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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

As indicated in Chapter 10, exercise is a key intervention strategy for preventing falls in older people. Many diverse forms of exercise have been used in trials, ranging from highly prescribed resistance training regimes and laboratory-based balance training to unstructured general exercise programmes. In addition to studying the efficacy of exercise programmes on falls, many studies have also assessed the effectiveness of such programmes on a range of physical outcome measures, including strength, balance and gait. These studies elucidate the mechanisms by which exercise may prevent falls. Although falls are relatively common, most older individuals do not fall very frequently. Thus, large studies with long follow-up periods are required to detect the effects of exercise on fall rates. In contrast, the effects of exercise on risk factors for falls can be detected with smaller studies. Thus, complementary information can be gleaned from the analysis of studies with falls risk factors as outcome measures. Indeed, Liu-Ambrose and colleagues found that the risk of falling, as measured on the Physiological Profile Assessment tool (PPA, described in Chapter 16), could be reduced by around 50% by resistance or agility training. This chapter describes the major forms of exercise that have been used in studies of older people, and summarizes the evidence for the effectiveness of each form on falls risk factors such as balance, strength and functional abilities. Additional considerations, including exercise setting selection, target population selection, and factors affecting adoption and adherence, are then explored.

Falls in Older People: Exercise interventions to improve physical functioning

We read with great interest the editorial on foot osteoarthritis (OA) by Golightly and Gates (1). Foot OA is prevalent but neglected compared with other commonly affected sites such as the knee and hand (2), hence such a high-profile statement of need for foot OA is long overdue.

Defining symptomatic radiographic foot osteoarthritis

INTRODUCTION
Access to healthcare services should be equitable no matter where you live. However, the podiatry needs of rural populations are poorly addressed, partly because of workforce maldistribution. Encouraging emerging podiatrists to work in rural areas is a key solution. The aims were to explore (1) recently graduated podiatrists' perceptions regarding working rurally and (2) broader industry views of the factors likely to be successful for rural recruitment and retention.


METHODS
Recruitment for interviews pertaining to podiatrist recruitment and retention was conducted during 2017. Recruitment was through social media, podiatry professional association newsletters, public health podiatry emails. Graduate perceptions were explored via two focus groups of Australian podiatrists enrolled in the Podiatrists in Australia: Investigating Graduate Employment longitudinal survey. Industry views were explored through semistructured interviews with podiatry profession stakeholders. Inductive thematic analysis was used to analyse data about the perceptions of recently graduated podiatrists and stakeholders and the themes were triangulated between the two groups.


RESULTS
Overall, 11 recent graduate podiatrists and 15 stakeholders participated. The overarching themes among the two groups were the importance of 'growing me' and 'growing the profession'. Three superordinate themes were generated through analysis of both datasets, including (i) building a career, (ii) why I stay, and (iii) it cannot be done alone.


CONCLUSION
This study identified that recently graduated podiatrists are likely to be attracted to rural work and retained in rural areas if they foresee opportunities for career progression in stable jobs, have a background of training and living in rural areas, like the lifestyle, and are able to access appropriate professional and personal supports. Building employment that spans public and private sector opportunities might be attractive to new graduate podiatrists seeking a breadth of career options. It is also important to recognise rural generalist podiatrists for any extended scope of services they provide along with raising public awareness of the role of rural podiatrist as a core part of multidisciplinary rural healthcare teams. Future training and workforce planning in podiatry must promote podiatrists taking up rural training and work so that maldistribution is reduced.

What recently graduated podiatrists think of rural work, and how services are responding: a qualitative study.

This chapter provides an overview of the epidemiology and management of common foot problems in older people and updates recently published reviews on this topic. Foot problems have a significant detrimental impact on mobility and health status in older people and a sizeable subsequent burden on the healthcare system. The management of foot problems in older people varies considerably between countries due to differences in the organisational structure of healthcare systems and scope of practice of various health professions. In the foot, xerosis typically presents as erythematous dry scaling and fissuring of the skin on the dorsum of the foot and between the toes. Foot ulcers have a characteristic clinical presentation depending on their underlying cause. Non-surgical management of hallux valgus may involve footwear advice or modification, foot orthoses, night splints, physical therapy, and foot and ankle exercises. Footwear advice is an essential component of the effective management of foot problems in older people. 

Foot problems

Abstract Background Footwear has been shown to influence balance and is an important consideration in relation to the prevention of falls. However, it remains unclear as to what type of footwear is most beneficial for balance in older people: sturdy, supportive footwear, or minimalist footwear to maximise plantar sensory input. The objectives of this study were therefore to compare standing balance and walking stability in older women wearing these two footwear styles, and to investigate participants’ perceptions in relation to comfort, ease of use and fit. Methods Older women ( n = 20) aged 66 to 82 years (mean 73.4, SD 3.9) performed a series of laboratory tests of standing balance (eyes open and closed on floor and foam rubber mat, near tandem standing) and walking stability (treadmill, level and irregular surface) using a wearable sensor motion analysis system. Participants were tested wearing supportive footwear (incorporating design features to improve balance) and minimalist footwear. Perceptions of the footwear were documented using structured questionnaires. Results There were no statistically significant differences in balance performance between the supportive and minimalist footwear. Participants perceived the supportive footwear to be significantly more attractive to self and others, easier to put on and off but heavier compared to the minimalist footwear. Overall comfort was similar between the footwear conditions, although the supportive footwear was reported to be significantly more comfortable in the heel, arch height, heel cup, heel width and forefoot width regions. Eighteen participants (90%) reported that they felt more stable in the supportive footwear and 17 (85%) reported that they would consider wearing them to reduce their risk of falling. Conclusion Balance performance and walking stability were similar in supportive footwear designed to reduce the risk of falling and minimalist footwear, although participants preferred the supportive footwear in relation to aesthetics, ease of use, comfort and perceived stability. Prospective studies are now required to ascertain the longer-term advantages and disadvantages of these footwear styles on comfort and stability in older people. Trial registration Australian New Zealand Clinical Trials Registry. ACTRN12622001257752p, 20/9/2022 (prospectively registered). 

/pdf/effects-of-supportive-and-minimalist-footwear-on-standing-20oj690s.pdf

Hylton B. Menz

Papers

Falls in Older People: Exercise interventions to improve physical functioning

Defining symptomatic radiographic foot osteoarthritis

What recently graduated podiatrists think of rural work, and how services are responding: a qualitative study.

Foot problems

Effects of supportive and minimalist footwear on standing balance and walking stability in older women