Factors associated with change in health-related quality of life in people with gout: a 3-year prospective cohort study in primary care.

OBJECTIVE: To describe factors associated with change in health-related quality of life (HRQOL) in people living with gout in primary care. METHODS: In a UK prospective cohort study, adults with a diagnosis of gout registered with 20 general practices completed the Gout Impact Scale (GIS; scale 0-100), 36-item Short Form Physical Function subscale (PF-10; 0-100) and HAQ Disability Index (HAQ-DI; 0-3) via postal questionnaires at baseline and 6, 12, 24 and 36 months. Linear mixed modelling was used to investigate factors associated with changes in HRQOL over 3 years. RESULTS: A total of 1184 participants responded at baseline (adjusted response 65.6%); 990 (83.6%) were male, with a mean age of 65.6 years (s.d. 12.5). A total of 818, 721, 696 and 605 responded at 6, 12, 24 and 36 months, respectively. Factors associated with worse disease-specific and generic HRQOL over 3 years were flare frequency (five or more flares; GIS subscales, PF-10), oligo/polyarticular flares (GIS subscales, PF-10, HAQ-DI), worse pain (GIS subscales, PF-10, HAQ-DI), body pain (GIS subscales, PF-10, HAQ-DI) and more severe depression (GIS subscales, PF-10, HAQ-DI) (P ≤ 0.05). More severe anxiety was associated with worse disease-specific HRQOL only (GIS subscales). Older age (PF-10), being female (PF-10, HAQ-DI) and BMI (HAQ-DI) were associated with worse generic HRQOL (P ≤ 0.05). CONCLUSION: Gout-specific, comorbid and sociodemographic factors were associated with change in HRQOL over a 3-year period, highlighting people at risk of worse outcomes who could be targeted for interventions.

Foot orthoses for treating paediatric flat feet.

BACKGROUND: Paediatric flat feet are a common presentation in primary care; reported prevalence approximates 15%. A minority of flat feet can hurt and limit gait. There is no optimal strategy, nor consensus, for using foot orthoses (FOs) to treat paediatric flat feet. OBJECTIVES: To assess the benefits and harms of foot orthoses for treating paediatric flat feet. SEARCH METHODS: We searched CENTRAL, MEDLINE, and Embase to 01 September 2021, and two clinical trials registers on 07 August 2020. SELECTION CRITERIA: We identified all randomised controlled trials (RCTs) of FOs as an intervention for paediatric flat feet. The outcomes included in this review were pain, function, quality of life, treatment success, and adverse events. Intended comparisons were: any FOs versus sham, any FOs versus shoes, customised FOs (CFOs) versus prefabricated FOs (PFOs). DATA COLLECTION AND ANALYSIS: We followed standard methods recommended by Cochrane. MAIN RESULTS: We included 16 trials with 1058 children, aged 11 months to 19 years, with flexible flat feet. Distinct flat foot presentations included asymptomatic, juvenile idiopathic arthritis (JIA), symptomatic and developmental co-ordination disorder (DCD). The trial interventions were FOs, footwear, foot and rehabilitative exercises, and neuromuscular electrical stimulation (NMES). Due to heterogeneity, we did not pool the data. Most trials had potential for selection, performance, detection, and selective reporting bias. No trial blinded participants. We present the results separately for asymptomatic (healthy children) and symptomatic (children with JIA) flat feet. The certainty of evidence was very low to low, downgraded for bias, imprecision, and indirectness. Three comparisons were evaluated across trials: CFO versus shoes; PFO versus shoes; CFO versus PFO. Asymptomatic flat feet 1. CFOs versus shoes (1 trial, 106 participants): low-quality evidence showed that CFOs result in little or no difference in the proportion without pain (10-point visual analogue scale (VAS)) at one year (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.67 to 1.07); absolute decrease (11.8%, 95% CI 4.7% fewer to 15.8% more); or on withdrawals due to adverse events (RR 1.05, 95% CI 0.94 to 1.19); absolute effect (3.4% more, 95% CI 4.1% fewer to 13.1% more). 2. PFOs versus shoes (1 trial, 106 participants): low to very-low quality evidence showed that PFOs result in little or no difference in the proportion without pain (10-point VAS) at one year (RR 0.94, 95% CI 0.76 to 1.16); absolute effect (4.7% fewer, 95% CI 18.9% fewer to 12.6% more); or on withdrawals due to adverse events (RR 0.99, 95% CI 0.79 to 1.23). 3. CFOs versus PFOs (1 trial, 108 participants): low-quality evidence found no difference in the proportion without pain at one year (RR 0.93, 95% CI 0.73 to 1.18); absolute effect (7.4% fewer, 95% CI 22.2% fewer to 11.1% more); or on withdrawal due to adverse events (RR 1.00, 95% CI 0.90 to 1.12). Function and quality of life (QoL) were not assessed. Symptomatic (JIA) flat feet 1. CFOs versus shoes (1 trial, 28 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain (0 to 10 scale, 0 no pain) between groups (MD -1.5, 95% CI -2.78 to -0.22). Low-quality evidence showed improvements in function with CFOs (Foot Function Index - FFI disability, 0 to 100, 0 best function; MD -18.55, 95% CI -34.42 to -2.68), child-rated QoL (PedsQL, 0 to 100, 100 best quality; MD 12.1, 95% CI -1.6 to 25.8) and parent-rated QoL (PedsQL MD 9, 95% CI -4.1 to 22.1) and little or no difference between groups in treatment success (timed walking; MD -1.33 seconds, 95% CI -2.77 to 0.11), or withdrawals due to adverse events (RR 0.58, 95% CI 0.11 to 2.94); absolute difference (9.7% fewer, 20.5 % fewer to 44.8% more). 2. PFOs versus shoes (1 trial, 25 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain between groups (MD 0.02, 95% CI -1.94 to 1.98). Low-quality evidence showed no difference between groups in function (FFI-disability MD -4.17, 95% CI -24.4 to 16.06), child-rated QoL (PedsQL MD -3.84, 95% CI -19 to 11.33), or parent-rated QoL (PedsQL MD -0.64, 95% CI -13.22 to 11.94). 3. CFOs versus PFsO (2 trials, 87 participants): low-quality evidence showed little or no difference between groups in pain (0 to scale, 0 no pain) at 3 months (MD -1.48, 95% CI -3.23 to 0.26), function (FFI-disability MD -7.28, 95% CI -15.47 to 0.92), child-rated QoL (PedsQL MD 8.6, 95% CI -3.9 to 21.2), or parent-rated QoL (PedsQL MD 2.9, 95% CI -11 to 16.8). AUTHORS' CONCLUSIONS: Low to very low-certainty evidence shows that the effect of CFOs (high cost) or PFOs (low cost) versus shoes, and CFOs versus PFOs on pain, function and HRQoL is uncertain. This is pertinent for clinical practice, given the economic disparity between CFOs and PFOs. FOs may improve pain and function, versus shoes in children with JIA, with minimal delineation between costly CFOs and generic PFOs. This review updates that from 2010, confirming that in the absence of pain, the use of high-cost CFOs for healthy children with flexible flat feet has no supporting evidence, and draws very limited conclusions about FOs for treating paediatric flat feet. The availability of normative and prospective foot development data, dismisses most flat foot concerns, and negates continued attention to this topic. Attention should be re-directed to relevant paediatric foot conditions, which cause pain, limit function, or reduce quality of life. The agenda for researching asymptomatic flat feet in healthy children must be relegated to history, and replaced by a targeted research rationale, addressing children with indisputable foot pathology from discrete diagnoses, namely JIA, cerebral palsy, congenital talipes equino varus, trisomy 21 and Charcot Marie Tooth. Whether research resources should continue to be wasted on studying flat feet in healthy children that do not hurt, is questionable. Future updates of this review will address only relevant paediatric foot conditions.

Foot orthoses for treating paediatric flat feet.

BACKGROUND: Paediatric flat feet are a common presentation in primary care; reported prevalence approximates 15%. A minority of flat feet can hurt and limit gait. There is no optimal strategy, nor consensus, for using foot orthoses (FOs) to treat paediatric flat feet. OBJECTIVES: To assess the benefits and harms of foot orthoses for treating paediatric flat feet. SEARCH METHODS: We searched CENTRAL, MEDLINE, and Embase to 01 September 2021, and two clinical trials registers on 07 August 2020. SELECTION CRITERIA: We identified all randomised controlled trials (RCTs) of FOs as an intervention for paediatric flat feet. The outcomes included in this review were pain, function, quality of life, treatment success, and adverse events. Intended comparisons were: any FOs versus sham, any FOs versus shoes, customised FOs (CFOs) versus prefabricated FOs (PFOs). DATA COLLECTION AND ANALYSIS: We followed standard methods recommended by Cochrane. MAIN RESULTS: We included 16 trials with 1058 children, aged 11 months to 19 years, with flexible flat feet. Distinct flat foot presentations included asymptomatic, juvenile idiopathic arthritis (JIA), symptomatic and developmental co-ordination disorder (DCD). The trial interventions were FOs, footwear, foot and rehabilitative exercises, and neuromuscular electrical stimulation (NMES). Due to heterogeneity, we did not pool the data. Most trials had potential for selection, performance, detection, and selective reporting bias. No trial blinded participants. We present the results separately for asymptomatic (healthy children) and symptomatic (children with JIA) flat feet. The certainty of evidence was very low to low, downgraded for bias, imprecision, and indirectness. Three comparisons were evaluated across trials: CFO versus shoes; PFO versus shoes; CFO versus PFO. Asymptomatic flat feet 1. CFOs versus shoes (1 trial, 106 participants): low-quality evidence showed that CFOs result in little or no difference in the proportion without pain (10-point visual analogue scale (VAS)) at one year (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.67 to 1.07); absolute decrease (11.8%, 95% CI 4.7% fewer to 15.8% more); or on withdrawals due to adverse events (RR 1.05, 95% CI 0.94 to 1.19); absolute effect (3.4% more, 95% CI 4.1% fewer to 13.1% more). 2. PFOs versus shoes (1 trial, 106 participants): low to very-low quality evidence showed that PFOs result in little or no difference in the proportion without pain (10-point VAS) at one year (RR 0.94, 95% CI 0.76 to 1.16); absolute effect (4.7% fewer, 95% CI 18.9% fewer to 12.6% more); or on withdrawals due to adverse events (RR 0.99, 95% CI 0.79 to 1.23). 3. CFOs versus PFOs (1 trial, 108 participants): low-quality evidence found no difference in the proportion without pain at one year (RR 0.93, 95% CI 0.73 to 1.18); absolute effect (7.4% fewer, 95% CI 22.2% fewer to 11.1% more); or on withdrawal due to adverse events (RR 1.00, 95% CI 0.90 to 1.12). Function and quality of life (QoL) were not assessed. Symptomatic (JIA) flat feet 1. CFOs versus shoes (1 trial, 28 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain (0 to 10 scale, 0 no pain) between groups (MD -1.5, 95% CI -2.78 to -0.22). Low-quality evidence showed improvements in function with CFOs (Foot Function Index - FFI disability, 0 to 100, 0 best function; MD -18.55, 95% CI -34.42 to -2.68), child-rated QoL (PedsQL, 0 to 100, 100 best quality; MD 12.1, 95% CI -1.6 to 25.8) and parent-rated QoL (PedsQL MD 9, 95% CI -4.1 to 22.1) and little or no difference between groups in treatment success (timed walking; MD -1.33 seconds, 95% CI -2.77 to 0.11), or withdrawals due to adverse events (RR 0.58, 95% CI 0.11 to 2.94); absolute difference (9.7% fewer, 20.5 % fewer to 44.8% more). 2. PFOs versus shoes (1 trial, 25 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain between groups (MD 0.02, 95% CI -1.94 to 1.98). Low-quality evidence showed no difference between groups in function (FFI-disability MD -4.17, 95% CI -24.4 to 16.06), child-rated QoL (PedsQL MD -3.84, 95% CI -19 to 11.33), or parent-rated QoL (PedsQL MD -0.64, 95% CI -13.22 to 11.94). 3. CFOs versus PFOs (2 trials, 87 participants): low-quality evidence showed little or no difference between groups in pain (0 to 10 scale, 0 no pain) at 3 months (MD -1.48, 95% CI -3.23 to 0.26), function (FFI-disability MD -7.28, 95% CI -15.47 to 0.92), child-rated QoL (PedsQL MD 8.6, 95% CI -3.9 to 21.2), or parent-rated QoL (PedsQL MD 2.9, 95% CI -11 to 16.8). AUTHORS' CONCLUSIONS: Low to very low-certainty evidence shows that the effect of CFOs (high cost) or PFOs (low cost) versus shoes, and CFOs versus PFOs on pain, function and HRQoL is uncertain. This is pertinent for clinical practice, given the economic disparity between CFOs and PFOs. FOs may improve pain and function, versus shoes in children with JIA, with minimal delineation between costly CFOs and generic PFOs. This review updates that from 2010, confirming that in the absence of pain, the use of high-cost CFOs for healthy children with flexible flat feet has no supporting evidence, and draws very limited conclusions about FOs for treating paediatric flat feet. The availability of normative and prospective foot development data, dismisses most flat foot concerns, and negates continued attention to this topic. Attention should be re-directed to relevant paediatric foot conditions, which cause pain, limit function, or reduce quality of life. The agenda for researching asymptomatic flat feet in healthy children must be relegated to history, and replaced by a targeted research rationale, addressing children with indisputable foot pathology from discrete diagnoses, namely JIA, cerebral palsy, congenital talipes equino varus, trisomy 21 and Charcot Marie Tooth. Whether research resources should continue to be wasted on studying flat feet in healthy children that do not hurt, is questionable. Future updates of this review will address only relevant paediatric foot conditions.

Effects of worn and new footwear on plantar pressure in people with gout.

BACKGROUND: In clinical trials, good quality athletic shoes offer short-term improvements (two-months) in foot pain and disability in people with gout, but these improvements are not sustained over time. This may be due to wear and subsequent changes to the structural integrity of the shoe. The aim of this study was to examine the effects of wear on plantar pressures and footwear characteristics in shoes over six-months in people with gout. METHODS: Forty people with gout participated in a cross-sectional repeated measures study. Participants wore a pair of commercially available athletic footwear for six-months. Participants then attended a study visit where the worn footwear was compared with a new pair of the same model and size of footwear. Wear characteristics (upper, midsole, outsole) and plantar pressure were measured in the two footwear conditions. Wear characteristics were analysed using paired t-tests and Fisher's exact tests. Plantar pressure data were analysed using linear mixed models. RESULTS: Increases in medial midsole (P < 0.001), lateral midsole (P < 0.001) and heel midsole (P < 0.001) hardness were observed in the worn shoes. Normal upper wear patterns (P < 0.001) and outsole wear patterns (P < 0.001) were observed in most of the worn shoes. No differences in peak plantar pressures (P < 0.007) were observed between the two footwear conditions. Reduced pressure time integrals at the first metatarsophalangeal joint (P < 0.001), second metatarsophalangeal joint (P < 0.001) and hallux (P = 0.003) were seen in the worn shoes. CONCLUSIONS: The study found signs of wear were observed at the upper, midsole and outsole in the worn footwear after six-months. These changes to the structural properties of the footwear may affect forefoot loading patterns in people with gout.

Health professional views on the assessment and management of foot problems in people with psoriatic arthritis in Australia and New Zealand: a qualitative investigation.

BACKGROUND: Active foot disease persists in a high proportion of people with psoriatic arthritis despite the availability of pharmacological and non-pharmacological interventions to modify the course of the disease. Limited information exists on the provision of health care for foot disease in psoriatic arthritis. The objective of this study was to explore the views of health professionals on the assessment and management of people with psoriatic arthritis-related foot involvement. METHODS: Convenience sampling was used to recruit health professionals working in rheumatology outpatient clinics in Sydney, Australia and Auckland, New Zealand. Three focus groups were undertaken to explore the views and experiences of health professionals on the assessment and management of foot problems in people with psoriatic arthritis. All interviews were audio-recorded and transcribed verbatim. Qualitative data was analysed using a constant comparative analytic approach to identify themes. RESULTS: A total of seventeen health professionals participated including rheumatologists, podiatrists and a physiotherapist. Key themes derived from the focus groups suggest that health professionals perceived that people with psoriatic arthritis-related foot problems experience suboptimal management from symptom onset, to diagnosis and treatment. Frustration was expressed throughout discussions relating to lack of appropriate training and expertise required for the specialised management of foot problems typically encountered with psoriatic arthritis and poor access for patients to specialist podiatry services. CONCLUSIONS: This study provides new insight into the perspectives of health professionals on the management of foot problems related to psoriatic arthritis. Deficiencies in the diagnosis, assessment and treatment of foot problems were revealed. To meet the foot health needs of people with psoriatic arthritis, reducing diagnostic delay, improving knowledge and awareness about the disease among people with psoriatic arthritis and health professionals, and increasing specialist podiatry service provision may be required.

The first metatarsophalangeal joint in gout: a systematic review and meta-analysis.

BACKGROUND: The aim of this review was to qualitatively synthesise studies that have investigated characteristics of the first metatarsophalangeal joint (1(st) MTP) in gout and to undertake a meta-analysis to estimate the average prevalence of acute 1(st) MTP arthritis across studies in people with gout. METHODS: Studies published in English were included if they involved participants who had a diagnosis of gout and presented original findings relating to the following outcome measures associated with the 1(st) MTP: epidemiology; clinical features; structural and functional characteristics; and microscopic and imaging features. RESULTS: Forty-five studies were included in the qualitative synthesis. 1(st) MTP pain was a prominent feature in people with gout. People with 1(st) MTP gout reported walking- and general-disability. Structural and functional characteristics of 1(st) MTP gout included hallux valgus, osteoarthritis, and restricted joint motion. Successful crystal aspiration ranged from 81 to 91 % and positive crystal identification via microscopy ranged from 83 to 93 % in patients with a history of 1(st) MTP gout. Imaging features were common at the 1(st) MTP including the double contour sign, tophi and erosions. Eleven studies involving 2,325 participants were included in the meta-analysis, providing an estimate of the average prevalence of acute 1(st) MTP arthritis across studies of 73 % (95 % prediction interval 40-92 %; range 48-97 %; I(2) = 93 %). CONCLUSIONS: 1(st) MTP acute arthritis is highly prevalent in people with gout and has a substantial impact on patient-reported pain and disability. Gout affects the structure and function of the 1(st) MTP. Microscopic and imaging studies have demonstrated crystal deposition and joint damage at the 1(st) MTP in people with gout.

Foot and ankle characteristics associated with falls in adults with established rheumatoid arthritis: a cross-sectional study.

BACKGROUND: People with rheumatoid arthritis (RA) have an increased risk of falls. The foot is a common site of pathology in RA and foot problems are reported in up to 90% of patients with established disease. The aim of this study was to determine whether foot and ankle characteristics are associated with falls in people with RA. METHODS: Adults with RA were recruited from rheumatology outpatient clinics in Auckland, New Zealand. Participants reported whether they had fallen in the preceding year, and the number of falls. Clinical characteristics, common fall risk factors, and foot and ankle variables were measured. Univariate parametric and non-parametric analysis compared fallers and non-fallers on all variables to determine significant differences. Logistic regression analysis identified variables independently associated with falls. RESULTS: Two hundred and one participants were prospectively recruited. At least one fall in the preceding 12-months was reported by 119 (59%) participants. Univariate analysis showed that fallers had significantly longer mean disease duration, more co-morbid conditions, an increase in lower limb tender joints, higher midfoot peak plantar pressures and were more likely to have a history of vascular disease than non-fallers. Fallers also reported greater difficulty with activities of daily living, increased fear of falling and greater self-reported foot impairment. Logistic regression analysis revealed that increased midfoot peak plantar pressures (odds ratio (OR) 1.12 [for each 20 kPa increase], 95% confidence interval (CI) 1.00-1.25), self-reported foot impairment (OR 1.17 [for each three point increase], 95% CI 1.05-1.31) and history of vascular disease (OR 3.22, 95% CI 1.17-8.88) were independently associated with a fall in the preceding 12 months. CONCLUSIONS: Elevated midfoot peak plantar pressures, self-reported foot impairment and vascular disease are associated with falls in people with RA. Assessment of foot deformity, foot function and self-reported foot impairment may be of benefit when considering falls prevention strategies in people with RA. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry (trial ACTRN12612000597897).

Clinical characteristics of foot ulceration in people with chronic gout.

Gout is the most common form of inflammatory arthritis and it has an affliction to the foot. Foot involvement in gout has been linked to foot pain, impairment and disability. There has been limited research on the effect of ulceration on foot pain, impairment, disability and health-related quality of life in patients already living with gout. The aim of the study was to describe the wound characteristics and the effect on foot pain, disability and health-related quality of life in patients with foot ulceration associated with gout. Participants were recruited from rheumatology clinics in Auckland, New Zealand. All the current foot ulceration sites and wound characteristics were recorded using the TIME wound assessment tool. The outcome measures included general pain, patient global assessment scale, foot pain, disability and impairment. Participants completed the Cardiff Wound Impact Schedule to assess the effect of ulcers on health-related quality of life. Sensory loss, vibrational thresholds and ankle brachial pressure index were collated to assess for lower limb arterial disease. Six participants were predominantly older men with a long duration of gout, high rates of obesity and co-morbidities such as hypertension, hyperlipidaemia, diabetes and cardiovascular disease. The mean (SD) duration of the foot ulcers was 4 (2) months. The majority of foot ulcers observed were 0·5 cm(2) or smaller superficial thickness with surrounding callus. Partial thickness and full-thickness ulcers were also observed. Two patients presented with ulcers on multiple sites. There was only one case of infection. Gouty tophi were evident in most of the wounds. The dorsal aspect of the third toe was found to ulcerate in most cases. Moderate scores of foot pain, disability, impairment and health-related quality of life were observed. Most participants wore shoes deemed as poor. Foot ulceration in gout is chronic and multiple ulcers can occur with the potential of leading to delayed wound healing, infection and a reduced quality of life. Poor footwear may contribute to the development and delayed healing of ulceration in people with gout.

Gait characteristics associated with the foot and ankle in inflammatory arthritis: a systematic review and meta-analysis.

BACKGROUND: Gait analysis is increasingly being used to characterise dysfunction of the lower limb and foot in people with inflammatory arthritis (IA). The aim of the systematic review was to evaluate the spatiotemporal, foot and ankle kinematic, kinetic, peak plantar pressure and muscle activity parameters between patients with inflammatory arthritis and healthy controls. METHODS: An electronic literature search was performed on Medline, CINAHL, SportsDiscus and The Cochrane Library. Methodological quality was assessed using a modified Quality Index. Effect sizes with 95% confidence intervals (CI) were calculated as the standardised mean difference (SMD). Meta-analysis was conducted if studies were homogenous. RESULTS: Thirty six studies with quality ranging from high to low met the inclusion criteria. The majority of studies reported gait parameters in Rheumatoid arthritis (RA). The gait pattern in RA was characterised by decreased walking speed (SMD 95% CI -1.57, -2.25 to -0.89), decreased cadence (SMD -0.97, -1.49 to -0.45), decreased stride length (SMD -1.66, -1.84 to -1.49), decreased ankle power (SMD -1.36, -1.70 to -1.02), increased double limb support time (SMD 1.03, 0.84 to 1.22), and peak plantar pressures at the forefoot (SMD 1.11, 0.76 to 1.45). Walking velocity was reduced in psoriatic arthritis and gout with no differences in ankylosing spondylitis. No studies have been conducted in polymyalgia rheumatica, systemic sclerosis or systemic lupus erythematosus. CONCLUSIONS: The review identified the majority of studies reporting gait adaptations in RA, but limited evidence relating to other IA conditions. Poor data reporting, small sample sizes and heterogeneity across IA conditions limit the interpretation of the findings. Future studies may consider a standardised analytical approach to gait analysis that will provide clinicians and researchers with objective evidence of foot function in people with IA.

Reproducibility of a peripheral quantitative computed tomography scan protocol to measure the material properties of the second metatarsal.

BACKGROUND: Peripheral quantitative computed tomography (pQCT) is an established technology that allows for the measurement of the material properties of bone. Alterations to bone architecture are associated with an increased risk of fracture. Further pQCT research is necessary to identify regions of interest that are prone to fracture risk in people with chronic diseases. The second metatarsal is a common site for the development of insufficiency fractures, and as such the aim of this study was to assess the reproducibility of a novel scanning protocol of the second metatarsal using pQCT. METHODS: Eleven embalmed cadaveric leg specimens were scanned six times; three times with and without repositioning. Each foot was positioned on a custom-designed acrylic foot plate to permit unimpeded scans of the region of interest. Sixty-six scans were obtained at 15% (distal) and 50% (mid shaft) of the second metatarsal. Voxel size and scan speed were reduced to 0.40 mm and 25 mm.sec(-1). The reference line was positioned at the most distal portion of the 2(nd) metatarsal. Repeated measurements of six key variables related to bone properties were subject to reproducibility testing. Data were log transformed and reproducibility of scans were assessed using intraclass correlation coefficients (ICC) and coefficients of variation (CV%). RESULTS: Reproducibility of the measurements without repositioning were estimated as: trabecular area (ICC 0.95; CV% 2.4), trabecular density (ICC 0.98; CV% 3.0), Strength Strain Index (SSI) - distal (ICC 0.99; CV% 5.6), cortical area (ICC 1.0; CV% 1.5), cortical density (ICC 0.99; CV% 0.1), SSI - mid shaft (ICC 1.0; CV% 2.4). Reproducibility of the measurements after repositioning were estimated as: trabecular area (ICC 0.96; CV% 2.4), trabecular density (ICC 0.98; CV% 2.8), SSI - distal (ICC 1.0; CV% 3.5), cortical area (ICC 0.99; CV%2.4), cortical density (ICC 0.98; CV% 0.8), SSI - mid shaft (ICC 0.99; CV% 3.2). CONCLUSIONS: The scanning protocol generated excellent reproducibility for key bone properties measured at the distal and mid-shaft regions of the 2(nd) metatarsal. This protocol extends the capabilities of pQCT to evaluate bone quality in people who may be at an increased risk of metatarsal insufficiency fractures.

Reliability of an ultrasound imaging acquisition procedure for examining osteoarthritis in the first metatarsophalangeal joint.

OBJECTIVE: Given the ability of ultrasound imaging (USI) to depict tissue-specific morphological changes before the onset of pain and before the point of irreversible structural damage, USI could play a fundamental role in earlier detection and assessment of foot osteoarthritis (OA). The current guidelines require further refinement of anatomical landmarks to establish a standardized imaging procedure to improve the interpretability and reproducibility between studies evaluating the first metatarsophalangeal joint (MTPJ). The aims were to develop an USI acquisition procedure and grading system to examine OA features in the first MTPJ and to determine intra-examiner and inter-examiner reliability of a newly developed USI acquisition procedure. DESIGN: Thirty participants with first MTPJ OA confirmed radiographically with the use of the La Trobe Foot Atlas were included. An experienced sonographer applied a newly developed USI procedure to examine the following features: joint effusion, synovial hypertrophy, synovitis, joint space narrowing, osteophytes, and cartilage thickness. A semiquantitative grading system was applied to all features. A continuous measure was also examined for osteophyte size, joint space narrowing, and cartilage thickness. To determine the intra-examiner and inter-examiner reliability, an experienced radiologist and sonographer applied the developed grading system to the images acquired from two imaging sessions. Intra-examiner and inter-examiner reliability were calculated using intraclass correlation coefficients (ICCs). RESULTS: ICCs for intra-examiner between session reliability ranged from 0.58 to 0.92 for semiquantitative grading and 0.39 to 0.94 for continuous measures. Joint effusion and osteophytes achieved the highest intra-examiner reliability (ICC = 0.78-0.94). ICCs for session one inter-examiner reliability ranged from 0.61 to 1.0 for semiquantitative grading; all continuous measures had an ICC of 1. ICCs for session two inter-examiner reliability ranged from 0.55 to 1.0 for semiquantitative grading and 0.9 to 0.97 for continuous measures. Inter-examiner reliability was good for grading joint effusion (ICC = 0.55-0.62) and was excellent for all other USI features (ICC = 0.77-1.0). CONCLUSION: The USI acquisition procedure and grading system are reliable in evaluating first MTPJ OA features in participants with radiologically confirmed OA. The study will inform the methodological development of an ultrasound atlas for grading the degree of osteoarthritic change in the first MTPJ.

The effects of wearing textured versus smooth shoe insoles for 4-weeks in people with diabetic peripheral neuropathy: a randomised controlled trial.

PURPOSE: To determine whether short-term wear of textured insoles alters balance, gait, foot sensation, physical activity, or patient-reported outcomes, in people with diabetic neuropathy. MATERIALS AND METHODS: 53 adults with diabetic neuropathy were randomised to wear textured or smooth insoles for 4-weeks. At baseline and post-intervention, balance (foam/firm surface; eyes open/closed) and walking were assessed whilst barefoot, wearing shoes only, and two insoles (textured/smooth). The primary outcome was center of pressure (CoP) total sway velocity. Secondary outcomes included other CoP measures, spatiotemporal gait measures, foot sensation, physical activity, and patient-reported outcomes (foot health, falls efficacy). RESULTS: Wearing textured insoles led to improvements in CoP measures when standing on foam with eyes open, relative to smooth insoles (p ≤ 0.04). The intervention group demonstrated a 5% reduction in total sway velocity, indicative of greater balance. The intervention group also showed a 9-point improvement in self-perceived vigour (p = 0.03). Adjustments for multiple comparisons were not applied. CONCLUSIONS: This study provides weak statistical evidence in favour of textured insoles. Wearing textured insoles may alter measures of balance, suggestive of greater stability, in people with diabetic neuropathy. Plantar stimulation, through textured insoles, may have the capacity to modulate the perception of foot pain, leading to improved well-being.IMPLICATIONS FOR REHABILITATIONShort-term wear of textured insoles can lead to improvements in centre of pressure sway measures when standing on a compliant supporting surface.Wearing textured insoles may have the capacity to help relieve foot pain leading to enhanced self-perceived vitality in people with diabetic peripheral neuropathy.

Ultrasonic evaluation of the abductor hallucis muscle in hallux valgus: a cross-sectional observational study.

BACKGROUND: The aim of the study was to investigate the abductor hallucis muscle characteristics, defined as dorso-plantar (DP) thickness, medio-lateral (ML) width, and cross-sectional area (CSA) in relation to the severity of hallux valgus using musculoskeletal ultrasound. One hundred and two feet, mean (SD) age of 60.3 (20.54) years old, displaying varying severities of hallux valgus were stratified into four groups representing the four grades of the Manchester Scale (grade 0: no deformity, grade 1: mild deformity, grade 2: moderate deformity and grade 3: severe deformity). METHODS: The abductor hallucis muscle was imaged in each foot using a portable ultrasound system. The mean (SD) DP thickness, ML width, and CSA measurements were compared across the four Manchester Scale grades using a one-way ANOVA. RESULTS: Significant differences in DP thickness were found between feet with no hallux valgus (grade 0) and feet with hallux valgus grade 2 (p=0.001) and 3 (p<0.001). Significant differences were also found in ML width between feet with no hallux valgus (grade 0) and feet with grade 2 hallux valgus (p=0.010). Significant differences in CSA were found between feet with no hallux valgus (grade 0) and feet with grade 2 (p<0.001) and grade 3 (p<0.001) hallux valgus. No significant differences in these three muscle characteristics were found between grades 1, 2 and 3 (p>0.0125). CONCLUSIONS: We speculate that morphological changes to the abductor hallucis muscle occur early in the development of the deformity.

The effects of commercially available footwear on foot pain and disability in people with gout: a pilot study.

BACKGROUND: There is limited evidence on non-pharmacological interventions for gout. The aim of the study was to determine whether a footwear intervention can reduce foot pain and musculoskeletal disability in people with gout. METHODS: Thirty-six people with gout participated in a prospective intervention study over 8 weeks. Participants selected one of 4 pairs of shoes and thereafter wore the shoes for 8 weeks. The primary outcome was foot pain using a 100 mm visual analogue scale. Secondary outcomes related to function and disability were also analysed. RESULTS: The Cardio Zip shoe was selected by 58% of participants. Compared with baseline, overall scores for all shoes at 8-weeks demonstrated a decrease in foot pain (p = 0.03), general pain (p = 0.012), Health Assessment Questionnaire (HAQ)-II (p = 0.016) and Leeds Foot Impact Scale (LFIS) impairment subscale (p = 0.03). No significant differences were observed in other patient reported outcomes including patient global assessment, LFIS activity subscale, and Lower Limb Task Questionnaire subscales (all p > 0.10). We observed significant improvements between baseline measurements using the participants' own shoes and the Cardio Zip for foot pain (p = 0.002), general pain (p = 0.001), HAQ-II (p = 0.002) and LFIS impairment subscale (p = 0.004) after 8 weeks. The other three shoes did not improve pain or disability. CONCLUSIONS: Footwear with good cushioning, and motion control may reduce foot pain and disability in people with gout.

International multispecialty consensus on how to image, define, and grade ultrasound imaging features of first metatarsophalangeal joint osteoarthritis, a Delphi consensus study.

Objective: To reach consensus concerning which ultrasound imaging features should be assessed and graded, and what ultrasound imaging procedure should be performed when examining osteoarthritic change in the first metatarsophalangeal joint. Design: An online Delphi study was conducted over four iterative rounds with 16 expert health professionals. Items were scored from 0 to 100 (0 â€‹= â€‹not at all important; 100 â€‹= â€‹extremely important). Consensus was defined based upon an item receiving a median score of ≥70% acceptance. Items receiving median score of ≤50% were rejected. Items considered ambiguous (median score 51%-69% of acceptance) were assessed in an additional round. A final round determined the content validity of items through calculation of the content validity ratio and content validity index. Results: Sixteen items were deemed essential, which included osteophytes graded dichotomously, cartilage damage graded continuously, synovitis and joint space narrowing graded on a semiquantitative scale. The panel deemed essential that the first metatarsophalangeal joint start in a neutral position, then move through range of motion for both dorsal and plantar scanning, orientating the probe in longitudinal and in transverse, whilst using first metatarsal head and proximal phalanx as anatomical landmarks. A supine body position was only deemed essential for a dorsal scan and a neutral foot/ankle position was only rated essential for a plantar scan. The content validity index of the 16 essential items was 0.19. Conclusion: The consensus exercise has identified the essential components the ultrasound imaging acquisition procedure should encompass when examining first metatarsophalangeal joint osteoarthritis.

Immediate effects of wearing textured versus smooth insoles on standing balance and spatiotemporal gait patterns when walking over even and uneven surfaces in people with multiple sclerosis.

PURPOSE: To investigate the immediate effects of wearing novel sensory-stimulating textured insoles on balance and gait in 41 people with multiple sclerosis (pwMS). MATERIALS AND METHODS: Assessments of balance (firm/foam surface; eyes open/closed) and walking (when negotiating even/uneven surfaces) were performed wearing textured insoles, smooth insoles, shoes only, and barefoot. Outcome measures were centre of pressure (CoP) movement during standing (elliptical area, sway path velocity) and spatiotemporal gait patterns (stride/step width, stride time, double-limb support time, stride length, velocity). RESULTS: Wearing textured insoles led to reductions in CoP velocity measures when standing on foam with eyes open and closed when compared to barefoot (p values ≤0.02). Textured insoles did not appear to be consistently superior to smooth insoles or shoes only for improving gait. Relative to the insole/shoe conditions, walking barefoot led to poorer gait performance for the even and uneven surface tasks (p values ≤0.03). CONCLUSIONS: For pwMS, stimulating the foot with "texture" appears to provide enhanced sensory input with the capacity to improve CoP movement control during standing; offering a potential new treatment option for balance rehabilitation. Further research is needed to identify which individuals may benefit most from textured insoles.Implications for rehabilitationTextured shoe insoles, designed to stimulate plantar mechanoreceptors, are a novel approach to improve standing balance and walking patterns in people with multiple sclerosis (pwMS).Wearing textured insoles for the first time can lead to improvements in centre of pressure movement control when standing on an unstable compliant supporting surface.Textured insoles offer a potential new treatment technique for balance rehabilitation in pwMS who show early signs of diminished foot sensation.

Effects of wearing textured versus smooth shoe insoles for 12 weeks on gait, foot sensation and patient-reported outcomes, in people with multiple sclerosis: a randomised controlled trial.

BACKGROUND: Innovative shoe insoles, designed to enhance sensory information on the plantar surface of the feet, could help to improve walking in people with Multiple Sclerosis. OBJECTIVE: To compare the effects of wearing textured versus smooth insoles, on measures of gait, foot sensation and patient-reported outcomes, in people with Multiple Sclerosis. METHODS: A prospective, randomised controlled trial was conducted with concealed allocation, assessor blinding and intention-to-treat analysis. Thirty ambulant men and women with multiple sclerosis (MS) (Disease Steps rating 1-4) were randomly allocated to wear textured or smooth insoles for 12 weeks. Self-reported insole wear and falls diaries were completed over the intervention period. Laboratory assessments of spatiotemporal gait patterns, foot sensation and proprioception, and patient-reported outcomes, were performed at Weeks 0 (Baseline 1), 4 (Baseline 2) and 16 (Post-Intervention). The primary outcome was the size of the mediolateral base of support (stride/step width) when walking over even and uneven surfaces. Independent t-tests were performed on change from baseline (average of baseline measures) to post-intervention. RESULTS: There were no differences in stride width between groups, when walking over the even or uneven surfaces (P ≥ 0.20) at post-intervention. There were no between-group differences for any secondary outcomes including gait (all P values > 0.23), foot sensory function (all P values ≥ 0.08) and patient-reported outcomes (all P values ≥ 0.23). CONCLUSIONS: In our small trial, prolonged wear of textured insoles did not appear to alter walking or foot sensation in people with MS who have limited foot sensory loss. Further investigation is needed to explore optimal insole design. CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ACTRN12615000421538).

Prospective observational cohort study of Health Related Quality of Life (HRQOL), chronic foot problems and their determinants in gout: a research protocol.

BACKGROUND: Gout is the commonest inflammatory arthritis affecting around 1.4% of adults in Europe. It is predominantly managed in primary care and classically affects the joints of the foot, particularly the first metatarsophalangeal joint. Gout related factors (including disease characteristics and treatment) as well as comorbid chronic disease are associated with poor Health Related Quality of Life (HRQOL) yet to date there is limited evidence concerning gout in a community setting. Existing epidemiological studies are limited by their cross-sectional design, selection of secondary care patients with atypical disease and the use of generic tools to measure HRQOL. This 3 year primary care-based prospective observational cohort study will describe the spectrum of HRQOL in community dwelling patients with gout, associated factors, predictors of poor outcome, and prevalence and incidence of foot problems in gout patients. METHODS: Adults aged ≥ 18 years diagnosed with gout or prescribed colchicine or allopurinol in the preceding 2 years will be identified through Read codes and mailed a series of self-completion postal questionnaires over a 3-year period. Consenting participants will have their general practice medical records reviewed. DISCUSSION: This is the first prospective cohort study of HRQOL in patients with gout in primary care in the UK. The combination of survey data and medical record review will allow an in-depth understanding of factors that are associated with and lead to poor HRQOL and foot problems in gout. Identification of these factors will improve the management of this prevalent, yet under-treated, condition in primary care.

Reliability of the conditioned pain modulation paradigm to assess endogenous inhibitory pain pathways.

BACKGROUND: Conditioned pain modulation paradigms are often used to assess the diffuse noxious inhibitory control (DNIC) system. DNICs provide one of the main supraspinal pain inhibitory pathways and are impaired in several chronic pain populations. Only one previous study has examined the psychometric properties of the conditioned pain modulation technique and this study did not evaluate intersession reliability. OBJECTIVES: To evaluate and compare the intra- and intersession reliability of two conditioned pain modulation paradigms using different conditioning stimuli, and to determine the time course of conditioned pain inhibition following stimulus removal. METHODS: An electronic pressure transducer was used to determine the pressure-pain threshold at the knee during painful conditioning of the opposite hand using the ischemic arm test and the cold pressor test. Assessments were completed twice on one day and repeated once approximately three days later. RESULTS: The two conditioning stimuli resulted in a similar increase in the pressure-pain threshold at the knee, reflecting presumed activation of the DNIC system. Intrasession intraclass correlation coefficients for the cold pressor (0.85) and ischemic arm tests (0.75) were excellent. The intersession intraclass correlation coefficient for the cold pressor test was good (0.66) but was poor for the ischemic arm test (-0.4). Inhibition of the pressure-pain threshold remained significant at 10 min following conditioning, but returned to baseline by 15 min. CONCLUSIONS: Within-session reliability of DNIC assessment using conditioned pain modulation paradigms was excellent, but the applicability of assessing pain modulation over multiple sessions was influenced by the conditioning stimulus. The cold pressor test was the superior technique.