Rethinking Fall Prevention Footwear for MS: Nathan Estrada, DPT

Trips account for a substantial share of falls among older adults and people with neurological conditions such as multiple sclerosis (MS), yet footwear has largely been designed to prevent slips, according to Nathan Estrada, DPT, vice president of clinical affairs at Cadense. In a retrospective survey of 705 people wearing shoes designed to reduce trips by adjusting friction during each step, respondents reported an 87% reduction in falls and 93% fewer injurious falls. Estrada cautioned that the findings are an early signal and said prospective studies are underway.

In an interview with The American Journal of Managed Care® (AJMC®), Estrada discussed who is the best candidate for this kind of footwear and what it will take for it to become part of standard fall prevention care.

This transcript has been lightly edited for clarity.

AJMC: The study included people with MS, neuropathy, stroke, Parkinson disease, and other conditions. Who do you see as the best candidates for this kind of footwear, and who might still need other approaches?

Estrada: I would start with the person’s walking mechanics rather than the diagnosis. People with MS, peripheral neuropathy, stroke, Parkinson disease, age-related changes, or shuffling often have mechanics that shoes designed to reduce toe catch are well suited to address. But 2 people with very similar diagnoses can have very different mobility needs. One person may have good balance and strength but frequently make contact with the ground during swing. Another may have more significant postural instability or weakness and have difficulty supporting their body when standing still. Those individuals need different interventions. You don’t need a Parkinson shoe or an MS shoe. You need a shoe that lessens the consequences when something in the environment would cause someone to trip.

It’s not intended to replace rehab, strengthening, or bracing; the best approach to fall prevention is multimodal. The opportunity is to look for decreased foot clearance or repeated toe contacts. Ask people, “Do you hear yourself scuffing a lot?” Then consider whether responsive footwear can complement their existing care. Physical therapy programs are designed to end. You make the home safe with grab bars and anti-slip mats, but then the whole rest of the world exists. Footwear is an intervention that travels with the person throughout the day.

AJMC: What comes next for this research, and what would future studies need to show for footwear like this to become part of standard fall prevention care?

Estrada: The next step is moving from a promising clinical signal to the evidence that health care relies on, which is prospective controlled studies, and we’re already in process for those. We need to compare variable friction footwear and conventional footwear objectively, using fall outcome measures. One question I’m interested in is whether, in our mission to reduce slips, traditional shoes have inadvertently increased trips.

We also need to understand who benefits most. Right now we see it in populations like MS, peripheral neuropathy, chronic stroke, and age-related changes, but those are really changes in walking patterns. Anyone with low foot clearance could benefit, not only someone with MS. Identifying mechanics that a provider can recognize without a diagnosis would be an important next step.

Then it gets into cost of care and health care utilization. We have a prospective actuarial study underway in Medicaid to show what happens when you take a population health approach to something as simple as footwear. Almost every intervention requires significant behavior change, like scheduling appointments, leaving the house, and exercising. Here, people put on a pair of shoes and go live their lives. For many people with neurological conditions, it’s not true that they would fall less if they just worked harder. We need to give them tools that make the environment less unsafe.