The Ergonomics Open Journal


ISSN: 1875-9343 ― Volume 10, 2017

Influence of Footwear on Gait Characteristics that are Associated With Increased Fall Risk in Older Persons



Tischa JM van der Cammen1, 2, 3, Carolyn Shanty Sterke4, 5, Alen Halilovic1, Johan Molenbroek1, *
1 Faculty of Industrial Design Engineering, Department of Industrial Design, Delft University of Technology, Landbergstraat 15, 2628 CE Delft, The Netherlands
2 Department of Internal Medicine, Section of Geriatric Medicine, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
3 Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
4 Aafje Nursing Homes, PO BOX 9293, 3007 AG Rotterdam, The Netherlands
5 Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands

Abstract

Objective:

To investigate the influence of three different types of shoe models frequently worn at home, including an open heel shoe model, on gait parameters that are associated with fall risk in older persons.

Methods:

Twenty-five community-dwelling independent older persons were asked to walk on an electronic walkway system, the GAITRite® walkway, while wearing three different shoe models which are frequently worn at home. We measured spatial and temporal gait parameters.

Results:

Gait velocity and stride length were significantly reduced, and step time, stance, and double support time were significantly increased, when older persons wore an open heel shoe model compared to the high collar shoe models.

Conclusion:

Wearing an open heel shoe model is associated with gait parameters that are associated with fall risk, compared with a high collar shoe model, in community-dwelling older persons. With regard to falls prevention, further attention for footwear in older persons seems warranted, especially for footwear worn in and around the home.

Keywords: Electronic walkway, Footwear, Fall risk, Gait parameters, Older persons.


Article Information


Identifiers and Pagination:

Year: 2016
Volume: 9
First Page: 43
Last Page: 49
Publisher Id: TOERGJ-9-43
DOI: 10.2174/1875934301609010043

Article History:

Received Date: 02/06/2016
Revision Received Date: 20/10/2016
Acceptance Date: 27/10/2016
Electronic publication date: 30/12/2016
Collection year: 2016

© van der Cammen et al.; Licensee Bentham Open

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (https://creativecommons.org/licenses/by-nc/4.0/legalcode), which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the at the Faculty of Industrial Design Engineering, Department of Industrial Design, Delft University of Technology, Landbergstraat 15, 2628 CE Delft, The Netherlands; Tel: +31152783021; Fax: +31152787179; E-mail: j.f.m.molenbroek@tudelft.nl




1. INTRODUCTION

Falls are a major problem in the older population. One third of community-dwelling older persons experience a fall at least once a year, of those fallers 50% fall more than once a year [1Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990; 19(2): 136-41.
[http://dx.doi.org/10.1093/ageing/19.2.136] [PMID: 2337010]
-3Tromp AM, Pluijm SM, Smit JH, Deeg DJ, Bouter LM, Lips P. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 2001; 54(8): 837-44.
[http://dx.doi.org/10.1016/S0895-4356(01)00349-3] [PMID: 11470394]
]. Most falls occur in and around the home [4Veiligheid NL. Valongevallen 65-plussers 2013 [Retrieved from the website of VeiligheidNL]; Available from: http://www.veiligheid.nl/csi/veiligheidnl.nsf/content/brongegevens-onderzoek. [2014 February 26];], however information on the footwear worn during these falls is not available [4Veiligheid NL. Valongevallen 65-plussers 2013 [Retrieved from the website of VeiligheidNL]; Available from: http://www.veiligheid.nl/csi/veiligheidnl.nsf/content/brongegevens-onderzoek. [2014 February 26];].

In a pilot study in the Geriatrics Out Patients Clinic of the Erasmus University Medical Center we found that open heel slippers were the usual and preferred footwear of older people in and around the home [5Oei BH. Design of footwear for the prevention of falls among seniors: Final Master project Faculty Industrial Design Engineering. Delft, The Netherlands: Delft University of Technology 2005.]. In 2003 the Easington primary care trust found that “sloppy slippers” were responsible for a considerable number of falls [6Easington primary care trust. 'Sloppy slipper' scheme cuts old people's falls. 2003 [Retrieved from the website of the Guardian]; Available from: http://www.theguardian.com/society/2003/dec/23/longtermcare [2014 March 21];]. In 2004, a study in residential care homes in New Zealand reported that wearing slippers was associated with injurious falls [7Kerse N, Butler M, Robinson E, Todd M. Wearing slippers, falls and injury in residential care. Aust N Z J Public Health 2004; 28(2): 180-7.
[http://dx.doi.org/10.1111/j.1467-842X.2004.tb00933.x] [PMID: 15233359]
].

Inappropriate footwear has been identified as a contributor of up to 45% of falls [8Boelens C, Hekman EE, Verkerke GJ. Risk factors for falls of older citizens. Technol Health Care 2013; 21(5): 521-33.
[PMID: 24077498]
, 9Gabell A, Simons MA, Nayak US. Falls in the healthy elderly: predisposing causes. Ergonomics 1985; 28(7): 965-75.
[http://dx.doi.org/10.1080/00140138508963219] [PMID: 4043031]
]. Walking barefoot or in socks can elevate fall risk [10Koepsell TD, Wolf ME, Buchner DM, et al. Footwear style and risk of falls in older adults. J Am Geriatr Soc 2004; 52(9): 1495-501.
[http://dx.doi.org/10.1111/j.1532-5415.2004.52412.x] [PMID: 15341551]
, 11Menz HB, Morris ME, Lord SR. Footwear characteristics and risk of indoor and outdoor falls in older people. Gerontology 2006; 52(3): 174-80.
[http://dx.doi.org/10.1159/000091827] [PMID: 16645298]
]. Also, wearing shoes with a low collar or a high heel has been shown to increase fall risk and impair balance [12Lord SR, Bashford GM. Shoe characteristics and balance in older women. J Am Geriatr Soc 1996; 44(4): 429-33.
[http://dx.doi.org/10.1111/j.1532-5415.1996.tb06416.x] [PMID: 8636591]
, 13Lord SR, Bashford GM, Howland A, Munroe BJ. Effects of shoe collar height and sole hardness on balance in older women. J Am Geriatr Soc 1999; 47(6): 681-4.
[http://dx.doi.org/10.1111/j.1532-5415.1999.tb01589.x] [PMID: 10366166]
].

Effects of footwear on gait characteristics have been reported [14Arnadottir SA, Mercer VS. Effects of footwear on measurements of balance and gait in women between the ages of 65 and 93 years. Phys Ther 2000; 80(1): 17-27.
[PMID: 10623957]
, 15Stephen DG, Wilcox BJ, Niemi JB, Franz JR, Kerrigan D, DAndrea SE. Baseline-dependent effect of noise-enhanced insoles on gait variability in healthy elderly walkers. Gait Posture 2012; 36(3): 537-40.
[http://dx.doi.org/10.1016/j.gaitpost.2012.05.014] [PMID: 22739049]
]. Wearing walking shoes increased gait speed compared to wearing dress shoes [14Arnadottir SA, Mercer VS. Effects of footwear on measurements of balance and gait in women between the ages of 65 and 93 years. Phys Ther 2000; 80(1): 17-27.
[PMID: 10623957]
]. The application of insoles with a mechanical stimulation to the soles of the feet decreased stride-to-stride variability in step width and stride length [15Stephen DG, Wilcox BJ, Niemi JB, Franz JR, Kerrigan D, DAndrea SE. Baseline-dependent effect of noise-enhanced insoles on gait variability in healthy elderly walkers. Gait Posture 2012; 36(3): 537-40.
[http://dx.doi.org/10.1016/j.gaitpost.2012.05.014] [PMID: 22739049]
].

In recent years several gait parameters as measured with an electronic walkway system (GAITRite®) have been shown to be associated with increased fall risk. Decreased velocity and stride length [16Sterke CS, van Beeck EF, Looman CW, Kressig RW, van der Cammen TJ. An electronic walkway can predict short-term fall risk in nursing home residents with dementia. Gait Posture 2012; 36(1): 95-101.
[http://dx.doi.org/10.1016/j.gaitpost.2012.01.012] [PMID: 22386897]
, 17Verghese J, Holtzer R, Lipton RB, Wang C. Quantitative gait markers and incident fall risk in older adults. J Gerontol A Biol Sci Med Sci 2009; 64(8): 896-901.
[http://dx.doi.org/10.1093/gerona/glp033] [PMID: 19349593]
], increased double-support time [18McDonough AL, Batavia M, Chen FC, Kwon S, Ziai J. The validity and reliability of the GAITRite systems measurements: A preliminary evaluation. Arch Phys Med Rehabil 2001; 82(3): 419-25.
[http://dx.doi.org/10.1053/apmr.2001.19778] [PMID: 11245768]
], and increased stride-to-stride variability in swing time [19Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil 2001; 82(8): 1050-6.
[http://dx.doi.org/10.1053/apmr.2001.24893] [PMID: 11494184]
, 20McGough EL, Logsdon RG, Kelly VE, Teri L. Functional mobility limitations and falls in assisted living residents with dementia: physical performance assessment and quantitative gait analysis. J Geriatr Phys Ther 2013; 36(2): 78-86.
[http://dx.doi.org/10.1519/JPT.0b013e318268de7f] [PMID: 22976811]
], have been shown to be associated with risk of falls [16Sterke CS, van Beeck EF, Looman CW, Kressig RW, van der Cammen TJ. An electronic walkway can predict short-term fall risk in nursing home residents with dementia. Gait Posture 2012; 36(1): 95-101.
[http://dx.doi.org/10.1016/j.gaitpost.2012.01.012] [PMID: 22386897]
-20McGough EL, Logsdon RG, Kelly VE, Teri L. Functional mobility limitations and falls in assisted living residents with dementia: physical performance assessment and quantitative gait analysis. J Geriatr Phys Ther 2013; 36(2): 78-86.
[http://dx.doi.org/10.1519/JPT.0b013e318268de7f] [PMID: 22976811]
].

A study with textured insoles worn by older adults with a history of falls did not show any benefit on gait parameters as measured with the electronic walkway system (GAITRite®) [21Hatton AL, Dixon J, Rome K, Newton JL, Martin DJ. Altering gait by way of stimulation of the plantar surface of the foot: the immediate effect of wearing textured insoles in older fallers. J Foot Ankle Res 2012; 5: 11.
[http://dx.doi.org/10.1186/1757-1146-5-11] [PMID: 22546376]
].

Literature on the use of open heel shoe models and fall risk is lacking. We were interested in the possible relationship between use of open heel shoes and fall risk. In this study we used gait parameters as measured with an electronic walkway system as a derivative of fall risk. We investigated the influence of footwear, including an open heel shoe model, on gait parameters which are associated with fall risk in older persons. We consider that this is a preferred and more reliable method for studying footwear in relation to falls, as compared to testing the shoe models in real life situations, where we would have to rely on self-reports of falls and footwear worn during the fall.

2. METHODS

2.1. Participants

A convenience sample of 25 community-dwelling independent older persons (14 women and 11 men), aged 59-85 years (mean age 68.5 years, SD ± 6.9), was recruited from visitors of a shoe store specialized in comfort shoes for older people, www.intersko.com, between 16 and 27 March 2013. All participants were able to walk independently at least 12 meters and gave their written informed consent. Participants were asked to walk on an electronic walkway system, the GAITRite® walkway, while wearing three different shoe models selected because they are frequently worn at home. With every shoe model each participant performed two walks on the walkway, the first walk being a test walk and the second walk the definite walk.

After six walks, the participants were asked whether they had experienced a fall in the past year; three out of 25 were single fallers, i.e., they experienced one fall in the past year; 22 out of 25 were non-fallers. Furthermore, participants were asked to fill in a questionnaire with questions relating to personal preference and experience with the three different shoe models. They had to indicate which shoe model they preferred for five aspects of the shoe, i.e., which shoe is easy to put on, is most comfortable, is most stable, is aesthetically pleasing, would you purchase? For each of the five aspects they could only rate one shoe model as the preferred one.

This study was approved by the Human Research Ethics Committee, Delft University of Technology.

2.3. Shoe models

Model 1 was an open heel soft material shoe, without collar. Model 2 was a soft material shoe, with closed heel and a high collar. Model 3 was a hard material shoe, with closed heel and a high collar. Model 2 and model 3 had a closing mechanism with Velcro (see Fig. 1).

2.3.1. Selection Criteria for the Three Shoe Models

Why did we choose for these three shoe models?

Fig. (1)
Shoe models 1, 2, and 3.


In the current market of shoes there are several solutions to make a shoe fit to the foot shape.

  1. Individual made to measure shoe: i.e., 3D-printing of a shoe after 3D-scanning of a foot shape (Additive Manufacturing).
  2. Adjustable fastening with Velcro or straps or pins
  3. Traditional shoes with laces
  4. Open heel slippers or shoes
  5. Closed heel slippers or shoes.

In putting shoes on and taking them off (donning and doffing), the ease plays an important role. Therefore shoes with laces(c) were excluded from this experiment for indoor shoed feet. Further requirements are the ease of fastening and the ease of adjustments to make the shoe fit.

2.4. Electronic Walkway

We used the GAITRite®-732 system (Biometrics France) to measure and record temporal and spatial parameters of gait. The GAITRite®-system is a portable computer based electronic roll-up walkway with an overall dimension of 823 cm x 90 cm x 0.6 cm connected to a personal computer with application software for calculation of temporal and spatial parameters of gait. The active area of the walkway is 732 cm x 61 cm. Pressure sensors are embedded into the carpet in a horizontal grid. We followed the guidelines for clinical applications of spatial-temporal gait analysis in older adults [22Kressig RW, Beauchet O. Guidelines for clinical applications of spatio-temporal gait analysis in older adults. Aging Clin Exp Res 2006; 18(2): 174-6.
[http://dx.doi.org/10.1007/BF03327437] [PMID: 16702791]
].

2.5. Gait Parameters

Spatial gait parameters used in this study were: stride length, and heel-to-heel base of support. Temporal parameters used were: cadence (steps/minute), step time, velocity, swing time, stance, and double support time. Variability in the GAITRite® parameters step time, swing time, stance, stride length, heel-to-heel base support, and double support time was expressed as coefficients of variation (CV), i.e. Standard deviation (SD)/mean *100%.

2.6. Analysis

The normal distribution of all the gait parameters was tested using the Shapiro–Wilk test. For the parameters that had a normal distribution, a repeated measures analysis of variance (ANOVA) was used to compare gait parameters between the three different shoe models. For the parameters that were not normally distributed, the Friedman test was used. In a post-hoc analysis we compared shoe model 1 to shoe model 2, shoe model 1 to shoe model 3, and shoe model 2 to shoe model 3. Student’s paired samples t-test with Bonferroni correction was used for post hoc analysis of the parameters that had a normal distribution. The Wilcoxon signed-rank test was used for the post-hoc analysis of the not-normally distributed gait parameters. A two-sided p value of less than 0.05 was considered as statistically significant. For each pairwise comparison we calculated Cohen’s d and 95% confidence intervals (CIs), which is defined as the difference between two means divided by a standard deviation for the data [23Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, New Jersey: Lawrence Earlbaum Associates 1988.].

All statistical analyses were performed using SPSS software (version 20.0, SPSS INC., Chicago, IL, U.S.A.).

With regard to the personal preference and experience with the three different shoe models, we counted for each shoe model the number of preferences.

3. RESULTS

3.1. Gait Parameters

Shoe model 2 and model 3 had a significantly better performance compared to model 1.

We found 5 gait parameters which performed significantly better for shoe model 2 compared to model 1, i.e., velocity, step time, stance, double support time, and stride length.

We found 3 gait parameters which performed significantly better for shoe model 3 compared to model 1, i.e., velocity, step time, and stride length.

Significant gait parameters, the effect sizes, and 95% CIs are shown in Table 1.

Table 1
Significant differences in GAITRite® parameters between the de different shoe models.


3.2. Acceptability

Fig. (2) shows the results of the participants’ ratings for personal preference and experience with different models. Model 2 was best accepted, and had the highest rating for comfort.

Ten persons had some physical difficulties when using the Velcro system.

4. DISCUSSION

This study compared the effects of three different shoe models for indoor use, including an open heel shoe, on gait parameters associated with falls in older people, using an electronic walkway system.

Fig. (2)
Participants’ opinions on comfort and aesthetics of the 3 shoe models.


The two high collar shoe models (model 2 and model 3) performed significantly better than the open heel shoe model (model 1) with respect to gait parameters known to increase fall risk. Gait velocity and stride length were significantly reduced when wearing the open heel shoe model compared to the high collar shoe models. Step time, stance, and double support time increased significantly when wearing the open heel shoe model compared to the high collar shoe models. This implies that with regard to fall risk [16Sterke CS, van Beeck EF, Looman CW, Kressig RW, van der Cammen TJ. An electronic walkway can predict short-term fall risk in nursing home residents with dementia. Gait Posture 2012; 36(1): 95-101.
[http://dx.doi.org/10.1016/j.gaitpost.2012.01.012] [PMID: 22386897]
, 17Verghese J, Holtzer R, Lipton RB, Wang C. Quantitative gait markers and incident fall risk in older adults. J Gerontol A Biol Sci Med Sci 2009; 64(8): 896-901.
[http://dx.doi.org/10.1093/gerona/glp033] [PMID: 19349593]
, 19Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil 2001; 82(8): 1050-6.
[http://dx.doi.org/10.1053/apmr.2001.24893] [PMID: 11494184]
, 20McGough EL, Logsdon RG, Kelly VE, Teri L. Functional mobility limitations and falls in assisted living residents with dementia: physical performance assessment and quantitative gait analysis. J Geriatr Phys Ther 2013; 36(2): 78-86.
[http://dx.doi.org/10.1519/JPT.0b013e318268de7f] [PMID: 22976811]
] a high collar shoe model should be preferred to an open heel shoe model.

Thus it appears that the preferred and commonly worn open heel shoe model for use in and around the home affects gait characteristics in such a way, that it is likely to increase fall risk. As most falls in older persons in the Netherlands have been shown to occur in and around the home [4Veiligheid NL. Valongevallen 65-plussers 2013 [Retrieved from the website of VeiligheidNL]; Available from: http://www.veiligheid.nl/csi/veiligheidnl.nsf/content/brongegevens-onderzoek. [2014 February 26];], the question arises whether the high number of falls in and around the home might be due, in part, to inappropriate footwear worn at home [5Oei BH. Design of footwear for the prevention of falls among seniors: Final Master project Faculty Industrial Design Engineering. Delft, The Netherlands: Delft University of Technology 2005.].

4.1. Strengths and Weaknesses of the Study

The strength of this study is that we provided the participants with standardized shoe models to control for specific footwear characteristics. This increases the information about shoe characteristics and their effects on gait parameters, and should improve generalisability of the results.

This study has several limitations. Firstly, sampling error could have influenced our results since the participants were volunteers and information about their health status is lacking. However, we expect that the hazardous effects of the open heel shoe model on gait parameters reported here might be magnified if applied to less able older people. Secondly, the findings should be treated with caution when applied to real life situations, since the testing was conducted in a shoe store where participants walked on an electronic walkway, i.e., on a flat surface. However, we think that in real life situations in and around the home, the differences in gait characteristics might be even more pronounced.

4.2. Comparison With Other Studies

As far as we are aware from the literature, this is the first study to test and demonstrate the effects of three specific shoe models on gait parameters associated with fall risk in community-dwelling older persons, as measured with an electronic walkway. Also, we believe it is the first study to include an open heel shoe model in the comparison.

We found only one study measuring the effect of textured insoles in community-dwelling older fallers with an electronic walkway system; this study showed a negative effect on gait parameters associated with falls, i.e., wearing the textured insoles led to a significantly lower gait velocity, step length, and stride length compared with wearing smooth insoles [21Hatton AL, Dixon J, Rome K, Newton JL, Martin DJ. Altering gait by way of stimulation of the plantar surface of the foot: the immediate effect of wearing textured insoles in older fallers. J Foot Ankle Res 2012; 5: 11.
[http://dx.doi.org/10.1186/1757-1146-5-11] [PMID: 22546376]
]. The difference between this study and the current study is that in our study, a history of falls was not an inclusion criterion.

CONCLUSION AND IMPLICATIONS

In conclusion, the current study demonstrates that wearing an open heel shoe model is associated with gait parameters that have been shown to be associated with fall risk, compared with a high collar shoe model, in community-dwelling independent older persons.

Further research is needed to identify the specific shoe characteristics that provide the greatest benefits for safety and comfort, especially for footwear worn in and around the home.

DECLARATION OF SOURCES OF FUNDING

This work was supported by the Foundation for Quality of Life in Ageing. The Foundation for Quality of Life in Ageing funded a travel grant for AH to travel between Delft University of Technology and the Intersko Shoe Company in Voorburg.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

We thank Marcel van t Hoff, Intersko Company, Voorburg, The Netherlands, for providing the shoe models. Marcel van t Hoff had no involvement in the study design, in the collection, analysis and interpretation of data, in the writing of the manuscript, and in the decision to submit the manuscript for publication.

REFERENCES

[1] Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990; 19(2): 136-41.
[http://dx.doi.org/10.1093/ageing/19.2.136] [PMID: 2337010]
[2] Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med 1997; 337(18): 1279-84.
[http://dx.doi.org/10.1056/NEJM199710303371806] [PMID: 9345078]
[3] Tromp AM, Pluijm SM, Smit JH, Deeg DJ, Bouter LM, Lips P. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 2001; 54(8): 837-44.
[http://dx.doi.org/10.1016/S0895-4356(01)00349-3] [PMID: 11470394]
[4] Veiligheid NL. Valongevallen 65-plussers 2013 [Retrieved from the website of VeiligheidNL]; Available from: http://www.veiligheid.nl/csi/veiligheidnl.nsf/content/brongegevens-onderzoek. [2014 February 26];
[5] Oei BH. Design of footwear for the prevention of falls among seniors: Final Master project Faculty Industrial Design Engineering. Delft, The Netherlands: Delft University of Technology 2005.
[6] Easington primary care trust. 'Sloppy slipper' scheme cuts old people's falls. 2003 [Retrieved from the website of the Guardian]; Available from: http://www.theguardian.com/society/2003/dec/23/longtermcare [2014 March 21];
[7] Kerse N, Butler M, Robinson E, Todd M. Wearing slippers, falls and injury in residential care. Aust N Z J Public Health 2004; 28(2): 180-7.
[http://dx.doi.org/10.1111/j.1467-842X.2004.tb00933.x] [PMID: 15233359]
[8] Boelens C, Hekman EE, Verkerke GJ. Risk factors for falls of older citizens. Technol Health Care 2013; 21(5): 521-33.
[PMID: 24077498]
[9] Gabell A, Simons MA, Nayak US. Falls in the healthy elderly: predisposing causes. Ergonomics 1985; 28(7): 965-75.
[http://dx.doi.org/10.1080/00140138508963219] [PMID: 4043031]
[10] Koepsell TD, Wolf ME, Buchner DM, et al. Footwear style and risk of falls in older adults. J Am Geriatr Soc 2004; 52(9): 1495-501.
[http://dx.doi.org/10.1111/j.1532-5415.2004.52412.x] [PMID: 15341551]
[11] Menz HB, Morris ME, Lord SR. Footwear characteristics and risk of indoor and outdoor falls in older people. Gerontology 2006; 52(3): 174-80.
[http://dx.doi.org/10.1159/000091827] [PMID: 16645298]
[12] Lord SR, Bashford GM. Shoe characteristics and balance in older women. J Am Geriatr Soc 1996; 44(4): 429-33.
[http://dx.doi.org/10.1111/j.1532-5415.1996.tb06416.x] [PMID: 8636591]
[13] Lord SR, Bashford GM, Howland A, Munroe BJ. Effects of shoe collar height and sole hardness on balance in older women. J Am Geriatr Soc 1999; 47(6): 681-4.
[http://dx.doi.org/10.1111/j.1532-5415.1999.tb01589.x] [PMID: 10366166]
[14] Arnadottir SA, Mercer VS. Effects of footwear on measurements of balance and gait in women between the ages of 65 and 93 years. Phys Ther 2000; 80(1): 17-27.
[PMID: 10623957]
[15] Stephen DG, Wilcox BJ, Niemi JB, Franz JR, Kerrigan D, DAndrea SE. Baseline-dependent effect of noise-enhanced insoles on gait variability in healthy elderly walkers. Gait Posture 2012; 36(3): 537-40.
[http://dx.doi.org/10.1016/j.gaitpost.2012.05.014] [PMID: 22739049]
[16] Sterke CS, van Beeck EF, Looman CW, Kressig RW, van der Cammen TJ. An electronic walkway can predict short-term fall risk in nursing home residents with dementia. Gait Posture 2012; 36(1): 95-101.
[http://dx.doi.org/10.1016/j.gaitpost.2012.01.012] [PMID: 22386897]
[17] Verghese J, Holtzer R, Lipton RB, Wang C. Quantitative gait markers and incident fall risk in older adults. J Gerontol A Biol Sci Med Sci 2009; 64(8): 896-901.
[http://dx.doi.org/10.1093/gerona/glp033] [PMID: 19349593]
[18] McDonough AL, Batavia M, Chen FC, Kwon S, Ziai J. The validity and reliability of the GAITRite systems measurements: A preliminary evaluation. Arch Phys Med Rehabil 2001; 82(3): 419-25.
[http://dx.doi.org/10.1053/apmr.2001.19778] [PMID: 11245768]
[19] Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil 2001; 82(8): 1050-6.
[http://dx.doi.org/10.1053/apmr.2001.24893] [PMID: 11494184]
[20] McGough EL, Logsdon RG, Kelly VE, Teri L. Functional mobility limitations and falls in assisted living residents with dementia: physical performance assessment and quantitative gait analysis. J Geriatr Phys Ther 2013; 36(2): 78-86.
[http://dx.doi.org/10.1519/JPT.0b013e318268de7f] [PMID: 22976811]
[21] Hatton AL, Dixon J, Rome K, Newton JL, Martin DJ. Altering gait by way of stimulation of the plantar surface of the foot: the immediate effect of wearing textured insoles in older fallers. J Foot Ankle Res 2012; 5: 11.
[http://dx.doi.org/10.1186/1757-1146-5-11] [PMID: 22546376]
[22] Kressig RW, Beauchet O. Guidelines for clinical applications of spatio-temporal gait analysis in older adults. Aging Clin Exp Res 2006; 18(2): 174-6.
[http://dx.doi.org/10.1007/BF03327437] [PMID: 16702791]
[23] Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, New Jersey: Lawrence Earlbaum Associates 1988.

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Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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