1. Underplantar Pressure Technology, Foot Problems and Footwear Prescription Olwen Finlay MBE, FCSP, HT, DMS Past President IPTOP, 1999 – 2007. Vice President CSP, 2003 -2007. www. Olwen.finlay@btinternet.com

2. Why is footwear not given a higher priority? The Effective health Journal cites footwear as a usual adjunct to treatment? (Ref 1& 2) Is it lack of public awareness about safe footwear? Is it lack of public awareness about safe footwear? Do older people tend to accept foot change as part of the ageing process? Do older people tend to accept foot change as part of the ageing process? Is advice not sought about foot change until mobility if affected? Is advice not sought about foot change until mobility if affected? Insufficient training in this specialised field? Insufficient training in this specialised field? Some physiotherapists perceive it as a task for others? Some physiotherapists perceive it as a task for others?

3. What would be the objectives of a footwear service? (Ref. 3) To identify those in need. To identify those in need. To help keep older people mobile. To help keep older people mobile. To provide well fitting shoes, assisting the wearer to stand, balance and move in comfort and safety. To provide well fitting shoes, assisting the wearer to stand, balance and move in comfort and safety. To organise a speedy need responsive service. To organise a speedy need responsive service. Help the elderly cope with a complex market place. Help the elderly cope with a complex market place. To provide sufficient information to reach an informed decision. To provide sufficient information to reach an informed decision. To provide a low cost effective service. To provide a low cost effective service. To provide well fitting shoes. To provide well fitting shoes. To increase environmental safety. To increase environmental safety.

4. Examples of footwear at admission (Ref. 4 & 5)

5. Need for growing recognition amongst professionals About the role of the ageing foot and the anticipated change. About the role of the ageing foot and the anticipated change. Physiotherapists require to recognise the role of footwear in falls. Physiotherapists require to recognise the role of footwear in falls. Require convincing that footwear is an effective adjunct to a rehabilitation programme. Require convincing that footwear is an effective adjunct to a rehabilitation programme. It is important to recognise that an inappropriate product can affect test results It is important to recognise that an inappropriate product can affect test results To increase knowledge relating to the interplay between flooring and footwear to ensure what surface is most advantageous to the older person To increase knowledge relating to the interplay between flooring and footwear to ensure what surface is most advantageous to the older person N.B. 40% of all fatal accidents take place in the home. N.B. 40% of all fatal accidents take place in the home.

6. An anticipated age change - flattening of the longitudinal arch. (Ref.6)

7. Wasting of the smaller foot muscles may be observed

8. Colour & design on floors can affect gait may increase falls (Ref.7).

9. This print illustrates how toe off is affected on different carpets. The soft velvet pile caused a rocking backwards causing instability and was disadvantageous if a person had poor mobility or balance.

10. Feet and footwear have to cope with enormous stresses 700 tons on each foot in the course of a day. 200, 000 miles in the course of a lifetime.

11. Obesity will increase daily load.

12. Physiotherapists are in a unique position to improve the stability of many older people and influence change (Ref.8) Knowledge of the internal foot structures. Knowledge of the internal foot structures. Understand gait. Understand gait. Understand the complex interplay between walking, footwear and balance. Understand the complex interplay between walking, footwear and balance. Can and should influence manufacturers to respond to needs of older people, as the fashion market rarely fulfils their need. Can and should influence manufacturers to respond to needs of older people, as the fashion market rarely fulfils their need.

13. Gait Analysis cubicle (Ref.9 ).

14. Underplantar Pressure Technology can help define the complex interplay between walking, balance and footwear by providing quantative and qualitative data (Ref. 9).

15. Footwear does affect gait Slip-on shoes increases tendency to shuffle. Slip-on shoes increases tendency to shuffle. Plastic /smooth soles produces a small fearful step. Plastic /smooth soles produces a small fearful step. Thick mid soles increase tendency to fall, due to edging effect causing instability. Thick mid soles increase tendency to fall, due to edging effect causing instability. Ill fitting shoes slow speed of movement. Ill fitting shoes slow speed of movement. (Walking speeds exceeding 1.07 metres/second is required to cross pelican crossings within the allocated time permitted. (Walking speeds exceeding 1.07 metres/second is required to cross pelican crossings within the allocated time permitted. In Northern Ireland approximately 230 older people (0ver 60 years of age) are involved in accidents on pedestrian road crossings per year. In Northern Ireland approximately 230 older people (0ver 60 years of age) are involved in accidents on pedestrian road crossings per year.

16. Edging Effect which causes imbalance.

17. Gait analysis should be carried out with the therapist behind the patient This patient needed help and advice (Ref. 10)

18. Balance is a problem for a large number of older people in Northern Ireland. One in three people over 65 years fall each year. One in three people over 65 years fall each year. 1750 hip fractures occur annually. 1750 hip fractures occur annually. Total cost is £21,000,000 annually. Total cost is £21,000,000 annually. One in six patients with hip fractures die within six months. One in six patients with hip fractures die within six months. (As the population ages, the number increases annually with an ever increasing budget). (As the population ages, the number increases annually with an ever increasing budget).

19. Tapering heels increases instability

20. Soft heel counters provide little support Admission Supplied

21. Excessive wear and tear can support or refute medical history

22. Typical deformities found in the Ulster patient (many are painful and arthritic in origin) Splayed Forefoot and Pronation of the hind foot Splayed Forefoot and Pronation of the hind foot

23. Hallux Valgus of varying degrees

24. Hallux Valgus – 97 year old female

25. Extra depth required at the toe box is required if Hallux Valgus is present.

26. Antalic Gait

27. Ulceration

28. Pressure Points This pressure area caused by a shallow shoe box Home made newspaper insoles were the cause of this pressure area.

29. Nail problems All nail problems were referred to the Podiatry Department

30. Nail problems

31. Vascular Insufficiency This patient has not sought advice prior to attending the shoe clinic. This patient was unaware of any skin discolouration.

32. Some vascular conditions can deteriorate quickly and one must recognise when not to supply.

33. Congenital & Acquired Deformities Genu ValgumShoe sixe varied by three sizes

34. Summary Complex interplay between walking, footwear and balance. Complex interplay between walking, footwear and balance. Assessment of the elderly person should include the foot. Assessment of the elderly person should include the foot. Correct fitting shoes are a requisite for daily living and should be documented. Correct fitting shoes are a requisite for daily living and should be documented. Written advice should be supplied to either patient or carer as appropriate or if advice rejected this should be documented. Written advice should be supplied to either patient or carer as appropriate or if advice rejected this should be documented. Feet fit for rehabilitation are an essential part of the care programme Feet fit for rehabilitation are an essential part of the care programme Supply of a safe product is a cost effective intervention. Supply of a safe product is a cost effective intervention. Need for physiotherapists to increase awareness in this field. Need for physiotherapists to increase awareness in this field. Further research required on interplay between footwear and flooring. Further research required on interplay between footwear and flooring.

35. Footwear References Footwear References 1, Nuffield Health Journal (1996. Preventing falls and subsequent injury in older people. Effective Health Care 2. 4.5 2. National Service Framework for Older People, Department of Health London, 3. Finlay O & Fullerton CJ, (1996). Foot & footwear of Older people I Squires (ed), The role of the multidisciplinary team. Chapman & Hall, London. (2 nd edition). 4. Kwok T, (1994). A survey of inpatients footwear. Care of the Elderly J. March, P. 118 5. Finlay O, (1986). Footwear in the elderly care programme (1986). Physiotherapy J Vol 72 No 10: 172 -178 6. Robbins S,. Waked E, McClaran J. (1995). Proprioception and stability; foot stability awareness of age and footwear. Age & aging 24; 67-72.. 7. Finlay O, Beringer TRO. (2007). Effects of floor covering on measurements of gait and plantar pressure. Physiotherapy J. Vol. 93 No.2 June P.144 -150. 8. Finlay O. (1996) Footwear Problems & Footwear Prescriptions. Chapter 26, P382 - 398. Physiotherapy with Older People. Edited by Pickles. Et al, London, Philadelphia Toronto, Sydney & Tokyo 9. Finlay O, (1995). The use of computers to assess problems associated with gait in elderly people. Information Technology of Nursing 1995 -7 (1): 9-12. 10. Olwen Finlay explains. (1996) Health Service J. February 8th