated with first metatarsophalangeal joint (MTPJ) osteoarthritis (OA). Ninety participants with first MTPJ OA will be randomised to receive full-length shoe-stiffening insert(s) (Carbon Fibre Spring Plate, Paris Orthotics, Vancouver, BC, Canada) plus rehabilitation therapy or sham shoe insert(s) plus rehabilitation therapy. Outcome measures will be obtained at baseline, 4, 12, 24 and 52 weeks; the primary endpoint for assessing effectiveness being 12 weeks. The primary outcome measure will be the foot pain domain of the Foot Health Status Questionnaire (FHSQ). Secondary outcome measures will include the function domain of the FHSQ, severity of first MTPJ pain (using a 100-mm Visual Analogue Scale), global change in symptoms (using a 15-point Likert scale), health status (using the Short-Form-12® Version 2.0 and EuroQol (EQ-5D-5L™) questionnaires), use of rescue medication and co-interventions, self-reported adverse events and physical activity levels (using the Incidental and Planned Activity Questionnaire). Data will be analysed using the intention-to-treat principle. Economic analysis (cost-effectiveness and cost-utility) will also be performed. In addition, the kinematic effects of the interventions will be examined at 1 week using a three-dimensional motion analysis system and multisegment foot model. This study will determine whether shoe-stiffening inserts are a cost-effective intervention for relieving pain associated with first MTPJ OA. The biomechanical analysis will provide useful insights into the mechanism of action of the shoe-stiffening inserts. Australian New Zealand Clinical Trials Registry, identifier: ACTRN12616000552482
 . Registered on 28 April 2016.

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Hylton B. Menz

Papers

Effects of Nonslip Socks on the Gait Patterns of Older People When Walking on a Slippery Surface

Falls in Older People: Epidemiology of falls and fall-related injuries

Management of Hallux Valgus in General Practice in Australia.

Custom-made foot orthoses: an analysis of prescription characteristics from an Australian commercial orthotic laboratory.

Shoe-stiffening inserts for first metatarsophalangeal joint osteoarthritis (the SIMPLE trial): study protocol for a randomised controlled trial